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

Inadequate quality, quantity, or aesthetics of the peri-implant soft tissues can result from a combination of factors related to the outcome of treatments performed before, during, or after implant placement. In this paper, we describe in detail the treatment errors that can pave the way for the onset of mucositis or give rise to soft tissue complications such as peri-implant soft tissue discoloration or dehiscence, graft exposure, or scar formation. By tracing the error back to the planning or surgical stage, clinical insights on surgical soft tissue management are provided to avoid or treat complications that affect the status of the peri-implant soft tissues. Mastering the learning curve and knowing the limitations of each technique are fundamental for preventing added treatment failures that can result in increased patient morbidity and overall discontent.

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study.

OBJECTIVES: The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators. MATERIALS AND METHODS: A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors' experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners. RESULTS: Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations. CONCLUSIONS: The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score. CLINICAL RELEVANCE: A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

Esthetic evaluation and patient-centered outcomes in root-coverage procedures.

Treatment of buccal gingival recession is performed for esthetic concerns, root sensitivity, root caries and cervical abrasion resulting from incorrect toothbrushing. Over the years, clinicians and researchers have improved surgical techniques to achieve surrogate end points, such as complete root coverage, gingival recession reduction or keratinized tissue increase, ignoring the input from the patient regarding the true indications for treatment. In the past few years there has been an emphasis to include patient-centered outcomes in the evaluation of root-coverage procedures. The aim of this narrative review is to describe the professional objective assessment of the esthetic results after root-coverage procedures and the patient perception of outcome in terms of esthetics, postoperative morbidity and dentinal hypersensitivity resolution after the treatment of gingival recessions. The need to align professional (surrogate) end points with patient-centered outcomes (true end points) in the future is emphasized.

Decision making in root-coverage procedures for the esthetic outcome.

The primary indication for treatment of gingival recessions is esthetics. In the last decades, patients have become increasingly more demanding in the esthetic outcome expected. In order to obtain a successful final result, periodontal plastic surgery should provide not only complete root coverage but also perfect blending in terms of color and texture. In the literature, many techniques have been demonstrated to be effective in obtaining complete root coverage, and the selection of one surgical technique over another depends on several factors related to the anatomic characteristics of the defect. The purpose of this paper was to suggest a decision-making process which starts from the clinical observation of the defects and is structured in progressive nodes that will guide the clinician through the most suitable surgical technique to achieve the ideal esthetic outcome.

Esthetic evaluation and patient-centered outcomes in single-tooth implant rehabilitation in the esthetic area.

Criteria for successful implants, in the rehabilitation of a single missing tooth in the esthetic area, should be determined by composite outcomes, including functional and esthetic aspects of soft tissues and the reconstruction, as well as patient-reported outcomes. This paper focuses on current methods in esthetic assessment and patient-centered/reported outcomes in single-tooth implant rehabilitation in the esthetic area. The relationship between subjective, patient-based esthetic evaluations and objective, professional-based esthetic evaluations is reviewed. In spite of increasing interest in the assessment of 'success' in implant dentistry, it is not yet possible to provide evidence-based conclusions because of the lack of consensus on a universal implant-supported crown esthetic index. There is also a need to standardize reporting of patient-centered outcomes in partially edentulous patients treated with implants.

Soft-tissue augmentation procedures in edentulous esthetic areas.

Loss of dentition leads to functional and esthetic challenges that are determined by the anatomic features of the edentulous area. These features can complicate the prosthetic rehabilitation of such patients, especially in situations where optimal esthetic outcomes are desired. For these reasons, reconstructive plastic surgery procedures, aimed at restoring the alveolar ridge to its former dimensions, have become of great clinical interest. These reconstructive plastic surgery procedures frequently involve soft-tissue augmentation, performed to improve the quality and quantity of mucogingival tissue with the aim to achieve an ideal esthetic result. This review will focus on the description and expected outcomes of different surgical techniques for soft-tissue augmentation in edentulous areas, as described in the literature. Although more information from a larger number of studies and randomized controlled clinical trials is needed, it is possible to draw some conclusions, namely: pouch procedures are the first choice for soft-tissue augmentation, especially in high-demand esthetic areas; roll techniques are possible in shallow buccolingual soft-tissue augmentations; and onlay, inlay and combination grafts are less suitable for soft-tissue augmentation because of their poor esthetic results.

Crown lengthening and restorative procedures in the esthetic zone.

Crown lengthening is one of the most common surgical procedures in periodontal practice. Its indications include subgingival caries, crown or root fractures, altered passive eruption, cervical root resorption and short clinical abutment, and its aim is to re-establish the biologic width in a more apical position. While the procedure in posterior areas of the dentition has been thoroughly investigated, crown lengthening performed for esthetic reasons in the anterior areas is still a matter of debate and an evidence-based technique is not available. This paper provides accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how should the healing phase be managed in relation to the timing and the position of the provisional restoration with respect to the gingival margin?

Coronally advanced flap + connective tissue graft techniques for the treatment of deep gingival recession in the lower incisors. A controlled randomized clinical trial.

AIM: The aim of this study was to compare the clinical and aesthetic outcomes of two different surgical approaches for the treatment of deep gingival recession affecting the mandibular incisors. METHODS: Fifty patients with Miller class I and II gingival recessions (≥ 3 mm) in the lower incisors were enrolled. Twenty-five patients were randomly assigned to the control group and the other 25 patients to the test group. All defects were treated with the coronally advanced flap + connective tissue graft (CAF + CTG) and in the test group the labial submucosal tissue (LST) was removed. Post-operative morbidity was evaluated at 1 week. Clinical and aesthetic evaluations were made at 1 year. RESULTS: Statistically greater recession reduction, probability of CRC (adjusted OR 7.94 95% CI = 1.88-33.50, p = 0.0024) and greater increase in GT were observed in the test group. Greater graft exposure and increase in KTH were demonstrated in the control group. Better aesthetics outcomes were observed in the test group. No statistically significant between groups differences were demonstrated in patient analgesic assumption and post-operative discomfort and bleeding. CONCLUSIONS: LST removal during CAF + CTG surgery is indicated to provide better root coverage and aesthetic outcomes in the treatment of gingival recessions affecting the lower incisors.

Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial.

AIM: The aim of this study was to compare short- and long-term root coverage and aesthetic outcomes of the coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CTG) for the treatment of multiple gingival recessions. METHODS: Fifty patients with multiple (≥2) adjacent gingival recessions (≥2 mm) in the upper jaw were enrolled. Twenty-five patients were randomly assigned to the control group (CAF), and the other 25 patients to the test group (CAF + CTG). Clinical outcomes were evaluated at 6 months, 1 and 5 years. The aesthetic evaluations were made 1 and 5 years after the surgery. RESULTS: No statistically significant difference was demonstrated between the two groups in terms of Rec Red and complete root coverage (CRC) at 6 months and 1 year. At 5 years, statistically greater recession reduction and probability of CRC, greater increase in buccal KTH and better contour evaluation made by an independent periodontist were observed in the CAF + CTG group. Better post-operative course and better colour match were demonstrated in CAF-treated patients both at 1 and 5 years. CONCLUSIONS: CAF + CTG provided better CRC at 5 years; keloid formation due to graft exposure was responsible for the worse colour match evaluation.

Root coverage in molar teeth: a comparative controlled randomized clinical trial.

AIM: To compare the clinical outcomes of laterally moved, coronally advanced flap (LMCAF) versus Bilaminar technique (BT) in the treatment of single gingival recession on molar teeth. MATERIAL AND METHODS: Fifty patients showing Miller I and II gingival recessions at first molar teeth were treated: 25 were randomly assigned to the BT group and 25 belonged to the LMCAF group. Patient's post-operative morbidity was assessed 1 week after the surgery, while aesthetic evaluation and the clinical evaluation were made 1 year later. RESULTS: No statistically significant difference was demonstrated in terms of recession and PPD reduction. Statistically greater probability of complete root coverage (CRC, Odds Ratio 22.1) and greater increase in gingival thickness were observed in the BT group. Greater increase in keratinized tissue was obtained in the LMCAF. Patient satisfaction with aesthetics was very high in both treatment groups. Better post-operative course was observed in the LMCAF, while better post-operative sensitivity and root coverage evaluation were demonstrated in patients treated with BT. CONCLUSIONS: Gingival recession at first molar teeth can be successfully treated with LMCAF and BT. Better CRC was achieved with BT, while more comfortable post-operative course was associated with the LMCAF.

Vertically Coronally Advanced Flap (V-CAF) to Increase Vestibule Depth in Mandibular Incisors.

Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.

Patient morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: a comparative randomized-controlled clinical trial.

AIMS: The aim of this randomized-controlled clinical trial was to compare the patient morbidity and root coverage outcomes of a coronally advanced flap (CAF) with connective tissue (CTG) or de-epithelialized gingival (DGG) grafts. METHODS: Fifty patients with one recession each were treated. In the control group, the CTG was harvested using the trap-door approach while in the test group the CTG resulted from the de-epithelialization of a free gingival graft. RESULTS: No statistically significant differences were demonstrated between groups in patients's pain killer consumption, post-operative discomfort and bleeding. Lower stress and better ability to chew were demonstrated in the CTG group. Analgesic consumption increased with increasing height of the graft and in the case of dehiscence/necrosis of the primary flap. Pain was negatively correlated with the residual thickness of soft tissue covering the palatal bone. A statistically greater increase in buccal soft tissue thickness was observed in the DGG group. CONCLUSIONS: No differences were demonstrated in the post-operative pain and root coverage outcome in patients subjected to CAF with CTG or DGG.

Peri-implant Papillae Reconstruction at an Esthetically Failing Implant.

This case report aimed to describe a soft tissue approach to restore a buccal soft tissue dehiscence (BSTD) combined with the loss of peri-implant papillae and loss of periodontal attachment on the adjacent teeth. The first step of the proposed approach was the removal of the crown and abutment to leave the interproximal soft tissue to fill the space previously occupied by the crown. After 3 months, during which time the patient was wearing a provisional restoration (a temporary Maryland bridge), the implant site was treated as an edentulous area with a soft tissue augmentation procedure: the most substantial modification with respect to the original connective tissue platform technique was the use of the wide mesial and distal papillae of the implant, once de-epithelialized on the occlusal surface, as a "partial" connective platform to suture the connective grafts and submerge the implant. At the 4-month reevaluation visit, a minor soft tissue defect remained in both apico-coronal and buccolingual dimensions, and thus a second surgery was performed to obtain further soft tissue augmentation. A flapless punch procedure was used to expose the implant head, and after conditioning the augmented peri-implant soft tissue with a new provisional crown, the definitive restoration was delivered. Complete coverage of the BSTD was achieved, and both papillae entirely filled the interproximal spaces. The results were well maintained up to the 5-year follow-up visit.

Simplified osteotome sinus augmentation technique with simultaneous implant placement: a clinical study.

The aim of this study was to describe and evaluate a modified maxillary sinus floor augmentation technique: the simplified osteotome technique. The study consisted of 26 patients treated with 39 Brånemark implants (Nobel Biocare) placed using the simplified osteotome technique between September 1997 and November 2004 (87 months). Implant length ranged from 10 to 15 mm, while the loading time ranged from 5 to 74 months (mean: 35.2 months). The success rate was 97.4% according to Albrektsson's criteria. These preliminary data indicate that the simplified osteotome technique is effective and safe, though long-term, multicenter studies are still needed.

Coronally Advanced Flap with Site-Specific Application of Connective Tissue Graft for the Treatment of Multiple Adjacent Gingival Recessions: A 3-Year Follow-Up Case Series.

The aim of this study was to evaluate the short- (1 year) and longer-term (3 years) effectiveness of a surgical procedure combining coronally advanced flap (CAF) with site-specific application of connective tissue graft (CTG) in the treatment of multiple gingival recessions (MGR). A total of 60 periodontally healthy subjects with esthetic complaints due to excessive tooth length presenting multiple (at least three) Miller Class I and II gingival recession defects (≥ 1 mm) affecting adjacent teeth in the maxilla and mandible were enrolled in the study. All recessions were treated with CAF. The CTG was applied in gingival defects with a baseline keratinized tissue height (KTH) < 1 mm or with KTH between 1 and 2 mm and gingival thickness < 1 mm. Complete root coverage (CRC) was obtained in 98.5% (263 of 267 recessions) and in 94.7% (256 of 267 recessions) of the sites at the 1- and 3-year follow-up visits, respectively. No statistically significant differences were found at 1 and 3 years in terms of CRC between sites with or without CTG and between sites belonging to the maxilla or mandible. A greater increase in KTH at 3 years was demonstrated in sites treated with CTG. This was ascribed to the tendency of the mucogingival line to regain its genetically determined position and not to graft exposure. The present study demonstrated that the proposed surgical technique combining CAF with site-specific application of CTG was an effective treatment modality for the management of MGR, obtaining 93% CRC in the CAF-treated sites and 100% CRC in the sites treated with CAF + CTG at 3 years.

5-year outcomes after coverage of soft tissue dehiscence around single implants: A prospective cohort study.

PURPOSE: To report the 5-year clinical and aesthetic outcomes of a novel surgical-prosthetic approach for the treatment of buccal soft tissue dehiscence around single dental implants. MATERIALS AND METHODS: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were treated by removing the implant-supported crown, reducing the implant abutment, coronally advanced flap in combination with connective tissue graft and final restoration. After the first year, patients were recalled three times a year until the final clinical re-evaluation performed 5 years after the final prosthetic crown. Complications, bleeding on probing (BoP), peri-implant probing depth (PPD), clinical attachment level (CAL), keratinized tissue height (KTH), soft tissue coverage and thickness (STT), patient satisfaction (VAS) and aesthetic assessment (PES/WES) were evaluated 5 years after the final restoration. RESULTS: Of the 20 patients enrolled in the study, 19 completed the study at 5 years. A total of 99.2% mean soft tissue dehiscence coverage, with 79% of complete dehiscence coverage, was achieved at 5 years. A statistically significant increase in buccal soft tissue thickness (0.3 mm 0.1-0.4 P < 0.001) and keratinized tissue height (0.5 mm 0.0-1.0; P < 0.001) at 5 years with respect to 1 year was demonstrated. The patient aesthetic evaluation showed high VAS scores with no statistical difference between 1 year and 5 years (8.75 ± 1.02 and 8.95 ± 0.91 respectively). A statistical significant PES/WES score improvement was observed between baseline and 5 years (9.48 ± 2.68; P < 0.001), but not between 1 and 5 years. CONCLUSIONS: Successful aesthetic and soft tissue dehiscence coverage outcomes were well maintained at 5 years. The strict regimen of post-surgical control visits and the emphasis placed on the control of the toothbrushing technique could be critical for the successful long-term maintenance of soft tissue dehiscence coverage results.

Connective Tissue Graft Wall Technique and Enamel Matrix Derivative for the Treatment of Infrabony Defects: Case Reports.

The present case report describes a modification of the connective tissue graft wall technique with enamel matrix derivative applied to treat deep vertical bony defects. The technique presented uses a palatal incision to gain access to the bony defect. Deep infrabony defects affecting two maxillary central incisors associated with interdental and buccal gingival recession were treated. At 1 year after surgery, 9 and 6 mm of interdental clinical attachment level gain were seen in cases 1 and 2, respectively. The position of the interdental papilla was improved, and complete root coverage was achieved. Radiographs demonstrated bone fill of the infrabony components of the defects. This report encourages the possibility to improve, in one surgical session, regenerative and esthetic parameters in the treatment of deep infrabony defects.

Coronally Advanced Flap with Different Designs in the Treatment of Gingival Recession: A Comparative Controlled Randomized Clinical Trial.

The aim of this parallel double-blind randomized controlled clinical trial was to describe a modified approach using the coronally advanced flap (CAF) with triangular design and to compare its efficacy, in terms of root coverage and esthetics, with a trapezoidal type of CAF. A sample of 50 isolated Miller Class I and II gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with CAF. Of these recessions, 25 were randomly treated with trapezoidal CAF (control group) while the other 25 (test group) were treated with a modified triangular CAF. The clinical and esthetic evaluations, made by the patient and an independent periodontist, were performed 3 months, 6 months, and 1 year after the surgery. No statistically significant difference was demonstrated between the two CAF groups in terms of recession reduction, complete root coverage, or 6-month and 1-year patient esthetic scores. Better 3-month patient esthetic evaluations and better periodontist root coverage, color match, and contiguity assessments were reported after triangular CAF. Trapezoidal CAF was associated with greater incidence of keloid formation. Single-type gingival recessions can be successfully covered with both types of CAF. The triangular CAF should be preferred for esthetically demanding patients.

Transmucosal Implant Placement with Submarginal Connective Tissue Graft in Area of Shallow Buccal Bone Dehiscence: A Three-Year Follow-Up Case Series.

The aim of the present case series study was to evaluate the short- and long-term (3 years) soft tissue stability of a surgical technique combining transmucosal implant placement with submarginal connective tissue graft (CTG) in an area of shallow buccal bone dehiscence. A sample of 20 patients were treated by positioning a transmucosal implant in an intercalated edentulous area. A CTG sutured to the inner aspect of the buccal flap was used to cover the shallow buccal bone dehiscence. Clinical evaluations were made at 6 months (T1) and 1 (T2) and 3 (T3) years after the surgery. Statistically significant increases in buccal soft tissue thickness and improvement of vertical soft tissue level were achieved at the T1, T2, and T3 follow-ups. A significant increase in keratinized tissue height was also found at T3. No significant marginal bone loss was recorded. The submarginal CTG technique was able to provide simultaneous vertical and horizontal soft tissue increases around single implants with shallow buccal bone dehiscence and no buccal mucosal recession or clinical signs of mucositis or peri-implantitis at 1 and 3 years.

Esthetic treatment of peri-implant soft tissue defects: a case report of a modified surgical-prosthetic approach.

A major esthetic concern is soft tissue defects around implant restorations, which often result in an extra long prosthetic crown. This report describes a modified prosthetic-surgical approach to the treatment of peri-implant horizontal and vertical soft tissue defects in an esthetically demanding patient. One month before surgery, the implant crown restoration was removed, the preexisting implant abutment was reduced, and a short provisional crown, at the level of the homologous contralateral incisor, was applied. A bilaminar technique, consisting of an envelope coronally advanced flap covering two connective tissue grafts, was used to treat the soft tissue defects around the implant site. Four months after surgery, a new implant abutment and provisional crown were applied for soft tissue conditioning before the final impression. Nine months after surgery, the peri-implant soft tissue margin was 4 mm more coronal compared with baseline and at the same soft tissue margin level of the right central incisor. A 2.2-mm increase in buccal soft tissue thickness measured 1.5 mm apical to the soft tissue margin was accomplished. The emergence profile of the replaced tooth faithfully reproduced that of the healthy homologous contralateral central incisor. Two years after surgery, the soft tissue margin was stable and the esthetic appearance of the implant site was well maintained. This report demonstrates the possibility of fully correcting severe vertical and horizontal peri-implant soft tissue defects and achieving high patient satisfaction through a combined mucogingival and prosthetic treatment.