Jumping gap in immediate implant placement in the esthetic zone: A virtual implant planning using cone-beam computed tomography.

PURPOSE: A jumping gap (JG) refers to the implant's future buccal wall; this study aims to estimate the jumping gap dimension in relation to virtual implant placement and subsequently link the implant diameter and implant position with the anatomical site. METHODS: This observational study was conducted to analyze the maxillary teeth in the esthetic zone from cone-beam computed tomography (CBCT) scans using OnDemand software. The horizontal jumping gap dimension of each tooth was assessed by subtracting the calculated virtual implant diameter from the socket dimensions. RESULTS: A total of 253 anterior and premolar maxillary teeth were analyzed from 52 CBCT scans. The estimated JG dimensions were 1.23 ± 0.59 mm, 1.80 ± 0.64 mm, 3.02 ± 0.69 mm, for central incisors, lateral incisors and canines respectively, 3.70 ± 0.68 mm for the first premolars showing the highest horizontal gap and 3.19 ± 0.88 mm for second premolars. The incisors showed the smallest horizontal gap compared to the canines and premolars. CONCLUSIONS: In terms of JG, immediate implant placement is more favorable at the canine and premolar sites. By contrast, the incisors sites should be handled with extreme caution, where the use of narrower implants is advisable when necessary.

Clinical Evaluation of the Coronally Advanced Lingual Flap Technique for Maintaining Primary Wound Closure Over Titanium Mesh After Guided Bone Regeneration: A Randomized Control Trial.

PURPOSE: To evaluate the clinical efficacy of the coronally advanced lingual flap (CALF) technique in terms of the extent of lingual and buccal flap advancement, the maintenance of primary wound closure, and safety in comparison to buccal flap advancement alone during horizontal ridge augmentation in the posterior mandible. MATERIALS AND METHODS: A total of 14 patients were randomly allocated to two different groups: buccal flap advancement without the CALF technique (control), referred to as the NO-CALF group, and buccal flap advancement with the CALF technique (test), referred to as the CALF group. Wound healing was monitored weekly for the first 4 weeks, then at 2, 4, 6, and 9 months postoperatively for any soft tissue dehiscence (titanium mesh [TM] exposure) along the incision line. The extent of lingual and buccal flap advancement was measured, and any intraoperative and postoperative CALF-related complications were reported. RESULTS: The difference between groups was statistically significant (P < .0001) in terms of (1) TM exposure: 83.3% of cases in the NO-CALF group showed early Class П exposures, whereas the CALF group showed no exposure; (2) mean lingual flap advancement: 3.9 ± 1.1 mm and 14.4 ± 3.8 mm for the NO-CALF and CALF groups, respectively; and (3) mean buccal flap advancement: 15.8 ± 2.1 mm and 10.5 ± 1.4 mm for the NO-CALF and CALF groups, respectively. There were no reported complications related to the CALF technique. CONCLUSION: Tension-free primary wound closure was facilitated and maintained during the healing period by applying the CALF technique, which is a reliable technique to safely advance the lingual flap coronally.

Evaluation of esthetic outcome of delayed implants with de-epithelialized free gingival graft in thin gingival phenotype with or without immediate temporization: a randomized clinical trial.

AIM: The current study investigates the effect of immediate temporization on the pink esthetics of delayed implants in patients with thin gingival phenotype in combination with a De-epithelialized Free Gingival Graft in the maxillary premolar area. METHODOLOGY: The study population was randomly assigned into two groups. The two groups were treated with delayed implants with simultaneous placement of a de-epithelialized free gingiva graft. The test group was immediately temporized while the control group had no temporization. The pink esthetic score was assessed as the primary outcome. Additional secondary outcomes were assessed such as the keratinized tissue width and the soft tissue thickness. RESULTS: Twenty implants were placed in the current study, split into 10 implants per group. The results showed that the Pink Esthetic Score of the IT group was 11.88 ± (1.13) and 11.33 ± (1.25) for the CTG group, which showed no statistical difference between the groups after 1 year of follow-up. There was also no significant difference between the two groups at 12 months regarding the keratinized tissue width and the soft tissue thickness. CONCLUSIONS: Immediate and delayed temporizations have no effect on the Pink Esthetics of the delayed implants; however, immediate temporization allowed earlier provisional crown delivery. Soft tissue augmentation of the thin gingival phenotype improved esthetics for both groups. Trial registration Name of the registry: clinicaltrials.gov; trial registration number: NCT03792425. Date of registration: January 3, 2019. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03792425?term=NCT03792425&draw=2&rank=1.

Soft tissue esthetics around immediately provisionalized delayed implants with and without connective tissue graft: A randomized clinical trial pilot study.

OBJECTIVE: Evaluate the peri-implant soft tissue esthetics following a single, immediately provisionalized, delayed implant with/-out subepithelial connective tissue graft (SCTG). MATERIAL AND METHODS: The eligible patients were randomized into two groups. Immediate provisionalization was performed with (test group: SCTGG) or without SCTG (control group: NGG). The soft tissue esthetics was assessed by Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI), at 6 and 12 months, following final implant restoration. RESULTS: The SCTGG, compared to NGG, yielded a 0.2 increased PES at 12 months (95% confidence interval (CI): -1, 1.4) and a 0.2 decreased MSI score (95% CI -0.9, 0.5) with no statistically significant differences in PES and MSI between both groups (p > 0.05). CONCLUSION: Soft tissue grafting around immediately provisionalized delayed implants could exhibit comparable results to immediate provisionalization alone in terms of peri-implant soft tissue esthetics using PES and MSI (ClinicalTrials.gov Identifier: NCT03770975).

Esthetic patient satisfaction, marginal bone loss and peri-implant tissue success in esthetic zone: systematic review / Satisfação estética do paciente, perda óssea marginal e sucesso do tecido peri-implantar na zona estética: revisão sistemática

Increased patient demands for highly esthetic implant superstructure in the anterior esthetic zone has increased in the last decades. Moreover, the absence of periodontal ligament in implant supported prosthesis causes forces to be transferred without cushioning effect to the alveolar bone, resulting in increased marginal bone loss (MBL) and influence the heath of peri-implant tissue. Evaluate the available evidence on the effect implant superstructure and it consequences on patient satisfaction, MBL, bleeding on probing (BOP) and probing depth (PD). A protocol of electronic and hand research was performed for English based researches comparing implants inserted in the esthetic zone with all ceramic superstructure: "Will the use of different types of all ceramic superstructure show different esthetic patient satisfaction, marginal bone loss, bleeding on probing and probing depth? Thirteen publications from one thousand one hundred and sixteen research studies were included. This systematic review showed that all ceramic implant superstructure was a versatile treatment option with higher esthetic patient satisfaction and better color of peri-implant mucous especially in patients having thin biotype. On the other hand there wasn't significant difference in MBL, PD and BOP compared to other conventional implant superstructure. More randomized controlled clinical trials with bigger samples are needed to confirm our findings. All ceramic implant superstructure is versatile and highly esthetic treatment option for implant placed in the anterior esthetic zone.(AU)

A demanda do paciente por superestruturas de implante altamente estéticas na zona anterior aumentou nas últimas décadas. Além disso, a ausência de ligamento periodontal em próteses implantossuportadas faz com que as forças sejam transferidas para o osso alveolar sem amortecimento, resultando em aumento da perda óssea marginal (MBL) e influenciando na saúde do tecido peri-implantar. Avaliar as evidências disponíveis sobre o efeito da superestrutura do implante e suas consequências na satisfação do paciente, perda óssea marginal, sangramento à sondagem (SS) e profundidade de sondagem (PS). Um protocolo de pesquisa eletrônica e manual foi realizado para a análise de artigos em inglês comparando implantes com toda a superestrutura em cerâmica inseridos na zona estética: "O uso de diferentes tipos de superestrutura em cerâmica mostrará diferentes níveis de satisfação estética do paciente, perda óssea marginal, sangramento em profundidade de sondagem e sondagem?". Foram selecionadas 1116 publicações e apenas treze estudos foram incluídos na análise final. Esta revisão sistemática mostrou que toda superestrutura do implante em cerâmica foi uma opção de tratamento versátil, com maior satisfação estética do paciente e melhor coloração da mucosa peri-implantar, especialmente em pacientes com biótipo fino. Por outro lado, não houve diferença significativa em MBL, PS e SS em comparação com outras superestruturas de implantes convencionais. Porém, mais ensaios clínicos controlados randomizados com amostras maiores são necessários para confirmar nossos achados. Implicações clínicas: Toda superestrutura do implante em cerâmica é uma opção de tratamento versátil e altamente estética para implantes colocados na zona anterior (AU)

Evaluation of Oversized Drilling on Implant Survival and Stability Versus Traditional Drilling Technique: A Randomized Clinical Trial.

PURPOSE: This study aimed to investigate the influence of oversized drilling on the stability of the implant and the bone response during osseointegration. MATERIALS AND METHODS: The trial was designed as a prospective, parallel-group randomized controlled clinical trial with 20 implants placed in the posterior region of the maxilla. The sample size was divided into two groups, 10 each, with implants being placed with manufacturer-recommended implant osteotomy preparation according to the manufacturer guidelines in one group (MR group) vs oversized osteotomy preparation (3 to 5 mm) in the other group (oversized drilling [OD] group). The implant stability was monitored for 3 months by means of resonance frequency analysis, while the crestal bone levels were recorded using parallel technique periapical radiography for 6 months. Patient-reported outcomes including pain, swelling, satisfaction, and implant survival were all monitored throughout the study. RESULTS: In the MR group, a mean decrease in implant stability quotient (ISQ) values was detected during the first 4 weeks, after which a gradual increase in values was recorded. In comparison, the OD group showed a rapid increase in ISQ value over the entire follow-up period from baseline and up to week 12. Regarding crestal bone level, follow-up showed a significant difference when comparing baseline and 6-month radiographs (P = .00) between the OD group, 0.908 mm ± 0.343, and the MR group, 1.3 ± 0.23 mm. CONCLUSION: Within the limitations of this study, the results suggest that the oversized osteotomy technique may lead to earlier implant stability and postsurgical recovery compared with the manufacturer-recommended technique for osteotomy preparation. However, further studies are needed to confirm these findings.

Clinical comparison of different flap advancement techniques to periosteal releasing incision in guided bone regeneration: A randomized controlled trial.

OBJECTIVES: To compare Double Flap Incision (DF), Coronally Advanced Lingual Flap (CALF), and Modified Periosteal Releasing Incision (MPRI) to Periosteal Releasing Incision (PRI) in flap advancement, postoperative complications in augmentation using titanium mesh. MATERIAL AND METHODS: Forty patients with partially edentulous posterior mandibles were randomly assigned to the four groups. We evaluated: (a) Flap advancement in mm (Primary outcome). (b) Pain using the Numerical Rating scale (NRS). (c) Swelling using the Visual Analogue Scale (VAS). (d) Exposure in mm and exposure percentage at 1 week to 6 months. RESULTS: The CALF showed the highest mean flap advancement of 19.9 (±5.0) mm while the PRI showed the lowest; 10.2 (±1.7) mm. The difference between groups was statistically significant (P value <.0001). MPRI showed the highest pain score of 5.3 (±1.3) while the DF showed the lowest; 2.39 (±1.7). Swelling did not show a significant difference between groups. MPRI showed the highest exposure mean; 18.6 mm (±26.3) while CALF showed the lowest; 2.5 mm (±4.0). PRI showed the highest exposure percentage; 7.4% (±9.3) while CALF showed the lowest; 0.4% (±0.7). The difference between groups was insignificant. CONCLUSIONS: CALF reported highest advancement, least complications while PRI reported the highest complications.

Patient Satisfaction and Pink Esthetics of PEEK Versus Zirconium Abutments in the Esthetic Zone (A Randomized Controlled Trial) / Satisfação do paciente e estética rosa dos pilares PEEK versus Zircônia na zona estética (um ensaio clínico randomizado)

Objective: This study was performed to evaluate the use of PEEK abutments versus zirconium abutments with lithium disilicate superstructure on the esthetic acceptance and peri-implant clinical parameters. Zirconium abutments were found to have high surface roughness even after polishing. This causes a remarkable collapse of the soft tissue papilla that is a primary factor in the Pink Esthetic Score(PES), resulting in failed esthetic restoration in the anterior esthetic zone. Material and Methods:Twenty patients who needed a single implant restoration in the esthetic zone were included in this study. Eighteen patients completed screening, baseline, three-month, six-month, and twelve-month follow-up visits. At the screening visit, the patients were randomly allocated into two groups: Zirconia abutments (A) Group, and PEEK abutments (B) Group, both of which were restored with IPS e.max CAD superstructure. Patients Satisfaction was assessed by visual analogue scale (VAS). Pink esthetics score (PES), modified plaque index (mPI) and modified gingval index (mGI) were also assessed. Results: All implants were successfully osseo-integrated with a 100% survival rate over one year. Patient satisfaction was significantly higher for the PEEK group than the zirconium group. The pink esthetic score showed no statistical significance between both groups. The modified plaque index was significantly lower for the PEEK group than the zirconium group. The modified gingival index showed no statistical difference between both groups. Conclusion: PEEK revealed to be a versatile material to replace zirconium for implant abutments, due to its lower plaque affinity and higher patient satisfaction (AU)

Objetivo: Este estudo foi realizado para avaliar o uso de pilares PEEK versus pilares de zircônia com estrutura de dissilicato de lítio quanto a aceitação estética e parâmetros clínicos peri-implantares. Os pilares de zircônia apresentam alta rugosidade superficial, mesmo após o polimento. Isso causa um colapso notável da papila do tecido mole, que é um fator primário no índice estético rosa (Pink Esthetic Score - PES), resultando em falha na restauração estética na zona estética anterior. Materiais e Métodos:Vinte pacientes que precisavam de um implante unitário na zona estética foram incluídos neste estudo. Dezoito pacientes completaram a triagem, a consulta inicial e as visitas de acompanhamento de três, seis e doze meses. Durante a triagem, os pacientes foram aleatoriamente divididos em dois grupos: Grupo Pilares de Zircônia (A) e Grupo de Pilares PEEK (B), ambos foram restaurados com IPS e.max CAD. A satisfação dos pacientes foi avaliada pela escala visual analógica (VAS). O PES, o índice de placa modificado (mPI) e o índice gengival modificado (mGI) também foram avaliados. Resultados: Todos os implantes foram osseointegrados com sucesso, com uma taxa de sobrevivência de 100% ao longo de um ano. A satisfação do paciente foi significativamente maior para o grupo PEEK quando comparado com o grupo de pilares de zircônia. O índice da estética rosa não apresentou significância estatística entre os dois grupos. O índice de placa modificado foi significativamente menor para o grupo PEEK quando comparado com o grupo de pilares de zircônia. Conclusão: O PEEK revelou-se um material versátil para substituir a zircônia em pilares de implante, devido a sua menor afinidade de placa e maior satisfação do paciente. (AU)

Lip repositioning with or without myotomy: A randomized clinical trial.

BACKGROUND: Lip repositioning is a conservative surgical method for the correction of excess gingival display (EGD) by limiting the upward retraction of the lips. Lip repositioning presents a simple method for the treatment of gummy smile. The aim of this randomized clinical trial (RCT) was to assess lip repositioning, compared to lip repositioning with muscle severance for efficacy in treatment of EGD and resultant stability. METHODS: A single-blinded, controlled, parallel-group RCT was performed. Twenty patients with EGD were enrolled in the study, treated with lip repositioning with and without muscle severance. Participants were assessed for EGD reduction, changes in lip length and result stability at 3, 6 and 12 months. Additionally, pain, swelling and satisfaction, were assessed. RESULTS: Classic lip repositioning was found capable of reducing EGD by 2.73 mm (SD ± 1.281), while lip repositioning with muscle severance offered an improved reduction in EGD with a mean reduction of 3.57mm (SD ± 1.62). Lip length, swelling and pain scores were found comparable between the two techniques. CONCLUSION: Lip repositioning is an effective method for treating EGD, however, muscle severance provides a more stable result at 12 months when compared to the classical technique. More studies are necessary to fully assess this procedure.

Lip repositioning for the treatment of excess gingival display: A systematic review.

BACKGROUND: Lip repositioning is a conservative surgical technique used to treat excess gingival display. An array of modifications has been introduced to the technique over time and as studies show the technique and its modifications to be successful, there is little standardized information for clinicians to make informed decisions when choosing this technique for the treatment of patients with excessive gingival display (EGD). OBJECTIVES: To review the current literature on the topic of lip repositioning for the treatment of excessive EGD, exploring outcome, and result longevity. METHODS: A structured systematic search was carried out using the Ovid database and Web of Science to identify published studies on lip repositioning technique. Search was restricted to studies in the English language, describing a surgical intervention. Case reports were included as the number of published studies was limited. RESULTS: The electronic search identified 93 articles, hand search identified 1 article, and reference search identified 1 article. After excluding duplicates and screening articles, a total of 22 articles met the inclusion criteria. An estimated mean improvement of 3.4 mm (95% confidence interval, 3.0-3.8 mm) was found possible with lip repositioning. Data analysis was performed using only 4 studies, amounting to a total of 33 patients. Potential risk of bias was identified in some of the studies included. CONCLUSIONS: Despite the limited available studies on lip repositioning, an estimated mean improvement of 3.4 mm was found to be possible with surgical lip repositioning, suggesting that the technique could be used successfully to treat EGD. However, more studies are necessary to properly evaluate the treatment approach and stability of the technique. CLINICAL SIGNIFICANCE: Recently, the demand for esthetics has significantly increased, driven by increased patient awareness and the search for an ideal smile. Creating the perfect smile is an intricate process that requires a multidisciplinary approach, with careful consideration of the lips and the gingival outline. Excess gingival display results in an unaesthetic smile, lip repositioning offers a comparatively simple solution for this problem. While the quality literature on this topic is limited statistical analysis of collected studies show that an estimated mean improvement of 3.4 mm can be achieved with surgical lip repositioning.

Anterior Maxilla Augmentation Using Palatal Bone Block with Platelet-Rich Fibrin: A Controlled Trial.

PURPOSE: This study was conducted to characterize clinically and radiographically the effect of using platelet-rich fibrin (PRF) autologous graft on the augmentation results of autogenous palatal bone blocks. MATERIALS AND METHODS: Patients who suffered from horizontal alveolar bone defects in the anterior maxillary ridge (≤ 4.5 mm) with one or two missing teeth were augmented with autogenous palatal bone blocks 4 months prior to implant placement. PRF was used to cover the block in the test group, while only the block was used in the control. Bone width was measured with a manual caliper preaugmentation (t0), and at 0 (t1) and 4 months (t2). Cone beam computed tomography (CBCT) scans were performed at t0 and t2. Nonparametric tests (Mann-Whitney, Friedman's, and Wilcoxon signed-rank tests) were used for the comparisons. The significance level was set at P ≤ .05. RESULTS: In the 14 sites (12 patients), all but one autograft (from the control group) integrated successfully after 4 months. No statistically significant difference was found between demographic data in the two groups. There was a statistically significant increase in the buccopalatal bone width in both groups by time as measured by CBCT as well as the manual caliper. The test group showed statistically significantly lower mean graft resorption than the control group (test, 0.8 ± 0.6 mm; control, 1.6 ± 0.9 mm; P = .006). CONCLUSION: Autogenous palatal bone block surface resorption is significantly decreased by the use of PRF coverage.

Analysis of the dimensions of the labial bone wall in the anterior maxilla: a cone-beam computed tomography study.

BACKGROUND: Immediate implant placement in extraction socket does not appear to prevent the resorption of the labial wall. It has been recommended that a minimal thickness of 1-2 mm of buccal bone should be available to preclude the resorption of the facial vertical dimension of the socket wall. OBJECTIVE: The aim was to determine the dimension of the facial buccal plate of bone in the anterior esthetic zone at different levels and relate it to immediate implant placement. MATERIALS AND METHODS: Seventy-three patients' cone-beam tomographic scans were included in the study (42 female and 31 male, mean age 39.6 years). The images were acquired using OnDemand software. The measurements taken included: 1. Distance between the CEJ and the alveolar crest. 2. The labial bone thickness at different levels in relation to alveolar crest: at 1, 2, and 4 mm. THE RESULTS: The measurements demonstrated that the distance between the CEJ and the crest was 2.10 ± 0.85 for the central and 2.09 ± 0.72 for the lateral incisor. The measurement taken at M0 (crestal level) revealed that only 1% of the incisors showed a thick labial bone (1-2 mm) and 73% showed a thin bony wall (0.5-1 mm) and 25% showed very thin wall <0.5 mm. At the M1, 7% showed very thin bony wall and 86% showed a thin bony wall while only 6% exhibited a thick bony wall. The M2 showed only 1% of very thin bony wall, and about 85% showed a thin bony wall and 14% exhibited a thick bony level. The M4 demonstrated very thin bony wall and about 75% thin bony wall and 23% showed thick bony wall. Males showed statistically significantly higher mean distance between cemento-enamel junction and alveolar crest (CEJ-AC) than females at the central as well as lateral incisors. To obtain good results, meticulous preoperative analysis is recommended. Thus, to chose an adequate treatment approach, the utilization of CBCT is recommended.

A Novel Method to Cover Metal Display in Implants Using a Modified Free Gingival Graft: A Case Report.

INTRODUCTION: Correction of an esthetic failure in the anterior esthetic zone is difficult, especially after placement of the final restoration. This case report describes a novel technique to cover metal display with a graft that combines the advantages of the free gingival and the subepithelial connective tissue grafts. CASE PRESENTATION: A patient presented to the author's private practice with marked metal display leading to compromised esthetics. To cover the metal display, it was decided to increase the amount of soft tissue surrounding the implant. A free gingival graft was obtained from the palate with two de-epithelialized extensions to ensure adequate blood supply and excellent color match. The graft was adapted to the recipient site, which included a previously prepared bed and two pouches. The pouches accommodated the de-epithelialized extensions. The clinical outcome exhibited superior results in both volume and quality of the gained soft tissue. CONCLUSION: The technique described in this case report could be considered as a method to cover metal display in the esthetic zone to improve the volume and quality of the tissue.