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

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

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

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

A 5 to 7-year case series on single angulated implants installed following papilla-sparing flap elevation.

BACKGROUND: Bony concavities at the buccal aspect may cause a distortion between the implant axis and ideal prosthetic axis. Angulated implants can overcome this problem, yet long-term data are lacking. In addition, papilla-sparing incisions have been proposed to reduce tissue loss, yet aesthetic outcomes have not been published. PURPOSE: To evaluate the 5 to 7-year outcome of single angulated implants installed following papilla-sparing flap elevation. MATERIALS AND METHODS: Patients who had been consecutively treated with a single angulated implant (Co-axis®, Southern Implants, Irene, South Africa) in the anterior maxilla were re-examined after 5 to 7 years. Available data at 1 year (T1) were compared to those obtained at 5 to 7 years (T2). RESULTS: Twenty out of 22 treated patients (11 females, 9 males, mean age of 52) with 22 implants attended the 5 to 7-year reassessment. All implants survived and stable clinical conditions could be reached with mean marginal bone loss of 1.28 mm at T2. Papilla-sparing flap elevation resulted in Pink Esthetic Score of 9.83 at T1 and 8.23 at T2 (p = 0.072). Mucosal Scarring Index was 4.61 at T1 and 3.50 at T2 (p = 0.165). The overall appearance of scarring significantly improved over time (p = 0.032), yet 59% of the cases still demonstrated scarring at T2.c CONCLUSIONS: Within the limitations of the study, angulated implants (Co-axis®, Southern Implants) reached stable clinical conditions. Papilla-sparing incisions may not be recommended in aesthetically demanding patients due to high risk of scarring.

A 5-year cohort study on early implant placement with guided bone regeneration or alveolar ridge preservation with connective tissue graft.

PURPOSE: To assess on the one hand the 5-year outcome of early implant placement with guided bone regeneration (EIP/GBR) and on the other hand of alveolar ridge preservation with late implant placement and connective tissue graft (ARP/CTG). MATERIALS AND METHODS: Patients who had been treated with a single implant in the anterior maxilla in 2014 were selected for reevaluation in 2019. In the EIP/GBR cohort, implants were installed 4 to 8 weeks following extraction and the buccal contour was overbuilt by means of GBR. In the ARP/CTG cohort, collagen-enriched deproteinized bovine bone mineral was applied at the time of extraction and implants were installed 5 months later. All ARP/CTG cases received a buccal CTG 3 months after implant installation to reestablish buccal convexity. Primary outcomes were the pink esthetic score (PES) (Belser et al 2009) and the mucosal scarring index (MSI) (Wessels et al 2019). Clinical and radiographical parameters were secondary outcomes. RESULTS: Eighteen patients (9 females; mean age 52) in the EIP/GBR cohort, and 20 patients (9 females; mean age 38) in the ARP/CTG cohort were evaluated. PES was 6.28 following EIP/GBR. A (nearly) perfect aesthetic outcome defined as PES ≥8 was found in 3/18 cases. Perfect root convexity / soft tissue color and texture seemed most difficult to achieve. PES was 7.80 following ARP/CTG. A (nearly) perfect aesthetic outcome was found in 11/20 cases. MSI was 2.94 following EIP/GBR with 14/18 cases showing scarring. MSI yielded 0.50 following ARP/CTG with 6/20 cases showing scarring. In both cohorts, all implants survived, and none had developed periimplantitis. However, implants in the ARP/CTG cohort demonstrated a 5.4 times higher risk for periimplant mucositis than implants in the EIP/GBR cohort at 5 years follow-up. CONCLUSION: EIP/GBR and ARP/CTG showed acceptable long-term outcomes. The aesthetic outcome was particularly favorable following ARP/CTG, yet this should be interpreted with caution due to selection bias and because soft tissue grafting was not performed in the EIP/GBR cohort. Randomized controlled trial (RCTs) comparing EIP with ARP are required to assess the need for soft tissue grafting and to evaluate clinical, aesthetic, volumetric, and patient-reported outcomes. Only on the basis of such studies clinical recommendations can be made.

Long-Term Follow-up on Root Coverage with a Double Pedicle Flap and Connective Tissue Graft.

Partial-thickness double pedicle flap and connective tissue graft (CTG) is a procedure to treat single gingival recession in the anterior mandible. However, long-term data have not been reported. Patients who had been treated by the same periodontist in a private practice in Belgium between 2002 and 2009 were invited to return for a clinical examination in 2017. Seventeen patients (15 females, 2 males; mean age: 34.6 years) with a total of 23 treated single recessions were reexamined after 8 to 15 years of follow-up. Between 1 and 8 to 15 years of follow-up, mean and complete root coverage did not differ and amounted to 75% and 44% at study termination, respectively (P = .204). The esthetic outcome was mediocre, given a final mean root coverage esthetic score of 6.52. The Mucosal Scarring Index demonstrated a significant reduction in scarring between 1 and 8 to 15 years of follow-up; however, 31% of the cases still demonstrated some scarring in the end. Patients were less critical than clinicians, as they expressed high esthetic (mean: 81) and low scarring (mean 14) scores on visual analog scales. Partial-thickness double pedicle flap and CTG is an effective root-coverage procedure. However, alternative techniques may need to be considered for esthetically demanding patients.

The Mucosal Scarring Index: reliability of a new composite index for assessing scarring following oral surgery.

OBJECTIVES: A critical and uniform assessment of mucosal scarring following oral surgery is needed to refine surgical decision-making. For that purpose, the Mucosal Scarring Index (MSI) was developed. MATERIALS AND METHODS: The MSI is a composite index based on five parameters: width, height/contour, color, suture marks, and overall appearance. Each parameter is assessed with a 0-1-2 score, yielding a MSI score ranging from 0 (no scar) to 10 (most extreme scar). Five periodontists, 5 prosthodontists, and 5 orthodontists assessed scarring using the new index on the basis of 30 clinical photographs of post-surgical sites. Cases had been carefully selected making sure that the complete spectrum of the index would be represented in the analysis. Duplicate evaluation was performed with a 2-h interval and in random order of cases. RESULTS: On a total of 450 assessments, the mean MSI amounted to 4.91 (SD 3.087) with no significant differences between scores given by periodontists (mean 4.65; SD 3.054), orthodontists (mean 5.04; SD 3.301), or prosthodontists (mean 4.81; SD 2.842) (p = 0.548). The MSI appeared a highly reliable index given excellent inter- as well as intra-examiner agreement (ICC > 0.9; p < 0.001). Clinicians agreed most on 'overall appearance' (kappa = 0.582; p < 0.001) and least on 'suture marks' (kappa = 0.352; p < 0.001). CONCLUSION: The MSI is an effective, easy-to-use, and reliable composite index to assess mucosal scarring following oral surgical procedures. CLINICAL RELEVANCE: The MSI can be used as an adjunct to other indices in the esthetic evaluation of oral surgical procedures.