Minimal invasiveness in the alveolar ridge preservation, with or without concomitant implant placement.

The aim of this systematic review was to evaluate the benefit of ridge preservation (RP) with minimally invasive (MI) approaches with or without concomitant implant placement on morbidity, esthetics, and patient-related outcomes. Three Internet sources were used to search for appropriate papers. The search strategy was designed to include any clinical study published on RP with MI approaches such as flapless surgery, socket shield and socket sealing techniques and, use of biological agents. Characteristics of the individual studies, regarding methodological aspects, quantitative and qualitative data were extracted. The potential risk of bias was estimated, and the acquired evidence was graded. Independent screening of 860 reports resulted in 26 included original articles. Nine publications evaluated MI approaches for RP without concomitant implant placement. Eleven studies evaluated interventions for RP with immediate implant placement (IIP). Six studies compared RP with IIP vs RP without IIP. This systematic review found that MI approaches in most of the studies failed to improve clinical variables regarding morbidity, esthetics, and patient-related outcomes. Based on the limited number of studies analyzed and the methodological discrepancies observed, it is not possible to confirm that MI approaches promote a significant benefit when applied to RP procedures.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5-year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes.

AIM: Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 5 years after gingival recession therapy. MATERIALS AND METHODS: In 18 patients contributing 36 RT1 recessions, study models were collected at baseline and follow-ups. Optical scans assessed recessions computer-assisted [recession depth, recession reduction (RECred), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used for aesthetic evaluation and visual analogue scales for patient-centred data collection applied. RESULTS: Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG: 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG: 0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99). The study failed to find significant differences related to patient-centred outcomes (TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136). CONCLUSIONS: Five years after treatment, CTG resulted in better clinical and aesthetic outcomes than CAF+EMD. Increased THK was associated with improved outcomes for RECred and RC.

The socket-shield technique: a step-by-step protocol after 12 years of experience.

The socket-shield technique, first published in 2010, has gained worldwide scientific and clinical acceptance. To address possible complications with this innovative approach in esthetic implant dentistry, we provide a comprehensive step-by-step protocol incorporating what we have learnt in the past decade. After initial decoronation of the tooth, the implant bed is prepared through the root of the tooth to be extracted. Following extraction of the palatal root fragments, the shield is prepared according to either a mechanical or biologic 'locking' principle. The mechanical 'locking' comprises a direct contact between the implant and the shield, whereas the biologic approach facilitates ankylosis of the shield, preventing its coronal displacement. The coronal part of the shield is brought into a concave shape, ending up 0.5 mm coronal to the buccal bone. The implant is consequently inserted, and an individualized healing cap fabricated. When performed according to the underlying biologic and mechanical principles, the socket-shield technique can provide highly esthetic and predictable outcomes.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 2-year results of an RCT using 3D digital measuring for volumetric comparison of gingival dimensions.

AIM: The aim of this randomized clinical trial was to compare clinical and volumetric outcomes of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 2 years after gingival recession (GR) treatment. MATERIALS AND METHODS: Twenty-three patients contributed 45 Miller class I or II GR. At baseline and follow-up examinations, study models were collected. Their three-dimensional scans allowed precise computer-assisted measurement of recession depth (REC), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness. Clinical examination delivered probing depths (PPD) and height of keratinized tissue. RESULTS: 24 months after surgery, digitally evaluated CRC was present in 60.0% of the TUN + CTG and 0.0% of the CAF + EMD-treated sites (p < .0001), meaning a certain relapse of the gingival margin ragarding both approaches. RC amounted to 94.0% (TUN + CTG) and 57.3% (CAF + EMD), respectively (p < .0001). REC reduction (RECred) was significantly higher for TUN + CTG (1.81 ± 0.56 mm) than for CAF + EMD (0.90 ± 0.45 mm) (p < .0001). pTHK and aTHK values were significantly greater in the TUN + CTG group (1.41 ± 0.35 mm and 1.11 ± 0.26 mm) than in the CAF + EMD group (0.78 ± 0.32 mm and 0.60 ± 0.26 mm) (p < .0001). Statistical analysis detected positive correlations between THK and both RC and RECred (p < .001). CONCLUSIONS: Two years post-operatively, CTG showed better clinical and volumetric outcomes than EMD. Increased THK values were associated with improved outcomes regarding RC and RECred.

Surgery without papilla incision: tunneling flap procedures in plastic periodontal and implant surgery.

Diverse clinical advancements, together with some relevant technical innovations, have led to an increase in popularity of tunneling flap procedures in plastic periodontal and implant surgery in the recent past. This trend is further promoted by the fact that these techniques have lately been introduced to a considerably expanded range of indications. While originally described for the treatment of gingival recession-type defects, tunneling flap procedures may now be applied successfully in a variety of clinical situations in which augmentation of the soft tissues is indicated in the esthetic zone. Potential clinical scenarios include surgical thickening of thin buccal gingiva or peri-implant mucosa, alveolar ridge/socket preservation and implant second-stage surgery, as well as soft-tissue ridge augmentation or pontic site development. In this way, tunneling flap procedures developed from a technique, originally merely intended for surgical root coverage, into a capacious surgical conception in plastic periodontal and implant surgery. The purpose of this article is to provide a comprehensive overview on tunneling flap procedures, to introduce the successive development of the approach along with underlying ideas on surgical wound healing and to present contemporary clinical scenarios in step-by-step photograph-illustrated sequences, which aim to provide clinicians with guidance to help them integrate tunneling flap procedures into their daily clinical routine.

Wound closure and wound healing. Suture techniques in contemporary periodontal and implant surgery: Interactions, requirements, and practical considerations.

In contemporary reconstructive periodontal and implant surgery, attaining uncomplicated wound healing in the early postoperative healing phase is the key to achieving a successful treatment outcome and is of central interest, from the clinical as well as the scientific perspective. The realization of primary wound healing is the central challenge in most cases. Two of the evidence-based factors that affect postoperative wound healing can be influenced by the surgeon: the blood supply to the surgical site and postoperative wound stability. The surgical suture is a key determinant of whether adequate wound stability is achieved in this context without complicating the course of wound healing by exerting unnecessary trauma or excessive tensile strain on the wound edges. Therefore, the inclusion of anchors in the suturing process that make it possible to achieve the best wound stability possible is often an important key to success. This article provides an overview of the principles of successful wound closure that are relevant to postoperative wound healing in order to equip dentists with the tools needed for the correct, indication-specific selection and performance of surgical suturing techniques in daily practice.

Socket Shield Technique for immediate implant placement - clinical, radiographic and volumetric data after 5 years.

OBJECTIVES: Implant placement immediately after tooth extraction is often accompanied by resorption of surrounding tissues. A clinical technique was developed where the buccal portion of the root is retained to preserve the periodontal ligament and bundle bone. This technique is based on animal studies showing the potential to preserve the facial tissues utilizing this approach. The purpose of this study was to gain more insight regarding the safety of the technique with regard to biological and implant-related long-term complications and to observe the clinical appearance of the peri-implant tissues. Another objective was to evaluate volumetric changes of the affected facial contours in long-term and the esthetic outcomes. MATERIAL AND METHODS: This study is a retrospective case series of 10 consecutive patients with implant replacement between the maxillary first premolars. Impressions were made prior to extraction (t1) and 5 years post-implant placement (t2). 3D-surface scans of the casts were digitally superimposed for quantitative evaluation of alterations of the facial peri-implant tissue contours and soft tissue recessions. Additionally, clinical data were collected (PPD, BOP, peri-apical radiographs and photographs). RESULTS: All implants healed without adverse events. Peri-implant probing revealed healthy conditions. The comparison of radiographic images showed physiologic bone remodeling at the implant shoulders. Mean tissue loss on the facial side in oro-facial direction was -0.21 ± 0.18 mm. Average recession at implants was -0.33 ± 0.23 mm and at neighboring teeth -0.38 ± 0.27 mm. Mean loss of the marginal bone level at the implant shoulder amounted to 0.33 ± 0.43 mm at the mesial and 0.17 ± 0.36 mm at the distal aspect of the implants. A mean pink esthetic score of 12 was recorded. CONCLUSION: Volumetric analysis showed a low degree of contour changes from extraction and implant placement to the follow-ups. Mucosal recession at the implant restoration was comparable to that of the neighboring teeth. Within the limitations of this descriptive study, the socket shield technique offers reduced invasiveness at the time of surgery and high esthetic outcomes with effective preservation of facial tissue contours. This technique should not be used in routine clinical practice until a higher level evidence in the form of prospective clinical trials is available.

Clinical Benefits of the Immediate Implant Socket Shield Technique.

OBJECTIVE: Extraction-socket resorption is considered a major problem that can limit implantological rehabilitation options and compromise the esthetic outcome. Surgical techniques to reduce remodeling are of restricted predictability and commonly require several surgical interventions and grafting. This increases the treatment cost and places a physical and psychological strain on the patient. This clinical case report presents a replacement of an upper canine using the socket-shield technique (SST) with a CAD/CAM surgical guide, resulting in a predictable, high esthetic, and functional result. CLINICAL CONSIDERATIONS: The SST is an alternative approach to curbing remodeling and resorption by retaining the facial part of the root during tooth extraction. An immediately placed implant supports the facial root fragment, preventing the collapse of the buccal wall. The SST with digital precision planning in combination with a CAD/CAM surgical guide benefits patients by preserving their tissue architecture and causing only insignificant trauma. Furthermore, the SST reduces the number of surgical and prosthetic interventions required to one each for pre-operative planning, surgical procedures, and prosthetic rehabilitation. CONCLUSIONS: The socket shield technique is a minimally invasive implantological approach offers patients and clinicians multiple benefits. CLINICAL SIGNIFICANCE: The socket-shield technique (SST) represents an alternative approach to intervene remodeling and resorption processes by the maintenance of the facial part of the root during tooth extraction. The immediate placement of an implant supports the facial root fragment and thereby prevents a collapse of the buccal wall. The SST associated with a CAD/CAM fabricated surgical guide, can reduce the amount of appointments, due to the immediate fabrication of the definitive restoration with the existing model. Therefore, no further necessary appointments are required apart from first pre-operative planning, second for surgical treatment, and third for prosthetic rehabilitation. (J Esthet Restor Dent 29:93-101, 2017).

Replacement of mandibular central incisors with implant-supported crowns: a case report.

Anterior teeth are often affected by accidental dental trauma and may eventually be lost. When the neighboring teeth are unharmed, implant-supported crowns are often the preferred treatment choice. When not only the teeth but also the supporting hard and soft tissue has been lost, surgical reconstruction may be needed. However, in combined horizontal and vertical class III defects, the available augmentation techniques are often not predictable. In this case report, two neighboring mandibular central incisors were replaced by two implants after soft and hard tissue augmentation with the cortical bone plate method. The interdental soft tissue was reconstructed with remarkable success, making this an example of what can be achieved in cases such as this.

Experimental Peri-Implantitis around Different Types of Implants - A Clinical and Radiographic Study in Dogs.

BACKGROUND: The influence of the implant micro and macrostructure on peri-implantitis is not fully understood. PURPOSE: To determine the effect of ligature-induced peri-implantitis on three commercially available implant types. MATERIALS AND METHODS: Five beagle dogs were used. Two months following tooth extraction, three different implant types (BIOMET 3i T3, BIOMET 3i, Palm Beach Gardens, FL, USA; Straumann Bone Level, Straumann GmbH, Basel, Switzerland; Nobel Replace Tapered, Nobel Biocare, Gothenburg, Sweden) were placed in a randomized fashion in each hemi-mandible. Peri-implantitis was initiated by ligature placement and soft diet. Ligatures were added every 2 weeks for a total of four ligature advancements. After 2 weeks, the ligatures were removed, oral hygiene measures initiated for 3 weeks, and clinical (probing depth, mucosal recession, bleeding on probing), intrasurgical (intrasurgical defect depth, intrasurgical defect width), and radiographic (radiographic bone level) parameters assessed. RESULTS: Nobel Replace Tapered implants showed significantly higher intrasurgical defect depth, intrasurgical defect width, probing depths, and radiographic bone level when compared to BIOMET 3i T3 or Straumann Bone Level implants. Straumann Bone Level implants showed largely similar clinical outcomes to BIOMET 3i T3. No significant differences between the groups were observed for mean mucosal recession. CONCLUSION: In an experimental peri-implantitis model, Nobel Replace Tapered implants are associated with pronounced tissue loss.

Porcine dermal matrix in the treatment of dehiscence-type defects--an experimental split-mouth animal trial.

OBJECTIVES: To describe histometrical outcomes (tissue thickness, tissue height) of a porcine dermal matrix (PDX) and subepithelial connective tissue (CTG) in the treatment of dehiscence-type defects. MATERIAL AND METHODS: In five beagle dogs buccal dehiscence defects were created on both upper canines. The defects were covered in a split-mouth design either with a porcine dermal matrix or subepithelial connective tissue. After 4 months histometrical outcomes were evaluated using a nonparametric Brunner-Langer model. RESULTS: Neither in the test nor in the control specimen signs of inflammation or foreign body reaction was detected. Histometrically, no significant difference was found for tissue thickness and height between both treatment groups. CONCLUSIONS: Porcine dermal matrix can be used for grafting of dehiscence-type defects. Augmentation of tissue thickness seems to be comparable to subepithelial connective tissue.

The socket-shield technique: first histological, clinical, and volumetrical observations after separation of the buccal tooth segment ­ a pilot study.

BACKGROUND: The "socket-shield technique" has shown its potential in preserving buccal tissues. However, front teeth often have to be extracted due to vertical fractures in buccolingual direction. It has not yet been investigated if the socket-shield technique can only be used with intact roots or also works with a modified shield design referring to vertical fracture lines. PURPOSE: The aim of this study was to assess histologically, clinically, and volumetrically the effect of separating the remaining buccal root segment in two pieces before immediate implant placement. MATERIAL AND METHODS: Three beagle dogs were selected in the study. The third and fourth premolars on both sides of the upper jaw were hemisected and the clinical crown of the distal root was removed. Then, the implant bed preparation was performed into the distal root so that a buccal segment of healthy tooth structure remained. This segment was then separated in a vertical direction into two pieces and implants placed lingual to it. After 4 months of healing, the specimens were processed for histological diagnosis. In a clinical case, the same technique was applied and impressions taken for volumetric evaluation by digital superimposition. RESULTS: The tooth segments showed healthy periodontal ligament on the buccal side. New bone was visible between implant surface and shield as well as inside the vertical drill line. No osteoclastic remodeling of the coronal part of the buccal plate was observed. The clinical volumetric analysis showed a mean loss of 0.88 mm in labial direction with a maximum of 1.67 mm and a minimum of 0.15 mm. CONCLUSION: The applied modification seems not to interfere with implant osseointegration and may still preserve the buccal plate. It may offer a feasible treatment option for vertically fractured teeth.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part II. Volumetric studies on healing dynamics and gingival dimensions.

AIM: The aim of this randomized clinical trial (RCT) was to compare the clinical performance of the tunnel technique with subepithelial connective tissue graft (TUN) versus a coronally advanced flap with enamel matrix derivative (CAF) in the treatment of gingival recession defects. The use of innovative 3D digital measuring methods allowed to study healing dynamics at connective tissue (CT)-grafted sites and to evaluate the influence of the thickness of the root covering soft tissues on the outcome of surgical root coverage. MATERIAL & METHODS: Twenty-four patients contributed a total of 47 Miller class I or II recessions for scientific evaluation. Precise study models collected at baseline and follow-up examinations were optically scanned and virtually superimposed for digital evaluation of clinical outcome measures including mean marginal soft tissue thickness (THK). Healing dynamics were measured in a defined region of interest at CT-grafted sites where volume differences between time points were calculated. RESULTS: At 12 months, recession reduction as well as mean root coverage were significantly better at CT-grafted sites treated in the TUN group (1.94 mm and 98.4% respectively) compared to the non-augmented sites of the CAF group (1.17 mm and 71.8% respectively) and statistical analysis revealed a positive correlation of THK (1.63 mm TUN versus 0.91 mm CAF, p < 0.0001) to both these variables. Soft tissue healing following surgical root coverage with CT-grafting was mainly accomplished after 6 months, with around two-thirds of the augmented volume being maintained after 12 months. CONCLUSIONS: The TUN resulted in thicker gingiva and better clinical outcomes compared to CAF. Increased gingival thickness was associated with better surgical outcomes in terms of recession reduction and root coverage.

The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution.

Soft tissue replacement grafts have become a substantial element to increase tissue volume in plastic periodontal and implant surgery. Autogenous subepithelial connective tissue grafts are increasingly applied in aesthetic indications like soft tissue thickening, recession treatment, ridge preservation, soft tissue ridge augmentation and papilla re-construction. For the clinical performance of connective tissue graft harvesting and transplantation, a fundamental understanding of the anatomy at the donor sites and a sound knowledge of tissue integration and re-vascularization processes are required. Possible donor sites are the anterior and posterior palate including the maxillary tuberosity, providing grafts of distinct geometric shape and histologic composition. The selective clinical application of different grafts depends on the amount of required tissue, the indication and the personal preference of the treating surgeon. One of the main future challenges is to volumetrically evaluate and compare the efficacy and long-term stability of soft tissue autografts and their prospective substitutes. The aim of this review was to discuss the advantages and shortfalls of different donor sites, substitute materials and harvesting techniques. Although standardized recommendations regarding treatment choice and execution can hardly be given, guidelines for predictable and successful treatment outcomes are provided based on clinical experience and the available scientific data.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivative for root coverage: a RCT using 3D digital measuring methods. Part I. Clinical and patient-centred outcomes.

AIM: The aim of this randomized clinical trial (RCT) was to introduce 3D digital measuring methods for evaluating the outcomes after surgical root coverage (RC) and to assess the clinical performance of the tunnel technique with subepithelial connective tissue graft (TUN) versus the coronally advanced flap (CAF) with enamel matrix derivative in the treatment of shallow localized gingival recession defects. MATERIAL AND METHODS: Twenty-four patients contributed a total of 47 Miller class I or II recessions for scientific evaluation. Clinical outcomes were evaluated at 6 and 12 months. Precise study models gained at baseline and follow-up examinations were optically scanned and virtually superimposed for digital evaluation of clinical outcome measures including percentage of RC and complete root coverage (CRC). Patient-centred outcomes were evaluated with questionnaires. Final aesthetic outcomes were assessed using the root coverage esthetic score (RES). RESULTS: At 12 months, RC was 98.4% for TUN-treated and 71.8% for CAF-treated defects (p = 0.0004). CRC was observed in 78.6% (TUN) and 21.4% (CAF) of the cases (p = 0.0070). Results for patient-centred outcomes were equivalent for both groups but evaluation of the final aesthetic outcomes using the RES revealed a significant difference (9.06 versus 6.92, p = 0.0034) in favour of TUN. CONCLUSIONS: TUN resulted in significantly better clinical outcomes compared with CAF. The new measuring method provided high accuracy and unforeseen precision in the evaluation of treatment outcomes after surgical RC.

Pre-extractive interradicular implant bed preparation: case presentations of a novel approach to immediate implant placement at multirooted molar sites.

Immediate implant placement at multirooted molar sites involves a series of site-specific anatomical challenges, including implant bed preparation in the presence of interradicular bone septa. The aim of this article is to present and discuss a novel approach that gives improved guidance during implant bed preparation for immediate implants at multirooted extraction sites in both the mandible and maxilla. Following decoronation of the concerned teeth, osteotomies were performed directly through the teeth's initially retained root complexes. After completion of the drilling protocol, the remaining root aspects were extracted, and treatment was continued in the usual manner. With the osteotomy drills stabilized and guided by the retained root aspects, this approach allows for precise positioning and angulation of the implant bed preparation, thus enabling ideal implant positioning during immediate implant placement at multirooted extraction sites.

Bone loss after full-thickness and partial-thickness flap elevation.

OBJECTIVES: the aim of this study was to histologically assess whether elevation of partial-thickness flaps results in reduced bone alterations, as compared with full-thickness flap preparations. MATERIAL AND METHODS: in five beagle dogs, both mandibular second premolars (split-mouth design) were subjected to one of the following treatments: Tx1: elevation of a partial-thickness flap over the mesial root of P(2) and performing a notch at the height of the bone. Tx2: elevation of a full-thickness flap over the mesial root of P(2) and performing a notch at the height of the bone. After 4 months, sections were evaluated for: (i) vertical bone loss and (ii) osteoclastic activity using histometry. RESULTS: elevation of both full- and partial-thickness flaps results in bone loss and elevated osteoclastic activity. Partial-thickness flaps can result in less bone loss than full-thickness flaps, but are subject to some variability. CONCLUSION: use of partial-thickness flaps does not prevent from all bone loss. The procedure may result most of the times in less bone loss than the elevation of full-thickness flaps. Further research has to evaluate the determinants of effective outcomes of partial-thickness flap procedures.

Local tolerance and efficiency of two prototype collagen matrices to increase the width of keratinized tissue.

AIM: to evaluate the local tolerance and efficiency of two experimental collagen matrices to increase the width of keratinized tissue. METHODS: in 12 pigs, two apically positioned flaps were prepared on both sides of the mandible. The denuded defect areas were randomly covered with one of two experimental porcine-derived collagen matrices (M1; M2). The other defect area was left untreated (control). At 1 and 6 months, clinical measurements for the width and thickness of the keratinized tissue were recorded. At 6 months, all animals were sacrificed. Descriptive and semi-quantitative histologic analyses were performed. For statistical analysis, the Kruskal-Wallis test and the Mac Nemar test were applied. RESULTS: the collagen matrices integrated well into the surrounding tissue without any signs of inflammation. The thickness and width of the keratinized tissue increased significantly over 6 months in all the groups, resulting in slightly more favourable results for M1 (compared with M2) with respect to the thickness and for M2 (compared with M1) with respect to the width of keratinized tissue. No statistically significant differences were observed for any of the evaluated clinical and histologic parameters among the three treatment modalities. CONCLUSIONS: within the limits of this animal study, the prototype collagen matrices can be used safely to increase the width of keratinized tissue.