Early implant placement versus ridge preservation and delayed implant placement: Analysis of profilometric, clinician- and patient-reported outcomes from a two-centre RCT.

OBJECTIVES: To compare early implant placement (EP) to alveolar ridge preservation and delayed implant placement (ARP/DP) in terms of contour changes, along with clinician- and patient-reported outcome measures (PROMs) until the delivery of the implant-supported restoration. MATERIALS AND METHODS: Patients with a failing single tooth in the maxilla or mandible were recruited in two centres. After tooth extraction, patients were randomly assigned (1:1) to either EP or ARP/DP. At abutment connection and crown delivery, the buccal contour changes at 3 mm below the mucosal margin (primary outcome) along with clinician- (ease of treatment) and patient-reported outcomes were assessed using numeric rating scales and OHIP-14. RESULTS: A total of 46 patients were analysed. The mean buccal contour at abutment connection decreased by -1.2 ± 0.6 mm in group EP and -1.6 ± 0.8 mm in group ARP/DP (estimated mean difference; 0.45 [95%CI, -0.02; 0.94]; p = .061) with no significant differences between the groups. ARP/DP was consistently easier than EP across all stages of the surgery (estimated mean difference; 2.0 [95%CI, 1.3; 2.7] p < .001): during flap elevation (EP: 4.8 vs. ARP/DP: 1.6), implant placement (EP: 5.7 vs. ARP/DP: 2.2) and wound closure (EP: 3.4 vs. ARP/DP: 1.6). Both interventions improved quality of life but patients who underwent ARP/DP were significantly more satisfied at the time of crown delivery (ARP/DP: 9.6 vs. EP: 9.1, p = .02). CONCLUSIONS: EP and ARP/DP show no significant differences in buccal contour changes, aesthetics and patient-reported outcomes. However, ARP/DP is an easier procedure at all stages of the surgery compared to EP and could therefore be the preferred therapy for less experienced clinicians.

Accuracy of immediately placed implants using surgical guides from different 3-dimensional printers: An in vitro study.

AIM: The aim of this study was to evaluate the accuracy of 3-dimensional (3D)-printed surgical guides for fully guided immediate implants from different manufacturers. METHODS: Eighteen 3D printed fully guided surgical guides (split into 3 groups [n = 6] according to their manufacturer: Company, Desktop, or Lab), were used to place 72 implants (n = 24) in identical maxillary models. After placement, the mean global, angular, mesiodistal, buccopalatal, and vertical deviation at the platform and apex of the placed implants, relative to their preoperatively planned positions, was calculated. RESULTS: Significant differences in global apex deviation, angular deviation, mesiodistal apex deviation, and vertical platform and apex deviation were found between the Lab and Desktop groups (p ≤ 0.007). Significant differences in mesiodistal platform and apex deviation and buccopalatal apex deviation were also found between the Company and Desktop groups (p ≤ 0.005). Finally, significant differences in buccopalatal apex deviation, and vertical platform and apex deviation were found between the Company and Lab groups (p ≤ 0.003). Mean differences between guide groups across all parameters never exceeded 0.5 mm or 1°. CONCLUSIONS: The choice of 3D printer has a significant effect on the accuracy of fully guided immediate implants. However, the clinical relevance of these differences may be considered limited.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-Year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All were fully healed sites with a bucco-palatal bone dimension of at least 6 mm, and received an immediately restored single implant using a full digital workflow. Patients were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary endpoints were increase in BSP at T1 (immediately postop), T2 (3 months), T3 (1 year) and T4 (3 years) based on superimposed digital surface models. Secondary endpoints included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control group: 15 males, 15 females, mean age 50.1 years; test group: 14 males, 16 females, mean age 48.2 years) and 50 could be re-examined at T4. The changes in BSP over time were significantly different between the groups (p < .001). At T4, the estimated mean increase in BSP amounted to 0.83 mm (95% confidence interval [CI]: 0.58-1.08) in the control group and 0.48 mm (95% CI: 0.22-0.73) in the test group. The estimated mean difference of 0.35 mm (95% CI: 0.06-0.65) in favour of the control group was significant (p = .021). No significant differences between the groups could be observed in terms of patients' aesthetic satisfaction (p = .563), probing depth (p = .286), plaque (p = .676), bleeding on probing (p = .732), midfacial recession (p = .667), Pink Esthetic Score (p = .366) and Mucosal Scarring Index (p = .438). However, CMX resulted in significantly more marginal bone loss (-0.43 mm; 95% CI: -0.77 to -0.09; p = .015) than CTG. CONCLUSIONS: CTG was more effective in increasing buccal soft tissue profile and resulted in less marginal bone loss than CMX. Therefore, CTG remains the gold standard to increase soft tissue thickness at implant sites. CLINICAL TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT04210596).

Lateral bone augmentation with a composite graft covered with a stretched and pinned collagen membrane: A retrospective case series using cone-beam computed tomography.

AIMS: (1) To assess the effectiveness of the Sausage Technique™ when applied for lateral bone augmentation by multiple experienced clinicians; (2) To identify risk indicators for a poor outcome and to assess the need for adjunctive surgery. MATERIALS AND METHODS: All patients who had been treated with the Sausage Technique™ for lateral bone augmentation by three experienced surgeons between January 2019 and December 2021 were included in a retrospective case series. The Sausage Technique™ technique includes the use of autogenous bone chips and deproteinized bovine bone mineral (1:1 ratio), covered with a stretched and pinned collagen membrane. The increase in alveolar width between the pre-operative situation and 9 months was assessed at different levels on superimposed cone-beam CT scans. RESULTS: Twenty-five augmentations performed in 25 patients (17 males, 8 females, mean age 51 years) were available for evaluation. Mean alveolar width increased from 4.35 to 7.43 mm at 3 mm below the crest. The mean increase of 3.08 mm (95% CI 2.10-4.06; p < 0.001) was significant. The outcome of non-containing single implant sites was significantly worse than the outcome of other sites (MD 2.67 mm; p = 0.008). The need for regrafting was 4% and the need for soft tissue augmentation was 48%. Twenty percent of the patients needed soft tissue augmentation due to a lack of keratinized mucosa width, and 32% due to a lack of buccal convexity. The former was mainly needed at multiple implant sites, whereas the latter was mainly required at single implant sites. All implant survived and remained healthy until the final follow-up. CONCLUSION: The Sausage Technique™ is an effective bone augmentation technique. Non-containing single implant sites were associated with a poor outcome and adjunctive soft tissue augmentation was needed in about half of the patients.

A multi-centre randomized controlled trial on alveolar ridge preservation with immediate or delayed implant placement: Need for soft-tissue augmentation.

AIM: To assess the impact of the timing of implant placement following alveolar ridge preservation (ARP) on the need for soft-tissue augmentation (STA) and to identify the risk factors for horizontal and vertical soft-tissue loss. MATERIALS AND METHODS: Patients with a single failing tooth in the anterior maxilla (15-25) were treated at six centres. Following tooth extraction, they were randomly allocated to the test group (immediate implant placement, IIP) or control group (delayed implant placement, DIP). ARP was performed in both groups and implants were immediately restored with an implant-supported provisional crown. Six months after tooth extraction and ARP, a panel of five blinded clinicians assessed the need for STA on the basis of anonymized clinical pictures and a digital surface model. Lack of buccal soft-tissue convexity and/or mid-facial recession qualified for STA. Pre-operative and 6-month digital surface models were superimposed to assess horizontal and vertical soft-tissue changes. RESULTS: Thirty patients were included per group (test: 20 females, 10 males, mean age 53.1; control: 15 females, 15 males, mean age 59.8). The panel deemed STA as necessary in 24.1% and 35.7% of the cases following IIP and DIP, respectively. The difference was not statistically significant (odds ratio [OR] = 1.77; 95% confidence interval [CI] [0.54-5.84]; p = .343). Loss of buccal soft-tissue profile was higher following DIP (estimated mean ratio = 1.66; 95% CI [1.10-2.52]; p = .018), as was mid-facial recession (mean difference [MD] = 0.47 mm; 95% CI [0.12-0.83]; p = .011). Besides DIP, regression analysis identified soft-tissue thickness (-0.57; 95% CI [-1.14 to -0.01]; p = .045) and buccal bone dehiscence (0.17; 95% CI [0.01-0.34]; p = .045) as additional risk factors for mid-facial recession. Surgeons found IIP significantly more difficult than DIP (visual analogue scale MD = -34.57; 95% CI [-48.79 to -20.36]; p < .001). CONCLUSIONS: This multi-centre randomized controlled trial failed to demonstrate a significant difference in the need for STA between IIP and DIP when judged by a panel of blinded clinicians. Based on objective soft-tissue changes, patients with thin buccal soft tissues, with a buccal bone dehiscence and treated with a delayed approach appeared particularly prone to soft-tissue loss.

A Multi-Centre Randomized Controlled Trial Comparing Connective Tissue Graft with Collagen Matrix to Increase Buccal Soft Tissue Thickness: A Cone-Beam CT Analysis.

(1) Aim: a cross-linked porcine-derived collagen matrix (CMX) has been developed for soft tissue augmentation. Although this grafting material does not require a second surgical site, recent findings have indicated deeper pockets, more marginal bone loss and more midfacial recession in the short term when compared to connective tissue graft (CTG). Hence, the aim of the present study was to evaluate the safety of CMX based on buccal bone loss over a one-year period. (2) Methods: Patients who were missing a single tooth in the anterior maxilla were included, in whom the failing tooth had been removed at least 3 months prior and who presented a horizontal mucosa defect. All sites had a bucco-palatal bone dimension of at least 6 mm as assessed on Cone-Beam Computed Tomography (CBCT) to ensure complete embedding of an implant by bone. All patients received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. All surgeries were performed by means of full thickness mucoperiosteal flap elevation, placing CTG and CMX in contact with the buccal bone wall. Safety was assessed by evaluating the impact of CTG and CMX on buccal bone loss over a one-year period using superimposed CBCT scans. (3) Results: thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48) and 51 (control: 25; test: 26) could be analyzed for buccal bone loss. At 1 mm apical to the implant-abutment interface (IAI), most horizontal resorption was found pointing to 0.44 mm in the control group and 0.59 mm in the test group. The difference of 0.14 mm (95% CI: -0.17-0.46) was not statistically significant (p = 0.366). At 3 mm and 5 mm apical to the IAI, the difference between the groups was 0.18 mm (95% CI: -0.05-0.40; p = 0.128) and 0.02 mm (95% CI: -0.24-0.28; p = 0.899), respectively. Vertical buccal bone loss amounted to 1.12 mm in the control group and 1.14 mm in the test group. The difference of 0.02 mm (95% CI: -0.53-0.49) was not statistically significant (p = 0.926). (4) Conclusions: In the short term, soft tissue augmentation with CTG or CMX results in limited buccal bone loss. CMX is a safe alternative to CTG. Longer follow-up is needed to assess the impact of soft tissue augmentation on buccal bone.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 1-year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) at 1 year when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm, received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. The primary outcome was the increase in BSP at 1 year when compared with the pre-operative situation based on superimposed digital surface models. The changes in BSP over time were registered at a buccal area of interest reaching from 0.5 mm below the soft tissue margin to 4 mm more apical. Secondary outcomes included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50.1; test: 53% females, mean age 48.2). The increase in BSP at 1 year was 0.98 mm (98.3% confidence interval [CI]: 0.75-1.20) for CTG and 0.57 mm (98.3% CI: 0.34 to 0.79) for CMX. The mean difference of 0.41 mm (98.3% CI: 0.12 to 0.69) in favour of CTG was significant (p < .001). Based on an arbitrarily chosen threshold for success of 0.75 mm increase in BSP, 89.7% of the patients in the control group and 10% of the patients in the test group were successfully treated (odds ratio = 77.90; 95% CI: 13.52 to 448.80; p < .001). Sites treated with CMX demonstrated 0.89 mm (98.3% CI: 0.49 to 1.30) more shrinkage between postop and 1 year than sites treated with CTG. In addition, CMX resulted in significantly more marginal bone loss (0.39 mm; 95% CI: 0.05 to 0.74; p = .026) than CTG. There were no significant differences between the groups in terms of patients' aesthetic satisfaction (p = .938), probing depth (p = .917), plaque (p = .354), bleeding on probing (p = .783), midfacial recession (p = .915), Pink Esthetic Score (p = .121) and Mucosal Scarring Index (p = .965). CONCLUSIONS: CTG remains the gold standard to increase soft tissue thickness at implant sites. Clinicians need to outweigh the benefits of CMX against considerable resorption of the graft. This study was registered in ClinicalTrials.gov (NCT04210596).

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.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-month results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of changes over time in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm and received a single implant and immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary outcome was increase in BSP at T1 (immediately after operation) and T2 (3 months) based on superimposed digital surface models. Secondary parameters included patient-reported clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48). Even though surgeons applied thicker grafts when using CMX, sites treated with CMX demonstrated 0.78 mm (95% CI 0.41-1.14) more shrinkage between T1 and T2 than sites treated with CTG. The final increase in BSP was 1.15 mm (95% CI 0.88-1.43) for CTG and 0.85 mm (95% CI 0.58-1.13) for CMX. The mean difference of 0.30 mm (95% CI -0.01 to 0.61) at T2 in favour of CTG was of borderline significance (p = .054). There were no significant differences between the groups in terms of post-operative bleeding (p = .344), pain (p = .331), number of analgesics taken (p = .504), oedema (p = .227), and pink aesthetic score (p = .655). VAS for post-operative haematoma was 6.56 (95% CI 0.54-12.59) lower for CMX, and surgery time could be reduced by 9.03 min (95% CI 7.04-11.03) when applying CMX. However, CMX resulted in significantly more marginal bone loss (0.38 mm; 95% CI 0.15-0.60), deeper pockets (0.30 mm; 95% CI 0.06-0.54), and more mid-facial recession (0.75 mm; 95% CI 0.39-1.12) than CTG. CONCLUSIONS: CTG remains the gold standard for increasing soft tissue thickness at the buccal aspect of implants.

A multicenter cohort study on the association of the one-abutment one-time concept with marginal bone loss around bone level implants.

OBJECTIVES: To investigate the association of the one-abutment one-time concept with marginal bone loss (MBL) around bone-level implants in relation to other factors. MATERIALS AND METHODS: Records from patients treated by four experienced implant surgeons between January 2016 and July 2019 were scrutinized. Subjects treated with two bone-level implant types with varying machined collar (subgroups: 0.5 and 0.8 mm) were considered, receiving a healing abutment (HA cohort) or a permanent abutment at the time of surgery (OT cohort). The primary outcome was MBL registered at 3 months and the longest follow-up. A clustered two-part regression model for semicontinuous data was used. RESULTS: Data pertaining to 160 patients (92 females, mean age 54) and 344 implants (125 in HA cohort, 219 in OT cohort) were available for evaluation. Mean MBL amounted to 0.52 mm (SD 0.68) after a mean follow-up of 20 (SD 9.2) months, with 33.8% of the implants showing complete bone preservation and 5.0% demonstrating >2mm MBL. OT was not related to the presence of MBL using MBL as dependent binary variable (0: no MBL; 1: MBL irrespective of its magnitude). However, OT significantly reduced the magnitude of MBL with 0.300mm when compared to HA (p = .023) in the cases where MBL was detected. Subgroup (p = .212), smoking (p = .789), history of periodontitis (p = .839), type of edentulism (p = .054), implant surgeon (p = .079), patient compliance (p = .617), and follow-up (p = .443) failed to show a significant association with MBL in the regression model. Ninety-eight % of the implants survived. CONCLUSION: Within the limitations of a cohort study, the one-abutment one-time concept was associated with a decrease in MBL at implant sites with bone loss. Therefore, the placement of a permanent abutment at the time of surgery seems relevant to limit marginal bone-level alterations.

A randomized controlled study comparing guided bone regeneration with connective tissue graft to reestablish buccal convexity at implant sites: A 1-year volumetric analysis.

OBJECTIVES: To volumetrically compare guided bone regeneration (GBR) with connective tissue graft (CTG) to reestablish convexity at the buccal aspect of single implants. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal alveolar defect were enrolled in a single-blind randomized clinical trial (RCT). All sites had a buccopalatal bone dimension of at least 6 mm, received a single implant, and were randomly allocated to the control (GBR) or test group (CTG) to reestablish buccal soft tissue convexity. Patients received a provisional crown at 3 months and a permanent crown at 6 months. Primary outcomes were volumetric increase (mm3 ) and linear increase (mm) in buccal soft tissue profile (BSP) within a well-defined area of interest at fixed time points. Alveolar process deficiency was a secondary outcome. RESULTS: Twenty-one patients were included per group (control: 11 females, mean age 51; test: 9 females, mean age 48). After 1 year, GBR resulted in a significant volumetric increase of 20.74 mm3 (P < .001) corresponding to linear increase in BSP of 1.30 mm (P < .001). For CTG, this was 15.86 (P < .001) and 1.19 mm (P < .001), respectively. The changes over time in volume (P = .173) and BSP (P = .241) were not significantly different between the groups. Twenty-nine percentage and 26% of the final volumetric increase was the result of installing and altering prosthetic components in the control and test groups, respectively. Alveolar process deficiency significantly reduced from pre-op to 1 year following GBR (P < .001) and CTG (P < .001). The difference between the groups was not significant (P = .342). However, 58% of the patients treated with GBR and 38% treated with CTG failed to show perfect soft tissue convexity at the buccal aspect. CONCLUSION: GBR as well as CTG are effective in reducing horizontal alveolar defects for aesthetic purposes. However, in about half of the cases, either strategy failed to optimally reestablish buccal convexity.

A 3-Year Prospective Study on a Porcine-Derived Acellular Collagen Matrix to Re-Establish Convexity at the Buccal Aspect of Single Implants in the Molar Area: A Volumetric Analysis.

BACKGROUND: Xenogeneic soft tissue substitutes are currently being investigated as an alternative to subepithelial connective tissue grafts (CTG) with the intention to avoid postoperative morbidity associated with autologous grafting. The aim of the present study was to volumetrically evaluate the effectiveness and mid-long-term stability of a porcine-derived collagen matrix (PDCM) (Mucoderm®, Botiss gmbh, Berlin, Germany) in increasing soft tissue volume at the buccal aspect of molar implant sites. METHODS: Periodontally healthy non-smoking patients with a single tooth gap in the molar area were selected for a prospective case series. All sites had a bucco-oral bone dimension of at least 8 mm and demonstrated a horizontal alveolar defect. A wide diameter implant was placed under the elevated buccal flap and a PDCM was applied. The primary outcome was the linear increase in buccal soft tissue profile (BSP) within a well-defined area of interest. This was performed with designated software (SMOP; Swissmeda AG, Zurich, Switzerland) on the basis of superimposed digitalized study casts taken before surgery (T0), immediately after surgery (T1), at three months (T2), one year (T3) and three years (T4). Secondary outcomes were alveolar process deficiency and clinical parameters. RESULTS: Fourteen out of 15 treated patients attended the three-year re-assessment (four females; mean age 51.4 years). Mean linear increase in BSP at T1 was 1.53 mm (p = 0.001). The PDCM showed substantial resorption at T2 (1.02 mm or 66.7%) (p = 0.001). Thereafter, a 0.66 mm volume gain was observed (p = 0.030), possibly due to the installation of a permanent crown displacing the soft tissues to the buccal aspect. This resulted in a linear increase in BSP of 1.17 mm (76.5%) at T4. Alveolar process deficiency significantly reduced over time (p = 0.004). However, 50% of patients still demonstrated a slight (6/14) or obvious (1/14) alveolar process deficiency at study termination. Implants demonstrated healthy clinical conditions. CONCLUSIONS: The PDCM demonstrated marked resorption during the early stages of healing. Due to the matrix thickening the tissues, and the permanent crown displacing the tissues, 76.5% of the initial increase in BSP could be maintained over a three-year period. Half of the patients failed to show perfect soft tissue convexity at the buccal aspect.

A randomized controlled study comparing guided bone regeneration with connective tissue graft to re-establish buccal convexity: One-year aesthetic and patient-reported outcomes.

OBJECTIVES: To compare guided bone regeneration (GBR) with connective tissue graft (CTG) in terms of aesthetic and patient-reported outcomes (PROMs). 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 buccopalatal bone dimension of at least 6 mm, received a single implant and were randomly allocated to the control (GBR) or test group (CTG) to re-establish buccal soft tissue convexity. Primary outcomes were Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI) assessed after 1 year. Secondary outcomes included PROMs registered during the early stages of healing and after 1 year. RESULTS: Twenty-one patients were included per group (control: 11 females, mean age 51; test: nine females, mean age 48). Although there was no significant difference in the PES between the groups (control: 10.11; test: 10.48; p = .577), the MSI was significantly lower in the test (1.10) than in the control group (2.53) (p = .017). Based on descriptive statistics, the latter demonstrated wider scars, more colour mismatch and slightly more suture marks. However, these were not considered disturbing by the patients given similar VAS on soft tissue aesthetics (control: 84; test: 87). Oedema and haematoma were rated twice as high in the control group on at least two postoperative time points, and patients took more painkillers (7.10 vs. 4.86). OHIP-14 decreased in both groups between baseline and 1-year follow-up, indicative of less discomfort in daily life. Differences in MSI and PROMs between the groups may be explained by the need of a vertical releasing incision in order to achieve sufficient access for GBR, periosteal incisions and the use of biomaterials that may induce inflammation. CONCLUSION: GBR and CTG resulted in favourable aesthetic outcomes as assessed by professionals and patients. However, given additional vertical and periosteal incisions, GBR resulted in more scarring, postoperative discomfort and a higher need for painkillers.

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.

A one-year prospective study on alveolar ridge preservation using collagen-enriched deproteinized bovine bone mineral and saddle connective tissue graft: A cone beam computed tomography analysis.

BACKGROUND: Although there is ample research on alveolar ridge preservation (ARP), changes of the soft tissue profile are seldom reported. In addition, the use of a saddle connective tissue graft (S-CTG) has only been described in one study. PURPOSE: To evaluate changes in bone and external soft tissue profile following ARP of intact and nonintact sockets using collagen-enriched deproteinized bovine bone mineral (C-DBBM) and a S-CTG (a); to assess the need for additional hard and soft tissue grafting after ARP (b). MATERIALS AND METHODS: Patients in need of a single or multiple unit fixed reconstruction in the premaxilla were included in this prospective case series. After tooth extraction, sockets were grafted with C-DBBM and sealed with a S-CTG. Cone beam computed tomography slides taken before tooth extraction and 4 to 6 months after ARP were superimposed to measure changes in bone dimensions and external soft tissue profile. The need for additional hard and soft tissue grafting was registered. Implants were evaluated at 1 year. Patient-reported outcomes were registered on a 100 mm visual analogue scale at suture removal and 1 year following ARP. RESULTS: Nineteen teeth (10 with intact sockets, 9 with nonintact sockets) in 14 patients (11 females; mean age 34) were extracted and treated with the abovementioned protocol. Volume loss could not be prevented and mainly occurred at the buccal aspect. Maximum horizontal bone resorption was 1.27 mm and maximum horizontal shrinkage of the soft tissue profile amounted to 0.87 mm, both at the most cervical aspect. Additional GBR was necessary in two sites with a nonintact buccal bone wall. The need for additional soft tissue grafting was moderate in sites with intact (3/10) and high in nonintact sockets (6/9). Implants demonstrated favorable clinical and esthetic outcomes. Pain intensity and patient satisfaction were 17 and 94, respectively. CONCLUSION: Alveolar ridge preservation was not able to prevent relevant tissue changes. However, implants could be installed as planned. Although the application of a S-CTG partly compensated for the buccal bone loss, the need for additional soft tissue grafting was still moderate in intact sockets and high in nonintact sockets.

A 2-year prospective case series on volumetric changes, PROMs, and clinical outcomes following sinus floor elevation using deproteinized bovine bone mineral as filling material.

BACKGROUND: A sinus floor augmentation may be indicated when a lack of hard tissue impedes implant placement. Although clinically successful, evidence supporting the long-term three-dimensional stability of the grafted volume is scarce. Second, evidence on the patient's acceptance of this type of treatment is limited. PURPOSE: First is to evaluate the changes in graft volume after lateral wall sinus lifting based on superimposed cone beam computed tomography (CBCT) images and then to assess patient-reported outcome measures (PROMs) and clinical outcomes. MATERIALS AND METHODS: Partially edentulous patients in need of a sinus lift and fixed reconstruction on at least two neighboring implants were selected for a prospective case series. Lateral wall sinus augmentation was performed using deproteinized bovine bone mineral (DBBM) as the only filling material. Volumetric changes were quantified on the basis of a preoperative CBCT and three postoperative CBCTs (at 2 weeks, 3 months, and 2 years). PROMs and clinical parameters were registered. RESULTS: Twenty-two patients (7 males, 15 females; mean age 59 years) participated of which three patients dropped out during the follow up. Graft volumes amounted to 1418.26 mm3 at 2 weeks, 1201.21 mm3 at 3 months, and 1130.13 mm3 at 2 years postoperative pointing to a relative graft volume stability of 79.7%. Swelling was the leading symptom during the first week. A peak in visual analogue scale scores was observed for pain, swelling, and hematoma the day of surgery and 1 day postoperation with a statistically significant decline between days 3 and 7. Hemorrhage and nose bleeding occurred in 18.2% and 27.3% of the subjects, respectively. About 95.5% of the subjects would undergo the treatment again. All implants integrated successfully and demonstrated healthy clinical conditions. CONCLUSION: Lateral wall sinus augmentation using DBBM as the only filling material is a viable treatment concept given limited graft resorption, good patients' tolerance, and clinical outcomes.

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.

A randomized controlled trial on the efficiency of free-handed, pilot-drill guided and fully guided implant surgery in partially edentulous patients.

OBJECTIVES: To compare the effectiveness of free-handed (FH), pilot-drill guided (PG) and fully guided (FG) implant surgery by means of the apical global deviation (AGD) in relation to the additional financial cost and time spent. MATERIALS AND METHODS: Thirty-three partially edentulous patients in need of ≥2 implants in the posterior maxilla were randomly allocated to one of the following treatment groups: FH, PG and FG. Eleven patients (mean age 57; eight females; altogether 26 implants) were treated by FH surgery, 11 (mean age 53; seven females; altogether 24 implants) by PG surgery and 10 (mean age 60; six females; altogether 21 implants) by FG surgery. The accuracy in implant positioning was assessed by comparing the actual implant position to its planned position with the AGD as the main measure of effectiveness. Cost analysis included data on time investment (pre- and per-operative) and operational cost. The efficiency of PG and FG surgery was assessed by means of the incremental cost-effectiveness ratio (ICER), defined as the extra investment that is needed per unit reduction in AGD when compared to FH surgery. RESULTS: FG surgery was most effective (mean AGD: 0.97 mm) and FH surgery was least effective (mean AGD: 2.11 mm) in terms of surgical accuracy. As a result, 5/26 implants had to be restored with a cement-retained restoration following FH surgery, although screw-retention was planned for all implants in every group. The total time investment did not differ significantly between the 3 groups (p = 0.811). A significant additional cost per implant was found for PG and FG as compared to FH surgery pointing to 8.29% (€176.54) and 10.45% (€222.52), respectively (p < 0.001). The ICER revealed an additional cost of €5.48 and €4.12 per per cent reduction in AGD for PG and FG surgery, respectively. CONCLUSION: The extra operational cost for guided implant surgery is acceptable and clinically justified since cementation can be avoided. FG surgery is the most efficient surgical approach, even though the absolute operational cost is higher when compared to PG and FH surgery.

A 5-year prospective study on the clinical and aesthetic outcomes of alveolar ridge preservation and connective tissue graft at the buccal aspect of single implants.

AIM: To evaluate the 5-year aesthetic outcome of single implants following alveolar ridge preservation (ARP) and connective tissue graft (CTG) at the buccal aspect. MATERIALS AND METHODS: Thirty-seven periodontally healthy non-smoking patients received flapless tooth extraction, ARP with a deproteinized bovine bone mineral with 10% collagen (DBBMC), implant placement (4-6 months later), a provisional screw-retained crown and CTG at the buccal mucosa (3 months later) and a permanent crown (3 months later). The aesthetic results were the primary outcome and the clinical results the secondary outcome of the study. Both outcomes were compared to those after 1 year. Mucosal thickness (MT) was registered using a non-invasive ultrasonic device. RESULTS: Thirty-two patients attended the 5-year re-assessment, and all implants survived. Mean marginal bone loss was 0.53 mm at 1 year and 0.47 mm at 5 years (p = 0.439). Mesial Papilla showed a further re-growth between 1 and 5 years (p = 0.043). Mid-facial recession amounted to 0.05 mm and 0.12 mm at 1 and 5 years, respectively (p = 0.161). The Pink Esthetic Score was 11.00 and 11.17 at 1 and 5 years, respectively (p = 0.596). MT gain amounted to 0.97 mm (relative stability: 90.5%) and 0.91 mm (relative stability: 85%) at 1 and 5 years, respectively (p = 0.249). CONCLUSION: ARP and CTG resulted in favourable clinical and aesthetic outcomes. CTG substantially increased MT with acceptable stability over a 5-year period.

A randomized controlled study comparing guided bone regeneration with connective tissue graft to re-establish convexity at the buccal aspect of single implants: A one-year CBCT analysis.

AIM: To compare guided bone regeneration (GBR) with connective tissue graft (CTG) to re-establish convexity at the buccal aspect of single implants. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal alveolar defect were enrolled in a single-blind randomized controlled trial. Sites had to demonstrate buccopalatal bone dimension of at least 6 mm prior to surgery to ensure complete embedding of an implant without the need for bone augmentation. All received a single implant and were randomly allocated to the control group (GBR) or the test group (CTG). Cross-sectional CBCT images at t0 (before surgery), t1 (2 weeks after surgery) and t2 (1 year after surgery) were used to evaluate the buccal soft tissue profile (BSP). Secondary outcome variables were buccal bone thickness (BB), buccal soft tissue thickness (BST), vertical bone loss (VBL) and clinical parameters. RESULTS: Twenty-one patients were included per group (control: 11 females, mean age: 51; test: nine females, mean age: 48). At t2 , a significant increase in BSP between 0.7 and 1.5 mm was observed in each group (p ≤ 0.010). There was no significant difference between the groups at 1 year (p ≥ 0.126). The increase in BSP in the control group was basically the result of BB gain ranging from 0.69 to 1.15 mm. BSP gain in the test group was the result of an increase in BST ranging from 0.67 to 1.38 mm. VBL did not differ significantly between the groups (p ≥ 0.644). Implants demonstrated healthy clinical conditions with no significant differences between the groups for any of the parameters (p ≥ 0.095). CONCLUSION: Within the limitations of superimposed CBCT images, GBR and CTG are effective to re-establish convexity at the buccal aspect of single implants in the short term.