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Peri-Implant Soft Tissue Augmentation. Proper Timing and Surgical Procedure Izquierdo Orts, Rocío Candidate for the Master’S Degree for Predictable Surgical Outcomes

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Peri-Implant Soft Tissue Augmentation. Proper Timing and Surgical Procedure Izquierdo Orts, Rocío Candidate for the Master’S Degree for Predictable Surgical Outcomes Volver Bibliographic review Peri-Implant Soft Tissue Augmentation. Proper Timing and Surgical Procedure Izquierdo Orts, Rocío Candidate for the Master’s Degree for Predictable Surgical Outcomes. A in Oral Surgery and Implantology program at the Universidad Complutense de Madrid (UCM). Bibliographic Review Specialist in Dental Prostheses degree from the UCM. Visiting Professor in Pathology and Complex Dental Therapeutics, UCM. Bachelor’s in Published in spanish Científica Dental Vol. 15. Nº 3. 2018 Dentistry from the UCM. www.cientificadental.es Del Canto Díaz, Alejandra Master’s Degree in Dental Sciences, surgical site, such as a xenogeneic Universidad Complutense de ABSTRACT Madrid. Master’s Degree in collagen matrix, which can be equally Oral Surgery, Implantology and The role that the width of keratinized effective and predictable in outcome. Periodontics from the Universidad de León. Visiting Professor in mucosa (KM) surrounding dental implants Both a xenogeneic collagen matrix and Pathology and Complex Dental connective tissue grafting offer superior Therapeutics, UCM. Bachelor’s plays in the long-term stability of peri- in Dentistry from the UCM. implant tissues remains a topic for debate. aesthetic results to those achieved with Candidate for the Master’s Degree in Aesthetic Restorative Dentistry free gingival grafting. at the Universidad Internacional de The aim of this review is to evaluate Cataluña. and describe the outcomes of available Pérez González, Fabián surgical procedures and the proper timing Candidate for the Master’s Degree in Oral Surgery and Implantology for augmenting peri-implant soft tissue. at the Universidad Complutense de KEYWORDS Madrid. Bachelor’s in Dentistry from the UCM. A bibliographic search was conducted Dental implants; Connective tissue graft; on the online PubMed and Medline López-Quiles, Juan Mucograft; Peri-implant keratinized Director of the Master’s Degree databases, as well as a manual search for mucosa; Peri-implant soft tissue volume; program in Oral Surgery and Implantology at the Universidad relevant articles comprising the period Increased soft tissue. Complutense de Madrid. Associate between 2012 and 2017, selecting for Professor, Departamento de Facultad de Odontología, articles dealing with the various surgical Universidad Complutense de procedures performed starting at time B Madrid. (implant placement). Indexed in: - IME - IBECS A total of 10 articles was selected, - LATINDEX contrasting them in terms of the moment - GOOGLE SCHOLAR in time at which the surgical procedure was Correspondence address: performed while analyzing the following Rocío Izquierdo Orts study variables: keratinized mucosa width, Facultad de Odontología de la keratinized mucosa thickness, postoperative Universidad Complutense de Madrid (UCM). contraction, surgical timing, and aesthetic Plaza Ramón y Cajal s/n. outcome and postoperative discomfort. 28040 Madrid [email protected] Phone: 699078617 The conclusion may be drawn that free gingival grafting has been shown to result Date of receipt: 11 May 2018. Date of acceptance for publication: in the greatest widths of keratinized November 29, 2018. mucosa. However, there are other materials available that reduce patient morbidity and eliminate the need for a second cientÍFICA dentAL vol 16 (special supplement) 2019 45 INTRODUCTION of the attached mucosa can facilitate oral hygiene procedures, thus preventing peri-implant inflammation Long-term successful outcomes in dental implants and tissue degradation. Consequently, in order to depend not only on osseointegration of the implants prevent biological complications and improve long- in the surrounding bone tissue, but also on preserving term prognosis, the condition of soft tissues should the health and integrity of the surrounding soft tissues. be carefully evaluated when planning implant therapy. The soft tissue surrounding the teeth is subdivided Knowledge of the appropriate surgical procedure and into keratinized mucosa (KM) and immobile keratinized the most suitable timing for carrying it out appears to mucosa (attached mucosa, (AM)) separated by the be of the utmost clinical significance when considering 9 mucogingival junction. However, in implantology, peri- implant therapy . implant soft tissues are unevenly dealt with1,2. The Two methods for augmenting peri-implant soft tissue structure and composition of the peri-implant mucosa can be distinguished1,2: are organized into a well-keratinized oral sulcus followed by a long binding epithelium and an insertion 1. Augmented KM width: apical replacement of connective tissue (Figure). flaps (in combination with free gingival (FGG), allogeneic, or xenogeneic grafts). Despite many similarities, peri-implant tissues differ from the tissue surrounding the teeth in a number 2. Augmented KM thickness: subepithelial connective of ways, such as the amount of blood supply, the grafts, other soft tissue replacement grafts directionality of connective tissue fibers, the amount of (xenogeneic, allogeneic). fibroblasts and collagen fibers present, the permeability of the binding epithelium, and the presence of a In terms of optimal timing, four different loading minimum width of keratinized soft tissue attached to protocols for carrying out an augment in the width or the teeth1-3. thickness of the soft tissues around implants can be distinguished1,2: The role that the width of keratinized mucosa (KM) surrounding dental implants plays in the long-term a. Prior to implant placement. stability of peri-implant tissues remains a topic for b. During implant placement. debate4. c. During second surgery (2nd phase). Recent systematic reviews conclude that inadequate KM peri-implant width is associated with increased d. After the implant is osseointegrated, uncovered, plaque buildup, the presence of inflammation, soft and definitively loaded. tissue loss and insertion loss1-7. The aim of this study is to review the literature on the Also important for long-term success is the sealing of the available surgical procedures and the proper moment circumferential tissues around the implants; namely, in time at which to carry out an augment of peri-implant the early formation of an effective barrier capable of soft tissues in order to make the outcome predictable. biologically protecting peri-implant structures, thus preventing bacterial penetration and the progression A total of 10 articles, listed in Table 1, were included. of marginal bone loss8. Our review centered on describing the various In line with this view, scientific data and clinical augmentation procedures in use only once the implant reports seem to indicate that an adequate width has been placed; namely, procedures b, c, and d. 46 cientÍFICA dentAL vol 16 (special supplement) 2019 KERATINIZED MUCOSA (KM) In the case of connective tissue grafting (CTG), gains of 0.90 mm were observed. No statistically significant Whether or not there is a need for surgical intervention differences were found between the use of XCM (1.2 to augment the keratinized tissue surrounding implants mm) and CTG (0.9 mm) procedures in the Cairo et al. in patients with reduced or insufficient tissue width study14. remains controversial in the literature10. Time d: After the implant has been osseointegrated, On the one hand, several studies suggest that the uncovered, and definitively loaded. absence of KM in implants may favor peri-implant inflammation and recession. However, others find that In the articles reviewed, KM gains between 2.36 and there is insufficient evidence regarding the influence 4.05 mm were seen to be obtained using the FGG of KM width on the survival rate of KM implants and protocol. (15-16) Statistically significant differences 4 future recession . were obtained in favor of FGG (2.36 mm) with respect Regardless of medical opinion, although the absence of to VP (1.15 mm). (15) With respect to the CTG protocol, KM tissue may not justify surgery, in situations where KM width gain values ranging from 1.7 to 2.33 mm there is discomfort during brushing, poor control of were observed1,17. bacterial plaque, or persistent inflammation or aesthetic 18 alteration, the performance of soft tissue augmentation The data obtained by Zucchelli et al. resulted in a procedures around the implants may be advisable for gain of 0.57 mm when using coronal flap repositioning restoring health and peri-implant aesthetics. (CFR+CTG). Various surgical procedures and materials have been Lorenzo et al.11 observed KM width gains of 2.3 mm proposed to increase the amount of soft tissue around with the use of XCM. Comparing the outcome with dental implants11. the CTG and XCM procedure shows that there are no statistically significant differences between the two11,19. Surgical procedures for increasing the width of keratinized tissue can be divided into free grafting procedures, bilamellar procedures, use of an autograft, xenograft, or allograft along with a replacement flap, or flap/vestibuloplasty (VP) procedures. The results of the studies included are listed in Table 2. Time b: During the placement of implants. Bruschi et al.12 describe an apically repositioned partial-thickness flap (APPTF) procedure performed on patients who were to be treated with implants with the aim of increasing KM width. They reported a gain of 5.03 mm at one year and 5.14 mm at four years. Time c: Coinciding with second surgery (2nd phase) In the study comparing the use of a xenogeneic collagen matrix (XCM) with a free gingival graft (FGG), a gain of 7.76 mm
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