Midfacial Recession Research Articles

The Effect of Preformed Anatomic Provisional Restorations on Peri-Implant Mucosal Dimensions with Immediate Tooth Replacement Therapy.

Immediate Tooth Replacement Therapy (ITRT) has become popular due to its ability to reduce treatment time and provide immediate esthetic results. However, long-term challenges, such as mid-facial recession and labial bone resorption, have been reported. Anatomic temporary cylinders (ATC), which allow for efficient fabrication of provisional transitional restorations in the esthetic zone, were designed to mimic the natural emergence profile and guide mucosal tissue healing. This study examines the effect of ATCs on the fabrication of provisional restorations compared to conventional non-anatomic temporary cylinders (CTCs) in terms of peri-implant mucosal preservation and stability in patients undergoing ITRT using the dual-zone grafting technique. Parameters evaluated were peri-implant mucosal tissue thickness (PIMTT), Pink Esthetic Score (PES), and radiographic outcomes, including labial plate dimension (LPD). The use of ATCs resulted in a statistically significant increase in PIMTT compared to CTCs, suggesting better preservation of peri-implant mucosal architecture. Additionally, the ATC group exhibited a positive change in LPD, although this difference was not clinically significant. The findings indicate that ATCs may offer advantages in maintaining peri-implant mucosal stability, contributing to the esthetic and functional outcomes of implant-supported restorations. Further long-term studies are needed to validate these preliminary results. The use of anatomic temporary cylinders (ATC) in immediate tooth replacement therapy (ITRT) demonstrated improved peri-implant mucosal tissue thickness, suggesting enhanced maintenance of peri-implant mucosal architecture. This can contribute to healthier and more esthetic outcomes while potentially reducing the risk of complications such as mid-facial recession.

Feasibility of Immediate, Early and Delayed Implant Placement for Single Tooth Replacement in the Premaxilla: A Retrospective Cone-Beam Computed Tomography Study of 100 Cases.

To assess the feasibility of immediate (IIP), early (EIP) and delayed implant placement (DIP) for single tooth replacement in the premaxilla on the basis of the complete indication area of each approach in routine practice. Data from 100 patients (59 women, 41 men, all Caucasians) aged between 19 and 81 years old (mean age 51.71) who had been consecutively treated with a single implant in the premaxilla (13-23) in one private periodontal practice were retrospectively collected. Demographic data, diagnostic information and linear measurements were extracted from patient files and CBCTs. The feasibility of IIP, EIP and DIP was assessed for all cases by both authors, based on the following criteria: availability of apical bone, position of the tooth in relation to the morphology of the alveolar process, buccal bone morphology and presence of midfacial recession. The reasons for not being able to perform an approach, and the viable alternatives for each approach were secondary outcomes. DIP was considered to have been preceded by alveolar ridge preservation (ARP). Ninety-two patients could be treated by means of IIP, EIP or DIP. In eight patients none of these approaches were possible as they required bone augmentation prior to implant placement. Fifty-two patients (95% CI: 42%-62%) could by treated with IIP, 58 (95% CI: 48%-67%) with EIP and 88 (95% CI: 80%-93%) with DIP. The feasibility proportions of IIP and EIP were significantly lower than the one of DIP (p < 0.001). All patients who could be treated with IIP could also be treated with EIP or DIP. Lack of apical bone for implant anchorage was the main reason for not being able to perform IIP and EIP. Complete loss of the buccal bone wall and the need for bone augmentation prior to implant placement were the reasons for not being able to perform DIP. From the results of this retrospective CBCT analysis, DIP is nearly always possible in contrast to IIP and EIP. Therefore, and since it is much easier than IIP and EIP, inexperienced clinicians should mainly focus on ARP and DIP in clinical practice deferring IIP and EIP until more surgical skills have been acquired.

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.

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. 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. 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. 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. This study was registered in ClinicalTrials.gov (NCT04210596).

The modified socket shield technique with immediate implant placement-A case report with procedural tips

The tooth root always aids in preserving the surrounding hard and soft tissues, favouring their functionality and aesthetics. Resorption of the alveolar bone following tooth extraction leads to deficits in both the hard and soft tissues. In order to prevent resorption after extraction, immediate implant placement, the use of graft materials, and the use of barrier membranes have all been reported in the literature. Despite different degrees of cortical bone preservation, none of these procedures completely avoided mid-facial recession after immediate implant placement. The socket shield technique can be used to prevent this. Here, in this clinical case report we present “the modified socket shield technique” in achieving successful aesthetic and functional outcome with procedural tips.

EAO Position Paper: Immediate Implant Placement: Managing Hard and Soft Tissue Stability from Diagnosis to Prosthetic Treatment.

In this position paper, the state of the art in immediate implant placement (IIP) at incisor-cuspid-premolar sites is described. The literature supports that the following prerequisites need to be simultaneously met for a predictable outcome: (1) there must be no acute infection; (2) there must be apical and palatal/lingual bone for implant anchorage; (3) the tooth must be inside the bone envelope; (4) the alveolar socket must have a favorable morphology (type I, IIa, IIb avoiding wide dehiscences); (5) there must be no midfacial recession; (6) the right implant must be selected; and (7) the surgeon needs to be experienced and skilled. A preoperative CBCT is required for IIP because multiple aforementioned prerequisites (2, 3, and 4) can only be assessed on the basis of 3D imaging. The final prerequisite relates to the importance of a perfect implant position, preferably leaving a horizontal gap of at least 2 mm between the implant shoulder and buccal bone wall. Guided surgery is preferred over free-hand surgery to accomplish this. Flapless surgery, socket grafting, connective tissue graft (CTG), and immediate provisionalization have been shown to contribute to hard and/or soft tissue stability. When the previously mentioned prerequisites are fulfilled, IIP may be considered over alternative treatment concepts (eg, early implant placement [EIP] and delayed implant placement [DIP]) based on time gain, minimal invasiveness, and similar outcomes in the literature. Given very strict selection criteria, clinicians should primarily screen patients for IIP before considering other treatment options with wider indications. Int J Prosthodont 2023;36:533-545.

Clinical performance of immediately placed and immediately loaded single implants in the esthetic zone: A systematic review and meta-analysis.

The aim of this study was to assess the following PIO question: In adult patients treated with an indication for single tooth extraction in the maxillary esthetic zone (15-25), what is the influence of an immediate implant placement and immediate loading protocol on the clinical performance (primary aim) and esthetic outcomes (secondary aim) focusing on investigations published after 2010. An electronic search in Medline (PubMed), the Cochrane Central Register of Controlled Trials, and EMBASE databases up to April 2022 was performed to identify clinical studies investigating the outcome of single implants subjected to immediate placement with immediate restoration/loading (Type 1A). Sixty-three studies (10 randomized controlled trials, 28 prospective and 25 retrospective cohort studies) were included with a follow-up ranging from 12 to 96 months. One thousand nine hundred sixty-one implants reported survival rates of 99.2 (98.6-99.5) % at 1 year, 97.5 (95.9-98.4) % after 3 years, and 95.8 (93.3-97.4) % after 5 years; 1064 immediately loaded restorations presented survival rates of 98.9 (97.8-99.5) % after 1 year, 96.8 (93.6-98.4) % after 2 years, and 94.8 (89.6-97.4) % after 5 years. Comparing baseline to 12-month data using the Hedges' g effect size (95% CI), papilla height presented an overall effect size of -0.71 (-1.25, -0.1) mm, midfacial recession change of -0.15 (-0.66, 0.36) mm, and a 0.82 (0.37, 1.28) gain in PES. Immediate implant placement and immediate loading can be considered a predictable and safe treatment option for single maxillary anterior restorations with adequate survival rates and favorable esthetics outcomes for up to 5 years.

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.

Surgical Approach for Facial Peri-implant Soft Tissue Deficiency in the Esthetic Area

Peri-implant soft tissue dehiscence/deficiency (PSTD) is an apical shift in the peri-implant facial soft tissue margin, including mid-facial recession, mucosal recession or dehiscence, soft-tissue dehiscence/deficiency, or a soft-tissue defect. PSTD of maxillary anterior implants can be resolved with soft tissue grafting to improve esthetics of the implant-supported crown and health of peri-implant tissue. Here, we report two cases of efficiently managed PSTD using different surgical procedures in the esthetic area. The soft tissue augmentation technique, including subepithelial connective tissue grafting with a coronally advanced flap and free gingival graft, could achieve healthy peri-implant tissue and esthetics of the implant-supported crown through coverage of PSTD. Clinicians should prevent PSTD by fully considering the factors that increase the risk of PSTD before implant placement.

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.

To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) at 1year when applied at single implant sites. 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 1year 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. 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 1year 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 1year 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). 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).

Clinical evaluation of the buccal aspect around immediate implant using dual zone therapeutic concept versus buccal gap fill to bone level: A randomized controlled clinical trial.

Soft tissue esthetics for immediate implant is considered challenging when restoring a tooth in an esthetic zone. This study aimed to evaluate the buccal aspect after immediate implant using the dual-zone therapeutic concept compared to grafting the buccal gap to the bone crest. Twenty-four patients were randomly assigned into either immediate implant with the dual-zone therapeutic concept (DZ, test group) or with bone grafting till buccal bone crest with immediate temporization (BCG, control group). Pink esthetic score (PES), buccal bone loss (BBL), mid-facial recession (MFR), soft tissue thickness (STT), keratinized tissue width (KTW), post-operative swelling (POS), and patient satisfaction (PS) were evaluated for 1year. At 12 months the PES in the test group was 11.36 ± 1.69, and 10.80 ± 1.55 in the control group, with no statistically significant difference (p= 0.45). MFR in the DZ and BCG groups was 0.27 ± 0.34 and 0.45 ± 0.44 after 12 months with no statistical significance difference (p= 0.195). The STT assessment showed a statistically significant increase in both groups, however the intergroup comparison was statistically not significant (p= 0.23). The mean KTW in the DZ and BCG groups was 4.55 ± 1.08 and 4.20 ± 0.82 mm, respectively with no statistical significance (p= 0.42). There was no statistical significant difference in patient satisfaction between the two groups except in question number 10 concerning the post-operative swelling which was higher in the DZ group (p= 0.009). Both treatment modalities are considered reliable methods to achieve good soft tissue esthetics. However, both treatment modalities were not effective in preventing facial bone resorption despite the use of bone graft.

Interdisciplinary management of recession defects on maxillary single tooth implants: Diagnosis and treatment strategies.

One of the most common complications with dental implants placed in the smile zone is the development of mid-facial recession, creating an undesirable esthetic result. When deciding how to remediate these clinical scenarios, the question becomes whether it may be feasible to save the problematic implant or if it is more predictable to remove the implant and start all over again. However, patients may be invested emotionally, physically, and financially in the implant and remediation may be a viable option depending on the diagnosis of the specific issues at hand and multi-disciplinary clinical execution. What is crucial to understand in order to remediate these cases is answering four separate criteria: (1) is the implant in a restorable position, (2) is the implant healthy, (3) is the implant placed at an adequate depth, and (4) are components available to restore the implant. Two different clinical reports are presented that demonstrate various treatment remedies when saving implants in the esthetic zone.

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.

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. 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 (3months) based on superimposed digital surface models. Secondary parameters included patient-reported clinical and aesthetic outcomes. 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. CTG remains the gold standard for increasing soft tissue thickness at the buccal aspect of implants.

Is the timing of implant placement and loading influencing esthetic outcomes in single-tooth implants?-A systematic review.

To address the following question: "Is the timing of implant placement and/or loading influencing the esthetic outcomes of implant-supported single crowns?" A literature screening was performed in four electronic databases until June 2020. Randomized controlled clinical trials with a minimum of 10 patients and 1year of follow-up and reporting on dimensional changes of the peri-implant mucosa (midfacial recession, papilla level) and esthetic indexes were included. Cochrane Risk of Bias Tool was used, and comparable trials were subjected to meta-analyses. Out of 8549 articles, 72 full-text articles were assessed for eligibility and 18 were included. Nine trials evaluated the timing of implant placement, and nine trials evaluated the timing of loading. The included trials comparing immediate implant placement to delayed implant placement evaluating the midfacial recession reported heterogeneous findings. No differences were found at 1 and 2-years, when comparing midfacial recession and papilla level between immediate and early implant placement. In immediate and delayed implant placement, when comparing conventional and immediate loading, the midfacial mucosal margin change was not statistically significant at the 1-year follow-up. When evaluating the timing of implant placement and/or loading the included trials found no differences in the Pink Esthetic score, White Esthetic score, and Papilla Index between groups. Both immediate and early implant placement protocols presented stable treatment results in terms of esthetic outcomes at the 1-, 2-, and 10-years follow-up. Loading protocols did not seem to influence esthetic outcomes in short- and medium-term follow-ups.

Implant-prosthetic rehabilitation of patients with severe horizontal bone deficit on mini-implants with two-piece design\u2014retrospective analysis after a mean follow-up of 5 years

BackgroundAs a consequence of tooth loss due to trauma or extraction, a reduced alveolar crest volume limits the deployment of standard implants in certain patient cases. For this reason, minimal-invasive treatment with mini-dental implants (MDI) might be an option to allow implant treatment even in cases with severe horizontal bone loss without augmentation measures. The aim of this retrospective cohort study was to investigate clinical and radiological implant, as well as patient-related parameters after treatment with MDI.ResultsClinical and radiological records of 19 female (82.6%) and 4 male patients (17.4%) (N = 23), who received 52 mini-dental implants with a two-piece design in a single surgical center between November 2011 and October 2018, were retrospectively analyzed. Implants were submitted to conventional loading on different types of screwed superstructures. Crestal bone loss was measured on standardized periapical radiographs. Patient-related outcome parameters (PROMs) were recorded during follow-up period. Mean clinical and radiological follow-up was 69.6 months (5.8 years) and 51.6 months (4.3 years), respectively. Three implants were lost in two patients, leading to an implant survival rate of 94.2%. Mean radiological crestal bone loss was 1.6 mm. Both amount of peri-implant recession and crestal bone loss were significantly correlated (r = 0.65; p < 0.001). Likewise, a significant correlation was observed between deeper probing depths and increased peri-implant bone loss (r = 0.41; p = 0.012). Alveolar ridges with a reduced alveolar crest width were significantly correlated with higher peri-implant bone loss as well (r = − 0.33; p = 0.011). No prosthetic complications were reported during follow-up. Extent of midfacial recession and papilla height loss had a significant negative impact on most of the PROMs.ConclusionsTreatment with MDI seems to be a successful alternative treatment option, especially for elderly patients with reduced crest width at implant sites. Due to the good clinical results and high survival and success rates, this treatment option was associated with high patient satisfaction. Despite the promising results, particular consideration should be given to appropriate treatment planning in these patients due to the strong correlation between peri-implant soft-tissue parameters, crestal bone loss, and reduced alveolar crest width.

Immediate implant placement with or without connective tissue graft: A systematic review and meta-analysis.

To assess the effect of connective tissue graft (CTG) in terms of vertical mid-facial soft tissue change when applied at the buccal aspect following single immediate implant placement (IIP). Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, EMBASE and Cochrane databases as well as a manual search to identify eligible clinical studies up to January 2020. Randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP with CTG and without CTG over a mean follow-up of at least 12months were included for a qualitative analysis. Meta-analyses were performed on data provided by RCTs. Out of 1814 records, 5 RCTs and 3 NRSs reported on 409 (IIP + CTG: 246, IIP: 163) immediately installed implants with a mean follow-up ranging from 12 to 108months. Only 1 RCT showed low risk of bias. Meta-analysis revealed a significant difference in terms of vertical mid-facial soft tissue change between IIP + CTG and IIP pointing to 0.41mm (95% CI [0.21; 0.61], p<.001) in favour of soft tissue grafting. This outcome was clinically relevant since the risk for ≥1mm asymmetry in mid-facial vertical soft tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p=.002) lower following IIP + CTG. Soft tissue grafting also resulted in a trend towards less bleeding on probing (MD 17%, 95% CI [-35%; 1%], p=.06). Meta-analyses did not reveal significant differences in terms of pink aesthetic score, marginal bone level change and probing depth. Results were inconclusive for horizontal mid-facial soft tissue change and papilla height change. Based on GRADE guidelines, a moderate recommendation for the use of a CTG following IIP can be made. CTG contributes to mid-facial soft tissue stability following IIP. Therefore, CTG should be considered when elevated risk for mid-facial recession is expected in the aesthetic zone (thin gingival biotype, <0.5mm buccal bone thickness).

A 10‐year prospective study on single immediate implants

Aim To evaluate the clinical, aesthetic and radiographical outcome of single immediate implant placement (IIP) after 10 years (a) and to identify putative risk factors for advanced mid-facial recession (b). Material and methods Periodontally healthy patients with a thick gingival biotype and intact buccal bone wall were consecutively treated with a single immediate implant and crown in the aesthetic zone (15-25). Flapless surgery and socket grafting with deproteinized bovine bone mineral were performed. Seven patients received a connective tissue graft (CTG) at 3 months due to obvious alveolar process deficiency (n = 5) or advanced mid-facial recession (n = 2). Clinical, aesthetic and radiographical outcomes at 10 years were compared to those at 5 years and CBCTs were taken at 10 years. Results Twenty-two patients (10 women; mean age 50) were consecutively treated and 18 could be re-examined. Two implants failed and two patients died. None of the parameters differed between the 5- and 10-year re-assessment (marginal bone loss: 0.31 mm; plaque score: 15%; probing depth: 3.4 mm; bleeding on probing: 32%; pink aesthetic score: 10.61; mesial papillary recession: -0.03 mm; distal papillary recession: 0.22 mm; mid-facial recession: 0.58 mm). Six implants (33%) demonstrated ≥1 mm mid-facial recession. Putative risk factors were merely based on descriptive statistics and included buccal shoulder position, no CTG, convex emergence profile and central incisor position. Three implants (17%) had no visible buccal bone on CBCT. One of these was too buccally positioned, another yielded peri-implant mucositis and another demonstrated peri-implantitis. Conclusions Advanced mid-facial recession is common in the long term following IIP. Therefore, caution is required for IIP in the aesthetic zone.

A 10-year prospective study on single immediate implants.

To evaluate the clinical, aesthetic and radiographical outcome of single immediate implant placement (IIP) after 10years (a) and to identify putative risk factors for advanced mid-facial recession (b). Periodontally healthy patients with a thick gingival biotype and intact buccal bone wall were consecutively treated with a single immediate implant and crown in the aesthetic zone (15-25). Flapless surgery and socket grafting with deproteinized bovine bone mineral were performed. Seven patients received a connective tissue graft (CTG) at 3months due to obvious alveolar process deficiency (n=5) or advanced mid-facial recession (n=2). Clinical, aesthetic and radiographical outcomes at 10years were compared to those at 5years and CBCTs were taken at 10years. Twenty-two patients (10 women; mean age 50) were consecutively treated and 18 could be re-examined. Two implants failed and two patients died. None of the parameters differed between the 5- and 10-year re-assessment (marginal bone loss: 0.31mm; plaque score: 15%; probing depth: 3.4mm; bleeding on probing: 32%; pink aesthetic score: 10.61; mesial papillary recession: -0.03mm; distal papillary recession: 0.22mm; mid-facial recession: 0.58mm). Six implants (33%) demonstrated ≥1mm mid-facial recession. Putative risk factors were merely based on descriptive statistics and included buccal shoulder position, no CTG, convex emergence profile and central incisor position. Three implants (17%) had no visible buccal bone on CBCT. One of these was too buccally positioned, another yielded peri-implant mucositis and another demonstrated peri-implantitis. Advanced mid-facial recession is common in the long term following IIP. Therefore, caution is required for IIP in the aesthetic zone.

The effectiveness of immediate implant placement for single tooth replacement compared to delayed implant placement: A systematic review and meta-analysis.

To compare immediate implant placement (IIP) to delayed single implant placement (DIP, ≥3months post-extraction) in terms of implant survival (primary outcome), surgical, clinical, aesthetic, radiographic and patient-reported outcomes (secondary outcomes). Two reviewers independently performed an electronic search in PubMed, Web of Science, EMBASE and Cochrane and a hand search to identify eligible studies up to May 2018. Only randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP to DIP with at least 1year of follow-up were selected for a qualitative analysis and meta-analysis. The search identified 3 RCTs and 5 NRSs out of 2,589 titles providing data on 473 single implants (IIP: 233, DIP: 240) that had been in function between 12 and 96months. One RCT showed unclear risk of bias, whereas all other studies demonstrated high risk. Meta-analysis showed significantly lower implant survival for IIP (94.9%) as compared to DIP (98.9%) (RR 0.96, 95% CI [0.93; 0.99], p=0.02). All were early implant failures. A subgroup meta-analysis demonstrated a trend towards lower implant survival for IIP when postoperative antibiotics had not been administered (RR: 0.93, 95% CI [0.86; 1.00], p=0.07). This was not observed among studies including the administration of postoperative antibiotics (RR: 0.98, 95% CI [0.94; 1.02], p=0.35). Meta-analyses showed similar probing depth (WMD 0.43mm, 95% CI [-0.47; 1.33], p=0.35) and aesthetic outcomes as assessed by the pink aesthetic score (standardized WMD -0.03, 95% CI [-0.46; 0.39], p=0.88) for IIP and DIP. Data on marginal bone loss were conflicting and highly biased. Soft tissue recession was underreported and available data were highly biased. Patient-reported outcomes were underreported, yet both IIP and DIP seemed well tolerated. Immediate implant placement demonstrated higher risk for early implant loss than DIP. There is a need for RCTs comparing IIP to DIP with CBCT analyses at different time points and data on midfacial recession with the preoperative status as baseline. In these studies, the need for hard and soft tissue grafting should also be evaluated.

Labial soft tissue contour dynamics following immediate implants and immediate provisionalization of single maxillary incisors: A 1-year prospective study.

Soft tissue dynamics in the esthetic zone are gaining increasing attention in recent years. Emerging intraoral scanning technology allows easier capture of soft tissue contours. To quantitatively assess the time-dependent contour alterations of labial soft tissue following single immediate implants and immediate provisionalization (IIPP) in maxillary incisors via intraoral scanning. This was a prospective cohort study. Thirty eligible consecutive patients were included and received immediate replacement of a failure maxillary single incisor. A screw-retained immediate restoration was delivered for each patient. Subsequently, the anterior maxillary region was scanned by an intraoral scanning system at four time points: preoperation (baseline, BL), 3 months (3 m), 6 months (6 m), and 12 months (12 m). The Standard Tessellation Language files were exported to a dedicated software and superimposed for visual analysis. At 3, 6, and 12 months, the mid-facial mucosa level (ML) was assessed, and the precise three-dimensional (3D) configuration of the altered volume was calculated and reconstructed for visual analysis. Furthermore, quantitative analysis of the reconstructed morphology was performed using the following parameters: mean change in thickness (△d), mesio-distal width (w), coronal-apical height (h), and horizontal and vertical position of the thickest point represented by coordinates (x, z). Twenty-seven of thirty enrolled patients were finally available for analysis at the 1-year follow-up. In general, the frontal view of the reconstructed volume exhibited a crescent shape. The mid-facial ML change at 3, 6, and 12 months was -0.05 ± 0.36 mm, -0.03 ± 0.32 mm, and -0.24 ± 0.37 mm, respectively (P = .012). The mean change in thickness at 3 months (△d3m ), 6 months (△d6m ), and 12 months (△d12m ) was 0.50 ± 0.19 mm, 0.59 ± 0.21 mm, and 0.62 ± 0.22 mm, respectively (P <.001). At 12 months, nine patients had a △d less than 0.5 mm. The mean △d3 m /△d12 m and △d6 m /△d12 m was 0.81 ± 0.17 and 0.96 ± 0.13. The w, h, x, and z results showed no significant differences during the 1-year observation (P = .126, P = .324, P = .635, P = .263). At 12 months, w, h, x, and z were 11.57 ± 1.77 mm, 6.46 ± 2.01 mm, 0.03 ± 1.43 mm, and 2.16 ± 0.65 mm, respectively. During the 1-year observation following single IIPP treatment in maxillary incisors, the labial soft tissue contour showed a continuous alteration resulting in a mean change in thickness of 0.62 mm that occurred mainly in the first 3 months and tended to be relatively stable after 6 months, while the crescent-like shape, width, height, and thickest point position of the alteration volume remained stable after 3 months. No advanced mid-facial recession was observed.

Quantitative three-dimensional methodology based on intraoral scan to assess the soft tissue contour alterations following single immediate implant and immediate provisionalization in maxillary central incisor: a 1-year prospective study

Objective: To establish a quantitative three-dimensional method based on intraoral scan and apply it to evaluation of the facial soft tissue contour alterations following single immediate implant and immediate provisionalization (IIPP) in central incisor via intraoral scanning. Methods: This study was a prospective clinical study. The trial was conducted at Department of Implantology, Peking University School and Hospital of Stomatology, from January 2016 to September 2017. Twenty-nine eligible consecutive patients (15 women, 14 men) with a mean age of (34.3±12.0) were included and received immediate replacement of the failure maxillary single central incisor. A screw-retained immediate restoration was delivered for each patient. At 6-month follow-up, impression was taken and a screw-retained permanent restoration was performed for each patient. The anterior maxillary region was scanned by an intraoral scanning system at pre-surgery and 1-year follow-up. The Standard Tessellation Language (STL) files were output to a dedicated software and superimposed. Mid-facial recession and gingival zenith symmetry at 1-year follow-up were measured in the digital models. Three-dimensional configurations of the contour change volume were calculated and reconstructed for visual analysis. Furthermore, the following parameters were used to analyze the reconstructed volume: mean contour change in thickness (△d), mesio-distal width (D(W)), coronal-apical height (D(H)), contour change at 0, 1, 2, 3, 4, 5 mm apical to the free gingival margin on the implant site. Results: Twenty-seven out of twenty-nine enrolled patients were finally available for analysis. At 1-year follow-up, the mid-facial mucosa level at implant site was (0.23±0.39) mm apical to the gingival zenith of the contralateral tooth. In general, a contour collapse was found in every patient. △d, D(W) and D(H) of the collapsed volume were (0.62±0.22), (11.03±1.74) and (6.82±1.52) mm, respectively. Contour change at 0, 1, 2, 3, 4, 5 mm apical to the free gingival margin on the implant site were (0.54±0.48), (0.87±0.62), (1.03±0.46), (0.96±0.52), (0.90±0.52), (0.89±0.57) mm. Conclusions: The described quantitative measurement based on intraoral scan can be an effective method for assessment of soft tissue contour changes. At 1 year following single IIPP treatment in maxillary incisor, free gingival margin is stable, with only mild recession. The mean level of the facial soft tissue contour collapse is 0.62 mm.