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Meta-Analysis
. 2012 Feb 15;2012(2):CD006697.
doi: 10.1002/14651858.CD006697.pub2.

Interventions for replacing missing teeth: management of soft tissues for dental implants

Marco Esposito  1 , Hassan Maghaireh, Maria Gabriella Grusovin, Ioannis Ziounas, Helen V Worthington
Affiliations
Meta-Analysis

Interventions for replacing missing teeth: management of soft tissues for dental implants

Marco Esposito et al. Cochrane Database Syst Rev. .

Abstract

Background: Dental implants are usually placed by elevating a soft tissue flap, but in some instances, they can also be placed flapless reducing patient discomfort. Several flap designs and suturing techniques have been proposed. Soft tissues are often manipulated and augmented for aesthetic reasons. It is often recommended that implants are surrounded by a sufficient width of attached/keratinised mucosa to improve their long-term prognosis.

Objectives: To evaluate whether (1a) flapless procedures are beneficial for patients, and (1b) which is the ideal flap design; whether (2a) soft tissue correction/augmentation techniques are beneficial for patients, and (2b) which are the best techniques; whether (3a) techniques to increase the peri-implant keratinised mucosa are beneficial for patients, and (3b) which are the best techniques; and (4) which are the best suturing techniques/materials.

Search methods: The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 9 June 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), MEDLINE via OVID (1950 to 9 June 2011), EMBASE via OVID (1980 to 9 June 2011). Several dental journals were handsearched. There were no language restrictions.

Selection criteria: All randomised controlled trials (RCTs) of root-form osseointegrated dental implants, with a follow-up of at least 6 months after function, comparing various techniques to handle soft tissues in relation to dental implants. Outcome measures, according to the different hypotheses, were: prosthetic and implant failures, biological complications, aesthetics evaluated by patients and dentists, postoperative pain, marginal peri-implant bone level changes on periapical radiographs, patient preference, ease of maintenance by patient, soft tissue thickness changes and attached/keratinised mucosa height changes.

Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted at least in duplicate and independently by two or more review authors. Trial authors were contacted for missing information. Results were expressed using risk ratios for dichotomous outcomes and mean differences for continuous outcomes with 95% confidence intervals.

Main results: Seventeen potentially eligible RCTs were identified but only six trials with 138 patients in total could be included. One study was at low risk of bias, two studies were judged to be at unclear risk of bias and three at high risk of bias. Two trials (56 patients) compared flapless placement of dental implants with conventional flap elevation, one trial (10 patients) compared crestal versus vestibular incisions, one trial (20 patients) Erbium:YAG laser versus flap elevation at the second-stage surgery for implant exposure, one split-mouth trial (10 patients) evaluated whether connective tissue graft at implant placement could be effective in augmenting peri-implant tissues, and one trial (40 patients) compared autograft with an animal-derived collagen matrix to increase the height of the keratinised mucosa. On a patient, rather than per implant basis, implants placed with a flapless technique and implant exposures performed with laser induced statistically significantly less postoperative pain than flap elevation. Sites augmented with soft tissues connective grafts showed a better aesthetic and thicker tissues. Both palatal autografts or the use of a porcine-derived collagen matrix are effective in increasing the height of keratinised mucosa at the price of a 0.5 mm recession of peri-implant soft tissues. There were no other statistically significant differences for any of the remaining analyses.

Authors' conclusions: There is limited weak evidence suggesting that flapless implant placement is feasible and has been shown to reduce patient postoperative discomfort in adequately selected patients, that augmentation at implant sites with soft tissue grafts is effective in increasing soft tissue thickness improving aesthetics and that one technique to increase the height of keratinised mucosa using autografts or an animal-derived collagen matrix was able to achieve its goal but at the price of a worsened aesthetic outcome (0.5 mm of recession). There is insufficient reliable evidence to provide recommendations on which is the ideal flap design, the best soft tissue augmentation technique, whether techniques to increase the width of keratinised/attached mucosa are beneficial to patients or not, and which are the best incision/suture techniques/materials. Properly designed and conducted RCTs, with at least 6 months of follow-up, are needed to provide reliable answers to these questions.

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Conflict of interest statement

Marco Esposito is among the authors of three of the eligible trials, however, he was not involved in the inclusion/exclusion decision process or the quality assessment of these trials. Marco Esposito is working as independent methodological consultant in various implant related projects for some of the companies whose implants were used both in the included and excluded trials, however, in this review, implant brands were not under evaluation.

From April 2011 Marco Esposito became a full‐time freelance consultant in dentistry specialising in implantology. Therefore he receives funding for conducting clinical trials and presenting the results of trials/Cochrane reviews at international dental meetings. This funding comes from universities, companies (in alphabetical order: Apollonia e Fama Implant, Biomax, Biomet 3i, Bioteck, Bone System, Branemark Integration, CMS Dental, Dentsply‐Friadent, Geistlich Pharma, Geass, Keystone Dental, MegaGen Implant, Mozo‐Grau, Nano Bridging molecules, Nobel Biocare, Ricerfarma, Saint Jude Medical, Southern Implants, Supercharched production, Techoss Dental Thommen Medical, Tutogen Medical, Zimmer Dental, Z‐Systems), scientific societies, publishing companies, and private dentists. This list of companies was provided by Marco on Friday 4th November 2011 and the funders will change all the time.

This is to certify that: a) Marco does not own stock in companies that produce products included in the reviews; b) he does not have patents on any of the products included in the reviews; c) his salary will not be affected by company sales of any of the products included in the reviews.

Marco's authorship has been authorised by The Cochrane Collaboration Funding Arbiter (reference 071111/057: Oral Health Group).

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Flap versus no flap, Outcome 1 Prosthetic failure.
1.2
1.2. Analysis
Comparison 1 Flap versus no flap, Outcome 2 Implant failure.
1.3
1.3. Analysis
Comparison 1 Flap versus no flap, Outcome 3 Biological complications.
1.4
1.4. Analysis
Comparison 1 Flap versus no flap, Outcome 4 Postoperative pain.
1.5
1.5. Analysis
Comparison 1 Flap versus no flap, Outcome 5 Peri‐implant marginal bone level.
1.6
1.6. Analysis
Comparison 1 Flap versus no flap, Outcome 6 Patient preference.
2.1
2.1. Analysis
Comparison 2 Crestal versus vestibular incision, Outcome 1 Prosthesis failure.
2.2
2.2. Analysis
Comparison 2 Crestal versus vestibular incision, Outcome 2 Implant failure.
2.3
2.3. Analysis
Comparison 2 Crestal versus vestibular incision, Outcome 3 Biological complications.
3.1
3.1. Analysis
Comparison 3 Laser versus flap at implant exposure, Outcome 1 Biological complications.
3.2
3.2. Analysis
Comparison 3 Laser versus flap at implant exposure, Outcome 2 Postoperative pain.
4.1
4.1. Analysis
Comparison 4 Soft tissue thickening versus no thickening, Outcome 1 Aesthetics (PES) by dentist.
4.2
4.2. Analysis
Comparison 4 Soft tissue thickening versus no thickening, Outcome 2 Soft tissues thickness changes.
4.3
4.3. Analysis
Comparison 4 Soft tissue thickening versus no thickening, Outcome 3 Peri‐implant marginal bone level changes.
5.1
5.1. Analysis
Comparison 5 Different techniques to increase keratinised mucosa height, Outcome 1 Keratinised mucosa height changes.
5.2
5.2. Analysis
Comparison 5 Different techniques to increase keratinised mucosa height, Outcome 2 Recession (aesthetics).
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References

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