Soft tissue grafting and single implant treatment in the aesthetic region
Zuiderveld, Elise
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Zuiderveld, E. (2018). Soft tissue grafting and single implant treatment in the aesthetic region. Rijksuniversiteit Groningen.
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This chapter is an edited version of the manuscript:
Zuiderveld, E.G., Meijer, H.J.A., Vissink, A., Raghoebar, G.M. Outcome of single implant treatment in preserved versus non-preserved
alveolar ridges: a 1-year cohort study
Submitted for publication, 2018
CHAPTER 7
Outcome of single implant treatment in
preserved versus non-preserved
alveolar ridges:
Abstract
Aim:
To assess the effect of single implant placement in the maxillary aesthetic zone in preserved alveolar ridges (PAR) compared to non-preserved alveolar ridges (non-PAR) on the change in mid-buccal mucosal level (MBML), aesthetics, marginal bone level and patient satisfaction.
Materials & Methods:
Patients with a single failing tooth displaying a large buccal bone defect of the extraction socket were pre-augmented with a mixture of autologous bone and Geistlich Bio-Oss®. The
socket was sealed with a mucosa graft. After four months a single implant was placed in this PAR (test group, n=20). Results were compared with patients with an already missing single tooth treated with a single implant placed in a non-PAR in whom placement of the implants was combined with the application of a connective tissue graft (CTG; control group, n=20). Changes in MBML were assessed on intra-oral pictures and changes in marginal bone level on intra-oral radiographs taken one (T1) and twelve (T12) months after final crown placement.
Aesthetics according to Pink Esthetic Score-White Esthetic Score (PES/WES) were measured at T12. Patient satisfaction was assessed before treatment (Tpre), and at T1 and T12.
Results:
Mean changes in MBML between T1 and T12 were -0.15±0.23 mm and 0.07±0.29 mm for
the test and control group, respectively (p=0.01). Regarding the other outcome variables, no inter-group differences were found.
Conclusion:
Single implant treatment in PAR and non-PAR are accompanied by clinically non-relevant changes in MBML. Changes in MBL, aesthetics and patient satisfaction were comparable between the groups.
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Introduction
Conventional implant treatment in the maxillofacial aesthetic zone has been shown to be a highly predictable treatment procedure for the rehabilitation of single failing teeth or already removed single failed teeth (den Hartog et al. 2011a, 2013, Jung et al. 2012). However, signifi- cant recession and unpleasing aesthetics of the peri-implant mucosa may occur (Raes et al. 2011, Mangano et al. 2017), also on the long term (Rokn et al. 2016).
A prerequisite for obtaining a favourable outcome seems to be a sufficient thick buccal bone wall (Grunder et al. 2005, Merheb et al. 2014, Chappuis et al. 2017a). In case of a deficient buccal bone wall as a result of the bone resorption process (Merheb et al. 2014, Araújo et al. 2015), proper soft tissue support and thus aesthetics may be impaired too (Grunder et al. 2005, Chappuis et al. 2017a). Local augmentation of a deficient buccal bone wall by means of guided bone regeneration (GBR) (Grunder et al. 2005, Benic & Hämmerle 2014) was demon-strated to effectively increase the buccal soft tissue contour (Benic et al. 2017, Chappuis et al. 2017b). Since the peri-implant soft tissue volume at the buccal aspect of a dental implant was also presumed to be a key factor for a maximal aesthetic outcome (Thoma et al. 2014), it was suggested to additionally graft the buccal peri-implant soft tissue with connective tissue to effectively increase the soft tissue contour (Wiesner et al. 2010, Schneider et al. 2011, Hanser & Khoury 2016, Stefanini et al. 2016). Connective tissue grafting has been shown to limit the change in mid-buccal mucosal level (MBML) at the buccal aspect of the implant (Schneider et al. 2011, Zuiderveld et al. 2018).
To preserve the alveolar ridge to a maximum extent, it was suggested to perform augmentation surgery of the extraction socket immediately after tooth extraction to limit the dimensional changes, especially of the buccal bone wall, due to the resorption process (Araújo et al. 2015, Barone et al. 2015, Buser et al. 2017, MacBeth et al. 2017). Moreover, it is presumed that aug-mentation of the extraction socket prior to implant placement significantly reduces the need for further bone augmentation at implant placement to reconstruct the contour of the buccal bone wall (Barone et al. 2012, Cardaropoli et al. 2015, Lee & Poon 2017). Additionally, sealing the socket with a soft tissue graft was demonstrated to be beneficial in limiting the shrinkage of the buccal soft tissue contour and maintaining the soft tissue volume, again favouring the aesthetic outcome (Raghoebar et al. 2009, Jung et al. 2013, Thalmair et al. 2013, Fickl et al. 2017). Possibly, applying a soft tissue graft to seal the augmented socket has a comparable effect on the peri-implant aesthetic outcome as applying a connective tissue graft (CTG) at implant placement, which would make any further soft tissue grafting superfluous.
The aim of this cohort study was to assess the effect of single implant treatment in preserved alveolar ridges (PAR) on the change in MBML, MBL, aesthetic rating of soft tissues and res-toration by a professional, clinical outcomes of peri-implant tissues, and patient satisfaction. The effect was compared to patients treated with single implants placed in non-preserved alveolar ridges (non-PAR) accompanied with connective tissue grafting at the time of implant placement.
Materials & Methods
Patient selection
Twenty patients with a single failing tooth in the maxillary aesthetic zone (incisor, canine, first premolar) received a single implant placed in a preserved alveolar ridge (PAR; test group, n=20; for details on implant placement see paragraph on surgical and prosthetic procedures). These patients originally participated in a randomized controlled trial performed at the Department of Oral and Maxillofacial Surgery (University Medical Center Groningen, the Netherlands). In all PAR cases, the extraction socket had displayed a vertical buccal bone wall defect of >5 mm, according to a post-extraction bone sounding technique, after removal of the failing tooth. Thereupon, the extraction socket was augmented with autologous bone from the maxillary tuberosity and anorganic bovine bone (Geistlich Bio-Oss®, Geistlich Pharma AG). First, the
tuberosity bone graft was shaped to match the buccal bone wall defect and inserted with the cortical side facing the periosteum. Next, a 1:1 mixture of autologous bone and Geistlich Bio-Oss® (Geistlich Pharma AG) spongiosa granules (0.25-1.0 mm) was tightly packed into
the socket. The alveolus was closed with a full-thickness mucosa graft from the maxillary tuberosity. Implant insertion was done four months following the augmentation procedure. Patients from the PAR group were compared with 20 patients presenting with an already missing single tooth in the maxillary aesthetic zone (control group, n=20). The extraction socket had not been augmented at time of removal of the failing tooth, thus had healed unassisted for at least three months following removal of the failing tooth (non-PAR). Both the PAR and non-PAR patients fulfilled following criteria: ≥18 years, adequate oral hygiene (i.e., modified plaque and sulcus bleeding index ≤1; Mombelli et al. 1987), ≥6 mm diastema width and sufficient space for a non-occluding temporary crown, no medical and general contraindications for the surgical procedure (i.e., ASA score ≥III; Smeets et al. 1998), no active and uncontrolled periodontal disease probing pocket depths ≥4 mm and bleeding on prob-ing (index score >1), no smokprob-ing, no history of head and neck radiation, and no pregnancy. Before enrollment patients signed an informed consent form. The trial was approved by our Medical Ethical Committee (NL43085.042.13) and registered (www.trialregister.nl: NTR3815).
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Surgical and prosthetic procedures
All surgical procedures were done under local anaesthesia and antibiotic prophylaxis (amox-icillin 500mg, 3 t.i.d. for 7 days or clindamycin 300mg, q.i.d. for 7 days in case of amox(amox-icillin allergy). For oral disinfection a 0.2% chlorhexidine mouthwash (twice daily for 7 days) was used.
For implant insertion, the same procedure was applied in both groups. The alveolar ridge was exposed elevating a minimal mucoperiosteal flap with a slightly palatal crest-incision, extensions through the buccal and palatal sulcus of the neighbouring teeth and a divergent relieving incision at the distal tooth (Figs. 1a, 2a). The implant site was prepared according to the manufacturer’s manual and using a surgical guide according to the ideal position of the future implant crown. All patients were provided with an implant (NobelReplace CC, Nobel Biocare AB, Gothenburg, Sweden) installed with 45Ncm and provided with a cover screw (Figs. 1b, 2b). For a good emergence profile the implant shoulder was placed 3 mm apical to the most buccal and cervical aspect of the prospective implant crown and was leveled to the alveolar bone.
When the bone wall thickness facially to the implant was <2 mm (Grunder et al. 2005), a local augmentation procedure was performed with a mixture of autologous bone chips collected during implant bed preparation and Geistlich Bio-Oss® (Fig. 2c), which was covered with a
Geistlich Bio-Gide® membrane.
All patients in the non-PAR group additionally received a connective tissue graft harvested from the palate and placed in the prepared mucoperiosteal flap at the facial site and secured with vertical and horizontal mattresses (4-0 vicryl, Johnson & Johnson Gateway, Piscatatway, USA; Fig. 2d). The wound at the palate was sutured with Ethilon 5-0 nylon (Johnson & John-son). All patients with an implant placed in the PAR group (n=20) received no soft tissue graft. In all patients, the wound at the implant site was closed with Ethilon 5-0 nylon (Johnson & Johnson). All sutures were removed two weeks later. Patients were provided with a removable partial denture not interfering with the wound.
Three months after implant insertion, implants were uncovered and an implant-level impres-sion for fabrication of a screw-retained temporary implant crown was taken. Then, implants were provided with a healing abutment (Nobel Biocare AB). At the end of the same day, the temporary crown was placed with 20Ncm using a manual torque wrench (Nobel Biocare AB) adjusted to function without centric and eccentric contact with the antagonist teeth. Addition-ally, patients should follow a soft diet and avoid exerting forces on the temporary restoration.
Figs. 1a,b – Implant insertion in a preserved alveolar ridge:
a
b
a Clinical view of a preserved alveolar ridge and
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Figs. 2a,b – Implant insertion in a non-preserved alveolar ridge:
a
b
a Clinical view of a deficient alveolar ridge and
Fig. 2c – Local augmentation of the buccal bone wall, which was covered with a Geistlich
Bio-Gide® membrane.
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After a three-month provisional phase, a final open-tray implant-level impression was taken using polyether impression material (Impregum Penta, 3M ESPE, Seefeld, Germany). An individualized zirconia abutment (NobelProcera, Nobel Biocare AB) was made according to the digital design of the final implant crown, which was either screw- or cement-retained depending on the location of the screw access hole. The abutment screws were torqued with 35Ncm.
Photographic assessment
Change in mid-buccal mucosal level (MBML) and change in interproximal mucosal level (IML) was assessed on standardized intra-oral pictures (Canon EOS 650D with ring flash) taken one (T1) and 12 months (T12) after placement of the final implant crown.
First, pictures were calibrated with a periodontal probe (Williams Color-Coded probe; Hu-Friedy, Chicago, IL, USA) captured in close contact and parallel to the long axis of the neighbouring tooth. Full-screen analysis was done with Adobe Photoshop CS5.1 (Adobe Systems Inc., San Jose, USA). Changes between T1 and T12 were determined measuring the
length of the implant crown.
Aesthetics of the peri-implant mucosa and the implant crown were assessed on pictures taken at T12 using the Pink Esthetic Score-White Esthetic Score (PES/WES; Belser et al. 2009).
Radiographic assessment
The marginal bone level was measured on standardized digital intra-oral radiographs taken with an individualized device (Meijndert et al. 2004). In specifically designed software the distance between implant platform and first bone-to-implant contact was measured. Bone transcending the implant platform was scored as no bone loss.
Clinical assessments
The following clinical data were collected at T1 and T12 by a single, independent examiner
(E.G.Z.) not involved in the implant placement and fabrication of the crown: (1) gingival biotype, as measured before treatment (Tpre) by means of transparency of a periodontal probe
through the mucosal margin of the failing tooth or contralateral tooth when the tooth was missing already (Kan et al. 2010); (2) probing pocket depth using a periodontal probe; (3) amount of plaque (modified plaque index; Mombelli et al. 1987); (4) bleeding after probing (modified sulcus bleeding index; Mombelli et al. 1987); (5) gingival condition (gingival-index; Loe 1967); (6) keratinized mucosa width; (7) interproximal papilla volume (papilla index; Jemt 1997); (8) implant survival; (9) implant success, defined as ≤1 mm marginal bone loss
Patient satisfaction
Patients completed OHIP-14 questionnaires (van der Meulen et al. 2012) and questions about overall satisfaction with the current dentition to be answered on a 10 cm Visual Analogue Scale (VAS) at Tpre, T1 and T12. Additionally, questions about aesthetics and satisfaction with
the treatment procedure were answered on a 10 cm VAS. All questions were answered in the absence of the examiner.
Statistical analysis
The distribution of continuous data was assessed using the Shapiro-Wilk test. Normal distrib-uted variables were analysed with independent t-test. For non-normal distribdistrib-uted variables the Mann-Whitney test was used. Within-group statistical analysis was done with Wilcoxon tests. All analyses used p<.05 to indicate statistical significance (SPSS Statistics 23.0, SPSS Inc.; IBM Corporation, Chicago, IL, USA).
Results
Data of all patients were available at all data points. Baseline characteristics of both groups are given in Table 1. No significant differences between the groups were detected for gingi-val biotype, implant location and implant diameter (p=0.44, p=0.31, p=0.06, respectively). Local augmentation of the buccal bone wall at implant placement was significantly different between the groups (p=0.00).
In case preservation of the extraction socket was performed, no signs of soft tissue compli-cations and no extensive bleedings at the donor site were noted. Also no objective signs of infections were observed during follow-up. One-year post-loading, no implants had been lost (implant survival rate: 100%) as well as that the implants in both groups fulfilled all success criteria (success rate: 100%).
Table 1 – Patient characteristics and treatment specifications per group.
Variable Test group(n=20) Control group(n=20)
Male/female ratio 7/13 4/16
Age (years) mean±SD
(range) 42.0±15.7 (18-71) 35.1±16.2 (18-66)
Gingival biotype thin/thick 15/5 17/3
Implant site location I1/I2/C/P1 12/8/0/0 7/12/1/0
Implant diameter (mm) 3.5/4.3 9/11 15/5
Bone grafting during implant placement:
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Change in mid-buccal and interproximal mucosal level
At T12 compared to T1, changes in MBML were significantly different between the groups
(p=0.01; Table 2). Changes in IML between T1 and T12 at both implant sides were comparable
for the groups (mesial: p=0.20; distal: p=0.14; Table 2).
Change in marginal bone level
Between T1 and T12 mean change in marginal bone level was 0.03±0.4 mm for the mesial
side and 0.13±0.5 mm for the distal side in the test group. The change in the control group was on average 0.06±0.5 mm mesially and -0.01±0.4 mm distally. Changes were comparable between the groups (p=0.55 for mesial implant side; p=0.62 for distal implant side; Table 2).
Table 2 – Changes in marginal soft tissue level and marginal bone level between one (T1) and twelve months (T12) after final crown placement.
Test group (n=20) Control group (n=20) Variable T1 – T12 p-value MBML (mm; mean±SD) -0.15±0.23 0.07±0.29 0.01 IML (mm; mean±SD) Mesial of implant Distal of implant 0.21±0.38 0.07±0.58 0.05±0.40 0.30±0.31 0.20 0.14 MBL (mm; median (IQR)) Mesial of implant Distal of implant 0.00 (-0.18-0.00) 0.00 (-0.02-0.39) 0.05 (-0.37-0.49) 0.03 (-0.13-0.27) 0.55 0.62 Resulting negative values of subtracting T1 with T12 means recession, positive values
mean tissue gain.
Abbreviations: MBML, mid-buccal mucosal level; IML, interproximal mucosal level; MBL, marginal bone level.
Clinical outcome
At T12, in all patients no plaque around the implant crown was detected. Probing pocket depths
at T12 were on average for respectively the test and control group: 2.9±1.3 mm and 3.0±0.8
mm on the mesial implant side, 3.3±1.1 mm and 3.0±1.1 mm for the distal implant side, 2.9±0.9 mm and 2.7±1.0 mm for the mid-buccal implant side and 1.9±0.8 mm and 2.4±0.8 mm for the palatal implant side. A healthy gingiva was seen in all patients of the control group and in all but one patient of the test group. Also one patient in the test group showed a mild
Aesthetic assessment
For aesthetics of the peri-implant mucosa according to PES total and separate scoring items no significant differences between the groups were found (Table 3). Acceptable levels of aesthetics for peri-implant mucosa (PES ≥6) were reached in 75% of the test group and in 70% of the control group.
Aesthetics of the implant crown according to WES total were not significantly different between the groups. Only the item outline and volume of the implant crown scored signifi-cantly different, which is believed to be a coincidence. Acceptable levels of implant crown aesthetics (WES ≥6) were achieved in 100% of all groups.
Patient satisfaction
Patient satisfaction according to VAS-scores and total OHIP-14 scores revealed no differences between the groups (Table 4). Satisfaction with the current dental situation was significantly increased in both groups following implant treatment (p=0.00 for both groups between Tpre
-T1). Between T1 and T12 no further improvement in satisfaction was noted (p=0.94 for the
test group and p=0.09 for the control group). Satisfaction according to the total OHIP-14 questionnaire also significantly improved during the first month after final crown placement (p=0.00; Table 4), where after the obtained gain in satisfaction remained at that level in the control group (p=0.07), whereas it did further improve in the test group (p=0.03).
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Table 3 – Changes in aesthetics and clinical outcome measures twelve months (T12) after final crown placement.
Test group (n=20) Control group (n=20) Variable T12 p-value
PES total (max 10; mean±SD) Mesial papilla
Distal papilla
Curvature of facial mucosa Level of facial mucosa
Root convexity/soft tissue colour and texture
6.55±1.50 1.50±0.51 1.35±0.49 1.40±0.60 1.25±0.79 1.05±0.76 6.60±1.39 1.40±0.50 1.45±0.51 1.55±0.51 0.90±0.85 1.30±0.57 0.93 0.53 0.52 0.45 0.19 0.29
WES total (max 10; mean±SD) Tooth form
Outline/volume Colour (hue/value) Surface texture
Translucency/characterization
PES/WES total (max 20; mean±SD)
8.70±0.92 1.80±0.41 1.95±0.22 1.70±0.47 1.70±0.47 1.55±0.51 15.25±1.89 8.00±1.21 1.50±0.51 1.55±0.51 1.75±0.44 1.65±0.49 1.55±0.51 14.60±2.52 0.06 0.05 0.00 0.73 0.74 1.00 0.33
Bleeding upon probing
No bleeding (score 0)
Isolated bleeding spots (score 1) Confluent red line (score 2)
55% 30% 15% 40% 45% 15% N/A Papilla volume Mesial/distal of implant No papilla (score 0)
Less than half papilla (score 1) At least half papilla (score 2) Entire papilla (score 3) Hyperplastic papilla (score 4)
0%/0% 0%/0% 45%/55% 55%/45% 0%/0% 0%/0% 0%/0% 30%/45% 70%/55% 0%/0% N/A
Width of the keratinized mucosa
≥ 2 mm 1-2 mm < 1 mm 90% 5% 0% 85% 5% 0% N/A
Table 4 – Patient satisfaction regarding general satisfaction, aesthetics and after final crown placement.
treatment procedure before treatment (Tpre), one (T1) and twelve months (T12)
Test group (n=20) Control group (n=20) Test group (n=20) Control group (n=20) Test group (n=20) Control group (n=20)
Tpre (median (IQR)) p-value T1 (median (IQR)) p-value T12 median (IQR) p-value
VAS-questions (0-10)
How satisfied are you with your current
dental situation? 5.8 (3.6-6.3) 5.4 (4.1-6.4) 0.85 8.1 (7.4-8.9)* 7.6 (7.0-8.8)* 0.23 8.2 (7.4-8.8) 7.9 (6.7-9.5) 0.92 How satisfied are you with your current
dental situation compared to the situation before treatment?
8.6 (8.0-9.7) 8.2 (7.0-9.3) 0.36 8.5 (7.9-9.1) 8.5 (7.9-9.6) 0.60
How satisfied are you with the implant and
the implant crown? 8.9 (7.9-9.6) 8.6 (7.7-9.3) 0.19 8.7 (8.3-9.5) 9.2 (8.0-9.6) 0.69
Aesthetics (0-10) Colour of the crown Form of the crown
Colour of the peri-implant mucosa Form of the peri-implant mucosa
9.4 (8.6-9.9) 9.5 (8.5-9.9) 9.0 (7.9-9.8) 7.6 (7.9-9.8) 9.3 (8.5-9.8) 8.9 (8.1-9.6) 7.9 (6.0-9.3) 7.9 (5.7-8.9) 0.82 0.33 0.06 0.34 9.3 (7.2-9.9) 9.0 (7.7-9.7) 8.0 (6.9-9.7) 7.6 (5.3-9.5) 9.1 (7.4-9.6) 8.9 (7.5-9.6) 8.7 (7.6-9.6) 8.2 (6.6-9.5) 0.68 0.69 0.92 0.44 Treatment procedure (0-10) I regret that I chose this treatment
I would recommend the treatment to other patients 9.6 (8.2-10.0)0.1 (0.0-0.3) 0.1 (0.0-0.3)9.2 (8.4-9.9) 0.980.75 9.8 (9.0-10.0)0.1 (0.0-0.8) 0.1 (0.0-0.5)9.7 (9.1-9.9) 0.530.46
Total OHIP-score (0-70) 24.5 (21.3-41.0) 27.5 (22.3-33.5) 0.93 18.0 (14.3-22.0)* 21.0 (15.0-26.8)* 0.31 15.0 (14.0-21.3)* 15.5 (15.0-20.0)* 0.16
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Table 4 – Patient satisfaction regarding general satisfaction, aesthetics and after final crown placement.
treatment procedure before treatment (Tpre), one (T1) and twelve months (T12)
Test group (n=20) Control group (n=20) Test group (n=20) Control group (n=20) Test group (n=20) Control group (n=20)
Tpre (median (IQR)) p-value T1 (median (IQR)) p-value T12 median (IQR) p-value
VAS-questions (0-10)
How satisfied are you with your current
dental situation? 5.8 (3.6-6.3) 5.4 (4.1-6.4) 0.85 8.1 (7.4-8.9)* 7.6 (7.0-8.8)* 0.23 8.2 (7.4-8.8) 7.9 (6.7-9.5) 0.92 How satisfied are you with your current
dental situation compared to the situation before treatment?
8.6 (8.0-9.7) 8.2 (7.0-9.3) 0.36 8.5 (7.9-9.1) 8.5 (7.9-9.6) 0.60
How satisfied are you with the implant and
the implant crown? 8.9 (7.9-9.6) 8.6 (7.7-9.3) 0.19 8.7 (8.3-9.5) 9.2 (8.0-9.6) 0.69
Aesthetics (0-10) Colour of the crown Form of the crown
Colour of the peri-implant mucosa Form of the peri-implant mucosa
9.4 (8.6-9.9) 9.5 (8.5-9.9) 9.0 (7.9-9.8) 7.6 (7.9-9.8) 9.3 (8.5-9.8) 8.9 (8.1-9.6) 7.9 (6.0-9.3) 7.9 (5.7-8.9) 0.82 0.33 0.06 0.34 9.3 (7.2-9.9) 9.0 (7.7-9.7) 8.0 (6.9-9.7) 7.6 (5.3-9.5) 9.1 (7.4-9.6) 8.9 (7.5-9.6) 8.7 (7.6-9.6) 8.2 (6.6-9.5) 0.68 0.69 0.92 0.44 Treatment procedure (0-10) I regret that I chose this treatment
I would recommend the treatment to other patients 9.6 (8.2-10.0)0.1 (0.0-0.3) 0.1 (0.0-0.3)9.2 (8.4-9.9) 0.980.75 9.8 (9.0-10.0)0.1 (0.0-0.8) 0.1 (0.0-0.5)9.7 (9.1-9.9) 0.530.46
Total OHIP-score (0-70) 24.5 (21.3-41.0) 27.5 (22.3-33.5) 0.93 18.0 (14.3-22.0)* 21.0 (15.0-26.8)* 0.31 15.0 (14.0-21.3)* 15.5 (15.0-20.0)* 0.16
Discussion
Patients receiving an implant in a PAR demonstrated only negligible changes in peri-implant soft tissue levels. Compared to the control group, changes in MBML were also minor and although a significant level was reached, changes and differences between the groups were clinically not relevant. Furthermore, satisfying aesthetics and clinical outcomes of peri-implant soft tissue and high appreciation of patients were reached in both groups without significant differences.
Regarding the minor change in MBML and aesthetics according to the total score of PES observed in the test group, results are comparable to those of other studies (Schneider et al. 2011, Slagter et al. 2016). Patients in the control group also demonstrated limited changes in MBML, which is in line with the results of a case series study (Stefanini et al. 2016), as far as we know, being the only study reporting on the change in MBML when investigating implant placement in non-PAR with CT grafting. Although we observed a significant difference for change in MBML between both groups in favour of the control group, the mean changes of -0.15 mm for the test group and +0.07 mm for the control group were minor and well within aesthetically acceptable changes of 0.5 mm (Bienz et al. 2017) and therefore can be judged as clinically insignificant. We like to hypothesize that it is generally irrelevant whether the bone augmentation procedure is done at tooth removal prior to implant placement or at implant placement concomitantly with a CTG, as done in this study. However, bone augmen-tation surgery together with sealing the socket with a soft tissue graft immediately after tooth removal has shown to be beneficial in preserving the buccal bone and soft tissue contour (Raghoebar et al. 2009, Jung et al. 2013, Fickl et al. 2017) and in reducing the further need to reaugment the buccal bone wall (Cardaropoli et al. 2015, Lee & Poon 2017), which was also demonstrated in this study. Compared to cases with a major buccal bone wall defect, which healed unassisted and often are in need of an extensive bone augmentation procedure with autologous bone in a separate surgical procedure before even an implant can be placed (den Hartog et al. 2013, Buser et al. 2017), augmenting the extraction socket would provide a shortening of the treatment time. Instead of removing the failing tooth and waiting for unassisted socket healing before starting implant treatment without being sure that the implant can be inserted in the deficient alveolar ridge, implant treatment is started immediately after removal of the failing tooth when the socket is augmented, because implant placement can be done four months thereafter.
In accordance with the literature (den Hartog et al. 2013, Buser et al. 2017, Chappuis et al. 2017a), we like to state that when possible an augmentation procedure of the extraction socket after removal of a failing tooth should be done. Furthermore, based on the comparable results for aesthetics and the clinically irrelevant differences for change in MBML between the groups, the application of a soft tissue graft to seal the extraction socket in the test group,
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which was suggested to be beneficial in maintaining the buccal soft tissue contour (Raghoebar et al. 2009, Jung et al. 2013, Thalmair et al. 2013, Avila-Ortiz et al. 2014, Fickl et al. 2017), seems to have a comparable effect to the application of a CTG in the control group. Possibly, therefore, no further soft tissue grafting in the test group is necessary at implant placement. Most studies investigating the effect of CT grafting focused on the change in mid-buccal mucosal volume (MBMV). Stefanini et al. (2016) in a case series study and Hanser & Khoury (2016) in a consecutive clinical study both observed a significant thickening of the mid-buc-cal mucosa when applying a CTG at implant placement in a non-PAR. Wiesner et al. (2010), investigating the effect of CT grafting compared to no grafting in a split-mouth study in the (pre)molar area, observed also a significant thickening of the mid-buccal mucosa accompa-nied with a better aesthetic outcome according to a significant better PES when placing an implant in a non-PAR concomitantly with a CTG. These outcomes are in contrast to our results. Although we observed a significant difference for the change in MBML, we could not find a difference between the groups for the PES, which possibly can be explained by the comparable effect of the application of a soft tissue graft in a PAR (test group) to seal the socket after bone augmentation and in a non-PAR (control group) to graft the buccal soft tissue contour at implant placement. Although soft tissue grafting at implant placement in a non-PAR is presumed to be beneficial (Schneider et al. 2011, Hanser & Khoury 2016, Stefanini et al. 2016, Zuiderveld et al. 2018), it might be possible that not grafting the buccal soft tissue contour is also an option, which needs further investigation.
The only aspect focusing on the change in MBMV in our study is the last item in the PES, assessing the root convexity combined with soft tissue texture and colour. We could not observe a difference between the groups, but on average this item did not score very high in the groups, suggesting that in all patients at least one aspect is deficient compared to the contralateral tooth. It might be that the MBMV, according to this PES item, compared to the volume at the contra-lateral tooth in both groups is less beneficial. However, scoring this item of PES has limitations, since it combines three aspects of the mid-buccal mucosa in one score. It only makes statements about whether all aspects of this item (score 2), two aspects of this item (score 1) or only one or no aspect of this item (score 0) are comparable to the contralateral tooth, without being specific about which aspect is deficient compared to the contralateral tooth.
Changes in marginal bone level were comparable between the groups and are in line with other studies (Raghoebar et al. 2009, den Hartog et al. 2011b, Santing et al. 2013, Slagter et al. 2016). The comparable marginal bone level may be explained by the fact that both bone augmentation procedures performed in test and control group result in a comparable stable
more on the change in MBML, since recession of the MBML of 0.5 mm can have a disturbing effect on the aesthetic outcome (Bienz et al. 2017) and is underexposed in available literature.
Conclusion
Rehabilitation of a single failing tooth with a single implant placed in a PAR or of a single missing tooth with single implant treatment in a non-PAR accompanied with CT grafting demonstrated clinically non-relevant changes in MBML and good aesthetic and clinical out-comes. Changes in MBL, aesthetics and patient satisfaction were comparable between the groups. In order to reduce the treatment time for rehabilitation of the maxillofacial aesthetic zone, an alveolar ridge preserving augmentation procedure of the extraction socket would be preferable.
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