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01-06-2018 | Original Article

Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients

Authors: Daniel S. Thoma, AbdulMonem Alshihri, Alain Fontolliet, Christoph H. F. Hämmerle, Ronald E. Jung, Goran I. Benic

Published in: Clinical Oral Investigations | Issue 5/2018

Abstract

Objectives

This work aimed to investigate the effectiveness and predictability of different treatment modalities for gain of keratinized tissue (KT) in fully edentulous jaws prior to dental implant placement: apically positioned flap (APF), APF plus xenogeneic collagen matrix (XCM), and APF plus free gingival graft (FGG).

Materials and methods

In fully edentulous patients with insufficient zones of KT at the prospective implant positions, four treatment modalities were performed in the lower jaw: APF, XCM, FGG, and an untreated control group (control). APF and XCM were applied in the first molar positions, FGG and control in the canine positions. Assessed outcomes up to 3 months post-surgery included changes in width of KT (over a 3-month period), histomorphometric analysis of harvested soft-tissue biopsies (at 3 months postoperatively), and patient-reported outcomes measures (PROMs).

Results

For the primary outcome, changes in KT width demonstrated an increase of 1.93 ± 1.6 mm (APF), whereas XCM and FGG showed an increase of 4.63 ± 1.25 mm and 3.64 ± 2.01, respectively. Histomorphometric analyses revealed a thickness of the epithelium ranging between 375 ± 122 μm (APF), 410 ± 116 μm (XCM), 336 ± 122 μm (FGG), and 413 ± 109 μm (control). All biopsies showed a regular muco-periosteal structure with a keratinized epithelium of comparable thickness in all groups.

Conclusion

All three methods were suitable to increase the width of KT, although APF alone rendered roughly 50% less gain compared to XCM and FGG.

Clinical relevance

The use of XCM in conjunction with an APF represents a valuable treatment option for the gain of keratinized tissue in edentulous sites.

Lin GH, Chan HL, Wang HL (2013) The significance of keratinized mucosa on implant health: a systematic review. J Periodontol 84(12):1755–1767. https://doi.org/10.1902/jop.2013.120688 PubMedCrossRef

Wennstrom JL, Derks J (2012) Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res 23 Suppl 6:136–146. https://doi.org/10.1111/j.1600-0501.2012.02540.x PubMedCrossRef

Adell R, Lekholm U, Rockler B, Branemark PI, Lindhe J, Eriksson B, Sbordone L (1986) Marginal tissue reactions at osseointegrated titanium fixtures (I). A 3-year longitudinal prospective study. Int J Oral Maxillofac Surg 15(1):39–52. https://doi.org/10.1016/S0300-9785(86)80010-2 PubMedCrossRef

Artzi Z, Tal H, Moses O, Kozlovsky A (1993) Mucosal considerations for osseointegrated implants. J Prosthet Dent 70(5):427–432. https://doi.org/10.1016/0022-3913(93)90079-4 PubMedCrossRef

Langer B (1996) The regeneration of soft tissue and bone around implants with and without membranes Compend Contin Educ dent 17:268-70, 272 passim; quiz 280

Romanos G, Grizas E, Nentwig GH (2015) Association of keratinized mucosa and periimplant soft tissue stability around implants with platform switching. Implant Dent 24:422–426. https://doi.org/10.1097/ID.0000000000000274 PubMed

Souza AB, Tormena M, Matarazzo F, Araujo MG (2016) The influence of peri-implant keratinized mucosa on brushing discomfort and peri-implant tissue health. Clin Oral Implants Res 27(6):650–655. https://doi.org/10.1111/clr.12703 PubMedCrossRef

Schrott AR, Jimenez M, Hwang JW, Fiorellini J, Weber HP (2009) Five-year evaluation of the influence of keratinized mucosa on peri-implant soft-tissue health and stability around implants supporting full-arch mandibular fixed prostheses. Clin Oral Implants Res 20(10):1170–1177. https://doi.org/10.1111/j.1600-0501.2009.01795.x PubMedPubMedCentralCrossRef

Ueno D, Nagano T, Watanabe T, Shirakawa S, Yashima A, Gomi K (2016) Effect of the keratinized mucosa width on the health status of periimplant and contralateral periodontal tissues: a cross-sectional study. Implant Dent 25(6):796–801. https://doi.org/10.1097/ID.0000000000000483 PubMedCrossRef

10.

Oh SL, Masri RM, Williams DA, Ji C, Romberg E (2017) Free gingival grafts for implants exhibiting lack of keratinized mucosa: a prospective controlled randomized clinical study. J Clin Periodontol 44(2):195–203. https://doi.org/10.1111/jcpe.12660 PubMedCrossRef

11.

Bassetti RG, Stahli A, Bassetti MA, Sculean A (2017) Soft tissue augmentation around osseointegrated and uncovered dental implants: a systematic review. Clin Oral Investig 21(1):53–70. https://doi.org/10.1007/s00784-016-2007-9 PubMedCrossRef

12.

Thoma DS, Buranawat B, Hammerle CH, Held U, Jung RE (2014) Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review. J Clin Periodontol 41 Suppl 15:S77–S91. https://doi.org/10.1111/jcpe.12220 PubMedCrossRef

13.

Seibert JS (1983) Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 4(5):437–453PubMed

14.

McGuire MK, Nunn ME (2005) Evaluation of the safety and efficacy of periodontal applications of a living tissue-engineered human fibroblast-derived dermal substitute. I. Comparison to the gingival autograft: a randomized controlled pilot study. J Periodontol 76(6):867–880. https://doi.org/10.1902/jop.2005.76.6.867 PubMedCrossRef

15.

McGuire MK, Scheyer ET, Nunn ME, Lavin PT (2008) A pilot study to evaluate a tissue-engineered bilayered cell therapy as an alternative to tissue from the palate. J Periodontol 79(10):1847–1856. https://doi.org/10.1902/jop.2008.080017 PubMedCrossRef

16.

Soileau KM, Brannon RB (2006) A histologic evaluation of various stages of palatal healing following subepithelial connective tissue grafting procedures: a comparison of eight cases. J Periodontol 77(7):1267–1273. https://doi.org/10.1902/jop.2006.050129 PubMedCrossRef

17.

Farnoush A (1978) Techniques for the protection and coverage of the donor sites in free soft tissue grafts. J Periodontol 49(8):403–405. https://doi.org/10.1902/jop.1978.49.8.403 PubMedCrossRef

18.

Griffin TJ, Cheung WS, Zavras AI, Damoulis PD (2006) Postoperative complications following gingival augmentation procedures. J Periodontol 77(12):2070–2079. https://doi.org/10.1902/jop.2006.050296 PubMedCrossRef

19.

McGuire MK, Scheyer ET (2014) Randomized, controlled clinical trial to evaluate a xenogeneic collagen matrix as an alternative to free gingival grafting for oral soft tissue augmentation. J Periodontol 85(10):1333–1341. https://doi.org/10.1902/jop.2014.130692 PubMedCrossRef

20.

Nevins M, Nevins ML, Kim SW, Schupbach P, Kim DM (2011) The use of mucograft collagen matrix to augment the zone of keratinized tissue around teeth: a pilot study. Int J Periodontics Restorative Dent 31(4):367–373PubMed

21.

Schmitt CM, Moest T, Lutz R, Wehrhan F, Neukam FW, Schlegel KA (2016) Long-term outcomes after vestibuloplasty with a porcine collagen matrix (Mucograft(R) ) versus the free gingival graft: a comparative prospective clinical trial. Clin Oral Implants Res 27(11):e125–e133. https://doi.org/10.1111/clr.12575 PubMedCrossRef

22.

Jepsen K, Jepsen S, Zucchelli G, Stefanini M, de Sanctis M, Baldini N, Greven B, Heinz B, Wennstrom J, Cassel B, Vignoletti F, Sanz M (2013) Treatment of gingival recession defects with a coronally advanced flap and a xenogeneic collagen matrix: a multicenter randomized clinical trial. J Clin Periodontol 40(1):82–89. https://doi.org/10.1111/jcpe.12019 PubMedCrossRef

23.

Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M (2009) Clinical evaluation of a new collagen matrix (Mucograft prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: a randomized prospective clinical trial. J Clin Periodontol 36(10):868–876. https://doi.org/10.1111/j.1600-051X.2009.01460.x PubMedCrossRef

24.

Thoma DS, Zeltner M, Hilbe M, Hammerle CH, Husler J, Jung RE (2016) Randomized controlled clinical study evaluating effectiveness and safety of a volume-stable collagen matrix compared to autogenous connective tissue grafts for soft tissue augmentation at implant sites. J Clin Periodontol 43(10):874–885. https://doi.org/10.1111/jcpe.12588 PubMedCrossRef

25.

Sam G, Pillai BR (2014) Evolution of barrier membranes in periodontal regeneration—“are the third generation membranes really here?”. J Clin Diagn Res 8:ZE14–ZE17. https://doi.org/10.7860/JCDR/2014/9957.5272 PubMedPubMedCentral

26.

Sheikh Z, Qureshi J, Alshahrani AM, Nassar H, Ikeda Y, Glogauer M, Ganss B (2017) Collagen based barrier membranes for periodontal guided bone regeneration applications. Odontology/the Society of the Nippon Dental University 105(1):1–12. https://doi.org/10.1007/s10266-016-0267-0 CrossRef

27.

Vignoletti F, Nunez J, Sanz M (2014) Soft tissue wound healing at teeth, dental implants and the edentulous ridge when using barrier membranes, growth and differentiation factors and soft tissue substitutes. J Clin Periodontol 41 Suppl 15:S23–S35. https://doi.org/10.1111/jcpe.12191 PubMedCrossRef

28.

Cortell-Ballester I, Figueiredo R, Valmaseda-Castellon E, Gay-Escoda C (2015) Effects of collagen resorbable membrane placement after the surgical extraction of impacted lower third molars. J Oral Maxillofac Surg 73(8):1457–1464. https://doi.org/10.1016/j.joms.2015.02.015 PubMedCrossRef

29.

Meloni SM, Tallarico M, Lolli FM, Deledda A, Pisano M, Jovanovic SA (2015) Postextraction socket preservation using epithelial connective tissue graft vs porcine collagen matrix. 1-year results of a randomised controlled trial. Eur J Oral Implantol 8(1):39–48PubMed

30.

Perelman-Karmon M, Kozlovsky A, Liloy R, Artzi Z (2012) Socket site preservation using bovine bone mineral with and without a bioresorbable collagen membrane. Int J Periodontics Restorative Dent 32:459–465PubMed

31.

Vignoletti F, Nunez J, Discepoli N, De Sanctis F, Caffesse R, Munoz F, Lopez M, Sanz M (2011) Clinical and histological healing of a new collagen matrix in combination with the coronally advanced flap for the treatment of Miller class-I recession defects: an experimental study in the minipig. J Clin Periodontol 38(9):847–855. https://doi.org/10.1111/j.1600-051X.2011.01767.x PubMedCrossRef

32.

Lorenzo R, Garcia V, Orsini M, Martin C, Sanz M (2012) Clinical efficacy of a xenogeneic collagen matrix in augmenting keratinized mucosa around implants: a randomized controlled prospective clinical trial. Clin Oral Implants Res 23(3):316–324. https://doi.org/10.1111/j.1600-0501.2011.02260.x PubMedCrossRef

33.

Herford AS, Akin L, Cicciu M, Maiorana C, Boyne PJ (2010) Use of a porcine collagen matrix as an alternative to autogenous tissue for grafting oral soft tissue defects. J Oral Maxillofac Surg 68(7):1463–1470. https://doi.org/10.1016/j.joms.2010.02.054 PubMedCrossRef

34.

Basegmez C, Ersanli S, Demirel K, Bolukbasi N, Yalcin S (2012) The comparison of two techniques to increase the amount of peri-implant attached mucosa: free gingival grafts versus vestibuloplasty. One-year results from a randomised controlled trial. Eur J Oral Implantol 5(2):139–145PubMed

35.

Lee KH, Kim BO, Jang HS (2010) Clinical evaluation of a collagen matrix to enhance the width of keratinized gingiva around dental implants. J Periodontal Implant Sci 40(2):96–101. https://doi.org/10.5051/jpis.2010.40.2.96 PubMedPubMedCentralCrossRef

36.

Chiu YW, Lee SY, Lin YC, Lai YL (2015) Significance of the width of keratinized mucosa on peri-implant health. J Chin Med Assoc 78(7):389–394. https://doi.org/10.1016/j.jcma.2015.05.001 PubMedCrossRef

37.

Aroca S, Molnar B, Windisch P, Gera I, Salvi GE, Nikolidakis D, Sculean A (2013) Treatment of multiple adjacent Miller class I and II gingival recessions with a modified coronally advanced tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol 40(7):713–720. https://doi.org/10.1111/jcpe.12112 PubMedCrossRef

38.

Atieh MA, Alsabeeha N, Tawse-Smith A, Payne AG (2016) Xenogeneic collagen matrix for periodontal plastic surgery procedures: a systematic review and meta-analysis. J Periodontal Res 51(4):438–452. https://doi.org/10.1111/jre.12333 PubMedCrossRef

39.

Thoma DS, Sancho-Puchades M, Ettlin DA, Hammerle CH, Jung RE (2012) Impact of a collagen matrix on early healing, aesthetics and patient morbidity in oral mucosal wounds—a randomized study in humans. J Clin Periodontol 39(2):157–165. https://doi.org/10.1111/j.1600-051X.2011.01823.x PubMedCrossRef

40.

Willershausen I, Barbeck M, Boehm N, Sader R, Willershausen B, Kirkpatrick CJ, Ghanaati S (2014) Non-cross-linked collagen type I/III materials enhance cell proliferation: in vitro and in vivo evidence. J Appl Oral Sci 22(1):29–37. https://doi.org/10.1590/1678-775720130316 PubMedPubMedCentralCrossRef

41.

Evian CI, al-Maseeh J and Symeonides E (2003) Soft tissue augmentation for implant dentistry. Compend Contin Educ Dent 24:195–8, 200–2, 204–6; quiz 208

42.

Marquez IC (2004) The role of keratinized tissue and attached gingiva in maintaining periodontal/peri-implant health. Gen Dent 52:74–78 quiz 79PubMed

43.

Schmitt CM, Tudor C, Kiener K, Wehrhan F, Schmitt J, Eitner S, Agaimy A, Schlegel KA (2013) Vestibuloplasty: porcine collagen matrix versus free gingival graft: a clinical and histologic study. J Periodontol 84(7):914–923. https://doi.org/10.1902/jop.2012.120084 PubMedCrossRef

44.

Eufinger H, Gellrich NC, Sandmann D, Dieckmann J (1997) Descriptive and metric classification of jaw atrophy. An evaluation of 104 mandibles and 96 maxillae of dried skulls. Int J Oral Maxillofac Surg 26(1):23–28. https://doi.org/10.1016/S0901-5027(97)80841-7 PubMedCrossRef

45.

Jung RE, Hurzeler MB, Thoma DS, Khraisat A, Hammerle CH (2011) Local tolerance and efficiency of two prototype collagen matrices to increase the width of keratinized tissue. J Clin Periodontol 38(2):173–179. https://doi.org/10.1111/j.1600-051X.2010.01640.x PubMedCrossRef

46.

Thoma DS, Hilbe M, Bienz SP, Sancho-Puchades M, Hammerle CH, Jung RE (2016) Palatal wound healing using a xenogeneic collagen matrix—histological outcomes of a randomized controlled clinical trial. J Clin Periodontol 43(12):1124–1131. https://doi.org/10.1111/jcpe.12624 PubMedCrossRef

Title: Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients
Authors: Daniel S. Thoma
AbdulMonem Alshihri
Alain Fontolliet
Christoph H. F. Hämmerle
Ronald E. Jung
Goran I. Benic
Publication date: 01-06-2018
Publisher: Springer Berlin Heidelberg
Published in: Clinical Oral Investigations / Issue 5/2018
Print ISSN: 1432-6981
Electronic ISSN: 1436-3771
DOI: https://doi.org/10.1007/s00784-017-2319-4

At a glance: The STEP trials

Springer Medicine

Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients

Abstract

Objectives

Materials and methods

Results

Conclusion

Clinical relevance

At a glance: The STEP trials

Springer Medicine

Abstract

Objectives

Materials and methods

Results

Conclusion

Clinical relevance

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