Abstract
This review is based on a
Cochrane systematic review entitled 'Interventions for replacing missing
teeth: management of soft tissues for dental implants' published in The
Cochrane Library (see http:// www.cochrane.org/ for information).
Cochrane systematic reviews are regularly updated to include new
research, and in response to comments and criticisms from readers. If
you wish to comment on this review, please send your comments to the
Cochrane website or to Marco Esposito. The Cochrane Library should be
consulted for the most recent version of the review. The results of a
Cochrane review can be interpreted differently, depending on people's
perspectives and circumstances. Please consider the conclusions
presented carefully. They are the opinions of the review authors, and
are not necessarily shared by the Cochrane Collaboration. Purpose: To
evaluate whether flapless procedures are beneficial for patients and
which is the ideal flap design, whether soft tissue
correction/augmentation techniques are beneficial for patients and which
are the best techniques, whether techniques to increase the
peri-implant keratinised mucosa are beneficial for patients and which
are the best techniques, and which are the best suturing techniques/
materials. Materials and methods: The Cochrane Oral Health Group's
Trials Register, CENTRAL, MEDLINE and EMBASE were searched up to the 9th
of June 2011 for randomised controlled trials (RCTs) of rootform
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. Primary outcome measures were prosthetic
failures, implant failures and biological complications. 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. The statistical unit was
the patient and not the prosthesis, the procedure or the implant.
Results were expressed using risk ratios for dichotomous outcomes and
mean differences for continuous outcomes with 95% confidence intervals
(CI). Results: Seventeen potentially eligible RCTs were identified but
only six trials with 138 patients in total could be included. The
following techniques were compared in the six included studies: flapless
placement of dental implants versus conventional flap elevation (2
trials, 56 patients), crestal versus vestibular incisions (1 trial, 10
patients), Erbium:YAG laser versus flap elevation at the second-stage
surgery for implant exposure (1 trial, 20 patients), whether a
connective tissue graft at implant placement could be effective in
augmenting peri-implant tissues (1 split-mouth trial, 10 patients), and
autograft versus an animal-derived collagen matrix to increase the
height of the keratinised mucosa (1 trial, 40 patients). On a patient
rather than per implant basis, implants placed with a flapless technique
and implant exposures performed with laser lead to statistically
significantly less postoperative pain than flap elevation. Sites
augmented with soft tissue connective grafts had better aesthetics 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 cost of a 0.5 mm recession of peri-implant soft tissues.
There were no other statistically significant differences for any of the
remaining analyses. 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 and 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 cost 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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