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Various surgical flap advancement techniques for bone regeneration have been described in the literature; however, the clinical challenges of managing tissue that contains scars or embedded foreign materials have not been thoroughly described, especially around metal foramen. Fibrotic and thickened scar periosteum as well as mental foramen restrict the tissue from responding in the same way as native tissue. Therefore, additional considerations and approaches must be considered to achieve tension-free flap closure. This article presents a flap advancement classification that describes three common clinical scenarios based on the periosteum and soft tissue quality and provides surgical approaches for tissue management in each classification, with a focus on flap advancement around the mental foramen.

Severe alveolar ridge deficiencies in concomitance with periodontal attachment loss can represent a serious clinical challenge in the context of implant therapy. The present case report describes the management of a complex defect in the esthetic zone via ridge augmentation and periodontal regenerative therapy using a biologic material. A systemically healthy 55-year-old man diagnosed with peri-implantitis around an implant in the maxillary left central incisor position and with severe bone loss on the mesial aspect of the maxillary left lateral incisor underwent several surgical interventions to achieve simultaneous vertical ridge augmentation and periodontal regeneration. These interventions included implant removal, bone augmentation using a composite bone graft (autogenous bone + xenograft particles), and a bioactive protein (recombinant human platelet-derived growth factor), soft tissue augmentation using connective tissue grafts, and peri-implant keratinized mucosa width augmentation via a labial gingival graft strip and a xenogeneic collagen matrix. Substantial gains in vertical bone and clinical attachment were achieved, which allowed for delayed implant placement and subsequent completion of tooth replacement therapy with an implant-supported prosthesis. The present case report demonstrates how simultaneous vertical ridge augmentation and periodontal regeneration can be achieved to manage a challenging clinical situation. Key factors to consider in this type of scenario are proximal bone level, tooth mobility, surgical flap design and management, biomaterial selection, and proper treatment sequencing.

The aim of the present study was to generate an international and multidisciplinary consensus on the clinical management of implant protrusion into the maxillary sinuses and nasal fossae. A total of 31 experts participated, 23 of whom were experts in implantology (periodontologists, maxillofacial surgeons and implantologists), 6 were otolaryngologists and 2 were radiologists. All the participants were informed of the current scientific knowledge on the topic based on a systematic search of the literature. A list of statements was created and divided into three surveys: one for all participants, one for implant providers and radiologists and one for otolaryngologists and radiologists. A consensus was reached on 15 out of 17 statements. According to the participants, osseointegrated implants protruding radiographically into the maxillary sinus or nasal fossae require as much monitoring and maintenance as implants fully covered by bone. In the event of symptoms of sinusitis, collaboration between implant providers and otolaryngologists is required. Implant removal should be considered only after pharmacological and surgical management of sinusitis have failed. Keywords: consensus, dental implants, maxillary sinus, nasal fossae Conflict-of-interest statement: The authors declare there are no conflicts of interest relating to this study.

Implant-related esthetic demands have increased tremendously in recent years. The presence of shallow papillae or open interproximal spaces (black triangles) are some of the most troubling dilemmas in dentistry. Among the many factors associated with the presence of papilla or papilla height, the interproximal bone is one of the main factors dictating the presence of an adequate papilla between implants. The present case report describes a patient with severe hard and soft tissue deficiencies with a high smile line in the esthetic zone, requiring multiple implants. The step-by-step process of the utilized techniques for achieving inter-implant papilla reconstruction through a multidisciplinary approach using both hard and soft tissue augmentation procedures, as well as soft tissue conditioning with customized abutments, is delineated.

Several techniques involving the harvesting of a soft tissue graft from the palate have been proposed for regenerating keratinized mucosa (KM) at implant sites. However, patient morbidity and poor esthetic outcomes are considered the main drawbacks of these approaches. Therefore, the aim of this study was to describe and evaluate a new technique for harvesting keratinized tissue from the adjacent labial site (labial gingival graft [LGG]), in combination with a xenogeneic collagen matrix (XCM) or a connective tissue graft (CTG). Eighteen patients were enrolled and participated in this case series. The primary outcomes were KM gain after 12 months and patient-reported satisfaction, esthetics, and morbidity using a visual analog scale (VAS). All treated sites healed uneventfully, showing a mean KM gain of 6.8 ± 2 mm. The average VAS score for patient satisfaction and the self-reported esthetic outcomes were 95.6 ± 6.9 and 93.4 ± 9.2, respectively, and the score for morbidity was 22.8 ± 22.3. However, the VAS score for morbidity dropped to 8.7 ± 8.4 when CTG-treated subjects were excluded. Higher esthetic results were observed when XCM was used instead of CTG and when LGG was harvested from the anterior region of the implant site (P < .05 for both comparisons). LGG with XCM or CTG is a viable technique for regenerating KM at implant sites with high patient satisfaction and esthetics and low morbidity outcomes.

The significance of keratinized mucosa around dental implants for the prevention of biologic complications has been a subject of controversy. Agreement, however, exists on the benefits provided to achieve more satisfactory oral hygiene measures and reduced clinical inflammation. A prospective interventional case series of 14 patients (31 implants) were examined every 3 months for up to 12 months. The effect of soft tissue conditioning by means of free autologous epithelial graft on the management of peri-implantitis with supracrestal and/or dehiscence-type defect morphology was evaluated. All clinical parameters were significantly reduced (P < .001), with complete disease resolution in 78.6% of the patients and 87.1% of the peri-implantitis implants. Unsuccessful cases were associated with less gain of keratinized mucosa, deep probing pocket depths, bleeding on probing, and less satisfaction during brushing at 12 months. Dimensional changes following soft tissue grafting were more significant during the first 3 months and led to a 42.4% shrinkage at 12 months. Soft tissue conditioning by means of free autologous epithelial graft in combination with apically positioned flap is a viable and effective therapy to manage peri-implantitis associated with deficient keratinized mucosa.

Purpose: There is a lack of knowledge concerning the critical buccal bone thickness required for securing favorable functional and esthetic outcomes, conditioned to the dimensional changes after implant placement. A preclinical study was therefore carried out to identify the critical buccal bone wall thickness for minimizing bone resorption during physiologic and pathologic bone remodeling. Materials and Methods: A randomized, two-arm in vivo study in healthy beagle dogs was carried out. The first group of dogs was sacrificed 8 weeks after implant placement for histomorphometric examination of postsurgical resorption of the buccal bone wall. The second group of dogs was monitored during three ligature-induced peri-implantitis episodes and a spontaneous progression episode. Morphometric and clinical variables were defined for the study of physiologic and pathologic buccal and lingual bone loss. Results: Seventy-two implants were placed in healed mandibular ridges of 12 beagle dogs. Two groups were defined: 36 implants were placed in sites with a thin buccal bone wall (< 1.5 mm), and 36 were placed in sites with a thick buccal bone wall (≥ 1.5 mm). No implants failed during the study period. For the great majority of the histomorphometric parameters, a critical buccal bone wall thickness of at least 1.5 mm seemed to be essential for maintaining the buccal bone wall during physiologic and pathologic bone resorption. Suppuration (+) and mucosal recession (-) were more often associated with implants placed in sites with a thin buccal bone wall. Conclusion: A critical buccal bone wall thickness of 1.5 mm at implant placement is advised, since a thicker peri-implant buccal bone wall (≥ 1.5 mm) is exposed to significantly less physiologic and pathologic bone loss compared with a thinner buccal bone wall (< 1.5 mm). Keywords: alveolar bone, dental implants, diagnostic, implant stability, peri-implant mucositis, peri-implantitis

Predictable and effective surgical techniques that aim to increase the width of keratinized gingiva, relocate the mucogingival junction, and deepen the vestibule often involve soft tissue autografts; however, soft tissue autograft supply is limited and its harvesting is associated with patient morbidity. With a strip autograft and xenogeneic collagen matrix (XCM) technique combination, autograft harvest requirements and patient morbidity are reduced. In this histologic evaluation, 12 strip autograft/XCM biopsy samples were compared with 3 reference samples of palatal strip autografts. Tissue morphology, keratin, and collagen expression appear identical, indicating that the combined grafting technique provides desired and physiologically normal keratinized gingiva.