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Purpose: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. Materials and methods: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. Results: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. Conclusion: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable. Keywords: diagnostic procedure, implant dentistry, lateral window technique, pterygoid implants, sinus floor elevation, transcrestal sinus floor elevation, zygomatic implants The authors report no conflicts of interest relating to this study.

Implant esthetic complications can negatively affect a patient's perception of implant therapy and their quality of life. This article discusses the etiology, prevalence, and strategies for the treatment of peri-implant soft tissue dehiscences/deficiencies (PSTDs). Three common scenarios of implant esthetic complications were identified and described, in which PSTDs could be managed without removing the crown (scenario I), with the surgical-prosthetic approach (crown removal; scenario II), and/or with the horizontal and vertical soft tissue augmentation and submerged healing (scenario III).

Purpose: To describe the treatment of malpositioned implants in the esthetic area using the angulated welded abutment (AWA) approach together with peri-implant soft tissue surgery. Materials and Methods: A clinical case with extreme buccal angulation of two implants in the anterior maxilla was used to illustrate the AWA technique. After implant impression-taking, digital analysis was used to determine the ideal prosthetic angulation of the abutment and the ideal position of its screw hole in relation to the gingival margin of the adjacent teeth. The AWA was designed in two combinable components that were meant to be welded together. Before the welding process, an angulated screw was included in the abutment. Since the angulated screw was inside the abutment, the screwdriver hole could be designed as narrow as possible and put in an ideal position. After periodontal and peri-implant surgery were carried out, the AWA was applied to the implants. Results: The AWA allowed correction of the prosthetic axis. Moreover, relocation of the screw hole allowed the gingival tissue to creep over the abutment. In this way, a new esthetic restoration can be placed after the mucogingival surgery. Conclusion: The excessive misangulation of the implants was efficiently recovered. Further studies are needed to evaluate long-term clinical success, and standardization of this technique is required for routine clinical use.

Common challenges encountered for atrophic maxilla rehabilitation are the inadequate width and height of attached keratinized mucosa (AKM) and shallow vestibular depth. This study presents a buccally displaced palatal (BDP) flap technique to increase the tissue thickness and AKM width at the second-stage surgery and reestablish the correct fornix depth. The peri-implant pocket depths, modified Plaque Index score, modified sulcus Bleeding Index score, and soft tissue recession were evaluated 6 and 12 months after prostheses loading. A total of 52 implants were placed and analyzed, and no implant failures were found. No significant changes in peri-implant parameters were observed between 6 and 12 months, and mean recession was less than 0.2 mm after 12 months. Though this change was statistically significant, it was clinically irrelevant. The results demonstrate that adequately healthy peri-implant soft tissues and substantial dimensional stability of vestibular soft tissues at the 1-year follow-up were achieved with the BDP flap technique. The BDP flap could represent a viable option for increasing the width and the height of AKM and establishing the correct maxillary fornix depth.

Autogenous soft tissue grafting is a commonly performed procedure in periodontal and implant surgery. Reharvesting a connective tissue graft (CTG) from the same palatal donor site is often required, but little is known about the volumetric changes that occur after harvesting a free gingival graft and how long the palatal mucosa takes to regain its original form and thickness. This study evaluated the volumetric changes that occur at the palatal donor site after harvesting a soft tissue graft with a noninvasive digital technology. Nineteen patients needing a CTG for a single site were enrolled. Intraoral digital scans of the palatal donor sites were obtained at baseline and at 1, 3, 6, and 12 months. The digital scans were imported and analyzed with an imaging software to evaluate volumetric changes. Average volume losses of 5.82 ± 2.63 mm³ and 11.03 ± 5.47 mm³ were observed after 1 and 3 months, respectively. Only minor changes were observed at 6 and 12 months. Linear dimensional changes at 5 and 7 mm from the gingival margin were substantially higher than the changes at 3 mm for the 1- and 3-month interval comparisons compared to baseline. Graft dimension was associated with volume loss at 1 and 3 months (P < .01). After palatal harvesting, the donor site undergoes volumetric changes, mostly during the first 3 months, and is attenuated thereafter.

Tooth malposition negatively affects the outcome of root coverage procedures, limiting chances for complete root coverage (CRC). This case series introduces a combined orthodontic-mucogingival approach for the treatment of deep (> 4 mm) isolated gingival recession defects affecting mandibular incisors with a buccally displaced root. Twenty patients were treated with a novel orthodontic device (FZ Root Torque Controller) for selective correction of tooth malposition at the affected site, turning all isolated recessions into Miller Classes I and II. Subsequent surgical treatment of the gingival recession with a vertically-coronally advanced flap plus a connective tissue graft achieved 90% CRC at the 1-year follow-up, with a recession reduction of 5.6 ± 1.5 mm, a 1.24 ± 0.24 mm increase in gingival thickness, and improved esthetic outcomes.

The gingival thickness (GT) and keratinized tissue width (KTW) constitute the gingival phenotype, a concept that has received a great deal of appreciation in recent years. Gingival phenotype modification has been achieved via different surgical techniques and grafting materials. Despite the superiority of autogenous grafts, their increased patient morbidity and limited recourse has led to the development of graft substitutes. The human dermal matrix is a notable example that, depending on its processing method, can become freeze-dried or solvent-dehydrated acellular dermal matrix (FDADM and SDADM, respectively). This article reports the 9-year outcomes of a randomized clinical trial regarding gingival phenotype modification following root coverage with FDADM and SDADM. Twelve of the original 20 patients were available at the 9-year follow-up. Overall, the outcomes of gingival phenotype modification were maintained in both groups and at all sites after 9 years. For KTW, an incremental increase was observed over time in both groups, and minimal or no changes were noted in GT from the 1-year recall to the 9-year recall. However, the gingival margin level showed an apical shift for both groups.

The coronally advanced flap technique is one of the most commonly used approaches for treating gingival recession. Several modifications of the technique have been proposed over the years, making it a highly predictable treatment option for gingival recession; however, as dental implants are structurally and biologically different from natural teeth, a further modification of the conventional coronally advanced flap technique has been suggested to overcome the challenges posed by the treatment of peri-implant soft tissue dehiscences. The present article aims to describe the state of the art of the technique at implant sites presenting with peri-implant soft tissue dehiscences, and highlight the main differences between this and the coronally advanced flap approach in natural teeth. The timing of crown removal and abutment modification/replacement are discussed, along with the different methods for management of the flap and connective tissue graft that are recommended at implant sites. The outcomes of this approach compared to the conventional coronally advanced flap technique, and other approaches are also presented. Keywords: connective tissue graft, dental implants, gingival recession, soft tissue augmentation, surgical flap Conflict-of-interest statement: The authors do not have any financial interests, either directly or indirectly, in the products or information listed in the paper.