The esthetic buccal flap, which allows access to the apical area of a tooth or extraction socket via a submarginal incision, was initially introduced for buccal fenestration defects correction during immediate implant placement. This case report describes its expanded use for ridge augmentation at the time of extraction when immediate implant placement is not indicated. The esthetic buccal flap was used for ridge augmentation in three patients with significant maxillary anterior hard tissue defects. At the time of implant placement, which was delayed five to six months, soft tissue augmentation was performed to enhance esthetic outcomes. After provisionalization, final restorations were delivered, and esthetics were assessed using the modified Pink Esthetic Score (mPES). All three cases obtained mPES scores of 9 or 10, which indicates excellent soft tissue contour, symmetry, and integration. Within the limitations of this case report, these results indicate that the esthetic buccal flap is a minimally invasive, soft tissue preserving technique that can be adapted to treat complex alveolar ridge defects. In combination with newer biomaterials and the use of a delayed implant procedure, this strategy provides predictable results for regenerative as well as esthetic success in difficult anterior cases.
This split-mouth randomized controlled trial evaluated the effect of implant surface roughness (hybrid vs. moderately rough) on long-term crestal bone remodeling and peri-implant health. Oral Health-related Quality of Life (OHRQoL) was evaluated after 1 and 8 years. Twenty-four fully edentulous patients received a mandibular overdenture supported by two implants: one with a complete moderately rough (DCC) surface (Sa: 1.3 μm, Sdr: 60%) and one hybrid (MSC) implant, with a minimally rough machined surface (Sa: 0.9 μm, Sdr: 34%) at the coronal 3 mm. After 8 years, 19 patients (38 implants) were evaluated. Crestal bone loss (CBL) was measured radiographically at 1, 6, and 8 years. Plaque score, bleeding on probing (BoP), probing pocket depth (PPD), and OHRQoL (OHIP-14) were assessed at 1 and 8 years. There were no implant failures. CBL after 8 years was 0.43 mm (MSC) and 0.48 mm (DCC), with no significant difference (p > 0.05). Periodontal parameters were comparable, and the improvement in OHRQoL remained stable. Two-implant bar-retained mandibular overdentures showed high survival, stable bone levels, and sustained improvement in OHRQoL after 8 years. No differences were detected between both implant surfaces under the conditions of this study.
This cross-sectional study aimed to evaluate the diagnostic accuracy, reliability, and reproducibility of visual digital image-based assessments of peri-implant keratinized mucosa width (KMW) and mucosal thickness (MT) compared with direct clinical measurements. Calibrated evaluators assessed KMW and MT, standardized intraoral photographs, and intraoral scans (IOS) obtained from adult patients with non-molar implant-supported prostheses. Diagnostic accuracy was determined using sensitivity, specificity, predictive values, diagnostic odds ratios (DOR), and receiver operating characteristic (ROC) curve analysis. Inter- and intra-observer agreement were assessed using Fleiss' kappa, weighted kappa, and intraclass correlation coefficients (ICC). Based on sample size calculation, a total of 60 patients with 60 non-molar implant-supported prostheses were included. Twenty calibrated evaluators with different professional backgrounds assessed 140 digital images, with 20 images repeated. This resulted in 2800 KMW and 2800 MT evaluations. Overall, a limited ability to distinguish inadequate from adequate KMW and thin from thick MT was shown when assessing digital images. Photographs tended to be associated with slightly higher sensitivity and specificity than IOS, with overall sensitivity ranging from 31.3% to 56.9% and specificity from 45.6% to 63.7% across modalities. ROC analysis confirmed poor discriminatory capacity for both imaging modalities, with area under the curve values ranging from 0.427 to 0.633. Inter-observer agreement was generally fair, whereas intra-observer reproducibility remained poor across evaluator groups and imaging modalities. In conclusion, visual assessment of peri-implant KMW and MT based on digital imaging demonstrated limited diagnostic accuracy and reproducibility compared with direct clinical measurements.
The accuracy of full-arch implant impressions is critical for prosthetic passivity and long-term clinical success. This study compared the trueness and repeatability of twelve digital impression systems (DIS), including nine intraoral scanners (IOS) and three stereophotogrammetric (SPG) systems, for a fully edentulous maxilla restored with eight multi-unit abutments (MUAs). Accuracy was assessed using a coordinate measuring machine-derived reference model and a clinically driven 'worst-MUA' approach, considering the suprastructure as a single functional unit. Trueness and repeatability were evaluated along vertical (Z), horizontal (XY), three-dimensional, and angular dimensions across five repeated acquisitions per system. Significant variability in both trueness and repeatability was observed among DIS. Median trueness deviations ranged from 0.009-0.042 mm (Z), 0.027-0.117 mm (XY), 0.026-0.107 mm (3D), and 0.140°-0.427° (angular). Median repeatability deviations ranged from 0.0014-0.0230 mm (Z), 0.0015-0.0380 mm (XY), 0.0016-0.0372 mm (3D), and 0.0217°-0.1558° (angular). Principal component analysis identified three performance clusters: high-performing systems (Itero Lumina, Imetric 4D, Shining 3D scan, Primescan2), intermediate systems (Shining 3D photogrammetry, Medit i900, Primescan, Panda Eletra, Medit i700, Nobel Fast Map), and low-performing scanners (Trios5, Trios6). Errors were more pronounced at terminal arch positions, on MUAs #1 and #8. These findings highlight the system-dependent nature of digital impression accuracy and demonstrate that several next-generation intraoral scanners achieved accuracy levels comparable to those of photogrammetric systems under the standardized in vitro conditions of this study.
Contemporary full-arch implant rehabilitation increasingly incorporates digital workflows and staged prototyping. However, delayed-loading cases continue to require a structured method for transferring prosthetic and biologic information during the transition from removable to fixed prostheses. This technique report introduces the QuadroJig protocol, an analog-driven, transdisciplinary workflow that enables simultaneous acquisition of implant position, occlusal relationships, esthetic parameters, and peri-implant soft-tissue dimensions. A stabilized intraoral construct derived from a flangeless denture duplicate permits vertical bone sounding to guide prosthetically driven periosteal mapping and execution at prosthetic loading, including gingivoplasty or selective flap modification when indicated. By reverse-engineering the prosthetic tissue junction, the protocol supports fabrication of a prototype-level prosthesis while preserving coordination between prosthetic design and peri-implant anatomy. The construct may be incorporated into either a conventional analog or a hybrid analog-digital workflow, allowing both clinical execution and digital verification. Consequently, the QuadroJig protocol serves as a prosthetic-periodontal co-acquisition and execution workflow, offering a practical approach to delayed full-arch rehabilitation, particularly in digitally underserved clinical arenas.
In tooth replacement therapy with implant-supported prostheses, optimal outcomes depend on a wide range of variables, including anatomic, phenotypic, surgical, and prosthetic factors. Adequate management of the restorative interface is particularly important for achieving predictable esthetic outcomes in the anterior maxilla and for maintaining long-term soft and hard tissue health and stability. This article describes an approach based on the use of intermediate multi-unit abutments on bone-level implants. A comprehensive workflow is presented, integrating digital planning, surgical protocols, and prosthetic strategies for both immediate and delayed implant placement. In immediate implant placement, these intermediate abutments may be used as adjuncts to ridge preservation and reconstructive procedures by facilitating provisional restoration and supporting peri-implant tissue stability. In delayed implant placement, they may promote bone preservation between adjacent implants, potentially reducing the remodeling associated with repeated retrieval and insertion of prosthetic components directly onto the implant platform. This therapeutic strategy may help maintain stable marginal bone levels, support long-term peri-implant tissue health, esthetics, and, in specific situations, compensate for suboptimal implant position.
INTRODUCTION:Achieving tension-free flap closure is a critical challenge in vertical ridge augmentation of the anterior maxilla, where anatomical constraints limit flap mobility and soft tissue advancement. This study compares the split-thickness flap (control) and sub-orbicularis full-thickness flap (test) in cadaveric models to evaluate their impact on soft tissue thickness, flap integrity following periosteal release, and mucogingival junction (MGJ) displacement. The goal is to characterize and optimize surgical approaches for vertical bone augmentation in the anterior maxilla. MATERIALS AND METHODS:Twelve edentulous human cadaveric maxillae were randomized to receive either split-thickness or sub-orbicularis full-thickness flap preparation in a split-mouth design. Standardized alveolar ridge conditions were established. Primary outcome was postoperative soft tissue thickness measured with high-frequency ultrasonography (HFUS); secondary outcomes were flap structural integrity assessed with HFUS and MGJ displacement evaluated using 3D optical scan superimposition). RESULTS:Ultrasound revealed significant soft tissue thickness differences at 0 mm (0.45 mm, P = 0.009), 2 mm (-0.31 mm, P = 0.015), and 4 mm (-0.42 mm, P = 0.024) apical to the crest. Flap trauma was greater in the control group, with hypoechoic zones near deep vascular structures. The test group showed minimal soft tissue and vascular damage. MGJ displacement did not differ significantly between groups. CONCLUSION:Both groups achieved tension-free flap closure. However, the 0.45 mm reduction in soft tissue thickness associated with the split-thickness flap may compromise blood supply and elevate the risk of tissue compression. Additionally, inadvertent trauma to deeper vascular structures in this group could delay healing and increase the likelihood of postoperative complications.
Full circumferential application of biologically oriented preparation concepts in prosthetic retreatment remains highly technique sensitive and may compromise prosthetic margin control. This concept-driven clinical report describes a mixed vertical preparation strategy that differentiates cervical objectives by tooth surface to balance periodontal tissue conditioning with prosthetic predictability. Based on a selective literature review and one illustrative clinical case, a vertical preparation performed according to Biologically Oriented Preparation Technique (BOPT) principles, combined with provisional-driven biologically oriented tissue conditioning, is confined to the vestibular surface where esthetic integration is most critical. A VertiPrep-type preparation is applied on proximal and palatal surfaces to preserve epithelial attachment and ensure a controlled prosthetic margin. The provisional restoration is central to the therapeutic mechanism, guiding soft tissue maturation over a 6 to 8-week healing period. Vestibular tissue conditioning allowed localized modulation of marginal tissue thickness. Proximal and palatal VertiPrep facilitated precise margin positioning and improved communication with the dental laboratory. This mixed vertical preparation approach represents a pragmatic option for selected crown retreatment scenarios, particularly when attempting to balance vestibular soft tissue conditioning with proximal/palatal margin control. Further prospective controlled studies are required to confirm its clinical predictability and long-term outcomes.
This pilot split-mouth randomized clinical trial aimed to compare the stability of the gingival margin following esthetic clinical crown lengthening surgery performed with electronic scalpel versus conventional scalpel blade. Patients indicated for esthetic crown lengthening in non-molar area of the maxilla were selected. Gingivoplasty was performed using an electronic scalpel (test) and a conventional scalpel blade (control) in contralateral quadrants. Intraoral scanning was conducted preoperatively and postoperatively at 15 and 180 days. Gingival margin migration between 15 and 180 days of follow up was measured in millimeters using 3D model superimposition. Patient-reported outcomes were assessed using visual analogue scales. Fourteen patients were enrolled, and ten completed the 180-day follow-up. Gingival margin migration was minimal and comparable between groups, with no significant intra- or inter-group differences for any tooth type (p > 0.05). Median migration was 0.26 mm for the electronic scalpel group and 0.20 mm for the conventional scalpel group. Patient-reported outcomes were similar, with most participants reporting greater comfort with the electronic scalpel. Both electronic and conventional scalpels resulted in stable gingival margin positioning over 180 days, with minimal migration from early healing stages. These findings support the clinical use of either technique for esthetic crown lengthening procedures.
BACKGROUND:Successful root coverage with or without connective tissue graft (CTG) in the mandibular anterior region is influenced by multiple factors, including flap mobility, stability, and the effectiveness of periosteal and mucosal releasing incisions. However, the underlying musculature-particularly the mentalis (MT) and incisivus labii inferioris (ILI)- has been described macroscopically but remains insufficiently characterized histologically. This study aimed to clarify the anatomical structures relevant to these procedures. METHODS:Twelve hemi-mandibles from six adult cadaveric heads were examined using gross dissection (n = 4 hemi-mandibles) and histological analysis (n = 8 hemi-mandibles). The morphology of the MT and ILI were assessed following standardized dissection and Masson trichrome staining protocols. RESULTS:The MT and ILI consistently originated from the alveolar bone of the central and lateral incisors, with no midline attachment. The MT comprised two distinct portions: a superior part that integrated with the orbicularis oris and an inferior part that ran toward the subcutaneous tissue. Histological findings corroborated gross anatomy. The broad muscular attachments suggest limited flap extensibility in the mandibular anterior region, while the absence of major neurovascular structures within MT indicates that deeper releasing incisions may be anatomically feasible; however, such approaches should be undertaken with caution under direct visualization, and with awareness of adjacent neurovascular structures. CONCLUSIONS:Recognizing these anatomical features of the MT/ILI complex provides an anatomical basis for understanding flap stability and predictability in mandibular anterior mucogingival surgery.
The rehabilitation of worn dentition involves both indirect and direct techniques. Although direct techniques are becoming popular, standardized protocols are lacking and often the final esthetic and functional outcome is extremely technique sensitive. This article describes a new standardized approach to full-mouth direct rehabilitation using the "Composite Ball Technique.' The method offers improved stabilization of a transparent silicone index, ensures accurate transfer of the planned wax-up and facilitates composite excess removal during the restoration procedure.
This split-mouth trial investigated the efficacy of treating bilateral gingival recessions with either a xenogeneic cross-linked collagen matrix (CCM) or recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with a bone allograft (AG). Ten patients were treated with a coronally advanced flap, either with CCM or rhPDGF-BB + AG. The primary outcome was percentage of mean root coverage (mRC) at 12 months. Additional outcomes included clinical and volumetric measurements; patient-reported outcome measures (PROMs) for pain, swelling, and esthetics; and ultrasonographic assessment of gingival thickness (GT) and position of the buccal bone. At 12 months, both groups showed significant improvements, with an mRC of 78.6% in the CCM group and 82.3% in the rhPDGF-BB + AG group. A 3D analysis of both groups showed comparable volumetric gain. CCM-treated sites displayed higher ultrasonographic echogenicity in GT (P < .01) than rhPDGF-BB + AG sites. The rhPDGF-BB + AG group showed greater reductions in the buccal bone dehiscence (mean: 2.03 mm; P < .01), less swelling during the first 3 days, and slightly greater mRC. CCM and rhPDGF-BB + AG were effective in treating multiple adjacent gingival recessions. CCM promotes greater gains in gingival thickness, while rhPDGF-BB + AG resulted in significantly less buccal bone dehiscenace.
BACKGROUND:Recession Type 1 (RT1) multiple adjacent gingival recessions (MAGR) represent a clinically relevant condition and may compromise esthetics and function. Connective tissue grafts (CTG) remain the reference treatment but involve donor-site morbidity. Porcine acellular dermal matrices (PADM) have been proposed as substitutes. This prospective exploratory case series evaluated the clinical performance of the modified coronally advanced tunnel (MCAT) combined with a PADM, while also exploring microcirculatory behavior assessed by laser speckle contrast imaging (LSCI) and volumetric soft tissue changes. METHODS:Fifteen patients with 92 RT1 recession defects were treated using MCAT and a PADM (NovoMatrix®) in this prospective, single-center exploratory case series. The primary clinical outcome was site-level mean root coverage (MRC) at 6 months and 1 year, with recession sites clustered within patients. Key secondary outcomes were microcirculatory perfusion assessed by laser speckle contrast imaging (LSCI) in 53 sites, volumetric soft tissue change, and complete root coverage (CRC). RESULTS:At 6 months and 1 year, MRC was 73.2%, and CRC was achieved at 52.2% of sites. Recession depth and width decreased significantly (p < 0.001), while keratinized tissue width remained stable. Volumetric gain averaged 71.0 ± 37.4 mm³ at 6 months and 46.2 ± 23.5 mm³ at 1 year; values remained significantly above baseline at both time points, while volumetric gain decreased significantly from 6 months to 1 year (p < 0.001). Microcirculatory measurements showed an early reduction in perfusion followed by partial recovery over time, although some regions remained below baseline at later follow-up time points. Modest but significant site-level correlations were observed between day-30 perfusion and MRC at 6 months and 1 year. CONCLUSIONS:Within the limitations of this prospective exploratory case series, MCAT with PADM was associated with clinically relevant root coverage and supportive volumetric and microcirculatory findings in RT1 MAGRs.
BACKGROUND:Periodontal regenerative approaches have demonstrated predictable outcomes mainly in contained intrabony defects, where residual bony walls provide space maintenance and wound stability. Non-contained vertical periodontal defects lack these anatomical prerequisites and are therefore generally considered unsuitable for regenerative treatment, often leaving resective approaches or tooth extraction as the only therapeutic options. OBJECTIVE:The objective of this proof-of-concept report was to describe a novel reconstructive surgical technique =(PerioTAG (tuberosity autogenous graft for periodontal reconstruction) designed to recreate a stable three-dimensional compartment to support periodontal reconstruction and defect stabilization, and to illustrate its clinical feasibility through representative cases. MATERIALS AND METHODS:Three patients presenting with non-contained vertical periodontal defects in the anterior maxilla were treated using the PerioTAG technique. This approach involves reconstruction of the defect with an autogenous corticocancellous block graft harvested from the maxillary tuberosity and rigidly fixed to re-establish a three-dimensional bony compartment. Clinical and radiographic outcomes were evaluated over follow-up periods of up to three years. RESULTS:In all cases, the PerioTAG technique allowed stabilization of non-contained vertical periodontal defects, contributing to the preservation of the affected teeth and maintenance of periodontal support. Healing was uneventful, and clinical and radiographic follow-up demonstrated stable periodontal conditions with minimal impact on the esthetic appearance. CONCLUSIONS:Within the limitations of this proof-of-concept report, the PerioTAG technique may represent a reconstructive option for the management of non-contained vertical periodontal defects not amenable to conventional regenerative or resective approaches. Further controlled studies are required to assess its predictability and long-term stability.
Adequate keratinized mucosa width (KMW) is important for maintaining peri-implant health, mechanical stability, and patient comfort. Although the free gingival graft (FGG) remains the most predictable method for increasing KMW, harvesting large grafts is often limited by palatal donor-site anatomy and associated morbidity. The slit free gingival graft (slit-FGG) is a straightforward modification that enables controlled width expansion without compromising structural continuity, thereby reducing donor tissue requirements. In this technique, a single full-thickness longitudinal incision is made in the harvested graft, creating two juxtaposed ribbons connected by intact lateral platforms. These ribbons can be displaced unidirectionally or bidirectionally to achieve the desired expansion and adapted over an apically positioned mucosa on a prepared periosteal bed. Four systemically healthy patients with insufficient KMW in large edentulous areas were treated using the slit-FGG as part of staged implant therapy. All patients reported minimal postoperative discomfort, and at 6 months the augmented sites demonstrated stable vestibular depth and maintained increases in KMW. Within the limitations of this report, the slit-FGG appears to represent a practical graft-efficient alternative for peri-implant soft-tissue phenotype modification when donor tissue is limited or extensive coverage is required.
This prospective, single-arm observational cohort study evaluated 6-year outcomes of inverted body-shift implants placed in the maxillary esthetic zone. Twenty-six patients received twenty-six implants (19 immediate placements, 7 in healed ridges). Buccal grafting was performed in twenty sites (12 xenograft, 8 allograft) and omitted in six. Cone-beam computed tomography (CBCT) and intraoral scanning were used to measure buccal-bone thickness and soft-tissue stability at baseline, 18-24 months, and 74-84 months. All implants survived (100%) at a mean follow-up of 80.0 ± 6.7 months, and no major complications were reported. Mean labial plate remodeling after six years was -0.27 mm (L1) and -0.37 mm (L2). Pink Esthetic Scores (PES) averaged 12.8, with 15 implants scoring >13. Within the limitations of this small, uncontrolled cohort and descriptive design, these findings suggest favorable long-term survival and maintenance of hard- and soft-tissue contours associated with inverted body-shift implants placed in the anterior maxilla. However, causal inferences and claims of superior or definitive long-term stability should be interpreted cautiously and require confirmation in larger controlled comparative studies.
This cross-sectional study evaluated the association between interproximal contact loss (ICL) and peri-implant diseases, determined its prevalence and distribution, and examined relationships with clinical and radiographic variables. Calibrated evaluators examined adult patients with single implant-supported prostheses (ISPs) in non-molar sites. Logistic regression models were used to assess the relationship between ICL and peri-implant diseases, as well as with variables of interest. A total of 262 patients with 323 ISPs were evaluated. Mean follow-up time since implant placement was 11.2±1.5 years. ICL was observed in 43.6% of mesial and 34.6% of distal sites at the implant level (p=0.03), and in 62.6% of participants. Open mesial and distal contacts were associated with increased odds of peri-implantitis (OR=1.648, p=0.045; OR=1.938, p=0.004). Light mesial contacts were also associated with a higher risk of presenting this disease (OR=2.214, p=0.008). Marginal bone loss was associated with light mesial (OR=1.104, p=0.009) and with both open (OR = 1.175, p = 0.008) and light distal contacts (OR = 1.181, p = 0.009). Food impaction was associated with open (OR=10.555, p=0.003), light mesial (OR=12.210, p=0.002), and light distal contacts (OR=5.999, p=0.006). At mesial sites, open contacts were further associated with reduced interproximal soft tissue height and a history of periodontitis (OR=10.641, p=0.036). In conclusion, ICLs are highly prevalent and associated with peri-implantitis, Marginal bone loss, food impaction, reduced papilla height, and a history of periodontitis.
The aim of this retrospective case series is to provide evidence of the performance of a surgical concept, the 'Compensatory Alveolar Socket Seal' (CASS) by sealing not only the coronal part of the alveolar socket but also its buccal aspect using a subepithelial connective tissue graft to enhance soft tissue volume and adequately restore a proper emergence profile. MATERIAL AND METHODS:In this retrospective case series, 389 patients underwent treatment with this modified surgical technique (CASS). This treatment includes minimally traumatic extraction, immediate implant placement and a connective tissue sealing the buccal aspect of the socket. Radiographic bone level (RBL) was stablished as the main outcome variable. Other variables such as implant osteointegration or need for secondary subepithelial connective tissue graft surgery were also recorded. Additionally, Pink Esthetic Score (PES) was also evaluated. RESULTS:Although no statistical differences in RBL were observed, a trend was seen for increased bone level changes in the upper first left premolar (0.97 mm (SD=0.89)) while the least was observed in the upper left canine (0.07 mm (SD=0.88)). Bone level changes varied according to implant site and type of connection. Implants with an external connection had a deeper bone remodeling compared with an internal connection (0.65 mm SD=1.12 vs 0.47 mm SD=1.34 respectively. PES levels improved during the follow up period. The highest increase (1.61) was found between baseline (V1) and 12 weeks postoperatively (V2) (p < 0.001). CONCLUSIONS:The CASS technique appears to be a reliable technique for preserving the alveolar process without requiring hard tissue replacement strategies, with excellent aesthetic results.
