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The aim of this study was to assess the surface and tissue quality of keratinized mucosa grafts (KMG) obtained using the conventional scalpel and mucotome techniques. This was an experimental in vitro/ex vivo study involving six porcine hemi-mandibles. Specimens were harvested using both the mucotome and conventional scalpel techniques, with randomization determining the choice of technique for tissue removal. The specimens were prepared following predefined laboratory protocols and subsequently subjected to optical microscopy for evaluating epithelial and connective tissue and scanning electron microscopy for topographical and 3D profilometry analysis. Tissues harvested using the mucotome exhibited a linear base and uniform thickness, along with the presence of submucosa and fibrous connective tissue, all of which are ideal for graft success. Differences in the surface characteristics of specimens obtained through the two techniques were observed during a comparative analysis of images obtained through both microscopy types. KMG obtained using the mucotome technique displayed greater uniformity and reduced undesirable cell presence compared to the scalpel technique, thereby enhancing the likelihood of success in soft tissue graft surgical procedures. This study provides valuable insights to oral healthcare professionals and may contribute to future research aimed at achieving more successful surgeries, shorter postoperative recovery times, reduced discomfort, and an overall more positive patient experience.

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OBJECTIVE: The present study aimed to assess the relationship between keratinized mucosa width and peri-implant diseases, namely peri-implant mucositis and peri-implantitis. MATERIALS AND METHODS: Ninety-one dental implants in function for ≥ 6 months from 40 partially or completely edentulous non-smoker subjects (24 females and 16 males) were evaluated clinically and radiographically. The width of keratinized mucosa, probing depth, plaque index, bleeding on probing, and marginal bone levels were assessed. Keratinized mucosa width was categorized as ≥ 2 mm or < 2 mm. RESULTS: There was no statistically significant association between keratinized buccal mucosa width and peri-implant mucositis or peri-implantitis (p ≥ 0.37). In the regression analysis, peri-implantitis was associated with longer implant function time (RR: 2.55, 95% CI: 1.25-11.81, p = 0.02) and implants in the maxilla (RR: 3.15, 95% CI: 1.61-14.93, p = 0.003). Mucositis was not associated with any of the factors analyzed. CONCLUSION: In conclusion, in the present sample, keratinized buccal mucosa width was not associated with peri-implant diseases, suggesting that a band of keratinized mucosa may not be necessary to maintain peri-implant health. Prospective studies are required to better understand its role in the maintenance of peri-implant health.

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OBJECTIVES: The aim of this cross-sectional study was to evaluate the effect of brushing discomfort (BD) on peri-implant health in sites exhibiting inadequate keratinized mucosa (KM) width. MATERIAL AND METHODS: Patients presenting with at least one implant exhibiting KM <2 mm and in function for ≥1 year were eligible for inclusion. BD was assessed with the visual analogue scale (VAS), and implants were classified into two groups: Absence (aBD; VAS = 0) or Presence (pBD; VAS > 0) of BD. Bleeding on probing (BoP), modified plaque index (mPI), probing depth (PD), clinical attachment level (CAL), suppuration (Sup), and marginal bone level (MBL) were recorded. Mann-Whitney, chi-square test, and a multilevel model were used for analysis. RESULTS: Fifty-nine patients with 155 dental implants were analyzed, of which 60 presented no BD, and 95 presented some level of BD. BoP, PD, CAL, and MBL were significantly higher in the pBD than in the aBD group (p < .05). The prevalence of peri-implant diseases at implant level was also higher in the pBD group than in the aBD group. However, after controlling for confounding factors, only mPI showed an effect on BoP. In addition, difficulty to perform oral hygiene was statistically higher in the pBD group. CONCLUSIONS: The findings of the present study suggest that although BD around implants exhibiting KM <2 mm did not influence tissue inflammation, it could represent a symptom of peri-implant diseases. Further clinical trials assessing the long-term effect of BD must be considered to better ascertain its effects on peri-implant health.

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A gengiva oral pode ser dividida em inserida ou livre. A gengiva inserida é queratinizada e apresenta grande importância na proteção do periodonto contra inflamações, sendo importante na proteção mecânica durante à escovação e ao acúmulo de biofilme. Uma faixa de gengiva queratinizada aderida é importante para a saúde dos tecidos periodontais. Os tecidos peri-implantares tem aspecto e estruturas parecidas com o epitélio ao redor dos dentes. A faixa de mucosa queratinizada ao redor da área peri-implantar de 1 a 2mm pode diminuir o acúmulo de placa e consequentemente a peri-implantite que é um dos fatores responsáveis pela perda de implantes. Diversas técnicas têm sido utilizadas para se ter um aumento dessa faixa de mucosa queratinizada favorecendo um aumento da taxa de sucesso instalações de implantes como: enxertos gengivais livres, de tecido conjuntivo, de matriz dérmica acelular, de matriz de colágeno, membranas e implantes imediatos ao invés da técnica comum. O objetivo do estudo foi discutir as características anatômicas da mucosa aderida ao redor de implantes e sua importância para saúde peri-implantar. Para o desenvolvimento do estudo proposto de revisão da literatura, foram realizadas pesquisas em diferentes plataformas de bases de dados bibliográficos sendo: Scielo (scientific Eletronic Library online), PubMed e Google Acadêmico e livros de referência na área da Periodontia. Com base, na revisão crítica realizada, conclui-se que, quando há a presença de uma mucosa queratinizada aderida ao redor do implante maior que 1mm, os implantes apresentam melhor selamento biológico, menor acúmulo de biofilme e baixo risco para a peri-implantite.

The oral gingiva can be divided into attached or free. The attached gingiva is keratinized and is of great importance in protecting the periodontium against inflammation, being also important in mechanical protection during brushing and biofilm accumulation. A range of keratinized mucosa is important for the health of periodontal tissues. Peri-implant tissues have an appearance and structures similar to the epithelium around the teeth. The keratinized mucosa range around the peri-implant area of ​​1 to 2 mm can reduce plaque accumulation and consequently peri-implantitis, which is one of the factors responsible for implant loss. Several techniques have been used to increase this range of keratinized gingiva, favoring an increase in the success rate of implant installations such as: free gingival grafts, connective tissue, acellular dermal matrix, collagen matrix, membranes, and immediate implants. instead of the common technique. The aim of the present study was to discuss, based on the scientific literature, the anatomical characteristics of the keratinized attached mucosa around implants and their importance for peri-implant health. For the development of the proposed study of literature review, searches were carried out on different platforms of bibliographic databases, namely: Scielo (scientific Electronic Library online), PubMed and Google Scholar and reference books in ​​Periodontics. Based on the critical review performed, it was concluded that when there is a keratinized mucosa adhered around the implant greater than 1mm, the implants present better biological sealing, less biofilm accumulation and low risk for peri-implantitis.

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OBJECTIVES: This study aimed to evaluate the clinical effects of xenogeneic collagen matrix (XCM) in augmenting keratinized mucosa width (KMW) around dental implants. MATERIALS AND METHODS: Articles that were published before or during April 2020 were electronically searched in four databases without any date or language restrictions and manually searched in regular journals and grey literature. The eligibility criteria comprised randomized controlled trials (RCTs) or prospective studies that analysed the clinical efficacy of XCM for augmenting KMW around dental implants. This systematic review (SR) was registered in PROSPERO under number CRD42018115399. RESULTS: Eleven studies published between 2009 and 2019 were included in this SR. There was no significant difference in KMW increase (p = 0.14), probing depth (PD) decrease (p = 0.17) or participants' aesthetic satisfaction (PAS) (p = 0.32) when XCM was compared to connective tissue graft (CTG). However, the increase in gingival thickness (GT) was significantly higher (p = 0.001) with the use of CTG. CONCLUSIONS: The use of XCM improved KMW and PD with rates comparable to those for CTG. XCM showed lower results for GT when compared to CTG. XCM presented similar results in terms of PAS when compared to CTG. CLINICAL RELEVANCE: The presence of a KMW around dental implants is associated with better peri-implant tissue health.

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Las complicaciones del tejido blando periimplantar condicionan la apariencia estética y el pronóstico clínico de los implantes y son, en la actualidad, cada vez más diagnosticadas. Los defectos gingivales asociados a implantes dentales incluyen recesiones, fenestraciones o dehiscencias en la superficie mucosa vestibular, inflamación gingival, ausencia de encía insertada/queratinizada, falta de volumen y presencia de concavidades gingivales que generan sombras y oscuridad en la mucosa. La detección de éstas en forma temprana permite establecer un plan de tratamiento en busca de soluciones eficaces. Mediante la presentación de una serie de casos, abordaremos distintos procedimientos para aumento de los tejidos blandos periimplantarios y la corrección de defectos. La ganancia de encía queratinizada ha demostrado tener un impacto positivo en la estabilidad a largo plazo de todos los tejidos implantarios (AU)

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The aim of this case report was to describe a modified free gingival graft technique for gaining vertical and horizontal soft-tissue growth in the posterior region of the mandible before installation of dental implants. Patient A.A., a 38-year-old female, received a modified free gingival graft in the posterior region of the mandible. After 90 days, an increase, both horizontally and vertically, of the gingival tissue was observed, and the patient was satisfied with the result. The dental implant was installed, and a 3-mm of the vertical gain of keratinized gingiva was observed. Further research is needed to evaluate the effectiveness of this technique before prosthetic dental implantation.

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OBJECTIVE: The purpose of the present prospective follow-up study was to evaluate the long-term influence of the peri-implant keratinized mucosa (KM) on marginal bone level (MBL), peri-implant tissues health, and brushing discomfort. MATERIAL AND METHODS: Eighty patients were initially recruited during their maintenance visit from January to October 2013 and allocated in two groups according to KM width around implants: Wide Group (KM ≥ 2 mm) and Narrow Group (KM < 2 mm). In the four-year follow-up examination (T4), marginal bone level (MBL), modified plaque index (mPI), probing depth (PD), clinical attachment level (CAL), bleeding on probing (BoP), and brushing discomfort (BD) were reassessed and compared to the initial assessments (T0). Mann-Whitney, Wilcoxon signed-rank test, and a multilevel model were used for the statistical analysis. RESULTS: Fifty-four patients with 202 implants returned at T4. Mean mPI (0.91 ± 0.60), BoP (0.67 ± 0.21), and BD (12.28 ± 17.59) were higher in the Narrow Group than in the Wide Group (0.54 ± 0.48, 0.56 ± 0.26, and 4.25 ± 8.39, respectively). Marginal bone loss was higher in the Narrow Group (0.26 ± 0.71) than in the Wide Group (0.06 ± 0.48). Multilevel analysis suggested that KM width and time in function had a statistically significant effect on MBL. CONCLUSIONS: The findings of the present study indicate that KM width had an effect on MBL, plaque accumulation, tissue inflammation, and brushing discomfort over the studied period. Thus, the presence of a KM ≥ 2 mm around implants appears to have a protective effect on peri-implant tissues.

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Levando em consideração que a peri-implantite é de etiologia multifatorial, embora o fator determinante seja o biofilme dentário, é interessante buscar formas de minimizar as perdas ósseas ocorridas. Desta maneira, ainda que ressalvas possam ser feitas à possibilidade concreta de se obter uma regeneração tecidual guiada, pode-se entender como uma alternativa válida para buscar, pelo menos, estabilizar o processo de progressão desta perda. Concomitantemente a este procedimento, e tendo em vista a indicação de vestibuloplastia para melhor prevenção da recidiva de peri-implantite, foi possível obter um resultado favorável dentro do objetivo proposto, em uma única intervenção cirúrgica. Material e métodos: paciente do sexo feminino, com 68 anos de idade, fumante moderada (8-10 cigarros/dia), se apresentou com exsudato purulento na face mesiovestibular do implante 46. Debelada a fase aguda por meio de fisioterapia local, a paciente foi submetida à cirurgia peri-implantar visando à interceptação da perda óssea por meio de "regeneração tecidual guiada" associada à vestibuloplastia, com a utilização de enxerto gengival subepitelial. Resultados: foi possível obter estabilização da perda óssea, bem como diminuição na profundidade de sondagem, além da redução de exsudato no implante em discussão. Conclusão: além disso, a vestibuloplastia criou melhores condições anatômicas estruturais devido ao tecido ceratinizado obtido e, sobretudo, criou um favorável acesso à escovação em toda a extensão dos quatro implantes, antevendo- -se melhor possibilidade de preservação do resultado.

Taking into account that the peri-implantitis is of multifactorial etiology, although the determining factor is the dental biofilm, it is interesting to look for ways to minimize the bone losses that have occurred. Thus, although safeguards can be made to the concrete possibility of obtaining a guided tissue regeneration, it can be understood as a valid alternative to seek to at least stabilize the process of progression of this loss. Concomitantly to this procedure and in view of the indication of vestibuloplasty for better prevention of recurrence of peri-implantitis, it was possible in a single surgical intervention to obtain a favorable result within the proposed objective. Material and methods: a 68-year-old female patient, moderate smoker (8-10 cigarettes/day) presented with purulent exudate on the mesiobuccal surface of the implant in the region of the 46. After the acute phase, through local physiotherapy, the patient underwent to peri-implant surgery aiming the interception of bone loss by means of "guided tissue regeneration" associated with vestibuloplasty with the use of subepithelial gingival graft. Results: it was possible to obtain a stabilization of the bone loss, as well as a decrease in the depth of probing, besides the reduction of exudate in the implant under discussion. Conclusion: the vestibuloplasty created better anatomical structural conditions due to the keratinized tissue obtained, and above all, the favorable access to brushing throughout the four implants, predicting a better possibility of preservation of the result.

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OBJECTIVE: This study aimed to evaluate the effect of initial periodontal clinical parameters on the final outcome of the treatment of periodontal recessions by means of a coronally positioned flap (CPF). MATERIALS AND METHODS: The CPF technique was used in a total of 39 Miller Class I/II gingival recessions of the upper canines and/or premolars. The clinical periodontal parameters evaluated were: probing depth, gingival recession height, gingival recession width, keratinized mucosa, attached keratinized mucosa, flap thickness and free gingival margin thickness. The degree of root coverage was evaluated 6 months and 1 year after the surgery. The data were analyzed by Student's t-test, Mann-Whitney and Pearson's correlation tests, as well as linear regression. RESULTS: A significant reduction in gingival recession height, gingival recession width, keratinized mucosa, and attached keratinized mucosa were observed. A significant negative correlation was found between gingival recession and root coverage percentage at 1 year, and a significant negative correlation between gingival margin thickness and coverage percentage at 1 year. The gingival recession and flap thickness significantly predicted the amount of root coverage. CONCLUSIONS: The initial dimensions of gingival recession and the mucosa thickness were correlated to the percentage of root coverage. The gingival recession width was the major predictor of root coverage.

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OBJECTIVE: The aim of this study was to evaluate the influence of periodontal clinical parameters on the treatment of gingival recession by means of a coronally positioned flap (CPF). MATERIALS AND METHODS: In this clinical study, the coronally positioned flap technique was used in a sample of 14 individuals with Miller's Class I or II gingival recession of the canines and/or maxillary premolars, totaling 39 recessions. The clinical periodontal parameters evaluated were: probing depth (PD), gingival recession height (GRH), gingival recession width (GRW), clinical attachment level (CAL), keratinized mucosa (KM), attached keratinized mucosa (AKM), gingival thickness (GT) and free gingival margin thickness (GMT). The degree of root coverage was evaluated 3 months after the surgical procedures were performed. The data were analyzed using Student's-t, Mann-Whitney and Pearson's correlation tests, as well as the Cohen's d. RESULTS: After root coverage, there was no significant change in PD. Significant reductions in GRH and GRW were observed. In addition, a significant reduction in KM and AKM, and an increase in GMT were also observed. A significant negative correlation was found between initial GMT and gingival recession at 3 months, and a significant negative correlation between GT and periodontal recession at 3 months. There was large effect size for GRH, GRW, CAL, KM, AKM and GMT parameters. CONCLUSIONS: The initial gingival recession height, keratinized mucosa and free gingival margin thickness were the parameters that had the most influence on root coverage by the coronal sliding flap technique.

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OBJECTIVE: The aim of this study was to compare the level of brushing discomfort (BD) during oral hygiene and peri-implant clinical variables between patients presenting implant sites with a band ≥2 mm and <2 mm of keratinized mucosa (KM). MATERIALS AND METHODS: Participating patients were recruited during routine maintenance follow-up visits from January to October 2013. Based on the presence of KM, patients were allocated into two groups: implant sites with ≥2 mm of KM (Wide Group); and implant sites with <2 mm of KM (Narrow Group). Patients were clinically assessed, and plaque index (PI), probing pocket depth (PPD), clinical attachment level (CAL), and bleeding on probing (BoP) data were collected from three sites at the buccal aspect of each implant. Subsequently, patients received standardized oral hygiene instructions and cleaning devices and were asked to clean around the experimental implant sites. All patients reported on the level of BD using the visual analog scale (VAS). Non-paired Student's t-test, Wilcoxon's signed-rank test, and chi-square tests were performed to analyze the outcome variables (P < 0.05). RESULTS: Eighty patients with a total of 270 implant sites were included. Implant sites in the Narrow Group exhibited higher levels of BD (P < 0.001), PI (P = 0.0021), and BoP (P = 0.017) than implant sites in the Wide Group. CONCLUSION: Implant sites with a band of <2 mm of KM were shown to be more prone to brushing discomfort, plaque accumulation, and peri-implant soft tissue inflammation when compared to implant sites with ≥2 mm of KM.

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OBJECTIVE: To investigate the influence of the presence or absence of keratinized mucosa on the alveolar bony crest level as it relates to different buccal marginal bone thicknesses. MATERIAL AND METHODS: In six beagle dogs, the mandibular premolars and first molars were extracted bilaterally. In the right side of the mandible (test), flaps were elevated, and the buccal as well as part of the lingual masticatory mucosa was removed. The flap was released coronally to allow a primary wound closure. In the left side, the wounds were left unsutured with the keratinized mucosa remaining (control). After 3 months of healing, a complete absence of keratinized mucosa was found at the test sites. Two recipient sites were prepared at each side of the mandible, one in the premolar and one in the molar region. A buccal bony ridge width of approximately 1 and 2 mm was obtained at the premolar and molar region, respectively. Implants were installed with the shoulder flush with the buccal alveolar bony crest, and abutments were connected to allow a nonsubmerged healing. At least 2 mm of keratinized mucosa was surrounding the control sites, while at the test sites, the implants were bordered by alveolar mucosa. After 3 months, the animals were euthanized and ground sections obtained. RESULTS: A higher vertical bony crest resorption was observed at the test compared with the control sites both at the premolar and molar regions, the differences being statistically significant. The top of the peri-implant mucosa was located more coronally at the control compared with the test sites. The horizontal resorption measured 1 mm below the implant shoulder was similar at the test and control sites. Only limited differences were found between premolar and molar sites, with the exclusion of the horizontal resorption that was higher at the test compared with the control sites. CONCLUSIONS: A higher alveolar buccal bony crest resorption and a more apical soft tissue marginal position should be expected, when implants are surrounded with thin alveolar mucosa at the time of installation, independently of the thickness of the buccal bony crest.

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O tecido peri-implantar constitui uma adaptação da mucosa mastigatória aos diferentes sistemas de implante instalados na cavidade bucal. A falta do cemento radicular para ancoragem das fibras gengivais à superfície do implante resulta em uma orientação paralela das fibras ao seu redor. A ausência de uma inserção conjuntiva entre a mucosa e o implante pode sugerir uma deficiência da defesa estrutural na região e relacionar-se à progressão mais rápida das peri-implantites, quando comparadas às periodontites. Dessa forma, estudos abordam a importância da conexão epitelial para formação de um selamento adequado ao redor dos implantes. Outras discussões concentram-se em avaliar se uma situação de saúde gengival peri-implantar poderia estar correlacionada com a presença de uma quantidade específica (altura e espessura) da mucosa ceratinizada. Nesse contexto, a realização desse estudo teve como objetivo relacionar a importância estrutural do tecido mole e a influência do fenótipo gengival na manutenção da saúde peri-implantar. Os estudos revisados demonstram a importância de um bom selamento biológico em torno desse sistema, a função protetora que as estruturas desse tecido oferecem à interface osso-implante, e a discussão sobre a necessidade da presença de uma faixa de mucosa ceratinizada ao redor dos implantes dentários para um melhor prognóstico. Atualmente, as pesquisas apontam para a necessidade de mais estudos que avaliem a influência das características clínicas dos tecidos moles peri-implantares no estabelecimento e manutenção da saúde peri-implantar.

Peri-implant tissue is an adaptation of the masticatory mucosa to the different implant systems placed in the oral cavity. The lack of root cement to anchor gingival fibers to the surface of the implant is responsible for the parallel direction of the fibers around it. The absence of connective attachment between the mucosa and the implant may suggest a deficiency of the structural defenses in the region and may be associated with the more rapid progression of peri-implantitis than of periodontitis. Several studies have evaluated the importance of epithelial connections to form an adequate seal around implants. Other discussions have focused on the evaluation of whether peri-implant gingival health may be correlated with the presence of a specific amount (height and thickness) of keratinized mucosa. Thisstudy evaluated the association of the structural role of the soft tissue and the effect of gingiva phenotype on periimplant health. The studies that were reviewed stressed the importance of a good biological seal around the implant system, the protective function that the structures of this tissue provide to the bone-implant interface, and the discussion about the need to have a band of keratinized mucosa around tooth implants to ensure a better prognosis. Current studies point to the need to conduct further investigations to evaluate the effect of the clinical characteristics of soft peri-implant tissues so that peri-implant health may be ensured and preserved.

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Introdução: Estudos recentes são direcionados a explorar a relação da faixa da mucosa queratinizada com a saúde dos tecidos peri-implantares. Quando esta faixa não é suficiente, uma cirurgia para o aumento de mucosa queratinizada pode ser indicada, pois tem sido relatado que a presença ou a reconstrução de tecido queratinizado ao redor de implantes pode facilitar os procedimentos restauradores, promover a estética e ainda permitir a manutenção de uma higienização oral rotineira sem irritação ou desconforto ao paciente. Dentre os procedimentos cirúrgicos disponíveis, a técnica do enxerto gengival livre é consagrada na literatura periodontal para aumento da faixa de mucosa queratinizada. Objetivo: Este estudo relata um caso clínico em que foi realizada cirurgia de enxerto gengival livre com objetivo de aumentar a faixa da mucosa queratinizada na região de implantes previamente instalados na maxila, para suporte de prótese tipo protocolo. Relato de caso: Foi realizada a cirurgia de enxerto gengival livre na região anterior da maxila, obtido do palato, na qual haviam sido instalados implantes osseointegrados para suporte de prótese tipo protocolo e a mucosa peri-implantar apresentava-se sem tecido queratinizado e inflamada. Após dois meses de reparação da cirurgia mucogengival, foi possível observar que o enxerto gengival livre favoreceu a saúde peri-implantar e os procedimentos protéticos de moldagem. Conclusão: Diante dos resultados clínicos, pode-se concluir que o enxerto gengival livre é uma técnica previsível e de fácil realização para aumento da faixa de mucosa queratinizada em mucosa peri-implantar de prótese protocolo.

Introduction: Recent studies have evaluated the relationship between the width of keratinized mucosa and peri-implant tissue health. Insufficiently wide keratinized tissue can be increased surgically, for example by free gingival grafting. The presence or reconstruction of keratinized tissue around the implant can facilitate restorative procedures, promote aesthetics and allow the maintenance of an oral hygiene routine without irritation or discomfort to the patient. Objective: To describe a patient who underwent free gingival graft surgery to increase the width of keratinized tissue in the region of previously implants to support a type of prosthetic protocol. Case Report: A patient who had received dental implants to support a type of prosthetic protocol presented with inflamed peri-implant mucosa, but with no keratinized tissue. Free gingival tissue was obtained from the palate and grafted into the anterior maxilla. Sixty days after muco-gingival surgery, we observed that the free gingival graft favored peri-implant health and prosthetic casting. Conclusion: The free gingival graft technique is both easy to perform and effective in increasing the width of keratinized mucosa following implantation.

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