I risultati del presente lavoro di tesi hanno evidenziato un miglioramento dell’estetica dei tessuti molli peri-implantari a un anno per pazienti sottoposti ad innesto di tessuto
connettivo, in zona estetica, su impianti singoli.
È stato osservato che non sussistono differenze significative tra gli innesti di tipo autologo e quelli di origine animale in ambito estetico.
L’eccellenza del risultato estetico ottenuto è da attribuirsi non solo all’utilizzo di innesti connettivali (autologhi o eterologhi), ma anche ad un approccio chirurgico e protesico minimamente invasivi, che sono stati applicati sistematicamente a tutti i pazienti.
In conclusione, è possibile affermare che nei casi più complessi, in cui si vengono a combinare una carenza di tessuto osseo vestibolare e di gengiva cheratinizzata, la sola GBR potrebbe non essere sufficiente a ricreare la corretta anatomia dei tessuti molli, mentre l’innesto di tessuto connettivo, senza distinzione d’origine, è la soluzione più rapida ed efficace per raggiungere il miglior risultato estetico dei tessuti peri-implantari a un anno.
Ulteriori studi condotti su un numero più ampio di soggetti e con follow-up a lungo termine saranno comunque necessari per poter confermare i risultati del presente studio.
Bibliografia
1. Abrahamsson I., Berglundh T., et al. 1998. «Soft tissue response to plaque formation at different implant systems. A comparative study in the dog.» Clinical Oral Implants
Research.
2. Abrahamsson, I. et al. 1989. «The mucosal attachment at different abutments. An experimental study in dogs.» Journal of Clinical Periodontology.
3. Abrams, L. 1971. «Esthetics in fixed prothesis.» Dental Society.
4. Albrektsson. 1981. «Osseointegrated titanium implants. Requirements for ensuring a long- lasting, direct bone-to-implant anchorage in man.» Acta Orthopaedica Scandinavica. 5. Albrektsson, T. 1986. «The long-term efficacy of currently used dental implants: a review and
proposed criteria of success.» Int J Oral Maxillofac Implants.
6. Albrektsson, T. 1983. «Direct bone anchorage of dental implants.» The Journal of Prosthetic
Dentistry.
7. Aslam, A. et al. 2018. «Effect of platform switching on peri-implant bone: A 3D finite element analysis.» Journal of Prosthetic Dentistry.
8. Atieh, MA. et al. 2012. «The frequency of peri-implant diseases: a systematic review and meta- analysis.» Journal of Periodontology.
9. Barone. 2012. «Tissue changes of extraction sockets in humans. A comparison of spontaneous healing vs. ridge preservation with secondary soft tissue healing. .» Clinical Oral Implant
Research.
10. Barone, A. 2011. «A randomised clinical trial to evaluate and compare implants placed in augmented vs. non-augmented extraction sockets: a 3-year evaluation.» Journal of
Periodontology.
11. Barone, A. et al. 2008. «. Xenograft versus extraction alone for ridge preservation after tooth removal: a clinical and histomorphometric study.» Journal of Clinical Periodontology. 12. Bavetta, Giuseppe. 2014. «Valutazioni estetiche nella sostituzione di elementi dentari anteriori
mediante tecnica socket repair modificata: studio retrospettivo.» ResearchGate. 13. Belser. 2004. «Consensus statements and recommended clinical procedures regarding
esthetics in implant dentistry. .» International Journal of Oral and Maxillofacial Implants. 14. Belser, U.C. et al. 2007. «Implant therapy in the esthetic zone. Single tooth re-placements.»
15. Belser, UC. 2009. «Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores.» Journal of Periodontology. 16. Berglundh. 2007. «Morphogenesis of the peri-implant mucosa: an experimental study in
dogs.» Clinical Oral Implants Research.
17. Berglundh, T. et al. 1991. «Soft tissue reaction to de novo plaque formation on implants and teeth. An experimental study in the dog.» Clinical Oral Implants Research.
18. Block, MS. et al. 1990. «Factors associated with soft- and hard-tissue compromise of endosseous implants.» Journal of Oral and Maxillofacial Surgery.
19. Bornstein, MM et al. 2017. «Use of cone beam computed tomography in implant dentistry: current concepts, indications and limitations for clinical practice and research.»
Periodontology 2000.
20. Botticelli, D. et al. 2004. «Hard tissue alterations following immediate implant placement in extraction site.» Journal of Clinical Periodontology.
21. Brånemark, PI. 1983. «Osseointegration and its experimental background.» The Journal of
Prosthetic Dentistry.
22. Brindis MA, Block MS. 2009. «Orthodontic tooth extrusion to enhance soft tissue implant esthetics.» J Oral Maxillofac Surg .
23. Buser. 2016. «Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late?» Periodontology 2000.
24. Buser, D. et al. 1992. «Soft tissue reactions to non-submerged unloaded titanium implants in beagle dogs.» Journal of Periodontology.
25. Calesini, G. et al. 2009. «Edentulous site enhancement: a regenerative approach to the management of edentulous areas. Part 2: Peri-implant tissues.» Int J Periodontics
Restorative Dentistry.
26. Calvo-Guirado, et al. 2013. «Crestal bone loss related to immediate implants in crestal and subcrestal position: a pilot study in dogs.» Journal of Clinical Research.
27. Canullo, L. et al. 2017. «Soft and hard tissue response to an implant with a convergent collar in the esthetic area: preliminary report at 18 months.» Int J Esthet Dent.
28. Cardaropoli, D. et al. 2015. «Evaluation of Dental Implants Placed in Preserved and
Nonpreserved Postextraction Ridges: A 12-Month Postloading Study.» Int J Periodontics
Restorative Dentistry.
29. Cecchinato, D. et al. 2018. «Bone loss at implants and teeth in the same inter-proximal unit: A radiographic study.» Clinical Oral Implants Research.
30. Chang, M. et al. 1999. «Implant supported single-tooth replacements compared to contralateral natural teeth. Crown and soft tissue dimensions.» Clinical Oral Implant
Research.
31. Chappuis, V. et al. 2016. «Influence of implant neck design on facial bone crest dimensions in the esthetic zone analyzed by cone beam CT: a compara- tive study with a 5-to-9-year follow-up.» Clinical Oral Implants Research.
32. Choquet, V. et al. 2001. «Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region.»
Journal of Periodontology.
33. Chung, S. et al. 2011. «Immediate single tooth replacement with subepithelial connective tissue graft using platform switching implants: a case series.» J Oral Implantology. 34. Covani, U. et al. 2011. «Analysis of the pattern of the alveolar ridge remodelling following
single tooth extraction. .» Clinical Oral Implant Research.
35. Dahlin, C. et al. 1988. «Healing of bone defects by guided tissue regeneration.» Plast Reconstr
Surg.
36. De Lange, G.L. 1995. «Aesthetic and prosthetic principles for single tooth implant procedures: an overview.» Practical Periodontics and Aesthetic Dentistry.
37. Dorfman, HS et al. 1980. «Longitudinal evaluation of free autogenous gingival grafts.» Journa
of Clin Periodontology.
38. Dye, BA. et al. 2012. «Global periodontal disease epidemiology.» Periodontal 2000.
39. Edel, A. 1974. «Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva.» Journal of Clinical Periodontology.
40. Fürhauser, R. et al. 2005. «Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score.» Clin. Oral Impl. (Blackwell Munksgaard).
41. Farman, AG. 2005. «ALARA still applies.» Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Food and Drug Administration, HHS. 2014. «Dental devices; reclassification of blade-form
endosseous dental implant. Final order.» Fed Registr.
42. Freedman. 1999. «An 18-year longitudinal study of untreated mucogingival defects.» Journal
of Periodontology.
43. Gould, TR. 1984. «Ultrastructural study of the attachment of human gingiva to titanium in vivo.» Journal of Prosthetic Dentistry.
44. Gould, TR. et al. 1981. «The attachment mechanism of epithelial cells to titanium in vitro.»
45. Grunder, U. et al. 2005. «Influence of 3-D bone–to-implant relationship on esthetics.» Int J
Periodontics Restorative Dent.
46. Harris, R.J. 2001. «Clinical evaluation of 3 techniques to augument keratinized tissue without root coverage.» Journal of Periodontology.
47. Hartman, G.A. et al. 2004. «Initial implant position determines the magnitude of crestal bone remodeling. .» Journal of Periodontology.
48. Horner, K. et al. 2009. « Basic principles for use of dental cone beam computed tomog- raphy: consensus guidelines of the European Academy of Dental and Maxillofacial Radiology.»
Dentomaxillofacial Radiology.
49. James, RA. 1980. «Peri-implant considerations.» Dental clinics of North America. 50. Jemt. 1997. «Regeneration of gingival papillae after single-implant treatment.» Int J
Periodontics Restorative Dentistry.
51. Kan, JY. 2011. «Facial gingival tissue stability following immediate placement and
provisionalization of maxillary anterior single implants: a 2- to 8-year follow-up.» Int J Oral
Maxillo Implants.
52. Kan, JY. et al. 2003. «Dimensions of peri-implant mucosa: an evaluation of maxillary anterior single implants in humans.» Journal of Periodontology.
53. Kao, RT et al. 2008. «Thick vs. thin gingival biotypes: a key determinant in treatment planning for dental implants.» J Calif Dent Assoc.
54. Löe, H. 1967. «The Gingival Index, the Plaque Index and the Retention Index Systems.» Journal
of Periodontology.
55. Lang, NP., et al. 2011. «Periimplant diseases: where are we now? - Consensus of the Seventh European Workshop on Periodontology.» Journal of Clinical Periodontology.
56. Langer, B. et al. 1982. «The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics.» Int J Periodontol Rest Dent.
57. Lekholm, U. et al. 1986. «The condition of the soft tissues at tooth and fixture abutments supporting fixed bridges. A microbiological and histological study.» Journal of Clinical
Periodontology .
58. Lewis, J.L. and Galante J.O. 1985. «The Bone-implant Interface.» American Academy Surgeons. 59. Liljenberg, B. et al. 1997. «Composition of plaque-associated lesions in the gingiva and the
peri-implant mucosa in partially edentulous subjects.» Journal of Clinical Periodontology. 60. Ludlow, J.B. 2011. «Dosimetria unità Carestream CS 9300 CBCT.»
61. Ma, S. et al. 2015. «Screw- versus cement-retained implant prostheses: a systematic review of prosthodontic maintenance and complications.» Int J Prosthodont.
62. Maiorana, C. et al. 2012. «Slow Orthodontic Teeth Extrusion to Enhance Hard and Soft Periodontal Tissue Quality before Implant Positioning in Aesthetic Area.» The Open
Dentistry Journal.
63. Meijndert, L. et al. 2004. «A technique for standardized evaluation of soft and hard peri- implant tissues in partially edentulous patients.» J of Periodontology.
64. Melloing, JT et al. 1995. «Guide bone regeneration of bone defects associated with implants: an evidence-based outcome assessment.» Int J Periodontics Restorative Dent.
65. Menchini-Fabris, GB et al. 2019. «A methodological approach to standardize and control the quality of the position and alignment of lamina implants on two-dimensional radiographs. .» Oral Radiology.
66. Misch, CE et al. 2008. «Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference.» Implant Dentistry.
67. Mombelli, A. et al. 1987. «The microbiota associated with successful or failing osseointegrated titanium implants.» Oral Microbiol Immunolog.
68. Moon, IS. et al. 1999. «The barrier between the keratinized mucosa and the dental implant. An experimental study in the dog.» Journal of Clinical Periodontology.
69. Mozzo, P. et al. 1998. «A new volumetric CT machine for dental imaging based on the cone- beam technique: preliminary results.» Eur Radiol.
70. Noelken, R. et al. 2018. «Influence of soft tissue grafting, orofacial implant position, and angulation on facial hard and soft tissue thickness at immediately inserted and provisionalized implants in the anterior maxilla.» Clin Implant Dent Relat Research. 71. Nyman, S. et al. 1980. «Healing following implantation of periodontitis-affected roots into
gingival connective tissue.» Journal of Clin Periodontology.
72. Orban, B. 1948. «Clinical and histologic study of the surface characteristics of the gingiva. .»
Oral Surg Oral Med Oral Pathol.
73. Papi, P. et al. 2018. «The Use of a Novel Porcine Derived Acellular Dermal Matrix (Mucoderm) in Peri-Implant Soft Tissue Augmentation: Preliminary Results of a Prospective Pilot Cohort Study.» Biomed Res Int.
74. Poli, P.P. et al. 2019. «Influence of Timing on the Horizontal Stability of Connective Tissue Grafts for Buccal Soft Tissue Augmentation at Single Implants: A Prospective Controlled Pilot Study.» Journal of Oral and Maxillofacial surgery.
75. Poli, PP. 2019. «Influence of Timing on the Horizontal Stability of Connective Tissue Grafts for Buccal Soft Tissue Augmentation at Single Implants: A Prospective Controlled Pilot Study.»
J Oral Maxillofac Surg.
76. Protection, International Commission on Radiological. 2007. « The 2007 Recommendations of the International Commission on Radiological Protection. .» ICRP publication 103.
77. Proussaefs, P. et al. 2002. «Evaluation of two vitallium blade-form implants retrieved after 13 to 21 years of function: a clinical report. .» J Prosthetic Dentistry.
78. Puišys, A. et al. 2017. «Bone augmentation and simultaneous soft tissue thickening with collagen tissue matrix derivate membrane in an aesthetic area. A case report.»
Stomatologija.
79. Ruggeri, A. et al. 1992. «Supracrestal circular collagen fiber network around osseointegrated nonsubmerged titanium implants. .» Clinical Oral Implants Research.
80. Rungcharassaeng, K. et al. 2012. «Immediate implant placement and provisionalization with and without a connective tissue graft: an analysis of facial gingival tissue thickness.» Int J
Periodontics Restorative Dentistry.
81. Ryser, MR. et al. 2005. «Correlation of papilla to crestal bone levels around single tooth implants in immediate or delayed crown protocols.» Journal of oral and maxillofacial
surgery.
82. Schnitman, P.A. et al. 1979. «Recommendation of the consensus development conference on dental implants.» J. Am. Dentistry Association.
83. Schou, S. et al. 2002. «Probing around implants and teeth with healthy or inflamed peri- implant mucosa/gingiva. A histologic comparison in cynomolgus monkeys (Macaca fascicularis).» Clinical Oral Implants Research.
84. Sculean, A. et al. 2014. «Soft tissue wound healing around teeth and dental implants.» J Clin
Periodontology.
85. Serino, G. Ström, C. 2009. «Peri-implantitis in partially edentulous patients: association with inadequate plaque control. .» Clinical Oral Implants Research.
86. Simion, M et al. 2018. «A 13- to 32-Year Retrospective Study of Bone Stability for Machined Dental Implants. .» Int J Periodontics Restorative Dent.
87. Tabanella, G. et al. 2009. «Clinical and microbiological determinants of ailing dental implants. .» Clinical Implant Dentistry and Related Research.
88. Tarnow. 2003. «Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants.» Journal of Periodontology.
89. Tarnow, D.P. et Eskow, R.N. 1995. «Considerations for single-unit esthetic implant restorations.» Compendium of Continuing Education in Dentistry.
90. Thoma, DS. et al. 2014. «Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review.» Journal of Clinical Periodontology. 91. Tirone, F. et al. 2018. « Esthetic treatment of alveolar ridge atrophy in the anterior maxilla via
connective tissue graft performed simultaneously with implant placement: A three-case series.» Quintessence International.
92. Traini, T. et al. 2005. «Collagen fiber orientation in human peri-implant bone around immediately loaded and unloaded titanium dental implants.» J Periodontology.
93. Veisman, H. et al. 1998. «The palatal roll. Soft tissue ridge augmentation using a subepithelial connective tissue pedicle graft.» Oral Health.
94. Vignoletti, F. et al. 2012. «Surgical protocols for ridge preservation after tooth extraction. A systematic review.» Clinical Oral Implants Research.
95. Wang, C. et al. 2014. «Protein-directed synthesis of pH-responsive red fluorescent copper nanoclusters and their applications in cellular imaging and catalysis. .» Nanoscale.
96. Welander, M. et al. 2008. «The mucosal barrier at implant abutments of different materials.»
Clinical Oral Implants Research.
97. Yadav, MK et al. 2018. «Minimally invasive transgingival implant therapy: A literature review.»
National Journal of Maxillofacial Surgery.
98. Zitzmann. 2001. «Alveolar ridge augmentation with Bio-Oss: a histologic study in humans.» Int
J Periodontics Restorative Dent.
99. Zitzmann, NU. et al. 1997. «Resorbable versus nonre- sorbable membranes in combination with Bio-Oss for guided bone regeneration.» Int J Oral Maxillofac Implants.
100. Zufìa, J. et al. 2019. «The four-layer graft technique, a hard and soft tissue graft from the tuberosity in one piece.» J Esthetic Restor Dentistry.
101. Zuiderveld. 2014. «Significance of Buccopalatal Implant Position, Biotype, Platform Switching and Pre-Implant Bone Augumentation on the Level of the Midbuccal Mucosa.» Journal of
Prosthodontics.
102. Zuiderveld, EG. et al. 2018. «The influence of different soft-tissue grafting procedures at single implant placement on esthetics: A randomized controlled trial.» J Periodontology.
INDICE DELLE FIGURE
FIGURA 1SCHEMA DI OSTEOINTEGRAZIONE.DIFFERENZE TRA ATTACCO PARODONTALE FISIOLOGICO E ASPETTO DEI TESSUTI MOLLI PERI-
IMPLANTARI. ... 10
FIGURA 2GENGIVA (A) E MUCOSA PERIMPLANTARE (B) CLINICAMENTE SANE. ... 12
FIGURA 3SCHEMA D'INSERIMENTO IMPIANTO PRAMA A LIVELLO TRANSMUCOSO. ... 17
FIGURA 4RIPRODUZIONE GRAFICA E FOTOGRAFIA AL SEM DELLA SUPERFICIE IMPLANTARE. ... 20
FIGURA 5 VARIABILI DEL PINK ESTHETIC SCORE. ... 27
FIGURA 6CARESTREAM 9300CBCT.(A) VISIONE LATERALE DESTRA (B) VISIONE LATERALE SINISTRA. ... 34
FIGURA 7KIT CHIRURGICO ESEMPLIFICATIVO. ... 39
FIGURA 8PANORAMICA DELLE FASI OPERATIVE. ... 41
FIGURA 9CLASSIFICAZIONE DEL PAPILLA INDEX SCORE DI JEMT. ... 44
INDICE DELLE TABELLE
TABELLA 1PINK ESTHETIC SCORE SECONDO FÜRHAUSER E COLL. ... 27
TABELLA 2DISTRIBUZIONE DEMOGRAFICA DEL CAMPIONE ... 45
TABELLA 3VALUTAZIONI AL BASELINE (T0) E DOPO UN ANNO,1-YEAR (T1) ... 46
TABELLA 5GRAFICO DEL TESSUTO CHERATINIZZATO NEI GRUPPI CM E SCTG. ... 47
TABELLA 4GRAFICO A VIOLINO DEL PINK ESTHETIC SCORE NEI DUE GRUPPI CM E SCTG ... 47
Ringraziamenti
Devo i miei ringraziamenti all’Istituto Stomatologico Toscano per avermi concesso di accedere ai dati necessari per lo svolgimento di questa tesi.
Ringrazio il Professor Barone e il Professor Marconcini per essersi resi disponibili alla realizzazione di questo studio, fornendo i loro casi e la loro professionalità.
Ringrazio in particolar modo la Dottoressa Giammarinaro Enrica che mi ha aiutata durante la stesura della tesi, e che mi ha sostenuta nei momenti più difficili dandomi preziosi consigli.