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8 . Clinical Outcomes in the Presence and Absence of Keratinized Mucosa in Mandibular Guided Implant Surgeries a Pilot Study With a Proposal for the Modification of the Technique

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  VOLUME 44     2        2013    149 QUINTESSENCE INTERNATIONAL  IMPLANTOLOGY on the mucosa and stimulates osteoclastic activities. 1 The result is a decrease in the width and height of the residual ridge, and a progressive reduction of the keratinized mucosa (KM) width, causing sensitivity and impairment of salivary flow. Consequently, the prostheses become unstable and loose, the lips become thinner, and there is loss of muscle tone, changing the facial expres-sion and esthetic appearance. 2 Despite the new position taken on osseointegration, some authors state that there is no evidence that the absence of KM around the implants interferes with osseoin-tegration. 3-5  In a systematic review, it was found that there was insufficient evidence to provide recommendations about whether the width of keratinized/attached mucosa The use of inappropriate total prostheses was identified as one of the etiologic factors in the reduction of the residual ridge height, since it causes nonphysiologic pressures 1 Clinician, Department of Oral Surgery, Malo Clinic, Lisbon, Portugal. 2 Clinician, Department of Oral Surgery, Malo Clinic, Campinas, Brazil. 3 Dental Hygienist, Department of Research and Development, Malo Clinic Lisbon, Portugal. 4 Clinician, Department of Oral Surgery, Malo Clinic, Milan, Italy. Correspondence:  Dr Paulo Maló, Avenida dos Combatentes, 43, 9° C, Ed. Green Park, 1600-042, Lisboa, Portugal. Email: research@maloclinics.com. The object of this article was presented at the National Congress of the Order of Medical Dentistry in Lisbon, Portugal, on November 12, 2011. Clinical outcomes in the presence and absence of keratinized mucosa in mandibular guided implant surgeries: A pilot study with a proposal for the modification of the technique Paulo Maló, DDS, PhD 1  /Mauricio Rigolizzo, PhD, MSc 2  /Miguel de Araújo Nobre, RDH, MSc Epi 3  /Armando Lopes, DDS 1  /Enrico Agliardi, DDS 4 Objective: To test the hypothesis of the outcome of complete arch flapless guided implant surgery mandibular rehabilitations in the presence or absence of a residual band of kera-tinized mucosa (KM) < 6 mm wide in the vestibular-lingual aspect, with and without a modification of the surgical protocol. Method and Materials:  Thirty-nine patients were included in this study (12 men and 27 women), with a mean age of 62.5 years (range, 42 to 79 years), divided into 3 groups of 13 patients according to the status of residual band of KM: group 1, KM < 6 mm rehabilitated through a modified guided surgical protocol with flap opening to preserve KM; group 2, KM ≥ 6 mm; and group 3, KM < 6 mm; patients from both groups 2 and 3 were rehabilitated through flapless guided implant surgery with-out modification of the protocol. Group 2 and 3 patients were age- and sex-matched with                (backward conditional regression), incidence of dehiscences, dental plaque, bleeding, and implant infections. The level of significance chosen was 5%. Results:  Thirty-nine               of a residual band of KM ≥ 6 mm in the vestibular-lingual aspect was significantly associ-       P = .036) and dehiscences ( P = .003). Conclusion:  Within the limitations of this study, the absence of a residual band of KM ≥ 6 mm wide in the vestibular-lingual aspect in patients rehabilitated in the complete edentulous mandible               of dehiscences after 1 year of follow-up. This possible association needs to be confirmed in studies with stronger designs and longer follow-ups. (Quintessence Int 2013;44:149–157)  Key words:  flapless surgery, guided surgery, immediate function, implant  150 VOLUME 44     2        2013  QUINTESSENCE INTERNATIONAL  Maló et al was beneficial to patients. 6  Other authors agree that a proper width of peri-implant KM with appropriate height and thickness provides functional and esthetic benefits for our restorations. 7,8  Those advantages may be identified in the conditioning maneuvers of peri-implant tissue, in the molding, and in the biofilm control during oral hygiene pro-cedures. It is also confirmed that, in the presence of KM, an additional protection against pathologic processes is found in tissues surrounding the implants, especially mucositis and peri-implantitis. 9,10  On the other hand, the absence of KM (< 2 mm), may influence the accumulation of dental plaque, 1-13  bleeding tendencies (especially on lingual sites), 12,13  and larger soft tissue recessions on buccal sites. 13-15  Furthermore, the absence of KM can negatively influence marginal bone resorption. 14,15 The introduction of flapless surgery cre-ated several advantages in favor of reha-bilitation with dental implants, such as its minimally invasive technique (minimal dis-ruption of the peri-implant soft tissue and minimal changes in crestal bone levels, probing depths, and inflammation), less postsurgical discomfort, and reduced treat-ment time to the patient. 6,16-22 Currently, it is possible to obtain a three-dimensional (3D) structure denominated surgical guide that will lead to a physical model. Details of sur-gical and prosthetic procedures for com-plete edentulous rehabilitations were described in previous reports. 16,17,23       -able and safe procedure, some factors, such as the presence of a proper width of KM surrounding the implants, were not considered. The lack of this attached gin-giva may configure a potential complicat-ing factor.The purpose of this study was to evalu-ate the outcome of complete arch flapless implant surgery mandibular rehabilitations in the presence or absence of a residual band of KM < 6 mm wide in the vestibular-lingual aspect, with and without a modifica-tion of the surgical protocol. METHOD AND MATERIALS This article was written following the     Observational Studies in Epidemiology   24 This study was performed in a private clinic (Malo Clinic, Lisbon, Portugal) between March 2006 and June 2011. This retrospective study analyzed 39 patients (12 men and 27 women), with an age range of 42 to 79 years (mean, 62.5 years). Included patients presented with edentu-lous mandibles in need of fixed prosthetic implant-supported restorations and fulfilled the criteria for a computer-guided flapless implant surgery approach. 23  Patients were excluded from this study if they presented with insufficient bone volume, remaining teeth that could interfere with implant treat-ment, insufficient mouth opening to accom-modate surgical instruments (at least 50 mm), hindrance of the patient to provide informed consent to participate in the study, emotional instability, undergoing maxillary radiation therapy, or undergoing active che-motherapy. This study was approved by a local Ethical Committee (Ethics Committee for Health, Lisbon, Portugal; authorization no. 008/2009). The patients were divided into 3 groups of 13 patients with 4 men and 9 women: group 1, patients with a residual band of KM < 6 mm wide in the vestibular-lingual aspect, submitted to rehabilitation of the edentulous mandible through a modified guided surgical technique with flap opening to preserve KM (test group, Fig 1); group 2, patients with a residual band of KM ≥ 6 mm wide in the vestibular-lingual aspect submit-ted to rehabilitation of the edentulous man-dible through the standard guided surgical technique (positive control group, Fig 2); group 3: patients with a residual band of KM < 6 mm wide in the vestibular-lingual aspect submitted to rehabilitation of the edentulous mandible through the standard guided surgical technique (negative control group, Fig 3). The patients from groups 2 and 3 were age- and sex-matched with the patients from group 1.The residual band of KM was evaluated by one operator and measured in the inter-  VOLUME 44     2        2013    151 QUINTESSENCE INTERNATIONAL  Maló et al foramina area to the nearest half millimeter in each future implant site using a calibrat-      Hu-Friedy). Each measurement was made from the lingual to the vestibular aspect of the gingival margin. The classical computer guided flapless implant surgery for rehabilitation of edentu-lous mandibles was followed for groups 2 and 3. 23  For the radiographic guide preparation, each patient’s previously worn prosthesis (when adequate) or a new removable pros-thesis was used. When a new removable prosthesis was fabricated, an impression was made with silicone (Zhermack Spa) to       record in wax and a trial insertion of the teeth arrangement were carried out to record the maxillary-mandibular relation-ship. In the removable prosthesis, 6 buccal and 3 palatal holes 1.5 mm wide and 1 mm deep were made at different levels and filled with a radiopaque marker (gutta-per-        -occlusal record was made as a radiograph-ic index, and a computed tomography (CT) scan of the prosthesis with the same orien-tation as in the mouth was obtained. The computer planning followed the Procera        -fer the CT images into a 3D software plan-      25 that allowed planning the exact placement of the implants. The planning was then sent to a manufacturing facility that fabricated and delivered the surgical template. The laboratory process consisted of fabricating a working cast from the surgical template that was used as reference for the fabrica-tion of an all-acrylic resin fixed complete denture. The surgical procedures were per-formed under local anesthesia with artic-aine chlorhydrate with epinephrine 1:100,000 (Scandinibsa 4%, Inibsa                    125 mg clavulanic acid) (Labesfal) were given 1 hour prior to surgery and daily for 6 days thereafter. Prednisone (5 mg) (Meticorten Schering-Plough Farma) was administered daily in a regression mode (15 mg to 5 mg) from the day of surgery until 4 days postoperatively. 26   inflammatory medication (600 mg ibupro-       days postoperatively (twice daily) starting        (Clonix) were given on the day of surgery and postoperatively for the first 3 days, if      omeprazole) was given on the day of sur-gery and once daily for 6 days postopera-tively.The surgical template was oriented in the patient using a surgical index fit to the opposing arch and stabilized with anchor        surgical template, a flapless implant sur-gery was performed, following the manufac- Fig 1 Group 1. Patients with a residual band of KM < 6 mm wide in the vestibular-lingual aspect, submitted to rehabilitation of the edentulous mandible through a modi󿬁ed guided surgical technique to preserve KM. Fig 2 Group 2. Patients with a residual band of KM ≥ 6 mm wide in the vestibular-lingual aspect submitted to rehabilitation of the edentulous mandible through the standard guided surgical approach. Fig 3 Group 3. Patients with a residual band of KM < 6 mm wide in the vestibular-lingual aspect submitted to rehabilitation of the edentulous mandible through the standard guided surgical approach.  152 VOLUME 44     2        2013  QUINTESSENCE INTERNATIONAL  Maló et al      For group 1, the following modifications       -cal template (with the surgical index and anchor pins), the patient was asked to open his or her mouth and the pins and template were removed. The fact that the surgical template was already stabilized with the anchor pins in the correct position allowed the clinician to manipulate the soft tissues and reposition the template again without losing references or compromising the       from molar to molar dividing the KM was performed and only the lingual portion of         the left and right sides of the lingual flap was performed to avoid interferences with the template. In the situations in which the implant positions were more vestibular, the vestibular aspect of the flap was also reflected. The patient was asked to bite against the surgical template, and the surgi-cal index and pin positions were easily found to restabilize the template. The flap-less surgical protocol was followed, 23  with the exception of not using the soft tissue punch. For all groups, after the implant inser-tion, the surgical template was removed, and the anterior abutments (Multi-Unit abut-       -lowed by the posterior abutments                  -ment placement, nonresorbable sutures            in group 1. The prefabricated prosthesis was connected immediately, achieving immediate function, and minor occlusion      With these modifications from the srci-nal flapless surgical protocol, 24  the authors Fig 5 Intraoral photograph of the same patient in Fig 4 6 months after surgery. A band of KM remains around the implants. Fig 4 Intraoral photograph of a patient from group 1 10 days after surgery. Note the KM around the implants. Fig 6 Intraoral photograph of the same patient as in Figs 4 and 5 1 year after surgery. A band of keratin-ized mucosa remains present around the implants without any pathologic incidences during the com-pletion of the study.
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