Soft tissue handling during implant placement.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched. Handsearching included several dental journals. Authors of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCT).

STUDY SELECTION: All RCT of root-form osseo-integrated dental implants comparing various techniques to handle soft tissues when placing dental implants were included. Outcome measures considered were: prosthetic and implant failures, aesthetics evaluated by patients and dentists, biological complications, postoperative pain, patient preference, ease of maintenance by patient, and width of the attached or keratinised mucosa.

DATA EXTRACTION AND SYNTHESIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Authors were contacted for missing information. Results were expressed as random-effects models using mean differences for continuous outcomes, and risk ratios for dichotomous outcomes, with 95% confidence intervals. Heterogeneity was to be investigated, including both clinical and methodological factors.

RESULTS: Eight RCT were identified and five trials, which included 140 patients in total, were selected. Two trials (comprising 100 patients) compared flapless placement of dental implants with conventional flap elevation, two trials (20 patients) crestal versus vestibular incisions. On a patient (rather than per-implant) basis, implants placed with a flapless technique and implant exposures performed with a laser induced significantly less postoperative pain than flap elevation. There were no statistically significant differences for any of the other analyses.

CONCLUSIONS: Flapless implant placement is feasible and has been shown to reduce patient postoperative discomfort in appropriately selected patients. Sufficient, reliable evidence is not available for recommendations to be made about which techniques or materials for incision or suture are most beneficial to patients. This is also the case for techniques to correct or augment perimplant soft tissues or to increase the width of keratinised or attached mucosa. Properly designed and conducted RCT are needed to provide reliable answers to these questions.