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Regnerative dentistry

Research that should influence clinical practice

Systematic reviews, despite heterogeneity and standardization issues, can give the clinician a framework from which to assess and plan their patients, temporarily making up for the current lack of randomized controlled trials particularly in the fi eld of dental implantology. This article provides a short overview of key published systematic reviews and their relevance to the clinician.


Gain of keratinized tissue: Free gingival grafts to increase the keratinised tissue results in a signifi cant decrease of the bleeding on probing and gingival index, probing depths, higher marginal bone levels and reduced plaque scores when compared to maintenance sites with no grafting.

Gain of mucosal tissue thickness: Connective tissue grafts have a positive eff ect on reduction of the marginal bone levels, but result in no signifi cant improvement in the bleeding or plaque indices or probing depths.

Clinical relevance: Clinicians should include soft tissue quality and morphology assessment during the planning of implant treatment. Enhancing the keratinized tissue and/or thickness during implant treatment can be of great benefit toimprove outcomes.


Marginal bone loss is worse in smokers than in non-smokers, with the loss being worse in the maxilla than the mandible. Smokers have also been shown to have a higher risk of complications and smoking is reported to have a negative eff ect on implants placed in regenerated sites – most likely due to the eff ect of the nicotine on blood supply and bone healing.

Clinical relevance: Clinicians should take into account the role of smoking in treatment outcomes and be aware of the increased risk of implant failure and marginal bone loss particularly if grafting is planned. They should also understand the importance of a baseline reference of the bone levels after implant rehabilitation against which to monitor the marginal bone loss over time.


Patients receiving implants in augmented sites display higher variability in outcome and predictability than those receiving implants in pristine sites. In the literature this is partly due to eligibility criteria, patient sample, different techniques used for augmentation, and variable case definitions used for the biologic complications.

Clinical relevance: Clinicians need to be aware of the limitations in comparative data looking at augmented vs pristine sites. They should consider the importance of assessing patient related factors when planning implant treatment with augmentation.


The prevalence, extent and severity of peri-implant disease as reported by Derks et al. in their first paper was peri-impant mucositis 19-65% (weighted mean 43%) and peri-implantitis 1-47% (weighted mean 22%). This review highlights the limitations of the reported prevalence, extent and severity of peri-implant disease due to the lack of a standard case defi nition of peri-implant disease, the variable follow up time periods and the issues with using convenience samples as opposed to randomly selected samples. The EFP/AAP World Workshop 2017 has addressed these issues as reported in the second paper by Derks et al. where new standardized definititions for peri-implant health and disease have been included and the need for using these highlighted.

Clinical relevance: Increasing reports suggest the rise in the prevalence of peri-implant disease. However, clinicians should consider the limitations of the published evidence and whether the reported data is infl ated. The role of planning and careful preoperative assessment of risk factors and predictability should not be overlooked, as a number of these factors will aff ect the post treatment predictability. Clinicians should be aware of the new defi nitions for peri-implant health and apply them when  considering a diagnosis of peri-implant disease.


Alveolar ridge preservation techniques may prevent bone loss in the horizontal and vertical dimensions. Better outcomes are achieved when a fl ap is raised and a membrane applied with a xenograft or allograft, especially in the mid-buccal and mid-lingual height.

Clinical relevance: Clinicians need to understand the need for preserving bone after tooth loss. Alveolar ridge preservation should therefore be considered for all extraction sites to minimize the extent of bone loss and also reduce the need for extensive grafting and augmentation at a later stage.

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