Esposito M, Grusovin M G, Maghaireh H, Coulthard P, Worthington H V
School of Dentistry, Department of Oral and Maxillofacial Surgery, University of Manchester, Higher Cambridge Street, Manchester, UK, M15 6FH.
Cochrane Database Syst Rev. 2007 Jul 18(3):CD006697. doi: 10.1002/14651858.CD006697.
Dental implants are usually placed by elevating a soft tissue flap, but in some instances, they can also be placed flapless reducing patient discomfort. Several flap and suturing techniques have been proposed. Soft tissues are often manipulated and augmented for aesthetic reasons. It is often recommended that implants are surrounded by a sufficient width of attached/keratinized mucosa to improve their long-term prognosis.
To evaluate whether (1a) flapless procedures are beneficial for patients, and (1b) which is the ideal flap design; whether (2a) soft tissue correction/augmentation techniques are beneficial for patients, and (2b) which are the best techniques; whether (3a) techniques to increase the perimplant keratinized mucosa are beneficial for patients, and (3b) which are the best techniques; and (4) which are the best suturing techniques/materials.
The Cochrane Oral Health Group's Trials Register, The 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of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCTs). The last electronic search was conducted on 15 January 2007.
All RCTs of root-form osseointegrated dental implants comparing various techniques to handle soft tissues in relation to dental implants. Outcome measures 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/keratinized mucosa.
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 (CI). Heterogeneity was to be investigated including both clinical and methodological factors.
Eight potentially eligible RCTs were identified and five trials including 140 patients in total were included. Two trials (100 patients) compared flapless placement of dental implants with conventional flap elevation, two trials (20 patients) crestal versus vestibular incisions, and one trial (20 patients) Erbium:YAG laser versus flap elevation at the second-stage surgery for implant exposure. On a patient, rather than per implant basis, implants placed with a flapless technique and implant exposures performed with laser induced statistically significant less postoperative pain than flap elevation. There were no other statistically significant differences for any of the remaining analyses.
AUTHORS' CONCLUSIONS: Flapless implant placement is feasible and has been shown to reduce patient postoperative discomfort in adequately selected patients. There is insufficient reliable evidence to provide recommendations on which are the best incision/suture techniques/materials, or whether techniques to correct/augment perimplant soft tissues or to increase the width of keratinized/attached mucosa are beneficial to patients or not. Properly designed and conducted RCTs are needed to provide reliable answers to these questions.
牙种植体通常通过掀起软组织瓣来植入，但在某些情况下，也可在不掀起瓣的情况下植入，从而减轻患者不适。已提出多种瓣和缝合技术。出于美学原因，软组织常被操作和增厚。通常建议种植体周围有足够宽度的附着/角化黏膜以改善其长期预后。
评估（1a）不掀瓣手术对患者是否有益，以及（1b）理想的瓣设计是什么；（2a）软组织矫正/增厚技术对患者是否有益，以及（2b）最佳技术有哪些；（3a）增加种植体周围角化黏膜的技术对患者是否有益，以及（3b）最佳技术有哪些；以及（4）最佳缝合技术/材料有哪些。
检索了Cochrane口腔健康组试验注册库、Cochrane对照试验中心注册库、MEDLINE和EMBASE。手工检索包括几本牙科杂志。联系了所有已识别试验的作者、一个互联网讨论组和55家牙种植体制造商，以查找未发表的随机对照试验（RCT）。最后一次电子检索于2007年1月15日进行。
所有关于根形骨结合牙种植体的RCT，比较与牙种植体相关的处理软组织的各种技术。结局指标包括：修复和种植体失败、患者和牙医评估的美学效果、生物学并发症、术后疼痛、患者偏好、患者维护的难易程度以及附着/角化黏膜的宽度。
两名综述作者独立且重复地对符合条件的研究进行筛选、评估试验的方法学质量并提取数据。就缺失信息与作者进行了联系。结果以随机效应模型表示，连续结局采用均数差，二分结局采用风险比，并给出95%置信区间（CI）。将对异质性进行调查，包括临床和方法学因素。
识别出8项潜在符合条件的RCT，纳入了5项试验，共140例患者。两项试验（100例患者）比较了牙种植体的不掀瓣植入与传统瓣掀起，两项试验（20例患者）比较了嵴顶切口与前庭切口，一项试验（20例患者）比较了铒激光与二期手术时掀起瓣暴露种植体。基于患者而非每个种植体，采用不掀瓣技术植入的种植体以及激光诱导暴露的种植体术后疼痛在统计学上显著低于瓣掀起。其余任何分析均无其他统计学显著差异。
不掀瓣种植体植入是可行的，且已证明在适当选择的患者中可减轻患者术后不适。没有足够可靠证据就最佳切口/缝合技术/材料提供建议，也无法确定矫正/增厚种植体周围软组织或增加角化/附着黏膜宽度的技术对患者是否有益。需要进行设计合理、实施良好的RCT来为这些问题提供可靠答案。
