Professor and Chair, Department of Periodontology, School of Dental Medicine, University of Bern, Bern, Switzerland.
Professor, Department of Periodontology, School of Dental Medicine, Stony Brook University, Stony Brook, NY.
Implant Dent. 2019 Apr;28(2):210-216. doi: 10.1097/ID.0000000000000870.
The data on the importance of soft-tissue management during surgical treatment of periimplantitis are still limited, and no clinical recommendations are yet available.
To give an overview on the rationale for periimplant soft-tissue augmentation procedures in the light of potential benefits/risks of the presence/absence of keratinized/attached mucosa (KAM) providing recommendations for the clinician.
The available evidence indicates that the presence of KAM favors periimplant tissue health evidenced by improved bleeding scores and facilitation of self-performed plaque removal, less mucosal recessions, and more stable marginal bone levels over time. Therefore, the rationales to augment KAM are (a) to optimize the possibility for performing an adequate level of oral hygiene, (b) to help maintaining periimplant soft-tissue health and stability, and (c) to improve esthetics. Various techniques with autogenous or xenogeneic membranes have been described so far for KAM augmentation. Additional soft-tissue grafting in conjunction with a combined regenerative and resective surgical procedure seems to be effective in treating and controlling advanced periimplantitis lesions and improving or maintaining the esthetic outcomes.
The limited available data seem to indicate that the best outcome to improve the width of KAM, and the bleeding and plaque scores, as well as to maintain the periimplant marginal bone level is the use of an apically positioned flap combined with a free gingival graft in nondiseased periimplant sites. However, at present, it is unknown: (a) to what extent soft-tissue grafting may additionally improve the outcomes after surgical (resective or regenerative) treatment of periimplantitis compared with the same approaches without soft-tissue grafting, and (b) if considered, when should soft-tissue grafting be performed (eg, before or during surgical treatment of periimplantitis).
Both soft-tissue resective and regenerative approaches may lead to successful outcomes depending on the clinical indication and defect location. However, the selection of one or another surgical approach should be based on defect type (eg, intrabony and suprabony) and location (esthetic or nonesthetic areas). The presence of an adequate width and thickness of KAM may facilitate soft-tissue (flap) management. In patients with a thin phenotype or lack of an adequate width of KAM, soft-tissue grafting may improve the clinical outcomes.
有关在种植体周围炎的外科治疗中软组织管理重要性的数据仍然有限，目前尚无临床推荐。
根据有/无角化黏膜（KAM）的存在/缺失时的潜在获益/风险，概述种植体周围软组织增量手术的基本原理，并为临床医生提供建议。
现有证据表明，KAM 的存在有利于种植体周围组织健康，表现为出血评分改善和便于自我进行菌斑清除、黏膜退缩减少以及随时间推移边缘骨水平更稳定。因此，增加 KAM 的基本原理是：（a）优化进行适当口腔卫生的可能性；（b）帮助维持种植体周围软组织健康和稳定性；（c）改善美观。迄今为止，已经描述了使用自体或异种膜进行 KAM 增量的各种技术。在联合再生和切除性外科手术中进行额外的软组织移植似乎可以有效治疗和控制晚期种植体周围炎病变，并改善或维持美观效果。
有限的现有数据似乎表明，改善 KAM 宽度、出血和菌斑评分以及维持种植体边缘骨水平的最佳结果是使用根尖定位瓣结合游离龈移植术，应用于无疾病的种植体周围部位。然而，目前尚不清楚：（a）与没有软组织移植的相同方法相比，软组织移植在多大程度上可以额外改善种植体周围炎的外科（切除或再生）治疗后的结果；（b）如果考虑软组织移植，何时进行软组织移植（例如，在种植体周围炎的外科治疗之前或期间）。
根据临床指征和缺损位置，软组织切除和再生方法都可能取得成功的结果。然而，应根据缺损类型（例如，骨内和骨上）和位置（美学或非美学区域）选择一种或另一种手术方法。有足够宽度和厚度的 KAM 存在可便于软组织（瓣）管理。在具有薄型表型或缺乏足够 KAM 宽度的患者中，软组织移植可能会改善临床结果。
