International Journal of Periodontics & Restorative Dentistry, 02/2017

Traditional guided bone regeneration techniques include flap mobilization and placement of a bone graft, often with the use of space-maintaining devices and cell-occlusive membranes. This approach is associated with frequent complications that negatively affect the outcome of the augmentation and the peri-implant soft tissue esthetics. Although current tunneling techniques have focused on periodontal soft tissue applications, earlier publications described their use for horizontal augmentation of mandibular posterior edentulous ridges in full-denture patients. More recently, the use of recombinant human plateletderived growth factor (rhPDGF-BB) was tested with different bone matrices to treat maxillary anterior edentulous spans. The present case series reports the use of a subperiosteal minimally invasive aesthetic ridge augmentation technique (SMART) to treat 60 single and multiple edentulous, dentate, and implant sites on 21 patients and five treatment categories with a follow-up period ranging from 4 to 30 months. The technique includes the use of a laparoscopic approach to deliver a growth factor/xenograft combination into a subperiosteal pouch. No flap elevation, cell-occlusive membranes, space-maintaining devices, or decortication procedures were used. The results from this case series demonstrated predictable and consistent bone regeneration. The average gain in ridge width for all treatment categories was 5.11 mm (SD 0.76 mm), which compares favorably with previously published reports. Morbidity and complication rates were consistently reduced as well. Human histology results show xenograft particles surrounded by newly formed bone. The role of the periosteum as a source of pluripotent cells in growth factor-mediated bone regeneration is discussed.

The goal of this investigation was to evaluate the efficacy of dental implants with a surface that was sandblasted with large grit and acid etched in a human model. Eight patients volunteered to allow the biopsy of a small implant in exchange for complete dental rehabilitation at no cost. All biopsy sites received soft and hard tissue reconstruction, and this report provides observation of successful bone-to-implant contact and successful prosthesis construction for the patient. The patients enthusiastically reported improved quality of life as a result of participation in this study. The surgeons' confidence in this implant was reflected by the clinical and histologic result of the study.

Medical and dental histories, clinical examination, study models, and photographs provide the data for a proper diagnosis and the treatment plan for esthetic dentistry. However, they do not offer all the information necessary to analyze the smile and create harmony with the lips and face without excessive intraoral adjustments. Dentolabial parameters vary according to lip dynamics and are influenced by both a static posed smile and a smile in motion as captured in video. This article describes a documentation protocol using smartphone videos to improve the analysis, smile design decisions, and elaboration of a 2D smile frame that will guide the 3D digital smile design project. The use of dynamic documentation of the smile (DDS) allows esthetic rehabilitative planning from a facial perspective, improvement of communication with the patient, integration between the specialists, and the predictable quality of the treatments.

This preliminary clinical and radiographic study examined the survival of, the marginal bone loss (MBL) around, and the influence of prosthetic abutment height (AH) on MBL around hybrid implants placed in two groups of partially edentulous patients: healthy (HPs) and periodontally compromised (PCPs) patients. A total of 93 patients requiring single or multiunit implant restoration, in the mandible or maxilla, were treated while undergoing cement-retained prosthetic restoration. A total of 54 implants (35 in the maxilla and 19 in the mandible) were placed in 45 HPs, and 56 implants (31 in the maxilla and 25 in the mandible) in 48 PCPs. All 110 hybrid implants positioned in pristine bone provided a 100% survival rate in both HPs and PCPs. No statistical differences were recorded comparing the MBL values of maxillae with those of mandibles. In HPs and PCPs, a similar and limited amount of MBL was recorded, and it was found that the higher the AH, the less MBL. In conclusion, results indicate that the hybrid implants examined could reduce the risk of peri-implantitis due to their coronal machined surfaces and improve osseointegration due to their apical rough surfaces.

The aim of this study was to analyze alveolar bone morphology following periodontally accelerated osteogenic orthodontics. Treated patients were called for a full periodontal examination and a cone beam computed tomography scan. Mean treatment time was 6.08 months. Mean probing pocket depth was 2.7 mm. No gingival recessions were noted. In the maxilla, buccal plate thickness was 0.48 to 2.14 mm. In the mandible, bone thickness was 0.2 to 1.82 mm. Root fenestrations and dehiscences were present in up to 40% of the anterior teeth. Although clinical outcomes were favorable, due to the presence of multiple posttreatment bone fenestrations and dehiscences, a revision of the treatment protocol might be considered.

Crown lengthening by forced eruption is usually followed by conventional surgical procedures. The aim of the present study was to evaluate clinical use of Nd:YAG laser fiberotomy in crown lengthening by forced eruption as an alternative to surgery. Patients who needed crown lengthening were enrolled in this prospective case series and underwent forced eruption. Fiberotomy by Nd:YAG laser was performed 2 days after initiation of forced eruption and every 2 weeks afterward to reach optimum clinical crown length. Measurements included sulcus depth (SD), distance between the gingival margin and the acrylic stent (GM-S), distance from the dental tissue to the gingival margin (clinical crown length) (DT-GM), and distance from the top of the alveolar bone crest to the stent (AC-S) at the mesiofacial, midfacial, distofacial, and midlingual surfaces. A total of 20 patients (9 men and 11 women) with a mean age of 35.25 were enrolled. The SD, GM-S, and AC-S did not change significantly after fiberotomy (P = .32, P = .33, and P = .08, respectively). The DT-GM increased significantly following fiberotomy (P = .001). The results of this study showed that the location of the gingival margin and alveolar bone crest remained unchanged following fiberotomy by Nd:YAG laser during forced eruption, and that Nd:YAG laser can be used as a proper method for fiberotomy in such procedures.

The maxillary sinus augmentation procedure has become a predictable treatment to regenerate bone for implant placement. The purpose of this study was to evaluate the effect of recombinant human platelet-derived growth factor BB (rhPDGF-BB) combined with a deproteinized cancellous bovine bone graft for sinus augmentation. The lateral window approach was used for maxillary sinuses with minimal residual bone. After a healing period of 4 months, dental implants were placed and then restored following a 2-month osseointegration period. The result demonstrated increased bone height and ISQ values and a 100% survival rate. This study indicates that the addition of rhPDGF-BB to deproteinized cancellous bovine bone accelerated the healing period in maxillary sinuses with minimal native bone.

Primary wound closure and uneventful early wound stability over the biomaterials are the most critical elements of successful periodontal regeneration. Yet the surgical elevation of the interdental papilla to access deep and wide intrabony defects entails an impairment of the papillary blood supply that can result in difficult healing due to a lack of primary closure in the early healing period. This negative event might complicate the healing process, favoring bacterial contamination. A novel modified tunnel surgical technique designed to maintain the integrity of the interdental papilla is presented in this article, with the aim of providing an optimal environment for wound healing in regenerative procedures. Entire papilla preservation is described and applied in three different cases, in association with the use of a combination of bone substitutes and enamel matrix derivative for periodontal regeneration. The entire papilla preservation technique was successfully applied to the three selected cases, resulting in an uneventful postsurgical period and a substantial defect fill over the 8-month follow-up. This tunnel-like technique can be recommended for further research to support the success identified in this case series.

This article aims to describe a modification of the semilunar coronally advanced flap. A total of 12 systemically and periodontally healthy patients presenting Miller Class I gingival recession were treated with the modified semilunar coronally advanced flap technique described in this article. After 1 year of follow-up, the mean root coverage was 85.4% ± 24.7%. Significant gingival recession reduction, clinical attachment gain, and reduction in dentin sensitivity was observed 1 year after surgery. This novel semilunar coronally advanced flap technique was demonstrated to be effective for root coverage in Miller Class I gingival recessions.

The objective of this study was to assess the influence of the extension of collar and fatigue cycling on the fracture load of anterior zirconia crowns. A total of 60 anterior full-crown preparations (central incisor) were machined in glass fiber- filled epoxy resin. Zirconia copings were designed and milled using computeraided design/computer-assisted manufacture (thickness: buccal = 0.62 mm, lingual = 0.65 mm, incisal = 0.72 mm). The cervical collars (occlusogingival height = 0.8 mm, buccolingual width = 1.0 mm) were totally or partially (buccal face) removed for modified copings. They were randomly allocated to six groups according to the type of cervical collar design and the presence (or not) of fatigue cycling (n = 10). The veneering ceramic layer was pressed, and the crowns were cemented with resin cement. The samples were tested until fracture in a universal testing machine and analyzed by stereomicroscopy. Data were statistically analyzed by two-way analysis of variance and Tukey test (5%). Removal of the cervical collar significantly affected the fracture strength of zirconia crowns (P = .000), whereas fatigue cycling did not (P = .428). The mean failure load was lower in the groups with no collar. The most frequent failure modes were cracking of the veneer porcelain in collarless crowns and catastrophic failure in the others. The authors concluded that removal of the vestibular collar of zirconia copings in anterior crowns does not reduce the fracture load of the crowns. However, removal of the entire collar reduces the fracture load and cannot be recommended.

This article presents a clinical protocol to reconstruct two accidentally damaged maxillary central incisors using composite resin material and a fractured tooth component. A patient was referred to the clinic with fracture of the two maxillary central incisors. Clinical examination revealed that both teeth were fractured in the middle third of the crown and that the fractures involved enamel and dentin with no pulp exposure. The patient had also suffered a lower lip laceration. When the lip was evaluated, a fractured fragment of the maxillary right central incisor was found inside the wound. The missing part of the tooth was replaced via adhesive attachment. Due to the damage of the fractured part of the maxillary left central incisor, direct composite restoration of this tooth was performed. With the advent of adhesive dentistry, the process of fragment reattachment has become simplified and more reliable. This procedure provides improved function, is faster to perform, and provides longlasting effects, indicating that reattachment of a coronal fragment is a realistic alternative to placement of conventional resin composite restorations.

Volumetric changes were evaluated to assess the regenerative efficacy of demineralized freeze-dried bone allograft (DFDBA) with and without amnion membrane (AM) in Grade II furcation defects both clinically and radiographically using cone beam computed tomography (CBCT). Sites were randomly assigned to Group I (DFDBA) and Group II (DFDBA + AM). Clinical parameters such as probing pocket depth, clinical attachment level, gingival recession, and horizontal probing depth were assessed at baseline, 3 months, and 6 months. Radiographic dimensions of the defect height, width, depth, and volume were assessed at baseline and 6 months postoperatively. DFDBA used with AM resulted in significant improvement in clinical and radiographic parameters when compared with DFDBA alone. The mean reductions in radiographic volume of the defect were 11.15 ± 6.39 mL for Group I and 17.02 ± 10.86 mL for Group II. Greater reduction in volume indicated a greater amount of healed regenerated tissue in Group II patients.

The objective of this study was to evaluate the clinical effectiveness of platelet-rich fibrin (PRF) membrane used in combination with a modified coronally advanced flap (MCAF) and to compare it with the use of a subepithelial connective tissue graft (SCTG) in combination with a MCAF in treatment of Miller Class I and II bilateral multiple gingival recessions. A total of 20 patients with multiple Miller Class I and II maxillary gingival recession defects participated in this randomized, split-mouth, controlled study. A total of 60 defects received either PRF + MCAF (test group, n = 30) or MCAF with SCTG (control group, n = 30). Gingival recession depth (RD), keratinized tissue width (KTW), probing depth (PD), clinical attachment level (CAL), and gingival thickness (GT) were evaluated at baseline and after 6 months. Patients' discomfort postsurgery was measured by comparing visual analog scale scores. The percentage of root coverage was 84% in the control group and 77.12% in the test group (P = .007). Complete root coverage of the control and test groups was 60% and 50%, respectively (P = .112). KTW and GT increased in both groups from baseline to 6 months (P .001). At 6 months postoperative, KTW was greater in the control group (P = .024) and GT was higher in the test group (P = .005). Use of a PRF membrane in gingival recession treatment decreased postoperative discomfort compared to SCTG-treated gingival recessions (P .001). Within the limitations of the present study, it was concluded that localized gingival recessions could be successfully treated with MCAF + PRF as well as MCAF + SCTG. The PRF technique has the bonus advantage of being more comfortable during the postoperative period. The author suggests that the use of PRF is a valid alternative to SCTG for the treatment of localized gingival recessions.

Esthetic implant therapy can be challenging in the anterior maxilla, and meticulous treatment is often required to deliver optimal esthetics. Close collaboration between surgical and prosthetic team members using the novel approach of prosthetic crown lengthening helped camouflage a shallow implant platform location, providing the proper gingival frame for esthetic restorations. This case report presents an interdisciplinary approach that included ridge augmentation, second-stage crown lengthening, and prosthetic soft tissue manipulation to address an implant placed too shallow in the alveolus of an extraction socket.

Alveolar ridge preservation has become a very common procedure following tooth extraction. This study presents a clinical, histologic, and histomorphometric analysis of postextraction bone changes using nanocrystalline hydroxyapatite (nc-HA) and exposed high-density polytetrafluoroethylene (d-PTFE) membrane. A total of 10 extraction sockets were treated. Clinical measurements were taken after tooth extraction with a customized acrylic stent to ensure the same measurement points. At 6 months, clinical measurements were repeated and bone specimens taken. An overall bone reduction was observed. The histologic and histomorphometric analysis revealed newly formed bone (25.92% ± 18.78%), soft tissue (28.55% ± 9.73%), and residual graft particles (15.43% ± 11.08%). Further studies are necessary to evaluate the efficacy of this technique over the long term.

Simvastatin (SMV) is a specific competitive inhibitor of 3-hydroxy-2-methylglutaryl coenzyme A reductase that promotes bone formation. The present clinical trial was designed to investigate the effectiveness of 1.2 mg SMV as a local drug delivery system and as an adjunct to scaling and root planing (SRP) in the treatment of aggressive periodontitis (AgP). A total of 68 intrabony defects from 24 patients with AgP were treated either with 1.2 mg SMV gel or placebo gel. The subjects were randomly assigned to SRP + placebo (group 1; n = 12) or SRP + SMV (group 2; n = 12). Clinical parameters were recorded at baseline and at 3 and 6 months and included bleeding index, Plaque Index, probing depth (PD), and clinical attachment level (CAL). At baseline and after 6 months, radiologic assessment of bone defect fill was done. The mean decrease in PD at 6 months was 1.14 ± 0.04 mm and 3.78 ± 0.62 mm in groups 1 and 2, respectively. Significant gain in mean CAL was found between the groups (P .05). Furthermore, significantly greater mean percentage of bone fill was found in group 2 (34.01%) compared to group 1 (2.62%). Locally delivered SMV provides a comfortable method to improve clinical parameters and promotes bone formation.

Today, innovative restorative materials and techniques allow for minimally invasive prosthetic procedures, which are paramount to the preservation of hard and soft dental tissues. An integrated approach combining dental and esthetic medical therapies could be useful to improve the quality of life of patients, improving function, esthetics, and self-confidence. Oral esthetics depends on several variables, including tooth visibility and proportions as well as healthy gingival tissues. Proper integration between teeth and periodontal tissues plays an important role in esthetic success, which is mainly represented by an appealing smile. The present case report was aimed at describing the multidisciplinary treatment of a woman who was unsatisfied with the shape of her central incisors and the dark gingival pigmentation displayed by a high smile line. The patient was treated with minimally invasive combined periodontal, prosthetic, and esthetic medical techniques. The described multidisciplinary approach based on surgical gingival depigmentation, adhesive ceramic veneers, and selective botulinum toxin injection was effective in solving the undesired high smile line and achieving patient satisfaction.

This study evaluated use of a solid-state laser to avoid the flap technique and suturing. An Er:YAG laser was used in 26 consecutive patients referred for osseous crown lengthening in 32 posterior teeth. The distance from the planned restoration margin to the alveolar crest (B) satisfied a 3-mm dentogingival complex. No tissue necrosis and no significant change in the distance from the gingival margin to B or probing depth were detected at 3 and 6 months. Minimally invasive Er:YAG laser surgery decreases the time needed to establish the gingival margin necessary for definitive restoration.

In this prospective study, 15 patients received 15 variable-thread tapered implants placed in fresh extraction sites in the maxillary esthetic zone and immediately were provisionalized out of occlusion. Of the 15 patients, 11 completed their 2-year follow-up. At 2 years, the success and cumulative survival rates were both 100%, and the mean bone level gain was 0.83 mm. Soft tissue assessment showed no zero esthetic scores, improved papilla indices, and low bleeding on probing and plaque accumulation. Overall, the study implants showed excellent hard tissue, soft tissue, and esthetic outcomes, indicating a healthy tissue response in single-tooth extraction sites in the maxillary esthetic zone.