International Journal of Periodontics & Restorative Dentistry, 05/2013

Webster's dictionary defines a "master" as "an artist or performer of great and exemplary skill"; a reminder that the world of sports offers metaphors that apply to our own private lives. The Masters Tournament, also known as "The Masters," originated in 1933 and is one of the four major championships in professional golf. It is played in April each year at Augusta National Golf Club, a private club in the city of Augusta, Georgia, USA. The tournament is invitational and has a number of traditions: the blooming of beautiful spring flowers around pristine fairways and greens, the pretournament dinner where all past champions meet and greet one another and share the camaraderie and bounty of their personal and professional lives, and, of course, the famous green jacket award ceremony when the winner is given the prestigious green jacket that is worn by Masters champions. Only a select group of elite corporations are given the privilege of sponsorship. For the 90 players who have earned an invitation to play in the Masters, the excitement begins to build weeks in advance, and each golfer has a personal story and a unique dream. The Masters Golf Tournament is truly inspirational and has a lasting effect on the participants, the patrons, and the international sponsors. Some distance north, the city of Boston, steeped in history, is the location of the International Symposium of Periodontics & Restorative Dentistry (ISPRD). The founders, Drs Gerald Kramer and Myron Nevins, are the Clifford Roberts and Bobby Jones of periodontics. They began hosting the Symposium in 1983 as co-editors of The International Journal of Periodontics & Restorative Dentistry. This past June marks the 11th anniversary of this momentous event that is held every 3 years in June in Boston. Myron Nevins and his son and co-editor, Marc Nevins, remain no less committed than 33 years ago in their quest to maintain the excellent tradition of this unique event in dentistry. The 2013 participants represent 59 countries and 38 US states, along with Washington DC, Puerto Rico, and the US Virgin Islands. The majority of attendees came from Japan, Canada, Mexico, Italy, the United Kingdom, Brazil, the Netherlands, Costa Rica, China, and the United States. To be named one of the 85 lecturers at the ISPRD meeting is an invitation to the Symposium's own champions' dinner. To arrive at the speakers' dinner at the Algonquin Club on Commonwealth Avenue is glorious. That flute of champagne as you climb the beautiful winding staircase to the second floor to the accompaniment of a piano rendition of "Some Enchanted Evening" is superb! To finally meet many of your idols who are lecturers, including authors, academicians, researchers, and clinicians, is as exciting as being on the great stage of the Masters at Augusta. If Dr Gerald Kramer were alive, I feel certain he would like what he saw at the 11th annual ISPRD! Young professional golfers and noted amateurs dream of receiving a ticket to play in the Masters. Likewise, young talented dentists dream of writing an original paper of significance, contributing a chapter to a textbook, or becoming an expert in an area of dentistry that might yield an invitation to lecture at the prestigious international Symposium. For a lecturer to win dentistry's green jacket, just one time, is in itself quite an accomplishment. As in other walks of life, the young will slowly replenish the esteemed ranks of participants. If you only receive one invitation in a lifetime to speak at the ISPRD, you can sleep well knowing that you made the team! Congratulations! The 90 players participating in the Masters in Augusta know that there can be only one winner each year. By winning, you receive a lifetime invitation to play in the Masters and attend the pre-tournament champions dinner. Names such as Jones, Player, Palmer, Nicholas, and Woods are synonymous with the recipients of the periodontal and restorative awards that are presented at each symposium for their contributions to the profession. These champions are Ulf Lekholm, George A. Zarb, Morton Amsterdam, Peter Schärer, Lloyd L. Miller, Gerald M. Bowers, Robert G. Schallhorn, Jörg Strub, James Mellonig, and Arnold Weisgold, and they are recognized as champions in this special society. Every 3 years, only 85 lecturers receive an invitation to participate in the ISPRD; many of these unique individuals are repeat invitees. The preparation is immense: A 1-hour lecture on a 10 × 30-ft screen with possibly 2,500 to 3,000 spectators (patrons) and sold-out signs at the registration desk are the norm, and early registration months in advance is suggested. The attire is coat and tie. Just looking around provides another reinforcement of the elegance and confidence of the select lecturers and audience. Like the patrons and sponsors of the Masters, the ISPRD attendees and sponsors are an esteemed group. Preparation is already underway for the 12th ISPRD to be held in Boston in June 2016. The audience will again look forward to long-term follow-up of cases as well as the new therapies that are continuing to evolve. Will the returning speakers' opinions on ideal care remain the same? Will new research unravel our established evidence-based care? Will our clinical judgments, based on evidence and experience, change dramatically? Will the lecturers at the 11th ISPRD be invited to return to the 12th? Who will be the newcomers? The ISPRD will continue to be the breeding ground for the future masters of the dental profession, and authorship of The International Journal of Periodontics & Restorative Dentistry will remain one of the valid qualifying mechanisms.

The purpose of this case series is to present radiographic results of implants immediately placed and restored with a definitive abutment and followed for 18 months. Ten patients who required extraction of the maxillary central or lateral incisor were treated with immediate extraction, implant placement, and provisionalization. Hard tissue measurements were performed using cone beam computed tomography. At follow-up, the mean buccal horizontal gap was -0.21 ± 0.3 mm. The mean vertical gap was 0.15 ± 0.23 mm. The mean distance between the bone crest and implant bevel was 1.73 ± 0.17 mm. The favorable results are related to a three-dimensional biologic space created around the abutment called the chamber.

The goal of this study was to evaluate the effectiveness of demineralized bone matrix (DBM) putty, consisting of demineralized human bone allograft matrix in a carrier of bovine collagen and alginate, for the treatment of periodontal defects in humans. Twenty subjects with at least one site having a probing depth ≥ 6 mm and radiographic evidence of bony defect depth > 3 mm were included. The infrabony defects were grafted with DBM putty bone graft. The following clinical parameters were assessed at baseline and 6 months posttreatment: probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). Bone fill was evaluated using transgingival probing and standardized radiographs taken at baseline and 6 months posttreatment. The 6-month evaluation showed a significant PD reduction of 3.27 ± 1.67 mm and clinical attachment gain of 2.27 ± 1.74 mm. Bone sounding measurements showed a mean clinical bone defect fill of 2.93 ± 1.87 mm and a mean radiographic bone fill of 2.55 ± 2.31 mm. The use of DBM putty was effective for treatment of periodontal bony defects in humans. Significant improvement in CAL, PD, and bone fill was observed at 6 months compared to baseline.

This case report presents a patient who underwent a major correction of malpositioned implants. Two implants were previously placed in a 30-year-old woman to replace the maxillary right central and lateral incisors without any attempt to reconstruct the alveolar and soft tissue defects. This resulted in a significant esthetic problem. The position of the implants was successfully corrected via the mobilization of a bone block in which the implants were maintained. The bone block was then fixed in a predetermined optimal position. After fixing the bone block, gaps were filled with Bio-Oss and covered with a membrane. Nine months after bone healing, a periodontal technique was used to improve soft tissue esthetics. The final result was achieved with the combination of bone surgery, soft tissue management, and progressive adaptation of implant-supported crown restorations.

This study evaluated the treatment of alveolar bone deficiencies combined with dental implant placement. Thirty-five endosseous implants were inserted into 20 patients. After implant placement, the mean height of the supracrestal bone defects measured 4.25 ± 1.34 mm. Bone regeneration procedures were performed using a combination of a bovine bone-derived mineral stabilized with a fibrin-fibronectin sealing system and covered with a bilayered porcine collagen membrane. Healing was uneventful in all instances with maintenance of primary closure throughout the healing period. Stage-two surgery was performed after 6 months, and a hard bonelike tissue was detectable at the defect sites. Histologic examination confirmed the presence of newly formed bone with residual particles of xenograft. The mean bone gain was 3.95 ± 1.47 mm. The positive outcomes in terms of bone regeneration and low complication rate demonstrated the potential of this technique for the treatment of supracrestal ridge deficiencies. Bovine bone mineral combined with a fibrin sealer and protected by a collagen membrane should be considered as an alternative in the treatment of vertical peri-implant bone defects.

The coronal advancement of surgical flaps and subsequent shift of the mucogingival junction during bone augmentation procedures are common. These mucogingival alterations may become a challenge to manage in the maxillary anterior region among patients with a high lip line upon smiling or high esthetic demands. To further complicate matters, the presence of physiologic gingival pigmentation in the esthetic zone creates challenges of its own. In this case, a free gingival graft from the buccal gingiva of the maxillary molars was used to correct the mucogingival deformity created from a guided bone regeneration procedure.

In an attempt to reduce postextraction alveolar bone resorption, ridge preservation and augmentation procedures have become standard-ofcare treatment following tooth removal. This consecutive case series compares histologic and histomorphometric bone regenerative findings at 4 months following grafting for ridge preservation and augmentation in intact sockets and sockets with buccal wall defects. Sites were treated with mineralized allograft alone (control) or in combination with 0.3 mg/mL recombinant human platelet-derived growth factor BB (rhPDGF-BB) (test). Sites were allowed to heal for 4 months and then re-entered for trephine core biopsy and implant placement. At the end of 4 months, the mean percent remaining mineralized allograft was statistically significantly less in the test group than in the control group. The difference in mean percent vital bone between the groups showed a strong trend toward greater bone formation for the test group (41.8%) compared to the control group (32.5%) at the end of 4 months. Addition of growth factor signaling molecules to current grafting procedures may lead to accelerated bone regeneration, making it possible to successfully place implants at earlier time points.

Posterior vertical alveolar ridge deficiencies are challenging defects to treat predictably and often require autogenous bone-harvesting procedures. Traditional treatment modalities, eg, guided bone regeneration, distraction osteogenesis, and autogenous grafts, present with a number of potential complications and limited success when used to restore vertical ridge height. Recent advances in recombinant growth factor technology may provide viable, alternative therapies for the treatment of significant alveolar ridge deficiencies. This proof-of-principle case report examines the utility and effectiveness of using a composite graft of freeze-dried bone allograft and recombinant human platelet-derived growth factor BB in conjunction with an overlying titanium mesh to regenerate well-vascularized bone in a significant posterior mandibular ridge defect prior to implant placement. The important role of the overlying periosteum as a possible key source of osteogenic cells during growth factor-enhanced regenerative procedures is emphasized.

One treatment approach for achieving healing by regeneration is the application of enamel matrix derivative (EMD) during periodontal surgery. The aim of this randomized clinical study was to compare the efficacy of EMD with a connective tissue graft (CTG) for the treatment of adjacent Miller Class l and II multiple gingival recessions. Twelve systemically healthy subjects with at least two Miller Class I or II multiple gingival recession defects affecting adjacent teeth on both sides of the mouth were enrolled. The surgical protocol was performed for both groups. The 56 recession defects were evaluated for recession depth (RD), recession width (RW), percentage of root coverage (PRC), height of keratinized tissue (HKT), probing depth (PD), and clinical attachment level (CAL). All measurements were repeated at 6 and 12 months. The mean PRC at the final evaluation was 89% ± 17% for the coronally advanced flap (CAF) + EMD group and 93% ± 17% for the CAF + CTG group. Both treatments resulted in statistically significant decreases in RD and RW and increases in HKT at 6 and 12 months. There was also a significant CAL gain for both groups. PD remained shallow over time. The results demonstrated that both procedures were successful in treating Miller Class I and II multiple gingival recessions; however, the greater results of the CAF + CTG group did not reach a statistically significant level.

Peri-implantitis is a frequently occurring inflammatory disease mediated by bacterial infection that results in the loss of supporting bone. Peri-implantitis should be treated immediately, but there is a lack of evidence regarding the most effective therapeutic interventions. Nonsurgical periodontics may be the treatment of choice in cases of peri-implant mucositis or if the patient has medical contraindications or refuses to consent to more appropriate treatment. Peri-implantitis defects will dictate the therapeutic approach and present a guideline for relative clinical management. The suggested therapeutic solutions are derived from clinical experience and are meant to be a useful guide.

Damage to periodontal tissue as a result of thermal injury often causes severe gingival recession and denuded alveolar bone. In this case report, two patients undergoing gingival coverage of iatrogenically denuded labial bone associated with the maxillary central incisor and the lateral incisor are presented. The first patient had gingival necrosis and labial alveolar bone exposure on the maxillary left central incisor and was referred from a local dental clinic. The patient had undergone root canal treatment 2 weeks previously. The gingival necrosis was assumed to be caused by a heated plugger. The denuded root surface was immediately covered by a laterally positioned flap over a connective tissue graft obtained from the palate. The gingival margin and overall appearance were symmetrically in harmony with those of the adjacent teeth. Another patient with the same symptoms and dental history was treated using the same procedure. Normal periodontal architecture was successfully reconstructed and maintained. In the cases presented, laterally positioned flap coverage over a subepithelial connective tissue graft was successfully applied to cover thermally injured bone and the root surface.

This study evaluated the effects of enamel matrix derivative (EMD) and basic fibroblast growth factor (bFGF) with β-tricalcium phosphate (β-TCP) on periodontal healing in intrabony defects in dogs. One-wall intrabony defects created in dogs were treated with β-TCP alone (β-TCP), EMD with β-TCP (EMD/β-TCP), bFGF with β-TCP (bFGF/β-TCP), and a combination of each (EMD/bFGF/β-TCP). The amount of new bone formation was not significant for any group. The EMD/bFGF/β-TCP group induced significantly greater new cementum formation than the β-TCP and bFGF/β-TCP groups and, although not significantly, formed more new cementum than the EMD/β-TCP group. These findings indicate that EMD/bFGF/β-TCP treatment is effective for cementum regeneration.

The aim of this study was to report the outcome of the management of alveolar crest vertical defects using the tunnel technique approach associated with autogenous bone blocks prior to implant placement in 10 partially dentate consecutively treated patients. Four clinical linear measurements were taken: maximal extension of the vertical defect (VD) at the time of the augmentation procedure (time 0), vertical bone graft (VBG) recorded at time 0, bone resorption at implant placement (time 1), and bone resorption during implant healing at the time of abutment connection (time 2). All patients healed uneventfully, and no complications were recorded. Both mean VD and VBG at time 0 were 6.50 ± 1.43 mm. Mean bone resorption at time 1 was 0.30 ± 0.48 mm and mean bone resorption at time 2 was 0.25 ± 0.26 mm, yielding an overall vertical bone remodeling of 0.55 ± 0.49 mm (8.4%) after 8 months. This study supports the capability of a minimally invasive approach to regenerate bone in vertical defects prior to implant placement.

Recent technologic advances allow clinicians to place dental implants using computer-generated templates. However, there are limited data regarding treatment outcomes for implants placed using these techniques. The purpose of this retrospective study was to report the 2- to 4-year prosthetic outcomes and survival of dental implants placed by postdoctoral residents with a flapless surgical protocol using computer-based planning and stereolithographic surgical templates. Thirty-six patients were treated using the NobelGuide concept, comprising an image-based three-dimensional implant planning software and flapless implant surgery with stereolithographic templates.

This study aimed to histomorphometrically evaluate the soft tissue reactions of one-piece zirconia implants versus titanium implants in regard to their insertion depth. Four one-piece implants of identical geometry were inserted on each side of six mongrel dogs: an uncoated zirconia implant, a zirconia implant coated with a calcium liberating titanium oxide, a titanium implant, and an experimental implant made of a synthetic material. Using a split-mouth design, they were inserted in both submerged and nonsubmerged healing modes. After 4 months, dissected blocks were stained with toluidine blue to histologically assess the marginal portion of the implant mucosa, apical extension of the barrier epithelium, and margin level of bone-to-implant contact. The inflammation status at the crestal part of the implant was assessed as well. The histomorphology presented the typical soft tissue configuration of barrier epithelium and connective tissue near the bone-to-implant contact. Histomorphometrically, the length of the barrier epithelium did not differ significantly concerning material type or healing modality. Furthermore, the inflammation signs were higher with nonsubmerged implants. The submerged uncoated zirconia implants, however, showed few signs of inflammation. Within the limits of this study, it is concluded that uncoated and coated zirconia implants are capable of establishing sufficient soft tissue configurations that are comparable to those of titanium implants.

The aim of this study was to evaluate, clinically and histometrically, the effects of subgingival placement of a resin-modified glass-ionomer restoration during flap surgery. Nine dogs were included in this study. The mandibular canines were randomly assigned to receive either a transgingival resin-modified glass-ionomer restoration (test group) or no restoration (control group). The apical margins of the restorations in the test group and a reference notch on those in the control group were placed at the level of the bone crest. Clinical parameters were recorded 7 days before sacrifice. The dogs were sacrificed after 107 days, and undecalcified sections were obtained for histologic evaluation. Clinically, both groups presented significant clinical attachment loss and an increase in probing depth, but differences between groups were not statistically significant (P > .05). Histologically, a significant difference between groups was observed for length of epithelium (test, 4.05 ± 0.57 mm; control, 3.36 ± 0.63 mm; P = .01). The test group showed more bone resorption (2.02 ± 1.47 mm) when compared with the control group (0.74 ± 0.37 mm) (P = .048). It can be concluded that even with the claimed favorable properties of resin-modified glass ionomer, the presence of the restoration within the biologic width causes increased migration of the apical epithelium and bone resorption.

The purpose of this study was nondecalcified histologic analysis of titanium implants modified by laser with and without hydroxyapatite. Implants with three modified surfaces were inserted into rabbit tibias: group 1, machined surface; group 2, irradiated (laser); and group 3, irradiated and hydroxyapatite coated (biomimetic method). The mean surface roughness (Ra) scores of groups 2 and 3 were higher than that of group 1. Boneimplant contact measurements at 30 and 60 days for groups 2 and 3 were higher than for group 1. Bone area at 30 and 60 days for group 2 was higher than for groups 1 and 3. Titanium implants modified by laser with and without hydroxyapatite exhibit increased early osseointegration.