International Journal of Periodontics & Restorative Dentistry, 02/2022

This article presents the surgical aspects of, and evaluates bone dimensional changes following, the application of the guided bone regeneration (GBR) technique using individualized titanium mesh on atrophied alveolar ridges to achieve an optimal crest volume for implant placement. Six patients were included and evaluated clinically and radiologically for at least 3 years. Every patient presented bone resorption affecting implant placement in a proper prosthetic position. During the regenerative procedure, customized titanium mesh was used to secure the contour of the augmented site and the stability of xenograft particles deposited on the atrophied crest. After 6 months of healing, the mesh was removed, and implants were placed in planned, prosthetic positions. CBCT scans were taken before the regenerative procedures and after 6 months, before the second-stage surgeries. This allowed for assessment of the postaugmentation vertical and horizontal bone tissue gain. The average volumetric gain of the augmented sites was 5.2 mm horizontally and 2.75 mm vertically. In 50% of cases, minor soft tissue perforation was observed after a few weeks. This complication did not influence the implant placement procedure and was treated during the second-stage procedure with the GBR technique, using a resorbable membrane and xenograft particles to compensate the localized bone defect. No implant failed during the control period. Panoramic radiographs were taken 1 to 3 years after completion of definitive prosthetic treatment to assess potential bone resorption around implants. No crestal bone resorption was observed within this period. It can be concluded that the use of customized titanium mesh is a predictable technique for bone regeneration in advanced, three-dimensional defects.

Several soft tissue graft materials have been utilized over the years as alternatives to the autogenous connective tissue graft for reducing patient morbidity. In particular, a novel volume-stable xenogeneic collagen matrix (VXCM) has recently been introduced for soft tissue augmentation at implant sites. The VXCM is porous in nature, and its mechanical properties suggest utilizing a specific flap approach when treating multiple adjacent gingival recessions (MAGRs). Herewith, a minimally invasive surgical technique is described in combination with VXCM for treatment of MAGRs. Five patients with 16 MAGRs were treated with this approach. All sites healed uneventfully, and patients reported minimal discomfort. At 6 months, the technique resulted in a mean root coverage of 94.73%, and complete root coverage was achieved in 13 sites (81.25%). The proposed minimally invasive approach may have potential to enhance flap blood supply and graft vascularization, promoting rapid healing with minimal postoperative discomfort. In addition, this approach can result in satisfactory clinical, esthetic, and patient-reported outcomes. Future adequately powered clinical trials are needed to validate the findings of this preliminary report.

Various types of digital dental technologies have been successfully implemented as a part of dental treatment to improve predictability and efficiency of dental procedures. Virtual smile design can be used to enhance predictability from an esthetic perspective, and the virtual articulator can be a useful tool to create a desired occlusal scheme. This case series describes a fully digital workflow that can predictably achieve desired esthetic and functional outcomes. The proposed protocol also includes other currently available digital technologies, such as intraoral scanning, computer-aided design, milling, and 3D printing. Three clinical cases are presented to describe the workflow in detail.

Maxillary sinus elevation by the lateral window approach has been shown to be a highly predictable surgical procedure for increasing bone volume in the posterior maxilla. There are occasions, however, where this procedure may be difficult or impossible to perform in a highly predictable manner. There are many presurgical conditions and anatomical features that can make lateral window access difficult, leading to an increase in intraoperative complications and procedural failures. These complicating factors include complex internal sinus anatomy (multiple septa, anteroposterior septa), a narrow available window space, a thin or absent labial plate on adjacent teeth, and the presence of a root apex in the proposed window area, or it may be due to iatrogenically created defects, such as a previous failed sinus elevation, a healed oroantral fistula, or defects created by difficult extractions. While not frequently used or routinely reported in the literature, the palatal window approach may negate many of these obstacles. When it is reported, success rates are similar to those of lateral window procedures, and as an added advantage, postoperative morbidity is dramatically reduced, allowing the patient to wear a removable appliance immediately after surgery. There are, however, anatomical limitations that dictate when this procedure can be used. This case report is unique in that many of the lateral window complicating factors are present, and the palatal anatomy proved ideal for performing the technique.

A healthy, 45-year-old woman requested that her general dentist whiten her two front teeth. Internal bleaching was performed on the teeth at sites 11 and 12 (FDI tooth-numbering system). An internal barrier was not placed, and tooth 11 developed external root resorption. The patient was referred to an oral surgeon to extract the tooth and place an implant. Tooth 12 was salvageable, but the surgeon recommended extraction of both teeth. Implants were immediately placed in the sockets. The implant at site 12 failed and was removed, resulting in a severe ridge defect. Multiple hard and soft tissue surgeries were unsuccessful and the defect worsened, resulting in a Class III ridge defect. The patient was referred to a prosthodontist for consultation, and he recommended referral to a periodontist to reconstruct the badly damaged ridge prior to prosthetic restoration. The periodontist successfully reconstructed the damaged ridge, and a restoration was placed on the implant at site 11 with a cantilevered pontic for site 12. This case elucidates the difficulty in reconstructing a damaged ridge and returning it to its preextraction contour when two adjacent teeth are extracted.

Soft tissue changes were evaluated over a period of 1 year in 48 patients who required extraction of a single tooth in the anterior maxillary arch (premolar to premolar) and its replacement with an implant. The patients were randomly divided into two groups: In group A, an immediate postextraction implant was placed, and the bone-to-implant gap was filled with bovine bone mineral; in group B, the alveolar ridge preservation technique was performed after extraction, and the implant was placed 4 months later. On the day of tooth extraction (T0) and 1 year after tooth extraction (T1), the soft tissue horizontal width, mesial and distal papillary levels, midfacial gingival level, and Pink Esthetic Score were evaluated in both groups. No significant differences were observed between the groups in any of the considered parameters. Statistically significant differences were found in the soft tissue horizontal width between T0 and T1. The clinical results of the two procedures were similar and comparable over time. When evaluating the stability of the soft tissue contour, and considering the specific indications of the two techniques, it is possible to choose either an immediate implant or an alveolar ridge preservation technique with staged placement.

Implant therapy for tooth loss in the molar area is challenging due to the anatomical limitations, requiring bone augmentation procedures that are associated with high surgical complexity and long postsurgical recovery. Recently, many studies have demonstrated the usefulness of short implants. However, few studies have been performed in Japanese patients to evaluate peri-implant bone changes, changes in peri-implant epithelial tissue, and patient satisfaction. The present study included 16 patients (5 men, 11 women; mean age: 60 years) who received 26 short (6-mm) implants. Changes in peri-implant bone and epithelial tissue were measured radiographically at superstructure loading and after 2 years. Peri-implant pocket probing depth was measured at the epithelial tissue and compared at both time points. Patient satisfaction was graded using the Oral Health Impact Profile (OHIP-14) before treatment and at follow-up. The mean mesial and distal bone levels were -0.05 mm and 0.37 mm at loading, respectively, and were 0.33 mm and 0.53 mm after 2 years, respectively. Significant peri-implant bone formation for mesial and distal bone levels at both time points were determined by Wilcoxon signed-rank test. Mean probing depth increased slightly, from 3.03 mm at loading to 3.33 mm after 2 years, but no significant difference was found. The OHIP-14 found that patient satisfaction levels increased after 2 years. Using 6-mm short implants in sites with insufficient bone levels can be a highly beneficial treatment option for patients, as it avoids the need for bone augmentation. However, more long-term and detailed studies on the clinical outcomes for these implants are required.

Allografts have been routinely used for immediate grafting of extraction sites as modalities of alveolar ridge preservation (ARP). Solvent-dehydrated bone allograft (SDBA), which is commonly utilized for socket grafting, exists in the form of cortical and cancellous particles. This study aims to provide a histologic comparison of cortical and cancellous SDBA for ARP. A total of 35 extraction sockets were allocated to receive either a cortical (17 sites) or cancellous (18 sites) SDBA, followed by application of a resorbable collagen wound dressing in both groups. At approximately 4 months, a bone core biopsy sample was obtained during implant placement. Histomorphometric assessment was then conducted to compare the differences between both forms of SDBA. Within its limitations, a higher percentage of vital bone was observed in the cortical bone group compared to the cancellous bone group (28.6% vs 20.1%, respectively, P = .042), while there was a lack of statistically significant differences among other fractions of the bone biopsy sample (residual graft particles and nonmineralized tissues such as connective tissue or other components).

Teeth affected by molar incisor hypomineralization (MIH) present micromorphologic changes and hypersensitivity, which increase the risk of developing caries lesions and affect bonding procedures. Considering that practitioners still misdiagnose teeth affected by MIH, there is an urge for more knowledge about this topic in order to propose a more adequate and conservative treatment. The purpose of this study was to report the clinical challenges regarding the restorative management of a patient with MIH. A 13-year-old girl sought dental treatment, complaining about hypersensitivity in posterior teeth. Under clinical exams, notable enamel alterations mainly affecting posterior teeth (including molars) presented particular characteristics frequently attributed to MIH, and visible stains on maxillary central incisors were present. Because the mineral and organic content of MIH-affected enamel differ from sound enamel, it may imply special care for bonding of a restorative material. Thus, in order to promote a minimally invasive approach, selective removal of carious tissue and restoration with microhybrid composite resin was conducted after application of a universal bonding system used as self-etching strategy. After a 2-year follow-up, the restorations presented good clinical performance and the patient had limited hypersensitivity discomfort, suggesting a promising performance.

Identifying the accurate location of the greater palatine artery (GPA) can be challenging. The purpose of the present cadaver study was to determine the location of the GPA from the cementoenamel junction (CEJ) of the maxillary canine to second molar teeth and to define its relationship with the palatal vault height (PVH) in Caucasian cadavers. Sixty-six sections from fully or partially dentate cadavers were examined. The location of the GPA from the CEJ ranged from a minimum of 8.7 ± 2.1 mm at the canine to 14.5 ± 1.3 mm at the second molar. The minimum distance of the GPA to the CEJ in different PVH ranged from 6 to 12 mm. There was a significant difference between male and female cadavers regarding shallow PVH. Only the PVH as an independent variable had a significant correlation with the GPA location. The present study is the first to identify the different PVHs with customized stents and to correlate them with the distance of the GPA to the CEJ of maxillary teeth.

The aim of this case series was to evaluate implants inserted in bone after guided bone regeneration (GBR). Fourteen patients with generalized aggressive periodontitis (GAP) who had lost one or two maxillary teeth in the incisor or premolar region were enrolled in the study. Due to bone resorption, the lateral width and vertical height of the bone were insufficient for implant placement. GBR was carried out in a staged approach using titanium-reinforced e-PTFE (expanded polytetrafluoroethylene) membranes. No bone grafts or bone substitute materials were used. After 6 to 8 months, turned-surface implants (n = 47) were inserted in augmented and nonaugmented bone sites and prosthetically treated with single crowns. All patients were examined during a 3- to 6-month recall schedule over a 10- to 20-year period, and clinical and radiographic examinations were performed. GBR yielded mean vertical and lateral bone gains of 4.5 and 7.0 mm, respectively. The implant survival rate was 100%, mucositis was present in 28.8% of sites, and peri-implantitis was not found. The annual bone loss at tooth sites was significantly higher than at implant sites in augmented bone (0.5% vs 0.2%, respectively; P = .000), and the adjacent teeth had significantly higher annual bone loss (0.8%; P = .000). Thus, severely periodontally compromised patients can be managed successfully in the long-term with the described clinical protocol.

Some cases of asymptomatic traumatic cyst can be sizable; therefore, they require complete curettage and grafting with bone substitution materials. This case report presents a sizeable traumatic mandibular cyst in a young man treated by surgical exploration and filled with autologous dentin graft (ADG) prepared from an extracted impacted tooth 48 (FDI tooth-numbering system) and advanced platelet-rich fibrin (A-PRF). Initially, an A-PRF membrane was used to cover the apices of teeth 42 and 43, which were protruding into the defect to protect their periapical structures. Then, a grafting strategy was introduced to achieve two fronts of bone formation: one by stimulation of bone outgrowth from the periphery due to A-PRF cellular activity, and a second by bone deposition directly on dentin particles in the center of the defect. On CBCT scans performed 7 months postoperatively, arrays of trabeculae that were extending from bone boundaries of the cyst defect were merged with more condensed bone deposited on ADG residuals in the center, thus filling the defect. It was found that autologous dentin combined with cellular A-PRF activity is a powerful tool to restore even sizable bone defects in a relatively short time frame with adequate bone remodeling.

This study aimed to evaluate the bone dimensional changes associated with extraction sockets preserved with calcium phosphosilicate (CPS) morsels and platelet-rich fibrin (PRF) at 6 months posthealing. Thirty fresh extraction sockets were randomly allocated to one of the following groups and grafted using PRF: Control (n = 10), CPS morsels (Test I; n = 10), or CPS+PRF (Test II; n = 10). All sites were sealed with PRF as a socket seal. CBCT scans were taken at 1 week postsurgery and at 6 months posthealing. The intergroup comparison showed a statistically significant difference in mean horizontal bone dimensional changes, and no such significance was observed for vertical bone changes. Bone density measured using Hounsfield units (HU) fell within the range of 350 to 850 HU (D3 bone quality) at 6 months posthealing for all three groups. Within the limitations of this study, socket preservation using CPS morsels with and without PRF demonstrated more favorable conditions for future implant placement.

Maintaining or creating adequate papillary form is a challenge when placing implants in the esthetic zone. Often, outcomes of procedures designed to maintain or enhance papillae at implant sites yield unsatisfactory results and require secondary microsurgical interventions. This article describes a surgical technique to augment interdental papillae between implants and teeth. The technique uses pedicle flaps from the palate combined with tunneling and is capable of creating a substantial papilla augmentation utilizing vascularized grafts. The surgical technique and requirements for success are presented with a case report.

This case report describes the diagnosis and multidisciplinary treatment of a clinically indiscoverable cementodentinal tear associated with a periodontal-endodontic combined lesion. The tear site was located at the palatal root surface of the maxillary left canine. Due to its position and concomitant periapical periodontitis, it was not noticed at the initial visit until a 3D CBCT examination was conducted. Through combined endodontic-periodontal therapy (which included root canal therapy, root debridement, and periodontal flap surgery), the tear fragment was removed, and the periapical lesion healed gradually. A histologic examination confirmed the definitive diagnosis of a cementodentinal tear. After 14 months, the periodontal and endodontic status of the maxillary left canine were stable. According to these results, CBCT examination and multidisciplinary cooperation seem to be effective and necessary for the diagnosis and treatment of such clinically indiscoverable cementodentinal/cemental tears.

The present randomized controlled study was undertaken to evaluate and compare peri-implant hard and soft tissue changes between implants restored with multiple disconnections and reconnections of the abutment (control group) vs implants restored with a definitive abutment (test group). Twenty edentulous sites from 13 systemically healthy participants were selected for the study. The recorded clinical parameters were bleeding on probing (BOP) and peri-implant pocket depth (PIPD). The measured radiographic parameter was peri-implant marginal bone loss (PMBL). Two parameters were measured both clinically and by CBCT: distance from the cementoenamel junction to the alveolar crest and alveolar ridge width. At the time of surgery, sites were randomly assigned to either the control or test group. At 6 months, (1) BOP was absent in both groups, (2) PIPD increased in both groups and was significantly greater in the control group, and (3) the mean PMBL was significantly higher in the control group than the test group. Thus, it can be concluded that the use of implants with a definitive abutment could be more beneficial in achieving better maintenance of marginal peri-implant tissue health.

This study assessed the effect of nano-hydroxyapatite incorporation into resin infiltrant on the mineral content, surface tomography, and resin tag penetration of demineralized enamel. Forty specimens were exposed to a demineralized solution to form subsurface caries lesions. The lesions were treated with negative control, a resin infiltrant (ICON), ICON with 5% nano-hydroxyapatite (NHA, Sigma-Aldrich), or ICON with 10% NHA. Mineral density was assessed using microcomputed tomography scans at various stages of the experiment. Specimens were scanned by scanning electron microscope (SEM) for surface analysis and resin tag penetration. Analysis of variance was used to assess the difference among groups. Specimens treated with ICON and 5% or 10% NHA showed the most favorable mineral density regarding the percent change in mineral content (32.4% and 29.7%, respectively), compared to 8.8% in teeth treated with ICON alone and -1.8% in teeth in the control group. SEM showed that teeth treated with ICON or ICON with 5% or 10% NHA had a smooth surface. The resin penetration in all tested groups showed high-quality resin tags, regardless of the treatment protocol. NHA resin infiltrant (ICON with 5% or 10% NHA) effectively enhanced the artificial enamel caries surfaces in terms of smooth surfaces, mineral density, and resin penetration.

This study retrospectively evaluated the effect of soft tissue condition on peri-implant health. Clinical variables (Plaque Index, keratinized tissue width, gingival biotype, and vestibular depth) were recorded. Probing depth, soft tissue recession, bleeding on probing, and radiographic marginal bone loss were assessed in relation to independent variables. Statistical analysis was performed using Mann-Whitney U test or Kruskal-Wallis rank test and a logistic regression model at the implant level. A total of 139 implants in 43 patients were assessed. Bleeding on probing was recorded at 54.7% sites, which was significantly related to the biofilm accumulation. Gender, history of periodontal disease, patient adherence to recall visits, and the presence of plaque were associated with higher peri-implant probing-depth values. The maximum soft tissue recession was recorded at sites with a thin biotype and shallow vestibular depth (P = .0). The logistic regression analysis revealed that plaque (P = .002) and vestibular depth (P = .043) were significantly associated with peri-implantitis. Within the study limitations, patients with high plaque accumulation and shallow vestibular depth are more prone to peri-implant disease.