International Journal of Periodontics & Restorative Dentistry, 06/2013

Since the introduction of implants into the armamentarium of the dental profession, periodontal disease is often overlooked or not treated appropriately. Patients with early or moderate disease that could be successfully treated with a positive long-term prognosis are allowed to smolder until they are virtually hopeless. Most patients prefer to preserve their own dentition as opposed to extractions and implants even if it requires periodontal surgery. This is especially true when we consider the regenerative possibilities that periodontists have to offer. Do not lose sight that our primary objective is to achieve optimum periodontal health using the most conservative measures, which may mean proper oral hygiene, subgingival scaling, and pocket elimination where possible, so that ancillary personnel can maintain this health with routine maintenance visits. The periodontal pocket is likely the most frequently encountered dental malady, but the treatment regimes run the course of paradox. Recently, an auditorium audience filled to the brim with clinicians expressing a keen interest in periodontology was asked if they would prefer to have significant pocket depth in their own dentitions. "Of course not," the incredulous audience proclaimed. Yet, how many practices have a double standard when contrasting their personal dental health with that of their patients? If one accepts the bacteriologic roles in the etiology of periodontal disease and is aware of the investigations conducted by Socransky and associates as to the presence or absence of periodontal pathogens (the red complex) located in the pocket, it would appear that the conclusions would be self-evident. The endpoint goal of all periodontal treatment should be the creation of an environment that the patient and hygienist can maintain. Dentitions exhibiting deep pocketing with compromised alveolar support are evidence of the patient's susceptibility to disease. Accepting the results of "soft tissue" therapies that do not result in a cleansable environment but provide pink, nonbleeding gingiva is only the first plateau of treatment. If the patient can't floss the depth of the probing and the hygienist cannot remove the accretions, the problem is not solved. All probing depths greater than 5 mm require more sophisticated analysis and treatment. The naysayers proclaim that this is an impossible goal or not lucrative, but are health care goals really impossible or beyond the knowledge of our therapies? W. Somerset Maughan wrote: "It's a funny thing about life; if you refuse to accept anything but the best, you very often get it." The obstacles to be encountered are predictable: the third parties will be aghast and patients wish to avoid surgery. Those who wait for statistical evidence will obviate the need to reach the previously stated endpoint goals. The manufacturers of products designed as alternatives to surgery would double their efforts to influence the clinical decisions of the less educated practitioners. Dentistry has come a long way in the last two decades. Let us maintain the momentum for the continued benefit of our patients. Thus, the litmus test is: What would I do if this were my own dentition?

The purpose of this study was to histomorphometrically evaluate the percentage of vital bone after grafting of maxillary sinuses using two different concentrations of recombinant human bone morphogenetic protein/acellular collagen sponge (rhBMP-2/ACS) combined with mineralized cancellous bone allograft (MCBA) and to compare the results to a control sinus grafted with MCBA only. Thirty-six sinuses in 18 patients had two of three of the graft combinations including: (1) control, MCBA only; (2) test one, MCBA + 5.6 mL of rhBMP-2/ACS (containing 8.4 mg of rhBMP-2); or (3) test two, MCBA + 2.8 mL of rhBMP-2/ACS (containing 4.2 mg of rhBMP-2). Histologic cores were taken 6 to 9 month following sinus augmentation. The results showed no statistically significant differences in vital bone between the two test groups compared to the control sinus group treated with MCBA alone. Future studies involving more cases and evaluating survival of implants placed in these augmented sinuses are needed to verify the results of this randomized prospective study.

The primary aim of this study was to test whether intraradicular posts of different colors induce different amounts of color change of the buccal gingiva. Twentythree patients in need of a post-and-core buildup at one endodontically treated incisor, canine, or premolar were included. Titanium (Ti), zirconia (Zi), and glass fiber (Gf) posts were consecutively inserted in each test tooth. Spectrophotometric color measurement of the buccal gingiva was performed prior to post bed preparation and after insertion of Ti, Zi, and Gf posts. For control purposes, the gingival color at the contralateral vital tooth was assessed. The differences of color components ΔL, Δa, and Δb and the total color difference (ΔE) between different experimental conditions were obtained. ΔE value of 3.7 was considered the threshold value for intraoral color distinction. The gingival thickness at test teeth was measured. No difference occurred with regard to the amount of gingival discoloration induced by different posts. In the majority of cases, posts did not exhibit a visible influence on the color of buccal gingiva. The gingiva at endodontically treated teeth presented a visible discoloration compared to the gingiva at vital teeth. The degree of gingival discoloration at endodontically treated teeth was correlated with the gingival thickness, with more pronounced discolorations in cases of thinner soft tissue.

An extremely rare case presenting two bilateral transposed and infraosseus impacted maxillary canines was treated with a combined two-step periodontal and orthodontic technique. The canines were transposed mesially and buccally to the lateral incisors, close to the midline and in a horizontal position. Direct orthodontically guided traction of the teeth toward the center of the alveolar ridge was not possible due to the roots of the lateral incisors. The procedure consisted of two distinct treatment phases for each side preceded by an initial orthodontic treatment to achieve the palatal inclination of the roots of the lateral incisors, creating a parallel buccal inclination of the crowns. This approach provided a submucosal buccal space into which the canines could be moved buccally and distally, avoiding any contact with the roots of the lateral incisors. In the first phase, the transposed canines were guided distally. When the canines, still in a submucosal position, were freed from those obstacles, the second phase was begun. The teeth were exposed, permitting the orthodontically guided traction toward the center of the ridge, simulating a proper physiologic eruption alignment pattern in the arch. The combined two-step periodontal and orthodontic approach used to treat two bilateral transposed and infraosseus impacted maxillary canines was extremely successful, resulting in adequate alignment in the arch associated with a physiologic sulcus depth, adequate keratinized tissue width, and absence of marginal recession at the end of the active treatment and 5 years postsurgery.

The aim of this study was to histologically and histomorphometrically analyze the peri-implant tissue reactions and the bone-titanium interface in loaded Ankylos implants retrieved after loading periods of longer than 1 year. The archives of the Implant Retrieval Center of the Dental School of the University of Chieti- Pescara were searched for Ankylos implants retrieved from humans after a loading period of longer than 1 year. A total of four implants were found: one had been retrieved after 3 years (Friadent plus surface), two after 3.5 years (Friadent plus surface), and one after 10 years (Deep Profile surface). All implants had been loaded; two had been loaded immediately. One implant was retrieved after fracture, one was retrieved after fracture of the superstructure, and the other two were retrieved because of bone resorption with or without infection. Compact bone with few small marrow spaces was present around the three implants retrieved after 3 and 3.5 years; trabecular bone was present around the implant retrieved after 10 years. The bone-implant contact of the three best threads was 35% for the implant retrieved after 10 years, 99% for the implant retrieved after 3 years, and 100% for the implants retrieved after 3.5 years. No untoward effects were present at the interface, and a high bone-implant contact was present around the implants with the microstructured surface. The data show that these implants had the potential to maintain osseointegration under long-term function with continuous and ongoing bone remodeling.

This cross-sectional study assessed the variability in supracrestal gingival tissue (SGT) dimensions in a healthy periodontium. SGT dimensions were evaluated for differences across various locations, tooth types, and periodontal biotypes. All measurements were made with a vernier caliper to the nearest 0.1 mm. A total of 1,932 sites in 366 teeth were statistically analyzed. Median overall SGT was recorded as 3.50 mm with a range from 1.80 to 6.20 mm. The thick-flat biotype exhibited greater median SGT than the thinscalloped biotype. When planning crown lengthening surgery, periodontal biotype may have a significant role in determining SGT dimensions.

The predictability of maxillary sinus augmentation has been extensively reported. Procedural outcomes, most often measured as implant survival rates, have customarily used inclusion criteria that included a minimum 1-year loading time. The inclusion criteria of this review extended the minimum postloading evaluation to 3 years to determine if the previously reported short-term survival rates are maintained. An electronic search of the literature was performed and retrieved articles were screened using specific inclusion criteria, paramount of which was a minimum of 3 years of follow-up. The search revealed 18 articles for the lateral window approach (6,500 implants in 2,149 patients) and 7 for the transalveolar approach (1,257 implants in 704 patients). Overall, implant survival after a minimum of 3 years loading was 93.7% and 97.2% for the lateral window and transalveolar approaches, respectively. Of importance is the fact that 80% of failures occurred within the first year and 93.1% of the failures occurred within 3 years. The risk of implant failure after 3 years can now be directly calculated as the overall risk of failure after 3 years (6.3%) × the incidence of late failures (6.9%), thus equaling 0.43%. This review discredits the theory that studies of a lower level of evidence report inflated results when compared with prospective randomized controlled clinical trials.

The aims of this study were to evaluate the influence of implant position on clinical crown length and marginal soft tissue dimensions at implant-supported single crowns of maxillary central incisors and to validate the papilla index score (PIS). Twenty-five patients were included. Standardized and clinical photographs and periapical radiographs from baseline were used to assess three-dimensional positional parameters. The contralateral central incisors were used as controls. Paired sample t test and Pearson correlation analysis were used to analyze implant position, dimension of crown, and papilla fill. Cohen κ and Spearman correlation were used to validate the PIS. The implant-supported crown was statistically significantly longer than the contralateral tooth, and there was significant correlation between the orofacial position of the implant and the crown length difference. The distal papilla was significantly shorter than the mesial papilla at implant-supported crowns, but this difference was not significant at the contralateral tooth. A significant relationship between the PIS and papilla fill was found. An implant protruding the mucosa in a buccal position will result in an increased implant crown length compared to the contralateral tooth. Minor buccal angulations of the implant could be corrected with customized angulated abutments and did not necessarily result in an increased crown length. The distal implant papilla height was obviously shorter, although the mesial papilla height was similar to that of the healthy dentition. The PIS was found to be a valid index for papilla fill.

The aim of this prospective, randomized, controlled, multicenter study was to evaluate and compare the histologic and histomorphometric aspects of extraction sockets grafted with two commercially available bovine bone xenografts: Endobon (test group) and Bio-Oss (control group). The study was designed to ensure that baseline variables between groups were as similar as possible to allow for a direct comparison of graft healing characteristics. Thirty-eight patients contributed 62 augmented extraction sites to the study. All sites were grafted with one type of bovine bone mineral and covered with a resorbable collagen membrane for 6 months of healing prior to implant placement surgery. The histologic outcomes between the two treatment groups are similar, with de novo bone (mean ± SD) for the test group at 28.5% ± 20% and for the control group, 31.4% ± 18%. Histologic specimens also include membrane remnants. All but two implants integrated successfully after 1 year of follow-up. This investigation provides support for the efficacy of bovine bone xenograft for socket preservation when subsequent implant placement is planned.

This clinical study evaluated the effectiveness of guided tissue regeneration using a resorbable collagen membrane and bone swaging in noncontained infrabony defects by assessing changes in probing pocket depth, probing attachment level, and radiographic bone level after 6 months, 1 year, and 2 years. Postsurgical clinical and radiographic measurements were statistically significantly different from presurgical measurements. The rate of bone fill was positively associated with the baseline depth of the bone defect but not associated with the width. The noncontained infrabony defects treated with this combined regenerative method improved clinically and radiographically.

The aim of this study was to investigate the hard tissue alterations of the alveolar bone crest following tooth extraction and immediate implant placement using cone beam computed tomography. Twelve consecutive patients in need of an immediate dental implant were included in the study. An implant of proper length was placed in the extraction socket with the coronal margin of the rough surface generally flush with or deeper than the buccal alveolar bone crest. All patients underwent a radiologic examination both immediately after implant placement (T1) and at the time of reentry 4 months after surgery (T2). The survival rate of 12 immediate implants at 4 months was 100%. Only 9 of 12 patients completed the study. The comparison between tomographies performed at T1 and T2 showed substantial variations in alveolar bone, mainly at the buccal aspect, registering a vertical gain of about 3.2 mm. The horizontal resorption of the alveolar bone crest appeared to be more marked at the buccal than at the lingual aspects. At the buccal aspect, the resorption was 1.9 mm, 1.0 mm, and 0.6 mm at the measurements performed at 1, 3, and 5 mm apical to the crest, respectively. At the lingual aspect, the corresponding values were 0.6 mm, 0.7 mm, and 0.5 mm, respectively. The bone crest area was more or less the same at T1 and T2, while the total area decreased after 4 months of healing but was not statistically significant. The results should be viewed with caution because of the small number of cases examined. The results confirm the success of immediate implant placement.

This retrospective study evaluated the long-term clinical success of combination therapy using resin-modified glass ionomer (RMGI) with flap surgery in treating subgingival radicular defects. The study population consisted of 142 patients with 188 radicular defects. Clinical parameters (pocket depth, recession, clinical attachment level [CAL], and bleeding on probing) were evaluated. Statistically significant CAL gain was observed from baseline to follow-up in successful cases (4.3 ± 0.1 mm to 4.1 ± 0.1 mm, respectively; P .01). RMGI with flap surgery demonstrated an overall success rate of 86.7% (77.7% with open flap debridement and 94.4% with coronally advanced flap with or without connective tissue graft), with favorable and stable clinical results over a mean period of 4.2 years (longest follow-up, 13 years).

Split-crest procedures performed with ultrasonic devices have proven to be a viable and effective surgical treatment when the alveolar ridge shows forms of resorption in thickness while its height remains virtually unchanged. However, in the case of stiff, type 1, corticalized mandibular bone, it may be very difficult or even impossible to have any elasticity and lateral augmentation in between the split bone walls. Furthermore, a complete detachment of the outer lamellae may also occur during expansion maneuvers or during implant insertion. This study describes the use of a steel-wire ligature osteosynthesis technique to give primary stability both to the expanded cortical window and to the implants themselves when they have none at all. This osteosynthesis is simple, quick, safe, and bone-saving in force delivery. It is also extremely cheap as well as being effective in obtaining ridge expansion, bone regeneration, and implant positioning in an all-in-one procedure. This article describes the foundations in the literature as well as new elements in the technique. Three short case studies are used by way of example.

The purpose of this study was to investigate the root morphology of teeth and efficiency of scaling after using Er:YAG and Er,Cr:YSGG lasers. Thirty-two periodontally hopeless teeth were extracted. The border of an appropriate calculus was marked using a diamond bur on each tooth, and the calculus was divided into two almost equal parts. An Er,Cr:YSGG laser with pulse energy of 50 mJ, power of 1 W, and energy density of 17.7 J/cm2 and an Er:YAG laser with pulse energy of 200 mJ, power of 2.4 W, and energy density of 21 J/cm2 were used to remove the calculus. The time for scaling was recorded for each group, and using stereomicroscopic analysis, the calculus remnant, carbonization, and number of craters were investigated. The mean time required for calculus removal in the Er,Cr:YSGG and Er:YAG laser groups was 15.22 ± 6.18 seconds and 7.12 ± 4.11 seconds, respectively. The efficiency of calculus removal in the Er:YAG laser group was significantly higher than in the Er,Cr:YSGG laser group. Under stereomicroscope examination, no carbonization or remaining calculus was found in samples from either group, but all samples had craters. The number of craters in the Er,Cr:YSGG laser group was significantly higher than in the Er:YAG laser group. According to the parameters used and limitations of this study, there was no significant difference in efficiency per power for calculus removal between the two groups.

This paper summarizes current knowledge on the benefits of laserablated microgrooves in neck regions of endosseous dental implants. Like machine-tooled coronal microthreads with particle-blasted surfaces, laser-ablated microgrooves help to preserve crestal bone. However, they also appear to uniquely favor a true gingival connective tissue attachment comparable to that of natural teeth.

The primary purpose of this clinical study was to compare architectural metric parameters using microcomputed tomography (micro-CT) between sites grafted with blocks harvested from the mandibular ramus and calvarium for horizontal bone augmentation in the maxilla. The second aim was to compare the primary stability of implants placed in both types of block grafts. Ten consecutive healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the maxilla were included. A total of 14 block grafts (7 each from the mandibular ramus and calvarium) were studied. After 4 to 6 months of healing, 41 implants were placed: 24 implants (58.5%) in calvarial (group 1) and 17 (41.5 %) in ramus grafts (group 2). A resonance frequency analysis (RFA) was performed to test implant stability. Furthermore, two biopsy specimens were randomly selected for histomorphometric analysis. Micro-CT analyses showed no significant difference in the morphometric parametric values analyzed between groups. Furthermore, RFA also showed no difference between groups. However, slightly higher RFA values were noted for implants placed in ramus grafts. Bone quality, as assessed by micro-CT and histomorphometric analyses, was similar in both ramus and calvarial block grafts. In addition, there was no difference in primary implant stability between groups.

The purpose of this article was to determine the individual visual perception thresholds of certain facial and dental discrepancies for a symmetric face model (SFM). A facial photograph of a female subject's smile was digitally manipulated into an artificially symmetric picture. Modifications were made on the SFM for shifts in the dental midline, nose, and chin (group 1) and cants of dental midline and incisal plane (group 2), resulting in a total of 24 different images divided into two groups. One-hundred randomly selected laypersons divided into two groups were used to evaluate each image according to their own personal beauty and esthetic criteria using a visual analog scale. The visual perception thresholds found for the SFM were 2 mm for a dental midline shift, 4 mm for nose deviation, 5 degrees for dental midline cant, and 3 degrees for frontal incisal plane cant. Chin deviations of 6 mm or less were not noticed. Dental midline shift, nose deviation, dental midline cant, and incisal plane cant relative to an SFM have an impact on the perception of facial attractiveness. Chin deviations did not have a statistically significant impact.