International Journal of Periodontics & Restorative Dentistry, 02/2023

The aim of this prospective study was to evaluate the efficacy of a cross-linked xenogeneic volume-stable collagen matrix (CCM) in treating gingival recessions (GRs) at teeth presenting with cervical restorations or noncarious cervical lesions (NCCLs). Fifteen patients with esthetic concerns for multiple sites with GRs and cervical restorations were consecutively enrolled. The sites were treated with a coronally advanced flap (CAF) design in combination with a CCM. When present, the previous restoration was removed, and the cementoenamel junction was reconstructed with a composite material. The CCM was stabilized on the root surface(s) previously occupied by the restoration. The CAF was sutured to completely cover the graft. Clinical measurements and intraoral digital and ultrasonographic scans were collected at baseline and at 3 and 6 months postsurgery. Limited postoperative discomfort was reported by patients during the healing. The mean root coverage at 6 months was 74.81%. Average increases in gingival thickness of 0.43 mm and 0.52 mm were observed when measured with ultrasonography 1.5 mm and 3 mm apical to the gingival margin, respectively (P < .05). Relatively high patient-reported satisfaction and esthetics were associated with the treatment outcomes. The treatment resulted in a significant reduction in dental hypersensitivity (mean: 33 VAS points). The present study demonstrated that CAF + CCM is an effective approach for treating GRs at sites with cervical restorations or NCCLs. Int J Periodontics Restorative Dent 2023;43:147–154. doi:

Maintaining facial soft tissue contour and inter-implant papilla are challenging for implants in the esthetic zone. To counteract the inevitable hard and soft tissue changes after tooth extraction, the socket shield technique (SST) has been advocated as means to maintain the facial and/ or interproximal osseous and gingival architecture. Because SST is a technique-sensitive procedure, various complications related to SST have been reported. This article presents a unique complication after a socket shield procedure and a novel management of the complication.

Implants present a predictable fixed option for patients who require tooth extraction. However, complications such as implant failure reduce the success of replacement implant restorations. A patient presented to the Department of Periodontology and Implant Dentistry (New York University College of Dentistry) with pain related to a broken implant-supported prosthesis. Two failed implants were removed, and new implants were placed. After restoration delivery, the patient reported soreness on the implant at site 35 (FDI tooth-numbering system), which was then removed (along with a sequestrum of bone) and sent for biopsy. A new implant was placed and restored successfully at the 1-year follow-up. The purpose of this case report is to demonstrate that with proper planning, surgery, and restoration, a new implant can be successfully placed and restored on a site with two previous failures.

After performing a tunneling mucogingival surgery procedure to cover generalized root recession in the anterior maxilla, a socket shield procedure was performed for immediate implant placement on a lateral incisor, leaving a root fragment coronal to the buccal bone margin with a long soft tissue attachment. This case report suggests that it is possible to achieve stable peri-implant results 30 months after the described therapy.

There are limited long-term treatment results for patients who receive full-mouth laser-assisted new attachment procedure (LANAP). The present study examined cases of full-mouth LANAP therapy for tooth retention, including clinical and radiographic changes. Sixty-six generalized stage III/IV periodontitis patients aged 30 to 76 years were identified via consecutive retrospective chart reviews in a private practice limited to periodontics. Following treatment with the LANAP protocol, differences between baseline and the patient’s most recent periodontal maintenance visit (mean: 6.7 years) were determined regarding interproximal probing depths (iPD) and interproximal bone loss (iBL) percentages. Factors affecting tooth loss were analyzed using Cox proportional hazard regression survival analysis. The average tooth loss for the study population was 0.11 teeth/ patient/year. Premolars were more likely to be retained compared to the reference group of incisors (hazard ratio = 0.38; 95% CI = 0.16 to 0.90; P = .03), adjusting for canines, molars, and other potential confounding factors. Age at the time of LANAP treatment, gender, history of diabetes, and baseline iBL and iPD were all significantly associated with tooth loss after full-mouth LANAP treatment. Clinical changes in iPD were more significant among premolars and molars when followed up for a period of less than 7 years. Tooth retention after full-mouth LANAP treatment was favorable in this cohort of private practice patients.

Growth factors are considered an important component for periodontal wound healing and a key element in the periodontal regeneration triad. Randomized controlled clinical trials have demonstrated that purified recombinant human platelet-derived growth factor-BB (rhPDGF-BB) in combination with bone graft materials is effective in treating intrabony periodontal defects. Many clinicians are currently using rhPDGF-BB in combination with xenogeneic or allogeneic bone. Therefore, the purpose of this case series was to assess the clinical effectiveness of combining rhPDGF-BB with xenogeneic bone substitutes to treat severe intrabony periodontal defects. Three patients with challenging deep and wide intrabony defects were treated using a combination of rhPDGF-BB and xenogeneic graft matrix. Probing depth (PD) reduction, bleeding on probing (BOP), mobility reduction, and radiographic bone fill (RBF) were observed for 12 to 18 months. PD decreased from 9 mm to 4 mm, BOP was eliminated, mobility decreased, and RBF ranged from 85% to 95% over the postsurgical observation period. These results indicate that combination of rhPDGF-BB with xenogeneic bone substitutes is a safe and effective graft that leads to favorable clinical and radiographic outcomes for treating severe intrabony periodontal defects. Larger case series or randomized studies will further elucidate the clinical predictability of this treatment protocol. Int J Periodontics Restorative Dent 2023;43:193–200. doi:

The loss of teeth causes inevitable resorption of the alveolar bone. In the anterior arches, the curved anatomy further adds to the challenge of rehabilitation. These areas often require the shaping of membranes and multiple bone blocks through complex surgery to compensate for the curvature. The split bone block technique (SBBT) has been successfully used in complicated cases. However, the inability to create curves from the blocks means that larger quantities of bone or membranes are needed to compensate for this. Bone bending based on an ancient woodbending technique known as kerfing is proposed to shape rigid SBB plates to recreate the natural anatomy of anterior arches. Three patients presenting with bone destruction of the anterior maxilla underwent bone augmentation before implant placement using the SBBT combined with kerfing. The plates were successfully bent to the shape of each maxilla without any deleterious effects. All bone grafts healed uneventfully, and the bone curvature was successfully reconstructed. No complications were reported. Implant placement took place after 4 months and definitive restorations after 7 to 9 months. Clinical and radiographic assessments were performed at 1 year. Full customization of autogenous bone plates was possible through kerfing. This approach resulted in an ideal bone curve and shape in the facial and palatal aspects of the anterior maxilla. In addition, it enabled ideal implant placement with reduced bone harvesting volumes and decreased the need for soft tissue augmentation to recreate the curved shape. This technique promoted close-fitting autologous osseous plates that followed the anatomical curvature of the anterior maxilla, leading to optimal healing and excellent regeneration of the ridge width. This principle can be valuable when dealing with complex anatomical defects.

Periodontal regeneration therapy has developed tremendously since its inception, becoming a clinical tool to preserve the periodontally compromised natural dentition. More challenging esthetic defects can often benefit from the combination of bone and soft tissue regeneration, such as the application of connective tissue grafts (CTGs) and techniques that approach the bone defect without interdental papillae incisions. However, periodontal tissue regeneration vertical to the alveolar bone crest in cases of severe periodontitis, with loss of both soft and hard tissues, has not been predictably established. This case report describes a patient with severe periodontitis that was treated with in supra-alveolar periodontal tissue reconstruction. This innovative surgical technique requires both horizontal buccal incisions and several vertical palatal incisions, avoiding the interdental papillae on the periodontal defect. Then, a space is created by suspending and fixating the flap coronally, and CTG and regenerative materials (such as recombinant human fibroblast growth factor-2) and bone graft material are applied. This technique has the potential to gain clinical attachment, achieve supra-/intraperiodontal regeneration, and enhance esthetic outcomes, including a reduced gingival recession and interdental papillae reconstruction. The clinical results of the present case were well maintained over the 2-year follow-up.

This study aimed to describe the step-by-step procedure of the polydioxanone dome technique associated with guided bone regeneration (GBR) and to report the results up to 72 months after implant loading. Patients with maxillary horizontal bone defects (< 5 mm residual width, confirmed by CBCT scan) were treated with the proposed intervention. During the GBR procedure, four bone perforations were strategically prepared in a roughly square configuration. Segments of polydioxanone suture material were introduced in the perforations, forming a dome-shaped structure. Six months after bone augmentation, a new CBCT was performed. After implant restoration, periapical radiographs were taken, which were then repeated annually. The following outcomes were analyzed: implant survival, horizontal bone gain, marginal bone level, and complications. Twenty implants were placed in 11 patients with a survival rate of 100% in a mean follow-up of 38.18 ± 19.65 months after loading. Mean horizontal bone gain was 3.82 ± 1.67 mm and mean marginal bone level was –0.12 ± 1.17 mm. Only minor complications were observed. The present results suggest that the polydioxanone dome technique may represent a promising approach during horizontal GBR, alone or in combination with implant placement.

Short dental implants are an alternative to surgical bone augmentation procedures and the placement of longer implants. The high predictability of short implants has encouraged clinicians to load them immediately. However, there are few studies assessing the influence of immediate vs delayed loading of short (< 8 mm) implants. The purpose of this retrospective study was to report the mid-term (5- year) outcomes (survival and marginal bone loss [MBL]) of immediate vs delayed loading of short implants. A total of 44 patients with 149 short implants fulfilled the inclusion criteria (95 and 54 implants with delayed and immediate loading, respectively). During the follow-up period, descriptive clinical variables, implant survival, MBL, and prosthetic complications were recorded and statistically analyzed. The mean follow-up time was 60 ± 40 months. The overall cumulative implant survival was 95.6%, and MBL was –0.1 ± 0.7 mm. No statistically significant differences were detected between the immediate and delayed loading groups in terms of implant survival (92.6% vs 97.5%) or MBL (–0.2 ± 0.8 mm vs –0.1 ± 0.7 mm), respectively. According to the results of this study, the immediate loading of short implants demonstrated predictability at the mid-term followup time. These results must be confirmed in future prospective studies.

The aim of this retrospective analysis was to evaluate the clinical and radiographic results of a shortened protocol (using a lateral approach) for early surgical reentry, following a large sinus membrane perforation that occurred during maxillary sinus augmentation (lateral approach), for the rehabilitation of patients with an atrophic posterior maxilla. Between May 2015 and October 2020, seven patients underwent reentry surgery using a lateral approach protocol 1 month after a large sinus membrane perforation during maxillary sinus floor augmentation with lateral approach surgery. All patients presented a residual under-sinus bone height < 3 mm in the posterior maxilla. The sinus membrane was elevated during the reentry surgery, without any difficulty for any patient, using manual blunt elevators or piezoelectric devices, and the sinus floor height was augmented with bone substitute particles. No further perforations were made, and no complications were recorded during the follow-up period from 18 months to 6 years. The 1-month waiting period after the initial sinus surgery allows easy sinus membrane elevation and a lack of complications. This timing could be a feasible option for surgical reentry after a large sinus membrane perforation occurs.

This in vitro study investigated color stability of two photo-polymerized nano-filled and nano-hybrid composite resins in different polymerization modes immersed in different staining solutions before and after brushing. Disc-shaped specimens (n = 120) were prepared from two composite resins based on filler particle size: nano-filled (Filtek Z350, shade A1, 3M ESPE) and nano-hybrid (Spectra ST-HV, shade A1, Dentsply Sirona) composite resins (n = 60 per composite type). Specimens of each resin type were photopolymerized using the following polymerization modes: LED conventional, ramp, and pulse (n = 20 specimens per resin type and LED mode). After preparation, baseline color of the specimens was evaluated using a spectrophotometer (Easyshade V, VITA), and color change was evaluated using the CIE L*a*b* formula. Specimens were soaked in distilled water for 4 weeks in separate containers. The specimens from each polymerization-mode group were separated into two groups of 10 specimens; one group was stored in tea and the other group was stored in cola, each 1 hour daily for 4 weeks. After 4 weeks, the color was measured again. The specimens were brushed for 2 minutes under 200-g weight using an electronically powered toothbrush on the polymerized side of the specimen. The color was reevaluated immediately after brushing. Color-difference data (ΔE) between groups were analyzed by one-way analysis of variance for main comparison and by independent t test for color change after brushing. Nano-filled composite resin was more color-stable than nano-hybrid composite resin (P < .001), regardless of the staining media. For both composite resin types, the conventional polymerization method produced a more color-stable result (P < .0001). ΔE after brushing was reduced significantly (P < .0001). Both staining solutions have significant effects on color change, with tea staining more than cola (P < .0001). Nanofilled composite resin had greater color stability than nano-hybrid composite resin after immersion in staining solutions. Polymerization mode influences the color stability of both composite resin types.

Lesion formation after soft tissue gingival grafting is a rare but challenging clinical scenario to manage. This report presents a unique case of cyst formation after connective tissue grafting. All previously reported cases are confined to the mandibular labial lateral-canine space, whereas the present case is the first found in the maxilla. These cysts manifest clinically 9 months to 1.5 years after grafting and may communicate with the surface, as evidenced by sinus tract or cystic discharge. Because of the unique nature of these lesions with respect to clinical history, appearance, symptoms, and location, the differential diagnosis should be limited. The treatment recommendation is complete surgical excision, which should eliminate the risk of recurrence. In this report, a novel case is presented, and the literature is reviewed to discuss etiology and provide treatment recommendations.

The aim of this study was to evaluate the effectiveness of hyaluronic acid (HA) injections used to reduce defects in the gingival papillae in esthetic areas. This randomized study included six patients requiring black triangle treatment in 19 defective papillae. After local anesthesia, less than 0.2 mL of HA was injected 2 to 3 mm into the tip of the deficient papilla in the apical direction. Analysis of the target regions with standardized photographs and 3D intraoral scanning (CEREC 4.5 software with RST files, Dentsply Sirona) was performed at baseline (T0) and at 1 month (T1), 2 months (T2), 3 months (T3), and 4 months (T4) after the initial application of HA. At each time period, the photographic analysis showed no statistically significant differences in linear tissue gain after HA gel application. The 3D analysis showed improvements in the vertical papillae tissue recovery at T3 (0.41 ± 0.21 mm) and T4 (0.38 ± 0.21 mm) when compared to T1 (0.13 ± 0.08 mm; P < .0001). Regarding the reconstruction of the interdental papillae, the general dimensions of the tissue in the black triangle areas showed a significant increase in size percentage at T3 (58% ± 32.9%) compared to T1 (30.41% ± 23.4%; P = .0054). Thus, the application of injectable HA was effective for filling papillae in the esthetic area.

Ehlers-Danlos Syndrome (EDS) is a group of congenital connective tissue disorders that commonly affect joints, muscles, soft tissue, and blood circulation in the affected population. Many oral manifestations are displayed in EDS patients, including gingival recession, lack of attached gingiva, early severe periodontal disease, and dental caries. However, the literature is limited and oftentimes contradictory regarding dental implants in EDS patients. The aim of this study is to report two successful cases of dental implants placed in EDS patients, one treated with bone augmentation and both restored with prosthetic implant rehabilitations.

This study assessed the histologic and histomorphometric changes of free gingival grafts in a canine model after mechanical expansion. A total of eight epithelialized tissue samples were obtained from the palate of eight Beagle dogs. Samples were cut in half and separated into two groups: the test group, in which a device was used to expand the grafts, and the control group, without expansion. After histologic processing, samples were evaluated by qualitative histology and histomorphometry. Histologic analysis revealed some differences in epithelial cell morphology and keratin layer integrity in the test group compared to the control group. Differences in histomorphometric parameters for the expanded and nonexpanded groups, including the thickness of the keratin layer (15.4 ± 13.4 μm and 32.3 ± 18.1 μm, respectively), thickness of the epithelium (398.0 ± 168.0 μm and 368.4 ± 142.8 μm, respectively), and the area occupied by collagen fibers in the connective tissue (62.0% ± 11.0% and 55.8% ± 7.6%, respectively), were not statistically significant (P > .05). Despite some changes in qualitative histology, free gingival grafts maintained their histomorphometric characteristics after mechanical expansion. These data provide a scientific basis for the use of mechanical expansion as a possible procedure to reduce the morbidity of autogenous grafts because a single soft tissue sample can be expanded before grafting.

This study evaluated the efficacy of buccal fat pad (BFP) as a natural barrier to cover nonresorbable devices for vertical ridge augmentation (VRA). Twelve consecutive patients with 14 vertical bone defects in need of bone augmentation for implantprosthetic rehabilitation were treated according to the described protocol. VRA was performed by means of customized titanium meshes, titanium-reinforced d-PTFE membranes, or resorbable membranes and titanium plates. After buccal flap release, the BFP was identified and isolated, then mesially and coronally advanced to cover the whole augmented area. BFP was used as a pedicle flap in 11 cases and as a free graft in 3 cases. The mean BFP surface area was 13.5 ± 5.5 cm2. Healing was uneventful in all 14 augmented sites. No patients reported healing complications or facial volumetric changes. The mean vertical bone gain (VBG) was 4.2 ± 1.8 mm. In this limited number of cases, using the BFP as a natural barrier has proven to be efficient in bone augmentation, as it improved the healing process while reducing the risk of complications.

Implant mandibular complete overdenture (IMCO) is a reliable prosthetic option. However, clinical and laboratory complications are associated with these restorations if not executed properly. In this clinical report, the combination of analog and digital workflow helps minimize the chairside time with fewer visits, which improves efficiency and patient satisfaction. Int J Periodontics Restorative Dent 2023;43:e111–e115. doi:

This study was designed to assess the use of enamel matrix derivative (EMD; Emdogain, Straumann) and alloplastic bone substitute (BoneCeramic [BC], Straumann) in postextraction alveolar sockets. A total of 45 patients requiring anterior single tooth extractions and subsequent implant placement were recruited and randomly assigned to one of three treatment groups. Postextraction sockets were filled with BC or BC + EMD, or were left to heal spontaneously. Tomographic dimensional changes were measured immediately following tooth extraction and at the 6-month follow-up. Computed tomographic (CT) scans were taken with a radiographic stent within 48 hours of extraction (CT1) and at 6 months (CT2). Paired comparisons related to the mean horizontal reduction of the vestibular crest (VC) showed significant differences between sockets left to heal spontaneously (Group 1) and the two groups filled with BC (Group 2) and BC + EMD (Group 3): 1.7 mm for Group 1 and 0.9 mm for Groups 2 and 3 (P < .05). Thus, the use of alloplastic bone substitute alone or with EMD resulted in better preservation of postextraction socket dimensions. No differences in socket preservation were found between Group 2 (BC) and Group 3 (BC + EMD).

In recent years, high esthetic expectations and natural appearance demands from patients have increased the popularity of ceramic restorations. The purpose of this study was to investigate the influence of restoration thicknesses and different resin cement brands on the translucency and final color of different types of monolithic zirconia and lithium disilicate ceramics. A total of 160 disc-shaped specimens (10-mm diameter; 1 mm, or 1.5 mm thick) were produced using different types of monolithic zirconia (Katana Zirconia UTML, Katana Zirconia ML, Katana Zirconia STML Blocks; Kuraray) and lithium disilicate ceramic (IPS e.max Press, Ivoclar Vivadent) (n = 40 discs per material, with 20 discs per thickness). Two different brands of dual-cured resin cements (RelyX Ultimate, 3M ESPE; and BisCem, Bisco) were applied to the specimen surfaces. The translucency and color changes of the lithium disilicate and monolithic zirconia ceramics were examined before and after cementation using a spectrophotometer. Within the limitations of this in vitro study, the resin cement brand and ceramic thickness variation influenced the translucency and final color of the monolithic zirconia and lithium disilicate ceramic specimens.