Pages 321-322, Language: English
Pages 325-333, Language: English
Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.
Pages 335-345, Language: English
This study evaluated a panel of clinical, dimensional, volumetric, implant-related, histomorphometric, and patient-reported outcome measures (PROMs) following reconstruction of dehiscence defects in extraction sockets with a minimally invasive technique using particulate bone allograft and a nonresorbable dense polytetrafluoroethylene (dPTFE) membrane. Subjects (n = 17) presenting severe buccal dehiscence defects at the time of single-rooted tooth extraction participated in the study. The mean vertical dimension of the dehiscence defects at baseline was 5.76 ± 4.23 mm. Subjects were followed up at 1, 2, 5, and 20 weeks postoperatively. The dPTFE barrier was gently removed at 5 weeks. CBCT and intraoral scans were obtained at baseline and at 20 weeks. A bone core biopsy sample was harvested at 24 weeks (before implant placement). Linear radiographic measurements revealed a mean increase in buccal bone height from baseline to 20 weeks (5.66 ± 5.1 mm; P < .0001). A total alveolar bone volume gain of 9.12% was observed. Although approximately half of the sites required some degree of additional bone augmentation at the time of implant placement, all implants were placed in a favorable restorative position with adequate primary stability. Histomorphometric analyses revealed a mean mineralized tissue area of 31.04% ± 15.22%, and the proportions of remaining allograft material and nonmineralized tissue were 16.23% ± 10.63% and 52.71% ± 9.53%, respectively. All implants survived up to 12 months after placement. PROMs were compatible with minimal discomfort at different postoperative stages and a high level of overall satisfaction upon study completion. This study demonstrated that the reconstructive procedure employed was successful and predictable in treating large, postextraction alveolar ridge deformities to optimize tooth replacement therapy with implant-supported prostheses.
Pages 347-355, Language: English
This case control study measured early crestal bone changes around subcrestally placed platform-switched implants surrounded by thin soft tissue and compared them with regular, matching-platform implants placed in a supracrestal position and surrounded by thick soft tissue. Sixty-six patients received two-piece internal hex dental implants. Control group patients (n = 33) received implants that had a horizontally matching implant-abutment connection and were placed approximately 0.5 to 1 mm supracrestally. Test group patients (n = 33) received platform-switched implants that were placed about 1.5 mm subcrestally. Clinical examinations were conducted, intraoral radiographs were taken, and statistical analysis was performed. After 2 months, the mean bone loss was 0.2 mm (SD: 0.22 mm; range: 0.1 to 1.2 mm) in the control group and –0.69 mm (SD: 0.65 mm; range: 0 to 2.6 mm) in the test group; this difference was found to be statistically significant (P < .05). After 1 year, mean bone loss was 0.28 mm (SD: 0.36 mm; range: 0.1 to 1.63 mm) in the control group and –0.6 mm (SD: 0.55 mm; range: 0.05 to 1.8 mm) in the test group. Platform-switched implants placed in a subcrestal position in vertically thin soft tissues showed statistically significantly more bone loss than non–platformswitched implants placed supracrestally with vertically thick tissues.
Pages 357-364, Language: English
Achieving primary stability is a critical challenge presented by immediate implant therapy. Surgeons often utilize wider, tapered implants for this purpose, or they use longer implants to achieve primary stability. Both strategies are associated with negative ramifications. Prosthetically guided implant placement must respect biologic principles, such as tooth-implant and implant-implant distance, gap space between the implant and the facial cortex, and, when possible, screw-retention of the prosthesis. A novel implant design geared toward achieving a predictable level of primary stability while adhering to the aforementioned physiologic principles was recently introduced. Both primary and secondary implant stability, along with hard and soft tissue stability, are demonstrated in this study of 107 consecutively placed implants. Rotational and axial stability can be produced with this newly designed implant, along with predictable osseointegration and tissue preservation.
Pages 367-373, Language: English
During bone augmentation procedures, primary wound healing determines the bone augmentation result. After a crestal incision in the maxilla, the palatal flap might not be an adequate length to correctly couple to the vestibular flap and to seal the wound with horizontal mattress and single sutures. Due to the histologic structure made of dense connective tissue, the palatal flap eversion is impossible, negatively impacting the wound seal and primary healing. This case report describes the effectiveness and efficacy of an incision design to improve palatal flap management during bone augmentation procedures in the maxilla. Indeed, palatal flap verticalization is achieved. The incision line is proportionally shifted on the vestibular side, based on the defect anatomy, to obtain a palatal flap length extending at least 4 mm coronal to the bone graft level prior to wound closure. The described approach simplifies the optimal adaptation of the inner faces of the palatal and vestibular flaps, reducing the risk of nonprimary wound healing.
Pages 375-381, Language: English
This article describes a novel approach for horizontal guided bone regeneration (GBR) using a dehydrated amnion/chorion membrane (dHACM) in conjunction with a composite mixture of cortical autogenous particulate bone scrapings and mineralized bovine bone particulate in the anterior maxilla, allowing for placement of dental implants in a previously deficient alveolar ridge. The grafted region was reentered 8 months after GBR surgery, and a substantial increase in horizontal bone width was observed. Endosseous dental implants were placed with excellent primary stability in a prosthetically driven manner (which could not have been done prior to GBR) and successfully restored with a screw-retained bridge prosthesis. To the authors’ knowledge, this is the first reported documentation of successful horizontal GBR using dHACM with subsequent implant placement and restoration, and the first to demonstrate the excellent clinical potential of this biomaterial.
Pages 383-389a, Language: English
Although several techniques and materials have been adopted to treat gingival recession, the therapeutic prognosis of various treatment modalities is not well established. This article proposes a multidimensional therapeutic prognosis system for the treatment of gingival recession based on the currently available literature. Gingival defect characteristics, patient behavioral habits, and surgical- and anatomical-related factors that may affect the outcome of root coverage procedures are reviewed. A therapeutic prognosis system is provided to enable clinicians to analyze these factors prior to the root coverage procedures. Three clinical cases are also discussed to demonstrate the assessment and validation of this therapeutic prognosis system.
Pages 391-395, Language: English
Varying amounts of bone resorption can occur following tooth loss, and this can lead to implant placement problems due to a lack of an alveolar ridge with suitable osseous dimensions. There are many techniques for bone regeneration and many types of barriers, including polytetrafluoroethylene, collagen, and titanium meshes. The present case report describes the use of a customized CAD/CAM zirconia barrier for vertical ridge augmentation. A bone height gain of 12 mm was observed, as well as 8 mm of width. Subsequent histologic analysis revealed an excellent bone quality, allowing successful implant placement.
Pages 397-403a, Language: English
Implant-supported restorations have proven to be a predictable option for replacing missing teeth. In cases of inadequate bone quantity, the bone volume can be increased by bone augmentation procedures. Several factors can affect bone regeneration, including the morphology of the defect at the implant site. A defect surrounded by bony walls (an intraosseous defect) is known to yield a highly successful regeneration. The purpose of this retrospective case series study was to present a new step-by-step surgical procedure known as the Custom Alveolar Ridge-Splitting (CARS) technique for maxillary anterior ridge augmentation. This technique creates an intraosseous defect while splitting and augmenting an atrophic ridge. Sixteen consecutive cases were treated with the CARS procedure. All implants were restored and followed for 12 to 24 months after loading, and all cases were effectively treated with successful implant placement. According to this retrospective study, the CARS procedure is simple, successful, and predictable and may be used as a surgical option for horizontal alveolar ridge augmentation in the anterior maxilla.
Pages 405-410, Language: English
Lip repositioning surgery is a predictable surgical technique that provides a solution for patients with excessive gingival smile. This case series presents four patients with 6 to 8 mm of excessive gingival display who received a modified surgical technique using internal horizontal mattress sutures to immobilize the labial superior elevator muscle. None of the patients exhibited complications, and their healing was uneventful. All patients demonstrated predictable results and presented with stability over an average of 3.5 years of follow-up. The modified lip repositioning surgery with internal horizontal mattress sutures seems to provide reliable long-term results in patients with an excessive gingival display.
Pages 413-421, Language: English
In dental implant surgery, bone grafts are used for the reconstruction and reestablishment of alveolar bone volume and to improve bone architecture for better positioning of an implant. The present report describes the use of the bone ring technique for vertical and horizontal bone augmentation with simultaneous implant placement. This is a simple technique for acquiring donor bone in a ring shape and performing 3D reconstruction of bone defects, with an increase in the alveolar crest, using autogenous bone in a surgical procedure together with implant placement. Block bone grafts taken from the mentum can be used for predictable bone augmentation of up to 6 mm in the horizontal and vertical dimensions. The thickness of the bone ring collected from the mentum is very important. It cannot be too thin due to the risk of fracture, nor can it be too thick, as its contour could become deformed when placed in the receptor site. For stabilization and synthesis, a horizontal mattress suture is performed at the receptor site without promoting tension, and simple sutures are used for the complete co-optation of the flap and consequent stabilization of the clot. In the present type of bone defect, singlestage implant placement may be useful to shorten the overall treatment period.
Pages 423-430, Language: English
The aim of the present study was to evaluate the efficacy of alveolar ridge preservation (ARP) protocol using deproteinized bovine bone mineral (DBBM) covered with a collagen matrix (CM), as well as to clinically and histologically analyze the alveolar bone healing at 12 months, prior to implant placement. Six patients had bone biopsy samples harvested and underwent implant placement at 12 months following ARP. At 12 months, DBBM granules represented a mean 29.52% ± 6.09% of the specimens and were embedded in the newly formed bone, which represented a mean 27.72% ± 5.64% of the sample. Data suggest that 12 months of ARP using DBBM granules covered with a CM may be considered a predictable technique providing favorable conditions for implant placement in the anterior maxilla.
Pages 433-441, Language: English
The aim of this retrospective study was to evaluate the long-term performance of the supercritical CO2 (Supercrit, BIOBank) viral-inactivated bone allografts in maxillary sinus augmentation. Thirty-four consecutive patients underwent 50 maxillary sinus augmentation procedures, and 103 implants were placed. At a mean of 8.8 years after graft surgery, 95 implants were well osseointegrated and functioning. Eight implants failed, and the overall implant survival rate at 10 years was 92.2%. The marginal bone loss averaged 1.2 ± 1.3 mm. Within the limitations of this study, the supercritical CO2 viral-inactivated bone allograft is a valuable bone graft material, achieving long-term satisfying outcomes when used alone.
Pages 443-448, Language: English
Retrograde peri-implantitis (RPI) is a periapical lesion that develops after implant insertion in which the coronal portion of the implant achieves a normal bone-toimplant interface. The most common etiology of RPI is the presence of an adjacent endodontic lesion. In most of the case reports available in the literature, the diagnosis of RPI occurred between 1 week and 4 years after implant placement. This case report illustrates the treatment of RPI that occurred more than 15 years ater implant loading, caused by endodontic infection of the adjacent tooth.
Pages 451-455 k, Language: English
The influence of the layer thickness and composite shade on the final color of Ceram.X composites (Dentsply Sirona) was tested, selecting five intermediatetranslucency Ceram.X Universal shades, three high-translucency Ceram.X Duo “enamel” shades, and four low-translucency Ceram.X Duo “dentin” shades. Using cylindrical molds, 850 specimens were obtained, representing the whole array of possible Universal single specimens (in seven thicknesses, ranging from 1.0 to 4.0 mm in 0.5-mm increments) and Duo combinations. The CIELAB coordinates of each specimen were determined with a spectrophotometer. Different thicknesses and composites were compared with Clark’s ΔE. The difference in color among specimens of different thicknesses was materialdependent. The thickness and shade of the composite markedly affected the color yield of the Ceram.X system. For each shade of the Universal systems, only one Duo enamel-dentin combination corresponded.
Pages 457-465a, Language: English
A simplified surgical technique is presented for closure and soft tissue augmentation of fresh extraction sockets that utilizes a xenogeneic collagen matrix as a substitute for a combined onlay-interpositional connective tissue graft. Ten alveoli receiving a socket preservation procedure (n = 5) or an immediate submerged implant (n = 5) were sealed with a xenogeneic collagen matrix, stabilized under small palatal and buccal full-thickness envelope flaps. Eight weeks after surgery, full wound closure was achieved in 9 out of 10 sites with satisfactory esthetic integration (mean ΔE score: 3.76). Results from this descriptive observational study suggest that this technique may represent a valuable and minimally invasive solution to simplify closure and soft tissue augmentation of fresh extraction sockets.
Online OnlyPages e73-e80, Language: English
The literature offers limited and even conflicting information on the etiology of gummy smile. Therefore, this study aimed to evaluate smile line, hypermobile upper lip (HUL), altered passive eruption (APE), and short upper lip (SUL) distribution in a group of patients seeking dental treatment and to examine their effects on gummy smile. A total of 501 individuals (265 men, 236 women) were included in the study. The patients were grouped by gingival display, and presence of HUL, APE, and SUL were evaluated. Multivariate Logistic Regression analyses were performed to investigate the impact of possible risk factors on gummy smile. Of the individuals, 173 (34.5%) had a low smile line, 127 (25.3%) had an average smile line, 146 (29.1%) had a high smile line, and 55 (10.9%) were gummy smile patients. Individuals with gummy smile were younger than the individuals with low smile line (P < .001). As for the possible risk factors for gummy smile, age (odds ratio [OR]: 0.936; 95% CI: 0.901 to 0.972; P = .001), HUL (OR: 18.85; 95% CI: 7.82 to 45.44; P < .001), and APE (OR: 8.819; 95% CI: 3.894 to 19.973; P < .001) were found to be significant together. Gender and SUL/upper lip length were not found to have any impact on gummy smile. HUL is the primary factor that increases the probability of having gummy smile, followed by APE as the secondary factor. It seems reasonable to focus on correction of the HUL for treatment in most gummy smile patients.
Online OnlyPages e81-e91, Language: English
It was hypothesized that hyperbaric oxygen (HBO) could increase bone healing efficiency according to a protocol with a special window of healing time when maxillary sinus lateral augmentation is performed with only xenograft. The histomorphometric efficiency of HBO on the maxillary sinus lateral augmentation was examined by designing five different in vivo healing periods. Five patients receiving maxillary sinus lateral augmentation with xenograft each received a different treatment healing protocol: 6 weeks natural healing (control [Ctl]), 5 weeks with HBO (T1), 6 weeks with HBO (T2), 9 weeks with HBO (T3), and 13 months natural healing (TM). Biopsy samples were harvested, and quantitative histomorphometric analysis was performed regarding key factors BMP-2 and RUNX2. Analysis of variance and Tukey test were used for pairwise comparisons. Time-dependent relationships of the factors’ expression densities were conducted using quadratic regression fitting. There were statistically significant differences among the groups, except for T2/T3 and T2/TM for BMP-2 and for T2/T3 and TM/Ctl for RUNX2. Both BMP-2 and RUNX2 showed quadratic trends, presenting an initial upward trend and eventually a downward trend depending on T1, T2, and T3 groups. Early stimulation, achieved by keeping HBO until 6 to 9 weeks after maxillary sinus lateral augmentation with xenograft, seemed to be the time window that benefitted bone healing efficiency the most.
Online OnlyPages e93-e101, Language: English
This prospective controlled clinical trial investigated the possible correlation among mucosa thickness, mucosa height, and width of keratinized mucosa on the contour changes of the peri-implant soft tissue collar over a period of 12 months. Forty patients were selected to undergo implant placement. Impressions were taken with polyether impression material at delivery of the final restorations (baseline) and at 1, 3, 6, and 12 months. Master casts were fabricated and scanned using an indirect digitalization. Baseline and corresponding follow-up scans were then virtually superimposed and matched. At 1 year, 20 patients who received the buccal pedicle flap showed an average thickness increase of 1.49 mm (ρs = 0.95; range: 0.01 to 2.56 mm), whereas the 5 patients who received a connective tissue graft at second-stage surgery reported an average thickness increase of 0.33 mm (ρs = 0.70; range: –0.62 to 1.23 mm). Finally, the remaining 15 patients who did not receive any soft tissue grafting nor any type of plastic surgery showed an average mucosa thickness increase of 0.51 mm (ρs = 0.28; range: –2.33 to 2.52 mm).
Online OnlyPages e103-e112, Language: English
Clinical evidence suggests using lateral and vertical ridge preservation procedures to make dental implant placement possible. This study evaluates and compares the radiographic and volumetric changes following ridge preservation procedures using either mineralized plasmatic matrix grafts (MPM) or bone grafts alone (non-MPM) in the existing crestal ridges of sockets in maxillary and mandibular regions using CBCT scans. Healthy volunteers (n = 26) were recruited and randomized into MPM and non- MPM groups (n = 13 patients per group). Ridge preservation (RP) was performed in sockets after extraction. Preoperative baseline vertical measurements (V1) were made from the existing highest level of the socket crestal ridges to a reference point in an apicocoronal direction. Similarly, baseline horizontal measurements (H1) were made in a buccolingual direction on CBCT scans. The measurements were repeated after 3 months (V2 and H2) and 6 months (V3 and H3) using the same reference points. Difference between V3 and V1 as well as H3 and H1 was used to assess the gains in height and width of the sockets after RP. No significant difference was found in the initial baseline V1 and H1 values in MPM and non-MPM groups. Median (Mdn) V2 and H2 scores were significantly different between MPM (Mdn = 18.91) and non-MPM groups (Mdn = 27.81) after 3 months of RP (U = 37, z = –6.302, P < .001). However, after 6 months of treatment, V3 and H3 scores were significantly different between the MPM (Mdn = 27.19) and the non-MPM group (Mdn = 37.81). MPM can be used as a valuable and predictable technique in obtaining bone fill in the maxillary and mandibular sockets with residual crestal ridges deemed necessary for RP in implant therapy.
Online OnlyPages e113-e120, Language: English
The purpose of this study was to evaluate the sorption, solubility, and color stability of amine-free conventional light-cure and dual-cure resin cements and an aminecontaining self-adhesive dual-cure resin cement. Sixty specimens were prepared using a light-cure resin cement (Variolink Esthetic LC, Ivoclar Vivadent; VE-LC), a dual-cure resin cement (Variolink Esthetic DC, Ivoclar Vivadent; VE-DC), and a self-adhesive dual-cure resin cement (RelyX U200, 3M ESPE; RXU200). The water sorption and solubility were tested by immersing the specimens in distilled water for 7 days. Kruskal-Wallis test was applied to the data. ΔE values of 1-day and 7-day immersion in black tea were analyzed using one-way analysis of variance followed by Tukey honest significant difference test (n = 10). There was no statistically significant difference among the groups in terms of sorption and solubility. The mean ΔE of RXU200 for the 0/1 and 0/7 days were found to be significantly lower than that of VE-LC and VE-DC (P < .05). ΔE values of the VE-LC and VE-DC groups did not reveal statistical difference. It should be taken into account that discoloration of resin cements remains a problem even with amine-free products.
Online OnlyPages e121-e128, Language: English
The posterior maxilla has traditionally presented a challenge for successful placement of dental implants due to a combination of poor bone quality, ridge atrophy, and pneumatization of the sinus floor following tooth extraction. However, with the successful and predictable surgical outcomes reported in the literature, more clinicians and patients are choosing an implant-supported restoration in the edentulous posterior maxilla. Consequently, sinus elevation and augmentation have gained more popularity. Extensive research has been conducted on types of bone graft materials and implants, less-invasive techniques to perform sinus augmentation, and timing for implant placement for sinus grafting. Despite the predictability of the techniques and biomaterials employed in sinus grafting procedures, intra- and postoperative complications are common. Much of the current literature discusses the local risk factors related to sinus augmentation, with few studies focusing on the patient-related risk factors. The purpose of this review is to identify, evaluate, and discuss the possible management of patient-related risk factors to allow for more predictable maxillary sinus floor augmentation outcomes.