International Journal of Periodontics & Restorative Dentistry, Pre-Print

Extraction-site alveolar remodeling is a major concern due to negative volumetric hard and soft tissue changes that inevitably limit rehabilitation options and diminish esthetic outcomes. Surgical techniques employed to minimize alveolar dimensional changes are not always predictable. Utilizing socket-shield with immediate implant surgical procedure provides maintenance of a thin portion of the root in the vestibular area that minimizes bone resorption especially at the coronal cortical aspect. This case series assesses the dimensional changes in peri-alveolar structures via superimposition of the pre-operative and six-month post-operative 3D digital quantification of soft tissue. Fifty patients with 50 sites fulfilled the inclusion criteria. Implant survival was 100%, with no incidence of complications. Tissue changes were mesial papilla (-0.85mm), distal papilla (-0.95mm), vertical central margin (-0.7mm), horizontal central margin (-0.7mm), 4mm from the margin (-0.21mm), palatal central margin (-0.64mm). Clinically, the buccal contour was convex in 100% of the cases. The site with highest frequency to lose more than 1mm was the distal papilla, with 42% sites losing more than 1mm. The site with lowest frequency to lose more than 1mm was the point 4mm from the mid-facial margin, with 0% sites losing more than 1mm. 

Purpose: This in vivo study in a canine model assessed the effect of recombinant human platelet-derived growth factor (rhPDGF) on healing of periapical tissues following apical surgery. Materials and Methods: Sixty-four premolar teeth of six 2-year-old beagle dogs were randomly assigned to 4 experimental groups; 16 teeth each. In each tooth, coronal access was done, and the pulp extirpated. The teeth were then left open to the oral cavity for one week and then sealed with IRM for 8 weeks. Nonsurgical endodontic treatment (NSRCT) was then performed. A split-mouth design was used, and intra-animal side randomization was applied to the 4 groups as follows: Group 1) Apical curettage +1.5 mm root-end resection; Group 2) Apicoectomy + mineral trioxide aggregate (MTA) root-end filling; Group 3) Apicoectomy + MTA root-end filling + rhPDGF; and Group 4) Apical curettage + rhPDGF. The animals were sacrificed 24 months following apical surgery and histological and μCT analyses were performed for bone volume loss (BVL). Results: Group 1 showed partial resolution of the periapical lesions but without signs of tissue regeneration. The BVL was 49.09 ± 10.97 mm³. Group 2 showed reformation of cementum in 9 out of 16 teeth. No direct attachment between the newly formed cementum and the MTA were observed. Bone regeneration was minimal and the BVL was 35.34 ± 10.97 mm³. Group 3 showed regeneration of all damaged apical tissues but without direct contact between the cementum and MTA. The BLV was 4.51± 1.55 mm3. Group 4 showed regeneration of PDL, bone, cementum, and attachment of functional cementum fibers was observed. The BVL for this group was 2.82 ± 2.3 mm3. The difference in BVL was statistically significant only for Group 1 and Group 2 (P<0.05). There was no significance difference in the BVL between Group 3 and Group 4. Conclusions: Recombinant human platelet-derived growth factor may play a role in regeneration of apical tissue structures following apical surgery. Clinical relevance: Oral healthcare providers should be aware that addition of recombinant human platelet-derived growth factor may positively impact the regeneration of periapical tissues following apical surgery. 

A clinical observation usually encountered after vestibuloplasty or interventions aiming at deepening the vestibule with or without simultaneous free epithelialized grafts in the posterior ridges is that they are subjected to major dimensional changes attributed to the buccinator fibers attachment. Hence, this study aimed at assessing the attachment of the buccinator muscles in relation to other anatomical landmarks. An ex-vivo study was performed in cadaver heads to explore the association of fibers attachment in relation to the distance from the crestal aspect of edentulous alveolar process (CAP) and the vestibular depth (VD), crestal band of keratinized mucosa (KM), and ridge height (RH). Interestingly, VD and KM were found to be strongly correlated. Likewise, VD/KM and CAP-BUC were further noted being correlated. CAP-BUC was negatively correlated with RH. Accordingly, the more atrophic the alveolar ridge (being more noticeable in the mandible) is, the shallower the vestibule, the lesser the crestal band of KM and the more crestal attachment of the buccinator muscular fibers. That might be the reason why whenever performing free epithelized graft in the posterior ridges to enhance the peri-implant soft tissue phenotype and deepening the vestibule, the graft is subjected to major dimensional changes. 

Aims: Aim of this retrospective study was to evaluate the incidence of complications and to determine the long-term survival rate of teeth with severely compromised clinical crowns treated with minimally invasive crown lengthening (MICL) and restorative treatment. Methods: A sample of 112 teeth in 86 patients was treated with MICL and restorative dentistry. Endodontic and orthodontic therapy was applied when needed. Clinical outcomes were assessed at baseline, 1 year and long-term. Results: The application of MICL resulted in very limited radiographic bone resection (RBR, 1 ± 0.1 mm on average). Limited local inflammation and shallow probing depth were detected at 1 year (2.6 ± 0.5 mm) and long-term (2.9 ± 1.0 mm). Most of the teeth (76.8%) maintained dental and periodontal health over time. The negative events observed in 26 teeth were caries (8.9%), fractures (7.1%), endodontic problems (1.8%), periodontal problems (4.5%) and restoration problems / complications (0.9%). The survival rate was 90.2%. Conclusions: the outcomes of this long-term retrospective analysis (8.9 ± 0.9 years, range 8 to 10) show high tooth survival rates and low incidence of complications of teeth treated with MICL and restoration of the clinical crown. 

This investigation was designed to evaluate clinical feasibility of the use of narrow-diameter implants to support mandibular overdenture. Twelve patients presenting with an edentulous mandible were recruited from 9 dental offices (n=1~2 per office). Each patient received two to four implants in the mandible. The implants were placed without additional bone augmentation. 36 implants were placed in total. All achieved satisfactory crestal bone stability and soft tissue maintenance at 1 year post final prosthetic restoration.

The aim of this PRISMA-compliant systematic review was to analyze the evidence pertaining to disease resolution after treatment of peri-implant diseases (PROSPERO: CRD42022306999) with the following PICO question: what is the rate of disease resolution following non-surgical and surgical therapy for peri-implant diseases in adult human subjects? A literature search to identify studies that fulfilled a pre-established eligibility criteria was conducted. Data on primary therapeutic outcomes, including treatment success, rate of disease resolution and/or recurrence, as well as a variety of secondary outcomes was extracted and categorized. Fifty-five articles were included. Few studies investigated the efficacy of different non-surgical and surgical therapies to treat peri-implant diseases using a set of pre-defined criteria and with follow-up periods of at least one year. The definition of treatment success and outcomes of disease resolution differed considerably among the included studies. Treatment of peri-implant mucositis was most commonly reported to be successful in arresting disease progression for ≤60% of the cases, whereas most studies on peri-implantitis treatment reported disease resolution occurring in <50% of the fixtures. In conclusion, disease resolution is generally unpredictable and infrequently achieved after the treatment of peri-implant diseases. A great variety of definitions have been used to define treatment success. Notably, percentages of treatment success and disease resolution were generally underreported. The use of standardized parameters to evaluate disease resolution should be considered an integral component in future clinical studies. Keywords: Peri-implantitis, dental implant, diagnosis, peri-implant endosseous healing, tooth loss, outcome assessment.

Dental implants have been commonly used to replace missing single teeth. However, esthetic rehabilitation of an adjacent tooth may also be required due to diastemas, crowding, or existing large direct restorations to improve the final esthetic outcome. With the advancements in ceramics and bonding techniques, minimally invasive esthetic approaches have become viable for compromised spacing issues. This case report describes a dental technique for the esthetic rehabilitation of compromised anterior spacing with a customized zirconia implant abutment at maxillary central incisor site and a partial ceramic veneer bonded to adjacent central incisor. Keywords: Anterior spacing; case report; implants; partial laminate veneer; prosthetic dentistry

Objective: The purpose of this retrospective study was to assess facial and palatal alveolar wall thickness (AWT) in relation to sagittal root position (SRP) of maxillary anterior teeth using cone-beam computed tomography (CBCT). Methodology: 102 CBCT images (60 females, 42 males) of anterior maxillary teeth were reviewed. SRP was classified according to Kan’s classification, and AWT was evaluated at coronal (4 mm from the cementoenamel junction), mid-root, and apical (2 mm from the apex) levels of the facial and palatal. Secondary variables of sex, age and tooth type were analyzed. Results: The SRP distribution was 76.6% class I, 11.3% class II, 0.8% class III, and 11.3% class IV. AWT, from thickest to thinnest, was found in palatal apical>mid>coronal, followed by facial coronal>mid>apical. Conclusions: AWT was thickest in SRP class II, followed by class I and III, and least thick in class IV at all measured areas (P<.05). A significantly higher AWT was associated with class I in central incisors, class II in canine teeth and in males, and class IV in central incisors and canines. Keywords: Alveolar Process; Cone-Beam Computed Tomography; Dental Implants.

ChatGPT, an artificial intelligence (AI) chatbot can generate text prompts based on user input. This study investigated the possibility of generating adequate and relevant patient education and management documents in the context of dental implant surgery utilizing this tool. Methods: Twenty-seven (n=27) periodontists were surveyed on the accuracy and usefulness of AI-generated documents comprising patient information handouts on surgical risks and post-operative instructions sheets for dental implant placement either in smokers or patients with diabetes. They were also asked in a blinded fashion about their preferences between the generic dental implant placement consent form currently used at Boston University and two AI-generated consent forms: one generic and one tailored to patients with diabetes. Results: A vast majority of participants found that the information in the AI-generated forms was accurate, useful and would feel comfortable using them with their own patients. The AI-generated generic consent performed as least as well as the human-written one, while the personalized informed consent for patient with diabetes performed significantly better (p<0.001). Conclusions: Within the limitations of this study, ChatGPT was able to independently generate accurate and useful patient information and management documents.

Choosing between screw-retained and cement-retained restorations in the esthetic zone may have a significant implication on the restorative contour. This study analyzes the effect of facial-palatal implant positioning on the facial emergence angle of implant restorations in the maxillary anterior region. 133 maxillary anterior implant cases were captured with intraoral scans and used to create digital prosthetic designs. The facial emergence angle of the restoration and the depth of the implant were determined using images at the mid-facial cross-section. Simple logistic and linear regression models were used to analyze the interrelation between the emergence angle, depth, and retention methods. The average facial emergence angle for all restorations in this study was 34.4 degrees. A significant difference was found in emergence angle between screw-retained and cement-retained groups, with an average emergence angle of 37.3 degrees and 27.9 degrees, respectively. There is no difference in the mean depth between those two groups. There is a strong negative linear relationship between depth and emergence angle for the screw-retained group. Overall, implant positioning in the anterior maxilla has a significant influence on emergence angle. Facial emergence angle is significantly greater for implants in screw-retained position. This may be partially alleviated by deeper implant placement. Keywords: Dental implants, emergence angle, dental prosthesis, implant position

Sinus floor augmentation is one of the most used approaches to obtain sufficient bone availability to place dental implants in cases with severe bone atrophy in the posterior maxilla. Several bone substitutes are indicated for sinus augmentation but they may obtain different clinical outcomes. This study aims to compare bovine bone mineral (BBM) with freeze dried bone allograft (FDBA) in two- stage lateral window sinus grafting approach. 20 patients received a lateral window sinus lift with either FDBA or BBM. Post-operative graft height was measured with a cone-beam computerized tomography (CBCT). 6 months later implants were placed. Biopsies were taken for histological analysis and new CBCts were performed to measure graft height at this point. 6 months after procedure, there was a height reduction of 20,27 ± 4,94 % for the FDBA sample and 5,36 ± 2,41% for the BBM group. The histological analysis revealed a ratio of newly formed bone of 43,70 ± 5,29% for the FDBA and 38,11 ± 4,03% for the BBM group. The FDBA also showed a higher amount of residual biomaterial 17,25 ± 10,10% and connective tissue 14,63 ± 4,38% compared to the BBM 15,53 ± 5,42% and 13,11 ± 4,42%. The differences between groups were statistically significant for the height reduction and for the newly formed bone (p ≤ 0.05) but not for the residual biomaterial amount and the non-mineralized connective tissue (p ≥ 0.05). It could be concluded that the percentage of newly formed bone 6 months after performing a lateral window sinus lift using FDBA was significantly higher than when using BBM, although the graft height reduction was also significantly higher for the FDBA group. Keywords: Sinus Floor Augmentation, allografts, heterografts.

Purpose: To compare survival, marginal bone loss (MBL) and prosthetic complications of 4.5-mm extra-short implants and longer implants splinted to the same type of implant. Materials and Methods: A retrospective controlled cohort study was performed. The 4.5-mm extra-short group (study group; SG) included 48 consecutively placed implants that met inclusion criteria. Control group (CG) included 48 implants splinted to them. The same surgical team treated the 39 patients included, and all the implants were restored with a screw retained fixed restoration and intermediate abutments. Immediate and conventionally loaded implants were included. Results: All the implants were in function during the follow-up period (14 ± 3.4 SD and 17 ± 13 SD months for SG and CG). No differences in technical complications were observed between both groups (1 and 2 screw loosening for SG and CG; 2 fractures in provisional prosthesis for SG; p=0.310). Marginal bone stability was similar for SG and CG at mesial level (SG: Mean -0.01 ± 0.28 SD mm Vs CG Mean -0.18 ± 0.72 SD mm; p=0.270) and at distal level (SG: Mean 0.02 ± 0.39 SD mm Vs CG Mean -0.18 ± 0.68 SD mm; p=0.076). Conclusions: The same good clinical performance could be observed for 4.5-mm implants and longer implants under the same prosthesis. Keywords: short dental implants, extra-short implants, marginal bone stability.

The management of marked horizontal bone atrophy represents a critical challenge for traditional implantology procedures. For this purpose, clinicians have developed several protocols and procedure to allow the most suitable and accurate surgical and prosthetic implant rehabilitation. Despite the development of guided-bone regeneration methods or the use of small-diameter implants, the rehabilitation of thin bone areas represents a clinical dilemma for the medium- and long-term survival of implant-prosthetic therapies. This clinical case evaluates the use of wedge implants for the full arch rehabilitation of an atrophic maxilla with a thin ridge. This treatment choice allowed a minimally invasive rehabilitation, avoiding regenerative bone surgery, while respecting biological and prosthetic limits. Furthermore, the evaluation of ISQ and MBL values during the first year of follow-up allowed us to analyse the behaviour of this rehabilitation solution in full arch maxillary cases.

Ultrathin ceramic veneers are a viable therapeutic option to manage esthetic challenges in the anterior zone. Proper conditioning of the intaglio surface of porcelain veneers is essential to achieve an adequate bonding. In clinical practice, this is typically done with chemical etching using an acid-containing agent, such as hydrofluoric (HF) acid. While it is well established that the etching effect is time- and acid concentration-dependent, little is known regarding the impact of etching time and the veneer fabrication method. The purpose of this pilot study was to evaluate the effect that different etching time protocols have on the intaglio surface characteristics of ultrathin ceramic veneers fabricated with either the platinum foil technique or the refractory die technique using scanning electron microscopy (SEM). Several replicas of an ultrathin feldspathic ceramic veneer for a maxillary central incisor were fabricated. Individual specimens were processed according to different intaglio surface etching protocols: no etching, etching for 90 seconds, etching for 120 seconds, and etching for 150 seconds, using 9.6% HF acid. It was observed that the 120 seconds etching protocol resulted in a favorable microroughness surface pattern in the platinum foil group. This pattern was comparable to that obtained by etching the intaglio of veneers fabricated with the refractory die technique by applying HF acid for 90 seconds. Increasing the etching time to 150 seconds did not result in a more favorable roughness pattern.

Objectives Schneider membrane thickening is a common maxillary sinus disease. However, the effect of Schneider membrane thickness on the transcrestal sinus floor elevation still has not reached a consensus. This retrospective study evaluated the perforation and bone formation outcome of the transcrestal sinus floor elevation sites with different Schneider membrane thicknesses. Material and Methods 117 sites of 87 patients treated with transcrestal sinus floor elevation were included in this study. The surgical sites were divided into four groups according to the baseline Schneider membrane thickness: group A (0 – 1 mm), group B (1 – 2 mm), group C (2 – 4 mm),and group D ( > 4 mm). The CBCT was taken before the surgery (T0), immediately after the surgery (T1), and 6 months after the surgery. Results The mean baseline Schneider membrane thickness was 2.16 ± 2.54 mm.The mean residual alveolar bone height was 6.58±1.85 mm. The mean endo-sinus new bone height was 3.76 ± 1.95 mm. The perforation rate and endo-sinus new bone height showed no significant difference among the groups of different membrane thicknesses (p > 0.05). The incidence rates of membrane thickening and perforation were significantly higher in the smoking patients (p < 0.05).Conclusions Membrane thickening without ostium obstruction may have little impact on transcrestal sinus floor elevation surgery in perforation rate and bone formation. In addition, smoking may be a risk factor for membrane thickening and the membrane of smoker is more likely to perforate during the transcrestal surgery.

Successful bone augmentation relies on primary wound closure. Labial frenum is a soft tissue that connects the lip to alveolar mucosa or gingiva. However, frenum may exert biomechanical forces to the wound edge, causing wound instability. The aim of this study is to (1) review the frenum composition and classifications; (2) understand the significance of frenum in wound stability upon bone regeneration. An electronic search was conducted through the three online databases together with manual search on studies published until September 2022. A total of 300 articles were identified and 11 studies were included in this review. Two of the included six studies discovered that 35-37.5% of the labial frenum had muscle fibers. Other studies showed that labial frenum was mainly composed of connective tissue with elastic fibers. There are two widely used classifications for frenum based on morphology and position of attachment. No studies specifically evaluated the impact of frenum on bone regeneration. Frenum location intercorrelated with the amount of keratinized tissue, which could influence wound stability. A modified frenum classification for the edentulous ridge and a decision diagram to manage the frenum is proposed for research and evidenced practice.

Collagen matrixes have been developed as possible connective tissue graft substitutes to overcome patient discomfort, undesired palatal healing, and the limited amount of donor tissue. The aim of this case series is to assess a coronally advanced flap (CAF) with a new volume-stable collagen matrix (VCMX) to treat single gingival recession (GR) associated with partially restored non-carious cervical lesions (NCCL). Twelve patients diagnosed with single GR RT1 + NCCL (B+) were included in this study and received a restorative – partial resin composite with apical margin 1 mm beyond the estimated cementoenamel junction (CEJ) – and a surgical approach – CAF+VCMX. Clinical and patient-centered assessments were recorded at baseline and 6 months postoperatively from ten patients. Significant recession reduction (RecRed:2.1mm), clinical attachment level gain (CAL:1.34mm), and combined defect coverage (CDC) of 51.67% were observed at 6 months. The estimate root coverage (RC) was 69.48%, obtained using the estimated CEJ. No difference in keratinized-tissue width (KTW) was observed over time. A gain in gingival thickness (GT) of 0.42 mm was observed after 6 months (p=.002) and an improvement in patient satisfaction due to better esthetics (p<.001). Within the present study’s limits, CAF plus VCMX provided significant improvement in treating single GR combined with partially restored NCCL (B+). Keywords: Gingival Recession. Heterografts. Tooth abrasion. Tooth cervix.

Objectives: The aim of this article is to introduce three treatments for patients with gingival fenestration as a result of chronic apical periodontitis. Gingival fenestration is a relatively uncommon soft tissue lesion in which the root apex is exposed in the oral environment after the destruction of the overlying buccal bone plate and mucosa. At present, no clear etiology or treatment guidelines exist for gingival fenestration. This article reports three successfully treated cases of gingival fenestration associated with chronic periapical infection. This report can help contribute to treatment guidelines for gingival fenestration. Methods: All cases were treated with apicoectomy in conjunction with a connective tissue graft (CTG). According to the different conditions of the patients, we used some slightly different treatment methods during the operation. In case 1, we treated gingival fenestration in the mandibular left first premolar by endodontic therapy with root-end resection and retrograde filling and regenerative surgical therapy using a xenograft and CTG. In case 2, we treated gingival fenestration in the maxillary left lateral incisor by endodontic therapy with root-end resection and retrograde filling in vitro and regenerative surgical therapy using advanced platelet-rich fibrin (A-PRF) and CTG. In case 3, we treated gingival fenestration in the mandibular left second premolar by endodontic therapy with root-end resection and retrograde filling and regenerative surgical therapy using CTG. Results: Endodontic treatment was combined with periodontal surgery to achieve predictable treatment results. After 13 to 25 months of follow-up, all cases showed that the gingival fenestration had healed well, and the patients had no discomfort. Conclusions: These three cases show the possibility of using apical excision combined with a CTG and/or bone graft/PRF in the treatment of gingival fenestration. Reporting these three cases may help advance the field of treatments for gingival fenestration. Keywords: gingival fenestration, root canal therapy, apical surgery, connective tissue graft, bone graft, platelet-rich fibrin.

Healing outcomes of periodontal and implant-related regenerative procedures are closely related to wound stability, which is partially determined by biomechanical properties and behaviors of oral mucosal tissues. Studies on soft tissue behaviors under biomechanical forces in oral regeneration models are scarce. The aims of this review article are to (1) contrast the microstructural differences between the attached gingiva (AM) and lining (LM) mucosa, (2) evaluate biomechanical behaviors of the two mucosal types,and (3) relate residual flap tension to the prevalence of wound opening after regenerative procedures. Results: Compositional and structural differences between the AM and LM explain the biomechanical property differences between AM and LM. Wound destabilizers, including tissue recoil stemming from its viscoelastic property, muscle pull, and inflammatory edema created after the flap releasing procedure for primary wound closure interfere with wound stability. Residual flap tension <0.05 N is a prerequisite for sustained wound closure. Tissues under stress can exert negative cellular changes, resulting in necrosis and wound dehiscence. Conclusion: Biomechanical properties and the variations between AM and LM dictate the degree of wound stability. Efforts should be made to reduce the negative impact of the potential destabilizers to optimize wound stability. Keywords: biomechanical properties, oral mucosa, viscoelastic, flap tension, regenerative procedures

Anterior mandible is the most challenging anatomical site for performing periodontal plastic surgeries. Increased demands for optimal root coverage and esthetic outcomes contribute to the development of pedicle flap-based surgical solutions, in contrast to predominantly used free gingival graft. The aims of this study were to (1) summarize the current literature to identify the mostly used techniques, indications, and their efficacy and (2) provide a decision table for surgeons to navigate through the selection of appropriate techniques. Four main approaches were identified: Free gingival graft, lateral sliding, tunneling, and coronally advanced flaps. The flap approaches are mostly combined with a connective tissue graft. The decision table considers (1) the patients’ chief complaint, (2) local anatomical factors, and (3) technique sensitivity. This table provides a framework for supporting an evidence-based selection of surgical techniques and for studying novel methods to achieve predictable root coverage in the anterior mandible.

Robotic systems have revolutionized various industries, and dentistry is no exception. Recently, due to the robust advancements in artificial intelligence and technology, there has been a significant evolution of dental robotic systems, ranging from surgeon controlled, robot-assisted operations, to more autonomous processes. The present clinical case report describes a 1-year follow-up of the successful use of an autonomous dental implant robot system with an osseodensification (OD) protocol for implant osteotomy preparation, maxillary sinus elevation, and simultaneous implant placement at the maxillary second premolar site. A prefabricated provisional prosthesis was delivered immediately after implant placement, with final prosthesis delivery at 3 months. The findings from this report demonstrate the integration and clinical augmentation of more autonomous protocols in the field of implant dentistry using dental robots. Keywords: Robotics surgery, Osseodensification, Maxillary sinus, Dental implant, Case report

Titanium has been proposed as a mesh material for GBR since the nineties. To overcome difficulties in shaping and adaptation to the defect, digital elaboration techniques were introduced to digitally print meshes capable of fitting the bone perfectly, reproduced through the CT scan of the patient. Five patients were included in this case series. CBCT data of patients were acquired and sent to the producer of the titanium mesh. 3-dimension regenerative surgery was performed with titanium meshes and a mix of Demineralized Bovine Bone Matrix (DBBM) and Autologous bone (1:1 ratio). Radiographic measures were evaluated on paraxial sections of the CBCT through a dedicated software. When possible, regenerated bone samples were obtained at implant insertion time. Four out of five regenerated areas healed without local and systemic complications. One mesh was removed after two months and two weeks because of exposition. Mean vertical bone gain was 4.3 ± 1.5 mm (range 2.5 – 7 mm). Two histologic samples were obtained. In sample n.1, Bone Tissue Area and  Graft Material Area were respectively 44.4% and 12.5%. In sample n.2, the same parameters were 15.6% and 16.9% respectively.

Guided bone regeneration (GBR) requires a tension-free flap without damaging the collateral circulation in order to secure better surgical outcomes. Topographical acknowledgment of the muscular and neurovascular structures in the territory of the mandible can prevent complications during lingual flap design. The lingual branch (LB) of the inferior alveolar- or maxillary arteries is not well illustrated or described in the literature. Nevertheless, it has an intimate relationship to the lingual nerve (LN) during ridge augmentation and implant-related surgeries of the posterior mandible. Therefore, this study aimed to clarify the morphology and topography of the LB related to GBR surgeries. In the present human cadaveric study, the LB was analyzed in twelve hemimandibles using latex injection and corrosion casting. We identified two types of LB based on its origin and course. For both types, LB was found in a common connective tissue sheath close to the LN's origin and supplied the nerve. Several anastomoses between the LB and other arteries on the posterior lingual aspect of the mandible were observed. The LB acted as an anatomical landmark in identifying LN at the posterior lingual aspect of the mandible. 

Critical to the success of dental implants is the ability for clinicians to adequately obtain primary stability into host bone. Nevertheless, a number of conditions require dentists to perform multi-stage approaches to rebuild deficient bone volume prior to surgically placing dental implants. Thus, in many instances, implant placement cannot be achieved owing to a lack of primary implant stability.  Recently, a novel mineral-organic resorbable bone adhesive (MORBA) has been the focus of intensive animal research demonstrating promising results for future clinical application. MORBA is a synthetic, injectable, self-setting, load-bearing adhesive biomaterial that exhibits osteopromotive properties and bonds bone-to-bone and bone-to-metal within a 10 minute period. Its unique novel formulation was developed from biomimetic proteins found in marine animal creatures (such as underwater sandcastle worms) that possess distinct adhesive properties underwater. A variety of animal studies have now confirmed excellent long-term results with the ability to offer clinicians immediate primary stability of dental implants using a biomaterial that is capable of fully resorbing within a 30 week period. The present case report demonstrates the use of MORBA in a first human patient on a non-restorable lower first molar. Following placement of a mobile 5.8mm Biohorizons implant, the use of MORBA was utilized to stabilize the implant. Following 3 months post-surgery, both clinical and CBCT radiographs demonstrated maintained implant stability. One year post-implant placement showed radiographic bone on the buccal surface of the implant with continued long-term stabilization of the implant. This case report now extends to 3 years whereby the use of MORBA, in an initially unstable situation, demonstrated excellent long-term follow-up in a first case report. Thus in conclusion, MORBA provided immediate implant stability, with resorbable characteristics leading to successful clinical long-term clinical outcomes up to 3 years. This innovative biomaterial will ultimately provide a more efficient solution to a critical problem in implant dentistry allowing for optimal primary stability during immediate implant placement and thus reducing the time and cost of current standards of care.

This pilot case series histologically and histometrically investigated the influence of implant surface hydrophilicity on early osseointegration and peri-implant bone formation around simultaneously grafted immediate implants. Core biopsies of the hydrophilic test (SLAactive®) or hydrophobic control (SLA®) implants immediately placed in maxillary molar extraction sites and simultaneously grafted with mineralized cancellous bone allograft (MCBA) obtained at 3 weeks post-placement were histometrically compared for bone to implant contact, the quantity of graft material, new bone formation, tissue reaction, and inflammatory scores. Test implants showed a more pronounced implant-bone apposition, peri-implant bone formation and bone aggregate than control implants. Trabecular bone formation and maturation were also qualitatively advanced around test implants. These results indicate that the implant surface bone graft combination may affect peri-implant bone formation. 

Traditional GBR procedures have been associated with frequent complications and compromised peri-implant esthetics. Tunneling techniques have been proposed as a promising alternative in this regard.  More recently, a subperiosteal minimally invasive aesthetic ridge augmentation technique (S.M.A.R.T.®) was reported to have been clinically successful in a prospective case series.  This technique includes the use of a bone graft/rhPDGF-BB combination delivered to the site utilizing a tunneling method.  However, published histologic information regarding the nature of the regenerated tissue has been limited.  The current study evaluated the histologic and histomorphometric findings of four human specimens harvested at 2, 5, 9, and 14 months, following ridge augmentation using the S.M.A.R.T.® method.  Evaluation of the wound healing and bone regeneration sequence over time found that the ridge augmentation was the result of extensive new bone formation that progressed through the woven bone to lamellar bone stages, with remodeling of the xenogeneic graft material and replacement by the patients’ bone.  This is the first study utilizing sequential human specimens to histologically examine the chronology of wound healing following alveolar ridge augmentation. 

The socket shield technique has been proposed as a surgical method to prevent the collapse of the buccal plate following tooth extraction, leading to excellent soft-tissue stability and long-term aesthetic outcomes. Despite its success, this technique is still not without potential risks. One of the most common complications is internal exposure of the socket shield. It can present as inflammation of the inner soft tissue with or without exposure of a portion of the shield. This case series discusses this complication's aetiology, diagnosis, treatment, management, and prevention. Data from ten patients with twelve internally exposed sites are presented. 

Surface contaminants on customized implant abutments could trigger inflammatory response in the peri-implant tissues. The aim of this randomized controlled study was to assess the radiographic bone changes around implants restored with customized, platform-switched abutments, with and without autoclave treatment, 12 months after definitive restoration. Dental implants were placed 1 mm subcrestally in 64 systemically healthy patients (mean age 63.3 ± 10.0 years, 31 with history of periodontitis) to replace single or multiple missing teeth. According to a randomization list, abutments were subjected to steam and autoclave sterilization (43 implants, test group) or steam cleaning alone (44 implants, control group). Periapical standardized radiographs were taken at the time of implant insertion, prosthetic abutment connection and 12 months after definitive cement-retained restoration. All implants were clinically stable without any sign of infection at the 12-month follow-up. An average marginal bone loss of 0.25 ± 0.19 mm was found in the test group compared to 0.35 ± 0.23 mm in the control group without statistically significant difference, while the percentage of bleeding sites was significantly higher in the control group (8.7 ± 13.1% versus 19.1 ± 19.8%, P = .035). Autoclave treatment of customized abutments would seem to reduce the inflammatory response around subcrestally placed implants. Keywords: bone loss, platform switching, dental implant, subcrestal, sterilization

Mucogingival deformities around implants are frequent findings in clinical practice and often present as inadequate keratinized tissue and insufficient mucosal thickness. Phenotype modification therapy can increase peri-implant mucosal thickness and the amount of keratinized mucosa, improving the long-term clinical outcomes of implants. Free gingival graft (FGG) is considered the gold standard to increase keratinized mucosa; however, FGGs on lingual aspects of implants are less predictable due to technique sensitivity and often present with insufficient gain in tissue thickness ue to limited blood supply. The Semilunar Lingualized Apically Positioned Flap (SLAP) with subperiosteal tunnel connective tissue graft (CTG) can increase both peri-implant mucosal thickness and keratinized mucosal width circumferentially. SLAP consists of one full-thickness, semilunar incision within keratinized mucosa on the buccal, and two vertical releasing incisions mesial and distal of the implant, extending lingually into the alveolar mucosa. The tissue is apically positioned lingual to the implant, and sutured in place creating buccal space for CTG via buccal subperiosteal tunneling. SLAP is a minimally invasive and predictable approach in improving peri-implant mucosal phenotype. This case reports demonstrates gain in peri-implant mucosal thickness and the amount of keratinized mucosa over a 10-month period utilizing SLAP with subepithelial CTG. 

Surgical treatment of infrabony defects may result in gingival recession of the neighboring teeth. The aim of this clinical report is to describe a surgical technique to promote gingival margin stability in the treatment of infrabony defects with thin or medium gingival phenotype. Coronally advanced entire papilla preservation (CA-EPP) flap with connective tissue graft (CTG) was executed in two different clinical cases. This technique showed substantial improvement in interproximal clinical attachment level gain and pocket closure, with no gingival recession. CA-EPP flap using CTG may promote gingival margin stability and can be recommended in regenerative periodontal procedures. 

Tooth autotransplantation is an effective treatment to replace missing teeth. Digital planning can facilitate successful autotransplantation. Guiding templates are highly recommended when performing cases in healed ridges in the posterior area to reduce excessive bone subtraction and increase the chances of fitting of the donor tooth in the new socket. This case report highlights the use of three-dimensional planning tools and fully-guided drilling templates for successful tooth autotransplantation in the posterior area. Two tooth autotransplantations were performed in a 51-year-old patient using lower wisdom teeth to replace hopeless lower molars. Root canal treatments were carried out before the surgeries and different alveoloplasty techniques were used in each recipient area. The prosthetic phase was carried out after 9 months. Both teeth were asymptomatic, functional, and exhibited no signs of resorption or apical radiolucency and complete regeneration of the periodontal apparatus at the 2-year follow-up. 

The aim of the present study was to compare by cone beam computerized tomography (CBCT) the influence of white and black ethnicity on the gingival and bone thickness. Eighty-four individuals, aged between 18 and 59 years old, of both genders, were divided into black (BG n=42) and white groups (WG n=42) and analyzed from June 2020 to April 2021. The gingival and bone thickness were measured using CBCT in all maxillary anterior teeth. T test, Mann-whitney, chi-square, Pearson's correlation and Spearman’s correlation were used for comparisons and correlations with a 5% significance level. The black individuals had mean gingival (1.45mm±0.29) and buccal bone plate (1.07mm±0.21) significantly (gingival: p<0.0001, bone: p=0.0002) thicker than white individuals (1.17mm±0.28 and 0.91mm±0.17, respectively). The variables presented greater values for the male individuals. A positive correlation between the thickness of buccal bone plate and gingiva for was found in two teeth in WG (left and right central incisor) and one tooth in BG (left canine). Moreover, a correlation between BBPT and GT immediately below alveolar bone crest (0 mm landmark) was found in four teeth in WG (left and right lateral incisor, left and right central incisor) and BG (left and right canine, left lateral incisor and left central incisor). The black ethnic showed to significantly influence the gingival and buccal bone plate thickness, with black individuals presenting thicker structures than whites. 

This study aimed at determining the correlation between gingival stippling (GS) and other phenotypical characteristics. Adult subjects in need of cone-beam computed tomography scans (CBCT) and comprehensive dental treatment in the maxillary anterior region were recruited. Facial gingival thickness [GT] and buccal bone thickness [BT] were assessed utilizing CBCT. Standardized intraoral photographs were obtained to determine keratinized tissue width (KTW), presence of GS in all facial and interproximal areas between the maxillary canines, and other variables of interest, such as gingival architecture (GA), tooth shape, and location. Statistical analyses to assess different correlations among recorded variables were conducted. A total of 100 participants and 600 maxillary anterior teeth constituted the study population and sample, respectively. Facial GS was observed in 56% of males and 44% of females, and it was more frequently associated with flat GA, triangular and square/tapered teeth, central incisors, and males. Greater mean values of GT, BT, and KTW were observed in facial areas that exhibited GS. Interdental GS was present in 73% of the sites and it was more frequently observed in males, the central incisor region, and when facial GS was present. Multilevel logistic regression revealed a statistically significant association between the presence of GS and KTW, BT measured at 3mm apical to the bone crest, and tooth type. This information can be used in the recognition of common periodontal phenotypical patterns associated with specific features of great clinical significance. 

Objectives: The aim of the present case series is to exhibit the long-term clinical and radiographic outcomes of resective surgery with adjunctive implantoplasty over a 6-to-11-year follow-up. Materials and Methods: Four patients presenting 4 implants diagnosed with peri-implantitis according a to an established case definition were included in the present case series. Subjects underwent resective surgery, a modified implantoplasty approach, and implant surface decontamination. Clinical and radiographic outcomes such as bleeding on probing (BOP), suppuration on probing (SoP), probing depth (PD), marginal recession (MR), modified plaque index (mPI), and marginal bone levels (MBL) were recorded over a long-term following surgical therapy. Results: Over 6-to-11-year follow-up, mean BOP, PD, and SoP scores amounted to 17 ±24%, 2.5 ±1.26 mm, and 0%, respectively. BOP scores were reduced in 17%, PD values in 2.5mm, and SoP scores in 100%. Radiographic analysis revealed a mean radiographic bone gain of 3.1 ± 1.84 mm. Peri-implant marginal bone loss surface area decreased by 5.7±3.77mm2 over the long-term follow-up. Conclusion: Resective therapy with adjunctive implantoplasty promoted favorable clinical and radiographic outcomes at peri-implantitis treated sites over a long-term period. Clinical Relevance: Diverse surgical approaches such as resective, reconstructive, and combined therapy have been proposed towards peri-implantitis treatment. A resective surgical approach with an adjunctive “modified” implantoplasty refers to the modification of the implant body into a constricted area to mimic a “waist” silhouette. This modified technique conforms an adequate concave smooth area that may favor the outcomes of resective surgical therapy for soft tissue adaptation, biofilm control, and possible peri-implant bone gain over the long term. 

The effects of buccal contour augmentation, for periodontally compromised teeth with horizontal bone loss, was assessed in this study. 30 subjects were divided into group A (open flap debridement [OFD] with buccal contour augmentation using deproteinized bovine bone mineral [DBBM]), jointly referred to as Contour augmentation for Periodontal Defects (CAPD); and group B (OFD alone). Bleeding on probing (BOP), clinical attachment level (CAL), probing depth (PD), gingival recession (GR), width (WKM) and thickness (TKM) of keratinized mucosa and labial cortical plate thickness were compared at baseline and 1-year. BOP, CAL, PD and GR did not show significant differences. TKM increased by 1.76 mm for group A, while decreased by 1 mm for group B. WKM increased from 2.86 ± 0.4 mm to 3.6 ± 0.71 mm (p<0.001) and 2.93 ± 0.32 mm to 3 ± 0.7 mm (p = 0.5) for groups A and B respectively, which showed a statistical significance. Labial cortical plate thickness increased from 0.94 ± 0.3 mm to 1.95 ± 0.54 mm (p<0.001) for group A, while decreased from 0.87 ± 0.45 mm to 0.68 ± 0.31 mm for group B. Visual analog scale score for pain perception showed no difference between the 2 groups. Contour augmentation (CAPD) with DBBM for periodontally compromised teeth improves WKM and TKM. Long-term analyses are needed to determine its benefits in daily clinical practice. 

Background: This study is aimed to investigate the types of knot failure (untying or breaking) and the tension required to break different sutures diameters. Methods: One hundred and fifty knots were fabricated using polyamide sutures diameters of 6/0, 7/0, and 8/0. The studied knots were either squared or slipped with different numbers of throws (2, 3, 4, 5 and 6), and the following data were recorded: type of failure (untied or broken), number of throws, the tension required to untie or break each knot, slippage, and elongation of the knot. The knots were created in a standardized way. with a device and weights and then subjected to a controlled tension. Results: The knots that got untied were: 1=1, 1x1, 2=1, and 2x1, whereas the remaining knots  got broken. Notably, at least three throws were required to prevent untying, but separately, as in 1=1=1 or 1x1x1. The mean tension to break the knots of 6/0, 7/0, and 8/0 sutures were 3.1, 1.3, and 0.6 N, respectively (P < 0.05), and they were independent of the knot type. Conclusion: Results from this study demonstrated that the knots with geometries of 2=2/2x2 and 1=1=1/1x1x1 were secure, and additional throws does not increase their security. Furthermore, tensile strength reduces with decreased suture size.

Introduction: Peripheral Giant Cell Granulomas (PGCGs) are benign oral cavity tumors, reactive in nature, caused by local trauma or irritation. Case presentation: A 51-year-old female patient presented with a soft tissue lesion related to implant site #19. Excisional biopsy was completed, and the soft tissue mass was diagnosed as a Peripheral Giant Cell Granuloma (PGCG). The biopsy led to absence of keratinized tissue and vestibular depth around the implant site. After the initial healing phase of the biopsy, a free gingival graft was completed and following the maturation of the soft tissue the cement retained implant supported prosthesis was converted into a screw retained implant supported prosthesis. Conclusion: With a combined periodontal and restorative approach increased KT, adequate vestibular depth, no recurrence of the PGCG was achieved as well as an easily accessible screw retained implant supported prosthesis.

The aim of this report is to describe a new sling suturing method with papillary anchorage that is found clinical applicable within the available conventional tunneling root-coverage procedures. Although caution is advised to not increase excessive tension on the fragile papilla tips, as they provide coronal and palatal suspension, it ascertains a firm and stable connection for the entire bucco-gingival-graft complex into the horizontal and vertical dimension of both single and multiple recession defects. This technical note described the "trapezoidal sling suture" technique, that allows fixation and stabilization for graft and flap around both natural teeth and implants. Keywords: suturing, gingival recessions, dental aesthetics

The aim of this present case series investigated the effect of a combination therapy utilizing connective tissue graft (CTG) in the treatment of periodontal regeneration of mandibular Class Ⅲ furcation involvement (FI). Six patients diagnosed with periodontitis stage Ⅲ or Ⅳ (grade A to C), presenting with Class Ⅲ or Ⅳ FI, were treated with fibroblast growth factor 2 and carbonate apatite in combination with CTG. The following clinical parameters were evaluated at baseline and after 6, 12 and 18 months: periodontal probing depth, clinical attachment level, furcation invasion, the radiographic vertical defect depth, and gingival phenotype. Significant improvements in clinical parameters were observed in all treated FI sites. Four Class Ⅲ Fls and one Class Ⅳ Fl obtained complete closure, and one Class Ⅳ furcation was improved to Class ?? . This case series showed the potential of administering combination regenerative therapy for changing the prognosis of hopeless teeth with severe furcation defects.

The purpose of the present study was to describe a novel protocol for a minimally invasive pocket elimination surgery (MI-PES) in the posterior maxilla and mandible, which consists of the combined use of i) an access flap based on an internally-beveled gingivectomy with minimal to no papilla mobilization at the buccal aspect and ii) a resective procedure with an apically-positioned flap on the oral aspect. The interproximal bone defects were accessed with a single (oral) flap and the bone architecture was modified by the adoption of piezoelectric inserts for a controlled bone recontouring associated with fiber retention. Mean probing depth (PD) was 5.5 ± 0.8 pre-surgery and shifted to 2.7 ± 0.6 mm at 6-month re-evaluation. All treated pockets showed a post-surgery PD < 4mm. Gingival recession (REC) was 0.3 ± 0.5 mm at baseline, and increased to 1.6 ± 0.8 mm. When buccal and oral pockets were separately analyzed, a trend towards a similar PD reduction, less REC increase and greater CAL gain was recorded for buccal pockets. These preliminary observations seem to support the use of MI-PES as a valuable option for pocket elimination at least when residual pockets are associated with a shallow interproximal osseous crater in the posterior maxilla/mandible.

Vertical ridge augmentation in the anterior mandible is a technically delicate procedure that requires knowledge of some anatomical structures to reduce peri- and post-operative complications. Proper soft tissue management is one of the primary aspects to the success of these techniques, enabling tension-free primary wound closure and preventing membrane exposure. In this cadaveric and clinical study, we provided an anatomical overview of the lingual portion of the anterior mandible. Moreover, we described a novel surgical approach for the release of the lingual flap that will help clinicians achieve primary closure without incurring intrasurgical complications.

Implants with deficient papillae and black triangle are common findings. The treatment of these esthetic complications is considered challenging, and with limited predictability. Therefore, the aim of the present report is to describe a novel technique for papilla augmentation (the "Iceberg" connective tissue graft [iCTG]) after extraction and interproximal bone reconstruction in the anterior region. A 35-year-old patient presented with a hopeless tooth with interproximal clinical attachment loss extending up the apical third of the adjacent tooth. Interproximal bone reconstruction was performed through alveolar ridge preservation by directly applying recombinant human platelet-derived growth factor-BB (rhPDGF-BB) to the exposed root surface of the adjacent tooth. A mixture of autogenous bone chips (obtained from the ramus) and bovine bone xenograft particles, previously mixed with the growth factor, was also used. The patient was able to come back for implant therapy only 2 years later. An incomplete regeneration of the interproximal bone was observed. Therefore, to compensate the interproximal deficiency, the iCTG approach, involving a double layer CTG with different origins, was utilized. Two small grafts from the tuberosity were sutured to the mesial and distal ends of a wider CTG harvested from the palate, aiming at gaining additional volume at the interproximal sites. The composite graft was then sutured on top of the implant platform, with the flap that was then released and closed by primary intention. After conditioning of the peri-implant tissues, the case was finalized with a satisfactory outcome. The described iCTG could be an effective approach for reconstructing peri-implant papilla following interproximal bone reconstruction.

Despite the various barrier membranes proposed, one of the main challenges for guided bone regeneration (GBR) is space maintenance for large defects as well as ensure adequate blood supply. The presented feasibility case series aims to introduce an original titanium frame (TF) design, customized for each defect, as a modification of well-known principles and materials for GBR, for an enhanced and more predictable horizontal and vertical bone augmentation. Three patients with significant horizontal defects were treated with pre-trimmed TFs to create needed space, a 50%-50% mixture of autograft and bovine xenograft was placed, and then covered with collagen membrane. After 8 months of healing, the sites were reopened, the titanium screws were removed with the frame. An average of 8.0 ± 1.0mm horizontal and 3.0 ± 0.0mm vertical bone gain was achieved at the time of re-entry and implant placement surgery. Bone core biopsy was obtained during the implant placement. Histomorphometric analysis revealed that 42.8% of the sample was new vital bone, 18.8% was residual bone graft particles, and 38.4% was bone marrow like structures. After 3-4 months from implant placement, the implants were restored with provisional crowns and then finalized with zirconia screw-retained crowns. This case series suggests that GBR utilizing TFs with or without collagen membranes can be considered a suitable approach for horizontal and vertical bone augmentation. However, based on only three reported cases, the result should be carefully interpreted.

The use of conventional scan bodies (SBs) with an intraoral scanner (IOS) to capture the position of a complete arch of dental implants has been proven to be challenging. The literature is unclear as to the accuracy of intraoral scanning techniques using SBs that are connected vertically to multi-unit abutments (MUAs) for numerous adjacent implants in the same arch.1 Recently, there has been a paradigm shift from vertical SBs to horizontal SBs which are positioned perpendicular to the long axis of the MUAs. Most IOSs available today can capture these horizontal SBs, called scan gauges (SGs), with better accuracy and consequently acquire the position of multiple adjacent implants using an effective scan path, reducing stitching and the number of images necessary. The key to implementing this novel technology is to strategically arrange the scan gauges to optimize horizontal overlap of multiple adjacent SGs without touching each other. By superimposing two high resolution intraoral scans of the SGs, an artificial intelligence (AI) algorithm is employed to produce a calibrated digital best-fit model on which a passive complete-arch prosthesis can be designed and then fabricated. The advantages and disadvantages of SBs and SGs will be discussed, and a case report will be presented using a digital workflow.

This study aimed to evaluate the periodontal responses of subgingival proximal margins elevated using different restorative materials. One hundred and twenty proximal cavities with dentin/cementum gingival margins were elevated using one of four materials and completed with the same overlaying resin composite, namely resin-modified glass ionomer, glass hybrid, flowable bulk-fill resin composite, or bioactive ionic resin. At varying time points after restoration, including baseline, six months, one, and two years, evaluations included examination of periodontal parameters and the radiographic distance between the restoration margin and bone crest. Appropriate statistical analysis was performed. The values of all periodontal parameters increased with time, although only the increases in plaque index and probing depth over time within each material group were statistically significant. There were no statistically significant differences in any of the periodontal parameters between the different materials within the same evaluation period nor between different time points or material groups in the radiographic distances between the restoration margin and bone crest. Both glass ionomer-based and resin-based materials were periodontally safe as subgingival open sandwich restorations.

The present study aims at assessing the impact on masticatory function of a fixed prosthetic rehabilitation in patients diagnosed with stage IV periodontitis. Eligible participants were adults, in need of complex rehabilitation due to masticatory dysfunction. The masticatory function was evaluated using the two‐colored chewing gum mixing ability test (VOH) at diagnostic phase (T0), one week after the delivery of the prosthetic prototype (T1) and one week after the delivery of the final prosthetic solution (T2). Ten subjects were treated with fixed prosthesis following periodontal and implant surgery using a full-digital individualized workflow. Full mouth plaque score, full mouth bleeding score, pocket depth and clinical attachment level improved significantly. VOH was 0.472±0.168 at T0, 0.358±0.166 at T1, and 0.250±0.123 at T2. A significant improvement in VOH was observed from T0 to T1, difference -0.114; 95%CI -0.199 to -0.029;P=0.014. An improvement in VOH was also observed from T1 to T2, difference -0.108; 95%CI -0.200 to -0.015;P=0.027. The percentage increase in VOH from T0 to T2 was 44.3%. Self-perceived assessment of masticatory function improved from T0 to T2 (P=0.002). The fixed prosthetic rehabilitation in patients with stage IV periodontitis allowed for a significant improvement in objective and subjective measurements of masticatory function.

The aim of this study was to present a periodontal plastic-surgery approach to treat gingival recessions and correct lower incisor mucogingival conditions and deformities. Isolated deep gingival recessions (≥ 3 mm) in the lower incisors (n=24 teeth) were treated: 66.6% of sites were recession type 2/3, and 58.3% of teeth were malpositioned. Recessions were treated using free mucogingival grafts (FMG) harvested from the buccal aspect of donor teeth with altered passive eruption or healthy periodontal support, with <3 mm between the cementum-enamel junction and buccal alveolar crest. Clinical parameters [gingival recession, clinical attachment level, interproximal papilla tip location, keratinized tissue, vestibule depth] and root coverage esthetic score were evaluated at 9 months. FMG significantly reduced gingival recession (p<0.001) and increased keratinized tissue (p<0.001) without loss of vestibule depth (p>0.05). Mean root coverage was 94.37±10.60%, mean residual gingival recession 0.08±0.65 mm and mean root coverage esthetic score 8.9±1.24. Recession types 2/ 3 showed significant interproximal clinical attachment gain (p<0.05). The interproximal papilla was significantly augmented at sites with papilla loss (p<0.001). No donor-site clinical attachment loss (p=0.346) was detected. Our results suggest FMG is a promising approach to root coverage in recession types 1, 2 and 3, correcting mucogingival conditions and deformities, and reconstructing the interproximal papilla.

Aim: To define immunophenotypes of stromal inflammatory and endothelial cells and fibroblasts 3-months post-augmentation of the peri-implant soft tissue using a porcine cross-linked collagen matrix (VCMX). Methods: Peri-implant soft tissue samples were obtained from 12 patients at the lining mucosa (LM) - masticatory mucosa (MM) junction, before and at 3-months post-augmentation. Immunohistochemical stains for identification of inflammatory cells [T (CD3) and B (CD20) lymphocytes, plasma cells (CD138)], macrophages (CD68-pro-inflammatory, CD163-anti-inflammatory/reparative), endothelial cells (CD31, CD34) and fibroblasts (CD90, TE-7), were performed. Differences in the mean positively-stained cells pre- and post-augmentation was analyzed by Wilcoxon Signed-Rank Test. Results: CD31+ endothelial cells showed increased mean numbers in MM2 compared to MM1 (p=0.025) and in LM2 compared to LM1 (p=0.047). CD163+ anti-inflammatory macrophages showed mean numbers in MM2 higher than MM1 (p=0.021) and in LM2 than LM1 (p=0.012). All other cell phenotypes showed insignificant changes between pre- and post-augmentation. Conclusion: This molecular study provided novel insight on the frequency of phenotypes of stromal cells in the wound healing process 3-months post-augmentation with VCMX, with anti-inflammatory CD163+ macrophages being predominant. This should be further investigated in order to find novel therapeutic approaches to modulate and promote the VCMX-related healing process. Keywords: soft tissue augmentation, mucosal thickness, collagen matrix, connective tissue, collagen fibers

Aim: To investigate the dimensional stability and quality of the alveolar ridge augmented using a synthetic bone block (SBB) at damaged extraction sockets. Materials and Methods: Four participants were included in whom socket augmentation was performed using SBB and a collagen membrane. Intraoral scan (IOS) was performed before extraction (baseline), immediately postoperative (IP), and at 6 months (6M). Cone-beam computed tomography (CBCT) was performed at IP and 6M. At 6M, a trephine biopsy was obtained during implant placement and the sample was observed using synchrotron. Profilometric change of soft tissue was measured from the IOS data, hard tissue dimensional change was measured from the CBCT data and the bone quality from synchrotron data. Results: There were minimal changes in the soft tissue profile between baseline and IP, baseline and 6M, and IP and 6M (0.11±1.08 and 0.02±0.8, and -0.65±0.82 mm3). Horizontal bone width measured at 1 mm increments from the augmented bone crest to 5 mm apically revealed only slight reduction (less than 1 mm) at all levels between IP and 6M. The augmented bone height was well maintained from IP until 6M (-0.21±0.53 mm). Synchrotron analysis revealed low to moderate bone quality after 6M (percentage new bone = 16.49±4.91). Conclusions: Augmentation of the damaged extraction socket using SBB is a viable technique, in which the dimensions of the augmented ridge can be maintained up to 6M. Further long term randomized clinical trial is needed. Keywords: alveolar ridge preservation, synthetic bone block, damaged extraction socket

Following implant placement, at healing abutment connection, a soft tissue barrier defined peri-implant mucosa will form. The dimension of this anatomical structure seems to play a key role in maintaining long- term peri-implant and marginal bone level stability. In its early stages, soft tissue healing is a process involving many cellular and molecular events. Enamel Matrix Derivative (EMD) may improve and fasten soft tissue wound healing and inflammatory resolution. In the present split-mouth randomized clinical trial, EMD was used to influence the early phase of soft tissue healing around dental implants placed with a single-stage approach into a completely healed ridge. A total of sixty implants were inserted in thirty patients. In the test group, EMD was administered around the healing abutment before soft tissues were sutured. Soft tissue healing index (HI), together with secondary endpoints (clinical, radiographic and PROMs), was measured. Better outcomes were recorded in patients receiving EMD when considering all parameters. Data here presented supports the use of EMD improve and accelerate soft tissue wound healing around implants.

This technical report describes the simplified subperiosteal sling (SPS) suture for connective tissue graft (CTG) stabilization in root coverage and phenotype modification of single and multiple recession defects via the vestibular incisional subperiosteal tunnel access (VISTA). The simplified SPS suture engages the CTG only and stabilizes it to the tooth in the coronal most position inside the subperiosteal tunnel independent of the overlying gingival tissue. The simplified SPS suture differs from the original SPS suture in that it engages the CTG first, and the needle and tail of the suture are knotted before the suture is introduced into the subperiosteal tunnel. This allows the needle to pass through the subperiosteal tunnel only once from the vestibular access to the intended gingival sulcus. When multiple teeth are treated, only one simplified SPS suture traverses the vestibular access at a time as the CTG is incrementally advanced into the tunnel. This prevents suture entanglement and improves the practical application of the technique.

Numerous surgical techniques have been developed as effective means to facilitate orthodontic treatment, although they may cause significant postoperative discomfort. Piezocision was established as a flapless and minimally invasive technique to accelerate orthodontic tooth movement by combining small vertical incisions and piezoelectric corticotomies. Computed tomography has been combined with the piezocision technique to fabricate computer-aided design and computer-aided manufacturing (CAD/CAM) surgical guides to prevent iatrogenic damage. A method to combine computer-assisted dynamic navigation with piezocision is introduced here. Cone-beam computed tomography was combined with motion-tracking technology to allow real-time tracing of the piezoelectric instruments during the surgical procedure. This technique delivers the location of piezoelectric knife in regard to roots and important anatomical structures to increase the safety and accuracy during corticotimies.

Bone graft materials are often used in implant treatment for optimizing functional and esthetic outcomes. The requirements for bone grafting materials should be that they must be able to maintain space for bone regeneration to occur and must be resorbed by osteoclasts and replaced with new bone tissue occurring in passive chemolysis and bone remodeling. Carbonate apatite (CO3Ap) granules (Cytrans Granules, GC) are chemically synthetic bone graft material that are similar to autologous bone mineral and more biocompatible than allografts and xenografts. The aim of this report is to evaluate the efficacy of CO3Ap granules in implant treatments using CO3Ap granules in combination with autogenous bone or CO3Ap granules separately. This report will show the clinical findings as well as radiographic and histological assessments in three cases of immediate implant placement, lateral GBR and vertical GBR. These results demonstrated, although it was a short-term report, that in histological findings CO3Ap granules were efficiently resorbed and replaced bone in clinical use. Furthermore, the clinical findings showed that CO3Ap granules contributed to maintaining their morphology tissue around the implant. In this limited short-term case report, it was suggested that this bone substitute was effective. However, further clinical studies and long-term reports of this new biomaterial are needed.

The aim of this morphometric study was to precisely determine the three-dimensional characteristics of the root complex of the posterior dentition. Extracted and well-preserved permanent posterior teeth were included in this analysis and grouped based on tooth type and arch location. All teeth were digitally scanned. Morphological and dimensional features of the root complex were assessed, including length and surface area of the root trunk and individual roots, width of root concavities (RC), and furcation entrance, when present. A total of 240 posterior teeth constituted the sample of this study. The root complex of multi-rooted maxillary first premolars presented with a long root trunk (10.49mm), representing 65.52% of the surface area, and two short roots comprising the remaining 34.8% of the surface area. Root trunks of mandibular molars were on average 0.8mm shorter compared to their maxillary counterparts. Class III furcation involvement is expected in all maxillary and mandibular molars as well as multi-rooted maxillary first premolars after 4.80mm and 10.49mm of clinical attachment loss (CAL), respectively. Root concavities were a common finding among the evaluated dentitions. The root complex morphology varies among the maxillary and mandibular posterior dentition. Particularly, the multi-rooted maxillary first premolar presents with unique features exhibiting a long root trunk that encompasses 65% of the root surface area. Root concavities are highly prevalent on both maxillary and mandibular dentition. The findings derived from this study can be utilized in daily clinical practice for the adequate management of posterior dentition and serve as a reference for future investigations in dental anatomy and digital technology. Also, these findings can guide the industry into creating and redefining tools that adequately adapt to the anatomical characteristics and variations of the specific tooth type.

Background: Gingival recession treatment is one of the major clinical challenges in periodontics, various surgical techniques were proposed to correct it. Most of these techniques are suitable for isolated recession sites and involve the harvesting of autogenous tissue graft; which increase patient morbidity and might result in inferior esthetics due to incision design. This study assessed the benefit of adding Platelets Rich Fibrin (PRF) to Vestibular Incision Subperiosteal Tunneling Approach (VISTA) in treating multiple gingival recession compared to using VISTA alone. Forty-one teeth with Miller Class I/II were randomized in a split mouth design. Multiple clinical parameters were tested including the change in gingival thickness over time, keratinized tissue width KTW and the gingival phenotype using the transparency of periodontal probe. Patient-centered outcomes were also assessed via Visual Analogue Scale VAS. Conclusion: Multiple Miller Class 1 and Class 2 recessions in the maxilla can be effectively treated with VISTA. However, when used in conjunction with PRF no significant differences were detected in any parameter. VISTA has been shown to be associated with a low level of pain for patients following surgery and can be used for patients with high esthetic demand. Int J Periodontics Restorative Dent 2023. doi: 10.11607/prd.6536

Background: Multiple adjacent gingival recessions (MAGRs) are commonly treated with autogenous grafts. However, several intra- and post-surgical complications have been described following autogenous grafts, leading clinicians to explore the use of different biomaterials for the treatment of these conditions. The aim of the present study was to evaluate the root coverage outcomes of a novel porcine-derived acellular dermal matrix (PADM) in combination with the tunneled coronally advanced flap (TCAF) for the treatment of MAGRs. Methods: Ten patients with 33 type 1 recession defects (RT1) were treated with PADM, in combination with the tunneled coronally advanced flap (TCAF). The outcomes of interest included the mean root coverage (mRC), the frequency of complete root coverage (CRC), changes in keratinized tissue width, volumetric gain at the treated sites assessed with digital intraoral scanning, as well as patient-reported outcome measures. Results: All treated sites healed uneventfully, and no complications were noted throughout the study. At 6 months, a statistically significant reduction in recession was noted at the treated sites, exhibiting an overall mRC of 89.14 ± 19.15% and a CRC of 72.7%. The average volume gain after 6 months was 26.28 ± 11.71 in mm3 (Vol) and 0.63 ± 0.28 in mm (ΔD). The region-specific volumetric analysis revealed an overall higher linear dimensional gain at the Mid-Root aspect (ranging from 0.72 mm to 0.78 mm when assessed 1-4 mm apical to the cemento-enamel junction) compared to the other regions. Conclusions: The present study presents the clinical and volumetric outcomes of PADM, in combination with TCAF for the treatment of MAGRs. A significant amount of volumetric gain was also observed as a result of the treatment at 6 months, along with satisfactory, esthetic and patient-reported outcomes. Keywords: Gingival recession, Acellular Dermal Matrix, Surgical flap, volumetric analysis, optical scanning

The reconstruction of alveolar ridge defects can be challenging, especially when the lesion is large, non-contained, and located in the esthetic region. The present report describes the guided bone regeneration (GBR) procedure and prosthetic rehabilitation of a severe perforation defect in the anterior maxilla. Clinical and radiographic evaluation of the lesion indicated an endodontic-periodontal origin, and biopsy results confirmed the absence of malignancy. GBR was performed with the use of cortical mineralized freeze-dried bone allograft (FDBA) combined with recombinant human platelet derived growth factor BB (rhPDGF-BB) and a resorbable collagen membrane without the use of tenting or fixation screws. At six months post-GBR, cone beam computed tomography (CBCT) revealed adequate bone fill for the placement of 4.1 x 10 mm or 4.1 x 12 mm dental implants. The implant surgery was fully guided with a two-stage approach. After a ten-month of healing phase, the implants were loaded with a screw-retained porcelain bridge. The staged GBR approach using a combination of FDBA, rhPDGF-BB, and a resorbable membrane without the use of tenting or fixation screws resulted in significant bone fill, successful implant placement, and a functional and esthetic implant-supported prosthesis. Keywords: Alveolar Bone Loss, Bone Regeneration, Dental Implant, Case Report

Successful rehabilitation of severely atrophic, short span edentulous ridges in esthetic can seldom be done without some form of vertical bone augmentation (VRA). The best available evidence shows guided bone regeneration (GBR) procedures may provide a very predictable option with a reduced potential for complications compared to alternative options. The present case series presents a novel technique to achieve predictable VRA with low complication tendency using tenting screws and cross-linked resorbable membranes. Ten patients with severe vertical defects in the esthetic zone participated in this study (5 males and 5 females; mean age of 35y). Following a mean healing time of 9.3 months, the mean defect resolution was 80%, with a mean vertical bone gain was 6.2mm (SD: 1.61 95% CI). Only one case presented with a reduced defect resolution (50%) of the defect, however, the bone gain for this case was 6mm.

Autotransplantation has been proven as a viable method of reconstructing missing teeth. During preparation of the recipient site, the location of bone reduction depends largely on the experience of the surgeon. Inappropriate overpreparation can cause biologic and esthetic complications such as buccal or lingual bone resorption. The aim of this paper is to provide an innovative method to aid clinicians in precisely preparing a recipient site with the assistance of medical image processing software and a real-time navigation system. This case report presents the autotransplantation of a mandibular molar using this technique with good short-term (6 months) clinical outcomes, including radiographic bone fill, normal probing pocket depth, physiologic tooth mobility, acceptable gingival level, and satisfactory restoration.

Background: The idea of minimally invasive non-surgical treatment (MINST) is to remove the etiology with minimal damage to the healthy periodontium and provide the ideal healing environment. In this case series, the novel protocol of laser-assisted minimally invasive non-surgical therapy (LAMINST) is introduced that combines the benefit of minimally invasive and the dental laser to maximize the therapeutic potential. Method: 25 patients (32 teeth) with advanced periodontal disease have enrolled in the study. All the patients have received periodontal treatment by following the laser-assisted minimally invasive non-surgical therapy protocol. Treated sites were evaluated by comprehensive Periodontal examination at the baseline and 6-month re-evaluation, including probing depth (PD), Recession, clinical attachment level (CAL), bleeding on probing (BOP), presence of plaque, and mobility. The diagnosis and prognosis of each tooth were assigned based on the Periodontal evaluation. Result: All the cases were diagnosed as Stage III and Grade C Periodontitis according to the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. The average probing depth reduction 6 months after completion of LAMINST was 4.44 mm and improved clinical attachment level by 4.38mm. There was the mobility of 1 (6 teeth), 2 (9 teeth), and 3 (3 teeth) in the beginning, and all of them decreased to 1 (5 teeth) or none (13 teeth). The prognosis was assigned based on McGuire and Nunn's system. The initial prognosis for teeth was assigned to hopeless (5) (15 teeth), questionable (4) (13 teeth), poor (3) (4 teeth), and it has improved to questionable (5 teeth), poor (12 teeth), fair (13 teeth), and good (2 teeth). Initially, there were 179 BOP sites. After treatment, it decreased to 12 sites. The plaque was found in 173 sites before the treatment and has reduced to 9 sites after the treatment. Conclusion: All clinical parameters such as PD, CAL, BOP, presence of plaque, and mobility are improved by receiving the laser-assisted minimally invasive non-surgical therapy protocol. The application of LAMINST may overcome the traditional limitation of non-surgical treatment, such as poor accessibility.  

The primary aim of this study was to evaluate the efficacy of alveolar ridge preservation (ARP) therapy compared with unassisted socket healing (USH) in attenuating interproximal soft tissue atrophy. Adult subjects that underwent maxillary single-tooth extraction with or without ARP therapy were included in this study. Surface scans and cone beam computed tomography were obtained to digitally assess interproximal soft tissue height changes and measure facial bone thickness (FBT), respectively. Logistic regression models were conducted to investigate the individual effect of demographic and clinical variables. Ninety-six subjects (USH=49; ARP=47) constituted the study population. Linear soft tissue assessments revealed a significant reduction of the interproximal soft tissue over time within and between groups (P<.0001). ARP therapy significantly attenuated interproximal soft tissue height reduction compared to USH (USH mesial: -2.0±0.9mm vs. ARP mesial: -1.0±0.5mm / USH distal -1.9±0.7mm vs. ARP distal: -1.1±0.5mm; P<.0001). Thin FBT (≤1mm) upon extraction was associated with greater interproximal soft tissue atrophy compared with thick FBT (>1mm), independently of the treatment received (P<.0001). Nevertheless, ARP therapy resulted in better preservation of interproximal soft tissue height especially in thin bone phenotype by a factor of 2 for the mesial site (+1.3mm) and a factor of 1.6 (+0.9mm) for the distal site. This study demonstrated that ARP therapy largely attenuates interproximal soft tissue dimensional reduction after maxillary single-tooth extraction compared with USH. Keywords: tooth extraction, bone resorption, alveolar ridge preservation, digital image processing, dental implants

Objective: The introduction of a new collagen substitute, that potentially will reduce the invasiveness of the two techniques, by avoiding the need for a second surgical site, i.e., the donor site, need to be evaluated in relation with the surgical procedure that could benefit the most by the utilization of such a matrix. The aim of this study was to compare the clinical outcomes following treatment of RT 1 multiple adjacent gingival recessions (MAGRs) using the modified coronally advanced tunnel technique (MCAT) or the multiple coronally advanced flap (MCAF) in conjunction with a new volume stable xenogeneic collagen matrix (VXCM). Secondarily, the study evaluated whether patients report a preference in terms of discomfort between the two surgical techniques. Methods: Twenty patients requiring treatment of MAGRs were randomly assigned to one of the two treatment groups (group A: MCAF+VCMX; group B: MCAT+VCMX). The following measurements were recorded at baseline (i.e. prior to surgery), at 6 and 12 months: gingival recession depth (REC), probing pocket depth (PPD), keratinized tissue width (KTW) and gingival thickness (GT). Post-operative pain and discomfort were recorded using a visual analogue scale (VAS) at 1 week. The primary outcome variable was mean root coverage (mRC), secondary outcomes were complete root coverage (CRC), change in KTW and GT, patient discomfort and satisfaction, and duration of surgery. Results: Healing was uneventful in both groups. At 12 months, both treatments resulted in statistically significant improvements of REC and GT compared with baseline (p < 0.05). The mRC measured 79.95 ± 29.92% at MCAF group, whereas 64.74 ± 40.5% MCAT group (p = 0.124). CRC was found at 65.6% of MCAF-treated sites and at 52% of MCAT-treated sites (p=0.181). Conclusions: Similar clinical results should be expected when MAGRs are treated with MCAF or MCAT, with the adjunct of VCMX.

This retrospective study evaluated the clinical outcomes of surgical crown reattachment in the treatment of complicated crown-root fractures in permanent teeth of 35 patients. Treatments were defined as follows: surgical crown reattachment combined with internal fixation with a fiber-reinforced core post, ostectomy, and reattachment of the original crown fragment. Patients were examined to record the periodontal pocket depth (PD), marginal bone loss, tooth migration, and coronal fragment looseness or loss. In most cases, the fracture lines on the palatal aspect were located below the alveolar crest. About 20% to 30% of teeth had periodontal pockets ≥ 3 mm present at least 1 year after surgery. Significant PD differences were observed between the traumatized teeth and adjacent untraumatized teeth at 6 months. The available evidence suggests that surgical crown reattachment is a feasible and effective technique for managing complicated crown-root fractures in permanent teeth.