Quintessence International, 05/2016

Objective: Dental erosion is a challenging problem. In addition to dental erosion's dental effects, general health also has to be taken into account. In particular, consumption of newly marketed beverages as well as psychosomatic and gastroesophageal disorders contribute to decayed dentitions. Without a comprehensive method for implementing preventive concepts in daily practice, many young adults will require large-scale, long-term treatment in the near future. Thus, dentists should be aware of preventative methods, prerequisites for rehabilitation, and treatment concepts available for such cases. Clinical Considerations: Patients with severe dental erosions are often young adults who suffer from hypersensitivity and loss of vertical dimension and occlusal structure. Modern ceramics enable a minimally invasive, esthetic, and rugged approach for achieving a complete rehabilitation. In particular, monolithic restorations using lithium disilicate or zirconia-reinforced lithium silicate seem to be promising treatment strategies. In addition to the dentist, the dental technician needs to be educated and experienced with complex occlusal and functional rehabilitation. Currently, clinical longterm experiences have only been reported for adhesively bonded silicate and lithium disilicate restorations. Conclusion: Heat-pressed and adhesively bonded monolithic lithium disilicate restoration fulfills all needs of complex treatment and long-term rehabilitation in young adults with dental erosion. Even if minimal tooth preparation is needed, in healthy teeth, adhesively bonded restorations require minimal thickness of the ceramic layer to obtain function, durability, and esthetics for this type of patient. Keywords: case report, complex rehabilitation, fixed restorations, in-vivo

Objectives: There are no data comparing coronal leakage of teeth prepared to different apical sizes and obturated with gutta-percha and sealer. The aim of this study was to investigate the effect of apical preparation size on the leakage of obturated root canals. Large apical openings are encountered as a result of pulp necrosis in immature teeth, apical resorption, or over-enlargement of the apical foramen. Complete cleaning, shaping, obturation, and apical seal of root canal systems are essential for the success of root canal treatment. Method and Materials: One hundred twenty-five extracted human teeth were divided into groups containing 25 samples each and prepared to apical file sizes 30, 40, 50, 60, and 70. Twenty teeth served as positive and negative controls. Obturation was completed with gutta-percha and sealer via warm vertical compaction. Bacterial leakage was investigated after 112 days using Proteus vulgaris. Data were analyzed via independent-samples Kruskal-Wallis test. Results: The average time for leakage of apical preparation sizes 30, 40, 50, 60, and 70 were 57.5, 52.4, 47.2, 37.5, and 28.4 days, respectively. Significant differences in leakage were observed between apical preparation sizes 70 versus 30, 70 versus 40, 70 versus 50, as well as 60 versus 30. A trend for more leakage occurred when apical preparation sizes exceeded size 60. Conclusions: Based on these results, it appears leakage of gutta-percha and sealer as obturation materials increases when apical preparation size exceeds 60. Consideration should be given to using sealing materials other than gutta-percha and sealer when the apex size exceeds 60. Keywords: bacterial leakage, gutta-percha, microleakage, open apex, Proteus vulgaris, trauma

Objective: To test the effectiveness of nonsurgical and surgical treatment methods for clinical and radiographic peri-implantitis symptoms resolution with respect to pocket probing depth (PD), bleeding on probing (BOP), and marginal bone-loss reduction (RBL); to propose guidelines for managing peri-implantitis. Method and Materials: An electronic literature search was conducted of the MEDLINE and EMBASE databases for articles published between 2002 and 2015. Sequential screening at the title/abstract and full-text levels was performed. Clinical human studies in the English language that had reported changes in PD and/or BOP and/or radiologic marginal bone level (RBL) changes after peri-implantitis treatment at 6-month follow-up or longer were included. A meta-analysis was performed using the random-effects model on the selected qualifying articles. Results: The search resulted in 29 articles meeting the inclusion criteria. The meta-analysis demonstrated improved BOP values (P = .001; OR = 1.567; 95% CI, 1.405 to 1.748) after the nonsurgical treatment but did not reveal a statistically significant difference in the PD changes (P = .8093; standardized mean difference [SMD] = 0.346 mm; 95% CI, 0.181 to 0.512). There was a significant improvement in PD (P .001; SMD = 1.647 mm; 95% CI, 1.414 to 1.880) and BOP values (P .001; OR = 4.044; 95% CI, 3.571 to 4.381) after surgical treatment and an intrabony defect fill was found to be 1.66 mm (1.0) using a regenerative treatment modality. Our meta-analysis confirms there is a significant reduction in RBL after nonsurgical (P = 0.037; SMD = 0.157 mm; 95% CI, −0.183 to 0.496), resective (P = .0212; SMD = −0.116 mm; 95% CI, −0.433 to 0.201), and regenerative (P = .0305; SMD = 1.703 mm; 95% CI, 1.266 to 2.139) surgical treatment. A novel complex management and maintenance (CMM) six-step protocol is thus suggested for treatment of peri-implantitis. Conclusion: Regenerative surgical treatment of peri-implantitis was found to be most effective. A novel six-step protocol aimed at managing patients with peri-implantitis can be a useful tool in peri-implantitis treatment. Keywords: peri-implantitis, review, treatment, therapy

Objective: The purpose of this systematic review was to compare the survival and complication rates of all-ceramic restorations after a minimum follow-up time of 5 years. Data Sources: A comprehensive search of studies published from 2005 to November 2015 and listed in the PubMed/MEDLINE, Scopus, and Cochrane Library databases was performed in accordance with the PRISMA statement. Two reviewers independently analyzed the abstracts. Relevant studies were selected according to predetermined inclusion criteria. Results: Twenty-nine studies were selected for the final analysis from an initial yield of 514. Only four studies fulfilled the requirement of having a randomized design, and 25 studies were prospective with a mean follow-up period of 5 to 16 years. Overall, the 5-year complication rates were low. The most frequent complications were secondary caries, endodontic problems, ceramic fractures, ceramic chipping, and loss of retention. Conclusion: This systematic review showed that all-ceramic restorations fabricated using the correct clinical protocol have an adequate clinical survival for at least 5 years of clinical service with very low complication rates. Minor ceramic chipping and debonding did not affect the longevity of the restorations. Clinical Relevance: Long-term clinical performance of all-ceramic restorations manufactured using various ceramic systems provides clinical evidence of complications and long-term management of these restorations. Available evidence indicates the effectiveness of many ceramic systems for numerous clinical applications. Correct planning and a rigorous technical execution protocol increase clinical success. Studies of ceramic prostheses indicate more problems with ceramic failure and debonding. Keywords: dental ceramic, failure, restorations, systematic review

Objective: A papilla preservation crown-lengthening procedure (PPCL) was proposed for treatment of the maxillary anterior teeth (canine to canine) and compared to two traditional techniques. Method and Materials: Thirty patients were assigned to three treatment groups: PPCL, the apically positioned flap with buccal approach (APF-B), and the apically positioned flap with buccal and palatal approach (APF-BP). Several clinical parameters were recorded at baseline and 6 months after surgery. Results: Although no statistically significant differences were reported in many of the clinical parameters examined, APF-B and APF-BP showed a significantly higher interproximal clinical attachment loss when compared to PPCL. In the PPCL group, there was a significant increase in esthetic appraisal by the patients. Conclusion: Crown lengthening using a papilla-preservation flap approach and osseous recontouring is a viable alternative approach and could be useful in esthetic regions. Keywords: anterior esthetic, apically positioned flap, osseous resection, papilla preservation, surgical crownlengthening

Although dental implants are proven to be a predictable longterm treatment for patients, it is important to realize that not all implants that survive are necessarily successful. Successful implants are those that remain fully functional and healthy within the oral cavity. Peri-implantitis is a disease that is associated with implant failure, and is becoming rather prevalent. Assessing risk factors and stabilizing existing oral disease prior to the placement of implants will aid in preventing implant disease and failure. After implant placement, a strict follow-up regime with a dental professional should be implemented in order to monitor the implant and surrounding teeth for disease. The dental professional should continually encourage the patient to adhere to consistent homecare to prevent peri-implantitis from occurring, and in turn increase the success of their implants. Early diagnosis and elimination of inflammatory processes around the implants will improve the longterm prognosis as well. Keywords: bone, bone loss, gingival health, implant, plaque, survival

Mucosal fenestrations are rarely encountered in clinical practice, and as such their management is not often reported. Their treatment might be further complicated due to a communication with the oral environment, making them more susceptible to accumulation of debris, plaque, and calculus, thereby reducing the probability of mucosal renewal. The aim of the present case report is to highlight one such rare clinical scenario and its apt and effective management. Surgical management of an uncommon presentation of concomitant gingival recession with an isolated mucosal fenestration in an atypical location, with an allograft matrix is presented here with 2 years' follow-up. A review of the literature reveals no previous application of AlloDerm graft for the management of a similar situation. Keywords: AlloDerm, coronally positioned flap, gingival recession, mucosal fenestration, root coverage

Objective: Medication-related osteonecrosis of the jaw (MRONJ) is a commonly reported side effect of antiresorptive drugs prescribed for osteoporosis. Oral bisphosphonates (BPs) are the most frequently administered antiresorptive drugs for osteoporosis, but because of low compliance of the patients with this treatment, which may require weekly or monthly administration, a new formulation (once a year) of zoledronic acid for intravenous infusion has been recently introduced. Although MRONJ has been repeatedly reported in oncologic patients treated with multiple infusions of zoledronic acid, to date MRONJ occurring in patients undergoing once-a-year infusion of zoledronic acid for osteoporosis has been described very rarely. The aim of this study was to report our experience with eight such patients. Method and Materials: Eight osteoporotic female patients came to our attention for intraoral necrotic bone exposures with subsequent diagnosis of MRONJ; they had a history of long-term oral antiresorptive therapy but soon developed MRONJ after the shift to once-a-year infusion of zoledronic acid. Consequently, the patients firstly underwent prolonged antibiotic therapy, then surgical removal of the necrotic bone was performed. Results: Following antibiotic and surgical treatments, all the patients healed without complications or recurrence. Conclusion: These cases suggest that, although rare and not yet well documented, MRONJ related to yearly infusion of zoledronic acid may occur in association with significant morbidity and should not be overlooked by either medical or dental clinicians. Keywords: medication-related osteonecrosis of the jaw, oral bisphosphonates, osteoporosis, zoledronic acid

Objective: The purpose of this study was to compare periapical radiographs (PA) and panoramic radiographs (PAN) in the measurement of proximal bone height around implants. Method and Materials: Patients files that contained digital PAN and PA together with information on implant lengths and diameters were selected for this study. For each radiograph, the implant size served as reference for calibration. Proximal radiographic bone levels and the linear distance between the bone crest and implant shoulder were measured twice by one examiner. Paired t test was used to assess intra-examiner variability and differences between the two radiographic methods. Correlation was then assessed using Pearson correlation coefficient test. Significance level was determined at 5%. Results: For the PAN measurements, the median mesial distances from bone crest to implant shoulder were 0.53 and 0.56 mm (first and second sets, P = .53). Likewise, for distal measurements these readings were 0.92 and 0.86 mm respectively (P = .66). For PA measurements, the corresponding measurements were 0.33 and 0.44 mm (P = .48) and 0.99 and 0.99 mm (P = .42), respectively. When PAN and PA measurements were compared, no statistically significant differences were detected between the two radiographic modalities. A very high positive correlation (r > 0.91) was attained for the PAN - PA measurements (P .0001). Conclusion: PAN are potentially as reliable and reproducible as PA for the assessment of proximal bone height around dental implants. Keywords: accuracy, dental implants, imaging, panoramic, periapical, radiography