Quintessence International, 07/2022

Preservation and restoration of teeth with little coronal tooth structure due to crown-root fractures or caries lesions, ensuring restoration margins do not encroach on the biologic width, constitute a challenge. Available treatment options include surgical crown lengthening and orthodontic or surgical extrusion. This report presents two patients in which teeth were restored by surgical extrusion with an atraumatic extraction system and prosthetic therapy. Keywords: atraumatic extraction system, atraumatic extrusion, biologic width, ferrule effect, surgical extrusion, tooth fracture

Objectives: Vitamin C (ascorbic acid) is widely used in dermatology for skin depigmentation. However, there are very few clinical studies on the efficacy of vitamin C in gingival depigmentation. This preliminary case series aims to present the clinical effectiveness, histologic changes, and patient-reported outcomes of intra-epidermal vitamin C injections (oral mesotherapy) for managing patients with gingival melanin hyperpigmentation. Method and materials: Five patients were administered locally injectable vitamin C (once per week for 4 to 5 visits) in maxillary or mandibular anterior pigmented gingiva. The depigmentation effect was evaluated using the Dummett Oral Pigmentation Index (DOPI) and Gingival Pigmentation Index (GPI). Digital photographs were used to assess gingival luminescence (L*) and pigmented surface area (PSA). Parameters were recorded at baseline and at 1 and 3 months. Melanocyte histopathologic count was determined at baseline and at 3 months. Pain, gingival color change, and patient satisfaction scores were also assessed. Results: Median GPI, DOPI, and PSA were significantly reduced (P ≤ .05) from baseline to 1 month. There was no statistically significant change from 1 month to 3 months. L* value significantly increased from baseline to 3 months. A median pain score of 3 (scale of 0 to 10) was observed on the day of the procedure. A score of 3 (scale of 0 to 4) was reported for the gingival color and scores 3 and 4 (scale of 0 to 4) for the overall patient satisfaction. Conclusion: Oral mesotherapy using locally injectable vitamin C is a nonsurgical, minimally invasive, and efficient technique for gingival depigmentation. Indian patients were satisfied with the gingival color obtained and the overall treatment experience. Clinical importance: As all the branches of medicine, specifically dentistry, direct to minimally invasive approaches, mesotherapy shows great importance to reduce the surgical interventions, especially when esthetic outcomes are needed. Oral mesotherapy using locally injectable vitamin C can be a useful nonsurgical technique for achieving gingival depigmentation in the esthetic zone. Keywords: ascorbic acid, gingiva, hyperpigmentation, melanin, oral mesotherapy

Objective: To describe a procedure that uses a definitive BioHPP hybrid abutment (polyether ether ketone [PEEK] reinforced with ceramic nanoparticles), to obtain a hermetic mucous seal with the peri-implant soft tissues. Method and materials: Between July 2017 and December 2019, seven patients aged between 40 and 60 years, who needed prosthetic rehabilitation in the esthetic zone, were treated. Among the various therapeutic solutions offered, patients chose an immediate or conventional implant rehabilitation using the “one abutment–one time” technique with the hybrid SKY elegance implant abutment (bredent medical). Ten implants were placed, five with immediate loading including two postextraction, and five in a conventional/classic loading protocol. The protocol required that the finishing margin of the provisional restoration was positioned approximately 1 to 2 mm from the implant platform, allowing the tissues to heal around the ceramic-reinforced PEEK abutment. After 6 months for the implants with immediate loading, and 3 months for those with conventional loading, the provisional restorations were replaced with definitive zirconia-ceramic prostheses. Results: The clinical evaluation on the 10 implants showed that the reinforced PEEK abutments integrated well with the peri-implant tissues, and were healthy, without plaque, and with no bleeding on probing. An average probing depth of 1.0 mm was observed for nine of the ten placed implants, and for the tenth the implant probing depth was 1.5 mm. Conclusions: The ceramic-reinforced PEEK abutments BioHPP SKY elegance associated with the one-time therapeutic protocol is a valid alternative to traditional implant loading procedures, leading to an effective peri-implant hermetic mucous seal. (Quintessence Int 2022;53:590–596; doi: 10.3290/j.qi.b3082565; Originally published (in Italian) in Quintenssenza Internationale 2021;35:48–57) Keywords: BioHPP, hybrid abutment, immediate implant, implant in the esthetic zone, one-time protocol, peri-implant tissue

Objective: To investigate the possible reduction in the need for dental general anesthesia through nitrous oxide sedation in combination with behavior management techniques among patients younger than 12 years of age referred to a specialized pedodontics practice due to high dental treatment need and poor cooperation with dental treatments. Method and materials: Retrospective analysis of the digital medical records of all children treated under nitrous oxide sedation in a specialized pedodontics clinic between 2012 and 2017 was performed. The reduction of the need for dental general anesthesia was measured depending on the success rate of nitrous oxide sedation at the patient level with relation to multiple related factors such as age, reason for referral, and treatment need. Results: Nitrous oxide was used in 406 dental treatment sessions on 228 pre-cooperative and/or anxious patients aged 3 to 12 years (mean 6.4 ± 1.7; 43.4% female); 91.9% of the nitrous oxide sedation sessions were successful in achieving the intended dental treatment. Complete oral rehabilitation was possible for 84.0% of the patients using nitrous oxide sedation without the need for dental general anesthesia. Regarding age, dental general anesthesia reduction among preschool children was lower than school children (77.8% and 87.9%, respectively). Conclusion: A high proportion of anxious or semi-cooperative children with high dental treatment need can be treated without the use of dental general anesthesia when a comprehensive concept of caries management is combined with the use of nitrous oxide sedation and behavior management techniques. Nitrous oxide sedation should therefore be considered as an option for dental treatment of semi-cooperative children with high dental treatment need before planning dental general anesthesia. Keywords: dental general anesthesia, nitrous oxide, pediatric dentistry, sedation, success rate

This case report presents a novel approach for minimally invasive fully guided apicoectomy of the palatal root of a maxillary first molar using a custom-made 3D-printed template. To date, the development of diagnostic radiographic tools such as high-resolution CBCT devices, as well as of CAD planning software and CAM technologies, like 3D printing, allow for increased application in endodontics. The patient (a 38-year-old woman) suffered from pain on the right side of the face since 4 weeks and was diagnosed with chronic apical periodontitis of the palatal root of the maxillary right first molar. The root treatment of this tooth was followed up recently and the buccal roots showed no pathologic findings. A guided apicoectomy with access from the palate was chosen as elective therapy. 3D radiographic and intraoral surface datasets were imported into an implant planning software and superimposed, and minimally invasive access to the palatal root apex was planned. Subsequently, a tooth-supported drilling template was designed and created by additive manufacturing. A flapless approach was adapted using a punch-drill and the access to the root apex as well as the apical resection were performed with a trephine drill. The connective tissue punch was finally replaced and sutured. No postoperative complication was reported and a complete remission of symptoms was reported after 2 weeks. The follow-up after 21 months showed clinically stable wound conditions and radiologically a slight reossification in the area of the palatal root tip. The presented technique may lead to novel minimally invasive approaches for the preservation of infected maxillary molars. Keywords: CAD/CAM, digital planning, drilling template, guided apicoectomy, guided surgery, 3D printing

Objective: The objective of this systematic review was to evaluate the risks of medication-related osteonecrosis of the jaw (MRONJ) in fibrous dysplasia (FD) and McCune-Albright syndrome (MAS) patients treated with bisphosphonates. Method and materials: A systematic review of the literature was performed by searching PubMed and Embase databases using MeSH terms (fibrous dysplasia of bone, “fibrous dysplasia, polyostotic,” osteonecrosis, jaw, therapeutics, diphosphonates, denosumab, teriparatide, estrogens, hormones, raloxifene hydrochloride, calcitonin, cathepsin K) and non-MeSH terms (antiresorptive therapy, antiresorptives, bisphosphonate, estrogen therapy, hormone therapy, bazedoxifene, cathepsin K inhibitor). Articles were limited to human studies, in English language, in which patients were on antiresorptives for at least 1 year. PRISMA statement guidelines were used to eliminate non-relevant studies. The PICOT question asked was, “Does exposure to bisphosphonates and other antiresorptives cause occurrence of MRONJ in fibrous dysplasia and fibrous dysplasia/McCune-Albright syndrome patients followed up for at least 1 year?” Results: Eight eligible articles were included in the quantitative synthesis after articles were screened using a PRISMA flowchart. There were 12 reported occurrences of MRONJ among a combined total of 312 fibrous dysplasia and fibrous dysplasia/McCune-Albright syndrome patients (3.85%). Conclusion: Patients with fibrous dysplasia or fibrous dysplasia/McCune-Albright syndrome have a low incidence of MRONJ and may apparently have low susceptibility to spontaneous development of MRONJ. Keywords: antiresorptives, bisphosphonate, estrogen, fibrous dysplasia, hormone therapy, jaw osteonecrosis, McCune-Albright syndrome, raloxifene

This case report describes the rare occurrence of an epidermoid tumor compressing the ipsilateral trigeminal nerve resulting in secondary trigeminal neuralgia. MRI is the imaging modality of choice for the diagnosis of secondary trigeminal neuralgia. The epidermoid tumor was discovered by an orofacial pain specialist after reassessing the MRI study, previously reported as normal. Clinicians encounter a diagnostic dilemma when the clinical picture is not consistent with the MRI reports, clinical presentation, and expected results of treatment. The reassessment of the MRI and discovery of the epidermoid tumor resulted in a prompt referral to a neurosurgeon with a successful treatment outcome. Keywords: diagnostic procedure, neoplasm, pain, radiography, surgical procedure, trigeminal

Bite force (occlusal force) may play a significant role in patient treatment outcomes. However, as a diagnostic risk assessment tool, it has been examined in the literature but is not commonly utilized by practicing clinicians and in academic studies. This diagnostic evaluation may assist the dental clinician in planning tooth- and implant-supported restorations, as damage to the tooth, implant, or restoration may be dependent upon a restoration’s resistance to loading conditions. The overall bite force has been estimated to be up to 2,000 N, with a clear sexual dimorphism and age dependence. The magnitude of these forces along the dental arch have been shown to be elevated in the posterior compared to the anterior region. The bite force magnitude has been inversely related to the proprioception, as a significant increase in bite force is seen in patients with endodontically treated teeth as compared to their vital teeth. Bite force has been linked to chewing efficiency, quality of life, and implicated in the life expectancy of the restorations. Restoration life expectancies have been associated with the material selection and preparation design parameters, both of which may be affected by masticatory bite force. Treatment planning criteria for preparation strategies affected by bite force include tooth location, material selection, occlusion pathways, and subsequent occlusal reduction amounts. When implants are used in patients with elevated magnitude of bite force, an increase in the number and diameter of the implants as well as occlusions with reduced occlusal tables buccolingually and lighter contacts may be recommended. An understanding of the magnitude and load of a patient’s bite force can assist the dental clinician in the design of dental treatments along with other standard risk assessment criteria. Keywords: dental prostheses, failure, occlusal force, occlusal load, restoration