International Journal of Periodontics & Restorative Dentistry, 06/2020

When it comes to complete root coverage of exposed root surfaces, several limiting factors have been suggested. Although tooth malposition and papillae dimension are capable of influencing root coverage, they have not received sufficient emphasis in the literature. Therefore, the aim of the present commentary is to discuss the impact of tooth malposition and papillae dimension on rootcoverage outcomes. This commentary combines evidence from the literature with the authors' experience. Limited evidence is available in the literature regarding the influence of tooth malposition on root-coverage outcomes. Severe buccal displacement and tooth extrusion and/or rotation may limit the amount of achievable root coverage, and the cementoenamel junction should no longer be considered the landmark for root coverage in these cases. The relationship between papillae dimension and root coverage has been tested in different clinical conditions and by applying different root-coverage approaches, thereby resulting in contradictory outcomes. The clinical experience of the authors suggests that having wider papillae is advantageous for coronally advanced flap and tunnel flap preparations and connective tissue graft stabilization. Although scientific evidence and the authors' clinical experience suggest that papillae dimension can play a major role in determining the surgical management of soft tissues and the amount of achievable root coverage, further studies are necessary to evaluate to which extent papillae dimensions contribute to treatment outcomes.

This investigation was designed to evaluate the reestablishment of bone-toimplant contact on infected dental implant surfaces following decontamination with an erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) laser and reconstructive therapy. Three patients presenting with at least one failing implant each were enrolled and consented to treatment with the Er,Cr:YSGG laser surface decontamination and reconstruction with a bone replacement allograft and a collagen membrane. The laser treatment was carried out at a setting of 1.5 W, air/water of 40%/50%, and pulse rate of 30 Hz. At 6 months, all three patients returned for the study. En bloc biopsy samples of four implants were obtained and analyzed. Two patients had excellent clinical outcomes, while one patient with two adjacent failing implants experienced an early implant exposure during the follow-up period. There was histologic evidence of new bone formation with two implant specimens and less bone gain with the others. Despite the small sample size, these were optimistic findings that suggested a positive role of Er,Cr:YSGG laser in debridement of a titanium implant surface to facilitate subsequent regenerative treatment. This investigation provides histologic evidence as well as encouraging clinical results that use of the Er,Cr:YSGG laser can be beneficial for treatment of peri-implantitis, but further long-term clinical studies are needed to investigate the treatment outcome obtained.

This study presents the histomorphometric results of the Wafer Technique, which is based on guided bone regeneration and onlay grafts for 3D bone augmentation. This two-stage technique utilizes autogenous cortical bone plates and collagen membranes, forming a barrier containing a mixture of deproteinized bovine bone matrix, autologous blood, and bone grafted from intraoral sites. Twelve patients were treated. At 6 months postsurgery, histologic analysis of the regenerated areas revealed the presence of compact newly formed bone with no sign of inflammation. The percentages of new bone and native bone (mineralized tissue) were 16.4% (95% CI: 9.5% to 23.2%) and 42.6% (95% CI: 28.2% to 57.0%), respectively. Twenty-five implants were placed. The procedure has been proven to be safe and reliable, and only one transient complication was observed.

Pterygoid implant placement has not been a common treatment modality to manage the atrophic posterior maxilla. This randomized, controlled clinical trial evaluated the accuracy of dynamic navigation using trace registration (TR) technology in pterygoid implant placement when compared to free-hand surgery. Partially edentulous patients requiring at least one pterygoid implant to rehabilitate the atrophic posterior maxilla were included. Implant accuracy (in a prosthetically directed context) and the relation of the placed implants to the greater palatine canal (GPC) were evaluated using EvaluNav to compare the preoperative CBCT plan with the postoperative CBCT implant location. Osseointegration success, mucosal thickness, implant length, time spent for surgical placement, and ease of prosthetic restorability via degree of multi-unit abutment angulation were assessed. A total of 63 pterygoid implants were placed (31 using TR, 32 using free-hand) in 39 partially edentulous patients. Mean deviations between the planned and actual position for TR-placed implants were 0.66 mm at the coronal level, 1.13 mm at the apical level, 0.67 mm in depth, and 2.64 degrees of angular deviation, compared to 1.54 mm, 2.73 mm, 1.17 mm, and 12.49 degrees, respectively, for free-hand implants. In relation to the GPC, TR implants were more accurate when compared to the presurgical plan and took less surgical time. The mean mucosal thickness measured for all implants was 5.41 mm. Most implants were 15 to 18 mm long, and most prostheses (92%) could be accommodated by a 17- or 30-degree multi-unit screw-retained abutment. TR implants had greater short-term osseointegration success rates than free-hand implants (100% vs 93.75%). Pterygoid implant surgery can be a predictable and successful modality for prosthetically directed implant rehabilitation in the atrophic posterior maxilla, is more accurate than free-hand surgery, and takes less time when using dynamic navigation via TR.

The fusion of orthodontic treatment and periodontal tissue–regeneration therapy has attracted attention. However, regenerated bone has a higher density than physiologic bone, which may cause problems including root resorption or stagnation of orthodontic movement. Therefore, the optimized periaodontal regeneration for orthodontic movement (O-PRO) approach was developed with the aim of regenerating periodontal tissues with sparse bone quality. Unlike conventional methods, this concept is specifically suited for orthodontic movement. A new classification for the preoperative evaluation of periodontal tissues was also devised, and results are reported from cases where orthodontic treatment was implemented using each type of O-PRO method.

Several techniques involving the harvesting of a soft tissue graft from the palate have been proposed for regenerating keratinized mucosa (KM) at implant sites. However, patient morbidity and poor esthetic outcomes are considered the main drawbacks of these approaches. Therefore, the aim of this study was to describe and evaluate a new technique for harvesting keratinized tissue from the adjacent labial site (labial gingival graft [LGG]), in combination with a xenogeneic collagen matrix (XCM) or a connective tissue graft (CTG). Eighteen patients were enrolled and participated in this case series. The primary outcomes were KM gain after 12 months and patient-reported satisfaction, esthetics, and morbidity using a visual analog scale (VAS). All treated sites healed uneventfully, showing a mean KM gain of 6.8 ± 2 mm. The average VAS score for patient satisfaction and the self-reported esthetic outcomes were 95.6 ± 6.9 and 93.4 ± 9.2, respectively, and the score for morbidity was 22.8 ± 22.3. However, the VAS score for morbidity dropped to 8.7 ± 8.4 when CTG-treated subjects were excluded. Higher esthetic results were observed when XCM was used instead of CTG and when LGG was harvested from the anterior region of the implant site (P < .05 for both comparisons). LGG with XCM or CTG is a viable technique for regenerating KM at implant sites with high patient satisfaction and esthetics and low morbidity outcomes.

The World Health Organization (WHO) declared COVID-19 a pandemic on March 11, 2020. SARS CoV-2, the virus that causes COVID-19, has shown the ability to become aerosolized with a potential airborne route of transmission. Dentists and dental hygienists are listed as two of the occupations in a nonhospital setting with the greatest risk of contracting the SARS-CoV-2 virus, as routine dental procedures involve aerosol generation. In a statement on interim guidance, WHO recommended that all routine dental procedures be delayed until COVID-19 transmission rates decrease from community transmission to cluster cases and until the risk of transmission in a dental office can be studied and evaluated. This prospective study involves 2,810 patients treated over a 6-month period (March 15 to September 15, 2020) in three different dental offices by two dentists and three hygienists during and shortly after the height of the pandemic in New York. By utilizing screening questionnaires, performing enhanced infection control, and having appropriate personal protective equipment, these dental offices were able to record no transmission of COVID-19 to the dental healthcare workers or patients during the study. In addition, 69% of the patients treated in these dental offices were recorded as having one or more high-risk comorbidities related to COVID-19 severity.

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.

This article aims to evaluate the effect of anatomically designed, single-unit provisional restorations on soft tissue preservation following immediate implant placement. Patients in need of a single-tooth replacement in the esthetic area were recruited for this study. An immediate provisional restoration with a transmucosal area anatomically designed to support the soft tissue was used for every patient. The horizontal volumetric tissue changes and the presence and amount of vertical recession were measured at baseline (T0) and after 1 month (T1), 3 months (T2), and 6 months (T3). Sixty-three patients received 66 implants that were placed into fresh extraction sites. The average follow-up time was 48 months (range: 24 to 60 months). All implant restorations were successful, and the cumulative implant survival rate and success of restorations was 100%. After 6 months, the mean horizontal ridge measured midbuccally had increased by 0.10 ± 0.10 mm at 1 mm from the free gingival margin, had decreased by 0.09 ± 0.10 mm at 3 mm, and had decreased by 0.20 ± 0.10 mm at 5 mm. In addition, the mean recession at the midbuccal surfaces was 0.04 ± 0.37 mm. Measurements were made clinically and compared to measurements made on the casts. According to the results of this study, the use of customized anatomically designed immediate provisional restorations following single-tooth extraction and immediate implant placement appeared to minimize the loss of tissue volume that results from postextraction bone remodeling, thus optimizing the final esthetic result.

A variety of surgical techniques and grafting materials for the purpose of ridge augmentation have been developed during the last three decades. Recently, the use of customized allogeneic bone blocks, prepared by CAD/CAM techniques, has been introduced. This new augmentation technology may significantly reduce surgical time and improve donor-recipient fit and adaptation. However, promising clinical and histologic results have been published in only a few short-term case reports. The 3-year follow-ups of these two case reports may provide more clinical data on the use of the customized bone blocks for horizontal and vertical ridge augmentation in the posterior mandible.

Amalgam tattoos are a serious cosmetic problem for patients. A 35-year-old woman came to a private periodontal practice complaining of black pigmentation (amalgam tattoo) above temporary crowns on the lateral and central maxillary incisors and asked that the cosmetic problem be solved before the new permanent crowns were cemented into place. A full-thickness coronoapical incision was made to raise a thick flap; another incision parallel to the surface of the alveolar mucosa made it possible to remove the pigmented connective tissue, which was sent for histologic examination. Due to the fact that the pigmentation extended into the gingival epithelium, the gingiva of the lateral and central incisors was completely removed, with a horizontal incision in the alveolar mucosa from the ends of the distal releasing incisions. Therefore, partially denuded alveolar bone was used as the recipient site for a free gingival graft (FGG). The histologic analysis revealed the presence of amalgam fragments of different sizes in both connective tissue and epithelium. At 6 months, 3 years, and 24 years postoperatively, the periodontal tissues appeared healthy, and the treated area was pink, without pigmentation or scarring, and was perfectly integrated with the adjacent tissues. The patient was very pleased with her appearance. A one-stage procedure, namely an FGG, should be considered an effective treatment of amalgam tattoo providing positive morphologic and cosmetic outcomes over a 24-year follow-up period.

The significance of keratinized mucosa around dental implants for the prevention of biologic complications has been a subject of controversy. Agreement, however, exists on the benefits provided to achieve more satisfactory oral hygiene measures and reduced clinical inflammation. A prospective interventional case series of 14 patients (31 implants) were examined every 3 months for up to 12 months. The effect of soft tissue conditioning by means of free autologous epithelial graft on the management of peri-implantitis with supracrestal and/or dehiscence-type defect morphology was evaluated. All clinical parameters were significantly reduced (P < .001), with complete disease resolution in 78.6% of the patients and 87.1% of the peri-implantitis implants. Unsuccessful cases were associated with less gain of keratinized mucosa, deep probing pocket depths, bleeding on probing, and less satisfaction during brushing at 12 months. Dimensional changes following soft tissue grafting were more significant during the first 3 months and led to a 42.4% shrinkage at 12 months. Soft tissue conditioning by means of free autologous epithelial graft in combination with apically positioned flap is a viable and effective therapy to manage peri-implantitis associated with deficient keratinized mucosa.

The aim of this study was to describe the basal bone and alveolar process in the maxillary anterior region by assessing patient CBCT scans. Parasagittal reconstructions were made to quantify basal bone and alveolar process dimensions and inclination of teeth in the maxillary anterior region. The CBCT scans of 87 patients and 522 tooth sites were included in this study. The results showed that the surface areas of the basal bone, alveolar process, and palatal triangle varied from 22.1 to 54.1 mm2, 87.8 to 144.0 mm2, and 37.1 to 66.0 mm2, respectively. The basal bone in the canine region had a significantly smaller cross-sectional area than in the incisor region. The alveolar process in the canine region was markedly larger than those of the central and lateral incisor regions. The mean overall thickness of the alveolar facial bone at 3, 5, and 7 mm above the CEJ were 0.6 ± 0.5 mm, 0.9 ± 0.5 mm, and 0.7 ± 0.6 mm, respectively. Additionally, the findings demonstrated that the cross-sectional area of the alveolar process and palatal triangle were greater among men than women. The study identified significant anatomical differences among various tooth regions in the anterior maxilla. The results also demonstrated that the tooth type, but not the tooth inclination or apex location, correlates with the size of the alveolar process.

This study evaluated the effect of the antimicrobial photodynamic therapy (aPDT) on the osseointegration of immediate implants in a healing situation with greater challenges. The mandibular premolars of eight beagle dogs were submitted to ligature-induced periodontal disease. After 3 months, teeth were extracted and immediate implants were placed in the sockets previously decontaminated by mechanical debridement (MD) or MD+aPDT. Following 12 weeks, the dogs were euthanized and the specimens were analyzed. Histologic and histomorphometric analyses demonstrated significantly better results for the immediate implants decontaminated by debridement associated with aPDT. The sites treated with MD+aPDT led to osseointegration of the immediate implants without evidence of inflammation; conversely, evidence of peri-implantitis was observed where aPDT was not used.

From a sample of 108 periodontally healthy volunteers with different combinations of morphometric data related to maxillary central anterior teeth and the surrounding soft tissues, this article aims to categorize gingival phenotypes according to tooth and gingival parameters, as well as assess the relationships between tooth shape and gingival characteristics, such as the papillary height (PH) and faciolingual thickness (FLT) of the papilla base. The periodontal phenotypes of 108 volunteers were confirmed using the periodontal probe transmission method for Kan classification. The FLT, PH, and the crown width to crown length (CW/CL) ratio for maxillary anterior teeth were measured. K-clustering was used to classify the anterior tooth shape into three groups: triangular, square, and compound. The mean CW/CL ratio for the maxillary anterior tooth position of the thick phenotype was greater than that of the thin phenotype. The PH and FLT for the maxillary anterior interdental papillae were greater for the thin phenotype group than for the thick phenotype group. A negative correlation was observed between the CW/CL ratio and both PH and FLT (P < .05 for both). However, a significant positive correlation was observed between FLT and PH. CW/CL ratio, FLT, and PH were all associated with the gingival phenotype with significant statistical correlations (P < .05 for all). Triangular teeth were correlated with scallop-shaped gingiva in the faciolingual area, while square teeth were associated with a flat gingiva.

For decades, the histologic evidence about osseointegration and the bone-implant interface has been discussed in the literature. In this review, the effectiveness of dental implants retrieved for different causes was evaluated. A literature search was performed in databases for papers about implants retrieved from humans published by the Implant Retrieval Center of the University of Chieti-Pescara, Italy. Sixty-eight articles were selected into categories based on topics. The data indicated high level of bone-toimplant contact, lamellar bone close to the surface, roughness related to an increased bone response, organized and remodeled bone after loading, and peri-implant interfaces subjected to a continuous dynamic function.

A link between periodontitis and cardiovascular disease has been reported in the literature. For this systematic review, the keywords "cardiovascular disease" (CVD) were combined with "periodontitis" and "peri-implantitis" and were used to search for literature published on MEDLINE and PubMed between 1990 and 2020. Hand searching was also performed. A total of 206 articles were identified, 51 of which were reviewed. A link between periodontal disease and CVD can be explained by both the infection and inflammatory pathways. Interventional studies on the treatment of periodontal disease related to CVD have shown conflicting results. Therefore, based on published studies, CVD should presently be considered a comorbidity of periodontitis (with an association but no direct cause and effect documented). The association of CVD with peri-implantitis has too few studies to draw any conclusions. More studies are necessary before any conclusions can be made between CVD and periodontitis and CVD and peri-implantitis regarding possible links and the extent of association.

This case report describes the rehabilitation of an extremely atrophic posterior mandible using 4-mm ultrashort implants and reports clinical and radiographic outcomes 7 years after loading. The patient refused to undergo any other treatment, from the removable prosthesis to the reconstructive surgery, and asked for a fixed, minimally invasive solution in the shortest possible time. The residual bone height above the alveolar nerve was an average of about 5 mm, so it was decided to treat the patient with four 4-mm ultrashort implants. Within the limitations of this case report, this procedure appears successful at 7 years after loading in this specific case and could reduce invasiveness, rehabilitative times, and costs. However, longer follow-ups on a large number of patients coming from randomized controlled clinical trials are necessary before making more reliable recommendations.

Trace registration is a new, alternative registration method for dynamic navigation implant surgery that eliminates the need for an artificial fiducial marker and stent to be present in the CBCT scan, substituting it with other high-contrast landmarks such as teeth, implants, or abutments. Clinical advantages include a streamlined, simplified workflow with fewer opportunities for error; elimination of presurgical steps associated with stent fabrication and imaging; and reduction in radiation risk. Sufficient high-contrast intraoral structures are a prerequisite for using this technique. This case series presents the trace registration protocol and workflow and reports on cases that demonstrate the application of this technology, including postoperative placement accuracy evaluation.