International Journal of Periodontics & Restorative Dentistry, 05/2022

Severe alveolar ridge deficiencies in concomitance with periodontal attachment loss can represent a serious clinical challenge in the context of implant therapy. The present case report describes the management of a complex defect in the esthetic zone via ridge augmentation and periodontal regenerative therapy using a biologic material. A systemically healthy 55-year-old man diagnosed with peri-implantitis around an implant in the maxillary left central incisor position and with severe bone loss on the mesial aspect of the maxillary left lateral incisor underwent several surgical interventions to achieve simultaneous vertical ridge augmentation and periodontal regeneration. These interventions included implant removal, bone augmentation using a composite bone graft (autogenous bone + xenograft particles), and a bioactive protein (recombinant human platelet-derived growth factor), soft tissue augmentation using connective tissue grafts, and peri-implant keratinized mucosa width augmentation via a labial gingival graft strip and a xenogeneic collagen matrix. Substantial gains in vertical bone and clinical attachment were achieved, which allowed for delayed implant placement and subsequent completion of tooth replacement therapy with an implant-supported prosthesis. The present case report demonstrates how simultaneous vertical ridge augmentation and periodontal regeneration can be achieved to manage a challenging clinical situation. Key factors to consider in this type of scenario are proximal bone level, tooth mobility, surgical flap design and management, biomaterial selection, and proper treatment sequencing.

Conventional approaches to full-arch implant dentistry require a verified master model created by luting together impression jigs. This process involves numerous steps and is sometimes prone to errors that require subsequent correction. A novel approach involving an extraoral scanning technique using an Imetric 4D Imaging system demonstrates an alternative for same-day delivery of printed full-arch prosthetics. Advantages include the ability to offer a same-day provisional restoration without needing to verify an analog master cast.

Maxillary canines are the second most commonly impacted teeth, with mandibular third molars being the most commonly impacted teeth. One-third of the impacted maxillary canines are labially impacted, and the remaining two-thirds are palatally impacted. Palatally impacted canines (PICs) comprise approximately 1% to 2.5% of the general population. These impactions can be managed with preventive, interceptive techniques or surgical uncovering. If preventive or interceptive measures are unsuccessful in allowing the canine to erupt, there are many techniques that can be employed to uncover the PIC. Canines that are very superficially impacted can be uncovered with a simple gingivectomy. Canines that are more deeply impacted will require flap reflection, bone removal, and the placement of some type of orthodontic bracket. Most often, the surgeon will attach a chain to the impacted tooth so the orthodontist can immediately begin movement with some form of traction device. The preorthodontic uncovering technique (POUT) allows spontaneous eruption of the impacted tooth without active orthodontic force. When this technique is employed early (approximately 6 months before orthodontic treatment is initiated), it will save considerable time and trauma in erupting these teeth. Research has shown that this technique decreases orthodontic treatment time to properly position these teeth. In addition, this technique has been shown to be healthier for the bone and root structure of the impacted tooth and surrounding teeth. This article elucidates the benefits of the POUT when uncovering simple and very complicated PICs.

Making treatment decisions in dental implantology has evolved over the last five decades. These decisions and the clinical management of sites thereafter are selected based on recent changes, including the achievement of osseointegration, reestablishment of biologic width bone remodeling, the peri-implant soft tissue phenotype, the way peri-implantitis is defined, and advancements in digital technology. This article discusses these key aspects and their effects and influence on implant therapy.

The free fibula flap is a reliable approach used to reconstruct maxillofacial osseous defects. Virtual surgical planning facilitates the execution of such segmental bony reconstruction, usually preceding the placement of endosseous implants for dental rehabilitation. Novel advances in digital technology allow for fabrication of 3D guides for implant placement in the fibula bone segments before their fixation to the facial defect, with reduced ischemic time, reduced treatment time, faster dental rehabilitations, and unprecedented improvements in the overall treatment efficiency. This case report illustrates the use of digitally designed 3D-printed surgical plates for a single-stage surgery of free fibula flap with implant placement. The patient was successfully treated and followed over 2 years. Comparison between preoperative virtual planning and postoperative scans revealed a high accuracy of implant and bone segment positioning.

The present case series evaluated implant survival and changes in bleeding on probing (BOP), probing depths, marginal tissue levels (recession), and bone levels following regenerative treatment of implants with advanced peri-implantitis. Forty-six implants with advanced peri-implantitis in 38 patients were treated with a regenerative protocol and evaluated for the above parameters at the final follow-up 3 to 15 years later. Patients returned every 2 to 3 months for maintenance and at the final evaluation. Measurements were made and compared to those recorded preoperatively. No implant was lost, BOP was reduced to 0 on all but 4 implants, the mean reduction in pocket depth was 6.7 mm, and the average soft tissue marginal position was 0.9 mm coronal to presurgical levels. Bone level changes showed a mean gain of 3.6 mm (radiographically) and 6.8 mm (bone sounding). These results appear to indicate that an implant with > 50% bone loss caused by peri-implantitis can successfully be treated and retained using a specific regenerative technique.

A fully tapered implant was recently introduced to increase primary stability and to be used in challenging situations. Twenty single implants were inserted in maxillary postextraction sockets, from premolar to premolar, and immediately restored. Marginal bone level (MBL) and probing depth (PD) were evaluated over a 12-month follow-up period. All implants osseointegrated, achieving a success rate of 100%. The difference in MBL between implant placement and 1 year later was 0.20 ± 0.04 mm, while PD was 2.82 ± 0.51 mm at 1 year. The data reported here support the use of a fully tapered implant for immediate placement and immediate provisionalization for single-tooth replacements in the esthetic area.

The present study evaluated the 2-year changes in soft tissue width after implant placement in healed sites, using two different methodologies to obtain tissue healing: preformed and anatomical abutment caps for customized healing (test) vs conventional healing abutments (control). The null hypothesis was that there would be no difference between the test group and the control group. Patients who suffered from a single-tooth edentulous area in the premolar/molar region were included. Both the standard abutments and the preformed and anatomical abutment caps were immediately screwed on the implants. The final crown restoration was fabricated 3 months later. Primary outcomes (changes in the alveolar soft tissue ridge) and secondary outcomes (testing adverse events and measuring implant/prosthesis survival) were evaluated. Thirty-nine patients (24 women) with a mean age of 57.7 ± 7.1 years (range: 42.6 to 72.8 years) were included. Alveolar widths in both groups showed significant increases from baseline to the 3-month follow-up, with augmentations of 3.6 ± 0.7 mm for the test group and 1.1 ± 0.9 mm for the control group. The gain in soft tissue appeared to be statistically different between the two groups (P < .0001). Contrarily, any subsequent change in width from 3 months to 2 years was negligible and insignificant (< 0.33 mm for both groups). The technique described in the present study encourages the potential for alternative healing based on the guided soft tissue concept, as it either eliminated the need for second-stage surgery or it reduced step-by-step peri-implant soft tissue conditioning, obtaining a tissue contour immediately very similar to that of a final prosthesis.

The aim of this retrospective study was to evaluate the effect of free gingival grafts (FGGs) at adjacent mandibular molar implants and to compare the clinical outcomes between the first molar (M1) and second molar (M2) sites. Twenty-one patients with 44 implants were included. At the 3-year follow-up, the mean increase in the keratinized mucosa width (KMW) was 2.35 ± 1.33 mm, and the mean KMW shrinkage rate was 58% ± 23%. M1 sites showed a significantly greater increase of KMW and less graft shrinkage than M2 sites (M1: 2.87 ± 1.40 mm and 49% ± 24%, M2: 1.83 ± 1.06 mm and 66% ± 19%, P < .05). The results show that using FGG to increase KMW in mandibular molar implants was a predictable treatment method, and M1 sites were associated with a greater KMW increase than M2 sites.

The purpose of this study was to investigate the effects of various titanium and zirconia polishing protocols on the colonization of oral bacteria. Titanium and zirconia discs were divided into five groups: unpolished (control, UNP) and polished with Brownie only (BRO), Brownie plus Greenie (BPG), Brownie plus Greenie plus Supergreenie (BGS), and CeraMaster Coarse plus CeraMaster polishing tips (CER). The samples were sterilized and immersed in unstimulated saliva, then incubated in a liquid suspension of Streptococcus gordonii (S gordonii). The number of attached bacteria were counted 48 hours after the diluted suspensions were inoculated. Data were analyzed with ANOVA and Tukey test (P < .05). For titanium discs, the average number of bacteria from each group (CFU/mm²) was 1.51 x 10³ for UNP; 3.71 x 10³ for BRO; 5.65 x 10³ for BPG; 8.99 x 10² for BGS; and 8.49 x 10² for CER. For zirconia, the averages were 2.87 x 10² for UNP; 3.16 x 10² for BRO; 3.50 x 10² for BPG; 1.83 x 10² for BGS; and 8.73 x 10¹ for CER. Inadequate polishing roughens surfaces and promotes microbial adhesion to titanium and zirconia. Sequential polishing to the finest-finish polishing tips minimizes bacterial adherence to abutment surfaces. Zirconia exhibited less bacterial adhesion than titanium.

Immediate implant placement with immediate restoration in the esthetic zone is a standardized protocol that aims to satisfy the patient with an immediate, esthetic rehabilitation. This study evaluated clinical and esthetic outcomes following immediate implant placement and provisionalization over a medium- to long-term period. A total of 57 implants in 44 patients were included in the present cross-sectional study, with a follow-up period of 3.97 ± 2.03 years. Surgical and prosthetic treatments were performed according to a standardized protocol. Clinical outcomes (modified Plaque Index, bleeding on probing, probing depth [PD], keratinized mucosa, mucosal recession [MR], and pink esthetic score [PES]) were evaluated during follow-up. Peri-implant tissue health was assessed based on the established case definitions. The mean PES value at the final control examination (mean PES follow-up time: 3.79 ± 1.85 years) was 12.06, the mean PD was 2.52 ± 0.88 mm, and mean MR was 0.03 ± 0.13 mm. No suppuration, pain, or implant or prosthetic failures were reported. The prevalence rates of mucositis and peri-implantitis were 45.5% and 0%, respectively. Immediate implant placement and restoration was associated with peri-implant tissue stability and esthetics over medium- and long-term follow-up periods.

This study evaluates the effect of two in-office bleaching agents with different compositions on the bond strength to enamel surface. Fifty bovine teeth were divided into five groups (n = 10 teeth per group), according to the bleaching agent used and the time elapsed to perform the restorative procedures: restorative procedures performed without bleaching (control group); bleaching with 35% hydrogen peroxide (HP), with restorative procedures 24 hours or 7 days after bleaching (HP/24h and HP/7d groups, respectively); and bleaching with 35% HP with calcium compost, with restorative procedures 24 hours or 7 days after bleaching (HP AutoMixx/24h and HP AutoMixx/7d groups, respectively). The specimens were stored at 37°C in artificial saliva. Restored teeth were submitted to a micro-shear bond strength test. The specimens were analyzed using a stereoscope to determine the fracture pattern, classified as adhesive, cohesive, or mixed. The results of the bond strength test were evaluated by analysis of variance, with significance set at P < .05. The groups showed similar bond strength values without significant difference among them (P > .05). There was a predominance of the adhesive-type fracture pattern in all groups. The bleaching agents with different compositions showed similar bond strength values when the restoration was performed 24 hours and 7 days after bleaching, and the results were similar to the control group.

The high biomechanical loads in molar region wounds challenge the indication for short implants to be used as a single-unit implant. This study reports on the outcomes of single-unit short implants (≤ 8.0 mm) in the maxillary and mandibular molar regions. Forty-nine short implants were placed in 48 patients to replace a missing molar tooth. Two-piece restorations with screw retention were fabricated. During the follow-up, implant survival and marginal bone loss (MBL) were assessed. The known implant length was used as a reference to calibrate the linear measurements on digital periapical radiographs, and descriptive statistical analysis was performed. The implants were followed over a period of 47 ± 12 months. No implant failure was recorded, and no prosthesis failure was observed. The average MBL was 0.15 ± 0.5 mm. The mean crown height space was 13 ± 3 mm. The overall crown-to-implant ratio was 1.7 ± 0.4. Two technical complications occurred due to the loosening of the unit abutment. After screw re-tightening, no more screw loosening was observed. This study supports the use of short implants as a single-unit implant in the maxillary and mandibular molar regions.

The aim of this systematic review and meta-analysis was to assess whether the addition of enamel matrix derivative (EMD) to a coronally advanced flap (CAF) combined with a connective tissue graft (CTG) resulted in a greater amount of root coverage in patients treated for gingival recessions, as compared to CAF+CTG alone. The search for clinical trials on root coverage procedures comparing CAF+CTG+EDM vs CAF+CTG was completed on online databases and gray literature, and it included studies published up to January 2022. The risk of bias was assessed using the Cochrane bias assessment tool, and the quantitative analysis was performed using a random effects model. A total of 1,917 articles were identified, and 12 underwent full-text review. Three studies were excluded, and 9 were selected for full analysis. The meta-analysis showed that there is a statistically significant difference (P = .04) in favor of CAF+CTG+EMD compared to CAF+CTG alone for the amount of root coverage (mean difference: 0.30 mm; 95% CI: 0.01, 0.58 mm). According to the results of this systematic review and meta-analysis, the addition of EMD to CAF+CTG results in a greater amount of root coverage in teeth treated for gingival recessions.

This study evaluated the survival and esthetic outcome of flapless postextraction placement and provisionalization in compromised single tooth sites in the esthetic area. Ten patients were included in the study, and 10 subcrestally angled (SCA) tapered implants were placed. Only maxillary central or lateral incisors and canines were included. Implants showed 100% survival rate, a limited mean marginal bone loss of 0.43 ± 0.23 mm, and a mean gain in coronal gingival level of 1.6 ± 1.17 mm; the mean vertical alveolar bone gain was 4.0 ± 1.5 mm, and the average pink esthetic score was 12.5 at a mean 3.5-year follow-up (range: 2 to 5 years). These results show that immediate replacement and restoration of a tooth with compromised hard and soft tissue condition in the esthetic area, with simultaneous use of connective tissue, bone graft, and membrane, could be a valid alternative to a more complex staged approach.

The aim of this cohort study was to assess the effect of connective tissue graft (CTG) following immediate implant placement (IIP) at maxillary central incisors on esthetic outcomes, buccal bone thickness, soft tissue dimensional alterations, and patient-centered outcomes. Twenty-eight patients treated with IIP at maxillary central incisor sites with approximately 6 ± 4 years in function were divided according to the use of CTG (n = 17) or no CTG (n = 11). The primary variable of the study was the Pink and White Esthetic Score (PES/WES), evaluated in photographs taken before and after implant placement. The thickness of the buccal bone, midbuccal mucosal level (MBML) changes, and patient satisfaction were assessed and compared between the two groups. The results showed similar PES/WES before IIP between the CTG and no-CTG groups (13.5 ± 3.7 and 12.6 ± 3.2, respectively). After IIP, the PES/WES value in the CTG group was significantly higher (15 ± 2.5) than in the no-CTG group (12.1 ± 3.1) (P = .012). No significant differences in the buccal bone thickness, MBML, or patient satisfaction were observed in CTG and no-CTG groups. This study found that CTG following IIP and socket grafting promoted better esthetic outcomes.

This study evaluated in vitro the biologic profile of manually polished surfaces of pressed lithium disilicate (LD) ceramic compared to zirconia (Zir) in human gingival fibroblasts. Samples with a 10-mm diameter and 3-mm thickness were used. After manual polishing, the average roughness (Ra) of the samples was measured. The cell proliferation and viability of gingival fibroblasts on the surfaces were assessed at 24, 48, and 96 hours. Additionally, the morphology, cell adhesion, and type III collagen (COLIII) and vimentin (VIM) expression by fibroblasts plated onto these surfaces was analyzed. Polystyrene (Pol) was used as control for all assays. The mean Ra was 0.261 ± 0.053 μm for Zir and 0.345 ± 0.130 μm for LD. Both surfaces presented similar cell proliferation and viability (P > .05). The cell morphology demonstrated that, for both surfaces, the cells were occasionally spindle-shaped, parallel to the direction of the grooves. Compared to Pol, an upregulation of COLIII and VIM gene expression was observed by fibroblasts cultured on Zir and LD at all time points (P < .05). The characteristics presented by LD and Zir surfaces after manual polishing protocol were similar and had biologically favorable performances, thus suggesting LD as a suitable alternative to Zir in the peri-implant region for esthetic purposes.