International Journal of Periodontics & Restorative Dentistry, 06/2022

Maxillary canines are the second most commonly impacted teeth. Two thirds of these impacted canines are palatal, and one third are labially impacted. Maxillary labial impactions comprise approximately 0.33% to 0.75% of the general population. Like palatal impactions, preventive and interceptive methods can be employed to help the impacted tooth erupt and avoid surgical uncovering. Early extraction of appropriate primary teeth and palatal expansion has helped some of these impactions erupt spontaneously. Most labially impacted canines are positioned "in the slot," in a midalveolar location between the lateral incisor and first premolar. If they do not erupt after preventive or interceptive means, they can be managed with simple closed-eruption uncovering techniques. The most difficult labial impactions are ectopically positioned. These are usually horizontally positioned, mesial to the lateral incisor. They can be very apically positioned, near the base of the nose and near the midline. The rarest labial impaction occurs between the central and lateral incisors or between the premolars. These are extremely rare and require special orthodontic and uncovering techniques. All of these ectopic impactions require a technique that leaves the impacted tooth uncovered so the orthodontist can employ the proper mechanics to move these teeth without damage to adjacent structures. This article elucidates the surgical uncovering techniques and the orthodontic mechanics to successfully move these teeth and minimize root resorption, bone loss, and recession.

This comparative case series presents 16 consecutively placed and temporized immediate implants in the maxillary esthetic zone. The implants have a novel, inverted body-shift design, intended to achieve high levels of primary stability via the tapered apical portion. The coronal narrow cylinder provides greater space between the implant platform and facial socket wall and adjacent teeth/implants, allowing a greater opportunity for augmentation. The restorative platform also features a subcrestal angle correction, which facilitates screw retention. The wider, facial platform-shift thus creates more room for augmentation via dual-zone bone grafting and the application of a dermal allograft, which yields greater soft tissue thickness after initial healing. This case series aimed to evaluate soft tissue thickness and compare the results to two previously published cohorts where implant design served as the only variable between groups.

This retrospective study evaluated the effect of combined periodontal-orthodontic treatment in terms of clinical, radiographic, and patient-reported outcomes in 40 stage IV periodontitis patients with advanced attachment loss and pathologic migration of anterior teeth. Full-mouth periodontal parameters were recorded at baseline (after diagnosis; T0), at the end of active periodontal therapy (APT; T1), at completion of orthodontic tooth movement (OTM; T2), and at the last supportive periodontal care (SPC) visit (T3). Radiographic analysis was performed at T0, T2, and T3. A total of 115 teeth were lost during APT, including 5 molars at T2 (used as orthodontic anchorage) and 10 premolars at T3 (due to root fracture). All anterior migrated teeth were in function at T3 (mean duration: 9.5 years). Significant mean probing pocket depth reduction (1.5 ± 1.1 mm) and attachment level gain (0.9 ± 1.0 mm) were observed after APT, whereas OTM and SPC were associated with furthering small changes. The alveolar bone level at T3 was slightly increased from T0 values. Patient-reported outcome measurements significantly improved in terms of esthetics and masticatory function. OTM should be considered an essential part of the comprehensive treatment plan to change the prognosis of severely compromised teeth in stage IV periodontitis patients.

The addition of grafting material to the tunnel procedure has yielded more stable outcomes than the tunnel procedure alone, but currently there is no available evidence about the most effective grafting material. This study compared two grafting materials-subepithelial connective tissue graft (SCTG) and acellular dermal matrix (ADM)-with the modified coronally advanced tunnel technique (MCAT) in the management of multiple adjacent gingival recessions (MAGRs). Patients (n = 24) with recession type 1 MAGR sites were randomly allocated to treatment with ADM+MCAT (test group) or SCTG+MCAT (control group). The clinical parameters were recorded at baseline (before treatment) and 9 months postsurgery and included gingival recession depth (GRD), gingival recession width (GRW), gingival thickness (GT), keratinized tissue width (KTW), probing pocket depth (PPD), clinical attachment level (CAL), and percentage of root coverage. Patient esthetic satisfaction and postoperative pain were recorded using a visual analogue scale (VAS). After 9 months, significant reductions in GRD (2.10 ± 0.64 mm; 2.23 ± 0.68 mm) and GRW (2.41 ± 1.19 mm; 2.41 ± 1.94 mm), increases in GT (0.53 ± 0.41 mm; 0.94 ± 0.52 mm), and gains in CAL (2.46 ± 1.94 mm; 2.47 ± 1.28 mm) were recorded in the test and control groups, respectively. However, the control group showed more KTW gain (P = .0003) and increased GT (P = .002) than the test group. Patient satisfaction with esthetic outcome 9 months after treatment did not differ between test (VAS score: 8.24 ± 0.43) and control (VAS score: 8.24 ± 0.65) groups (P = 0.99). The use of ADM may represent an alternative to SCTG when used in conjunction with MCAT.

Various surgical flap advancement techniques for bone regeneration have been described in the literature; however, the clinical challenges of managing tissue that contains scars or embedded foreign materials have not been thoroughly described, especially around metal foramen. Fibrotic and thickened scar periosteum as well as mental foramen restrict the tissue from responding in the same way as native tissue. Therefore, additional considerations and approaches must be considered to achieve tension-free flap closure. This article presents a flap advancement classification that describes three common clinical scenarios based on the periosteum and soft tissue quality and provides surgical approaches for tissue management in each classification, with a focus on flap advancement around the mental foramen.

Mini dental implants (MDIs) are an affordable alternative for overdentures in medically compromised patients with reduced bone volume. This human study reports the histomorphometric analysis of early loaded and flaplessly placed tapered, one-piece MDIs (ILZ, Southern Implants; Sa: 1.5 μm) after 7 to 11 months in function. Patients agreed to have an additional MDI placed and removed for evaluation. MDI stability was assessed via Periotest prior to implant removal. Histologic sections of four mandibular and three maxillary MDIs with surrounding bone were processed, and the bone-to-implant contact (BIC) was analyzed. At retrieval, the MDIs were in function for more than 6 months, were clinically healthy, and had mean probing pocket depths of 1.4 mm and 1.6 mm in the maxilla and mandible, respectively. Periotest values were < 5.5, indicating clinical stability. Most of the screw threads were filled with bone and revealed an intimate BIC, without any signs of intervening fibrous tissue layer. In both arches, the mean BIC was 68.5%. Large osteocytes could be identified in the calcified tissue, indicative of mature peri-implant bone. It can be concluded that MDIs, when loaded within 2 weeks in either arch, provide proper clinical stability and high BIC after 6 months.

This retrospective study aimed to describe the facially oriented crestal incision (FOCIS) and assess the incidence of flap dehiscence and its efficacy in simultaneous and staged guided bone regeneration (GBR) procedures. The data of 41 patients treated with FOCIS GBR were analyzed. The primary outcome analyzed was the rate of initial wound closure. Secondary outcomes were related clinical parameters, including mean resolution of dehiscences and fenestrations, crestal buccal bone thickness (BBT), and bone width (BW) increase. A total of 53 implants were placed. The initial wound closure rate was 92.7% (38/41) and 94.3% (50/53) at the patient and implant levels, respectively. The complete dehiscence resolution rate was 79.31%, and the mean dehiscence reduction was 3.12 ± 2.46 mm (95% CI: 2.19 to 4.06 mm). BBT had a mean increase of 1.22 ± 1.07 mm (95% CI: 0.86 to 1.59 mm), and the final BBT was an average of 1.56 ± 0.79 mm (95% CI: 1.32 to 1.80 mm). Lastly, BW increase averaged 3.38 ± 1.49 mm (95% CI: 2.58 to 4.17 mm) for the staged cases. Utilizing FOCIS at partially edentulous sites can help achieve and maintain wound closure in horizontal GBR procedures.

Implant bone loss and implant failure are growing concerns. In some cases, a possible factor leading to bone loss may be an allergy to titanium (Ti). In this report, the existing literature on Ti allergy as a factor in implant loss is reviewed, and the current views on its potential role in implant bone loss are discussed. A case report of implant loss and retreatment in a patient with a potential Ti allergy or intolerance is presented and clinically analyzed. The subsequent success of a ceramic implant may support the finding of a Ti allergy or intolerance. Unfortunately, the lack of prospective clinical trials and lack of a reliable test for Ti allergy makes it impossible to clinically verify whether Ti allergy plays a part in implant bone loss.

This study compared the bone turnover and volume stability of bovine-derived xenografts (Cerabone) vs porcine-derived xenografts (MinerOss XP) in horizontal ridge augmentation (HRA) for veneer contour and extraction socket preservation (ESP), with a 6-month follow-up. Participants were divided into Group 1 (HRA + bovine), Group 2 (HRA + porcine), Group 3 (ESP + bovine), and Group 4 (ESP + porcine). Buccolingual ridge width was measured on CBCT scans at baseline and 6 months. Representative histologic core samples were taken from the ESP groups at 6 months. Each group comprised 10 subjects (40 subjects total). The buccolingual width for Groups 1 and 2 increased from 5.43 ± 1.82 mm and 5.75 ± 1.64 mm (P = .36) to 7.75 ± 1.91 mm and 8.75 ± 1.38 mm (P = .03), respectively. However, the buccolingual widths for Groups 3 and 4 decreased from 6.3 ± 1.26 mm and 6.74 ± 1.29 mm (P = .16) to 5.8 ± 1.21 mm and 6.61 ± 1.56 mm (P = .01), respectively. Significantly lower dimensional changes were noted in Group 4 at 6 months. Porcine xenografts serve as a stable biocompatible osteoconductive bone substitute and expand a clinician's choice of bone grafts in dental applications.

Fourteen maxillary sinuses were reconstructed in 12 patients who presented with a previous sinus elevation failure. In all cases, large perforations of the sinus membrane occurred during removal of the failed graft from the sinus; the perforations were sealed with fibrin glue, then the site was grafted using homologous fibrin glue (HFG) mixed with a calcium phosphate scaffold (CPS). Histologic analyses revealed that the CPS-HFG graft was followed by an ossification process, with the formation of spongy bone similar to that of the normal skeleton. Twenty-four endosseous implants were successfully placed into the newly regenerated bone. All implants were successfully restored with ceramic crowns 6 months after placement. At the 3-year follow-up, no infections or implant failures were reported. The described technique offers several clinical advantages, as the removal of the failed graft, the sinus perforation repair, and the sinus elevation can be achieved in the same surgery without needing to postpone the regenerative surgery phase.

This retrospective study evaluated the long-term stability of teeth that were orthodontically treated with forced eruption for restorative purposes. A total of 25 participants with a total of 36 orthodontically extruded teeth were included in the study. The measured clinical parameters included (1) pre- and posttreatment radiographs, (2) activation time, (3) retention time, (4) total treatment time, (5) additional treatment required to restore the teeth, and (6) pre- and postsurgical complications. The results show a 96.0% survival rate for force-erupted teeth, with a 4.0% failure rate due to nonrestorable caries. When more than 1.0 mm of extrusion was completed, there was a statistically significantly higher chance that the tooth required additional surgeries (P < .05). Complications during treatment were higher in clinicians without orthodontic training (43.0%) vs clinicians with orthodontic training (10.0%). Forced eruption for prosthetic treatment and implant site development is a viable treatment option and is successful in the long-term.

This study evaluated the use of a xenogeneic acellular dermal matrix (XADM) combined with a modified coronally advanced flap (MCAF) and partial resin composite filling (anatomic crown plus 1 mm of the root surface) to treat multiple Type 1 gingival recessions associated with B+ noncarious cervical lesions (NCCLs). The study included 24 recessions in 10 patients. Bleeding on probing, probing depth, combined defect height, relative gingival recession, clinical attachment level, esthetics, and dentin hypersensitivity were recorded. After 6 months, the treatment provided statistically significant outcomes: It reduced the combined defect height by 2.02 ± 0.65 mm, increased clinical attachment level by 1.96 ± 0.83 mm, and increased keratinized tissue thickness by 0.46 ± 0.47 mm, and shallow probing depths were seen. Significant dentin hypersensitivity reduction and esthetic improvements were observed. Therefore, XADM associated with MCAF and partial restoration might be a promising alternative to autogenous grafts used to treat multiple gingival recessions associated with B+ NCCLs.

Regenerative and reconstructive periodontal plastic surgery are important options for treating marginal tissue recession and can be indicated for root coverage or periodontal procedures prior to implant placement. Among the available procedures, periodontal flaps with subepithelial connective tissue graft (CTG) is the most common treatment option to achieve proper tissue manipulation. The present study proposes a modification of a previous technique for inducing spontaneous gingival growth around teeth that will be extracted prior to implant placement, through successive reduction of the buccal root surface. This successive reduction of root surfaces is performed with diamond burs, and such reductions create space for the gingival tissue to grow coronally by reducing root convexity and, consequently, stimulating the healing process with the formation of granulation tissue that will then differentiate into keratinized tissue. The presented technique is suggested to improve the esthetic outcomes for cases involving tooth extraction, implant placement in the extraction socket, and immediate loading with interim restoration and CTG.

Postextraction bone grafting and implant placement help preserve alveolar bone volume. Collagen wound dressings and soft tissue graft substitutes may help protect extraction socket bone grafts and provide better gingival contours. This randomized, controlled, multicenter, and double-blinded study was conducted to compare a control (wound dressing) and a test (soft tissue graft) substitute in nearly intact extraction sockets. Both test and control sockets were grafted with a xenogeneic bone graft. Graft containment, extraction socket soft tissue gap closure, gingival contour, and gingival thickness were examined over 16 weeks, at which time implants were placed. Healing was uneventful for both groups, and there was no significant difference (P < .05) between the times required to close the extraction socket soft tissue gap (~80% of sites closed by 8 weeks). Bone grafts were covered and contained longer in the test group (~4 weeks vs ~2 weeks), with less contour disruption out to 4 weeks; however, at implant placement, soft tissue contours in both groups were comparable, and soft tissue thicknesses were not significantly different.

This study aimed to determine whether administering botulinum toxin type A (BT) prior to surgery would stabilize surgical lip repositioning. A randomized controlled parallel-group clinical trial was performed. A total of 18 participants with excessive gingival display (EGD) were divided into two groups. For the test group (TG), BT was injected into the smile muscle locations 15 days before the surgical procedure. For the control group (CG), only lip repositioning surgery was performed. Gingival display (GD) and upper lip displacement (LD) were measured 3 and 6 months postoperatively. Data were submitted to ANOVA, Tukey, and t tests. For GD and LD, the changes were statistically significant between the measurements taken at the baseline, 3-month, and 6-month marks. The GD presented a reduction of 5.2 ± 1.1 mm in TG and 3.2 ± 1.4 mm in CG after 6 months. The LD measurements reduced 45% for TG and 26% for CG in 6 months. The injection of BT 15 days before lip repositioning surgery provided more stable results and effectively reduced the GD at 6 months.

An internal root resorption lesion in the maxillary right central incisor was treated with orthodontic extrusion to improve the surrounding soft and hard tissue. Simultaneously with extraction, socket preservation was performed. After 4 months of healing, guided bone regeneration was performed and an implant was placed. At the second surgical phase, a flap was coronally advanced, and a connective tissue graft was placed. The emergence profile was modeled with a provisional crown before the final crown. The result was successful and well maintained over the 10-year follow-up period. The hard and soft tissue levels were stable, and no signs of inflammation were observed.

This case report proposes a unique approach for managing Cairo gingival recession types 1 and 2 (RT1 and RT2, respectively) in the mandibular anterior region, where anatomical features such as a high frenal attachment or a shallow vestibule preclude the use of a coronally advanced flap. Three systemically healthy patients presenting with Cairo RT1 and RT2 gingival recessions were included. The recessions were managed with a staged approach of frenectomy followed by a modified tunnel in combination with connective tissue graft. Significant root coverage was achieved in all three cases. This treatment approach allows for root coverage, relief of frenal pull, keratinized tissue gain, and increased vestibular depth in very challenging Cairo RT1 and RT2 gingival recessions in mandibular anterior teeth. A short-term follow-up of 3 to 6 months showed stable results in all presented cases.

Autologous tooth-derived grafts (ATDGs) have gained popularity as bone substitute biomaterials, owing to their promising healing dynamics in vivo and to patient preference for repurposing hopeless teeth. Nonetheless, concerns exist regarding the biologic response of these ATDGs in preparation for implant placement and subsequent osseointegration. After 12 weeks of extraction socket healing, an implant with an acid-etched surface was placed using osseodensification osteotomy preparation and was retrieved after 16 weeks of integration. Histologic analysis revealed ≥ 64% of direct bone-to-implant contact at multiple regions of interest along the implant surface. Residual dentin particles were scarce and were never found in contact with the implant, suggesting that the ATDG did not interfere with implant osseointegration. Despite the overall trabecular structure of the adjacent maxillary bone with large marrow spaces, the implant surface was delineated with a continuous dense mineralized zone (thickness of 2 to 5 cell layers) with vital osteoblasts in the lacunae. These results suggest that the healing dynamics of ATDG are well aligned with implant osseointegration dynamics.

A lack of bone volume may compromise a correct three-dimensional implant placement. This study was designed to evaluate the clinical and radiographic outcomes of simultaneous horizontal guided bone regeneration (GBR) performed using autogenous bone or blood-derived products mixed with a bone xenograft. The study population consisted of patients operated on using one of two clinical protocols for GBR: group A, which used autogenous bone mixed with a bone xenograft, and group B, which used advanced platelet-rich fibrin (A-PRF) mixed with a bone xenograft. The primary outcome was the clinical gain in the peri-implant defect. The secondary outcomes included an analysis of the postoperative healing, periodontal parameters, marginal bone loss, and occurrence of adverse events. All of the surgeries were carried out successfully. One patient in each group experienced a case of early implant loss, and three patients (one in group A and two in group B) presented biologic complications. The mean peri-implant vertical defect heights at baseline in group A and group B were 3.6 ± 0.9 mm and 4 ± 1.5 mm, respectively (P = .382). No statistically significant differences in the mean residual defect heights (P = .521) or in the postoperative wound healing (P = .611) were observed. Stable peri-implant marginal bone levels were recorded after loading in both groups. The use of A-PRF combined with a particulate bone xenograft and covered with a fixed collagen membrane may provide clinical results similar to those obtained via autogenous bone mixed with bone xenograft.

This retrospective cohort study aimed to evaluate the efficiency of supportive periodontal treatment (SPT) on peri-implant disease prevention. A total of 63 rehabilitated patients with 504 implants were selected with both maxillary and mandibular Brånemark-type protocols (all-on-four system) placed between 2004 and 2014 in a private practice with 5 to 15 years of follow-up. Study participants were divided into those who adhered to SPT with regular intervals of two or more times a year (Group 1) and those with irregular intervals with more than 1 year without attending SPT (Group 2). The implants placed were evaluated clinically and radiographically to assess peri-implant diseases. The prevalence of mucositis and peri-implantitis in the total population was 64.7% (326 implants) and 3.7% (19 implants), respectively. Group 2 had higher rates of mucositis (181 implants) and peri-implantitis (16 implants) than Group 1 (145 and 3 implants, respectively) (P < .05). The odds ratio for peri-implantitis in Group 2 was 7.1. The results suggest that patients who regularly received SPT had lower chances of developing peri-implant diseases.