International Journal of Periodontics & Restorative Dentistry, 06/2021

Minimally invasive prosthetic procedures (MIPPs) have been suggested and utilized for the esthetic rehabilitation of severely worn dentition. Minimizing the reduction of tooth structure and the use of additional adhesive techniques are key elements to ensure long-term results. This article presents the long-term result of this restorative technique. A total of 1,040 lithium disilicate restorations were adhesively luted, and 45 patients and 87 arches were treated. The cumulative survival rate recorded was 99.15%, with a 10-year survival probability of 96.5%. These remarkable results strongly support the use of MIPP as a restorative option for severely worn dentition.

Certain bone morphologies and soft tissue thickness (ie, phenotype) are considered to be risk factors for the development of gingival recessions following orthodontic tooth movement. Preoperative evaluation of the periodontal phenotype, in the frame of orthodontic treatment plan, identify teeth at high risk for mucogingival complications related to orthodontic therapy. The new surgical technique is illustrated in a clinical case. A patient with a thin phenotype without visible gingival recession had bone dehiscences in the anterior mandible. Prior to orthodontic treatment, simultaneous bone and soft tissue augmentation was performed using the combination of a highly cross-linked ribose porcine type I collagen membrane and a subepithelial palatal connective tissue graft. Two years after augmentation surgery and initiation of orthodontic treatment, a thick buccal tissue with a wide band of attached gingiva was observed without any clinical signs of root prominences, indicating a substantial change in periodontal phenotype. The clinical findings were corroborated by the 3D analysis, demonstrating substantial bone apposition on the buccal aspect of all roots in the treated area. The described surgical technique offers a valuable approach for regenerating hard and soft tissues in deficient areas prior to orthodontic therapy, thus preventing the development of gingival recessions.

This case report emphasizes how home and professional care can impact clinical outcomes following nonsurgical mechanical therapy with the adjunctive use of a diode laser to treat failing implants. Localized severe peri-implant disease was diagnosed in a patient who was susceptible to periodontal disease, not compliant, and did not accept the surgical approach. A cause-related, diode laser-assisted, nonsurgical treatment was therefore implemented, according to a dedicated protocol, in four closely scheduled appointments. The patient's oral hygiene skills became extremely effective. She then adhered to a bimonthly maintenance protocol in the first follow-up year and quarterly in the subsequent year. Bone remineralization was detected on comparative periapical radiographs 2 years after the diagnosis of peri-implantitis. At the 2-year observation, the patient's high standard of home care and dedicated maintenance arrested the progression of peri-implantitis and yielded clinical and radiographic improvements following nonsurgical mechanical therapy with adjunctive repeated application of a diode laser.

The aim of this report is to present a technique for buccal soft tissue contour augmentation with the use of a porcine volume-stable collagen matrix (VSCM). Augmentation of buccal soft tissue at the time of implant placement is often a necessity but is mostly performed using autogenous tissue. The technique using a VSCM can be done at the time of implant placement or, in the case of a two-stage procedure, at the time of implant uncovering. Here, clinical outcomes are reported in two cases when using VSCM concurrently with implant placement at sites in need of buccal contour augmentation to achieve a functional, esthetic result. The use of a xenograft poses several advantages over autogenous tissue while providing similar gains in soft tissue thickness. By eliminating the need to harvest a soft tissue graft from the palate, patient morbidity is reduced, and the reliance on palatal tissue thickness, to determine the amount of achievable augmentation, is eliminated.

The use of autologous dentin as an alternative to conventional regeneration biomaterials has become increasingly common, having been described in the literature since the 1960s, demonstrating its efficacy. Certain components that form the teeth, such as type 2 bone morphogenetic proteins (BMP-2), type I collagen, and hydroxyapatite, have been widely proven to be effective and are essential materials in the regeneration of alveolar bone. It is known that regenerated bone is histologically indistinguishable from native bone, and therefore, conditions and materials that allow for adequate replacement by host bone and that do not persist over time are key. With the present case report, encouraging advances in the use of autologous dentin as a graft material are demonstrated.

Surgical crown lengthening (SCL) is indicated to reestablish the biologic width and to increase the extent of supragingival tooth structure for restorative or esthetic purposes. The present study aimed to evaluate the postrestorative conditions and positional changes of the periodontal tissues following SCL 15 years or more after surgery. Moreover, an early postsurgical physiologically oriented crevicular tooth repreparation (POCR) approach for surgical and restorative phases of the SCL procedure is described. Eighteen patients who needed SCL to gain retention necessary for prosthetic treatment, or previous prosthetic margins, were included. During surgery, the bone level was reduced based on the future prosthetic margin and predetermined biologic width; flaps were placed at the bony crest. Relined temporary acrylic resin crowns were delivered 7 to 10 days postsurgery, and definitive crowns were delivered 9 months postsurgery. Patients were examined at baseline (BSL); at 3, 6, and 9 months postoperatively; and at each yearly recall visit. The following parameters were evaluated: Plaque and Gingival Indices, free gingival margin, width and thickness of the keratinized gingiva, probing depth, attachment level, bone level, direct bone level, and biologic width. Sixteen patients completed the study. No significant change in the position of the free gingival margin and periodontal parameters were seen from 9 months to > 15 years. Biologic width at 9 months was smaller compared to BSL (-0.06 ± 0.02 mm) and gradually increased during the follow-up period, almost reaching the initial levels at the examinations > 15 years later. The described SCL technique obtained a consistent 3-mm gain of coronal tooth structure and was successful in maintaining stable periodontal tissue conditions, reestablishing the biologic width to its original vertical dimension after 15 years.

Healing complications in guided bone regeneration (GBR) can be frequent when nonresorbable membranes are used. Exposure of dense polytetrafluoroethylene (d-PTFE) membranes to the oral cavity are usually located close to the incision line due to a lack of tension-free flap closure. This case report presents a safe, novel technique that uses d-PTFE membranes placed on the missing buccal and palatal bone walls without covering the coronal aspect of the regeneration. Therefore, these membranes can be kept away from the incision line to minimize the risk of exposure. The coronal part is then covered with a resorbable membrane. A clinical case is presented, using this novel technique to three-dimensionally reconstruct noncontained defects in the maxilla. This technique is safe and effective in regenerating these defects; after 8 months of healing, three implants could be placed with proper primary stability. Further, histologic and histomorphometric analyses revealed functional bone with areas of new bone formation. However, more long-term studies are required to validate this technique.

This case series demonstrates a surgical technique consisting of a digitally planned and guided placement of a bone ring allograft and implant in the anterior esthetic zone. Eight consecutive patients with horizontal and vertical defects in the anterior maxilla underwent augmentation with a commercially available bone ring allograft and simultaneous implant placement using two digital guides. After 6 to 8 months, implants were uncovered and restored with a screw-retained prosthesis. Follow-up periods ranged from 8 to 24 months. All eight implants met predefined success criteria with no adverse events. Radiographic measurements demonstrated stable peri-implant bone levels 1 year after implantation, with bone loss ranging from 0.0 to 1.4 mm. All patients were satisfied with the total treatment time, postsurgical healing, and final esthetic outcome. This case series describes a one-stage procedure in which a bone ring allograft and implant are simultaneously placed for treatment of a severely defective ridge in the anterior maxilla. The technique appears to be reliable for use in the esthetic zone, with minimal first-year loss of peri-implant bone. In combination with a digital guide, accurate implant and bone ring placement can be achieved, resulting in reduced chair time and fewer surgical procedures for the patient.

This clinical and histologic case series aims to evaluate a novel flapless approach to alveolar ridge reconstruction (ARR) of compromised extraction sockets by means of collagenated xenograft sealed with three resorbable layers of hole-punched membrane. Eight postextraction sockets without buccal and/or palatal bone walls and with adjacent natural teeth from eight consecutive patients were included. Pretreatment CBCT scanning was performed. After debridement of the selected sites, a flapless grafting procedure was carried out, and the three-membrane protection was applied. After 6 to 17 months, at implant placement, a posttreatment alveolar ridge CBCT was taken, and a bone core biopsy sample was harvested for histologic and morphometric analyses. Clinical outcomes showed predictable horizontal bone regeneration in all postextraction sockets with good preservation of soft tissue architecture. Pretreatment ridge CBCT measurements showed limited bone width (2.6 ± 1.08 mm). Posttreatment measurements revealed adequate bone width (9.05 ± 1.29 mm) with a mean bone gain of 6.4 ± 1.34 mm. Histologic and morphometric analyses revealed the absence of inflammatory cells and the presence of 25.4% ± 8.7% of new bone and 31.8% ± 8.3% of graft particles inside the biopsy samples. Many graft particles were surrounded and interconnected by new bone, thus demonstrating the formation of a bone-graft network. Rare osteoclasts were found. This novel technique seems to be effective in treating alveolar sockets prior to implant placement, preventing inflammation and bone resorption and promoting bone regeneration.

Treatment of gingival recession defects on the lingual surface of mandibular anterior teeth is a challenge for the periodontist because of the region's unique anatomical features. Although there are no esthetic issues, lingual recessions should be considered seriously, especially on mandibular incisors, because they are frequently associated with periodontitis and dental hypersensitivity. The treatments and the long-term outcomes (5 years) of three clinical cases of multiple lingual recessions are presented. The tunnel technique associated with subepithelial connective tissue graft was chosen. The postoperative period was almost uneventful in all treated cases, and the 1-year outcomes were successful. Great recession reduction, up to complete root coverage, was seen, as were significant increases of both the apicocoronal amount and thickness of keratinized tissue. At the 5-year follow-up, the tissues were stable; only a slight apical shift of the gingival margin was noted in one case. The modification of the periodontal phenotype following the tunnel technique with the subepithelial connective tissue graft allowed the patients to maintain good plaque control.

This study aimed to determine the impact of implant placement depth (bone-level [BL] and subcrestal [SC]) on soft-tissue inflammatory parameters bleeding on probing (BOP), probing depth (PD), and crestal bone resorption (CBR) in moderate cigarette-smokers and nonsmokers at 5 years postplacement. Patient details were recorded, including sex, age, smoking history, duration of implants in function, implant arch location, and daily toothbrushing and flossing habits. Peri-implant BOP, PD, and CBR were measured in all groups, and group comparisons were done; a probability score < .05 was selected as a value for statistical significance. Fifty-three patients (27 smokers, 26 nonsmokers) had BL implants, and 55 patients (28 smokers, 27 nonsmokers) had SC implants. Among all patients, PD was higher in smokers than nonsmokers (P < .05). The peri-implant sites that demonstrated BOP were higher (P < .05) in nonsmokers than smokers. Among smokers, the CBR was higher in those with BL implants than those with SC implants (P < .05). Among nonsmokers, there was a difference in BOP, PD, and CBR at the 5-year follow-up. At 5 years, SC implants demonstrated less CBR than BL implants. Peri-implant PD is higher in smokers than nonsmokers, irrespective of the implant placement depth.

Maxillary sinus grafting is generally a safe procedure. However, intraoperative complications, as well as early and late postoperative complications, may occur. Included in the latter group are graft infections that can be triggered by peri-implantitis. The aim of the present study was to report three cases of late maxillary sinus graft infections and to histologically evaluate the effects of peri-implantitis in the grafted area. In peri-implantitis cases in grafted sinuses, the sole removal of the implant along with accompanying debridement of the infected area may not be sufficient to resolve the infection, and a more-aggressive treatment may be necessary.

The emergence profile is a crucial factor in facilitating favorable esthetic outcomes and maintaining peri-implant health and stability. It should be evaluated not simply in terms of morphology but as a clinical variable closely related to material properties and clinical approaches; in this way, this critical factor-which can significantly influence the integration, stability, and preservation of bone and soft tissues-can be comprehensively planned. Soft tissue integration and adherence to prosthetic components are paramount elements in the preservation and protection of bone from contamination and infection. The present narrative paper presents a prosthetic concept suggested as an operative strategy to preserve peri-implant hard and soft tissues and achieve predictable prosthetic outcomes, optimizing soft tissue integration. Achieving an ideal soft tissue seal around implants is paramount in achieving stable restorations and protecting the bone interface from possible contamination and infection.

Smoking has a profound effect on platelet morphology and activation and has also been shown to affect hemostasis, coagulation, and healing cascade. To date, no previous reports are available to assess the impact of cigarette smoke on leukocyte- and platelet-rich fibrin (L-PRF) and advanced platelet-rich fibrin (A-PRF) membranes. Therefore, this study aims to analyze the impact of cigarette smoking on the mechanical and biologic properties of L-PRF and A-PRF membranes. Sixty blood samples from both smokers (n = 34) and nonsmokers (n = 26) who were matched for age and other factors were collected and subjected to complete blood count and platelet indices (mean platelet volume, platelet distribution width, platelet large cell ratio, and plateletcrit). The L-PRF membrane (2,700 rpm; 12 minutes) and A-PRF membrane (1,500 rpm; 14 minutes) were prepared using a standard protocol. A total of 64 experimental L-PRF and A-PRF membranes from 16 individuals selected randomly from the two groups were subjected to tensile strength evaluation using a micro universal testing machine and growth factor release analysis (platelet-derived growth factor [PDGF-AB], vascular endothelial growth factor [VEGF], and bone morphogenic protein-2 [BMP-2]) using ELISA (enzyme-linked immune sorbent assay). Results were tabulated, and statistical analysis was done using Mann-Whitney, Kruskal-Wallis, and Spearman correlation tests. Tensile strengths of L-PRF and A-PRF did not show a statistical difference between groups (P = .47). BMP-2 was not detected in any of the groups. A high initial release of PDGF-AB and VEGF was noticed in A-PRF samples from smokers. Although statistically insignificant, cigarette smoking does affect platelet activation and influences the tensile strength of L-PRF membranes as well as growth factor release in A-PRF membranes in smokers.

This pilot study aimed to assess the diagnostic accuracy of CBCT in identifying peri-implantitis-like bone defects in cadavers. Three cadaver dental arches treated with the Thiel embalming method were used. Three different types of peri-implant bone defects (buccal dehiscence, two- to three-wall defects, and circumferential defects) were prepared on 15 implants. Defect depths and lengths were identified clinically using a periodontal probe, radiologically by means of CBCT images, and histologically with a micrometer using an optic microscope. Peri-implant bone defect morphology evaluated using CBCT images matched the clinical defect configuration (100% accuracy). CBCT assessment demonstrated lower values in defect depth and defect length when compared with the clinical evaluation. A statistically significant difference in defect depth (0.35 ± 0.45 mm; P = .037) was recorded between the clinical and CBCT data. Regarding defect length, a statistically significant mean difference of 0.81 ± 0.83 mm (P = .003) was noted between the clinical and CBCT data. Similarly, a mean difference of 1.09 ± 1.52 mm was recorded between the defect length assessed histologically and the CBCT data (P = .031). No statistically significant differences were observed between the other evaluated variables. CBCT is a reliable tool for peri-implantitis diagnosis and treatment planning, though the underestimation of defect severity may affect the prognosis and clinical decision-making. Clinicians need to be flexible in establishing prognoses and treatment based on CBCT assessment.

This retrospective study compares clinical and radiographic results of implants with and without a laser-microtextured collar placed in patients with a past history of periodontitis after 10 years of follow-up. A total of 57 implants (29 implants with laser-microtextured collar, 28 implants with a smooth collar) were placed in 35 patients. After 10 years of follow up, the survival rates (SRs) were 87.9% and 84.8% for implants with and without a laser-microtextured collar, respectively. No statistically significant differences (P > .05) were found between groups in terms of full-mouth plaque and bleeding scores. However, a statistically significant difference (P < .05) was recorded in terms of probing depth (PD) and marginal bone loss (mBL). Within the limitations of this study, implants with a laser-microtextured collar and implants with a smooth collar placed in patients with a past history of periodontitis yielded no statistically significant differences in SRs after 10 years of follow-up. However, implants with a laser-microtextured collar showed lower PD and mBL compared to implants with a smooth collar.

This study evaluated long-term clinical and patient satisfaction outcomes following a modified lip repositioning technique that utilized periosteal sutures in a twin population. Twin sisters diagnosed with maxillary lip hypermobility were randomly assigned to either the control group (original LipStaT technique) or test group (addition of periosteal sutures). The participants (n = 12; 6 per group) were evaluated at intervals for up to 3 years postoperative. Clinical measurements, digital images, and patient satisfaction surveys were collected. Descriptive statistics were used to assess outcome variables: average lip width at rest (ALW), vertical lip translation (VLT), and average gingival display (AGD). Student t test, one-way analysis of variance, and Spearman rank correlation tests were used to compare mean values of variables at five time points for both groups. The level of significance was α = .05. In the control group, mean VLT and AGD values showed statistically significant decreases from baseline (14.8 mm and 7.0 mm, respectively) to 2 years (5.7 mm and 2.4 mm, respectively), but a slight increase was seen at 3 years (7.5 mm and 5.0 mm, respectively; P < .0001). In the test group, mean VLT and AGD values showed statistically significant decreases from baseline (14.8 mm and 6.9 mm, respectively) to 3 years (5.5 mm and 3.5 mm, respectively; P < .0001). A higher participant satisfaction score at 3-year follow-up was observed in the test group. The modified lip repositioning technique in a population of twins resulted in more stable outcomes that lasted up to 3 years postoperatively.

The aim of this case report was to present the preliminary results of a novel microsurgical approach to sinus floor elevation and bone augmentation. This technique was used to treat four patients in whom an implant could not be placed in the maxillary first molar position because of insufficient bone height. The maxillary first molar was extracted, and a sinus access window was created in the palatal area of the bony interradicular septum. The sinus membrane with the palatal septum fragment was elevated, and the sinus space between and above the roots was filled with xenograft. Alveolar preservation was done with xenograft and a nonresorbable membrane. Bone augmentation was evaluated 6 months after preservation by computed tomography and histology; clinical, radiologic, and histologic bone reconstruction were seen, allowing placement of implants. The novel approach utilized in this study demonstrated positive preliminary results in bone reconstruction with reduced morbidity.

This computational study analyzed the strain magnitude and distribution within trabecular bone structure around different materials and finish line (FL) configurations of implant abutments loaded axially. Differences in fracture resistance of these abutments were also assessed. Sixteen endosseous screw vent implants were embedded in eight bio-faithful mandibular simulators resembling D2 and D3 bone density (n = 4 models per bone type) in the second premolar and second molar positions. These models were further subdivided into eight subgroups with different FL configurations and abutment materials. Strain gauges were mounted adjacent to the implants, and the superstructures were successively placed on the abutments. A universal dynamometrical testing apparatus was used for a static compression load. Finally, all samples were subjected to load until fracture. Three-way analysis of variance for strain analysis showed a significant overall interaction between the three variables (bone type, FL configuration, and abutment materials; P < .001), while the analysis for fracture resistance showed significant two-way interactions between bone type and FL configuration (P < .001) and between bone type and abutment material (P < .001). The implant abutment material, the FL configuration of the abutment, and the bone type can influence the mechanical behavior of the abutment used. Zirconia abutments with anatomical FL configurations possess better fracture resistance than zirconia and titanium abutments with circular FL configurations in D2 bone density.

The present dry-mandible study evaluated the presence of the mental (MF), lingual (LF), and retromolar (RMF) foramina to assess the accuracy of CBCT in detecting these anatomical structures. In total, 38 human dry mandibles were analyzed (30 men, 8 women; mean age: 61.9 ± 13.7 years). CBCT scans were taken using low-dose parameters, and LF, MF, and RMF were assessed visually and radiographically. Both the presence (yes/no) and the count (n) of each foramen were compared between CBCTs and visual assessment. For the presence assessment, only RMF exhibited a significant difference between CBCT and visual inspection (P = .035). For count, the RMF (P = .049) and paramedian LF (P = .003) exhibited differences between the two methods. The agreement between CBCT and visual inspection was excellent for the MF, moderate-excellent for the LF, and low-moderate for the RMF. Intra- and interassessor agreement varied from excellent (MF), to moderate-excellent (LF), and low-moderate (RMF). The LF and RMF represent challenging structures to identify on CBCT images due to their limited dimension. False negative findings in CBCTs in the assessment of foramina, especially LF, might lead to surgical complications during implant surgery.

The aim of the present study was to compare leukocyte- and platelet-rich fibrin (L-PRF) membranes with a connective tissue graft (CTG) in combination with a coronally advanced flap (CAF) in the treatment of Miller Class I or II localized gingival recessions. A randomized controlled clinical trial with 17 recessions in each group was initiated; the control group received treatment with CAF+CTG, and the test group received CAF+L-PRF. The following variables were measured before treatment and after 1, 3, and 6 months: gingival recession depth (RD), gingival recession width (RW), gingival thickness (GT), probing depth (PD), clinical attachment level (CAL), and keratinized tissue height (KTH). Also, the root coverage percentage (RC), the pain score, postoperative complications, and the root coverage esthetic score (RES) were recorded after surgery. Both treatments presented significant improvements in the RD, RW, and CAL at 1, 3, and 6 months. CTG achieved a significantly higher RC at 1, 3, and 6 months and a significantly higher RES score at 6 months. L-PRF presented a significantly lower pain score and less postoperative complications. Both strategies were effective for the treatment of localized gingival recessions. The CTG obtained higher RC and esthetic results, and L-PRF had less pain and postsurgical complications.