Managing Patient Treatment Through Deming's PDCA Cycle: A Standardized Approach in Phases that Adds Value to Dental Care.

This essay is an expert opinion by 3 clinicians who feel the need for a clear phased approach capable of integrating all dental therapies for the care of patients suffering from multiple pathologies of the oral cavity. At the moment, the only guidelines available when treating interdisciplinary cases, i.e., patients with multiple overlapping pathologies (carious disease, periodontal disease, malocclusion, incongruous restorations, etc.), are those describing the proper sequence of periodontal therapy. The authors take inspiration from a method developed in the manufacturing world, the so called "lean management", and its tools to outline the sequence of therapy phases and the correct placement of the various activities within these phases. In the "lean healthcare", it is the patient at the center of the attention and it is him/her who "pulls" the process with his/her health as the main value.

Regenerative Orthodontics: GBR and Corticotomy to Stretch the Limits of Orthodontic Treatment.

Orthodontic therapy could lead to marginal bone resorption in cases where the teeth are moved outside the envelope of bone. The purpose of this case series was to test corticotomy with a guided bone regeneration (GBR) procedure to regenerate bone in the direction of movement outside the original bony housing. Ten adult patients (60 anterior teeth), all presenting with severe anterior crowding, were enrolled in the study. Orthodontic therapy in all investigated sites was associated with selective surgical corticotomies and a simultaneous GBR procedure. CBCT examinations were performed before starting orthodontic treatment (T0) and at the end of treatment (T1; mean: 7 months; range: 6 to 9 months). Pre- and postoperative CBCTs were superimposed with a DICOM viewer (3D Slicer) and studied with an image-processing software (ImageJ, National Institutes of Health) to measure the area of interest of the buccal plate. The average area was found to be 0.58 ± 0.22 mm2 at T0 and 1.76 ± 0.4 mm2 at T1, with a statistically significant difference (P < .05). The combination of corticotomy and a regenerative procedure seems to have the ability to augment the original osseous anatomy when the root is moved outside of the original bony envelope.

Oral Care and Quality Evaluation: A Multicentric Study on Periodontal Treatment.

PURPOSE: No information is available on the perception of the quality of care in patients treated for periodontitis. The purpose of this article was to assess how periodontitis-affected patients perceive the quality of periodontal treatment (PT) and to measure the factors which may influence it. MATERIALS AND METHODS: 306 subjects who completed PT were invited to participate. Questionnaires and visual analogic scales (VAS) evaluating perception of quality of care, symptoms, and oral health related quality of life (OHRQoL) were handed out. Oral and periodontal indicators were collected before and after treatment. The impact of different factors on perception of quality was assessed with a regression model. RESULTS: Quality evaluation was high yet unrelated for both patients and clinicians (p = 0.983). Quality was negatively influenced by the number of residual oral infections (p < 0.001), patient's age (p = 0.07) and presence of residual pain at completion of PT (p = 0.02). Professionalism, kindness of the staff and communication skills were the characteristics mostly appreciated. The OHRQoL was influenced by the number of residual teeth (p < 0.001), increasing age of patients (p = 0.08), number of residual infections (p < 0.01) and pain (p = 0.04). CONCLUSIONS: Patients' quality perception appeared to be influenced by clinical and emotional aspects. Oral care providers should be aware of the impact of non-clinical factors in patients' appreciation of quality of treatment.

Peri-Implant Mucosal Creeping: Two Case Reports.

While creeping attachment in natural teeth has been reported in the literature for decades, the same phenomenon around dental implants is a new concept. This article describes two implant cases treated with free gingival autograft with follow-up at 18 and 30 months. Progressive coronal creeping of the mucosal margin was observed covering the implant and abutment surfaces postoperatively. This report demonstrates that mucosal creeping around implants may occur after peri-implant plastic surgical procedures, further improving the final outcomes of therapy.

Randomized Clinical Investigation of Titanium Implants with and without Platform Switching: Six Months' Radiographic and Clinical Outcome.

The aim of this study was to obtain a randomized, clinical and radiological comparison of implants with and without platform switching (PFS). The two compared titanium implant types differed only in the microgap position: test (PFS) or control (StE, no PFS). All implants were inserted in posterior regions and followed up for six months after abutment connection (AC). Twenty one patients with 21 PFS and 18 StE implants completed the six-month evaluation. No implant failed. One complication (exposed cap screw) was reported at AC. No statistically significant difference was observed between the marginal bone level of PFS and StE implants. Their bone level stabilized approximately 1 mm below the microgap. Based on the outcome of this short-term study with a limited number of patients, it seems unlikely that the optimal clinical and radiological outcome obtained with the tested standard implant (no PFS) can be improved by introducing an inward microgap shift (PFS).

Simultaneous sinus augmentation with implant placement: histomorphometric comparison of two different grafting materials. A multicenter double-blind prospective randomized controlled clinical trial.

PURPOSE: Sinus elevation via the lateral approach for implant rehabilitation of atrophic posterior maxillae is considered a safe and predictable therapy. Several xenogeneic biomaterials of different biologic origin have been used as valid and predictable alternatives to autogenous bone. This multicenter randomized controlled double-blind prospective clinical trial aimed to compare histomorphometrically two xenogeneic grafting materials used for sinus elevation with simultaneous implant placement. MATERIALS AND METHODS: Seven private practices in Italy were involved. Patients presenting at least one site with a residual bone crest height between 2 and 4 mm were treated. Control sites were grafted with 100% deproteinated particulated bovine bone (DPBB), while test sites were grafted with prehydrated corticocancellous porcine bone (PCPB). Root-form implants were placed simultaneously. Insertion torque and clinical stability were assessed and recorded. At 6 months, a biopsy specimen was harvested from each site, and histomorphometric analyses were performed. RESULTS: Thirty-seven patients received 42 sinus elevations (24 test and 18 control). Eighty-two implants with adequate primary stability were placed. Fifty-five implants were placed in residual bone crests greater than 2 mm but less than 4 mm (average 2.7 mm) and achieved an average insertion torque of 22.8 ± 11.3 N/cm. Nineteen implants were placed in ridges greater than 3 mm but less than 5 mm, and eight were placed in ridges with more than 5 mm remaining. After 6 months, three implants had failed to integrate, leading to a survival rate of 96.34%. Forty-two specimens were analyzed histomorphometrically. No significant differences in total bone volume (PCPB 37.43%, DPBB 37.52%) or residual grafting material (PCPB 13.55%, DPBB 16.44%) were detected. CONCLUSIONS: In this study, PCPB compared well with DPBB as a grafting material for lateral sinus elevation.

Harvesting bone in the recipient sites for ridge augmentation.

A modified ridge augmentation technique is introduced for augmenting deficient alveolar ridges in preparation for endosseous implant placement. The technique is based on the principles for guided bone regeneration, in which a created space is kept isolated from the surrounding soft tissues by a resorbable membrane with an excellent extended resorption profile, thus permitting the accrual of bone-formative elements into the graft site. The absorbable membrane is propped up by an autogenous mixture of native corticocancellous bone cores taken in the graft site and reduced to smaller particle sizes and osseous coagulum collected in bone traps and with a special bone scraper. The major advantage of this technique is that all the autogenous bone graft material is obtained from the actual graft site, avoiding second remote intra- or extraoral surgical sites and attendant morbidities. Ridges augmented with this technique permit optimal endosseous implant placement.

Comparison of the effectiveness of scaling and root planing in vivo using hand vs rotary instruments.

The purpose of the present investigation was to compare the effectiveness of a scaling bur and conventional Gracey curettes in vivo. Ten teeth scheduled for extraction were scaled and root planed thoroughly before extraction. The instrumented areas were observed using SEM. Scaling with a No. 12 fluted carbide bur was more effective in removing debris and plaque than were conventional Gracey curettes. Because of the aggressive nature of the process, a certain learning curve is necessary to get accustomed to bur scaling; otherwise, dentinal hypersensitivity and patient discomfort may be increased.

The role of the implant housing in obtaining aesthetics: Part 2. Customizing the peri-implant soft tissue.

The successful placement of single-tooth implants can be evaluated by the degree of implant osseointegration, longevity of the restoration, and the aesthetics provided by the prosthesis. Implant aesthetics can be determined by the degree of scallop and harmony achieved with the surrounding peri-implant collar of gingivae. This article analyzes features of the abutment-restoration complex that are critical to customization of the peri-implant tissues and the development of the ultimate aesthetic peri-implant gingival profiles.

Augmentation of an anterior edentulous ridge for fixed prosthodontics with combined use of orthodontics and surgery: a clinical report.

Untreated periodontitis may lead to tooth and tissue loss that can result in diminished masticatory function and esthetic deformities. Combined periodontal/prosthodontic treatment for patients with advanced periodontal disease has been well documented, and treatment results can often be improved with the use of adjunctive orthodontic treatment such as forced eruption. This clinical report describes a method of preprosthetic preparation of an edentulous ridge for a fixed partial denture that incorporates the combined use of orthodontics and surgical ridge augmentation.

Crown lengthening in mandibular molars: a 5-year retrospective radiographic analysis.

BACKGROUND: Crown lengthening procedures are a significant part of the periodontist's armamentarium. In order to recreate the clinical space lost to caries or trauma necessary for prosthetic restoration, osseous surgery is often required. If the procedure is not carefully planned, it may result in furcation involvement of multirooted teeth. METHODS: Twenty-six subjects with 26 mandibular molar teeth requiring crown lengthening procedures prior to prosthetic crown placement were evaluated. Nineteen subjects with 24 prosthetic crowns on lower molars which had not undergone crown lengthening were included as control teeth. Bite-wing radiographs prior to surgery (for the test group) or placement of the crown (control group) and 5 years after completion of the prosthesis were compared and analyzed. RESULTS: Of the 26 test teeth, 10 teeth (38.5%) were found to have radiographic evidence of furcation involvement, whereas none of the control teeth developed furcation invasions. CONCLUSION: A critical distance from the furcation (CDF) of 4 mm was established as a landmark under which, if surgery was performed on mandibular molars, chances of furcation involvement in the future were very high.

The role of the implant housing in obtaining aesthetics: generation of peri-implant gingivae and papillae--Part 1.

The use of osseointegrated implants provides predictable, long-term aesthetics, providing that the implant housing and peri-implant gingivae are adequately maintained. Restoration-driven implant placement must, therefore, result in the development of harmonious peri-implant soft tissue contour as compared to the adjacent natural teeth. This article analyzes the implant housing features that influence aesthetics in implant therapy. Case presentations that include surgical and restorative innovations are described to illustrate methods used to achieve aesthetics with single-tooth implant restorations.

Oral piercing and gingival recession: review of the literature and a case report.

A young adult developed severe gingival recessions and radiographic signs of trauma to the periodontium after wearing a tongue barbell and a lip stud. Oral body art (piercing) can be hazardous to the periodontium; nevertheless, patients inclined to such practices do not see them as health hazards and are very reluctant to remove them.