Indications for implant-supported rehabilitation of the posterior atrophic maxilla: A multidisciplinary consensus among experts in the field utilising the modified Delphi method.

PURPOSE: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. MATERIALS AND METHODS: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. RESULTS: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. CONCLUSION: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable.

An Objective Assessment of Orthognathic Surgery Patients.

OBJECTIVES: To retrospectively assess malocclusions, skeletal relationships and the functional needs of orthognathic patients treated in a University teaching hospital. SUBJECTS AND METHODS: This study used clinical records of 100 consecutive patients [51 female, 49 males, mean (SD) age =21.5 (2.71) years] who had orthognathic surgery in a Shahid Beheshti University of Medical Sciences affiliated hospital (9/2014-7/2017). Malocclusion type (incisor classification), sagittal skeletal pattern (ANB angle), index of orthognathic functional treatment need (IOFTN) score, and osteotomy type were recorded. RESULTS: Overall, 66%, 31%, and 3% had Class III, II, and Class I malocclusions, respectively. Similarly, 68% and 32% had Class III and II sagittal skeletal relationships, respectively. Overall, 95% of patients scored IOFTN 4 or 5. The most prevalent IOFTN score were 4.3 (37%), 5.3 (16%), 5.4 (16%), and 4.2 (10%). There were no gender differences (P >0.05) for the distribution of malocclusions, sagittal skeletal relationships, different IOFTN scores, or when IOFTN scores were re-grouped (5, 4, and ≤3). When IOFTN scores were re-grouped (5, 4, and ≤3), they were equally distributed among patients with Class II or III skeletal relationships (P >0.05), but when the authors looked at different malocclusions, there were significant differences in IOFTN score distribution (P = 0.006). The use of genioplasty (4%) or distraction osteogenesis (2%) was limited. Single jaw surgery of either maxilla or mandible was used in 15% and 22% of patients, respectively. About 63% had undergone double-jaw surgery. CONCLUSION: Retrospective assessment using IOFTN identified 95% of patients as having great and very great functional needs, but prospective studies using IOFTN is needed to assess the need for orthognathic surgery. Class III malocclusions and Class III sagittal skeletal relationships were more common in this sample.

A Retrospective Analysis of Dentofacial Deformities and Orthognathic Surgeries.

BACKGROUND: Information regarding the prevalence of surgical osteotomies used for the correction of dentofacial deformities in Iran is lacking. MATERIALS AND METHODS: This retrospective cross-sectional study assessed the distribution of orthognathic surgeries performed (2011-2015) at major University hospital in Iran. Records of 103 orthognathic surgery patients were assessed (58 female, 45 males, aged = 23.47 [6.44] years). RESULTS: Class III malocclusion (incisor classification, 45.6%) and Class II skeletal pattern (based on ANB angle, 51.5%) were the most prevalent type. Overall, 4.8%, 51.5%, and 43.7% of subjects had Class I, II, and III sagittal skeletal patterns, respectively. The most prevalent (66%) osteotomy was the bimaxillary osteotomy. The frequencies of reported and corrected asymmetries in the lower third of the face (35%) were similar among patients with different malocclusions (χ2 = 4.134, P = 0.127) or sagittal skeletal patterns (χ2 = 2.133, P = 0.344), as well as between Class II and III malocclusions (P = 0.125) or sagittal skeletal patterns (P = 0.149). CONCLUSION: Compared to Class II subjects, Class III (malocclusions or sagittal skeletal patterns) subjects had more bimaxillary osteotomies, indicating the higher prevalence of skeletal discrepancies affecting both jaws in Class III subjects.

Three-Dimensional Alveolar Bone Anatomy of the Maxillary First Molars: A Cone-Beam Computed Tomography Study With Implications for Immediate Implant Placement.

PURPOSE: To retrospectively evaluate alveolar dimensions of healthy maxillary first molars (MFMs), which have implications for (immediate) implant placement and endodontic therapy. MATERIALS AND METHODS: Cone-beam computed tomographic records of 95 patients (150 MFMs) were used [32 men and 63 men, aged 37.2 (14.9) years]. The vertical distance from sinus floor (SF) and MFM apexes (mesio-buccal [MB] and disto-buccal [DB]) and also distance between root apexes (spreading of the roots, MB to palatal and DB to palatal, representing bone width) were measured. RESULT: The mean (SD) thickness of buccal and palatal bony walls (2 mm from crest) was 1.58 (0.6) mm and 1.34 (0.54) mm, respectively. The mesio-distal and bucco-lingual socket sizes at crest were 7.3 (0.84) mm and 10.5 (0.90) mm, respectively. The mean distance from SF to MFM furcation was 6.51 (2.94) mm. The mean distance (95% confidence interval) between SF and MB, DB, and palatal apexes was -0.36 mm (-0.91 to 0.19), 0.32 mm (-0.27 to 0.9), and -2.2 mm (-2.7 to -1.7), retrospectively. Significant differences were found for root apex distances to SF for MB versus palatal roots and DB roots versus palatal roots, but not for MB versus DB roots (P > 0.05). CONCLUSION: The present findings on MFM dento-alveolar morphology, in particular high intrusion of palatal roots into SF, can be used as a clinical risk management tool for immediate implant placement and endodontic therapy.

Simultaneous implant placement and bone grafting with particulate mineralized allograft in sites with buccal wall defects, a three-year follow-up and review of literature.

OBJECTIVES: To assess the relationship between the vertical buccal defect size and the outcome of single-stage (non-submerged) implant placement and simultaneously augmentation of sites with mineralized particulate allograft (Puros Cancellous) using collagen membranes (Ossix Plus). SUBJECTS AND METHODS: Records of 108 partially edentulous patients with localized, buccal bone defects in the posterior maxilla and/or mandible [156 tissue-level Straumann implants, 38 male, 70 female, average age = 46.7 (6.4) years] were used for this study. Sectional CBCT scans were used to evaluate ridge forms before implant placement and after bone grafting (36 ± 2.2 months). The initial vertical buccal wall defect was recorded by measuring the amount of vertical Implant Platform's Rough Surface Exposure (IPRSE) when implants were placed [small (<3 mm), medium (3-5 mm), and large (>5 mm)]. The ridge contour at 36 (±2.2) months was classified into 3 categories [completely corrected (no IPRSE seen on CBCT), partially improved (some IPRSE seen on CBCT), no difference/worse]. RESULTS: Complete defect correction occurred in 66 (61.1%) patients followed by improved ridge contours in 38 patients. Significant differences were observed in the outcome of simultaneous grafting of sites with different pre-treatment vertical defect sizes (chi-square = 69.394, df = 4, P < 0.001). Two graft failures (one needed regrafting) and 2 implant failures were also seen. Treatment was effective in complete correction of 100% and 79.3% of small and medium-sized vertical defects, respectively. Large-sized defects showed only partial improvement in 90% of cases, without any complete correction. Cumulative implant and graft survival was 98.1%. CONCLUSIONS: Single-stage implant placement and simultaneous grafting with mineralized particulate allograft showed promising outcome in correcting small and medium sized vertical buccal wall bone defects (<5 mm).

Assessment of short dental implants restored with single-unit nonsplinted restorations.

OBJECTIVES: To investigate the survival rate of short (≤9 mm) implants restored with single-unit, nonsplinted crowns after an average follow-up of 37 months (21-94 months). MATERIALS AND METHODS: Two hundred and twenty-one implants placed in 168 patients (74 men, 94 women, aged 34-87 years, mean = 61 years). Implant lengths were 6 (n = 16), 8 (n = 166), 8.5 (n = 2), or 9 mm (n = 34). The implant diameters ranged from 3.7 to 5.6 mm. Implants were placed in the maxillary (n = 44) and mandibular arches (n = 176). RESULTS: Survival rate was 94.1% (maxilla [88.6%] and mandible [96.0%]) and 12 early failures (first 4 months) and 1 late failure (4.5 years in the maxillary molar region) observed. Of the 12 early failures, 4 were in the maxilla (2 premolars and 2 molars) and 8 in the mandible (2 premolars and 6 molars). The early failures were 11 implants of 8 mm long and a 9-mm implant. Smoking cigarettes, diabetes mellitus, and bone augmentation procedures were not associated with implant failure significantly (P > 0.05). CONCLUSIONS: Survival rate of short implants restored with single-unit, nonsplinted restorations over an average period of 37 months was favorable and comparable with longer implants.

Labial bone thickness in area of anterior maxillary implants associated with crestal labial soft tissue thickness.

OBJECTIVE: To explore the relationship between implant's labial bone thickness (ILBT) and crestal labial soft tissue thickness (CLSTT). MATERIALS AND METHODS: This retrospective study used records of 32 (22 females and 10 males) patients who had 2 implants placed in their maxillary arch (64 implants; diameter range, 3.3-4.6 mm) between the canines at either maxillary lateral incisor (7 and 10) or central incisor (8 and 9) region. All patients had diagnostic and postoperative cone beam computed tomography scans; the ILBT at the crestal and midimplant levels were recorded. CLSTT was measured approximately 4 months after the placement of implants using a digital caliper at the crestal level. RESULTS: Mean (standard deviation) CLSTT and ILBT at crestal and at midimplant levels were 2.45 (0.88), 1.79 (0.68), and 2.33 (1.01) mm, respectively. Overall, 26 implants had prior bone augmentation. Significant relationships between the CLSTT and ILBT at crestal (Spearman's rho = 0.720) and midimplant levels (Spearman's rho = 0.707) were observed (P < 0.001). The determination coefficients (R) between CLSTT and ILBT at crestal and midimplant levels were 0.649 and 0.542, respectively. Following regression equations were produced: CLSTT = 1.043 * ILBT (crestal level) + 0.586 and CLSTT = 0.955 * ILBT (midimplant level) + 0.955. CONCLUSION: Based on this study, CLSTT and ILBT were highly associated in the anterior maxillary region.

Alveolar cleft repair in adults using guided bone regeneration with mineralized allograft for dental implant site development: a report of 2 cases.

Alveolar bone grafting is an integral part of the surgical management of oral clefts. The rationale behind alveolar cleft repair includes maxillary arch stabilization, closure of the oronasal fistula, nasal base support, nasolabial soft tissue reconstruction, and creation of bony support for tooth eruption or dental implant placement. Currently, the graft material of choice is autogenous bone graft from the anterior iliac crest. Nonetheless, autogenous bone grafting carries the significant risk of donor-site morbidity, leads to postoperative pain, and entails an additional operative cost. With the success of allograft bone material in implant site development, we explore the option of using human mineralized cancellous bone allograft in alveolar cleft patients. This article reports on the success of using mineralized human allograft to treat 2 adult patients with severe alveolar cleft defects. The repairs were accomplished with a guided bone regeneration technique without the use of any autogenous bone, with subsequent successful placement of endosseous implants. This opens up the possibility of avoiding harvesting iliac crest bone graft and its associated morbidities and expense by use of only mineralized allograft and a guided bone regeneration technique in an outpatient office setting.

Dental implants in a young patient with Papillon-Lefevre syndrome: a case report.

A case is reported of dental implant placement in a 13-year-old patient diagnosed with Papillon-Lefevre Syndrome. Two titanium dental implants were placed in the mandible for an implant-retained denture after the patient complained of having an unstable prosthesis. Follow-up radiographs showed successful osseointegration and preservation of alveolar bone 1 year after implant placement and the continual wearing of a functional dental prosthesis.

Referral patterns for the treatment of facial trauma in teaching hospitals in the United States.

PURPOSE: The management of facial trauma is considered an integral part of the training of several specialties, including general plastic surgery, otolaryngology, and oral and maxillofacial surgery. Referral patterns of patients who have sustained facial trauma to these various specialty services, however, vary at different institutions according to physician preferences and protocols. The purpose of this project was to examine the referral patterns of facial trauma in the United States at teaching hospitals. MATERIALS AND METHODS: A questionnaire survey of physician-chiefs of emergency or trauma services at teaching hospitals was carried out. Scenarios involving a variety of facial injury patterns were presented, and a hypothetical referral was requested. In addition, questions regarding preferences and opinions regarding the various services were included. RESULTS: Most teaching hospitals had a formal protocol for the referral of patients with facial injuries. With the exception of mandible fractures, referral patterns for patients with facial injuries were relatively even across the 3 specialties. Interestingly, only 56% of respondents would seek the same referral for themselves or relatives in the same way as they would refer a patient based on their in-house protocol. In regard to timeliness, efficiency, and perceived competency in the handling of facial trauma, oral and maxillofacial surgery had statistically significant higher scores than otolarygology and plastic surgery, which were not statistically distinguishable between each other. CONCLUSIONS: All 3 specialties appear to be involved in the management of facial trauma at teaching institutions in the United States; therefore, it seems unlikely that any one specialty will be singled out as the sole provider of these services at all institutions.