White discharge formation following a subepithelial connective tissue graft for anterior fixed partial denture pontics: A case report based on clinical and histological findings.

PATIENT: A 54-year-old woman presenting with anterior alveolar ridge resorption was submitted to a connective tissue graft (CTG) for esthetic improvement before rehabilitation with a fixed partial denture. Palate-harvested connective tissue was used as a graft after extra-oral removal of the epithelium. Unexpectedly, complete wound healing was not observed. Moreover, 6 months post-surgery, a white discharge was detected at the grafted site. The adjacent tooth showing a root fracture was initially associated with the symptoms and was then extracted. Concomitantly, the unhealed tissue at the grafted site was also excised, leading to temporary symptom resolution. However, the white discharge reappeared after 2 months. The excision area was expanded to remove the grafted tissue entirely, and the wound was completely healed. Since the alveolar ridge resorption had become larger compared to the preoperative condition, the patient was subjected to a second CTG, now using a connective tissue harvested from the palate by a single incision technique. The wound healed uneventfully, and the final prosthesis was delivered 6 months after soft tissue stabilization. The patient has been followed-up for more than 28 months without any recurrence of white discharge. DISCUSSION: Histopathological and cytological examination detected keratinized epithelial tissues and cells, respectively, in excised tissues and white discharge specimens. Consequently, a possible relationship between white discharge and residual epithelium in the harvested graft was strongly suspected. CONCLUSION: Success of the CTG procedure requires careful method selection for tissue transplantation and treatment execution.

Assessment of the Soft-Tissue Seal at the Interface between the Base of the Fixed Denture Pontic and the Oral Mucosa.

Fixed dentures (bridges) are often selected as a treatment option for a defective prosthesis. In this study, we assess the contact condition between the base of the pontic and oral mucosa, and examine the effect of prosthetic preparation and material biocompatibility. The molars were removed and replaced with experimental implants with a free-end type bridge superstructure after one week. In Experiment 1, we assessed different types of prosthetic pre-treatment: (1) the untreated control group (Con: mucosa recovering from the tooth extraction); (2) the laser irradiation group (Las: mucosa recovering after the damage caused by a CO2 laser); and (3) the tooth extraction group (Ext: mucosa recovering immediately after the teeth extraction). In Experiment 2, five materials (titanium, zirconia, porcelain, gold-platinum alloy, and self-curing resin) were placed at the base of the bridge pontic. Four weeks after the placement of the bridge, the mucosa adjacent to the pontic base was histologically analyzed. In Experiment 1, the Con and Las groups exhibited no formation of an epithelial sealing structure on the pontic base. In the Ext group, adherent epithelium was observed. In Experiment 2, the sealing properties at the pontic interface were superior for titanium and the zirconia compared with those made of porcelain or gold-platinum alloy. In the resin group, a clear delay in epithelial healing was observed.

Facial bone alterations on maxillary anterior single implants for immediate placement and provisionalization following tooth extraction: a superimposed cone beam computed tomography study.

OBJECTIVES: The purpose of this cone beam computed tomography (CBCT) study was to describe the facial bone changes around single implants for immediate placement and provisionalization following tooth extraction in the maxillary anterior. MATERIAL AND METHODS: The data between 2008 and 2013 were collected retrospectively. Superimposed facio-palatal cross-sectional CBCT images for the implants were derived from preoperative and postoperative radiographs via standardized CBCT processes. Horizontal and vertical facial measurements on the implants were identified at preoperative and approximately 1-year postoperative follow-ups. Correlation coefficient for those parameters was evaluated. RESULTS: A total of 12 single implants in 12 patients were included in this study. The mean loading period was 13.3 months (range 12-15 months). The median data of preoperative bone thickness 0.54 mm (A), preoperative vertical bone level 1.46 mm (B), postoperative bone thickness 1.77 mm (C), postoperative vertical bone level 1.08 mm (D), horizontal distance from outer surface of preoperative facial bone to implant surface 2.08 mm (E), horizontal gap distance 1.41 mm (E-A), horizontal bone resorption -0.26 mm (E-C), and vertical bone resorption -0.25 mm (B-D) were obtained. The data at the implant platform level (IPL) were selected for the horizontal measurements. Spearman's analysis demonstrated statistically significant correlations between B and D, C and E, E and E-A, and B and E-C (P < 0.01). Significant correlations between C and B, D, and E-A were also found, respectively (P < 0.05). CONCLUSIONS: Immediate placement and provisionalization of single implants procedure in the maxillary anterior showed excellent outcomes with the small facial bone alterations around the implants. Neither preoperative facial bone thickness nor horizontal gap distance influenced the amount of facial bone resorptions.

Immediate implant placement and provisionalization with and without a connective tissue graft: an analysis of facial gingival tissue thickness.

Facial gingival tissue thickness (FGTT) is important for an esthetically pleasing anterior restoration since it determines the soft tissue's ability to conceal the underlying restorative material. The purpose of this study was to investigate the change in FGTT after immediate implant placement and provisionalization with and without a connective tissue graft. Patients with a failing maxillary anterior tooth planned for immediate implant placement and provisionalization with (CT group) or without (NCT group) a subepithelial connective tissue graft were included in this study. After tooth extraction, direct measurement of the FGTT was performed; subsequent measurements were performed at the time of definitive prosthesis placement. Data were analyzed using independent and paired t tests at a significance level of α = .05. There was no statistically significant difference in the mean FGTT at tooth extraction between the CT and NCT groups. At prosthesis delivery, the mean FGTT for the CT group was significantly greater than that of the NCT group. The mean FGTT of both groups at prosthesis delivery was significantly higher than that at tooth extraction. The mean change in FGTT in the CT group was also significantly greater than that in the NCT group. Immediate implant placement and provisionalization in conjunction with a connective tissue graft is more likely to result in sufficient peri-implant tissue thickness to conceal underlying implant restorative materials than when performed without a connective tissue graft.

Biological adaptation to misfits of immediately loaded fixed prostheses following computer-guided surgery.

In this clinical report, following computer-guided (3D Procera Software Planning Program, Nobel Biocare, Yorba Linda, CA) placement and immediate provisionalization of 12 dental implants (NobelSpeedy™ Replace, Nobel Biocare), misfits of the prefabricated screw-retained interim prostheses were noted at several implant-abutment junctions. Nevertheless, adaptation of the misfits was observed 10 days later, after the loosened screws were tightened. While a high mean marginal bone loss of 2.1 mm (range: 1.4 to 3.5 mm) was noted, all implants remained osseointegrated at 3-year follow-up.

Gingival biotype assessment in the esthetic zone: visual versus direct measurement.

This study evaluated the reliability of assessing visually the facial gingival biotype of maxillary anterior teeth with and without the use of a periodontal probe in comparison with direct measurements. Forty-eight patients (20 men, 28 women) with a single failing maxillary anterior tooth participated in this study. Three methods were used to evaluate the thickness of the gingival biotype of the failing tooth: visual, periodontal probing, and direct measurement. Prior to extraction, the gingival biotype was identified as either thick or thin via visual assessment and assessment with a periodontal probe. After tooth extraction, direct measurement of the gingival thickness was performed to the nearest 0.1 mm using a tension-free caliper. The gingival biotype was considered thin if the measurement was =or<1.0 mm and thick if it measured>1.0 mm. The assessment methods were compared using the McNemar test at a significance level of a=.05. The mean gingival thickness obtained from direct measurements was 1.06+/-0.27 mm, with an equal distribution (50%) of sites with gingival thicknesses of =or<1 mm and >1 mm. The McNemar test showed a statistically significant difference when comparing the visual assessment with assessment using a periodontal probe (P=.0117) and direct measurement (P=.0001). However, there was no statistically significant difference when comparing assessment with a periodontal probe and direct measurement (P=.146). Assessment with a periodontal probe is an adequately reliable and objective method in evaluating gingival biotype, whereas visual assessment of the gingival biotype by itself is not sufficiently reliable compared to direct measurement.

Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone: consecutive case report.

PURPOSE: The present consecutive case report evaluated facial gingival tissue stability after immediate tooth replacement with connective tissue grafting in the esthetic zone. The implant success rate and peri-implant tissue response were also recorded. PATIENTS AND METHODS: A total of 20 consecutive patients with a mean age of 52.3 years (range 28 to 71), who had undergone 20 single immediate tooth replacement with connective tissue grafting, were evaluated clinically and radiographically at the preoperative examination, immediately after implant placement and provisionalization with connective tissue grafting, and at the latest follow-up appointment. The data were analyzed using the t test and Wilcoxon signed rank test at a significance level of alpha = .05. RESULTS: At the preoperative examination, a thick gingival biotype was observed in 8 patients and a thin gingival biotype in 12. At a mean follow-up of 2.15 years (range 1 to 4), all implants were functioning and exhibited a thick biotype. At the latest follow-up appointment, no significant differences (P > .05) were found between the initially thick and thin gingival biotypes in the mean mesial marginal bone level changes (-0.53 versus -0.55 mm), the mean distal marginal bone level changes (-0.50 versus -0.44 mm), and the mean facial gingival level changes (+0.23 mm versus +0.06 mm). The frequency distribution of the papilla index score showed that peri-implant papillae were well preserved at the latest follow-up visit. CONCLUSIONS: With proper 3-dimensional implant positioning and bone grafting into the implant-socket gap, the facial gingival level can be maintained after connective tissue grafting with single immediate tooth replacement, regardless of the initial gingival biotype, indicating that the thin gingival biotype can be converted to the thick gingival biotype morphologically and behaviorally with this procedure. Nevertheless, careful patient selection and treatment planning, as well as immaculate execution by skillful clinicians, are required to achieve a successful result.