Living cellular constructs for keratinized tissue augmentation: A 13-year follow-up from a split-mouth randomized, controlled, clinical trial.

BACKGROUND: A 13-year follow-up was conducted of a short-term investigation of the use of living cellular construct (LCC) versus free gingival graft (FGG) for keratinized tissue width (KTW) augmentation in natural dentition, to evaluate the long-term outcomes and assess the changes occurring since the end of the original 6-month study. METHODS: Twenty-four subjects out of the original 29 enrolled participants were available at the 13-year follow-up. The primary endpoint was the number of sites demonstrating stable clinical outcomes from 6 months to 13 years (defined as KTW gain, stability, or ≤0.5 mm of KTW loss, together with reduction, stability, or increase of probing depth, and recession depth [REC] ≤0.5 mm). Secondary outcomes included the assessment of KTW, attached gingiva width (AGW), REC, clinical attachment level, esthetics, and patient-reported outcomes at the 13-year visit, assessing the changes from baseline to 6 months. RESULTS: Nine sites per group (42.9%) were found to have maintained stable (≤0.5 mm or improved) clinical outcomes from 6 months to 13 years. No significant differences were observed for the clinical parameters between LCC and FGG from 6 months to 13 years. However, the longitudinal mixed model analysis showed that FGG delivered significantly better clinical outcomes over 13 years (p < 0.01). LCC-treated sites exhibited superior esthetic outcomes compared to FGG-treated sites at 6 months and 13 years (p < 0.01). Patient-evaluated esthetics were significantly higher for LCC over FGG (p < 0.01). Patient overall treatment preference was also in favor of LCC (p < 0.01). CONCLUSIONS: A similar stability of the treatment outcomes from 6 months to 13 years was found for LCC- and FGG-treated sites, with both approaches shown to be effective in augmenting KTW and AGW. However, superior clinical outcomes were found for FGG over 13 years, while LCC was associated with better esthetics and patient-reported outcomes than FGG.

Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: Longitudinal analysis of six randomized clinical trials.

AIM: To assess the prognostic value of soft tissue phenotype modification following root coverage procedures for predicting the long-term (10-year) behaviour of the gingival margin. MATERIALS AND METHODS: Participants from six randomized clinical trials on root coverage procedures at the University of Michigan were re-invited for a longitudinal evaluation. Clinical measurements were obtained by two calibrated examiners. A data-driven approach to model selection with Akaike information criterion (AIC) was carried out via multilevel regression analyses and partial regression plotting for changes in the level of the gingival margin over time and interactions with the early (6-month) results of soft tissue phenotypic modification. RESULTS: One-hundred and fifty-seven treated sites in 83 patients were re-assessed at the long-term recall. AIC-driven model selection and regression analyses demonstrated that 6-month keratinized tissue width (KTW) and gingival thickness (GT) influenced the trajectory of the gingival margin similarly in a concave manner; however, GT was the driving determinant that predicted significantly less relapse in the treatments, with stability of the treated gingival margin obtained beyond values of 1.46 mm. CONCLUSIONS: Among a compliant patient cohort, irrespective of the rendered therapy, the presence of at least 1.5 mm KTW and 1.46 mm GT was correlated with the long-term stability of the gingival margin.

Amnion-Chorion Membrane in Open-Wound Approach for Localized Horizontal Ridge Augmentation: A Case Series Report.

INTRODUCTION: Guided bone augmentation often requires extensive releasing of the mucoperiosteal flap to achieve primary wound closure, an invasive procedure that can compromise the keratinized tissue volume and increase patient morbidity. Amnion-chorion membranes have been used to actively promote healing in chronic open-wound situations in the medical field, suggesting that they could be used in a similar manner in the oral cavity.The ability to use open-wound healing techniques for guided bone regeneration would allow clinicians to avoid invasive procedures that cause additional tissue trauma at the surgical site. CASE SERIES: Amnion-chorion membranes were applied over the bone grafting material augmenting localized horizontal ridge defects, and a gap between the flaps was left intentionally during healing. Minor flap releasing procedures were performed in these cases, which demonstrated uneventful soft tissue healing, good volume of bone regeneration and preserved keratinized tissue. CONCLUSIONS: Preliminary clinical outcomes suggested contained minor horizontal ridge defects may be treated satisfactorily in a controlled, open-wound healing manner that reduces surgical trauma, chair time, and patient morbidity.

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE FOR TREATMENT OF STAGE IIII PERIODONTITIS.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Berglund T, Sculean A, Tonetti MS; EFP Workshop Participants and Methodological Consultants. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020 Jul;47 Suppl 22:4-60. doi: 10.1111/jcpe.13290. PMID: 32,383,274. SOURCE OF FUNDING: Internal funds of the European Federation of Periodontology. TYPE OF STUDY/DESIGN: Clinical guideline and recommendations developed based on 15 systematic reviews and consensus from the experts in the field of periodontology.

Ultrasonography for chairside evaluation of periodontal structures: A pilot study.

BACKGROUND: The crestal bone level and soft tissue dimension are essential for periodontal diagnosis and phenotype determination; yet, existing measurement methods have limitations. The aim of this clinical study was to evaluate the correlation and accuracy of ultrasound in measuring periodontal dimensions, compared to direct clinical and cone-beam computed tomography (CBCT) methods. METHODS: A 24-MHz ultrasound probe prototype, specifically designed for intraoral use, was employed. Periodontal soft tissue dimensions and crestal bone levels were measured at 40 teeth and 20 single missing tooth gaps from 20 patients scheduled to receive a dental implant surgery. The ultrasound images were interpreted by two calibrated examiners. Inter-rater agreement was calculated by using inter-rater correlation coefficient (ICC). Ultrasound readings were compared with direct clinical and CBCT readings by using ICC and Bland-Altman analysis. RESULTS: The following six parameters were measured: 1) interdental papilla height (tooth), 2) mid-facial soft tissue height (tooth), 3) mucosal thickness (tooth), 4) soft tissue height (edentulous ridge), 5) mucosal thickness (edentulous ridge), and 6) crestal bone level (tooth). Intra-examiner calibrations were exercised to achieve an agreement of at least 0.8. ICC between the two readers ranged from 0.482 to 0.881. ICC between ultrasound and direct readings ranged from 0.667 to 0.957. The mean difference in mucosal thickness (tooth) between the ultrasound and direct readings was -0.015 mm (95% CI: -0.655 to 0.624 mm) without statistical significance. ICC between ultrasound and CBCT ranged from 0.654 to 0.849 among the measured parameters. The mean differences between ultrasound and CBCT range from -0.213 to 0.455 mm, without statistical significance. CONCLUSION: Ultrasonic imaging can be valuable for accurate and real-time periodontal diagnosis without concerns about ionizing radiation.

Long term assessment of root coverage stability using connective tissue graft with or without an epithelial collar for gingival recession treatment. A 12-year follow-up from a randomized clinical trial.

AIM: To evaluate the long term root coverage outcomes of coronally advanced flap plus a connective tissue graft with (CAF + CTG) or without an epithelial collar (CAF + ECTG), and evaluate the adjacent treated sites included in the flap. METHODS: Seventeen of the original 20 subjects included in the randomized clinical trial were available at 12 years (43 sites). Mean root coverage (mRC), keratinized tissue width (KTW), gingival thickness (GT) on the grafted and adjacent sites were evaluated and compared with baseline and 6 months. RESULT: There was a reduction in the mRC at all sites: 16.52% in the CAF + CTG (p > .05), 19.42% in the CAF + ECTG (p < .05) and 34.12% in the CAF-alone (adjacent treated sites) group (p < .05). No significant differences were observed within the groups for changes in KTW, GT and clinical attachment level (CAL) (p > .05). Keratinized tissue width at baseline and at 6 months was found to be predictors for the stability of the gingival margin in the long term. CONCLUSIONS: CAF + CTG and CAF + ECTG were found equally efficacious in maintaining the levels of the gingival margin with a small amount of relapse over the period of 12 years while CAF-alone sites showed a greater gingival recession (GR) reoccurrence.

In vivo bone regeneration by differently designed titanium membrane with or without surface treatment: a study in rat calvarial defects.

The current objective was to evaluate six groups of titanium membranes in a rat calvarial defect model, regarding the surface treatment with or without calcium-phosphate coating and surface topography with no, small, or large holes. Critical size defects (Ф = 8 mm, n = 42) were surgically created in rat calvaria, and then were treated by one of the six groups. Biopsies were obtained at 4 weeks (n = 5 per group) for micro-computed tomography and histomorphometric analyses. Fluorochrome bone markers were injected in two rats each group at 1 (Alizarin red), 3 (Calcein green) and 5 weeks (Oxytetracyclin yellow), followed by histological examination at 7 weeks to assess bone regeneration dynamic. At 4 weeks, the highest bone volume was observed in no-hole groups independent of surface treatment (p < 0.05). Treated groups with no-hole and large-hole membranes showed increased bone mineral density than with respective non-treated groups (p < 0.05). Histology exhibited an intimate bone formation onto the treated membranes, whereas non-treated ones demonstrated interposition of connective tissue, which was confirmed through bone contact percentages. The results suggest that occlusive membranes showed more bone formation than other perforated ones, and calcium-phosphate treatment induces intimate bone formation toward the membrane.

What Is the Safety Zone for Palatal Soft Tissue Graft Harvesting Based on the Locations of the Greater Palatine Artery and Foramen? A Systematic Review.

PURPOSE: Palatal soft tissue graft harvesting is a common procedure in periodontal and implant dentistry. However, most of the complications after this procedure are associated with the underestimation of anatomic structures, such as the greater palatine artery (GPA). Therefore, the aim of this study was to provide guidelines for a safety zone for palatal harvesting. MATERIALS AND METHODS: A systematic search was conducted to identify cadaveric and computed tomography (CT) or cone beam CT studies assessing the location of the greater palatine foramen (GPF) and the path of the GPA in relation to the maxillary teeth. The effect of age, gender, and cadaveric and CT or cone beam CT studies on the location of the GPF and on the course of the GPA also was assessed. RESULTS: This systematic review included 26 studies, investigating 5,768 hemipalates. The most common location of the GPF was in the midpalatal aspect of the third molar (57.08%). As it traverses the palate anteriorly, the distance from the GPA to the maxillary teeth gradually decreases, except in the second premolar region, where it has the tendency to increase (13.8 ± 2.1 mm). The least distance from the GPA to the teeth was found in the canine area (9.9 ± 2.9 mm), whereas the greatest distance was in the second molar region (13.9 ± 1 mm). A safety zone for palatal harvesting was proposed based on the anatomic findings. CONCLUSIONS: This study provides guidelines for identifying the position of the GPF and defines a safety zone for harvesting a free gingival graft or connective tissue graft, minimizing the risk of GPA injury.

Adjunctive Use of Chlorhexidine Mouthwash to Nonsurgical Periodontal Therapy May Enhance Periodontal Pocket Depth Reduction.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Chlorhexidine mouthwash as an adjunct to mechanical therapy in chronic periodontitis: a meta-analysis. da Costa L, Amaral C, Barbirato D, Leao A, Fogacci M.JADA 2017;148(5):308-18. SOURCE OF FUNDING: The authors' own institutions. TYPE OF STUDY/DESIGN: A meta-analysis.

Adjunctive Use of Systemic Antibiotics (Amoxicillin 500 MG plus Metronidazole 500 MG 3 times a Day for 3 or 7 Days) to Nonsurgical Periodontal Therapy may Improve Clinical Outcomes in Treating Severe Chronic Periodontitis.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Non-surgical periodontal treatment in conjunction with 3 or 7 days systemic administration of amoxicillin and metronidazole in severe chronic periodontitis patients. A placebo-controlled randomized clinical study. Cosgarea R, Juncar R, Heumann C, et al. J Clin Periodontol 2016;43:767-77. SOURCE OF FUNDING: The authors' own institutions TYPE OF STUDY/DESIGN: A randomized clinical trial.

The Effect of Inital-Phase Bone Remodeling on Implant Wound Healing.

This case series aimed to investigate the initial-phase bone remodeling during implant wound healing and to discuss the possible contributing factors. A total of 11 implants with polished collars were placed in premaxillary regions via flapless approach with the aid of computer technology. After 15 months of follow-up, the results suggested that the presence of polished collars triggered bone resorption via a bone remodeling mechanism. The overall vertical crestal resorption was 0.78 ± 0.46 mm on average. This initial-phase bone remodeling primarily occurred within the first 3 months postoperatively. The slightly exposed polished collar may not worsen crestal bone level.

Comparison of Guided Bone Regeneration Between Surface-Modified and Pristine Titanium Membranes in a Rat Calvarial Model.

PURPOSE: The objectives of this study were to evaluate bioactivity of a titanium membrane with anodization, cyclic precalcification, and heat (APH) treatment (APHTM), and to compare APHTM and nontreated titanium membrane (NTTM) in guided bone regeneration using histologic analysis and microcomputed tomography (micro-CT). MATERIALS AND METHODS: APHTM samples were prepared and immersed in simulated body fluid for 2 days, then observed using field-emission scanning electron microscopy, followed by an analysis of calcium and phosphate precipitation using an energy dispersive x-ray spectroscopy. For the in vivo experiment, critical-size defects were created in rat calvaria (diameter, 8 mm) and treated with either APHTM or NTTM (n = 14 each). Biopsies were performed at 2 and 4 weeks for histologic analysis (n = 3 per group each time). Fluorochrome bone markers were injected in three rats in each group at 3 (alizarin red) and 5 weeks (calcein green), followed by histologic examination at 7 weeks. Micro-CT was performed at 8 weeks (n = 5 per group). RESULTS: APHTM exhibited high bioactivity, characterized by dense nano-sized flakelike crystals throughout the membrane and an increase in the calcium-phosphate concentrations after 2-day immersion in simulated body fluid. At 2 and 4 weeks, APHTM samples showed an intimate bone formation onto the membrane, whereas NTTM samples demonstrated interposition of connective tissue between the membrane and newly formed bone. The same pattern was found in the fluorescent study. The micro-CT analysis revealed significantly lower bone volume but higher bone mineral density in the APHTM samples than in the NTTM samples (P < .05). CONCLUSION: The results suggest that APH treatment on titanium membrane promotes intimate bone formation toward the membrane, thus increasing structural durability for bone regeneration. Further research is warranted to confirm the results found in these in vitro and in vivo experiments.

Comparison of Clinical and Radiographic Outcomes of Platform-Switched Implants with a Rough Collar and Platform-Matched Implants with a Smooth Collar: A 1-Year Randomized Clinical Trial.

PURPOSE: The aim of this study was to evaluate and compare the clinical and radiographic outcomes of single implants with a platform-switched rough collar (PSRC) and a platform-matched smooth collar (PMSC). MATERIALS AND METHODS: Twenty-six patients missing a tooth in the anterior maxilla (through the premolars) were randomly assigned to the PSRC or the PMSC group. All implants were placed in a flapless approach and restored with an early loading protocol. Clinical measurements were performed at surgery, loading, and at 3, 6, and 12 months after loading. In addition, radiographic evaluations were carried out using standardized periapical radiographs and cone beam computed tomography. Patient satisfaction surveys were completed, and microbial analysis with DNA probes was performed. RESULTS: The implant survival rate was 100% for both groups. The mean marginal bone level (MBL) was significantly higher in the PSRC group compared to the PMSC group at all time points. From the 2-week postoperative visit to 1 year postloading, the mean MBL change in the PSRC group was 0.21 ± 0.56 mm and in the PMSC group it was 0.74 ± 0.47 mm. Soft tissue profiles were stable over time, with no significant differences between groups. There were no significant differences between groups in the number of microbial species seen. Patients in both groups were highly satisfied with postoperative and postprosthetic experiences. CONCLUSION: In this study, the PSRC method preserved marginal bone by a mean of 0.53 mm more than the standard PMSC protocol. Within the limitations of the present study, it can be concluded that the PSRC protocol may be beneficial in marginal bone preservation. Longitudinal studies are needed to verify the long-term effects of this approach.

Impact of implant support on mandibular free-end base removable partial denture: theoretical study.

OBJECTIVES: This study investigated the impact of implant support on the development of shear force and bending moment in mandibular free-end base removable partial dentures (RPDs). MATERIAL AND METHODS: Three theoretical test models of unilateral mandibular free-end base RPDs were constructed to represent the base of tooth replacement, as follows: Model 1: first and second molars (M1 and M2); Model 2: second premolar (P2), M1, and M2; and Model 3: first premolar (P1), P2, M1, and M2. The implant support located either at M1 or M2 sites. The occlusal loading was concentrated at each replacement tooth to calculate the stress resultants developed in the RPD models using the free-body diagrams of shear force and bending moment. RESULTS: There was a trend of reduction in the peak shear force and bending moment when the base was supported by implant. However, the degree of reduction varied with the location of implant support. The moment reduced by 76% in Model 1, 58% in Model 2, and 42% in Model 3, when the implant location shifted from M1 to M2 sites. CONCLUSIONS: The shear forces and bending moments subjected to mandibular free-end base RPDs were found to decrease with the addition of implant support. However, the impact of implant support varied with the location of implant in this theoretical study.

Foreign Body Gingivitis.

Foreign body gingivitis (FBG) is a non-plaque induced chronic inflammatory process involving the marginal and/or attached gingiva. It results from the introduction of foreign particulate material, primarily dental prophylaxis paste and restorative dental materials, into the gingival tissues. Clinical presentation varies from an erythematous to vesiculoerosive-like process that may mimic a localized form of desquamative gingivitis or an erosive lichenoid process. Rarely, it may also present with a granular appearance. We describe the clinical presentation, differential diagnosis and clinical management of a 52-year-old Woman who presented with localized chronic inflammation of the maxillary anterior and left posterior gingiva secondary to the presence of foreign material.

Outcomes of regenerative treatment with rhPDGF-BB and rhFGF-2 for periodontal intra-bony defects: a systematic review and meta-analysis.

BACKGROUND: The aim was to evaluate the effects of recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and recombinant human fibroblast growth factor-2 (rhFGF-2) on treating periodontal intra-bony defects, compared to the control (carrier alone). METHODS: Electronic and hand searches were performed to identify eligible studies. The weighed mean differences of linear defect fill (LDF), probing depth (PD) reduction, clinical attachment level (CAL) gain and gingival recession (GR) were calculated using random effect meta-analysis. RESULTS: The searches yielded 1018 articles, of which seven studies were included. Only one included study was considered at low risk of bias. The outcomes that reached statistical significance in comparison to carriers alone included: LDF (0.95 mm, 95% CI: 0.62-1.28 mm or 20.17%, 95% CI: 11.81-28.54%) and CAL gain (0.34 mm, 95% CI: 0.03-0.65 mm) for PDGF, and LDF (21.22%, 95% CI: 5.82-36.61%) for FGF-2. CONCLUSIONS: Within the limits of this review, rhPDGF-BB demonstrated significantly more LDF and CAL gain; rhFGF-2 resulted in significantly higher percentage of LDF.

A randomized clinical trial evaluating the efficacy of the sandwich bone augmentation technique in increasing buccal bone thickness during implant placement. II. Tomographic, histologic, immunohistochemical, and RNA analyses.

OBJECTIVES: This study aimed to evaluate the biologic and structural phenotypes of the bone regenerated via the sandwich bone augmentation (SBA) technique, on buccal implant dehiscence defects. MATERIAL AND METHODS: Twenty-six patients with one buccal implant dehiscence defect each were randomly assigned to two groups. Both groups received a standardized amount of mineralized cancellous and cortical allogenic bone graft. In the test group, a bovine pericardium membrane was placed over the graft, while no membrane was placed in the control group. After 6 months of healing, a bone core biopsy of the regenerated bone was harvested and processed for histologic, immunohistochemical, mRNA, and micro-computed tomography (µCT) analyses. Of the 26 bone core biopsies, only six cores from the test group and six cores from the control group were suitable for the analysis. RESULTS: Bone volume (BV) in the test group was maintained, but tissue maturation appeared to be delayed. In contrast, tissue maturation appeared to be completed in the control group, but BV was compromised. Micro-CT analysis showed that specimens from the control group were more structured and mineralized compared with those from the test group. Histologic analysis showed more residual graft particles scattered in a loose fibrous connective tissue matrix with sparse bone formation in the test group, while the control group showed obvious vital bone formation surrounding the residual graft particles. Positive periostin (POSTN), sclerostin, and runt-related transcription factor-2 (RUNX2) immunoreactivities were detected in both the control and test groups. However, tartrate-resistant acid phosphatase (TRAP) positive was mostly noted in the control group. There were significant differences in POSTN, RUNX2 and VEGF expressions between the test and control groups. CONCLUSION: These findings indicated that the SBA technique was an effective method in preserving adequate structural volume while promoting new vital bone formation. Use of the collagen barrier membrane has successfully maintained the volumetric dimensions of the ridge but might have slowed down the complete maturation of the outermost layer of the grafted site.

Comparison between sandwich bone augmentation and allogenic block graft for vertical ridge augmentation in the posterior mandible.

INTRODUCTION: The purpose of this randomized controlled clinical trial was to evaluate 2 different techniques for vertical ridge augmentation (VRA) of the posterior mandible. MATERIALS AND METHODS: Sixteen subjects with 19 posterior mandibular edentulous sites requiring VRA were recruited for the study. Sites were randomly treated with either block allograft (BA; N = 9) or sandwich bone augmentation (SBA; N = 10). Clinical measurements were recorded at the time of surgery (baseline) and 6-month reentry with a custom-made acrylic surgical template. RESULTS: The mean vertical bone gain (VBG) after mean 6.8 months was 44.5% (mean = 1.78 mm [0-5 mm]) in the BA group and 33.3% (mean = 1.0 mm [-1 to 3 mm]) in the SBA group. Significantly higher rates of incision line openings and wound dehiscences were found in the BA group (n = 7/9, 77.8%) as compared with the SBA group (n = 3/10, 30%) (P = 0.037). After adjusting for graft exposure, BA group demonstrated significantly higher VBG than SBA (difference = 2.26 mm, P < 0.001). In addition, graft exposure resulted in significantly less VBG in both groups (P < 0.001). CONCLUSIONS: A higher tendency of wound exposure during VRA was demonstrated when a BA was used compared with the SBA technique. However, if wound exposure could be prevented, higher vertical ridge gain could be achieved with a BA. SUMMARY: The use of a BA in VRA resulted in a maximum of 2 mm more bone height gain compared with the SBA technique if the primary coverage can be achieved during the healing.

Systemic Chemotherapeutic Agents as Adjunctive Periodontal Therapy: A Narrative Review and Suggested Clinical Recommendations.

Periodontitis is an inflammatory condition of the periodontium that leads to destruction of the supporting structures of the tooth, including loss of attachment and alveolar bone. A clinician's first line of treatment for periodontitis is traditionally mechanical periodontal therapy, including oral hygiene instructions together with scaling and root planing. How- ever, it has been shown that mechanical therapy may not always be effective in halting disease. Adjunctive chemotherapeutics, such as systemic antibiotics or host-modulating agents, may improve the treatment outcome of periodontitis. Using relevant terms such as "adjunctive antibiotics" and "systemic chemotherapeutics" in a manual search of the PubMed database, the authors have prepared a narrative review of the chemotherapeutics currently used in the field. Results of the search and review show that adjunctive antibiotics may be useful in cases of aggressive periodontitis, refractory periodontitis, and in some patients who are immunocompromised, such as heavy smokers or poorly controlled diabetics. Host-modulating agents are generally recommended only as the last resort and are limited to the use of submicrobial dose doxycycline. Microbial testing may be indicated, particularly in aggressive periodontitis cases or refractory cases. Using these results, a decision tree is provided for clinicians to determine when adjunctive chemotherapeutics may be indicated.