Paradigm Shifts in the Evolution of Implant Therapy.

Making treatment decisions in dental implantology has evolved over the last five decades. These decisions and the clinical management of sites thereafter are selected based on recent changes, including the achievement of osseointegration, reestablishment of biologic width bone remodeling, the peri-implant soft tissue phenotype, the way peri-implantitis is defined, and advancements in digital technology. This article discusses these key aspects and their effects and influence on implant therapy.

Periodontal Plastic Surgery for Reshaping the Mucogingival Junction Following Grafting Procedures: Case Reports.

The present clinical and histologic case reports describe the periodontal plastic approaches used for the correction of gingival deformities following free gingival grafting (FGG) procedures. Five patients with poor esthetic and functional outcomes following soft tissue grafting voluntarily requested corrective treatment due to differences in color, texture, thickness, and mucogingival junction (MGJ) alignment between grafted and adjacent tissue, or because of food retention apical to the grafted site. Plastic surgical approaches included eliminating the thick borders the graft, aligning the MGJ, and reducing the excessive apicocoronal dimension of the graft. Histologic images confirmed the morphologic differences between the graft and adjacent alveolar mucosa. After intervention, all treated sites achieved a satisfactory esthetic appearance and function, with a soft tissue anatomy indistinguishable from those of adjacent sites. All patients agreed that their goals for the treatment were completely fulfilled.

Commentary: A Translational Medicine Approach to Tooth Transplantation.

The autogenous tooth transplantation approach to replace missing teeth has been in use for a long time. Different surgical techniques have been developed to improve prognosis and longevity of transplanted teeth with complete root formation. Many factors reportedly affected short- and long-term success of the procedure: complications such as ankylosis and root resorption up to the tooth exfoliation have occurred frequently. Several studies have appeared on this issue over the years. However, outcomes of transplantations have not yet been conclusively determined as no randomized clinical trials have been published on this issue, and their effectiveness has been evaluated only in observational studies. On the other hand, interesting information from specific experimental studies on the healing pattern of the interface between the root surface and alveolar bone in the replantation/transplantation model, and from non-related studies dealing with mechanically induced periodontal trauma, has been available and potentially useful since the 1970s to 1980s. However, this information has not been incorporated into clinical literature regarding tooth autotransplantation. This commentary aims to show how information from related and unrelated experimental models was translated to a clinical setting and led to a novel approach, successfully applied, in the autotransplantation of a multirooted tooth with completed root formation.

Evaluation of the literature: evidence assessment tools for clinicians.

The progressive improvement in the quality of scientific articles has led to an increase in difficulty in reading and interpreting them so that now clinical knowledge and experience must be complemented by methodological, statistical and computer skills. The aim of this article is to offer practitioners the tools, the simplest keys, that will allow them to understand and critically judge the results of scientific studies. The "peer-review" process of a clinical article submitted to a journal is described and the Science Citation Index and the Impact Factor are presented to the reader as essential instruments to evaluate a specific article's impact and the impact of a given journal on the scientific world, respectively. An article should be evaluated on the basis of some key issues which include, at least, an assessment of methodological aspects, a critical analysis of the statistical component and a proper understanding of the clinical impact of the study outcomes. The standard approach for evaluating the quality of individual studies is based on a hierarchical grading system of research design which represents an essential tool to identify the strength of the evidence of an article. Many different biases may affect the reliability of study results. Randomized Control Trials (RCTs) and Systematic Reviews (SRs) are able to minimize the number of biases and thus are at the highest level of the scale of evidence representing the final steps of a treatment's "career." Finally, moving from research to clinical practice, attention on the clinical impact of study's outcomes is of paramount importance as the literature contains studies (including RCTs) that present statistically significant results but which, from the clinical standpoint, are only relatively or not at all significant. Clinical Practice Guidelines represent a useful tool for practitioners assisting the decision-making process when choosing the most appropriate treatment for their patients.

The partly epithelialized free gingival graft (pe-fgg) at lower incisors. A pilot study with implications for alignment of the mucogingival junction.

AIMS: A partly epithelialized free gingival graft (PE-FGG) is described for the treatment of isolated and multiple gingival recessions in lower incisors to improve root coverage potential and mucogingival junction (MGJ) alignment. METHODS: Twelve single gingival recessions in 12 patients and 16 multiple recessions in 7 patients at lower incisors were included. A FGG partly deprived of epithelium was harvested from the palate. The epithelialized coronal part of the graft extended from the CEJ to the "ideal" position of the MGJ of the recession site/s. The apical part of the PE-FGG deprived of the epithelium was inserted between the alveolar mucosal flap and the recipient bed periostium. An aesthetic evaluation was performed. RESULTS: Treatment resulted in 94 ± 11% and 96 ± 11% root coverage and 75% and 87.5% of the treated teeth completely covered in the single recession and in the multiple recession groups respectively. The 1-year KT was associated with the baseline extent of the epithelialized part of the graft in both groups. As a consequence, the MGJ resulted in properly aligned teeth in 14 of 19 patients. Three independent clinicians assigned an aesthetic score ranging from 6.36 ± 2.5 to 7.91 ± 1.7 in the single REC group and from 6.62 ± 2.2 to 7.87 ± 1.8 in the multiple REC group. CONCLUSIONS: The application of the M-FGG resulted in high percentage of recessions completely covered with excellent alignment of the MGJ and appreciable aesthetic outcomes.

Orthodontic treatment of periodontal defects. A systematic review.

Several studies have been published focusing on the possibility to treat patients affected by periodontal defects by means of orthodontic treatment. The aim of this systematic review is to evaluate the efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions. To establish an appropriate search strategy, the PICO assessment worksheet was used. Only Randomized Controlled Trials and Systematic Reviews were selected for this review. The electronic search (from January 1966 to January 2008) and the hand search (from January 1988 to January 2008) were conducted by three independent reviewers. There were no language restriction. No Randomized Controlled Trials and Systematic Reviews were identified during the investigated period and therefore it was not possible to perform meta-analysis. It appears important to encourage the researchers to produce Randomized Controlled clinical Trials aimed to investigate the efficacy of the orthodontic treatment, alone or in combination with the periodontal therapy, for the resolution of periodontal defects.

Tunnel technique for the treatment of impacted mandibular canines.

The tunnel technique is a combined therapeutic approach that includes both surgical exposure of the impacted canine and orthodontic traction of the tooth to the center of the alveolar ridge, followed by final orthodontic alignment. A healthy periodontium at the completion of therapy is the expected outcome. The tunnel technique has been shown to be effective in the treatment of impacted maxillary canines and can be suggested for the treatment of infraosseous impacted canines in the mandible when the corresponding primary canine is still present. Through the description of clinical cases, the management of the tunnel technique is reported.

From initial case report to randomized clinical trial through 20 years of research in periodontal therapy.

AIM: Case reports (CRs) are often the first publication of a new treatment, but randomized clinical trials (RCTs) are needed to confirm the data. The aim of this study was to evaluate how many therapies published as CRs were followed by RCTs of these therapies over a 20-year period. MATERIAL AND METHODS: Two researchers conducted a search through international periodontal journals and found the CRs on periodontal treatments published from 1984 to 1986. Subsequent electronic searches made it possible to verify how many of the treatments published as CRs were also investigated through RCTs over the following 20 years. RESULTS: Thirty-one different therapies were selected out of the 33 published CRs; 15 (48%) of these 31 treatments were investigated by RCTs over the next 20 years. CONCLUSIONS: As 52% of the CRs were not validated by RCTs, practitioners should view their results with caution.

Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial.

AIMS: This parallel-group, multi-centre, double-blind, randomized-controlled clinical trial was undertaken to compare the clinical outcomes and patient morbidity of coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CAF+CTG) in single Miller Class I and II gingival recessions. MATERIAL AND METHODS: Three centres enrolled 85 patients with one recession each. Surgery was performed elevating a pedicle flap; 42 sites randomly received a graft under the flap. Measurements were taken by blind and calibrated examiners. Outcome measures included recession reduction, complete root coverage (CRC), intra-operative and post-operative morbidity, dentine sensitivity, and side effects. RESULTS: No differences were noted in the intra-operative and post-operative patient-related variables between the two groups. Surgical time was significantly shorter in the CAF group. Recession reduction was not statistically different between the two groups, even though a model showed a tendency towards improved outcomes in sites treated with CAF+CTG (adjusted difference 0.33 mm, 95% CI=-0.06 to 0.72, p=0.1002). Significantly greater probability of CRC was observed after CAF+CTG (adjusted OR=5.09, 95% CI=1.69-17.57, p=0.0033). Dentine hypersensitivity improved in both the groups. CONCLUSIONS: Both treatments were effective in providing a significant reduction of the baseline recession and dentine hypersensitivity, with only limited intra-operative and post-operative morbidity and side effects. Adjunctive application of a CTG under a CAF increased the probability of achieving CRC in maxillary Miller Class I and II defects.

Single minimally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra-bony defects: clinical outcomes and patient morbidity.

AIMS: This case cohort study was designed to evaluate the clinical performance and the intra-operative and post-operative morbidity of the "minimally invasive surgical technique" (MIST) associated with the application of an enamel matrix derivative (EMD) in the treatment of multiple deep intra-bony defects in a single surgical procedure. MATERIAL AND METHODS: Forty-four deep intra-bony defects in 20 patients (>or=2 defects/patient) were surgically accessed with the MIST. This technique was designed to limit the mesio-distal flap extension and the apical flap reflection in order to reduce the surgical trauma and increase flap stability. The incision of the defect-associated papilla was performed according to the principles of the papilla preservation techniques. EMD was applied on the debrided and dried root surfaces. Stable primary closure of the flaps was obtained with modified internal mattress sutures. Surgery was performed with the aid of an operating microscope and microsurgical instruments. Clinical outcomes were collected at baseline and at 1 year. Intra-operative and post-operative morbidity was evaluated with questionnaires. RESULTS: The 1-year clinical attachment level (CAL) gain was 4.4+/-1.4 mm (p<0.0001 compared with baseline). Seventy-three per cent of defects showed CAL improvements >or=4 mm. This corresponded to an 83+/-20% resolution of the defect (15 defects were completely filled). Residual probing pocket depths (PDs) were 2.5+/-0.6 mm. A minimal increase of 0.2+/-0.6 mm in gingival recession between baseline and 1 year was recorded. Twelve patients reported a mild perception of the hardship of the surgical procedure. Primary closure was obtained and maintained in all treated sites over time. Only six subjects reported moderate post-operative pain that lasted for 21+/-5 h. CONCLUSIONS: These data indicate that a MIST in combination with EMD can be applied successfully for the treatment of multiple deep intra-bony defects in the same surgical procedure with excellent clinical outcomes and very limited patient morbidity.

Aesthetic perception after root coverage procedure.

AIM: To investigate the aesthetic perception of the clinical outcomes of a simulated root coverage procedure in three different groups: patients, dentists, and periodontists. MATERIAL AND METHODS: 100 patients, 107 general dentists affiliated with the Dental Association of Prato, Italy, and 81 active members of the Italian Society of Periodontology were recruited for this study. The following variables: age, gender, level of education, place of residence, and years of practice (only for dentists and periodontists) were recorded by means of a questionnaire administered to each subject within the three different groups. In addition, the participants in the study were requested to assign scores to images of eight simulated clinical cases of gingival recessions: a pre- and post-treatment image for each case. RESULTS: Statistically significant differences between groups were not detected in most of the scores. Gender and residence were not significantly associated with the scores, while age was correlated for two clinical cases (p=0.0014 and 0.0017). All the cases of complete root coverage showed the highest scores among all the participants. CONCLUSIONS: These results showed that complete root coverage following root coverage procedure is perceived as the most successful outcome by patients, dentists, and periodontists.

Chlorhexidine with an anti discoloration system after periodontal flap surgery: a cross-over, randomized, triple-blind clinical trial.

UNLABELLED: The use of chlorhexidine (CHX) has been recommended for a number of clinical applications including plaque control in the post-operative period. However, the use of CHX is burdened by some side effects that could affect the compliance of the patient. The aim of this clinical trial was to evaluate the side effects, the staining in particular, the patient acceptance, and the efficacy of a 0.2% CHX mouthwash containing an anti discoloration system (ADS) compared with a 0.2% CHX alone, after periodontal flap surgery. MATERIAL AND METHODS: This single-centre, cross-over, triple-blind randomized clinical trial was carried out on 48 consecutive patients. After periodontal flap surgery, the patients were prescribed to rinse two times per day for 1 min for 1 week with 10 ml of test or control CHX, contained in anonymous bottles coded K or M and assigned randomly. No brushing and interdental cleaning of the surgical area was allowed. At week 1, after suture removal, patients received full-mouth prophylaxis and were given a second anonymous bottle, reversing the products, with the same instructions as at baseline. Patients resumed tooth-brushing but not interdental cleaning. At the end of week 2, prophylaxis was repeated, mouth rinsing was discontinued and patients resumed normal oral hygiene. At weeks 1 and 2, the following variables were recorded: presence of pigmentation, gingival parameters at the surgically treated sites (gingival inflammation, tissue inflammation around the sutures, gingival swelling and presence of granulation tissue), patient perception and acceptance of the 2 mouthwashes. RESULTS: Forty-seven patients completed the study. The difference between treatments related to gingival variables was not statistically significant. The test CHX caused consistently less pigmentations than the control CHX in all the evaluated areas of the dental surfaces (odds ratio (OR)=0.083 p<0.0001 in the incisal area, OR=0.036 p<0.0001 in the approximal area and OR=0.065 p<0.0001 in the gingival area). The CHX ADS was found to be more tolerated by patients than the control mouthwash and to cause less food alteration, less alterations to the perception of salt and to be less irritant for the oral tissues. CONCLUSIONS: (1) CHX ADS caused less pigmentation, was burdened by less side effects and was more agreeable than the control CHX; (2) CHX ADS was as effective as CHX without ADS in reducing gingival signs of inflammation in the post-surgical early healing phase; (3) the use of CHX ADS could be of value in treatment protocols in which the patient compliance with a CHX mouthwash prescription is relevant.

Retrospective Evaluation of the Influence the Interleukin-1 Genotype on Radiographic Bone Levels in Treated Periodontal Patients Over 10 Years.

BACKGROUND: A difference in genetic susceptibility to plaque accumulation has been advocated to explain different responses to periodontal therapy. The purpose of this study is to assess the role of the interleukin-1(IL-1) polymorphism on the rate of bone and tooth loss in non-smoking periodontally treated patients during maintenance. METHODS: Sixty consecutive non-smoking patients (mean age 46.8 ± 5.0) with moderate to severe periodontitis, treated and maintained for over 10 years were selected. At baseline (T0), radiographic evaluation (cementoenamel junction [CEJ]-root apex, CEJ-bottom of defect mesial and distal, CEJ-bone crest mesial and distal, crown-root ratio) was performed. All patients received scaling and root planing; 36 patients then underwent surgical therapy. Subsequently, all patients were enrolled in a periodontal maintenance program with recall visits every 3.4 ± 1.0 months for at least 10 years. At the latest recall visit (T2) the same radiographic measurements evaluated at baseline were taken and a DNA sample for IL-1 genetic susceptibility testing was collected and sent for analysis. RESULTS: Twenty-three of the 60 patients (38.3%) were IL-1 genotype positive. A total of 52 teeth (3.3%) out of 1,566 were lost due to periodontitis between T0 and T2; 28 of 957 (2.9%) in the IL-1 genotype negative group and 24 of 609 (3.9%) in IL-1 genotype positive group. The mean variation in bone defect level (ΔBD) averaged -0.04 mm in IL-1 genotype negative patients and 0.01 mm in IL-1 genotype positive patients. The mean variation in bone crest level (ΔBC) averaged -0.24 mm in IL-1 genotype negative patients and -0.28 mm in IL-1 genotype positive patients. However, a few patients showed significant differences in response to therapy based on initial bone levels and genotype. IL-1 negative patients who showed minimal initial bone loss responded to the therapy better than the IL-1 positive patients. IL-1 positive patients with severe initial bone loss showed a better response to the therapy than IL-1 negative patients. CONCLUSIONS: On average, there were no significant differences related to IL-1 genotype in tooth loss after 10 years in a non-smoking, well-maintained periodontal population. On an individual patient basis, the IL-1 genotype, in combination with the initial bone level, seems useful at the beginning of therapy for predicting bone level variation. J Periodontol 2001;72:767-773.