Classification of Mucogingival Defects in Implantology and Proposed Corrective Approaches.

The aim of this classification is to diagnose and grade four different types of soft tissue deficiency around loaded, osseointegrated implants according to increasing severity. The suggested soft tissue augmentation to increase the width of the peri-implant keratinized mucosa will improve the long-term stability of peri-implant tissues.

Long-Term Outcome of Surgical Regenerative Treatment of Peri-implantitis: A 2- to 21-Year Retrospective Evaluation.

The aim of this retrospective study was to evaluate long-term clinical and radiologic outcomes of submerged and nonsubmerged guided bone regenerative treatments for peri-implantitis lesions. Strict methods of implant-surface decontamination and detoxification were performed. Data on clinical probing depth, soft tissue measures, and marginal bone level that were documented by comparative radiographs were obtained from 45 patients, for a total of 57 implants prior to treatment and at the latest follow-up. The average follow-up period was 6.9 years (range: 2 to 21 years). Analysis of implant-based data revealed a success rate of 70.2% for a total of 40 implants. Recurrence of peri-implantitis was observed on 9 implants, and 8 implants were removed. The regenerative procedures, under a strict periodontal control, were effective in the treatment of moderate to advanced peri-implantitis lesions.

Ultra-Thin Veneers Without Tooth Preparation in Extensive Oligodontia.

Dental agenesis is the most commonly encountered dental anomaly in humans. Oligodontia, however, is a rare condition that involves the congenital absence of six or more teeth, excluding the third molars. Treatment of oligodontia requires an interdisciplinary approach. The prosthetic treatment plan should carefully consider esthetic and functional rehabilitation but should take a conservative approach. Adhesive techniques, combined with the new ceramic materials, permit functional and esthetic prosthetic restorations that are more conservative in comparison to those used in the past. Ultrathin occlusal veneers without tooth preparations may represent a good esthetic and conservative approach for oral rehabilitation of patients affected by severe hypodontia.

Peri-implantitis Treatment with a Regenerative Approach: Clinical Outcomes on Reentry.

This case series presents clinical outcomes on reentry using regenerative submerged and nonsubmerged approaches in peri-implant defects; pre- and posttreatment assessments of nine implants in six patients are presented. A mean bone fill value of 91.3% with a 4.88-mm mean bone gain was obtained. Neither approach led to additional bone loss or required additional bone augmentation procedures. Strict methods of implant surface decontamination and detoxification were used on all patients, regardless of implant surface characteristics. The regenerative procedure was effective in the treatment of moderate to advanced peri-implantitis lesions without compromising the previous fixed implant-supported prostheses. These preliminary results are reasonably encouraging in that all cases showed bone gains. Nevertheless, caution must be exercised when determining reosseointegration, because it is not possible to ascertain it in clinical practice.

Resorbable dome device and guided bone regeneration: an alternative bony defect treatment around implants. A case series.

This case series presents the use of a resorbable "dome device" made of a slow, long-lasting resorbable suturing material to support the barrier creating and maintaining a secluded space to promote bone regeneration. Acellular dermal matrix or cross-linked resorbable collagen membrane, as barriers, combined with mineralized freeze-dried bone allograft, with simultaneous implant placement, were utilized in reconstructing non-space-making defects. Eight implants in six healthy patients were treated with a combination of these resorbable regenerative materials. Only one of seven was treated with a nonsubmerged approach. All sites remained completely covered and no implant exposure occurred during healing. At the 9- to 24-month reentry surgeries, the clinical bone density was equivalent to that of the native bone and the mean number of final exposed threads was 0.5. The mean buccal bone thickness achieved was 3.12 mm, with a mean total coverage of exposed threads in approximately 87.5% of the cases.

The efficacy of mineralized allograft cortical and cancellous chips in maxillary sinus augmentations.

A mixture of mineralized allograft cortical and cancellous chips was used to augment the maxillary sinuses of 10 patients. Eleven sinus augmentation procedures were performed, and 19 bone cores were obtained at reentry after 6 to 7 months. Computed tomography at 6 months postaugmentation demonstrated bone formation in all sites. Light microscopic and histomorphometric evaluation confirmed bone formation at the treatment site that would receive osseointegrated implants to replace the missing maxillary posterior teeth. These encouraging results support the use of a mixture of mineralized allograft cortical and cancellous chips for sinus augmentation.

Treatment of peri-implantitis: surgical therapeutic approaches based on peri-implantitis defects.

Peri-implantitis is a frequently occurring inflammatory disease mediated by bacterial infection that results in the loss of supporting bone. Peri-implantitis should be treated immediately, but there is a lack of evidence regarding the most effective therapeutic interventions. Nonsurgical periodontics may be the treatment of choice in cases of peri-implant mucositis or if the patient has medical contraindications or refuses to consent to more appropriate treatment. Peri-implantitis defects will dictate the therapeutic approach and present a guideline for relative clinical management. The suggested therapeutic solutions are derived from clinical experience and are meant to be a useful guide.

Minimally invasive technique for gingival augmentation around dental implants.

This article describes a soft tissue surgical modification--the trap door technique--used to enhance contemporary patient esthetic expectations and preserve periodontal health longitudinally. This surgical modification is greatly indicated for single-stage single and multiple implant surgery to preserve the integrity of the papillae and eliminate buccal soft tissue concavity. This procedure also addresses the issue of interproximal papillary development to obviate the presence of a black triangle. The technique is very effective in cases of minimal interproximal bone loss, it does not require autogenous bone harvesting, and is therefore less invasive and well accepted by the patient.

The interproximally connected flap to treat intrabony defects: case reports.

The purpose of the present study was to evaluate a novel surgical procedure: the interproximally connected flap. This technique is intended to prevent membrane exposure by maintaining the integrity of the interproximal soft tissues in the treatment of deep intrabony defects, in conjunction with the use of nonresorbable barrier membranes, thereby increasing the space for hard and soft tissue regeneration. Eleven patients (11 defects) were treated with this new flap design, which avoided any type of incisions in the interproximal tissues of the defect-associated papillae. Primary closure over the titanium-reinforced membrane was achieved in 100% of defects at baseline, with no exposures occurring during the 4-month healing period. The difference between baseline and 1-year probing pocket depths and probing attachment levels was clinically significant.

A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots.

The objective of this investigation was to determine the fate of thin buccal bone encasing the prominent roots of maxillary anterior teeth following extraction. Resorption of the buccal plate compromises the morphology of the localized edentulous ridge and makes it challenging to place an implant in the optimal position for prosthetic restoration. In addition, the use of Bio-Oss as a bone filler to maintain the form of the edentulous ridge was evaluated. Nine patients were selected for the extraction of 36 maxillary anterior teeth. Nineteen extraction sockets received Bio-Oss, and seventeen sockets received no osteogenic material. All sites were completely covered with soft tissue at the conclusion of surgery. Computerized tomographic scans were made immediately following extraction and then at 30 to 90 days after healing so as to assess the fate of the buccal plates and resultant form of the edentulous sites. The results were assessed by an independent radiologist, with a crest width of 6 mm regarded as sufficient to place an implant. Those sockets treated with Bio-Oss demonstrated a loss of less than 20% of the buccal plate in 15 of 19 test sites (79%). In contrast, 12 of 17 control sockets (71%) demonstrated a loss of more than 20% of the buccal plate. In conclusion, the Bio-Oss test sites outperformed the control sites by a significant margin. No investigator was able to predict which site would be successful without the grafting material even though all were experienced clinicians. This leads to the conclusion that a patient has a significant benefit from receiving grafting materials at the time of extraction.

Prevention of alveolar ridge deformities and reconstruction of lost anatomy: a review of surgical approaches.

Prevention and treatment of alveolar ridge deformities aim at preserving and/or reconstructing soft and hard tissues of the edentulous ridge. Different surgical techniques may be used to prevent ridge collapse before tooth extraction or to reconstruct lost ridge anatomy before tooth replacement. In cases of mild or moderate ridge defects, soft tissue augmentation is generally sufficient to repair the deformity. On the other hand, hard tissue augmentation should be selected primarily when implant therapy is scheduled. In cases of severe ridge defects, a staged or a combined approach may be appropriate. This article reviews the various approaches for the prevention and treatment of ridge deformities.

Interdental papilla management: a review and classification of the therapeutic approaches.

Several reasons contribute to the loss of interdental papillae and the establishment of "black triangles" between teeth. The most common reason in the adult population is loss of periodontal support because of plaque-associated lesions. However, abnormal tooth shape, improper contours of prosthetic restorations, and traumatic oral hygiene procedures may also negatively influence the outline of the interdental soft tissues. Several surgical and nonsurgical techniques have been proposed to treat soft tissue deformities and manage the interproximal space. The nonsurgical approaches (orthodontic, prosthetic, and restorative procedures) modify the interproximal space, thereby inducing modifications to the soft tissues. The surgical techniques aim to recontour, preserve, or reconstruct the soft tissue between teeth and implants. This review categorizes the various approaches in different clinical situations.

Clinical classification of bone defects concerning the placement of dental implants.

The goal of this classification of bone defects related to dental implant placement is to help clinicians accurately discuss proposed treatment regimens and organize treatment for clinical correction. A further goal of this effort to categorize bone defects requiring bone augmentation for implant placement is to standardize terminology to allow for more accurate dental communication. The five most encountered categories of bony defects are described.

The ramp mattress suture: a new suturing technique combined with a surgical procedure to obtain papillae between implants in the buccal area.

This article has been written to show the opportunity and eventually the predictability to obtain new papillae between implants and a better esthetic result by the use of a new suturing technique. After raising a full-thickness flap from the palatal to the vestibular side, it can be stabilized in such a position using a new suturing technique (ramp mattress suture) to apply pressure and tearing forces on the flap in an apicocoronal direction at the vestibular site and an opposite traction in a coronoapical direction at the palatal site. The ramp mattress suture seems to be capable of pulling the flap in an apicocoronal direction in the vestibular site, as well as in a coronoapical direction in the palatal site. Thanks to such a mattress suture, it will be possible to obtain a more coronal gingival margin. After an adequate healing period of approximately 5 weeks, a vestibular scalloped gingivectomy is performed around the vestibular surface of the abutment to create either a scalloped gingival margin or interproximal papillae only in the vestibular area, forming a gingival ramp in a palatovestibular direction to reasonably reduce the residual increased vestibular depth and optimize the esthetic result. Eight patients, for a total of 56 papillae, were treated with this new suturing technique. The esthetic results satisfied both clinician and patient expectations.

Guided Tissue Regeneration in Mucogingival Surgery.

The use of expanded polytetrafluoroethylene (ePTFE) membranes in the treatment of mucogingival problems such as gingival recession, has been recently described. The major issues raised dealt with creating and maintaining space under the membrane and designing a flap that could be coronally positioned and at the same time capable of maintaining a good blood supply. The authors proposed the use of a trapezoidal flap and some technical space-making solutions, such as the use of a suturing technique and different metal structures to support the membranes. J Periodontol 1993; 64:1184-1191.