Peri-Implantitis: Application of a Protocol for the Regeneration of Deep Osseous Defects. A Retrospective Case Series.

BACKGROUND AND AIMS: Peri-implantitis is a complex pathology, both in its diagnosis and in the identification of etiological causes. Although we have been studying more and more over the years to try to answer the many questions that remain regarding everything that circulates around this disease which affects implants, nothing has yet been taken as an official consensus regarding its surgical treatment. There are still many proposed protocols, each of which has been shown to have comforting results and promising prospects, but no total predictability. The aim of this case series is to assess the clinical outcomes of a mixed protocol for the regeneration of deep osseous defects. MATERIALS AND METHODS: The data and clinical records of 23 patients, with 29 implants affected by peri-implantitis treated surgically in private practice, were analyzed retrospectively. The method used for the surgical treatment was a mixed protocol of mechanical-chemical decontamination and bone regeneration with bovine xenograft. RESULTS: All patients were followed for at least 2 years, averaging 28.9 months (a range of 24-38 months) with a reduction in the probing depth (PD) at one year from the initial 8.14 ± 1.156 mm to 3.72 ± 0.649 mm, and to 4.14 ± 1.093 mm at the final assessment. The differences between assessment time points were always statistically significant. The data regarding bleeding on probing (BoP) and suppuration also showed a statistically significant reduction at the final time point compared to the baseline. Only one patient, at 24 months, still showed BoP, suppuration, and a PD deeper than 5 mm, indicating a recurrence of the disease compared to the initial improvement of the PD (5 mm) at one year. CONCLUSIONS: In conclusion, within the limits of this retrospective analysis, it can be affirmed that this combined mechanical-chemical and regenerative decontamination therapy is effective in the treatment of peri-implantitis.

Clinical osseointegration of bone level implants with conical shape and textured surface with low primary stability.

BACKGROUND: Evidence shows lower chance for osseointegration of implants without sufficient primary stability. The present retrospective study observed bone level conical screw implants with textured surface without primary stability. METHODS: Twenty-six Stark conical screw implants, with V-Blast (Vanish Blast) surface treatment were placed with low primary stability, (insertion torque lower than 10 N/cm and visible mobility at lateral load of 250 g). A soft diet was prescribed. osseointegration was assessed applying 30 Ncm of reverse torque 6 months after placement. RESULTS: The 26 implants that did not achieve primary stability still had a survival rate of 96% after the observation period and were classified as successful according with ICOI Pisa consensus conference success, survival, failure classification .96% of the implants showed clinical osteointegration and were successfully restored. After 12 months, all implants remained functional. CONCLUSIONS: It can be concluded that bone-level implants with V-Blast surface in absence of functional loading are able to achieve osteointegration, even with low primary stability.

Clinical and Radiographic Evaluation of Nanohydroxyapatite Powder in Combination with Polylactic Acid/Polyglycolic Acid Copolymer as Bone Replacement Graft in the Surgical Treatment of Intrabony Periodontal Defects: A Retrospective Case Series Study.

The aim of this retrospective case series was to evaluate the clinical efficacy of nanohydroxyapatite powder (NHA) in combination with polylactic acid/polyglycolic acid copolymer (PLGA) as a bone replacement graft in the surgical treatment of intrabony periodontal defects. Medical charts were screened following inclusion and exclusion criteria. Periodontal parameters and periapical radiographs taken before surgery and at 12-month follow-up were collected. Intra-group comparisons were performed using a two-tailed Wilcoxon signed-rank test. Twenty-five patients (13 males, 12 females, mean age 55.1 ± 10.5 years) were included in the final analysis. Mean probing depth (PD) and clinical attachment level (CAL) at baseline were 8.32 ± 1.41 mm and 9.96 ± 1.69 mm, respectively. Twelve months after surgery, mean PD was 4.04 ± 0.84 mm and CAL was 6.24 ± 1.71 mm. Both PD and CAL variations gave statistically significant results (p < 0.00001). The mean radiographic defect depth was 5.54 ± 1.55 mm and 1.48 ± 1.38 mm at baseline and at 12-month follow-up, respectively (p < 0.0001). This case series, with the limitations inherent in the study design, showed that the combination of NHA and PLGA, used as bone replacement graft in intrabony periodontal defects, may give significant improvements of periodontal parameters at 12-month follow-up.

Comparison between two different techniques for peri-implant soft tissue augmentation: Porcine dermal matrix graft versus tenting screw.

BACKGROUND: The thickness of the soft tissues around dental implants is crucial for both the preservation of the marginal bone and esthetic profile. Many authors have showed the thickened soft tissues favor a better peri-implant bone stability; however, different thickening techniques can be used for this aim. METHODS: Forty-seven patients were enrolled in this study, each one had one implant included in this analysis. According to the thickening procedure, patients were assigned into group A (porcine dermal matrix, n = 24) or B (healing abutment used as tenting screw to sustain the soft tissues, n = 23), soft tissue thickness was measured after flap elevation in a standardized way. Six months after implant placement, implants were uncovered and soft tissue thickness measured again. RESULTS: At second stage, 6 months after implant placement, the mean vertical thickness was 3.01 ± 0.58 mm in group A and 2.25 ± 0.53 mm in group B. The difference between the two groups at 6 months was significant (P < 0.001). The mean vertical gain in group A was 1.33 ± 0.71 mm, whereas it was 0.43 ± 0.55 mm in group B. This difference was also statistically significant (P < 0.001). CONCLUSION: The use of a healing abutment for "tenting effect" has limited efficacy to obtain a significant increase in soft tissue thickness. The use of a porcine dermal matrix at time of implant placement is effective to thicken peri-implant tissues.

Immediate Loading of Implant-Supported Single Crowns after Conventional and Ultrasonic Implant Site Preparation: A Multicenter Randomized Controlled Clinical Trial.

AIM: To compare implant survival rate and marginal bone loss (MBL) of immediately loaded single implants inserted by using ultrasonic implant site preparation (UISP) (test) and conventional rotary instrumentation (control). METHODS: Two single implants were inserted for each patient: after randomization, test site was prepared by using an ultrasonic device (Piezosurgery Touch, Mectron, Italy) and control site was prepared by using the drills of the selected implant system (Premium AZT, Sweden & Martina, Italy), until reaching a final diameter of 3 mm in both groups. Identical implants (3.8x11.5 mm) were inserted in all sites at crestal level. Impressions were taken and screwed resin single crowns with platform-switched provisional abutments were delivered with 48 hours. Periapical radiographs were taken at provisional crown insertion (T0), 6 months (T1) and one year (T2) after prosthetic loading to measure MBL. All data were tested for normality and subsequently analyzed by paired samples t-test and forward multiple linear regression. RESULTS: Forty-eight patients were treated in six centers with the insertion of ninety-six implants (48 test; 48 control). Four implants in four patients failed within the first six months of healing (two in test group; two in control group; no difference between groups). Forty patients (age 60.1±10.7 years; 22 female, 18 male) were included in the final analysis. Mean MBL after six months of loading was 1.39±1.03 mm in the test group and 1.42±1.16 mm in the control group (p>0.05) and after one year was 1.92±1.14 mm and 2.14±1.55 mm in test and control, respectively (p>0.05). CONCLUSIONS: No differences in survival rate and MBL were demonstrated between UISP and conventional site preparation with rotary instruments in immediately loaded dental implants: UISP, with its characteristics of enhanced surgical control and safety in proximity of delicate structures, may be used as a reliable alternative to the traditional drilling systems.

Osteointegration of Tissue-Level Implants With Very Low Insertion Torque in Soft Bone: A Clinical Study on SLA Surface Treatment.

INTRODUCTION: Evidence shows lower percentage of osteointegration when implants are placed without sufficient primary stability. The present work tested the hypothesis that implants unstable at insertion could achieve osteointegration with proper implant surface treatment. MATERIALS AND METHODS: Eleven Straumann tissue-level implants with sandblasted, large-grit, acid-etched (SLA) surface treatment were placed in soft bone unfavorable to primary stability, as indicated by insertion torque lower than 10 N/cm and slight mobility on the application of a lateral load of 250 g. After 4 to 6 months of healing, a reverse torque of 35 Ncm was applied to assess osteointegration. RESULTS: All implants appeared to be clinically osseointegrated and were successfully restored and loaded with fixed partial dentures or single crowns. After 28.5 months, all implants remained functional. CONCLUSIONS: Within the limitations of the low number of implants analyzed, it can be concluded that tissue-level implants with sand-blasted and acid-etched surface treatment can achieve osteointegration, even in the absence of primary stability.

Patient-Based Comparison of Traditional Instruments and Piezoelectric Bone Surgery in Osseous Resective Surgery.

Osseous resective surgery has been widely advocated in the treatment of periodontitis. The treatment traditionally has been done with rotary and manual instruments, but piezoelectric devices recently have also been used. A total of 20 adult patients diagnosed with moderate to severe chronic periodontitis were selected. A split-mouth study design was conducted such that one sextant was operated using piezoelectric bone surgery (test) and one with traditional instruments (control) in two separate sessions. Patients were asked to evaluate their perception of cold sensitivity, spontaneous pain, bleeding, swelling, and chewing discomfort. Piezoelectric bone surgery seems to be tolerated slightly better than conventional rotary instruments.

Gummy Smile and Short Tooth Syndrome - Part 2: Periodontal Surgical Approaches in Interdisciplinary Treatment.

One of the most frequent causes of gummy smile is an altered eruption, ie, the gingival margins are located at a more coronal position than normal. These cases can be successfully treated with a periodontal surgical approach. Several techniques may be used, depending on the different anatomic variations. The surgery must be carefully planned so as to avoid discrepancies between the soft tissues and the teeth. Clinical examination and radiographic evaluation will allow clinicians to determine the position of the gingival margin, bone crest, and cemento-enamel junction and thus elicit a correct diagnosis of the subtype of altered eruption. The periodontist will need to consider these factors in order to obtain a satisfactory outcome, especially in multidisciplinary cases.

Gummy Smile and Short Tooth Syndrome--Part 1: Etiopathogenesis, Classification, and Diagnostic Guidelines.

Treating patients with "gummy smiles" and improving smile esthetics has become an integral part of dentistry. It is necessary to conduct an accurate diagnosis of what may be multiple causes that coexist simultaneously. Though all causes may not be resolved following treatment, they should be identified; otherwise it might not be possible to conduct an adequate order of treatment, which could involve multidisciplinary collaboration between various dental specialists, and may lead to unexpected and unacceptable final results. The authors propose a complete adult classification of the causes identified for gummy smile (GS) and short tooth syndrome (STS) to ascertain the etiopathogenetic origin(s). Used in combination with the proposed diagnostic procedure, which involves an "outside-in" evaluation of the patient, the classification system will enable clinicians to provide patients an accurate prediction of final results and determine the treatment required.

The use of a membrane and/or a bone graft may not improve the effects of enamel matrix derivatives in infrabony defects.

SELECTION CRITERIA: This study undertook a network meta-analyses of studies comparing the effect of enamel matrix derivatives when used alone or in combination with bone grafts and/or membranes in the treatment of infrabony periodontal defects. A literature search was conducted on several medical databases (Medline, EMBASE, LILACS, and CENTRAL) and also on regular Web search engines (Google). Twenty-eight randomized controlled trials (RCTs) were included in the review. For study inclusion, the patients (or the periodontal defects) had to be randomly assigned to the test or control group and there had to have been follow-up for a minimum of 6 months. KEY STUDY FACTOR: Treatment of infrabony defects with emdogain alone and with emdogain plus membrane and/or bone graft. MAIN OUTCOME MEASURE: The primary outcomes were reduction in pocket probing depth (PD), gain of clinical attachment level (CAL), and infrabony defect depth recorded at least 6 months after the procedure was completed. MAIN RESULTS: Twenty-eight publications were included in this systematic review with meta-analysis. In the initial search, 337 articles were found: 35 articles were found on medical databases (PubMed, EMBASE, LILACS, Central); 1 article was found through the gray search (Google); and 1 article was found through the electronic search in 3 periodontal journals. Of the 337 articles, 306 were excluded at the assessment of titles and abstracts phase because they were either case reports or they were not considered RCTs. The remaining 31 articles were examined in their full length (not just abstracts and titles). Three of these articles were excluded because they were not RCTs or because the adjunctive treatment was not considered regenerative. Because many variations of the treatment were used in the selected studies, the authors used network meta-analysis for the statistical synthesis of direct and indirect comparisons. Enamel matrix derivatives (EMDs) plus bone grafts and EMDs plus membranes attained 0.24 mm and 0.07 mm more PPD reduction than EMDs alone, respectively. For CAL gain, EMDs plus bone grafts and EMDs plus membranes attained 0.46 mm and 0.15 mm, respectively. CONCLUSIONS: The analysis shows that adding membranes and/or bone grafts to the EMDs does not provide significant benefits in the treatment of periodontal defects.

Apical surgery may cause gingival recession.

SUBJECTS: Two hundred forty-two subjects were treated with apical surgery from 2000 to 2004. All subjects were operated on by the same clinician. One hundred eighty-six subjects were later reevaluated. The study consisted of 102 female and 84 male patients. The mean age of the patients was 49.7 years (range, 9-81 years). Most of the 56 cases lost to follow-up did not want to participate at the follow-up exam (n = 23) or the treated tooth was extracted before the follow-up exam (n = 15). KEY EXPOSURE/STUDY FACTOR: Key study factors included gender, age, smoking status, treated tooth type, restoration presence, apical surgery incision procedure (intrasulcular, papilla-base, or submarginal), and healing status. Healing status was evaluated clinically and radiographically. MAIN OUTCOME MEASURE: The main outcome measures were the evaluation of probing depth, clinical attachment level, and recession in patients who were treated with apical surgery for endodontic periapical lesions. Measurement of these periodontal parameters was taken at time of the surgery and 1 and 5 years after the initial treatment. The most relevant change was recession on the facial and lingual surfaces of the teeth that had been operated on. MAIN RESULTS: Relevant changes were seen only for gingival recessions that had a mean value of about 0.3 mm. These changes were present at the 1-year postoperative exam and did not modify until the 5-year follow-up. Probing depth was not affected by the apical surgery procedure. Clinical attachment level (probing depth + recession) was affected as a consequence of the apically displaced gingival margin. Age, sex, smoking habit, and periapical healing had influence on the periodontal parameters. The most important factor, however, was the kind of incision used for the periapical surgery. Overall, baseline to 5-year changes in gingival recession for the facial aspect of treated teeth observed for intrasulcular, papilla-base, and submarginal incision procedures were 0.47 mm, 0.31 mm, and 0.12 mm, respectively. CONCLUSIONS: The authors conclude that periapical surgery may cause gingival recession.

Obliteration of the nasopalatine canal in conjunction with horizontal ridge augmentation.

The presence of a wide nasopalatine canal and the lack of an adequate ridge width may affect the correct placement of implants in the central incisor area. This could lead to functional and esthetic problems. This article describes bone grafting of the canal and concurrent ridge augmentation to obtain adequate bone quantity and quality and to allow correct 3-dimensional placement of the implant. The lack of sensorial complications utilizing this technique is also reported here.

Apical surgery may cause gingival recession.

PURPOSE/QUESTION: Does apical surgery affect periodontal parameters? SOURCE OF FUNDING: Information not available. TYPE OF STUDY/DESIGN: Case series. LEVEL OF EVIDENCE: Level 3: Other evidence. STRENGTH OF RECOMMENDATION GRADE: Not applicable.

The use of a membrane and/or a bone graft may not improve the effects of enamel matrix derivatives in infrabony defects.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Do bone grafts or barrier membranes provide additional treatment effects for intrabony lesions treated with enamel matrix derivatives? A network meta-analysis of randomized controlled trails. Tu Y-K, Woolston A, Faggion CM Jr. J Clin Periodontol 2010;37:59-79. REVIEWER: Simone Verardi, DDS, MSD. PURPOSE/QUESTION: Do membranes and bone grafts improve the outcomes in the treatment of intrabony defects when they are used in combination with enamel matrix derivatives? SOURCE OF FUNDING: Government: Higher Education Funding Council for England (HEFCE) and United Kingdom Research Council Fellowship. TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data. LEVEL OF EVIDENCE: Level 2: Limited-quality patient-oriented evidence. STRENGTH OF RECOMMENDATION GRADE: Grade B: Inconsistent or limited-quality patient-oriented evidence.

Role of fibroblast populations in peri-implantitis.

PURPOSE: To understand the contribution of stromal cells, such as granulation tissue fibroblasts, to peri-implantitis with regard to (1) the secretion of constitutive factors promoting migration/survival of infiltrates into osseointegrated sites; and (2) the effect of exogenous infiltrate cytokines on the cells' secretion. MATERIALS AND METHODS: Fibroblasts were cultured from eight peri-implantitis sites. Multiplexed enzyme-linked immunosorbent assay was used to quantify factors secreted by the cells either unstimulated or stimulated with gamma interferon (IFN gamma), interleukin 4 (IL4), or tumor necrosis factor alpha (TNF alpha). Controls consisted of fibroblasts cultured from healthy gingival and chronic periodontitis granulation tissues. RESULTS: Peri-implantitis fibroblasts differed significantly from periodontitis fibroblasts in their reduced secretion of the collagen inducer transforming growth factor beta-1 (TGF beta 1) and tissue inhibitor of metalloproteinase-1. The cells exhibited enhanced secretion of angiogenic factor vascular endothelial growth factor (VEGF) and collagenolytic matrix metalloproteinase 1 (MMP1) compared to both healthy and periodontitis fibroblasts. Fibroblasts from both periodontitis and peri-implantitis sites exhibited a pronounced proinflammatory profile compared to normal gingival fibroblasts with respect to secretion of chemokines IL6, IL8, and monocyte chemoattractant protein 1 (MCP1). Fibroblasts stimulated with TNF alpha showed increased levels of IL6, IL8, MCP1; neutrophil chemokine growth-related oncogene alpha stimulation with IFN gamma increased MCP1; and stimulation with IL4 increased VEGF. CONCLUSION: The results indicate that peri-implantitis fibroblasts represent a distinct stromal population. The cells might participate in the pathogenesis of peri-implantitis by up-regulating both vascularity and matrix breakdown, thus promoting migration/maintenance of infiltrates into the site. Cytokines produced by infiltrates could enhance the inflammatory nature of the cells in a self-feeding loop.

Management of the exposure of e-PTFE membranes in guided bone regeneration.

UNLABELLED: Guided bone regeneration (GBR) has been used extensively since its introduction in the late 1980s. In such treatment, e-PTFE membranes are often preferred because of their inert biological features and the predictability of the barrier effect. One complication of GBR is the premature exposure of the membrane. A consequence of the resulting soft tissue dehiscence is compromised bone regeneration. There are situations in which an exposed membrane can be maintained and obtain satisfactory results. This article discusses suggested guidelines for the treatment of exposed e-PTFE membranes. LEARNING OBJECTIVES: This article discusses treatment options for e-PTFE membranes that are exposed with or without infection. Upon reading this article, the reader should: Be able to identify both Class I and Class II exposures. Understand how to properly treat both a Class I and Class II exposed e-PTFE membrane.

A new incision design for mandibular symphysis bone-grafting procedures.

BACKGROUND: Traditional methods of procuring mandibular symphysis bone grafts may leave soft tissue scarring, and cause paresthesia and lip droop. METHODS: Nineteen patients selected for treatment were given general health, periodontal, and radiographic evaluations. Patients had inadequate bone volume for dental implant placement or required preprosthetic ridge augmentation procedures. Prior to surgery, bone sounding was performed to determine tissue thickness. All patients had a minimum of 4 mm of keratinized gingiva. Under local anesthesia, incisions were initiated within the keratinized gingiva. Full-thickness mucoperiosteal flaps were elevated, and small burs were used to obtain bone blocks from the mandibular symphysis. A bone-scraping device was used to obtain strips of cortical bone. A combination of sling and interrupted sutures was used for wound closure. RESULTS: All patients healed uneventfully without wound dehiscence, paresthesia, or lip droop. Sufficient bone was obtained for ridge or sinus augmentation with eventual implant placement. CONCLUSIONS: A new incision design is presented. This flap design is carried out within keratinized gingiva. Limiting the flap design to keratinized tissue facilitates flap closure and avoids wound dehiscence.