Efficacy of a collagen matrix for soft tissue augmentation after implant placement compared to connective tissue grafts: A multicenter, noninferiority, randomized controlled trial.

OBJECTIVES: To test whether soft tissue volume augmentation using a collagen matrix (VCMX) leads to noninferior results in terms of gain of mucosal thickness at single implant sites, compared to connective tissue grafts (SCTG). METHODS: The study was designed as a multi-center randomized controlled clinical trial. Subjects in need of soft tissue volume augmentation at single tooth implant sites were consecutively recruited at nine centers. The deficient mucosal thickness at the implant sites (one per patient) was augmented by applying either a VCMX or a SCTG. Patients were examined at 120 days (abutment connection = primary endpoint), 180 days (final restoration), and 360 days (1-year after insertion of the final restoration). Outcome measures included: transmucosal probing of the mucosal thickness (crestal = primary outcome), profilometric measurements of the tissue volume, and patient-reported outcome measures (PROMs). RESULTS: Out of the 88 patients, 79 attended the one-year follow-up. The median increase of the crestal mucosal thickness between pre-augmentation and 120 days was 0.3 ± 2.1 mm in the VCMX group and 0.8 ± 1.6 mm in the SCTG group (p = .455). Non-inferiority of the VCMX compared to the SCTG was not observed. The respective numbers at the buccal aspect amounted to 0.9 ± 2.0 mm (VCMX) and 1.1 ± 1.4 mm (SCTG; p = .431). PROMs including pain perception favored the VCMX group. CONCLUSION: It remains inconclusive whether soft tissue augmentation using a VCMX is noninferior to SCTG in terms of crestal mucosal thickening at single implant sites. However, the use of collagen matrices favors PROMs especially pain perception, while achieving similar buccal volume gains along with comparable clinical and aesthetic parameters to SCTG.

Randomized controlled clinical trial of digital and conventional workflows for the fabrication of zirconia-ceramic fixed partial dentures. Part III: Marginal and internal fit.

STATEMENT OF PROBLEM: Trials comparing the overall performances of digital and conventional workflows in restorative dentistry are lacking. PURPOSE: The purpose of the third part of this clinical study was to test whether the fit of zirconia 3-unit frameworks for fixed partial dentures fabricated with fully digital workflows differed from that of metal frameworks fabricated with the conventional workflow. MATERIAL AND METHODS: In each of 10 participants, 4 fixed-partial-denture frameworks were fabricated for the same abutment teeth according to a randomly generated sequence. Digital workflows were applied for the fabrication of 3 zirconia frameworks with Lava, iTero, and Cerec infiniDent systems. The conventional workflow included a polyether impression, manual waxing, the lost-wax technique, and the casting of a metal framework. The discrepancies between the frameworks and the abutment teeth were registered using the replica technique with polyvinyl siloxane. The dimensions of the marginal discrepancy (Discrepancymarginal) and the internal discrepancy in 4 different regions of interest (Discrepancyshoulder, Discrepancyaxial, Discrepancycusp, and Discrepancyocclusal) were assessed using a light microscope. Post hoc t tests with Bonferroni correction were applied to detect differences (α=.05). RESULTS: Discrepancyshoulder was 96.1 ±61.7 µm for the iTero, 106.9 ±96.0 µm for the Lava, 112.2 ±76.7 µm for the Cerec infiniDent, and 126.5 ±91.0 µm for the conventional workflow. The difference between the iTero and the conventional workflow was statistically significant (P=.029). Discrepancyocclusal was 153.5 ±66.8 µm for the iTero, 203.3 ±127.9 µm for the Lava, 179.7 ±63.1 µm for the Cerec infiniDent, and 148.8 ±66.8 µm for the conventional workflow. Discrepancyocclusal was significantly lower for the conventional workflow than for the Lava and the Cerec infindent workflows (P<.01). The iTero resulted in significantly lower values of Discrepancyocclusal than the Lava and the Cerec infiniDent workflows (P<.01). CONCLUSIONS: In terms of framework fit in the region of the shoulder, digitally fabricated zirconia 3-unit frameworks presented similar or better fit than the conventionally fabricated metal frameworks. In the occlusal regions, the conventionally fabricated metal frameworks achieved a more favorable fit than the CAD-CAM zirconia frameworks.

A strain gauge analysis comparing 4-unit veneered zirconium dioxide implant-borne fixed dental prosthesis on engaging and non-engaging abutments before and after torque application.

This study quantified the strain development after inserting implant-borne fixed dental prosthesis (FDP) to various implant-abutment joints. Two bone-level implants (∅ = 4.1 mm, RC, SLA 10 mm, Ti, Straumann) were inserted in polyurethane models (N = 3) in the area of tooth nos 44 and 47. Four-unit veneered zirconium dioxide FDPs (n = 2) were fabricated, one of which was fixed on engaging (E; RC Variobase, ∅ = 4.5 mm, H = 3.5 mm) and the other on non-engaging (NE) abutments (RC Variobase, ∅ = 4.5 mm, H = 5.5 mm). One strain gauge was bonded to the occlusal surface of pontic no. 46 on the FDP and the other two on the polyurethane model. Before (baseline) and after torque (35 Ncm), strain values were recorded three times. Data were analyzed using Kruskal-Wallis and Mann-Whitney U tests (α = 0.05). Mean strain values presented significant increase after torque for both E and NE implant-abutment connection type (baseline: E = 4.33 ± 4.38; NE = 4.85 ± 4.85; torque: E = 196.56 ± 188.02; NE = 275.63 ± 407.7; p < .05). Mean strain values based on implant level presented significant increase after torque for both E and NE implant-abutment connection (baseline: E = 4.94 ± 5.29; NE = 5.78 ± 5.69; torque: E = 253.78 ± 178.14; NE = 347.72 ± 493.06; p < .05). The position of the strain gauge on implants (p = .895), FDP (p = .275), and abutment connection type (p = .873) did not significantly affect the strain values. Strain levels for zirconium dioxide implant-borne FDPs were not affected by the implant-abutment connection type.

Non-interventional 1-year follow-up study of peri-implant soft tissues following previous soft tissue augmentation and crown insertion in single-tooth gaps.

AIM: To assess peri-implant soft tissue dimensions at implant sites, previously augmented with a collagen matrix (VCMX) or an autogenous subepithelial connective tissue graft (SCTG), between crown insertion and 1 year. METHODS: Twenty patients with single-tooth implants received soft tissue augmentation prior to abutment connection randomly using VCMX or SCTG. Following abutment connection 3 months later, final reconstructions were fabricated and inserted (baseline). Patients were recalled at 6 months (6M) and at 1 year (FU-1). Measurements included clinical data, soft tissue thickness, volumetric outcomes and patient-reported outcome measures (PROMs). RESULTS: The buccal soft tissue thickness showed a median decrease of -0.5 mm (-1.0;0.3) (VCMX) and 0.0 mm (-0.5;1.0) (SCTG) (p = .243) up to FU-1. The soft tissue volume demonstrated a median decrease between BL and FU-1 of -0.1 mm (-0.2;0.0) (p = .301) for VCMX and a significant decrease of -0.2 mm (-0.4; -0.1) (p = .002) for SCTG, respectively. Intergroup comparisons did not reveal any significant differences between the groups for peri-implant soft tissue dimensions and changes up to FU-1 (p > .05). PROMs did not show any significant changes over time nor differences between the groups. CONCLUSION: Between crown insertion and 1 year, the buccal peri-implant soft tissue dimensions remained stable without relevant differences between sites that had previously been grafted with VCMX or SCTG.

Randomized controlled clinical study comparing a volume-stable collagen matrix to autogenous connective tissue grafts for soft tissue augmentation at implant sites: linear volumetric soft tissue changes up to 3 months.

AIM: To test whether or not the use of a volume-stable collagen matrix (VCMX) results in soft tissue volume increase at implant sites non-inferior to an autogenous subepithelial connective tissue graft (SCTG). METHODS: In 20 patients, soft tissue augmentation at implant sites was performed using VCMX or SCTG. Casts obtained prior to augmentation (BL), at 30 (FU-30) and 90 days (FU-90) were digitized and transferred to stereolithography (STL) files. BL, FU-30 and FU-90 STL files were superimposed and linear volumetric changes evaluated in crestal and buccal regions of interest (ROI). Descriptive analysis was computed for both groups and a test for non-inferiority was performed. RESULTS: The median linear changes from BL to FU-90 in the crestal ROI amounted to 0.175 mm (0.06; 0.51) for VCMX (p = 0.002 over time) and to 0.51 mm (0.23; 0.94) for SCTG (p = 0.129). The differences between the two groups were not significant (p = 0.287). The respective values in the buccal ROI were 0.59 mm (0.26; 1.06) for VCMX (p = 0.002) and 0.94 mm (0.66; 1.13) for SCTG (p = 0.004). The differences between the two groups were not significant (crestal: p = 0.287; buccal: p = 0.534). Non-inferiority could be concluded for VCMX compared to SCTG for both ROI. CONCLUSION: VCMX and SCTG can be used for soft tissue augmentation at implant sites resulting in an at least short-term increase in volume.

Randomized controlled within-subject evaluation of digital and conventional workflows for the fabrication of lithium disilicate single crowns. Part III: marginal and internal fit.

STATEMENT OF PROBLEM: Trials comparing the overall performance of digital with that of conventional workflows in restorative dentistry are needed. PURPOSE: The purpose of the third part of a series of investigations was to test whether the marginal and internal fit of monolithic crowns fabricated with fully digital workflows differed from that of crowns fabricated with the conventional workflow. MATERIAL AND METHODS: In each of 10 participants, 5 monolithic lithium disilicate crowns were fabricated for the same abutment tooth according to a randomly generated sequence. Digital workflows were applied for the fabrication of 4 crowns using the Lava, iTero, Cerec inLab, and Cerec infinident systems. The conventional workflow included a polyvinyl siloxane impression, manual waxing, and heat-press technique. The discrepancy between the crown and the tooth was registered using the replica technique with polyvinyl siloxane material. The dimensions of the marginal discrepancy (Discrepancymarginal) and the internal discrepancy in 4 different regions of interest (Discrepancyshoulder, Discrepancyaxial, Discrepancycusp, and Discrepancyocclusal) were assessed using light microscopy. Post hoc Student t test with Bonferroni correction was applied to detect differences (α=.05). RESULTS: Discrepancymarginal was 83.6 ±51.1 µm for the Cerec infinident, 90.4 ±66.1 µm for the conventional, 94.3 ±58.3 µm for the Lava, 127.8 ±58.3 µm for the iTero, and 141.5 ±106.2 µm for the Cerec inLab workflow. The differences between the treatment modalities were not statistically significant (P>.05). Discrepancyshoulder was 82.2 ±42.4 µm for the Cerec infinident, 97.2 ±63.8 µm for the conventional, 103.4 ±52.0 µm for the Lava, 133.5 ±73.0 µm for the iTero, and 140.0 ±86.6 µm for the Cerec inLab workflow. Only the differences between the Cerec infinident and the Cerec inLab were statistically significant (P=.036). The conventionally fabricated crowns revealed significantly lower values in Discrepancycusp and Discrepancyocclusal than all the crowns fabricated with digital workflows (P<.05). CONCLUSIONS: In terms of marginal crown fit, no significant differences were found between the conventional and digital workflows for the fabrication of monolithic lithium disilicate crowns. In the occlusal regions, the conventionally manufactured crowns revealed better fit than the digitally fabricated crowns. Chairside milling resulted in less favorable crown fit than centralized milling production.

Randomized controlled clinical study evaluating effectiveness and safety of a volume-stable collagen matrix compared to autogenous connective tissue grafts for soft tissue augmentation at implant sites.

AIM: To test whether or not the use of a collagen matrix (VCMX) results in short-term soft tissue volume increase at implant sites non-inferior to an autogenous subepithelial connective tissue graft (SCTG), and to evaluate safety and tissue integration of VCMX and SCTG. METHODS: In 20 patients with a volume deficiency at single-tooth implant sites, soft tissue volume augmentation was performed randomly allocating VCMX or SCTG. Soft tissue thickness, patient-reported outcome measures (PROMs), and safety were assessed up to 90 days (FU-90). At FU-90 (abutment connection), tissue samples were obtained for histological analysis. Descriptive analysis was computed for both groups. Non-parametric tests were applied to test non-inferiority for the gain in soft tissue thickness at the occlusal site. RESULTS: Median soft tissue thickness increased between BL and FU-90 by 1.8 mm (Q1:0.5; Q3:2.0) (VCMX) (p = 0.018) and 0.5 mm (-1.0; 2.0) (SCTG) (p = 0.395) (occlusal) and by 1.0 mm (0.5; 2.0) (VCMX) (p = 0.074) and 1.5 mm (-2.0; 2.0) (SCTG) (p = 0.563) (buccal). Non-inferiority with a non-inferiority margin of 1 mm could be demonstrated (p = 0.020); the difference between the two group medians (1.3 mm) for occlusal sites indicated no relevant, but not significant superiority of VCMX versus SCTG (primary endpoint). Pain medication consumption and pain perceived were non-significantly higher in group SCTG up to day 3. Median physical pain (OHIP-14) at day 7 was 100% higher for SCTG than for VCMX. The histological analysis revealed well-integrated grafts. CONCLUSIONS: Soft tissue augmentation at implant sites resulted in a similar or higher soft tissue volume increase after 90 days for VCMX versus SCTG. PROMs did not reveal relevant differences between the two groups.

Fracture strength of implant abutments after fatigue testing: A systematic review and a meta-analysis.

PURPOSE: The use of implants and their respective suprastructures to replace missing teeth has become a common therapeutic option in dentistry. Prior to their clinical application, all implant components have to demonstrate suitable durability in laboratory studies. Fatigue tests utilising cyclic loading typically simulate masticatory function in vitro. The objectives of this systematic review were to assess the loading conditions used for fatigue testing of implant abutments and to compare the fracture strength of different types of implant abutment and abutment-connection types after cyclic loading. MATERIALS AND METHODS: Original scientific papers published in MEDLINE (PubMed) and Embase database in English between 01/01/1970 and 12/31/2014 on cyclic loading on implant abutments were included in this systematic review. The following MeSH terms, search terms and their combinations were used: "in vitro" or "ex vivo" or experimental or laboratory, "dental implants", "implants, experimental", "dental prosthesis, implant-supported", "fatigue", "dental abutments", "cyclic loading", "cyclic fatigue", "mechanical fatigue", "fatigue resistance", "bending moments", and "fracture". Two reviewers performed screening and data abstraction. Only the studies that reported, static fracture values before and after fatigue cycling of implant abutments, were included that allowed comparison of aging effect through cyclic loading. Data (N) were analyzed using a weighted linear regression analysis (α=0.05). RESULTS: The selection process resulted in the final sample of 7 studies. In general, loading conditions of the fatigue tests revealed heterogeneity in the sample but a meta-analysis could be performed for the following parameters: a) abutment material, b) implant-abutment connection, and (c) number of fatigue cycles. Mean fracture strength of titanium (508.9±334.6N) and for zirconia abutments (698.6±452.6N) did not show significant difference after cyclic loading (p>0.05). Internal implant-abutment connections demonstrated significantly higher fracture strength after cyclic loading compared to external ones (internal: 774.0±582.3N; external: 481.2±137.5N; p=0.022). The mean fracture strength of all abutment types decreased significantly when number of loading cycles exceeded 1,000,000 cycles (<1×10(-6): 1047.0±751.3N; >1×10(-6): 556.7±317.6N; p=0.032). CONCLUSION: The results of this meta-analysis, favour the use of internal implant-abutment connections in combination with either titanium or zirconia abutment materials. Number of cycles had a significant impact on the fracture strength after cyclic loading.

Volumetric analysis of chin and mandibular retromolar region as donor sites for cortico-cancellous bone blocks.

AIM: To test whether the mandibular retromolar region renders different results from the chin region with respect to the amount of bone available for the harvesting of block grafts. MATERIAL AND METHODS: Sixty cone beam computed tomography (CBCT) scans of mandibles of adult patients without pathologic findings in the chin and retromolar region were included. According to the number of mandibular teeth, 20 CBCT data sets were allocated to each of the following groups: group M1: dentition 36-46; group M2: dentition 37-47; and group M3: dentition 38-48. For the potential donor sites in the chin and the retromolar regions, the volume (VChin , VRetro ), the length (LChin , LRetro ), the height (HChin , HRetro ) and the width (HChin , HRetro ) were assessed using a computer software. Moreover, the chin was examined for the presence and the localization of the mandibular incisive canal. To compare the donor sites in the chin and in the retromolar regions, the quotients VRetro /VChin , LRetro /LChin , HRetro /HChin and WRetro /WChin were calculated and tested using the Wilcoxon signed-rank test or the sign test. RESULTS: The mean bone volume VChin measured 3.5 ± 1.3 cm(3) (SD), whereas the overall VRetro amounted to 1.8 ± 1.1 cm(3) (SD). VRetro amounted to 2.6 ± 1.4 cm(3) (SD) in the group M1, 1.8 ± 0.5 cm(3) in the group M2 and 1.0 ± 0.4 cm(3) in the group M3. For the group M1, VRetro /VChin measured 82 ± 39% (P = 0.036). VRetro /VChin reached 57 ± 20% in the group M2 and 32 ± 12% in the group M3 (P < 0.001). The mandibular incisive canal was detected in 97% of the CBCT scans. The distance between the mandibular incisive canal and the apices of the central incisors measured 10.5 ± 3.5 mm. CONCLUSION: The amount of bone available for the harvesting of cortico-cancellous blocks in the chin region was superior in comparison with the mandibular retromolar region. In the absence of the second and the third molars, the amount of bone harvestable in the retromolar region reached approximately 80% of the bone volume available in the chin region. In the majority of the cases, the mandibular incisive canal was detected within the donor site in the chin region.

Temperature changes during ultrasonic irrigation with different inserts and modes of activation.

This study evaluated temperature changes during passive ultrasonic irrigation. Root canals of three extracted maxillary canines were enlarged to size #45. Thermocouples were mounted 3, 6, and 9 mm from the apical foramen. Teeth were placed in a water bath at 37 degrees C. Distilled water (20 degrees C) was continuously delivered through an ultrasonic unit (group 1) or deposited into the root canal before ultrasonic activation (group 2); for activation, noncutting nickel-titanium (NiTi) inserts or stainless steel K-files #15, #25, and #35 were used. Before and during ultrasonic activation, temperatures were continuously measured for 210 seconds. Statistical analysis was performed using analysis of variance and Scheffé post hoc tests. Temperatures initially decreased by up to 7.4 degrees C; these drops were significantly smaller in group 1 than in group 2 (p < 0.001) in the middle and apical root canal third. The decreases were followed by temperature rises for all inserts in group 2. However, in group 1, temperatures just reached baseline values in middle and apical thirds; in the coronal root canal third, lower temperatures were measured. In group 2, mean temperature rises were 7.7 degrees , 7.5 degrees , and 4.2 degrees C in coronal, middle, and apical root canal thirds. Here, K-file type inserts size #35 generated highest and inserts size #15 the lowest temperatures rises; NiTi inserts were more effective than size #15 K-files and less effective than #35 K-files. Continuous flow negated the potential of ultrasonic activation to heat irrigation solutions. Noncutting NiTi instruments and large K-files were more effective than small K-files in warming deposited irrigants.