Decisions Before Incisions: Technique Selection for the Distal Wedge Procedure.

FOCUSED CLINICAL QUESTION: What factors identify the optimal surgical technique when a distal wedge procedure is indicated at a terminal maxillary or mandibular molar site? SUMMARY: Incision design for the distal wedge procedure is based primarily on the dental arch (maxilla or mandible), the distance from the terminal molar to the hamular notch or ascending ramus, and the dimensions of the attached gingiva. CONCLUSIONS: In most situations, favorable clinical results are achievable irrespective of the chosen distal wedge method, and technique selection is based more on operator preference than evidence. However, anatomic limitations can render distal wedge procedures challenging in some cases, and procedural advantages of specific techniques can simplify treatment. One systematic approach to distal wedge technique selection is presented in this report. Additionally, a laser-assisted distal wedge protocol is presented for cases in which unfavorable tooth-to-ramus distance or presence of a prominent external oblique ridge contraindicates conventional distal wedge techniques.

The Tissue-Supported Sling Suture: Technique and Clinical Applications.

INTRODUCTION: Continuous and interrupted sling sutures (ISSs) are used around teeth in contemporary periodontics. However, conventional ISSs depend upon favorable tooth morphology for stability through the early healing period. The purpose of this report is to present a variation of the classic ISS that does not rely on favorable tooth morphology. CASE SERIES: Tissue-supported sling sutures (TSSs) were used for six patients undergoing root coverage, gingival augmentation, or pontic site development (guided bone regeneration) procedures. CONCLUSIONS: Although techniques such as vertical mattress suturing may support greater coronal flap advancement, the TSS technique does maintain coronal flap position while minimizing trauma to papillae. TSS stability is independent of tooth morphology and may offer clinicians flexibility in achieving reliable closure over hard and soft tissue implants. Like mattress sutures, TSSs reduce tension at the crestal incision line in tissue grafting procedures.

Focus on Epithelialized Palatal Grafts. Part 3: Methods to Enhance Patient Comfort at Palatal Donor Sites.

INTRODUCTION: Postoperative discomfort is a documented complication of the epithelialized palatal graft (EPG) procedure, and the expectation of an unpleasant patient experience may cause some practitioners to avoid EPG altogether. However, EPG affords distinct advantages in a variety of clinical situations, and the postoperative discomfort associated with the procedure can be minimized. CASE SERIES: Three generally and periodontally healthy patients with gingival recession defects and minimal zones of attached gingiva received mandibular anterior EPG procedures. In all cases, collagen membranes were trimmed to fit the palatal donor sites and sutured in place. Two patients reported minimal donor site discomfort at any time point. One patient with large bilateral donor sites reported moderate palatal discomfort limited to the first postoperative week. All patients reported overall positive treatment experiences. CONCLUSIONS: Placement of a resorbable collagen membrane at large EPG harvest sites appears to limit topical irritation of the wound and may substantially improve patient comfort postoperatively. Combining local and systemic measures to minimize patient discomfort may render EPG procedures very tolerable for patients. Controlled clinical trials comparing patient-centered outcomes following EPG harvest with and without collagen membrane placement appear warranted.

The Extraction Socket Management Continuum: A Hierarchical Approach to Dental Implant Site Development.

FOCUSED CLINICAL QUESTION: How should clinicians manage dental extraction sockets when immediate implant placement is contraindicated, and alveolar ridge preservation is expected to result in inadequate bone volume for implant placement? SUMMARY: Three fundamental options for extraction socket management form a hierarchical continuum in sites where dental implant placement is planned: place an immediate implant, perform ridge preservation, or perform ridge augmentation. The available volume and quality of bone and keratinized mucosa are the primary considerations driving the decision, and each tier in the continuum encompasses a variety of techniques with attendant advantages and disadvantages. CONCLUSIONS: Some immediate implant protocols require no mucoperiosteal flap and possibly produce the most favorable clinical and patient-centered outcomes compared with other extraction socket management approaches. Conversely, guided bone regeneration at dental extraction sites can result in substantial gains in alveolar ridge dimensions, although this treatment may adversely influence mucosal architecture and carry increased risk of postoperative morbidity. When favorable bone and mucosa are present at a dental extraction site, immediate implant placement may be the treatment of choice, barring unusual circumstances. Ridge preservation, typically associated with minimal postoperative morbidity, is a rational second choice when acceptable ridge dimensions are anticipated after healing.

Focus on Epithelialized Palatal Grafts. Part 2: Implant Site Development.

INTRODUCTION: The epithelialized palatal graft (EPG), introduced in 1963, has persisted as the gold standard for gingival augmentation, and in the present era, mucosal augmentation around dental implants has become an important concern. A limited body of evidence suggests peri-implant mucosal augmentation may favorably impact bone and mucosal stability and peri-implant health under some circumstances. Although more contemporary procedures for peri-implant mucosal augmentation are often preferred based on convenience and esthetic considerations, EPG augmentation at dental implant sites is distinguishable from methods which do not deepen the vestibule and eliminate unfavorable superficial soft tissue. Implant sites augmented with EPG are qualitatively distinct from sites augmented using other methods. CASE SERIES: Seven generally healthy patients received EPG augmentation before dental implant placement, at implant placement, before implant uncovering, or after implant uncovering. In each case, the patient exhibited a favorable zone of attached peri-implant mucosa following treatment. CONCLUSIONS: Reliable mucosal augmentation with EPG is achievable at multiple phases in the course of dental implant therapy. EPG augmentation offers distinct clinical advantages and may be preferable to other mucosal augmentation strategies at some dental implant sites.

Adjunctive Nd:YAG Laser Irradiation for Ridge Preservation and Immediate Implant Procedures: A Consecutive Case Series.

INTRODUCTION: Whether or not laser use provides any meaningful benefit at immediate implant and ridge preservation sites remains an open question in periodontics. However, various lasers have been used in conjunction with tooth extraction and immediate implant placement. Evidence supporting adjunctive laser irradiation at immediate implant and ridge preservation sites is mostly limited to preclinical studies and a small number of case reports. CASE SERIES: Adjunctive neodymium‒doped: yttrium, aluminum, garnet (Nd:YAG) laser irradiation was used at six immediate implant sites and five ridge preservation sites. Three immediate implants were in maxillary incisor positions and three were in premolar positions, two maxillary and one mandibular. All cases exhibited favorable healing and satisfactory clinical outcomes. CONCLUSIONS: Nd:YAG laser energy application with 650-µs pulse duration consistently supported rapid clot formation and graft containment at immediate implant and ridge preservation sites. Histologic analyses and controlled clinical trials comparing ridge preservation and immediate implant procedures with and without laser use are needed. Because cellular responses and clinical outcomes may be exquisitely sensitive to irradiation parameters, studies should report materials and methods in detail.

Protocol for Maintaining Alveolar Ridge Volume in Molar Immediate Implant Sites.

INTRODUCTION: Numerous biomaterials are available for augmenting bone around dental implants. In contained extraction sockets, a demineralized freeze-dried bone allograft (DFDBA) appears capable of maintaining dimensional stability of the alveolar ridge as well as mineralized alternatives but may yield a higher percentage of new vital bone. When DFDBA is used in large horizontal gap defects at molar immediate implant sites, graft containment and protection must occur through provisional restoration, an anatomic custom healing abutment, or by other means. CASE SERIES: Two mandibular molar immediate implant sites received DFDBA covered by dense polytetrafluoroethylene membranes. CONCLUSION: The present report suggests a protocol for maintaining favorable dimensional stability of the alveolar ridge at molar immediate implant sites, while possibly minimizing residual peri-implant biomaterial.