Treatment of teeth with insufficient clinical crown. Long-term clinical outcomes of a minimally invasive crown lengthening approach: a retrospective analysis.

AIMS: Aim of this retrospective study was to evaluate the incidence of complications and to determine the long-term survival rate of teeth with severely compromised clinical crowns treated with minimally invasive crown lengthening (MICL) and restorative treatment. METHODS: A sample of 112 teeth in 86 patients was treated with MICL and restorative dentistry. Endodontic and orthodontic therapy was applied when needed. Clinical outcomes were assessed at baseline, 1 year and long-term. RESULTS: The application of MICL resulted in very limited radiographic bone resection (RBR, 1 ± 0.1 mm on average). Limited local inflammation and shallow probing depth were detected at 1 year (2.6 ± 0.5 mm) and long-term (2.9 ± 1.0 mm). Most of the teeth (76.8%) maintained dental and periodontal health over time. The negative events observed in 26 teeth were caries (8.9%), fractures (7.1%), endodontic problems (1.8%), periodontal problems (4.5%) and restoration problems / complications (0.9%). The survival rate was 90.2%. CONCLUSIONS: the outcomes of this long-term retrospective analysis (8.9 ± 0.9 years, range 8 to 10) show high tooth survival rates and low incidence of complications of teeth treated with MICL and restoration of the clinical crown.

Evaluation Of Gingival Biotype And Recession Following Non-Surgical Periodontal Treatment Using 3-Dimensional Scan Methods.

The study evaluated the position of gingival margins in anterior teeth using clinical and 3-dimensional (3D) optical scanning method among patients subjected to non surgical periodontal treatment (NSPT). A single arm, longitudinal study was undertaken at the Archway Dental Center, University of Manchester, UK. History and clinical examination were done. Gingival recession, attachment loss (AL), and periodontal probing depth (PD) were recorded at baseline and 12-weeks follow-up. NSPT was done using hand and ultrasonic instruments. Impressions were made, the resultant gypsum models were scanned to generate 3D images. The change in the gingival level and thickness of facial gingiva were assessed. Out of eight patientsrecruited, three were lost to follow up. The 3D scan showed a poor correlation with the clinical assessment of gingival recession in anterior teeth following NSPT (r=- 0.0089). Recession did not improve after NSPT (p= 0.20).

Comparative evidence of different surgical techniques for the management of vertical alveolar ridge defects in terms of complications and efficacy: A systematic review and network meta-analysis.

AIM: To systematically appraise the available evidence on vertical ridge augmentation (VRA) techniques and estimate a treatment-based ranking on the incidence of complications as well as their clinical effectiveness. MATERIALS AND METHODS: Searches were conducted in six databases to identify randomized clinical trials comparing VRA techniques up to November 2022. The incidence of complications (primary) and of early, major, surgical and intra-operative complications, vertical bone gain (VBG), marginal bone loss, need for additional grafting, implant success/survival, and patient-reported outcome measures (secondary) were chosen as outcomes. Direct and indirect effects and treatment ranking were estimated using Bayesian pair-wise and network meta-analysis (NMA) models. RESULTS: Thirty-two trials (761 participants and 943 defects) were included. Five NMA models involving nine treatment groups were created: onlay, inlay, dense-polytetrafluoroethylene, expanded-polytetrafluoroethylene, titanium, resorbable membranes, distraction osteogenesis, tissue expansion and short implants. Compared with short implants, statistically significant higher odds ratios of healing complications were confirmed for all groups except those with resorbable membranes (odds ratio 5.4, 95% credible interval 0.92-29.14). The latter group, however, ranked last in clinical VBG. CONCLUSIONS: VRA techniques achieving greater VBG are also associated with higher incidence of healing complications. Guided bone regeneration techniques using non-resorbable membranes yield the most favourable results in relation to VBG and complications.

Longevity of teeth in patients susceptible to periodontitis: Clinical outcomes and risk factors associated with tooth loss after active therapy and 30 years of supportive periodontal care.

AIM: (i) To evaluate the efficacy of active periodontal therapy supplemented by supportive periodontal care (SPC) in retaining dentition during a 30-year follow-up period in patients susceptible to periodontitis, and (ii) to assess the prognostic factors associated with tooth loss. MATERIALS AND METHODS: One-hundred and fifty-four patients with periodontitis, retrospectively classified as stage I-IV and grade B-C periodontitis, treated between 1984 and 1986 in a private practice, were enrolled in this study. After periodontal assessment, patients received non-surgical treatment followed by surgical periodontal therapy, orthodontic treatment, and tooth-splinting, where appropriate. SPC consisted of a strict recall programme every 3-6 months over a 30-year period. Recurrences were treated either with subgingival root planing or flap surgery. Dental and periodontal variables were measured at baseline (T0), end of active therapy (T1), and after 25 (T2) and 30 (T3) years. Generalized mixed models were analysed to assess the prognostic factors associated with and survival analyses for tooth loss. RESULTS: Data on 154 patients (4083 teeth) were available at baseline (T0). Teeth considered unworthy of treatment were extracted during active therapy (160, 3.9%) and at re-assessment (13, 0.3%; T1). After 25 years of SPC, 140 teeth out of 3910 in 154 patients (3.6%) were lost (24 in 18 patients for periodontal reasons). Between 25 and 30 years, 20 patients (482 teeth) dropped out, and 61 teeth (2%) were lost (15 in 14 patients for periodontal reasons). Overall, 201 teeth (5.1%) were lost (39 for periodontal reasons) in 30 years of SPC. Generalized mixed models showed that stage III or stage IV periodontitis was associated with greater tooth loss during SPC compared to stage I or stage II (OR = 2.10; p = .048). Generalized periodontitis showed a statistically significant OR = 3.24 (p = .016) compared to the localized one. In SPC (T1-T3), age (p = .011), gender (male; p = .038), molar teeth (p = < .001), T0 and T1 pocket depth (p = < .001), tooth mobility grades 2 (p = .018) and 3 (p = .050), T0 and T1 bone loss (p = < .001), and presence of a root canal treatment (p = < .001) and a crown (p = .009) were statistically significantly associated with tooth loss. CONCLUSION: (i) Periodontal therapy and a stringent SPC are effective in maintaining most of the teeth in patients with moderate/advanced periodontitis for 30 years, and (ii) age, gender, molar teeth, pocket depth, bone loss, and the presence of a root canal treatment and a crown are prognostic factors associated with tooth loss.

Buccal bone thickness and mid-facial soft tissue recession after various surgical approaches for immediate implant placement: A systematic review and network meta-analysis of controlled trials.

AIM: To evaluate the relative efficacy and confidence in the precision of the results of different surgical interventions for immediate implant placement in the anterior area. MATERIALS AND METHODS: Electronic searches were performed in PubMed, Embase, and Cochrane CENTRAL. Randomized controlled trials comparing different surgical techniques in anterior jaws for type 1 implant placement were included. Outcome measures included implant survival (primary outcome), buccal bone thickness (BBT) reduction, and mid-facial soft tissue recession (MSTR). Risks of bias assessment, network meta-analysis (NMA), sensitivity analysis, and quality-of-evidence assessment were performed. RESULTS: Twenty-two studies reporting on 948 subjects and 5 surgical interventions were included. Fourteen early failures were reported. Compared with open-flap surgery without tissue augmentation (F-N) and looking at BBT preservation, NMA showed that there was moderate confidence that flapless surgery with hard tissue augmentation (FL-HTA) was better than flapless surgery without tissue augmentation (FL-N) or open-flap surgery with hard tissue augmentation (F-HTA) (mean difference -0.8 mm, 95% confidence interval: -1.1 to -0.5 mm; -0.6 mm, -0.9 to -0.4 mm; and -0.5 mm, -0.7 to -0.3 mm, respectively). There was moderate confidence that flapless surgery with hard and soft tissue augmentation (FL-HTA&STA) could significantly prevent MSTR compared with FL-HTA (-0.5 mm, -0.7 to -0.3 mm) and FL-N (-0.6 mm, -1.2 to -0.04 mm). However, there was no significant additional benefit in BBT with the FL-HTA&STA approach compared to the FL-HTA approach (-0.30 mm, -0.81 to 0.21 mm). CONCLUSIONS: For immediate implant placement in the anterior areas, the FL-HTA approach better preserves BBT (moderate confidence); adding STA improves the stability of the mid-facial soft tissue level (moderate confidence) but at the expense of BBT (low confidence).

Comparison of clinical outcomes of immediate versus delayed placement of dental implants: A systematic review and meta-analysis.

OBJECTIVE: Two focused questions were addressed: Focused question (Q1) 1) Are there any differences between immediate and delayed placement in terms of (i) survival rate, (ii) success rate, (iii) radiographic marginal bone levels, (iv) height/(v)thickness of buccal wall, (vi) peri-implant mucosal margin position, (vii) aesthetics outcomes and (viii) patient reported outcomes? Focused question 2 (Q2) What is the estimated effect size of immediate implant placement for all parameters included in Q1? MATERIALS AND METHODS: An electronic search (MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials and OpenGray) and hand search were conducted up to November 2019. Randomised controlled trials (RCT) with delayed implant placement as controls were eligible in the analysis for Q1. Immediate dental implant arms RCTs, controlled clinical trials (CCTs) and prospective case series of immediate implant placement were eligible in the analysis for Q2. RESULTS: Six papers (RCTs) were included in the analysis for Q1 and 53 papers (22 RCTs, 11 CCTs and 20 case series) for Q2. Q1: Meta-analyses did not show any significant difference in implant survival, but it did for bone levels and PES scores at 1 year post-loading, favouring the immediate group. Q2: Meta-analyses showed that immediate implants had a high survival rate (97%) and presented high PES scores (range 10.36 to 11.25). Information regarding marginal bone loss and gingival/papillary recession varied among all included studies. CONCLUSION: Similar survival rate was found between immediate and delayed implants. Immediate implants presented threefold early complications and twofold delayed complications. Success criteria should be reported more consistently, and the incidence/type of complications associated with immediate implants should be further explored.

Recurrence and progression of periodontitis and methods of management in long-term care: A systematic review and meta-analysis.

AIM: To systematically review the literature to evaluate the recurrence of disease of people in long-term supportive periodontal care (SPC), previously treated for periodontitis, and determine the effect of different methods of managing recurrence. The review focused on stage IV periodontitis. MATERIALS AND METHODS: An electronic search was conducted (until May 2020) for prospective clinical trials. Tooth loss was the primary outcome. RESULTS: Twenty-four publications were retrieved to address recurrence of disease in long-term SPC. Eight studies were included in the meta-analyses for tooth loss, and three studies for disease progression/recurrence (clinical attachment level [CAL] loss ≥2 mm). For patients in SPC of 5-20 years, prevalence of losing more than one tooth was 9.6% (95% confidence interval [CI] 5%-14%), while experiencing more than one site of CAL loss ≥2 mm was 24.8% (95% CI 11%-38%). Six studies informed on the effect of different methods of managing recurrence, with no clear evidence of superiority between methods. No data was found specifically for stage IV periodontitis. CONCLUSIONS: A small proportion of patients with stage III/IV periodontitis will experience tooth loss in long-term SPC (tendency for greater prevalence with time). Regular SPC appears to be important for reduction of tooth loss. No superior method to manage disease recurrence was found.

Immediate implant placement in fresh alveolar sockets with a minimal split-thickness envelope flap: A randomised controlled clinical trial.

OBJECTIVES: Comparing PES/WES scores, modified success rate, survival, success, buccal bone thickness and patient-reported outcomes of immediate dental implants placed in fresh alveolar sockets using a flap or a minimal split-thickness envelope flap (MSTEF). MATERIALS AND METHODS: Implants following random assignment into a flap or MSTEF group were placed immediately in anterior and premolar areas. Guided bone regeneration and autogenous connective tissue graft were used in all cases. A temporary prosthesis was provided followed by the final prosthesis at 16-18 weeks. Success and survival rates together with radiographic buccal bone thickness and patient satisfaction were evaluated at 12-month post-loading. The aesthetic outcome was evaluated through the Pink (PES) and White (WES) Aesthetic Score by 8 blind clinicians of different training background and incorporated in modified success criteria. RESULTS: 28 implants were placed on 28 patients. No statistically significant differences were noted in PES (10.54 control versus 10.80 test), WES scores (6.97 control versus 6.95 test) or success criteria including aesthetic parameters (modified success criteria) for the different specialty groups (Range 69%-92%). In addition, no statistically significant differences were noted in survival (100%), success (100%), buccal wall thickness between control (0.72 ± 0.22) and test group (0.92 ± 0.31) and patients' reported outcomes. CONCLUSIONS: Immediate dental implant treatment with flap/ MSTEF provided similar mean PES/WES scores, modified success rate, survival, mean buccal bone levels and patients' satisfaction. However, aesthetic failures were common in both groups.

Adjunctive Effect of Systemic Antibiotics in Regenerative/Reconstructive Periodontal Surgery-A Systematic Review with Meta-Analysis.

BACKGROUND AND OBJECTIVE: Systemic antibiotics (AB) are often used in conjunction with regenerative/reconstructive periodontal surgery of intrabony defects and furcations; however, their potential benefits have not been systematically assessed. MATERIALS AND METHODS: Data were retrieved from two recent systematic reviews (a total of 105 randomized clinical trials (RCTs) on clinical and radiographic outcomes in intrabony defects (ID) and molars with furcation involvement (FI) treated by surgical access with regenerative techniques. Pair-wise meta-analysis of RCTs with and without AB was performed. Meta-regressions from single-arm (subgroup) RCTs including study arms with or without adjunctive AB were also conducted. RESULTS: No statistically significant benefits of systemic AB with regard to PPD, CAL and bone gain were detected in ID by pair-wise meta-analysis. Meta-regression revealed increased PPD reduction (-0.91 mm, 95% CI = -1.30; -0.51, p < 0.001), CAL gain (-0.92 mm, 95% CI = -1.32; -0.52, p < 0.001) and bone gain (-1.08 mm, 95% CI = -1.63; -0.53, p < 0.001) in ID but not in any of the outcomes in FI for arms treated with AB vs. study arms treated with no AB. No clear differences in adverse events were detected between AB and non-AB groups. CONCLUSION: There is only weak indirect evidence that AB may provide additional benefits in terms of clinical improvements in the regenerative/reconstructive periodontal surgery of intrabony defects and no evidence for a benefit in furcations. Until new data are gained and in the context of antibiotic stewardship, it may be questionable to justify the adjunctive use of systemic antibiotics.

Immediate Postextraction Single-Tooth Implants and Provisional Crowns in the Esthetic Area: 2-year Results of a Cohort Prospective Multicenter Study- Patient-Centered Outcomes.

PURPOSE: A prospective cohort multicenter study was undertaken to identify risk factors for implant survival, complications, and patient-centered outcomes following single-tooth immediate implant placement and loading in esthetic areas. MATERIALS AND METHODS: Consecutive immediate implants placed in incisors, canines, and premolar sites were included. Variables recorded as possible risk factors included smoking habit, systemic conditions or therapies, previous assumption of bisphosphonates, inability to take amoxicillin, untreated periodontitis, thin periodontium, parafunctional habits, suppuration, bone dehiscences, and buccal bone fracture during implant insertion. Outcome variables included implant survival, recession, other complications, and patient satisfaction. RESULTS: Data of 215 implants in 215 patients were collected in 15 centers in 2 years. One implant was seated with a torque < 30 Ncm and was not immediately loaded. It was successfully loaded 10 weeks after placement and was healthy 2 years later. This implant was excluded from subsequent analysis. Potential risk factors were identified in 116 patients (54.21%). There were 11 dropouts after 1 year and 37 after 2 years. Failures were relatively frequent (14.6%) before the delivery of the definitive prosthesis. No significant association was observed between early failures and risk factors. One failure and six recessions were observed after the definitive prosthesis. High satisfaction scores (mean score of 9.47/10 and 9.55/10 for esthetics and function, respectively) were recorded at 2 years. No recession occurred in the no-risk group. Five mucositis cases and one peri-implantitis case were observed in the 2-year follow-up. CONCLUSION: Failures were frequent before the definitive restoration and could not be explained by specific risk factors. Tissues appeared stable after the definitive restoration. Patients were very satisfied during the follow-up.

Clinical efficacy of minimally invasive surgical (MIS) and non-surgical (MINST) treatments of periodontal intra-bony defect. A systematic review and network meta-analysis of RCT's.

OBJECTIVE: The aim of this systematic review was to explore the efficacy of different minimal invasive surgical (MIS) and non-surgical (MINST) approaches for the treatment of intra-bony defect in terms of clinical attachment level (CAL) gain and periodontal pocket depth (PPD) reduction. METHODS: A detailed review protocol was designed according to PRISMA guideline. Online search was conducted on PubMed, Cochrane library and Embase. Only randomized clinical trials (RCTs) testing MIS or MINST procedure, with or without the application of a regenerative tool for the treatment of intra-bony defect, were included. Cochrane checklist for risk of bias assessment was used. Network meta-Analysis (NMAs) was used to rank the treatment efficacy. RESULTS: Nine RCTs accounting for 244 patients and a total of 244 defects were included. Only two studies were at low risk of bias. CAL gain for included treatment ranged from 2.58 ± 1.13 mm to 4.7 ± 2.5 mm while PPD reduction ranged from 3.19 ± 0.71 mm to 5.3 ± 1.5 mm. On the basis of the ranking curve, MINST showed the lowest probability to be the best treatment option for CAL gain. Pairwise comparisons and treatment rankings suggest superiority for regenerative approaches (CAL difference 0.78 mm, (0.14-1.41); P < 0.05) and surgical treatment elevating only the buccal or palatal flap (CAL difference: 0.95 mm, (0.33-1.57); P < 0.05). CONCLUSIONS: Minimally invasive surgical (MIS) and non-surgical (MINST) periodontal therapy show promising results in the treatment of residual pocket with intra-bony defect. CLINICAL RELEVANCE: MIS procedures represent a reliable treatment for isolated intra-bony defect.

Periodontitis is associated with hypertension: a systematic review and meta-analysis.

Recent evidence suggests a link between periodontitis (PD) and hypertension, but the nature of this association remains unclear. The overall aim of this review was to critically appraise the evidence linking these two common disorders. Systematic search was conducted for studies published up to December 2018. Prevalence of hypertension in patients with PD (moderate/severe groups) vs. those without PD (non-PD) was the primary outcome. Additional outcomes included adjusted mean difference in systolic (SBP) and diastolic (DBP) blood pressure (BP) levels in PD vs. non-PD, assessment of biomarkers in PD and hypertension, and BP changes after periodontal therapy. From 81 studies selected, 40 were included in quantitative meta-analyses. Diagnoses of moderate-severe PD [odds ratio (OR) = 1.22; 95% confidence interval (CI): 1.10-1.35] and severe PD (OR = 1.49; 95% CI: 1.09-2.05) were associated with hypertension. Prospective studies confirmed PD diagnosis increased likelihood of hypertension occurrence (OR = 1.68; 95% CI: 0.85-3.35). Patients with PD exhibited higher mean SBP [weighted mean difference (WMD) of 4.49 mmHg; 95% CI: 2.88-6.11] and DBP (2.03 mmHg; 95% CI: 1.25-2.81) when compared with non-PD. Lastly, only 5 out of 12 interventional studies confirmed a reduction in BP following periodontal therapy, ranging from 3 to 12.5 mmHg of SBP and from 0 to 10 mmHg of DBP. PD is associated with increased odds of hypertension (SORT C) and higher SBP/DBP levels. The evidence suggesting that PD therapy could reduce BP is inconclusive. Although additional research is warranted on this association, these results suggest that oral health assessment and management of PD could not only improve oral/overall health and quality of life but also be of relevance in the management of patients with hypertension.

Regenerative surgical treatment of furcation defects: A systematic review and Bayesian network meta-analysis of randomized clinical trials.

AIMS: To investigate the clinical performance of regenerative periodontal surgery in the treatment of furcation defects versus open flap debridement (OFD) and to compare different regenerative modalities. MATERIAL AND METHODS: A systematic search was conducted to identify RCTs evaluating regenerative surgical treatment of furcations with a minimum of 12-month follow-up. Three authors independently reviewed, selected and extracted data from the search conducted and assessed risk of bias. Primary outcomes were tooth loss, furcation improvement (closure/conversion) (FImp), gain of horizontal bone level (HBL) and attachment level (HCAL). Secondary outcomes were gain in vertical attachment level (VCAL), probing pocket depth (PPD) reduction, PROMs and adverse events. Data were summarized into Bayesian standard and network meta-analysis in order to estimate direct and indirect treatment effects and to establish a ranking of treatments. RESULTS: The search identified 19 articles, reporting on 20 RCTs (19 on class II, 1 on class III furcations) with a total of 575 patients/787 defects. Tooth loss was not reported. Furcation closure ranged between 0% and 60% (10 trials), and class I conversion from 29% to 100% (six trials). Regenerative techniques were superior to OFD for FImp (OR = 20.9; 90% CrI = 5.81, 69.41), HCAL gain (1.6 mm), VCAL gain (1.3 mm) and PPD reduction (1.3 mm). Bone replacement grafts (BRG) resulted in the highest probability (Pr = 61%) of being the best treatment for HBL gain. Non-resorbable membranes + BRG ranked as the best treatment for VCAL gain (Pr = 75%) and PPD reduction (Pr = 56%). CONCLUSIONS: Regenerative surgery of class II furcations is superior to OFD. FImp (furcation closure or class I conversion) can be expected for the majority of defects. Treatment modalities involving BRG are associated with higher performance.

Cell-Based Therapies for Alveolar Bone and Periodontal Regeneration: Concise Review.

Current regenerative strategies for alveolar bone and periodontal tissues are effective and well adopted. These are mainly based on the use of a combination of synthetic/natural scaffolds and bioactive agents, obviating the incorporation of cells. However, there are some inherent limitations associated with traditional techniques, and we hypothesized that the use of cell-based therapies as part of comprehensive regenerative protocols may help overcome these hurdles to enhance clinical outcomes. We conducted a systematic review of human controlled clinical trials investigating the clinical and/or histological effect of the use of cell-based therapies for alveolar bone and periodontal regeneration and explored the translational potential of the different cell-based strategies identified in the included trials. A total of 16 studies (11 randomized controlled trials, 5 controlled clinical trials) were included for data synthesis and qualitative analysis with meta-analyses performed when appropriate. The results suggest a clinical benefit from the use of cell therapy. Improved outcomes were shown for alveolar ridge preservation, lateral ridge augmentation, and periodontal regeneration. However, there was insufficient evidence to identify best-performing treatment modalities amongst the different cell-based techniques. In light of the clinical and histological outcomes, we identify extraction socket and challenging lateral and vertical bone defects requiring bone block grafts as strong candidates for the adjuvant application of mesenchymal stem cells. Given the complexity, invasiveness, and costs associated with techniques that include "substantial manipulation" of tissues and cells, their additional clinical benefit when compared with "minimal manipulation" must be elucidated in future trials. Stem Cells Translational Medicine 2019;8:1286&1295.

Short implants versus longer implants in vertically augmented atrophic mandibles: A systematic review of randomised controlled trials with a 5-year post-loading follow-up.

PURPOSE: To compare the clinical outcome of fixed prostheses supported by 4- to 8-mm-long implants with prostheses supported by longer implants placed in vertically augmented atrophic mandibles after a follow-up of 5 years in function. MATERIALS AND METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE were searched up to 1st September 2018 for randomised controlled trials (RCTs) with a follow-up of at least 5 years in function comparing fixed prostheses supported by 4- to 8-mm-long implants with prostheses supported by longer implants placed in vertically augmented atrophic mandibles. Outcome measures were prosthesis failure, implant failures, augmentation procedure failures, complications, and peri-implant marginal bone level changes. Screening of eligible studies, assessment of the risk of bias and data extraction were conducted in duplicate and independently by two review authors. The statistical unit of the analysis was the prosthesis. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CIs). RESULTS: Four eligible RCTs that included originally 135 patients were included. Two RCTs had a parallel-group design and two a split-mouth design. Short implants were 5.0 to 6.6 mm long and were compared with longer implants placed in posterior mandibles augmented with interpositional blocks of bone substitutes. All trials were judged at unclear risk of bias. Twelve (14%) bone augmentation procedures failed to achieve the planned bone height to allow placement of implants with the planned length. Five years after loading, 28 patients (21%) had dropped out from the four RCTs. There were no differences for patients having prosthesis (RR = 1.46; 95% CI: 0.52 to 4.09; P = 0.47; I2 = 0%) or implant (RR = 1.00; 95% CI: 0.31 to 3.21; P = 1.00; I2 = 0%) failures between the two interventions, but there were more patients experiencing complications (RR = 4.72; 95% CI: 2.43 to 9.17; P < 0.00001; I2 = 0%) and peri-implant marginal bone loss (mean difference = 0.60 mm; 95% CI: 0.36 to 0.83; P < 0.00001; I2 = 45%) at longer implants in augmented bone. CONCLUSIONS: Five years after loading, prosthetic and implant failures were similar between the two interventions, but complications and peri-implant marginal bone loss were higher and more severe at longer implants placed in vertically augmented mandibles. Larger trials and longer follow-ups up to 10 years after loading are needed to confirm or reject the present preliminary findings. However in the meantime short implants could be the preferable option.

Root coverage procedures for treating single and multiple recession-type defects: An updated Cochrane systematic review.

BACKGROUND: This updated Cochrane systematic review (SR) evaluated the efficacy of different root coverage (RC) procedures in the treatment of single and multiple gingival recessions (GR). METHODS: We included randomized controlled trials (RCTs) only of at least 6 months' duration evaluating Miller's Class I or II GR (≥3 mm) treated by means of RC procedures. Five databases were searched up to January 16, 2018. Random effects meta-analyses were conducted thoroughly. RESULTS: We included 48 RCTs in the SR. The results indicated a greater GR reduction for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (mean difference [MD]: -0.37 mm). There was insufficient evidence of a difference in GR reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix derivative (EMD) + CAF and SCTG + CAF. Greater gains in the keratinized tissue width (KTW) were found for SCTG + CAF when compared to EMD + CAF (MD: -1.06 mm), and SCTG + CAF when compared to GTR rm + CAF (MD: -1.77 mm). There was insufficient evidence of a difference in KTW gain between ADMG + CAF and SCTG + CAF. CONCLUSIONS: SCTG, CAF alone or associated with another biomaterial may be used for treating single or multiple GR. There is also some evidence suggesting that ADMG appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by SCTG.

Subcrestal placement of dental implants with an internal conical connection of 0.5 mm versus 1.5 mm: Three-year after loading results of a multicentre within-person randomised controlled trial.

PURPOSE: To evaluate whether there are some clinical benefits by placing single dental implants either 0.5 mm or 1.5 mm subcrestally in healed bone crests. MATERIALS AND METHODS: Sixty partially edentulous patients requiring two single implant-supported crowns had both sites randomly allocated either to 0.5-mm or 1.5-mm subcrestal implant placement according to a split-mouth design at six centres and submerged in aesthetic areas or non-submerged in non-aesthetic areas for 3 months. Provisional acrylic crowns were delivered and were replaced after 2 months by definitive metal-ceramic crowns. Patients were followed to 3 years after loading. Outcome measures were: crown and implant failures, complications, aesthetics assessed using the pink aesthetic score (PES), peri-implant marginal bone level changes and patient preference, recorded by blinded assessors. RESULTS: One patient dropped out. One patient lost both implants for infection at impression taking. Seven complications affected seven patients of the 0.5-mm group and four complications affected four patients of the 1.5-mm subcrestal group. Three patients had complications at both implants. There were no statistically significant differences for complications between group (OR = 4; 95% CI: 0.45 to 35.79; P (McNemar test) = 0.375). At delivery of definitive crowns, 2 months after loading, the mean PES was 11.22 ± 1.91 and 11.12 ± 1.59 for the 0.5- and 1.5-mm groups, respectively. At 1 year after loading, the mean PES was 12.09 ± 1.66 and 12.10 ± 1.52 for the 0.5- and 1.5-mm groups, respectively. At 3 years after loading, the mean PES was 11.99 ± 1.94 and 12.19 ± 1.78 for the 0.5- and 1.5-mm groups, respectively. There were no statistically significant differences between the two groups at 2 months (P = 0.626), at 1 year (P = 0.920) or at 3 years (P = 0.296). One year after loading, patients of the 0.5-mm group lost on average 0.21 ± 0.51 mm and those of the 1.5-mm group 0.11 ± 0.36 mm, the difference being not statistically significant (difference = 0.10 mm; 95% CI: -0.01 to 0.20; P = 0.078). Three years after loading, patients of the 0.5-mm group lost on average 0.34 ± 0.87 mm and those of the 1.5-mm group 0.19 ± 0.54 mm, the difference being statistically significant (difference = 0.15 mm; 95% CI: 0.00 to 0.30; P = 0.046). Patients did not prefer any depth of the implant placement over the other. There were no differences in outcomes between centres. CONCLUSIONS: No appreciable clinical differences were noticed when placing implants 0.5 mm or 1.5 mm subcrestally; therefore clinicians can do as they prefer.

On the role of keratinised mucosa at dental implants: a 5-year prospective single-cohort study.

PURPOSE: The purpose of this study was to evaluate the role of keratinised mucosa on the long-term success of dental implants. MATERIALS AND METHODS: Thirty-two edentulous patients had one of their dental arches rehabilitated with a provisional screw-retained resin reinforced cross-arch fixed prosthesis supported by four immediately loaded implants. The two central straight implants were randomly allocated in two equal groups, according to a parallel-group design, to receive or not intermediate abutments (Multi-Unit Abutment, MUA). However, for the purpose of the present publication, the study was considered as a prospective single cohort study. To be immediately loaded, implants had to be inserted with a minimum torque of 30 Ncm, which was achieved by all implants. Provisional prostheses were delivered within 24 hours and were replaced, after 4 months, by definitive screw-retained metal-ceramic prostheses. Patients were followed up to 5 years after loading. Prostheses were removed every 8 months to facilitate professionally delivered maintenance. Outcome measures were prosthesis and implant failures, complications, peri-implant marginal bone level (MBL) changes, bleeding on probing (BoP) and keratinised mucosa height (KMH). The absence of vestibular or lingual keratinised mucosa was put in relation with peri-implant bone loss and BoP. RESULTS: Five-years after loading two patients dropped out and no implant or prosthetic failure occurred. Four patients were affected by prosthetic complications. At delivery of definitive prostheses, 32 (25%) implants had at least one vestibular or lingual site with no KMH and 96 (75%) implants had both sites with some KMH. Multi-level models did not show any statistically significant association between KMH at the time of delivery of the definitive prosthesis and changes in MBL and BoP at 5 years (estimate = 0.02; 95% CI: -0.02 to 0.05; P = 0.3393; and 1.02; 95% CI: 0.79 to 1.33; P = 0.8695, respectively). When KMH was analysed as dichotomous variable, implants with presence of KMH at delivery of definitive prosthesis at both vestibular and lingual aspects showed a trend of less BoP (estimate = -0.8; 95% CI: -1.69 to 0.08; P = 0.0741) but a statistically significant greater MBL loss compared to implants where KMH was only present at one site (estimate = 0.18; 95% CI: -0.1 to 0.3; P = 0.0041). CONCLUSIONS: The 5-year after loading outcome of immediately loaded screw-retained cross-arch prostheses supported by four implants is excellent in both the maxilla and mandible. Although the height of the keratinised mucosa did not seem to alter the clinical outcomes, its presence both at vestibular and lingual sites was associated with an increased marginal bone loss when compared to implants having at least one side without keratinised mucosa.

Posterior atrophic jaws rehabilitated with prostheses supported by 6-mm-long 4-mm-wide implants or by longer implants in augmented bone. Five-year post-loading results from a within-person randomised controlled trial.

PURPOSE: To evaluate whether 6-mm-long by 4-mm-wide dental implants could be an alternative to implants at least 10-mm long placed in bone augmented with bone substitutes in posterior atrophic jaws. MATERIALS AND METHODS: A total of 20 patients with bilateral atrophic mandibles and 20 patients with bilateral atrophic maxillae, having 5 to 7 mm of bone height below the maxillary sinus or 6 to 8 mm above the mandibular canal, had their sides of the jaws randomly allocated according to a split-mouth design. They were allocated to receive one to three 6-mm-long and 4-mm-wide implants, or implants at least 10-mm long in augmented bone by two different surgeons in different centres. Mandibles were vertically augmented with interpositional equine bone blocks and resorbable barriers, and implants were placed 3 months later. Maxillary sinuses were augmented with particulated porcine bone via a lateral window and implants were placed simultaneously. All implants were submerged and loaded, after 4 months, with provisional prostheses. Four months later, definitive prostheses were delivered. Outcome measures were prosthesis and implant failures, any complication and radiographic peri-implant marginal bone level changes. The follow-up was 5 years after loading for all patients. RESULTS: Eight patients (five treated in mandibles and three in maxillae) dropped out before the 5-year post-loading follow-up. Four short implants (two maxillary and two mandibular) affected by peri-implantitis failed together with their prostheses versus three mandibular prostheses which could not be placed on implants at least 10-mm long due to graft failures; one was associated with the loss of three implants because of infection. There were no statistically significant differences in implant (P = 1.0) and prosthesis failures (P = 1.0). In total, 19 complications occurred in 14 patients at augmented sites versus five complications in four patients with 6-mm-long implants (P = 0.118). More complications occurred at grafted sites both in mandibles (P = 0.727), and maxillae (P = 0.063), although the differences were not statistically significant. In mandibles, patients with 6-mm-long implants lost an average of 1.34 ± 0.35 mm of peri-implant bone at 5 years versus 2.11 ± 0.59 mm in patients with implants at least 10-mm long. The difference was statistically significant (mean difference = 0.77 ± 0.70 mm; 95% CI: 0.32 to 1.21 mm; P = 0.003). In maxillae, patients with 6-mm-long implants lost an average of 1.52 ± 0.47 mm of peri-implant bone at 5 years versus 1.85 ± 0.51 mm in patients with implants at least 10-mm long. The difference was statistically significant (mean difference = 0.33 ± 0.36 mm; 95% CI: 0.14 to 0.53 mm; P = 0.002). CONCLUSIONS: Results at 5 years after loading indicate that 6-mm-long implants with a conventional diameter of 4 mm achieved similar results to longer implants placed in augmented bone. Short implants might be a preferable choice to bone augmentation, especially in posterior mandibles since the treatment was faster, cheaper and associated with less morbidity. However, 10-year post-loading data are necessary before making reliable recommendations.

Dental extractions for patients on oral antiplatelet: a within-person randomised controlled trial comparing haemostatic plugs, advanced-platelet-rich fibrin (A-PRF+) plugs, leukocyte- and platelet-rich fibrin (L-PRF) plugs and suturing alone.

PURPOSE: To compare the outcome of tooth extractions in patients taking oral antithrombotic without reducing their dose. Four different interventions were compared within the same patient: suturing alone (control group), suturing plus a haemostatic plug, suturing plus advanced-platelet-rich fibrin (A-PRF+) plug, and suturing plus leukocyte- and platelet-rich fibrin (L-PRF) plug into the socket. MATERIALS AND METHODS: Forty patients, taking oral antiplatelet agents, requiring the extraction of at least four non-adjacent teeth were selected for the study. After extractions the sockets were randomly allocated to suturing alone (control group), suturing plus haemostatic plug (HAEM), suturing plus advanced-platelet-rich fibrin (A-PRF+) plug, and suturing plus leukocyte- and platelet-rich fibrin (L-PRF) plug into the socket without reducing the dose of oral antiplatelets according to a split-mouth design. Outcome measures were complications, time to complete each procedure, postoperative bleeding, costs of the materials, patient preference and a wound healing index recorded 1 and 2 weeks postextraction by blinded assessors. RESULTS: Two weeks after extraction no patient dropped out and no complication was reported. The average time to complete suturing after tooth extractions was: 1.0 ± 0.00 minutes at control sites, 1.5 ± 0.41 at HAEM sites, 2.8 ± 0.61 at A-PRF+ sites, and 2.8 ± 0.56 at L-PRF sites, the difference being statistically significant between each pairwise comparison except A-PRF+ vs L-PRF. Postoperative bleeding 30 minutes after extractions was present at 8, 5, 1 and 2 sites for control, HAEM, A-PRF+ and L-PRF sites, respectively. A-PRF showed statistically significantly less bleeding compared to the control group (odds ratio = 0.1 (95% CI [0.01;0.86]; P < 0.0361). In all cases bleeding was moderate in nature and not severe. One week after extractions the mean wound healing index was 1.05 ± 0.60 for control, 1.18 ± 0.59 for HAEM, 1.00 ± 0.68 for A-PRF+ and 0.95 ± 0.50 for L-PRF sites. No statistically significant difference was detected across groups (P = 0.633). Two weeks after extractions the mean wound healing index was 0.33 ± 0.53 for control, 0.43 ± 0.50 for HAEM, 0.25 ± 0.49 for A-PRF+ and 0.15 ± 0.36 for L-PRF sites. No statistically significant difference across groups was detected (P = 0.255). One week after extractions, nine patients preferred control sites, eight HAEM, ten A-PRF+, four L-PRF and nine had no preference. No statistically significant differences were detected for control sites (P = 0.6779), HAEM (P = 1.0000), A-PRF+ (P = 0.4055) and L-PRF (P = 0.1472). Two weeks after extractions five patients preferred control sites, three HAEM, eight A-PRF+, eight L-PRF and 16 had no preference. No statistically significant differences were detected for control sites (P = 0.8147), HAEM (P = 0.2363), A-PRF+ (P = 0.3488) and L-PRF (P = 0.3488). Costs without counting sutures and blood centrifuges were 0.00, 14.49, 2.44 and 2.44 Euro for control, HAEM, A-PRF+ and L-PRF sites, respectively. CONCLUSIONS: It may not be necessary to discontinue the use of oral antiplatelets in patients undergoing dental extractions and, when present, the minor statistically significant differences between procedures were not clinically relevant; therefore clinicians can use any of the tested interventions according to their preference, keeping in mind that simple suturing is sufficient and is faster and cheaper, and that A-PRF+ was associated with less postoperative bleeding when compared to suturing alone.