Inter-implant Papilla Reconstruction using the Iceberg and 'Garage' Connective Tissue Graft Technique. A Case Report and Technique Illustration.

A 45-year-old female patient presented with a lack of inter-implant papilla after a partially edentulous anterior area was rehabilitated with dental implants. The soft tissue phenotype and inter-implant papilla was augmented using the 'iceberg' connective tissue graft, followed by a second surgical procedure where a strip gingival graft was combined with a connective tissue graft inserted underneath a pouch prepared into the previous 'iceberg' connective tissue graft at the level of the crest ('garage' approach), further enhancing soft tissue volume in that region. This technique aims to improve mucosal thickness and supracrestal tissue height while addressing esthetic concerns associated with multiple implant placements in the anterior region. The final esthetic outcome was excellent, harmonious soft tissue with appropriate thickness, symmetry with adjacent teeth, well-shaped interdental and inter-implant papilla with high patient satisfaction, making this approach a valuable addition to a surgeon's armamentarium. Future clinical studies are needed to evaluate the performance of this novel approach.

Evaluation of microhardness of short fiber-reinforced composites inside the root canal after different light curing methods - An in vitro study.

OBJECTIVES: Short fiber-reinforced composite (SFRC) materials make it possible to reinforce root canal treated teeth with individualized, directly layered intraradicular posts (the Bioblock technique). The question arises, however, as to whether the photopolymerization of the material is sufficient deep within the root canal space and if it can be improved through different light-conducting options. Our study aimed to investigate the hardness of intraradicular SFRC material applied using the Bioblock technique and cured with various illumination methods, as measured through nanoindentation. MATERIALS AND METHODS: For this investigation, thirty plastic artificial teeth that had undergone root canal treatment were selected. These teeth were randomly divided into six study groups (Group 1-6; each group consisting of 5 teeth). The restoration procedures involved the use of SFRC or conventional composite materials, placed 6 mm apically from the root canal orifice. In Group 1 and 2, a conventional composite was used, whereas in Group 3-6, SFRC was employed for interradicular reinforcement (with a layered technique in Group 3 and 4 and a bulk-fill technique in Group 5 and 6). A modified light source was utilized for photopolymerization in Group 2, 4, and 6, whereas in Group 3 and 5, the polymerization light was directed through a prefabricated glass fiber posts. The control group (Group 1) utilized conventional composite material with a standard light-curing method. Following embedding and sectioning, the hardness of the composite materials was measured at 2 mm intervals within the root canal (1st, 2nd, 3rd measurements, in the coronal to apical direction). RESULTS: During the 1st measurement, light curing conducted through the glass fiber posts (Group 3 and 5) led to markedly higher hardness levels compared to the groups restored with conventional composite (control group with p = 0.002, p = 0.001, and Group 2 with p = 0.043, p = 0.034, respectively). In the 2nd measurement, only Group 5 demonstrated significantly greater hardness in comparison to the control group (p = 0.003) and Group 2 (p = 0.015). However, in the 3rd measurement, no statistically significant differences were observed among the groups. CONCLUSION: light curing through the glass fiber post provides outstanding hardness for the SFRC material in the apical layer in the root canal.

Fatigue performance of endodontically treated molars reinforced with different fiber systems.

OBJECTIVE: The aim was to investigate the fatigue performance of root canal-treated (RCT) molars restored with different direct restorations utilizing discontinuous and continuous fiber-reinforced composite (FRC) systems. The impact of direct cuspal coverage was also evaluated. MATERIALS AND METHODS: One hundred and twenty intact third molars extracted for periodontal or orthodontic reasons were randomly divided into six groups (n=20). Standardized MOD, regular cavities for direct restorations were prepared in all specimens, and subsequently, root canal treatment and root canal obturation was carried out. After the endodontic treatment, the cavities were restored with different fiber-reinforced direct restorations as follows: SFC group (control), discontinuous short fiber-reinforced composite (SFC) without cuspal coverage (CC); SFC+CC group, SFC with cuspal coverage; PFRC group, transcoronal fixation with continuous polyethylene fibers without CC; PFRC+CC group, transcoronal fixation with continuous polyethylene fibers with CC; GFRC group, continuous glass FRC post without CC; and GFRC+CC, continuous glass FRC post with CC. All specimens underwent a fatigue survival test in a cyclic loading machine until fracture occurred or 40,000 cycles were completed. The Kaplan-Meier survival analysis was conducted, followed by pairwise log-rank post hoc comparisons between the individual groups (Mantel-Cox). RESULTS: The PFRC+CC group was characterized by significantly higher survival compared to all the groups (p < 0.05), except for the control group (p = 0.317). In contrast, the GFRC group showed significantly lower survival compared to all the groups (p < 0.05), except for the SFC+CC group (p = 0.118). The control group (SFC) showed statistically higher survival than the SFRC+CC group (p < 0.05) and GFRC group (p < 0.05), but it did not differ significantly from the rest of the groups in terms of survival. CONCLUSIONS: Direct restorations utilizing continuous FRC systems (in the form of polyethylene fibers or FRC post) to restore RCT molar MOD cavities performed better in terms of fatigue resistance when CC was performed compared to the same FRC restorations without CC. On the contrary, teeth restored with SFC restorations performed better without CC compared to the ones where SFC was covered. CLINICAL RELEVANCE: In the case of fiber-reinforced direct restorations for MOD cavities in RCT molars, direct CC is recommended when utilizing long continuous fibers for reinforcement, however, should be avoided when only SFC is used for their reinforcement.

Fracture Behavior of Short Fiber-Reinforced Direct Restorations in Large MOD Cavities.

The aim of this research was to study the impact of using a short fiber-reinforced composite (SFRC) core on the fatigue performance and fracture behavior of direct large posterior composite restorations. Moreover, the influence of the consistency (flowable or packable) of occlusal composite coverage was assessed. A total of 100 intact molars were collected and randomly distributed into five groups (n = 20). Deep mesio-occlusal-distal (MOD) cavities were prepared in all groups. After adhesive treatment and rebuilding the missing interproximal walls with conventional composite, the specimens in four experimental groups were restored by an SFRC core (everX Flow), which was applied and cured either in bulk or in oblique layers (each 2 mm thick). Packable (G-aenial Posterior) or flowable (G-aenial Injectable) conventional composites were used as a final occlusal layer. The control group was restored with only packable conventional composite. Fatigue survival was measured for all specimens using a cyclic loading machine until a fracture occurred or a total of 25,000 cycles was achieved. Kaplan-Meyer survival analyses were conducted, followed by pairwise log-rank post hoc comparisons. The static load-bearing capacity of surviving teeth was tested using a universal testing machine. Fracture patterns were evaluated visually. There was no statistically significant (p > 0.05) difference in terms of survival between the tested groups. All groups for which flowable SFRC was used showed statistically significantly higher load-bearing capacities compared to the control group (p < 0.05). There were no significant differences regarding fracture resistance among the fiber-reinforced study groups. Regarding the fracture pattern during the survival analysis, all specimens that received SFRC showed a dominantly restorable type of fracture, while the control specimens presented a dominantly non-restorable type. The use of flowable SFRC as a reinforcing core for large MOD direct restorations showed promising achievements regarding fracture behavior.

Vertical bone augmentation utilizing a titanium-reinforced PTFE mesh: A multi-variate analysis of influencing factors.

OBJECTIVE: To clinically evaluate the use of a titanium-reinforced PTFE mesh for vertical bone augmentation (VBA) of deficient alveolar ridges. MATERIALS AND METHODS: This case series documented consecutive patients treated for VBA with a newly developed PTFE mesh. VBA was performed in anterior and posterior, maxillary and mandibular arches using anorganic bovine bone combined with autogenous graft in a 1:1 ratio. Healing time from initial surgery to re-opening was recorded. Baseline vertical deficiency, absolute bone gain (gross height gained), and relative gain (percentage of defect fill with respect to the baseline deficiency) were registered. RESULTS: Fifty-seven patients (65 defects) were included in the analysis. The mean baseline vertical deficiency was 5.5 ± 2.6 mm. The mean absolute bone gain was 5.2 ± 2.4 mm. A relative gain of 96.5 ± 13.9% was achieved. Overall, 89.2% of cases showed complete regeneration, which occurred in all sites with baseline deficiencies of <5 mm, in 95.6% of sites with 5-8 mm deficiencies, and in 89.4% of sites with >8 mm deficiencies. Each 1-mm addition to the baseline height deficiency increased the likelihood of incomplete bone regeneration by 2.5 times. Defect location had a statistically significant but a limited clinical impact on the bone height gained (<0.5 mm). Complications were observed in three cases (3%). CONCLUSIONS: Vertical bone augmentation with titanium-reinforced PTFE mesh and a mixture of autologous bone and xenograft is a safe and predictable procedure. The extent of the baseline vertical deficiency influences the percentage of bone gained.

In Vitro Fracture Resistance of Adhesively Restored Molar Teeth with Different MOD Cavity Dimensions.

PURPOSE: Molar MOD (mesial-occlusal-distal) cavity preparation weakens relative cuspal stiffness by up to 63%, often resulting in cuspal fracture. This investigation inspects fracture resistance of MOD cavities restored using direct composite restoration. MATERIALS AND METHODS: 120 extracted, intact mandibular molars were selected. MOD cavities with different depth/wall thickness were prepared in 9 groups (n = 12): A: 3 mm/3.5 mm, B: 3 mm/2.5 mm, C: 3 mm/1.5 mm, D: 5 mm/3.5 mm, E: 5 mm/2.5 mm, F: 5 mm/1.5 mm, G: 7 mm/3.5 mm, H: 7 mm/2.5 mm, I: 7 mm/1.5 mm. Specimens with 7 mm deep cavities received root canal treatment. The teeth were restored with dental composite. Maximal fracture strength test was conducted. Intact natural teeth were used as control. For statistical analysis Kruskal-Wallis ANOVA with post-hoc pairwise comparisons was used (α = 0.05). RESULTS: Significant difference was indicated between the control and groups D, E, F, G, H, and I. No significant differences were found between the A, B, C groups and the control. Comparing the 5 and 7 mm cavity depth groups, there was no statistical difference between any of them. CONCLUSIONS: Within the limitations of this investigation, the following conclusions can be drawn regarding molar teeth with a MOD cavity: 3 mm or shallower cavities can be restored to the physiological fracture strength with direct composite restorations; 5 mm or deeper cavities cannot be restored to the physiological fracture strength with direct composite restorations. Cusp thickness does not significantly influence fracture strength in molar MOD cavities with a direct composite restoration.

In vitro fracture resistance of premolar teeth restored with fibre-reinforced composite posts using a single or a multi-post technique.

The purpose of this study was to evaluate the reinforcing effect of fibre-reinforced composites (FRC) applied in premolar teeth with different techniques and minimally invasive post space preparation. Fifty extracted and endodontically treated premolar teeth were used. The teeth were divided into five groups (n = 10) depending on the restorative technique (Groups 1-5). Group 1: one single conventional post, Group 2: one main conventional and one collateral post, Group 3: one elastic post, Group 4: one main elastic and one collateral post, and Group 5: individual post formed of elastic posts. After cementation and core build-up, the specimens were submitted to static fracture resistance test. Fracture thresholds and fracture patterns were measured and evaluated. Group 4 showed the highest average fracture resistance among the tested groups. The multi-post techniques (group 2 and 4) exhibited statistically higher fracture resistance compared to group 1. Regarding fracture patterns, there was no statistically significant difference between the tested groups. Within the limitations of this study, the application of multiple elastic or conventional FRC posts or a single elastic post in the same root canal is beneficial in terms of fracture resistance compared to a single conventional FRC post. The elasticity or the number of posts did not influence the fracture patterns.

[Fracture strength of elastic and conventional fibre-reinforced composite intraradicular posts--an in vitro pilot study]. / Flexibilis és merev üvegszál megerosítésu intraradikuláris csapok törési eIlenállásának in vitro összehasonlító vizsgálata--pilot study.

OBJECTIVES: The purpose of this in vitro investigation was to evaluate the reinforcing effect of different fibre-reinforced composite (FRC) posts and insertion techniques in premolar teeth when using minimal invasive post space preparation. MATERIALS AND METHODS: Thirty two extracted and endodontically treated premolar teeth were used and divided into four groups (n = 8) depending on the post used (Group 1-4). 1: one single conventional post, 2: one main conventional and one collateral post, 3: one flexible post, 4: one main flexible and one collateral post. After cementation and core build-up the specimens were submitted to static fracture toughness test. Fracture thresholds and fracture patterns were recorded and evaluated. RESULTS: The multi-post techniques (group 2 and 4) showed statistically higher fracture resistance compared to group one. Regarding fracture patterns there was no statistically significant difference between the tested groups. CONCLUSION: The application of multiple posts seems to be beneficial regarding fracture resistance independent from the used FRC post. Fracture pattern was not influenced by the elasticity of the post.

In vitro fracture resistance of molar teeth restored with a short fibre-reinforced composite material.

OBJECTIVES: The purpose of this in vitro study was to evaluate the efficiency of a short fibre-reinforced composite (SFRC) material compared to conventional composites when restoring class II. MOD cavities in molar teeth with different layering techniques. METHODS: One hundred and thirty mandibular third molars were divided into 5 groups (n=26). Except for the control group (intact teeth), in all other groups MOD cavities were prepared. The cavities were restored by either conventional composite with horizontal and oblique layering or by SFRC with horizontal and oblique layering. The specimens were submitted to static fracture toughness test. Fracture thresholds and fracture patterns were evaluated. RESULTS: In general, no statistically significant difference was found in fracture toughness between the study groups, except for horizontally layered conventional composite restorations, which turned out to be significantly weaker than controls. However, SFRC yielded noticeably higher fracture thresholds and only obliquely applied SFRC restorations exhibited favourable fracture patterns above chance level. CONCLUSIONS: The application of SFRC did not lead to a statistically significant improvement of the fracture toughness of molar teeth with MOD cavities. Still, SFRC applied in oblique increments measurably reduces the chance of unrestorable fractures of molar teeth with class II MOD cavities. CLINICAL SIGNIFICANCE: The restoration of severely weakened molar teeth with the use of SFRC combined with composite might have advantages over conventional composites alone. It was observed from the statistical data, that the application of SFRC with an oblique layering technique yielded not significantly but better fracture thresholds and more favourable fracture patterns than any other studied material/technique combination. Thus further investigations need to be carried out, to investigate the possible positive mechanical effects of SFRC. The application of the horizontal layering technique with conventional composite materials is inferior to the oblique technique and SFRC materials.

Human epithelial tissue culture study on restorative materials.

OBJECTIVES: Health condition of the gingival tissues contacting the surfaces of fixed prostheses is a result of multiple etiologic factors. The aim of the investigation discussed here was to evaluate the attachment and proliferation rate of cultured human epithelial cells on three commonly used restorative materials under in vitro conditions. METHODS: Morphological and chemical structure of polished lithium-disilicate (IPS e.max Press, Ivoclar Vivadent AG, Germany), yttrium modified zirconium dioxide (5-TEC ICE Zirkon Translucent, Zirkonzahn GmbH Srl, Germany) and cobalt chromium alloy (Remanium star, Dentaurum GmbH & Co. KG, Germany) discs were examined by scanning electron microscopy (SEM), energy dispersive X-ray spectroscopy (EDS) and atomic force microscopy (AFM). Human epithelial cells harvested and cultured from one donor, were applied to investigate cell attachment (24h observation) and proliferation (72h observation) via dimethylthiazol-diphenyl tetrazolium bromide (MTT) and AlamarBlue(®) (AB) assays on control surface (cell-culture plate) and on the restorative materials (n=3×20 specimens/material). RESULTS: SEM and AFM revealed typical morphology and roughness features for the materials. Zirconia presented significantly higher Ra value. EDS confirmed typical elements on the investigated restorative materials: lithium-disilicate (Si, O); Zirconia (Zi, Y, O); CoCr (Co, Cr, W). All surfaces except CoCr exhibited significant cell proliferation according to MTT and AB assays after 72h compared to 24h. Among the restorative materials, CoCr samples showed the highest cell attachment as indicated by MTT assay. AB results showed that attachment and proliferation of human epithelial cells is supported more on lithium-disilicate. Both assays indicated the lowest value for zirconia. CONCLUSIONS: The results indicate that the restorative materials examined are equally suitable for subgingival restorations. Lithium-disilicate exhibited the best biocompatibility. CLINICAL SIGNIFICANCE: The examined materials are indicated for use in restorative procedures, directly contacting the sulcular epithelial tissues. Thus it is essential to monitor the biological acceptibility of these materials in order to better understand their clinical properties. The results indicate that Lithium-disilicate is a suitable material for such purposes.

Width ratios in the anterior maxillary region in a Hungarian population: addition to the golden proportion debate.

STATEMENT OF PROBLEM: In the last 2 decades, several studies have questioned the application of the rule of golden proportion in dentistry. PURPOSE: The purpose of this study was to test the rule of golden proportion for the maxillary anterior region in a population of young, healthy people with excellent oral hygiene at the Faculty of Dentistry of the University of Szeged. MATERIAL AND METHODS: One hundred and nine participants (36 male, 73 female) were examined, 41 of whom had previously worn orthodontic appliances. A Canon 450D camera, Canon 100 mm Macro lens, and a Sigma 140 DG ring flash were used for digital documentation. The accreditation photography protocol of the American Academy of Cosmetic Dentistry was applied to standardize the images. The width of the teeth from the frontal view was measured digitally. Tooth dimension data were collected and the Mann-Whitney U test was performed (α=.05). RESULTS: The relative width of the central incisors, lateral incisors, and canines was 1.6:1:0.85 on both sides. The ratios were not influenced by either sex or previous orthodontic treatment. CONCLUSIONS: The results demonstrated that, because of the difference in canines in this population, the golden proportion in its original form was not valid for the maxillary anterior region. Orthodontic treatment does not change the dentition toward the golden proportion. The results suggest that the rule of golden proportion should not be used for treatment planning without observing individual modifying factors.

[Current concepts in tobacco cessation and prevention]. / A dohányzás megelozése és a leszokás támogatásának lehetoségei.

In the recent years, for oral care in general, both improving oral hygiene and tobacco use cessation have been identified as necessary measures to gain and maintain long-term periodontal health. This growing evidence has given the dental team a whole new task to tackle when achieving and maintaining oral health with their patients. In order to support dental patients to quit tobacco use, it is helpful for the clinician to have a clear understanding of the genesis of 'tobacco use disease' in general. At present, the evidence-based method for tobacco use cessation consists of professional counselling on behavioural change using the so called "5A Method" (Ask, Advise, Assess, Assist and Arrange") in combination with pharmacotherapy. A suitable model for behavioural support in tobacco use cessation would help patients to move from one stage to the next. People who want to quit the smoking habit do not always participate in carefully controlled nicotine withdrawal programs, e.g. in linear fashion and from start to finish. Nevertheless, simple instructions - like those offered in the "Assist" (to help) and "Arrange" (to organize follow-up visits) - can be valuable tools for dental professionals supporting their patients to quit smoking. On the basis of significant evidence on the recovery of the oral mucosa and the periodontal tissue following tobacco use cessation, a new task has been emerged in dentistry: the role of oral health professionals providing counselling for patients who ought to quit tobacco use.

[Clinical, microbiological and immunological findings in peri-implantitis patients with bar-retained lower removable partial dentures, compared to a healthy control group (12-month-follow-up)]. / Alsó részleges kiveheto fogpótlást viselo páciensek mikrobiológiai ées immunológiai vizsgálata peri-implantitiszes és egészséges kontrollcsoportba tartozó esetekben (12 hónapos utánkövetés).

Cause, treatment strategies and prognosis of peri-implantitis is not well understood. The aim of this study was to followup clinical, microbiological and immunological findings in individuals wearing bar-retained lower partial dentures with and without peri-implantitis, pre and post treatment. From the Tuebingen Implant Registry recall program 16 peri-implantitis patients were compared to 16 healthy individuals in a prospective, unblinded study. Peri-implantitis was treated with a single anti-inflammatory therapy according to the CIST protocol while the controls received professional implant cleaning. The following findings were recorded at four time points before treatment (T1) and 30, 90, 360 days post treatment (T2-T4): sulcular fluid flow rate, probing depth, plaque and bleeding index, implant stability (Periotest); sulcular concentrations of interleukin-1 beta, plasminogen activator inhibitor 2, prostaglandin E2, and the sum score of five periodonto-pathogenic bacteria species by PCR (Hain Microldent test). Statistically significant differences between healthy and diseased implants were found for probing depth, bleeding on probing, bacterial load, and implant stability. For the first three, a significant decrease in severity was observed after treatment, but reached initial pre-treatment values within one year. No changes could be observed in the individuals without peri-implantitis. The results of the present study confirm marked differences in peri-implant findings between healthy and diseased sites. They demonstrate that a single anti-inflammatory intervention can initially--but not sustained--reduce probing depth, bleeding on probing, and the total bacterial load as evident from PCR diagnostics. Further immunological diagnostic measures do not seem to provide more information in the patients investigated.

Attitudes of Hungarian dental professionals to tobacco use and cessation.

Smoking is the most preventable cause of death worldwide. The regularity of visits of patients to dental offices offers a valuable contact for health professionals and the healthcare system to initiate anti-smoking activity. However, these contacts remain unutilized and there is little interaction between doctor and patient with regard to prevention of smoking and its consequences. The aim of this study was to evaluate the current situation and attitudes towards smoking and giving up smoking among dental professionals. A survey was carried out in the sample consisting in total of 342 participants, 212 students of dentistry and 130 dentists. Students were asked to complete a questionaire during the enrolment period; dentists were asked to complete the questionnaire while attending an annual compulsory in-service training course at the University of Szeged. The data were analysed statistically using SPSS 10.0 software, significance was tested using the Mann-Whitney U test and results were compared with data from a similar study conducted by the same research group in 2004 in which general knowledge and attitude towards smoking and giving up smoking was measured and evaluated. Results demonstrated that there is a lower number of smokers among dental professionals (dentists: 22.3%; students: 20.3%) than in the Hungarian general population and high interest in encouraging and assisting patients in giving up smoking (dentists: 45%; students: 54%). Comparing the results of this study to earlier data collated in 2004, we find a decreasing ratio of smokers among students (34% in 2004 and 20.3% in 2011). An increasing need for information about smoking cessation, tobacco related health hazards and the lack of detailed knowledge about methods and patient education were identified.