Periodontal regeneration risk assessment in the treatment of intrabony defects.

BACKGROUND: Regenerative approaches performed in periodontics seems to be efficient in treating intrabony defects. There are, however, many factors that may affect the predictability of the regenerative procedures. The present article aimed to propose a new risk assessment tool for treating periodontal intrabony defects by regenerative therapy. METHODS: Different variables that could affect the success of a regenerative procedure were considered based on their impact on (i) the wound healing potential, promoting wound stability, cells, and angiogenesis, or (ii) the ability to clean the root surface and maintain an optimal plaque control or (iii) aesthetics (risk for gingival recession). RESULTS: The risk assessment variables were divided into a patient, tooth, defect, and operator level. Patient-related factors included medical conditions such as diabetes, smoking habit, plaque control, compliance with supportive care, and expectations. Tooth-related factors included prognosis, traumatic occlusal forces or mobility, endodontic status, root surface topography, soft tissue anatomy, and gingival phenotype. Defect-associated factors included local anatomy (number of residual bone walls, width, and depth), furcation involvement, cleansability, and number of sides of the root involved. Operator-related factors should not be neglected and included the clinician's level of experience, the presence of environmental stress factors, and the use of checklists in the daily routine. CONCLUSIONS: Using a risk assessment comprised of patient-, tooth-, defect- and operator-level factors can aid the clinician in identifying challenging characteristics and in the treatment decision process.

Translating Clinical Outcomes to Patient Value Through Use of the Periodontal Risk Score: An Evidence-Based Treatment Approach.

Periodontitis is a chronic, multifactorial inflammatory disease characterized by progressive destruction of the tooth-supporting apparatus. Determining tooth prognosis is of central importance in clinical practice to help both the clinician and patient understand the risks and benefits of treatment while shedding light on the patient's long-term periodontal prognosis and aiding in the development of an individualized treatment plan. Several indexing-type systems have been proposed for determining the prognosis of periodontally involved teeth. The periodontal risk score (PRS) is a simple, evidence-based, motivational tool that can be used in daily clinical practice in both healthy and periodontally involved patients. The PRS incorporates systemic and lifestyle prognostic factors to achieve superior predictive accuracy. With the PRS, patients are encouraged to achieve a target score (representing an "excellent" prognosis) that can be realistically attained through compliance with a periodontal maintenance plan. The purpose of this article is to present to clinicians how to implement this evidence-based tool into their daily practices and thus help patients improve their long-term periodontal prognosis.

Periodontal risk score: Initiation and model validation for 6,762 teeth.

BACKGROUND: Tooth-level prognostic systems are valuable tools for treatment planning and risk assessment of periodontally involved teeth. Recently the Miller-McEntire prognosis index was found to outperform comparable systems. However, it had some limitations. The present study aimed to develop and evaluate the prognostic performance of a modified version that addresses most limitations of the previous model called the periodontal risk score (PRS). METHODS: Data were retrieved retrospectively from patients who received surgical and non-surgical periodontal treatment at a university setting. Data on medical history and smoking status at baseline and the last maintenance visit were collected. Both univariate and multivariate Cox proportional hazard regression models were used to analyze the prognostic capability for predicting tooth loss due to periodontitis (TLP) risk. RESULTS: A total of 6762 teeth (281 patients) were followed up for a mean period of 22.6 ± 6.34 (10-47.6y) years. The PRS was successfully able to stratify the risk of TLP at baseline when the three different classes of association were compared for anterior and/or posterior tooth loss. After controlling for maintenance, age, and sex, the index showed an excellent predictive capacity for TLP with a Harrell C-index of 0.947. CONCLUSIONS: The periodontal risk score (PRS) displayed excellent predictive capability for anterior as well as posterior tooth loss due to periodontitis. This system was able to predict long-term tooth loss with a very high accuracy  in a population treated mainly by dental students and periodontics residents. The use of this/similar prognosis system is advisable as a means to establish tooth prognosis.

Selective osteotomy-assisted molar uprighting and simultaneous ridge augmentation for implant site development.

Orthodontic treatment to upright an inclined molar adjacent to an edentulous space is often necessary before implant placement. The implant site may also require a ridge augmentation if the bony volume is not sufficient. The time required for both treatment steps can be lengthy and can discourage patients from accepting dental implants. This case report presents a novel interdisciplinary approach to implant site development. Selective osteotomy and simultaneous ridge augmentation were performed on the bilateral mesially inclined second molars before orthodontic uprighting. The severely inclined second molars were uprighted in 5 months, and the enhanced implant sites were ready for implant placement without complications. A finite element analysis revealed that the osteotomy partially affected the biomechanical responses of the dentoalveolar structures during molar uprighting.

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.

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.

Prognostic Classification System for Implant Recession Defects.

PURPOSE: The etiology and progression of periimplant mucogingival defects are multifactorial. As such, the aim of this study was to discern and discuss the key long-term prognostic factors that change the balance of homeostasis/regeneration in periimplant mucogingival and recession defects. MATERIALS AND METHODS: This report provides cases and a discussion of anatomical factors that affect the long-term maintenance of periimplant soft tissue. RESULTS: The factors guiding long-term maintenance of the periimplant soft tissue apparatus are increasingly complex due to the additive combination of patient-related factors, anatomical variations, and unique material-host interactions. CONCLUSIONS: Severity and number of these contributing factors should be considered before implant placement and/or in the treatment of periimplant defects to achieve the best esthetic and functional outcome. In addition, assessment of prognostic factors should be used to provide the patient a realistic, long-term assessment of the esthetic and functional stability of both implant and the surrounding periimplant tissues.

An evidenced-based scoring index to determine the periodontal prognosis on molars.

BACKGROUND: This retrospective study evaluates and assigns scores to six prognostic factors and derives a quantitative scoring index used to determine the periodontal prognosis on molar teeth. METHODS: Data were gathered on 816 molars in 102 patients with moderate-to-severe periodontitis. The six factors evaluated (age, probing depth, mobility, furcation involvement, smoking, and molar type) were assigned a numeric score based on statistical analysis. The sum of the scores for all factors was used to determine the prognosis score for each molar. Only patients with all first and second molars at the initial examination qualified for the study. All patients were evaluated a minimum of 15 years after treatment. RESULTS: The post-treatment time ranged from 15 to 40 years and averaged 24 years. When the study was completed, 639 molars survived (78%), and, of those surviving molars, 588 survived and were periodontally healthy (92%). In molars with lower scores (scores 1-3), the 15-year survival rates ranged from 98% to 96%. In molars with middle scores (scores 4-6), the 15-year survival rates ranged from 95% to 90%, and, for molars with higher scores (scores 7-10), the survival rates ranged from 86% to 67%. CONCLUSION: The present results indicate that the periodontal prognosis of molars diagnosed with moderate-to-severe periodontitis can be calculated using an evidence-based scoring index.

Acellular dermal matrix seeded with autologous gingival fibroblasts for the treatment of gingival recession: a proof-of-concept study.

BACKGROUND: One of the most common esthetic concerns associated with periodontal tissues is gingival recession. There are multiple periodontal plastic surgery approaches documented in the literature for the treatment of such defects. With the tremendous advances being made in periodontal science and technology, tissue engineering could be considered among the latest exciting techniques for recession management. METHODS: In this split-mouth, controlled, double-masked clinical case series, 20 sites from 10 patients with Miller Class I or II recessions affecting canines or premolars in the maxillary arch were selected. One tooth in each patient was randomized to receive either a subepithelial connective tissue graft (SCTG) (control group) or an acellular dermal matrix allograft (ADMA) seeded with autologous gingival fibroblasts (test group) under a coronally positioned flap. Clinical parameters, including recession depth, probing depth, clinical attachment level, width of keratinized tissue, attached gingiva, and plaque scores, were recorded by a calibrated examiner at baseline and 3 and 6 months. The inflammation of grafted sites was scored, and the healing time was calculated. The final esthetic outcome of treated sites was assessed by the root coverage esthetic score at the end of 6 months. RESULTS: There were no significant differences between test and control sites for all measured clinical parameters. However, the test sites demonstrated less inflammation in the early postoperative period. CONCLUSION: Within the limits of this case series, the results indicate that an ADMA seeded with autologous gingival fibroblasts by tissue-engineering technology may be explored as a substitute to an SCTG for the treatment of Miller Class I and II recession defects.

Root coverage esthetic score: a system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases.

BACKGROUND: Generally, esthetic outcomes following root-coverage procedures are not assessed. This article proposes a score for evaluating the esthetic outcome following root-coverage surgery. METHODS: Thirty-one patients with Miller Class I and II recession defects treated with root-coverage procedures were evaluated. Esthetic outcomes were assessed using the root coverage esthetic score (RES) 6 months after surgery. This score evaluates five variables: level of the gingival margin, marginal tissue contour, soft tissue texture, mucogingival junction alignment, and gingival color. Because complete root coverage was the primary treatment goal, and the other variables were considered secondary, the value assigned for root coverage was 60% of the total score, whereas 40% was assigned to the other four variables. With regard to assessment of the final position of the gingival margin, 3 points were given for partial root coverage, and 6 points were given for complete root coverage; 0 points were assigned when the final position of the gingival margin was equal or apical to the previous recession. One point was assigned for each of the other four variables. Thus, 10 points was a perfect score. RESULTS: Of the 31 treated recession defects, 24 (77%) exhibited complete root coverage at 6 months. The mean amount of root coverage was 89.4% (range, 0% to 100%). The mean RES was 7.8. Five of 24 cases of complete root coverage achieved a perfect score (RES = 10). In one case, RES = 0. CONCLUSION: The RES system may be a useful tool to assess the esthetic outcome following root-coverage procedures.