Guided bone regeneration for dehiscence and fenestration defects on implants using an absorbable polymer barrier.

BACKGROUND: Guided bone regeneration (GBR) using a non-absorbable barrier has provided clinicians the ability to place implants in sites compromised by insufficient bone, including immediate extraction sites. Recent evidence suggests that successful GBR outcomes may be possible using bioabsorbable polymer barriers. METHODS: This report presents a case series of 9 patients with 8 fenestration and 3 dehiscence defects on implants consecutively treated with GBR. A bioabsorbable polymer barrier of poly(DL-lactide) was used in conjunction with a composite graft of freeze-dried bone allograft (FDBA)/demineralized freeze-dried bone allograft (DFDBA) mixed in a ratio of 1:1. Second-stage surgeries were performed at 4 to 8.5 months (5. 7 months average) post-placement. Biopsy material from 2 sites was obtained while exposing the implant for healing abutment connection. RESULTS: Ten of the 11 defects (90.9%) achieved complete coverage of the osseous defects. Histologic evaluations revealed the formation of viable bone, frequently in close amalgamation with residual graft particles. CONCLUSION: These case reports suggest that a poly(DL-lactide) polymer can be used as a physical barrier with a composite bone replacement graft to achieve successful GBR results of dehiscence/fenestration defects when placing implants.

Alveolar ridge and sinus augmentation utilizing platelet-rich plasma in combination with freeze-dried bone allograft: case series.

BACKGROUND: Alveolar bone regeneration is frequently necessary prior to placement of implants. Efforts to improve wound healing have focused on factors that may enhance bone formation following guided bone regeneration (GBR) techniques alone or in combination with bone replacement graft materials. Recent reports suggest that platelet-rich plasma (PRP), presumably high in levels of peptide growth factors, may enhance the formation of new bone when used in combination with autogenous graft material. METHODS: In this report, the clinical and radiographic results are presented on 15 consecutively treated patients using autologous PRP in combination with freeze-dried bone allograft (FDBA) for sinus elevation and/or ridge augmentation. FDBA and PRP (0.5 g/2cc PRP) were mixed and placed as a composite graft material. A gel formed by mixing autologous thrombin-rich plasma with PRP (1:4 ratio) was used to cover the graft material. Core biopsies of grafted areas were obtained in several patients as part of implant site preparation and were evaluated histologically to determine site maturation. RESULTS: Of 36 implant fixtures, 32 (89%) were considered clinically successful demonstrating complete bone coverage of the implant, no mobility, and a normal radiographic appearance at the time of re-entry and 12 months post-implant exposure. Four implants were removed due to mobility at the time of surgical exposure. Histologic evaluation of biopsy specimens revealed numerous areas of osteoid and bone formation around FDBA particles, with no evidence of inflammatory cell infiltrate. CONCLUSIONS: These clinical and histological findings suggest that ridge augmentation and sinus grafting with FDBA in combination with PRP provide a viable therapeutic alternative for implant placements. Future studies are necessary to determine whether PRP enhances new bone formation or maturation with bone replacement allografts.

The treatment of intrabony defects with bone grafts.

There is substantial clinical and histological evidence that support the concept that extraoral and intraoral autogenous bone grafts and demineralized freeze-dried bone allografts are effective regenerative materials in the treatment of intrabony defects. Moreover, long-term evaluations currently available suggest that the regenerative gains achieved remain clinically stable. Synthetic grafts may result in improved probing depths and clinical attachment levels but have yet to demonstrate the ability to initiate or enhance the formation of a new attachment apparatus.

The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients.

A retrospective clinical evaluation of patients consecutively treated from multiple centers was performed. The treatment of these patients utilized the bone-added osteotome sinus floor elevation (BAOSFE) procedure with immediate implant fixation. The BAOSFE method employs a specific set of osteotome instruments to tent the sinus membrane with bone graft material placed through the osteotomy site. A total of 174 implants was placed in 101 patients. Implants were of both screw and cylinder shapes with machined, titanium plasma-sprayed, and hydroxyapatite surfaces from various manufacturers. The 9 participating clinicians used autografts, allografts, and xenografts alone or in various combinations, and the type of graft was selected by the individual clinicians. The choice of graft material did not appear to influence survival rates. Loading periods varied from 6 to 66 months. The survival rate was 96% or higher when pretreatment bone height was 5 mm or more and dropped to 85.7% when pretreatment bone height was 4 mm or less. The most important factor influencing implant survival with the BAOSFE was the preexisting bone height between the sinus floor and crest. This short-term retrospective investigation suggests that the BAOSFE can be a successful procedure with a wide variety of implant types and grafting procedures.

The role of orthognathic surgery in the treatment of severe dentoalveolar extrusion.

BACKGROUND: When mandibular molars are not replaced after extraction, the long-term problem of inadequate interarch space for either a fixed or removable prosthesis can occur. In the past, practitioners needed to decide whether to shorten the teeth, extract the supererupted maxillary molars to recapture space or leave the area unrestored. The authors present another option. CASE DESCRIPTION: A 61-year-old man was referred to a periodontist by his general dentist for placement of mandibular implants in the posterior sextant. Extreme supereruption of the maxillary dentoalveolar segment prevented restoration of the opposing edentulous area. An oral and maxillofacial surgeon performed a segmental osteotomy of the posterior right maxilla to gain needed interarch space. After the osteotomy was stabilized, the periodontist placed implants that were subsequently restored with a fixed prosthesis. CLINICAL IMPLICATIONS: The role of orthognathic surgery in treatment planning should not be overlooked in the comprehensive management of severe extrusion. It offers patients the opportunity to gain both function and esthetics that might otherwise be impossible.

Polymer-assisted regenerative therapy: case reports of 22 consecutively treated periodontal defects with a novel combined surgical approach.

This report describes the clinical application of an in situ formed barrier of poly(DL-lactide) used in combination with a composite graft of demineralized freeze-dried bone allograft (DFDBA) mixed with calcium sulfate and tetracycline in a ratio of 7:2:1 and citric acid root conditioning for the treatment of intrabony and furcation defects. The clinical outcome was assessed by changes in clinical attachment level (CAL) and probing depth (PD) in 18 consecutively treated patients with 17 intrabony and 5 furcation lesions. After patients demonstrated acceptable oral hygiene, the lesions were surgically treated with combination therapy using an in situ formed barrier over a DFDBA composite graft. Patients followed a stringent postoperative protocol and were evaluated at 6 months postsurgery. CAL improved for all sites from a presurgical average of 8.8+/-2.3 mm to 4.4+/-1.6 mm at 6 months postsurgery (4.4+/-1.5 mm gain), while PD was reduced from an average of 8.3+/-2.1 mm presurgery to 3.3+/-1.1 mm at 6 months postsurgery (5.0+/-1.8 mm reduction). Five furcations were treated, of which 4 were Class II and 1 was Class III. Of these furcation lesions, 3 had complete clinical closure, while 1 improved by 1 grade. The Class III furcation remained the same. Results suggest that DFDBA composite graft covered by an in situ formed barrier on root surfaces treated with citric acid can enhance the prognoses of teeth with periodontal lesions as measured by CAL gains and PD reductions. Further studies are warranted to compare this treatment to other more traditional forms of regenerative therapy to determine its comparative efficacy.

A technique report on the in situ application of Atrisorb as a barrier for combination therapy.

This article describes a novel technique in which Atrisorb (Atrix Laboratories) is applied in situ as a barrier over a demineralized freeze-dried bone allograft on roots treated with citric acid. Follow-up reentry at 4.5 months demonstrated the effectiveness of this procedure. A rationale for in situ barrier application is presented.

Regenerative therapy in the treatment of maxillary molar Class II furcations: case reports.

This report demonstrates the use of regenerative therapy in the treatment of maxillary molar Class II furcations. The predominant therapy provided was open debridement in combination with DFDBA, e-PTFE membranes, and citric acid root conditioning. Case reports of consecutively treated patients that include radiographs and reentry photographs demonstrate that maxillary molar furcations can be successfully treated with predictability.

Pedicle procedure use in the management of regenerative therapy problems.

Regenerating a periodontium that has been lost because of disease has been made possible by the use of demineralized freeze-dried bone allografts (DFDBA), guided tissue regeneration with e-PTFE membranes, and combination therapies involving DFDBA covered by either an e-PTFE membrane or calcium sulfate. During regenerative therapy, problems may arise because of an adverse mucogingival condition, loss of a papilla, or significant exposure of the membrane from soft-tissue recession, slough, or fenestration leading to direct exposure of the site to the oral environment. Pedicle procedures can be used to cover these regenerative sites while providing mucogingival repair.

Influence of smoking on long-term clinical results of intrabony defects treated with regenerative therapy.

This retrospective study compares the short-term (1 year) and long-term (2 to 5 year) clinical results of regenerative therapy in clinical private practice using a bone allograft for the treatment of intrabony defects in smokers and non-smokers. A total of 110 intrabony lesions were treated with demineralized freeze-dried bone allograft (DFDBA) following thorough defect debridement and root preparation in 53 patients (15 cigarette smokers and 38 non-smokers). Assessments of clinical attachment level (CAL) and probing depth (PD) were recorded at pre-treatment, 1 year post-treatment, and 2 to 5 years post-treatment. At 1 year post-treatment, significant gains in mean CAL were maintained for both smokers (2.7 mm) and non-smokers (3.4 mm). Similarly, significant reductions in mean PD were observed for smokers (3.0 mm) and non-smokers (3.8 mm) at the 1-year follow-up. However, when comparing relative improvements in clinical measures, smokers were found to exhibit significantly poorer treatment results (i.e., sites exhibited less CAL gain) at 1 year and 2 to 5 years follow-up. Relative to pre-treatment scores, differences in improvements observed for CAL at the 1-year evaluation (29.2% for smokers and 42.5% for non-smokers) were sustained in the subgroup of patients at 2 to 5 years follow-up (31.3% for smokers and 41.8% for non-smokers). Similar but non-significant trends were observed for relative reductions in probing depth for smokers and non-smokers at 1 year (41.9% for smokers and 49.3% for non-smokers) and 2 to 5 years follow-up (43.9% for smokers and 48.3% for non-smokers) for the subgroup of patients followed beyond 1 year. These results suggest that smoking adversely affects treatment outcome, as measured by gains in clinical attachment levels of intrabony defects treated by regenerative therapy using DFDBA.

Modifications of the subpedicle connective tissue graft technique: a predictable procedure for covering exposed roots.

This article reviews modifications to Nelson's technique for covering exposed roots using an autogenous connective tissue graft covered by a double papilla pedicle graft. Case reports will illustrate how this technique can be used for both root surfaces pathologically exposed to the oral environment and those previously restored with cosmetic bonding procedures. Enhancements of this procedure over Nelson's original description will be enumerated, and advantages over other root coverage modalities will be presented.

Adult orthodontics: periodontic and cosmetic enhancements.

Approximately 30 years ago it became apparent that the periodontal, occlusal, and restorative needs inherent in the therapeutic management of the stomatognathic system required repositioning the teeth or the entire dentition. Precedence in adult orthodontics concentrated on correcting diastemas and malpositioned teeth, leveling infrabony defects, reducing periodontal depths, leveling occlusal planes, and creating harmonious gingival-lip line relationships. The desired result can be obtained by any of these procedures, but the perception and acceptance of an improved appearance or a beautiful smile will determine the ultimate success for the patient.

Comprehensive treatment for a subcrestal fractured incisor in the mixed dentition.

This case report describes the treatment of a transversely fractured developing permanent central incisor in the mixed dentition of a 9-year-old patient. A comprehensive approach was followed combining endodontics, orthodontics, prosthodontics, and periodontics to maintain arch integrity and alleviate the need for tooth replacement by a fixed or removable prosthesis.

Ankylosing spondylitis: survival in men with and without radiotherapy.

We investigated survival of a group of 151 Canadian war veterans with ankylosing spondylitis who were entered into a prospective study in 1947-1949. With 94% successful followup, total survival was 60.9%, significantly less than expected. However, a subgroup who had not been treated with radiotherapy had a survival not significantly different from the general population. Causes of death in both irradiated and nonirradiated subgroups were determined.

Synovial chondromatosis affecting the temporomandibular joint. Case report and literature review.

A case of synovial chondromatosis affecting the temporomandibular joint is reported and the literature is reviewed. Chondromatosis occurs most frequently in this joint in middle-aged women, and it presents with pain and tenderness over the joint. Radiologically, the condition is detected by widening of the joint space with variable presence of radiodense loose bodies. Pathologically, the loose bodies in the case presented were demonstrated arise from cartilaginous metaplasia of the synovial lining. The stimulus for synovial chondrometaplasia at this site is unknown.

Systemic lupus erythematosus with a vocal cord granulomatous nodule.

Systemic lupus erythematosus (SLE) with subcutaneous granulomatous nodules, joint symptoms, and a positive latex titre for rheumatoid factor may cause diagnostic confusion with rheumatoid arthritis (RA). This has been a subject of renewed interest in recent medical literature, but reports of nodules in SLE outside the subcutis are rare. This report presents a patient with SLE and with a vocal cord granulomatous nodule, arthralgia, and a positive latex titre for rheumatoid factor. The laryngeal manifestations of SLE are discussed.