Surface roughness associated with bacterial adhesion on dental resin-based materials.

This study investigates the surface quality and bacterial adhesion properties of various dental materials, including indirect composites, veneering composites, direct composites, polyether ether ketone (PEEK), and two millable polymethyl methacrylate (PMMA). Material specimens were processed following manufacturer instructions, initially evaluated for surface roughness and Streptococcus sanguinis (S. sanguinis) adhesion. Subsequently, toothbrushing simulation was employed to simulate aging, and changes in material surfaces were assessed via roughness measurements and bacterial adhesion testing. Prior to simulated aging, direct and indirect composites exhibited the lowest roughness values. However, after the simulated toothbrushing, veneering composites displayed the highest roughness levels. Both PMMA materials demonstrated the highest S. sanguinis adhesion levels, both before and after artificial aging. Interestingly, the indirect composite material showed a reduction in bacterial adhesion following toothbrushing simulation. Surprisingly, this study did not reveal a clear correlation between roughness and bacterial adhesion.

The comparison of visibility of the maxillary sinus septa between cone-beam computed tomography scans and panoramic radiograph images as dependent on the cortical bone thickness: a retrospective comparative study.

PURPOSE: To analyze the visibility of the maxillary sinus septa (MSS) in panoramic radiography (PR) versus cone beam computed tomography (CBCT) and to investigate whether the buccal cortical bone thickness (BT) or the septa dimensions influence their visibility. METHODS: Corresponding PR and CBCT images of 355 patients were selected and examined for MSS visibility. The septa dimensions (width, height, depth) and the BT were measured. Results were analysed statistically. RESULTS: Comparing the corresponding regions on CBCT and PR, 170 MSS were identified; however, only 106 of these were also visible using PR. The MSS visibility was significantly higher on CBCT versus PR images (P1: p = 0.039, P2: p = 0.015, M1: p = 0.041, M2: p = 0.017, M3: p = 0.000), except region C (p = 0.625). Regarding the measurements of MSS dimensions, only the height in region M1 (p = 0.013) and the width in region P2 (p = 0.034) were significantly more visible on CBCT. The BT in the area of the MSS was found to have a marginal influence on its visibility on the PR images only in regions M3 and M1 (M3: p = 0.043, M1: p = 0.047). In terms of MSS visibility based on the dimensions, significance was found for all three influencing variables only in region P2 (width; p = 0.041, height; p = 0.001, depth; p = 0.007). There were only isolated cases of further significance: M3 for width (p = 0.043), M2 for height (p = 0.024), and P1 for depth (p = 0.034), no further significance was noted. CONCLUSION: MSS visibility appears significantly higher on CBCT versus PR images. It is concluded that the septa dimensions and BT can influence MSS visibility on PR images just in certain regions.

A double-blind randomized clinical trial on the suggestive effect of anxiety management questionnaires in dental emergencies.

Objective: Dental anxiety is widespread among both children and adults. To diagnose dental anxiety, standardized anxiety questionnaires are recommended. Based on the suggestive nature of the questionnaires, the study aimed to find out whether asking respondents about personal coping strategies before dental treatment influences their anxiety. Methods: This prospective, double-blind, randomized controlled clinical trial included a total of 158 patients of a university dental clinic on emergency service. The intervention group (n = 82) received the Coping with Anxiety Questionnaire (CAQ) and the control group (n = 76) the Hierarchical Anxiety Questionnaire (HAF). State anxiety scores were assessed by using the State-Trait Anxiety Inventory (STAI) before and after the completion of each questionnaire. Results: Anxiety decreased in the intervention group (CAQ) (p < 0.001) and increased in the control group (HAF) (p < 0.001). Conclusion: Within the limitations of the current study, a diagnostic tool of a standardized questionnaire for the assessment to assess personal coping strategies decreased state anxiety in comparison to a questionnaire assessing anxiety. Clinical trial registration: https://www.drks.de, German Trials Register (DRKS00032450).

Comparative diagnosis of the alveolar antral artery canal in the lateral maxillary sinus wall in corresponding panoramic radiography and cone-beam computed tomography.

PURPOSE: Sinus lift operations are a tried and tested means of providing adequate implant prosthetics to patients with compromised jawbones. Knowledge of the arterial supply of the maxillary sinus region is essential for surgical treatment in this area. The aim of the present comparative study was to determine whether alveolar antral artery (AAA) canal can be diagnosed both in corresponding panoramic radiography (PR) and cone-beam computed tomography (CBCT). METHODS: A total of 335 patients with 635 sites and corresponding maxillary sinus in both PR and CBCT were selected and examined for AAA canal visibility. RESULTS: The visibility of the AAA canal was significantly higher in CBCT than in PR. A total of 154 (46.0%) AAA canals could be identified in the maxillary sinus on the right. However, only four (1.2%) of these were also visible in PR. The detected values of the AAA canals in the maxillary sinus on the left in the PR and CBCT images were similar to those of the right. While 164 AAA canals (49%) were observed in CBCT images, only 1 (0.3%) was identifiable in PR. CONCLUSIONS: The results show that CBCT can be recommended for visualising the AAA canal when surgically planning sinus augmentation procedures.

Evaluation of the contour of edentulous jaw sections in the transversal plane and the buccolingual vertical-level disparity in CBCT and panoramic radiography images: a retrospective comparative study.

PURPOSE: This study investigates whether edentulous jaw sections in the planned implant position exhibit jaw contours funnel-shaped or exhibit pronounced retraction of the jaw (unusual jaw contours) in the transversal plane of the three-dimensional (3D) images, not visible in two-dimensional (2D) images. METHODS: A total of 335 patients with an edentulous section of the jaw that required dental implants were selected. Anonymised radiologic patients' data were collected, comprising cone-beam computed tomography (CBCT) images of the edentulous jaw sections. In the first stage, unusual jaw contours were examined, including funnel-shaped or pronounced retraction of the jaw and hypodense regions with an undercut and/or bone deficit. In the second stage, the variation in the height of the alveolar ridge between the lingual and buccal contour in the edentulous jaw sections was assessed. RESULTS: The CBCT images of an unusual jaw contour were observed in 8 cases (2.4%) in the maxilla on the left and 10 cases (3%) in the maxilla on the right. In the mandible, a jaw contour deviates in 39 cases (12.1%) on the left side and 39 cases (12.1%) on the right side. A height difference was detected in the upper jaw in 307 cases and the lower jaw in 265 cases. The discrepancy was 2.09 mm (± 2.25 mm) in the maxilla and 3.97 mm (± 3.45 mm) in the mandible. CONCLUSIONS: The CBCT scan provides useful information to avoid complications in the preoperative planning phase and surgical planning in implant dentistry.

Human Gingival Fibroblast Adhesion and Proliferation on Hydroxyapatite-Coated Zirconia Abutment Surfaces.

Applying antibacterial coatings to dental implant materials seems reasonable but can have negative influences on desired cell adhesion and healing. In this study, zirconia abutment specimens interacting with gingival tissue were used. The aim was to compare the influence of machined or coated zirconia surfaces on the adhesion and proliferation of human gingival fibroblasts (HGF-1). Surface modifications were performed using atmospheric plasma coating with hydroxyapatite, zinc, and copper. Zirconia specimens were divided into four groups: hydroxyapatite, hydroxyapatite with zinc oxide (ZnO), hydroxyapatite with copper (Cu), and an untreated machined surface. After the characterization of the surface conditions, the morphology of adhered HGF-1 was determined by fluorescence staining and subjected to statistical evaluation. The visual analysis of cell morphology by SEM showed flat, polygonal, and largely adherent fibroblast cells in the untreated group, while round to partially flat cells were recorded in the groups with hydroxyapatite, hydroxyapatite + ZnO, and hydroxyapatite + Cu. The cell membranes in the hydroxyapatite + ZnO and hydroxyapatite + Cu groups appeared porous. The results show that HGF-1 adhere and proliferate well on machined zirconia, while plasma coating with hydroxyapatite or hydroxyapatite mixtures does not lead to increased adhesion or proliferation.

Cold Atmospheric Plasma Improves Shear Bond Strength of Veneering Composite to Zirconia.

Chipping of veneering is the most common clinical complication for zirconia restorations. Veneering composite could be a promising alternative to renew restorations. Zirconia discs (3-YSZ) were prepared with varying surface treatments and bonded to indirect composite as follows: air abrasion and Scotchbond Universal (A/SU); air abrasion and Clearfil Ceramic Primer (A/C); air abrasion and MKZ Primer (A/M); air abrasion and Monobond Plus (A/MP); silica-coating and Scotchbond Universal (S/SU); air abrasion (AP/SU), additional cold atmospheric plasma treatment, and Scotchbond Universal. An indirect composite material was then applied to the zirconia specimens. Specimens were divided into subgroups for short-term (14 days storage at 37 °C and 5000 thermal cycles) and long-term (250 days storage and 37,500 thermal cycles) artificial aging. Shear bond strength measurement (SBS) was performed, and data were analyzed by Kruskal-Wallis-test and multiple comparison testing with Dunn's correction (p ≤ 0.05). The median SBS values (MPa) of short- and long-term artificial aging were: 3.09/1.36 (A/SU); 0.77/1.43 (S/SU); 2.82/2.15 (AP/SU); 1.97/1.80 (A/C); 2.01/1.58 (A/M); and 1.70/1.68 (A/MP). For short-term artificial aging A/SU showed the highest median SBS values, whereas in the long-term trial, AP/SU showed the highest values and the difference was significant. A prolonged artificial aging decreased SBS in all groups, except S/SU. In summary, treatment with CAP can improve SBS in the long-term.

Shear bond strength of veneering composite to high performance polymers.

High performance polymers like PEEK (polyetheretherketone) and FRC (fiberreinforced composite) could substitute metallic alloys for removable partial dentures. However, these polymers require aesthetic veneering. This study was to determine the bond strength to direct composite. Specimens made of PEEK and FRC were produced and air-abraded (50 µm aluminum-oxide). Specimens were allocated to four experimental groups: Luxatemp Glaze & Bond, Scotchbond Universal, SR Nexco Connect and iBond Universal. Specimens were divided into three subgroups for short-term, long-term and no artificial aging and shear bond strength (SBS) was evaluated. SBS of specimens made of PEEK with no artificial aging showed values between 10.79-14.00 MPa, short-term artificial aging resulted in values between 3.78-13.85 MPa and after long-term artificial aging SBS decreased to 0-8.75 MPa. SBS measurement of FRC specimens resulted in values between 9.83-12.1 MPa without aging, after short-term artificial aging values decreased to 8.36-11.98 MPa and after long-term aging SBS showed a degradation to 4.52-7.82 MPa.

Cold atmospheric plasma as antiviral therapy - effect on human herpes simplex virus type 1.

In previous studies, cold atmospheric plasma (CAP) was explored as an antibacterial and antiviral agent for the treatment of chronic wounds. The aim of the present study was to investigate whether CAP may also be suitable as an antiviral therapy against herpes simplex virus type 1 (HSV-1). HSV-1 most frequently manifests as recurrent herpes labialis, but it can also cause encephalitis, conjunctivitis or herpes neonatorum as a perinatal infection. HSV-1 encoding the reporter gene GFP was propagated. The CAP dose for HSV-1 treatment was gradually increased, ranging from 0-150 s, and aciclovir was used as a positive control. After CAP treatment, the virus suspension was applied to a standard HSV research cell line (Vero cells) and the neuroblastoma cell line SH-SY5Y as a model for neuronal infection. The results showed that plasma treatment had a negligible antiviral effect on HSV-1 in both Vero- and SH-SY5Y cells at high dose. However, when we lowered the viral load 100-fold, we observed a significantly decreased number of internalized HSV-1 genomes 3 h post-infection for CAP-treated viruses. This difference was less pronounced with respect to GFP expression levels 24 h post-infection, which was in sharp contrast to the acyclovir-treated positive control, for which the viral load was reduced from 95 to 25%. In summary, we observed a low but measurable antiviral effect of CAP on HSV-1.

Marginal quality of ceramic inlays after three different instrumental cavity preparation methods of the proximal boxes.

OBJECTIVES: The marginal quality of ceramic inlays was evaluated after the use of three different instrumental finishing methods in mesio-occluso-distal (mod) cavity boxes in vitro after hydrothermal loading (HTL). MATERIALS AND METHODS: Caries-free human molars were divided into three groups. Mod-cavities were conventionally prepared. Box finishing was performed in every group with rotating (RI), sonic (SI), or ultrasonic (USI) instruments. Surface roughness was examined. Twelve mod-cavities remained untreated. Continuous margin quality was evaluated with scanning electron microscopy (SEM). Ceramic inlays were cemented into cavities. After HTL microleakage, marginal and absolute marginal gaps were examined. All data were analyzed statistically. RESULTS: Significant differences were found, between cavity surface roughness of RI and SI groups, the RI and USI groups, but not between microleakage, marginal, absolute marginal gaps after HTL and in proximal marginal quality. No correlations between microleakage and marginal gaps nor between microleakage and surface roughness were found. CONCLUSION: Mod-cavity proximal box finishing with SI or USI resulted in a higher surface roughness than the use of RI. The type of the finishing method did not influence the marginal quality of ceramic inlays. For the mod-cavity finishing, the use of SI and USI could be an alternative instrumental method to conventional RI methods with a lower risk of iatrogenic damage of the adjacent teeth. CLINICAL RELEVANCE: This study allows the practitioner to better determine the proper indications and limitations of the sonic and ultrasonic instruments for mod-cavity proximal box finishing.

Effect of cold atmospheric plasma (CAP) on human adenoviruses is adenovirus type-dependent.

More than 70 human adenovirus types were identified divided into 7 different species (A-G). Diseases caused by human adenoviruses are type-dependent and can range from mild to severe respiratory infections, gastrointestinal infections or eye infections such as epidemic keratoconjunctivitis. Unfortunately there is no specific anti-adenovirus therapy available. Here we addressed the question whether treatment with cold atmospheric plasma (CAP) for anti-adenoviral therapy such as virus-mediated ulcerations may be feasible. CAP has already been explored for the treatment of dermatological diseases such as chronic wounds. To investigate whether CAP is an effective antiviral tool, purified human adenovirus types derived from different human adenovirus species (HAdV -4, -5, -20, -35, -37, -50) tagged with luciferase were treated with defined dosages of plasma. The CAP treatment was varied by incrementally increasing the time span of CAP treatment. After CAP treatment, the virus containing solution was added to eukaryotic cells and the viral load was determined by measurement of luciferase expression levels. Through the plasma treatment the adenovirus driven luciferase expression directly correlating with adenovirus transduction efficiencies could be reduced for HAdV-5 and HAdV-37. Plasma treatment had no influence on adenovirus derived luciferase expression levels for HAdV-4 and HAdV-50 and it even had a positive effect on luciferase expression levels for HAdV-20 and HAdV-35. These results suggest that CAP has a type dependent effect on adenoviruses and that infectivity can be even increased for certain adenovirus types. Further studies should address the mechanisms behind this phenomenon. In summary we demonstrate that CAP may represent an interesting option for antiviral treatment in a virus type dependent manner.

Influence of Luting Materials on the Retention of Cemented Implant-Supported Crowns: An In Vitro Study.

The retention force of cemented crowns on implant abutments with various luting materials was evaluated. Cobalt⁻chromium crowns were cemented onto tapered titanium abutments (Camlog) with eugenol-free temporary cement (RelyX TempBond NE), composite-based temporary cement (Bifix Temp), zinc phosphate cement (Harvard Cement), glass-ionomer cements (Meron, Fuji I), and resin-modified glass-ionomer cements (Fuji II, Fuji Plus, Ketac Cem Plus). Specimen aging via hydrostress was performed in artificial saliva at 37 °C for 14 days (S1), followed by hydrothermal stress with thermocycling (S2). The crowns were removed, and the force was recorded (T1). Subsequently, the crowns were recemented, aged, and removed, and the force was recorded (T2, T3). The retention forces differences were statistically significant according to the storage conditions at T1 (p = 0.002) and T3 (p = 0.0002). After aging (S1), Ketac Cem Plus had the highest retention force median value difference (T3 versus T1) (-773 N), whereas RelyX TempBond NE had the lowest (-146 N). After aging (S2), Meron had the highest retention force median value difference (-783 N), whereas RelyX TempBond NE had the lowest (-168 N). Recementation decreased the retention force of the implant-supported cobalt⁻chromium crowns cemented and recemented with the same luting materials. Luting materials (at T1) and aging conditions significantly impacted the retention force.

Prosthetic rehabilitation for a patient treated for embryonal rhabdomyosarcoma.

A female patient, now aged 17 years, was diagnosed with rhabdomyosarcoma (RMS) in the right pterygopalatine fossa when she was 3 years old. The RMS was successfully treated by excision, but the subsequent radiation and polychemotherapy resulted in the complete anesthesia of the distribution area of the right trigeminal nerve and loss of vision in the right eye. The patient also experienced pain in the mandibular joints and masticatory muscles. Panoramic radiographs displayed a multiple agenesia of the permanent teeth and underdeveloped apices. Treatment involved the fabrication of a complete maxillary denture. A removable device was fabricated to evaluate her response to an occlusal vertical dimension increase of 6 mm and provide a stable intercuspal position. After wearing the prosthesis for 6 months, the patient reported that she was completely free of symptoms.

Relative Clinical Success of Bis-Acryl Composite Provisional Crowns.

The high demands on the clinical performance of a single-tooth provisional restoration necessitate that said performance be examined. The authors evaluated 24 teeth evaluated. Two test groups received bis-acrylic composite for provisional crowns (n = 12) and a single-unit, self-supporting, malleable, light-curing composite crown (n = 12). Final crowns (n = 24) served as paired controls. Evaluation of clinical success was measured using previously selected subcategories of FDI criteria. Statistical analysis was performed using McNemar's Test (α = 0.05). The null hypothesis of no improvement of the definitive crown relative to the provisionals was rejected at the 5% significance level (McNemar's P value <.001, Bonferroni corrected). Of the provisional crowns, 75% received a clinically insufficient valuation, while only 8% of the definitive crowns did. The authors concluded that, independent of the manufacturing process, a bis-acrylic composite provisional crown cannot serve as a replacement for a conventionally manufactured definitive crown.

Wear Behavior of Ceramic CAD/CAM Crowns and Natural Antagonists.

OBJECTIVE: Evaluation of wear behavior of computer-aided design/computer-aided manufacturing (CAD/CAM) crowns from various restorative materials and natural antagonists. METHOD: Full CAD/CAM crowns fabricated with nanoceramic resin (Lava Ultimate (LU)), a glass ceramic in a resin interpenetrating matrix (Vita Enamic (VE)) and a lithium silicate reinforced ceramic enriched with zirconia (Vita Suprinity (VS)) were cemented on human molars. The crown and antagonists were subjected to simulated chewing. 3D data sets, before and after the chewing simulation, were generated and matched. Occlusal surface roughness, vertical and volume loss of the crowns and antagonists were analyzed. RESULTS: Crown roughness was significantly different between the LU and VE groups after chewing simulation. Crown vertical loss differed in all groups. The highest crown volume loss was found in the LU group, and the lowest in the VE group. Comparisons between the LU and VE groups and the LU and VS groups were significantly different. The highest antagonist volume loss was reached in the VE group, the lowest was in the LU group. CONCLUSION: Roughness increased after chewing simulation. LU crowns are the most natural antagonist-friendly; these were the most susceptible to vertical and volume loss. Of the tested materials, the VE crowns are the most stable regarding occlusion.

Evaluation of hypersensitivity after the placement of metal-ceramic crowns cemented with two luting agents: Long-term results of a prospective clinical study.

STATEMENT OF PROBLEM: Different luting materials are available for the cementation of fixed dental prostheses. Postcementation hypersensitivity is an occasional complication in the definitive delivery. How the choice of luting agent affects long-term postcementation sensitivity is unknown. PURPOSE: The purpose of this prospective, randomized, controlled, split-mouth clinical trial was to compare the hypersensitivity of 2 cementation methods for metal-ceramic crowns. The primary endpoint was the evaluation of differences in hypersensitivity between the study groups over a study period of 5 years. MATERIAL AND METHODS: The study investigated 20 participants with 40 metal-ceramic crowns cemented with either zinc phosphate cement or a self-adhesive resin cement, each in nonantagonistic contralateral quadrants (observation period of 5 years). The data regarding postcementation hypersensitivity included continuous patient-related outcome variables assessed using a visual analog scale (sign test; primary endpoint, level of significance α/3=.0167; secondary endpoint, level of significance, α=.05) and categorical variables represented by yes/no replies (absolute and relative frequencies). The sensitivity of teeth was controlled in relation to mastication, air streams, and hot and cold temperatures. RESULTS: The observation period was 5 years, with a dropout rate of 12.5% in the last 2 years. The results indicated no significant differences between the cement groups for patient- and clinical-related outcomes at any of the observed time points. CONCLUSIONS: As no differences were found between the 2 different cementation modes with respect to developing hypersensitivity after 5 years, the choice of a luting agent remains an individual practitioner decision.

Polishing of Monolithic Zirconia Crowns-Results of Different Dental Practitioner Groups.

This pilot study evaluates the surface roughness of monolithic zirconia crowns after chairside polishing by different dental practitioner groups. Four practitioner groups (group I: dental clinical students (n = 6); group II: dentists < 2 years post-qualification experience (n = 6); group III: dentists > 2 years post-qualification experience (n = 6) and group IV: dental technicians (n = 6)) were asked to polish two CAD/CAM-fabricated full-contour zirconia crowns (48 in total). A two-step zirconia polishing kit was used in both trials. The first trial (T1) was conducted without a time limitation. In the second trial (T2), the polish was restricted to 15 seconds for each polisher. Two blinded investigators (I1 and I2) analyzed the surface roughness (Ra) before and after polishing (Alicona measuring system). No statistically significant difference in surface roughness was found between the polishing results of the dental practitioner groups. Major difference in surface finish was achieved by dental technicians, with a median value of 25.4 nm (interquartile range 10.15-35.26 nm) for I1 in T1. The lowest difference was achieved by dental students, with a median value of Ra = 6.72 nm (interquartile range 4.7-17.9 nm) in T1. In T2, experienced dentists showed the highest difference in surface finish, with a median value of 41.35 nm (interquartile range 7.77-54.11). No significant correlation was found between polishing time and polishing results. The polishing of monolithic zirconium dioxide crowns can be performed with the present polishing set directly chairside after occlusal adjustment, regardless of the practitioner's experience level.

Adhesion of different resin cements to enamel and dentin.

The purpose of this in vitro study was to compare the shear bond strength (SBS) of five different resin cements to human enamel and dentin under different storage conditions. Five resin cements and their dedicated systems were tested. Teeth were embedded, ground flat to expose enamel or dentin and polished with sandpaper. Adhesive systems were applied according to the manufacturers'instructions. V2A steel cylinders with were silicated, coated, and cemented onto the teeth. Specimens were stored at three different conditions and subsequently thermocycled. SBS was measured. Significant differences were observed between the tested resin cements depending on the tooth surface. Different storage conditions influenced the bond strength, independent of the tooth surface, in all test cements. The bond strength of all experimental materials to enamel is higher than that to dentin surfaces. Furthermore, the adhesiveness decreases after wetness (hydro-) and hydrothermal stress, regardless of the tooth surface.

Non-prep restoration of an ankylosed incisor: a case report.

Dental restorations without tooth preparation are among today's more advanced treatment options. This article presents the case of a young man who was treated with a non-prep laminate veneer that provided 3.5 mm of incisal elongation. A Photoshop assessment and functional evaluation, as well as a wax-up and mock-up, were used during pre-prosthetic planning. A combination of pressable and feldspathic ceramics was used as a restorative material, which was applied to the tooth surface without any preparation of dental hard tissue. An ideal functional and esthetic restoration was achieved thanks to close collaboration between the patient, the dentist, and the technician.

Severely scarred oronasal cleft defects in edentulous adults: initial data on the long-term outcome of telescoped obturator prostheses supported by zygomatic implants.

Objective : Prosthetic rehabilitation of edentulous patients presenting with severely scarred oronasal cleft defects. To document the outcome of telescopic obturator prostheses attached to zygomatic implants in edentulous cleft lip and palate patients. Patients and Methods : Four edentulous patients suffering from the consequences of cleft lip and palate were selected from a cohort of 52 patients who had received zygomatic implants between 1998 and 2010. Oronasal communication had persisted and severe scars and chronic infection were noted in the cleft region. Bone grafting procedures were contraindicated due to high risk for dehiscence. For the functional support of telescopic prostheses, nine zygomatic implants and two standard dental implants had been placed. Results : The zygomatic implants and the telescopic prostheses survived an average of 62 months (37 to 99 months) and were successful. Patients' satisfaction and oral function improved (on visual analog scale and oral health impact profile). Conclusions : Telescopic obturator dentures supported by zygomatic implants represent a feasible option for the prosthetic rehabilitation of cleft lip and palate patients with severe impairments of the edentulous ridges including atrophy, scar tissue, ridge defects, oronasal communication, and chronic infection in the cleft region.