Accuracy of immediately placed implants using surgical guides from different 3-dimensional printers: An in vitro study.

AIM: The aim of this study was to evaluate the accuracy of 3-dimensional (3D)-printed surgical guides for fully guided immediate implants from different manufacturers. METHODS: Eighteen 3D printed fully guided surgical guides (split into 3 groups [n = 6] according to their manufacturer: Company, Desktop, or Lab), were used to place 72 implants (n = 24) in identical maxillary models. After placement, the mean global, angular, mesiodistal, buccopalatal, and vertical deviation at the platform and apex of the placed implants, relative to their preoperatively planned positions, was calculated. RESULTS: Significant differences in global apex deviation, angular deviation, mesiodistal apex deviation, and vertical platform and apex deviation were found between the Lab and Desktop groups (p ≤ 0.007). Significant differences in mesiodistal platform and apex deviation and buccopalatal apex deviation were also found between the Company and Desktop groups (p ≤ 0.005). Finally, significant differences in buccopalatal apex deviation, and vertical platform and apex deviation were found between the Company and Lab groups (p ≤ 0.003). Mean differences between guide groups across all parameters never exceeded 0.5 mm or 1°. CONCLUSIONS: The choice of 3D printer has a significant effect on the accuracy of fully guided immediate implants. However, the clinical relevance of these differences may be considered limited.

Immediate versus early implant placement for single tooth replacement in the aesthetic area: A systematic review and meta-analysis.

OBJECTIVES: To compare immediate implant placement (IIP) with early implant placement (EIP) for single tooth replacement in the aesthetic area in terms of aesthetic, clinical, and patient-reported outcomes. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to February 2023. Randomized Controlled Trials (RCTs) comparing IIP with EIP were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue change. Secondary outcomes were horizontal midfacial soft tissue change, vertical papillary change, pink esthetic score (PES), implant survival, buccal bone thickness, marginal bone level change, patient discomfort, chair time, and patient satisfaction. RESULTS: Out of 1185 records, 6 RCTs were selected, reporting on 222 patients who received 222 single implants (IIP: 112 implants in 112 patients; EIP: 110 implants in 110 patients) in the anterior maxilla or mandible. Patients had a mean age ranging from 35.6 to 52.6 years and were followed between 8 and 24 months. Two RCTs showed some concerns, and four showed a high risk of bias. Four studies could be included in a meta-analysis on the primary outcome and three only considered cases with an intact buccal bone wall. Meta-analysis failed to demonstrate a significant difference in terms of vertical midfacial soft tissue change between IIP and EIP (mean difference: 0.31 mm, 95% CI [-0.23; 0.86], p = .260; I2 = 83%, p < .001). No significant differences were found for PES (standardized mean difference: 0.92, 95% CI [-0.23; 2.07], p = .120; I2 = 89%, p < .001), implant survival (RR: 0.98, 95% CI [0.93, 1.03], p = .480; I2 = 0%, p = .980), and marginal bone level change (mean difference: 0.03 mm, 95% CI [-0.12, 0.17], p = .700; I2 = 0%, p = .470). Insufficient data were available for meta-analyses of other secondary outcomes. CONCLUSION: In low-risk patients with an intact buccal bone wall, there seems to be no difference between IIP and EIP in terms of aesthetic and clinical outcomes. The strength of this conclusion is rated as low since studies showed an unclear or high risk of bias. In addition, state-of-the-art therapy was only delivered in a minority of studies. Future RCTs should also provide data on patient-reported outcomes since these have been underreported.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-Year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All were fully healed sites with a bucco-palatal bone dimension of at least 6 mm, and received an immediately restored single implant using a full digital workflow. Patients were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary endpoints were increase in BSP at T1 (immediately postop), T2 (3 months), T3 (1 year) and T4 (3 years) based on superimposed digital surface models. Secondary endpoints included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control group: 15 males, 15 females, mean age 50.1 years; test group: 14 males, 16 females, mean age 48.2 years) and 50 could be re-examined at T4. The changes in BSP over time were significantly different between the groups (p < .001). At T4, the estimated mean increase in BSP amounted to 0.83 mm (95% confidence interval [CI]: 0.58-1.08) in the control group and 0.48 mm (95% CI: 0.22-0.73) in the test group. The estimated mean difference of 0.35 mm (95% CI: 0.06-0.65) in favour of the control group was significant (p = .021). No significant differences between the groups could be observed in terms of patients' aesthetic satisfaction (p = .563), probing depth (p = .286), plaque (p = .676), bleeding on probing (p = .732), midfacial recession (p = .667), Pink Esthetic Score (p = .366) and Mucosal Scarring Index (p = .438). However, CMX resulted in significantly more marginal bone loss (-0.43 mm; 95% CI: -0.77 to -0.09; p = .015) than CTG. CONCLUSIONS: CTG was more effective in increasing buccal soft tissue profile and resulted in less marginal bone loss than CMX. Therefore, CTG remains the gold standard to increase soft tissue thickness at implant sites. CLINICAL TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT04210596).

Proof of Concept of a New 3D-Guided System for a Single Implant Overdenture in the Mandible: An In Vitro Study.

PURPOSE: To evaluate the precision and efficiency of a novel guide system for single implant placement in the mandibular symphyses and to evaluate whether the outcome is affected by the level of operator experience. MATERIALS AND METHODS: A total of 90 implants were placed in three different mandibular cast types (Cawood and Howell class III, IV, and V). For each model, a complete denture was 3D printed. A polyether ether ketone rail with a guide sleeve was embedded in the middle of the denture. To determine the ideal implant position, the sleeve could be moved in a buccolingual direction. Adjustment of implant angulation was possible, and an angle correction of 0, 12, or 24 degrees was available. A total of 30 clinicians were divided into three groups: group 1 (experienced, n = 10), group 2 (beginner, n = 10), and group 3 (inexperienced, n = 10). Each clinician was asked to plan and perform a guided flapless implant placement in the mandibular symphysis. Two preoperative CBCT scans were taken; the first was to verify the planning, and the second was to adjust the planning if needed. Finally, a postoperative CBCT scan was taken to compare the planning to the final implant position. RESULTS: Based on the first CBCT, the clinicians adjusted their planning by an average of 1.66 ± 1.65 mm coronally, 2.41 ± 2.44 mm apically, and by a mean angular correction of 6.08 ± 0.77 degrees. After implant placement, the mean deviation from the planned implant position was 0.87 ± 0.58 mm at the coronal aspect and 0.98 ± 0.64 mm at the apical aspect. The mean angular deviation was 6.05 ± 0.71 degrees. Overall, there were no significant differences in coronal and apical deviation (P > .05) based on the level of experience. In terms of angulation, a significant difference was found in both planning (P = .049) and placement (P = .038) between beginners and experienced clinicians. CONCLUSIONS: Guided implant placement of a single implant in the mandibular symphysis using a removable denture with guide sleeve had an acceptable level of accuracy. Clinicians with limited experience spent more time on the procedure, resulting in less angular deviation during implant planning and placement compared to experienced clinicians.

Accuracy of Intra-Oral Radiography and Cone Beam Computed Tomography in the Diagnosis of Buccal Bone Loss.

BACKGROUND: The use of cone beam computed tomography (CBCT) in dentistry started in the maxillofacial field, where it was used for complex and comprehensive treatment planning. Due to the use of reduced radiation dose compared to a computed tomography (CT) scan, CBCT has become a frequently used diagnostic tool in dental practice. However, published data on the accuracy of CBCT in the diagnosis of buccal bone level is lacking. The aim of this study was to compare the accuracy of intra-oral radiography (IOR) and CBCT in the diagnosis of the extent of buccal bone loss. METHODS: A dry skull was used to create a buccal bone defect at the most coronal level of a first premolar; the defect was enlarged apically in steps of 1 mm. After each step, IOR and CBCT were taken. Based on the CBCT data, two observers jointly selected three axial slices at different levels of the buccal bone, as well as one transverse slice. Six dentists participated in the radiographic observations. First, all observers received the 10 intra-oral radiographs, and each observer was asked to rank the intra-oral radiographs on the extent of the buccal bone defect. Afterwards, the procedure was repeated with the CBCT scans based on a combination of axial and transverse information. For the second part of the study, each observer was asked to evaluate the axial and transverse CBCT slices on the presence or absence of a buccal bone defect. RESULTS: The percentage of buccal bone defect progression rankings that were within 1 of the true rank was 32% for IOR and 42% for CBCT. On average, kappa values increased by 0.384 for CBCT compared to intra-oral radiography. The overall sensitivity and specificity of CBCT in the diagnosis of the presence or absence of a buccal bone defect was 0.89 and 0.85, respectively. The average area under the curve (AUC) of the receiver operating curve (ROC) was 0.892 for all observers. CONCLUSION: When CBCT images are available for justified indications, other than bone level assessment, such 3D images are more accurate and thus preferred to 2D images to assess periodontal buccal bone. For other clinical applications, intra-oral radiography remains the standard method for radiographic evaluation.

A Multi-Centre Randomized Controlled Trial Comparing Connective Tissue Graft with Collagen Matrix to Increase Buccal Soft Tissue Thickness: A Cone-Beam CT Analysis.

(1) Aim: a cross-linked porcine-derived collagen matrix (CMX) has been developed for soft tissue augmentation. Although this grafting material does not require a second surgical site, recent findings have indicated deeper pockets, more marginal bone loss and more midfacial recession in the short term when compared to connective tissue graft (CTG). Hence, the aim of the present study was to evaluate the safety of CMX based on buccal bone loss over a one-year period. (2) Methods: Patients who were missing a single tooth in the anterior maxilla were included, in whom the failing tooth had been removed at least 3 months prior and who presented a horizontal mucosa defect. All sites had a bucco-palatal bone dimension of at least 6 mm as assessed on Cone-Beam Computed Tomography (CBCT) to ensure complete embedding of an implant by bone. All patients received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. All surgeries were performed by means of full thickness mucoperiosteal flap elevation, placing CTG and CMX in contact with the buccal bone wall. Safety was assessed by evaluating the impact of CTG and CMX on buccal bone loss over a one-year period using superimposed CBCT scans. (3) Results: thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48) and 51 (control: 25; test: 26) could be analyzed for buccal bone loss. At 1 mm apical to the implant-abutment interface (IAI), most horizontal resorption was found pointing to 0.44 mm in the control group and 0.59 mm in the test group. The difference of 0.14 mm (95% CI: -0.17-0.46) was not statistically significant (p = 0.366). At 3 mm and 5 mm apical to the IAI, the difference between the groups was 0.18 mm (95% CI: -0.05-0.40; p = 0.128) and 0.02 mm (95% CI: -0.24-0.28; p = 0.899), respectively. Vertical buccal bone loss amounted to 1.12 mm in the control group and 1.14 mm in the test group. The difference of 0.02 mm (95% CI: -0.53-0.49) was not statistically significant (p = 0.926). (4) Conclusions: In the short term, soft tissue augmentation with CTG or CMX results in limited buccal bone loss. CMX is a safe alternative to CTG. Longer follow-up is needed to assess the impact of soft tissue augmentation on buccal bone.

Immediate implant placement with flap or flapless surgery: A systematic review and meta-analysis.

AIM: To assess the impact of mucoperiosteal flap elevation for single immediate implant placement (IIP) on buccal hard and soft tissue changes, and on clinical, aesthetic and patient-reported outcomes. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase and Cochrane databases as well as a manual search to identify eligible clinical studies up to June 2022. Randomized controlled trials (RCTs) comparing IIP without flap elevation to IIP with flap elevation were included for a qualitative and quantitative analysis. The primary outcome was horizontal buccal bone change. Secondary outcomes were implant survival, vertical buccal bone change, pain, and clinical and aesthetic parameters. RESULTS: Out of 1029 records, 5 RCTs were selected reporting on 140 patients who received 140 single immediate implants (flapless: 68; flap: 72). Patients had a mean age ranging from 30 to 67 years and were followed between 6 and 12 months. Four RCTs pertained to (nearly) intact alveoli. Risk of bias assessment yielded low risk for two RCTs and high risk for three RCTs. Meta-analysis demonstrated a mean difference of 0.48 mm (95% confidence interval [CI] [0.13, 0.84], p = .007) in horizontal buccal bone change between surgical approaches, favouring flapless surgery. Meta-analysis failed to demonstrate a significant difference in implant survival between the groups (RR 1.00, 95% CI [0.93, 1.07], p = .920). Given the scarcity of data, meta-analyses could not be performed on other secondary outcomes. Available studies were consistent in the direction of the effect favouring flapless surgery for vertical buccal bone change as well as for pain. Clinical and aesthetic parameters were underreported. CONCLUSIONS: Based on CBCT data, flapless surgery resulted in more buccal bone preservation at immediate implants. However, the clinical relevance of this finding is unclear, since clinical and aesthetic outcomes were underreported.

Adjunctive locally and systemically delivered antimicrobials during surgical treatment of peri-implantitis: A systematic review.

AIM: To answer the following PICOS question: "In patients with peri-implantitis, what is the efficacy of surgical therapy with adjunctive systemic or local antimicrobials, in comparison with surgical therapy alone, in terms of pocket probing depth reduction, as assessed in randomized controlled trials (RCTs) with at least 6 months of follow-up?" MATERIALS AND METHODS: A systematic literature search was conducted. Reduction in mean probing pocket depth (PPD) was the primary outcome. Secondary clinical outcomes were changes in suppuration (%), changes in bleeding on probing (BOP) (%), marginal bone level changes (mm), disease resolution (%), and implant/prosthesis loss (%). Patient-reported outcome measures, possible adverse effects, and oral-health-related quality of life were also extracted if such data were available. RESULTS: Four RCTs assessing the use of locally (two RCTs) and systemically (two RCTs) administered antimicrobial adjuncts to surgical treatment of peri-implantitis, with 6-36-month follow-up, were included. Because of the substantial heterogeneity of interventions between the studies, meta-analysis could not be performed. A reduction in the mean PPD was observed following all the involved surgical treatments, irrespective of the addition of antimicrobials. Except for the effect of systemic antimicrobials on marginal bone level changes and local antimicrobials on BOP, the effect of systemic and local antimicrobials was equivocal for all secondary outcome measures. CONCLUSIONS: Based on the limited available evidence, the adjunctive use of the currently tested systemic or local antimicrobials during surgical therapy, in comparison with surgical therapy alone, in patients with peri-implantitis does not seem to improve the clinical efficacy. With regard the use of systemic antimicrobials, only 50% of the cases showed disease resolution after 1 year. There is a lack of studies that consider the sole use of local antimicrobials. Therefore, their true effect remains unclear.

Screw loosening in angulation-correcting single implant restorations: A systematic review of in vitro studies.

STATEMENT OF PROBLEM: Various options are available to allow angle correction for screw-retained restorations for malaligned implants, including angled abutments, angled screw channel abutments, and angled implants. However, the effect these angle correction components have on prosthetic screw loosening is unclear. PURPOSE: The purpose of this systematic review was to assess the effect of angled abutments, angled screw channel abutments, and angled implants on prosthetic screw loosening. MATERIAL AND METHODS: This manuscript followed the Preferred Reporting Items for the Systematic Review and Meta-Analyses (PRISMA) statement. Searches were performed through 31 December 2021 in PubMed/MEDLINE, EMBASE, and Web of Science with no year limit targeting in vitro studies evaluating the effect of angulation correction components on screw loosening. RESULTS: A total of 460 articles were identified. After removing duplicates, 306 titles were screened. Nine of the remaining 36 articles selected for full-text analysis met the selection criteria. The qualitative analysis used data from 394 implants. All studies featured straight abutments as the control group, and, in 8 studies, the angle correction component was included on the level of the abutment. Only in 1 study was the angle correction component at the level of the implant. The angle correction of the prosthetic component varied from 0 degrees in all studies up to a maximum correction of 30 degrees. Statistically significant increases in screw loosening with increasing abutment angle correction were reported by multiple authors (P<.05). However, other articles reported nonsignificant differences in screw loosening because of angulation after cyclic loading (P>.05). The only study investigating angle correction at the implant level found significantly less screw loosening (P<.05) in the angled implant group compared with the nonangled implant group. CONCLUSIONS: Several options are available to correct discrepancies between the surgical axis and the ideal prosthetic axis for rehabilitations supported by dental implants. The current evidence does not clearly indicate the superiority of any single solution for minimizing screw loosening.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 1-year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) at 1 year when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm, received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. The primary outcome was the increase in BSP at 1 year when compared with the pre-operative situation based on superimposed digital surface models. The changes in BSP over time were registered at a buccal area of interest reaching from 0.5 mm below the soft tissue margin to 4 mm more apical. Secondary outcomes included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50.1; test: 53% females, mean age 48.2). The increase in BSP at 1 year was 0.98 mm (98.3% confidence interval [CI]: 0.75-1.20) for CTG and 0.57 mm (98.3% CI: 0.34 to 0.79) for CMX. The mean difference of 0.41 mm (98.3% CI: 0.12 to 0.69) in favour of CTG was significant (p < .001). Based on an arbitrarily chosen threshold for success of 0.75 mm increase in BSP, 89.7% of the patients in the control group and 10% of the patients in the test group were successfully treated (odds ratio = 77.90; 95% CI: 13.52 to 448.80; p < .001). Sites treated with CMX demonstrated 0.89 mm (98.3% CI: 0.49 to 1.30) more shrinkage between postop and 1 year than sites treated with CTG. In addition, CMX resulted in significantly more marginal bone loss (0.39 mm; 95% CI: 0.05 to 0.74; p = .026) than CTG. There were no significant differences between the groups in terms of patients' aesthetic satisfaction (p = .938), probing depth (p = .917), plaque (p = .354), bleeding on probing (p = .783), midfacial recession (p = .915), Pink Esthetic Score (p = .121) and Mucosal Scarring Index (p = .965). CONCLUSIONS: CTG remains the gold standard to increase soft tissue thickness at implant sites. Clinicians need to outweigh the benefits of CMX against considerable resorption of the graft. This study was registered in ClinicalTrials.gov (NCT04210596).

Immediate implant placement with or without immediate provisionalization: A systematic review and meta-analysis.

AIM: To assess the effect of immediate provisionalization (IP) on soft tissue changes, hard tissue changes, and clinical parameters following single immediate implant placement (IIP). MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to September 2021. Randomized controlled trials (RCTs) comparing IIP with IP (test) and IIP without IP (control) were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue changes. Secondary outcomes included horizontal midfacial soft tissue changes, implant survival, mesial and distal papillary changes, Pink Esthetic Score (PES) at final follow-up, marginal bone-level changes, probing depth at final follow-up, and bleeding on probing at final follow-up. RESULTS: Of the 8213 records, 7 RCTs reporting on 323 patients who received 323 single immediate implants (IIP + IP: 161 implants in 161 patients; IIP: 162 implants in 162 patients) were selected with a mean follow-up ranging from 12 to 60 months. Risk of bias assessment yielded some concerns for five RCTs and high risk for two RCTs. Meta-analysis on the cases with intact alveoli demonstrated 0.87 mm (95% confidence interval [CI] [0.57; 1.17], p < .001) less apical migration of the midfacial soft tissue level for IIP + IP when compared to IIP alone. Implant survival, papillary changes, marginal bone-level changes, probing depth, and bleeding on probing were not significantly affected by IP. Insufficient data were available for meta-analyses on horizontal midfacial soft tissue changes and PES. CONCLUSIONS: IP may contribute to midfacial soft tissue stability at immediate implants. However, high-quality RCTs are needed since the strength of this conclusion is currently rated as low according to GRADE guidelines.

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-month results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of changes over time in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm and received a single implant and immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary outcome was increase in BSP at T1 (immediately after operation) and T2 (3 months) based on superimposed digital surface models. Secondary parameters included patient-reported clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48). Even though surgeons applied thicker grafts when using CMX, sites treated with CMX demonstrated 0.78 mm (95% CI 0.41-1.14) more shrinkage between T1 and T2 than sites treated with CTG. The final increase in BSP was 1.15 mm (95% CI 0.88-1.43) for CTG and 0.85 mm (95% CI 0.58-1.13) for CMX. The mean difference of 0.30 mm (95% CI -0.01 to 0.61) at T2 in favour of CTG was of borderline significance (p = .054). There were no significant differences between the groups in terms of post-operative bleeding (p = .344), pain (p = .331), number of analgesics taken (p = .504), oedema (p = .227), and pink aesthetic score (p = .655). VAS for post-operative haematoma was 6.56 (95% CI 0.54-12.59) lower for CMX, and surgery time could be reduced by 9.03 min (95% CI 7.04-11.03) when applying CMX. However, CMX resulted in significantly more marginal bone loss (0.38 mm; 95% CI 0.15-0.60), deeper pockets (0.30 mm; 95% CI 0.06-0.54), and more mid-facial recession (0.75 mm; 95% CI 0.39-1.12) than CTG. CONCLUSIONS: CTG remains the gold standard for increasing soft tissue thickness at the buccal aspect of implants.

Soft tissue metric parameters, methods and aesthetic indices in implant dentistry: A critical review.

OBJECTIVES: The primary objective was to provide an overview of soft tissue metric parameters, methods, and aesthetic indices in implant dentistry. The secondary objective was to describe reliability and validity of aesthetic indices. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase, and Cochrane databases up to October 2020 to identify studies on soft tissue metric parameters, methods, and aesthetic indices. Aesthetic indices were evaluated in terms of reliability and validity. Data extraction was performed by the same reviewers. RESULTS: Five metric parameters (papilla height, linear changes in soft tissue level, color assessment, soft tissue thickness, and profilometric soft tissue changes) registered by means of several methods (intra-oral registrations, radiographic assessments, digital analyses, and ultrasonic assessments), and 15 aesthetic indices (Papilla Index (PI), ad hoc questions scored with Visual Analogue Scales, Pink Esthetic Score (PES), Implant Crown Aesthetic Index (ICAI), Implant Aesthetic Score (IAS), Rompen Index, Subjective Esthetic Score, White Esthetic Score, Copenhagen Index, Complex Esthetic Index, Californian Dental Association Index (CDAI), Peri-Implant, and Crown Index, Functional Implant Prosthodontic Score, Implant Restoration Esthetic Index (IREI), and Mucosal Scarring Index (MSI)) could be identified. With respect to metric parameters and methods, intra-oral registrations were least accurate whereas profilometric soft tissue changes on the basis of digital surface models were most accurate. Six aesthetic indices showed good inter-rater reliability (PI, PES, ICAI, CDAI, IREI, and MSI). Good validity could only be shown for two indices (PES and CEI). Given this and on the basis of ease of use and ease of interpretation, PES qualified best for clinical research on single implants. None of the indices fulfilled the quality criteria for clinical research on multiple implants. CONCLUSION: Many soft tissue assessment methods with varying reliability and validity have been described and used, which hampers uniform reporting in implant dentistry. Clinical investigators are advised to measure linear and profilometric soft tissue changes using digital surface models, and to use a reliable and validated aesthetic index. Currently, PES qualifies best for aesthetic evaluation of single implants. An index is to be developed to assess the aesthetic outcome of rehabilitations on multiple implants.

A questionnaire-based crossover study on the association of microbiological testing with prescription of systemic antibiotics following initial periodontal therapy.

AIM: (1) To assess prescription of systemic antibiotics following initial periodontal therapy with and without the availability of microbiological information; (2) To identify factors associated with prescription of systemic antibiotics following initial periodontal therapy. MATERIALS AND METHODS: Twenty-four clinicians were invited to complete a questionnaire on 20 patient records with respect to periodontal treatment planning, once with microbiological information available and once without. Randomization determined when the microbiological information was provided, and a 3-month washout period was respected between scoring sessions. Regression analysis was performed to identify factors associated with prescription of systemic antibiotics. RESULTS: Twenty-one clinicians completed both scoring sessions. Clinicians prescribed systemic antibiotics in on average 56% (95% Confidence Interval (CI) [0.51; 0.61]) of the cases having microbiological information, and in 52% (95% CI [0.47; 0.57]) of the same cases not having that information (p = 0.094). The odds for prescribing systemic antibiotics were 3.34 (95% CI [2.06; 5.42]) times higher when the clinician had at least 3 years of experience, 2.55 (95% CI [1.40; 4.66]) times higher for patients diagnosed with periodontitis stage IV when compared to stage III, 1.08 (95% CI [1.04; 1.11]) times higher for younger patients, 2.78 times (95% CI [1.37; 5.56]) times higher for non-smokers and 2.22 (95% CI [1.27; 3.85]) times higher when less than three teeth would require extraction. No significant associations with the prescription of systemic antibiotics were found for detection of A.actinomycetemcomitans (p = 0.287), grade of periodontitis (p = 0.499) and gender of the patient (p = 0.067). CONCLUSIONS: Based on a limited number of cases and clinicians, several patient and clinician related factors were associated with prescription of systemic antibiotics following initial periodontal therapy. However, microbiological testing was not.

A controlled study on the diagnostic accuracy of panoramic and peri-apical radiography for detecting furcation involvement.

BACKGROUND: The aims of this study were (1) to determine the accuracy, sensitivity, and specificity of panoramic and peri-apical radiographs in diagnosing furcation involvement, as well as (2) to evaluate the possible impact of clinical experience on these diagnostic parameters. METHODS: An existing radiographic dataset of periodontitis patients requiring implant surgery was retrospectively examined for furcation involvement. Criteria for inclusion were the presence of a CBCT, panoramic and peri-apical radiograph of the site of interest within a one-year time frame. All furcation sites were classified using the CBCT, which was considered as the gold standard, according to Hamp's index (1975). Ten experienced examiners and 10 trainees were asked to assess furcation involvement for the same defects using only the corresponding panoramic and peri-apical radiographs. Absolute agreement, Cohen's weighted kappa, sensitivity, specificity and ROC-curves were analyzed. RESULTS: The study sample included 60 furcation sites in 29 multi-rooted teeth from 17 patients. On average, 20/60 furcations were correctly classified according to the panoramic radiographs, corresponding to a weighted kappa score of 0.209, indicating slight agreement. Similarly, an average of 19/60 furcations were correctly classified according to the peri-apical radiographs, corresponding to a weighted kappa score of 0.211, also indicating slight agreement. No significant difference between panoramic and peri-apical radiography was found (P = 0.903). When recategorizing FI Grades into 'no to limited FI' (FI Grade 0 and I) and 'advanced FI' (FI Grade II and III), the panoramic and peri-apical radiography showed low sensitivity (0.558 and 0.441, respectively), yet high specificity (0.791 and 0.790, respectively) for identifying advanced FI. The ROC-curves for the panoramic and peri-apical radiographs were 0.79 and 0.69 respectively. No significant difference was found between experienced periodontists and trainees (P = 0.257 versus P = 0.880). CONCLUSION: Panoramic and peri-apical radiography are relevant tools in the diagnosis of FI and provide high specificity. Ideally, they are best used in combination with furcation probing, which shows high sensitivity. Furthermore, clinical experience does not seem to improve the accuracy of a radiological diagnosis of furcation sites. TRIAL REGISTRATION: Patient radiographic datasets were retrospectively analyzed.

A 5 to 7-year case series on single angulated implants installed following papilla-sparing flap elevation.

BACKGROUND: Bony concavities at the buccal aspect may cause a distortion between the implant axis and ideal prosthetic axis. Angulated implants can overcome this problem, yet long-term data are lacking. In addition, papilla-sparing incisions have been proposed to reduce tissue loss, yet aesthetic outcomes have not been published. PURPOSE: To evaluate the 5 to 7-year outcome of single angulated implants installed following papilla-sparing flap elevation. MATERIALS AND METHODS: Patients who had been consecutively treated with a single angulated implant (Co-axis®, Southern Implants, Irene, South Africa) in the anterior maxilla were re-examined after 5 to 7 years. Available data at 1 year (T1) were compared to those obtained at 5 to 7 years (T2). RESULTS: Twenty out of 22 treated patients (11 females, 9 males, mean age of 52) with 22 implants attended the 5 to 7-year reassessment. All implants survived and stable clinical conditions could be reached with mean marginal bone loss of 1.28 mm at T2. Papilla-sparing flap elevation resulted in Pink Esthetic Score of 9.83 at T1 and 8.23 at T2 (p = 0.072). Mucosal Scarring Index was 4.61 at T1 and 3.50 at T2 (p = 0.165). The overall appearance of scarring significantly improved over time (p = 0.032), yet 59% of the cases still demonstrated scarring at T2.c CONCLUSIONS: Within the limitations of the study, angulated implants (Co-axis®, Southern Implants) reached stable clinical conditions. Papilla-sparing incisions may not be recommended in aesthetically demanding patients due to high risk of scarring.

A one-year prospective study on alveolar ridge preservation using collagen-enriched deproteinized bovine bone mineral and saddle connective tissue graft: A cone beam computed tomography analysis.

BACKGROUND: Although there is ample research on alveolar ridge preservation (ARP), changes of the soft tissue profile are seldom reported. In addition, the use of a saddle connective tissue graft (S-CTG) has only been described in one study. PURPOSE: To evaluate changes in bone and external soft tissue profile following ARP of intact and nonintact sockets using collagen-enriched deproteinized bovine bone mineral (C-DBBM) and a S-CTG (a); to assess the need for additional hard and soft tissue grafting after ARP (b). MATERIALS AND METHODS: Patients in need of a single or multiple unit fixed reconstruction in the premaxilla were included in this prospective case series. After tooth extraction, sockets were grafted with C-DBBM and sealed with a S-CTG. Cone beam computed tomography slides taken before tooth extraction and 4 to 6 months after ARP were superimposed to measure changes in bone dimensions and external soft tissue profile. The need for additional hard and soft tissue grafting was registered. Implants were evaluated at 1 year. Patient-reported outcomes were registered on a 100 mm visual analogue scale at suture removal and 1 year following ARP. RESULTS: Nineteen teeth (10 with intact sockets, 9 with nonintact sockets) in 14 patients (11 females; mean age 34) were extracted and treated with the abovementioned protocol. Volume loss could not be prevented and mainly occurred at the buccal aspect. Maximum horizontal bone resorption was 1.27 mm and maximum horizontal shrinkage of the soft tissue profile amounted to 0.87 mm, both at the most cervical aspect. Additional GBR was necessary in two sites with a nonintact buccal bone wall. The need for additional soft tissue grafting was moderate in sites with intact (3/10) and high in nonintact sockets (6/9). Implants demonstrated favorable clinical and esthetic outcomes. Pain intensity and patient satisfaction were 17 and 94, respectively. CONCLUSION: Alveolar ridge preservation was not able to prevent relevant tissue changes. However, implants could be installed as planned. Although the application of a S-CTG partly compensated for the buccal bone loss, the need for additional soft tissue grafting was still moderate in intact sockets and high in nonintact sockets.

Clinical Guidelines for Implant Treatment in Patients with Down Syndrome.

This study evaluated implant outcome in patients with Down syndrome (DSPs) and provides clinical guidelines to maximize treatment outcome. A total of 57 implants were placed in eight DSPs. During follow-up, implant survival was recorded and crestal bone level was evaluated when possible. After a mean follow-up time of 5 years, six patients with 45 implants were evaluated and an implant survival rate of 84.4% was recorded. A mean crestal bone loss of 1.7 mm (SD 0.9) was measured in three patients around 20 implants. Down syndrome is not a contraindication to dental implant placement, but multiple complicating factors yield reduced implant survival.

A controlled study on the accuracy and precision of intraoral radiography in assessing interproximal bone defect morphology around teeth and implants.

PURPOSE: The primary objective of the present controlled study was to determine the accuracy and precision of intraoral radiography in assessing interproximal bone defect morphology in patients suffering from periodontal disease as well as in patients with peri-implantitis. A secondary objective was to evaluate the possible impact of clinical experience on accuracy and precision. MATERIALS AND METHODS: The study sample comprised a total of 99 interproximal bony defects (40 patients) needing surgical treatment. Forty-nine defects were periodontal (17 patients), while the remaining 50 were peri-implant defects (23 patients). Following reflection of a mucoperiosteal flap and removal of granulation tissue, the type of bone defect as classified by Goldman and Cohen (1958) was determined. This intrasurgical registration was considered the true bone defect morphology. An intraoral radiograph was taken for each interproximal site. Twenty clinicians determined the bone defect morphology on each intraoral radiograph twice, with a washout period of 3 months. RESULTS: Using the Goldman and Cohen (1958) classification, the overall accuracy of intraoral radiography in assessing interproximal bone defect morphology was slight for teeth/implants (κ = 0.132; 95% CI: 0.091 to 0.173/κ = 0.126; 95% CI: 0.091 to 0.162). Duplicate evaluation indicated fair precision (κ = 0.369; 95% CI: 0.308 to 0.430/κ = 0.355; 95% CI: 0.230 to 0.414). Pooling one-, two- and three-wall defects into one category had a positive impact on accuracy (κ = 0.254; 95% CI: 0.201 to 0.307/κ = 0.387; 95% CI: 0.340 to 0.435), as well as on precision (κ = 0.504; 95% CI: 0.423 to 0.584/κ = 0.560; 95% CI: 0.463 to 0.657). A significant difference between experienced clinicians and trainees was not found (P ≥ 0.285). CONCLUSIONS: Intraoral radiography lacks accuracy for assessing interproximal bone defect morphology around teeth and implants. Clinical experience does not seem to influence this.

Adapting the vertical position of implants with a conical connection in relation to soft tissue thickness prevents early implant surface exposure: A 2-year prospective intra-subject comparison.

AIM: To evaluate the effect of soft tissue thickness on bone remodelling and to investigate whether implant surface exposure can be avoided by adapting the vertical implant position in relation to the soft tissue thickness. MATERIALS AND METHODS: Twenty-five patients received two non-splinted implants supporting an overdenture in the mandible. Soft tissue thickness was measured using bone sounding and ultrasonically. One implant was installed equicrestally (control), and the vertical position of the second implant was adapted to the site-specific soft tissue thickness (test). Crestal bone levels were determined on digital peri-apical radiographs and compared with baseline (implant placement). RESULTS: Twenty-five patients were consecutively treated. No implants failed during the follow-up. A significant correlation was observed between soft tissue thickness and bone level alterations after 6 months (ultrasound ICC = 0.610; bone sounding ICC = 0.641) with inferior bone levels for equicrestal implants when thin tissues are present. Subcrestal implants showed significantly better bone levels after 6-month (n = 24, 0.04 mm versus 0.72 mm; p < .001), 1-year (n = 24, 0.03 mm versus 0.77 mm; p < .001) and 2-year follow-up (n = 24, 0.04 mm versus 0.73 mm; p < .001). CONCLUSION: Initial bone remodelling was affected by soft tissue thickness. Anticipating biologic width re-establishment by adapting the vertical position of the implant seemed highly successful to avoid implant surface exposure.