Simultaneous or staged lateral ridge augmentation: A clinical guideline on the decision-making process.

Lateral ridge augmentation is a standard surgical procedure that can be performed prior to (staged) or simultaneously with implant placement. The decision between a simultaneous or staged approach involves considering multiple variables. This paper proposed a decision-making process that serves as a guideline for choosing the best treatment choice based on the available evidence and the author's clinical experience.

Periodontal staging and grading: An international dental hygiene education survey.

OBJECTIVES: The 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions ushered in a new paradigm for assessing and classifying periodontal diseases. This has significant implications for dental hygiene (DH) education programs' curricula. The purpose of this international survey was to assess: if and how accredited DH education programs were integrating the new staging and grading system into their curricula, and program directors' perceptions of the barriers and benefits to integration and teaching it. METHODS: This study was deemed exempt from IRB oversight. A total of 339 undergraduate DH program directors from the US, Canada and Australia that had similar accreditation standards were recruited for the survey. An electronic survey was developed and disseminated via QualtricsXM . Survey design included demographics and other questions to assess program directors' knowledge, understanding, integration of and barriers to implementing the new staging and grading system into their curricula. RESULTS: A total of 140 surveys were completed, for a response rate of 42%. Results showed that 91% of DH education programs had integrated the new staging and grading system into their curricula. DH didactic/theory courses (99%) and clinical courses (94%) were the curricular areas hosting the content. There was a statistically significant difference in the confidence of teaching the staging and grading system across institutional settings (p = 0.02). The three main benefits identified were the consideration of expected disease progression (3.25 ± 2.06), individual risk factors (3.45 ± 1.73) and personalized treatment (4.04 ± 2.20). The most frequently reported barrier was the lack of faculty support (26%). CONCLUSION: DH educators have implemented the new staging and grading system into their clinical and didactic curricula. DH educators valued the individual, patient-specific components of the new system. While educators were confident in integrating the new system, those at community and technical colleges were less confident in teaching the system.

An Updated Decision Tree for Horizontal Ridge Augmentation: A Narrative Review.

Horizontal ridge augmentation is a common surgical procedure performed prior to or simultaneously with implant placement, depending on the extent of the ridge deficiency. Many horizontal augmentation surgical options have been developed, spanning a wide range of materials and techniques. Given the numerous permutations available, the most suitable strategy to regenerate ridge width for an individual case often confounds clinicians. Based on an extensive review of the literature, this article provides up-to-date technique selection guidelines, in the form of a decision tree, for predictable horizontal bone augmentation dependent on the amount of bone gain needed.

Split-Thickness Flap for the Management of a Maxillary Sinus Wall Bony Fenestration During Lateral Window Sinus Augmentation: Case Reports and Technical Surgical Notes.

Maxillary sinus wall fenestration at the lateral wall or floor of the sinus can result from many potential factors, such as the repair of oro-antral communication, Caldwell-Luc antrostomy, tooth extraction after an endodontic or periodontal infection that eroded the sinus wall, and the combination of sinus pneumatization and alveolar ridge resorption after teeth removal. When sinus wall fenestration is observed on radiographs, it usually indicates adhesion between the sinus membrane and buccal flap, which makes the reentry surgery for subsequent sinus augmentation challenging. To minimize surgical complications in these challenging scenarios, this paper presents a split-flap surgical technique for the management of soft tissue adhesion between the sinus membrane and alveolar mucosa when attempting a lateral window sinus augmentation.

Amnion-Chorion Membrane in Open-Wound Approach for Localized Horizontal Ridge Augmentation: A Case Series Report.

INTRODUCTION: Guided bone augmentation often requires extensive releasing of the mucoperiosteal flap to achieve primary wound closure, an invasive procedure that can compromise the keratinized tissue volume and increase patient morbidity. Amnion-chorion membranes have been used to actively promote healing in chronic open-wound situations in the medical field, suggesting that they could be used in a similar manner in the oral cavity.The ability to use open-wound healing techniques for guided bone regeneration would allow clinicians to avoid invasive procedures that cause additional tissue trauma at the surgical site. CASE SERIES: Amnion-chorion membranes were applied over the bone grafting material augmenting localized horizontal ridge defects, and a gap between the flaps was left intentionally during healing. Minor flap releasing procedures were performed in these cases, which demonstrated uneventful soft tissue healing, good volume of bone regeneration and preserved keratinized tissue. CONCLUSIONS: Preliminary clinical outcomes suggested contained minor horizontal ridge defects may be treated satisfactorily in a controlled, open-wound healing manner that reduces surgical trauma, chair time, and patient morbidity.

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINE FOR TREATMENT OF STAGE IIII PERIODONTITIS.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Berglund T, Sculean A, Tonetti MS; EFP Workshop Participants and Methodological Consultants. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020 Jul;47 Suppl 22:4-60. doi: 10.1111/jcpe.13290. PMID: 32,383,274. SOURCE OF FUNDING: Internal funds of the European Federation of Periodontology. TYPE OF STUDY/DESIGN: Clinical guideline and recommendations developed based on 15 systematic reviews and consensus from the experts in the field of periodontology.

Diagnosis of Stage III Periodontitis and Ambiguities of the "Gray Zones" in Between Stage III and Stage IV.

INTRODUCTION: How to best classify the Stage III and IV periodontitis cases that share common features of the most severe clinical attachment loss and the most severe radiographic bone loss? CASE PRESENTATION: Two patients presented features of generalized periodontitis, with severe probing depth and clinical attachment loss that would meet inclusion in both Stage III and IV. The cases retained all teeth but were further complicated by teeth drifting and secondary occlusal trauma. Appropriate disease classification required clinical judgement and led to the final classification of Stage III, Grade C for both cases. CONCLUSION: Patient-based clinical judgement, aiming for long-term preservation of natural dentition, drives the final assignment of staging when the case falls in the "gray zone" that focuses on major differences in Stage III and IV periodontitis.

Challenges and Decision Making for the Classification of Two Complex Periodontal Cases.

FOCUSED CLINICAL QUESTION: What are the fundamental debates and questions related to the newly developed two-vector system for classification of periodontal diseases that have emerged as to how to accurately assign, stage, and grade periodontitis cases? The aim of the present manuscript is to demonstrate the essential thought processes that are needed in utilizing the new periodontitis classification system to diagnose two gray zone cases. SUMMARY: Clinical case 1 includes an 83-year-old male diagnosed with periodontitis and classified as Stage III Generalized Grade B periodontitis, while clinical case 2, a 73-year-old male was classified as presenting Stage IV Generalized Grade B periodontitis. Although clinical and radiographic evaluations revealed similarities between the cases, the thought process that includes clinical judgment is described to guide a more accurate diagnosis following the guidelines of the new classification system. CONCLUSION: The two cases demonstrated here offer an opportunity for clinicians to recognize the essential role of sound clinical judgment in certain cases when applying the new periodontal disease classification system and also clarify questions emerging from implementing this classification system.

Maxillary Sinus Elevation Difficulty Score with Lateral Wall Technique.

Maxillary sinus augmentation is a procedure commonly performed in patients in need of posterior maxillary implants with limited vertical ridge height and sinus pneumatization. However, minimal information has been presented to evaluate the complexity of the sinus elevation procedure via a lateral window approach based on patient examination, including extraoral findings, anatomical factors, and the possible influence from the surgeon's experience. Therefore, this article presents a new scheme of maxillary sinus floor elevation difficulty score based on comprehensive patient- and surgical-related factors. The proposed scoring tool aims to aid surgeons in performing a comprehensive presurgical evaluation prior to the lateral wall sinus augmentation surgery and also enhance communication between clinicians and patients regarding the complexity of the case.

Peri-implant Soft Tissue Management: Cairo Opinion Consensus Conference.

Peri-implant soft tissues play a role of paramount importance, not only on the esthetic appearance, but also on the maintenance and long-term stability of implants. The present report presents the conclusions from the Consensus Conference of the South European North African Middle Eastern Implantology & Modern Dentistry Association (SENAME) (4-6 November 2016, Cairo, Egypt). The conference focused on the topic of the soft tissue around dental implants, and in particular, on the influence of implant configurations on the marginal soft tissues, soft tissue alterations after immediate, early or delayed implant placement and immediate loading, the long-term outcomes of soft tissue stability around dental implants, and soft tissue augmentation around dental implants. Thirty world experts in this field were invited to take part in this two-day event; however, only 29 experts were in the final consensus voting process.

Perforation Risk Assessment in Maxillary Sinus Augmentation with Lateral Wall Technique.

Maxillary sinus augmentation is a procedure commonly performed in patients in need of maxillary posterior implants with loss of vertical ridge height and sinus pneumatization. Previous studies have identified some factors associated with sinus membrane perforation during lateral-wall sinus elevation procedures. Although membrane perforation does not directly link to future implant failure, it has been shown to have an association with postoperative complications. In order to promote more predictable results and reduce complications during the sinus elevation procedure, especially for the lateral window approach, articles published in peer-reviewed journals were reviewed to support the proposal of a new risk-evaluation system prior to the sinus surgery. This article reviews anatomical and patient-related factors that might affect the risk of perforation during the surgery and also aims to provide a risk assessment table to enable clinicians to analyze these factors prior to the lateral sinus augmentation surgery.

Is periodontal phenotype modification therapy beneficial for patients receiving orthodontic treatment? An American Academy of Periodontology best evidence review.

BACKGROUND: Orthodontic treatment can greatly impact the periodontium, especially in dentitions with a thin periodontal phenotype. Orthodontic tooth movement can result into iatrogenic sequelae to these vulnerable anatomic conditions, such as development and exacerbation of bony dehiscence or fenestration defects, which can manifest loss of periodontal support and gingival recession (GR). This systematic review aimed to investigate whether periodontal phenotype modification therapy (PhMT) involving hard tissue augmentation (PhMT-b) or soft tissue augmentation (PhMT-s) has clinical benefits for patients undergoing orthodontic treatment. METHODS: An electronic search was performed in two major databases for journals published in English language from January 1975 to January 2019 and a hand search of printed journals was also performed to identify human clinical trials reporting clinical and radiographic outcomes of patients receiving orthodontic treatment with or without hard and soft tissue augmentation procedures. Data were extracted and organized into tables for qualitative assessment. RESULTS: Eight studies were identified evaluating the outcomes of PhMT in patients undergoing orthodontic therapy. Six studies evaluated patients receiving PhMT-b via corticotomy-assisted orthodontic therapy (CAOT) and simultaneous bone augmentation while the other two received PhMT-s before tooth movement. No studies investigated PhMT-b alone without CAOT and most studies focused on the mandibular anterior decompensation movements. There was high heterogeneity in the study design and inconsistency of the reported outcomes; therefore, a meta-analysis was not performed. Evidence at this moment supports CAOT with hard tissue augmentation accelerated tooth movement. However, only two studies provided direct comparison to support that CAOT with PhMT-b reduced the overall treatment time compared with conventional orthodontic treatment. No periodontal complications or evidence of severe root resorption were reported for both groups. Four studies provided radiographic assessment of the PhMT-b and demonstrated increased radiographic density or thicker facial bone after the treatment. Two studies reported an expanded tooth movement. One study reported an increase in keratinized tissue width post-CAOT plus PhMT-b, while another study with a 10-year follow-up showed a lower degree of relapse using the mandibular irregularity index when compared with conventional tooth movement alone. Two studies examined the effect of PhMT-s before orthodontic treatment. Unfortunately, no conclusions can be drawn because of the limited number of studies with contradicting outcomes. CONCLUSIONS: Within the limited studies included in this systematic review, PhMT-b via particulate bone grafting together with CAOT may provide clinical benefits such as modifying periodontal phenotype, maintaining or enhancing facial bone thickness, accelerating tooth movement, expanding the scope of safe tooth movement for patients undergoing orthodontic tooth movement. The benefits of PhMT-s alone for orthodontic treatment remain undetermined due to limited studies available. However, PhMT-b appears promising and with many potential benefits for patients undergoing orthodontic tooth movement. There is a need for a higher quality of randomized controlled trials or case control studies with longer follow-up to investigate the effects of different grafting materials and surgical sites other than mandibular anterior region.

Quantitative tooth mobility evaluation based on intraoral scanner measurements.

BACKGROUND: Tooth mobility assessment is subjective and current techniques require the translation of a continuous variable to a categorical variable based on the perception of the examiner. The aim of this study was to evaluate the reliability of a novel technique to assess tooth mobility. METHODS: Three experienced periodontists were asked to push tooth #16 into a buccal position to in a typodont model with different mobility (M1-M2). Tooth position was obtained using an intraoral scanner and files were compared in metrology software. Mobility was calculated at three reference points at the cervical (C), middle (M), and occlusal (O) regions of the buccal surface of the tooth to determine the linear deviation in the three axes (x, y, and z). Reliability was determined by intraclass-correlation coefficient, differences between M1 and M2 determined by t test, and the analysis of variance (ANOVA) was used to compare the data at the C-M-O regions. RESULTS: Excellent reliability was assessed by Cronbach alpha >0.9 on the x-y-z axes for both mobility tested, except for M1-C X (0.85), M1-M Y (0.89), and M2-M Z (0.89). The correlation between the examiners demonstrated excellent (˃0.90) or good (0.75˃ x ˂0.90) consistency, except for M1-C Y (0.73; examiner 1 to 2) and M1-M X (0.69; examiners 1 to 3). Significant changes were detected in all axes at the three reference points comparing M1 and M2, and a similar proportional change was observed between O-M-C reference points for M1 and M2. CONCLUSION: A novel technique to assess tooth mobility based on intraoral scanner measurements provided reliable data in an in vitro experiment.

Classification of Soft Tissue Grafting Materials Based on Biologic Principles.

Since periodontal plastic surgery's recent emergence and continuous, extensive development, various treatment modalities and materials have been developed alongside it to help clinicians pursue optimal esthetics and long-term stability around natural teeth and dental implants. To achieve satisfying and predictable long-term outcomes, promote more predictable results, and reduce complications following periodontal plastic surgery procedures, the authors reviewed articles published in peer-reviewed journals to better understand the biologic principles and potential of the soft tissue grafting materials and techniques being applied. That information was used to support a new classification system. This system aims to give clinicians guidance when selecting the most appropriate grafting materials and techniques for periodontal plastic surgery, using the graft materials' two most important features to guide the consideration/decision process: the source of blood supply and whether the grafts contain vital cells.

Sclerostin-Neutralizing Antibody Enhances Bone Regeneration Around Oral Implants.

BACKGROUND: Dental implants are an important option for replacement of missing teeth. A major clinical challenge is how best to accelerate bone regeneration and reduce the healing time for functional restoration after implant placement. A sclerostin-neutralizing antibody (Scl-Ab) has been shown to enhance alveolar bone formation and fracture repair. The aim of this study was to investigate the effects of systemic administration of Scl-Ab on dental implant osseointegration and bone regeneration in an experimental alveolar ridge tooth extraction model. MATERIALS AND METHODS: To investigate the effects of Scl-Ab on bone regeneration and dental implant osseointegration, an experimental alveolar bone osteotomy rat model was adopted. One month after extraction of maxillary right first molars, osteotomy defects were created at the coronal aspect of each of the extraction sites, and 1 × 2-mm custom titanium implants were installed into the osteotomies. Coincident with implant placement, Scl-Ab was administered subcutaneously at a dose of 25 mg/kg twice weekly for 10-28 days and compared with a vehicle control. Animals were sacrificed 10, 14, and 28 days after surgery, and maxillae were harvested and analyzed by microcomputed tomography (microCT), histology, and histomorphometry. RESULTS: microCT analysis demonstrated that the maxillary bone volume fraction was approximately 2- to 2.5-fold greater in Scl-Ab-treated animals compared with vehicle alone at days 14 and 28. Consistent with those findings, two-dimensional bone fill percentages within the coronal osteotomy sites were highest in Scl-Ab treatment groups at 28 days. In addition, bone-implant contact at 28 days was approximately twofold greater in the Scl-Ab group compared with the vehicle control. CONCLUSIONS: These results indicate that systemic Scl-Ab administration enhances osseointegration and bone regeneration around dental implants. This approach offers potential as a treatment modality for patients with low bone mass or bone defects to achieve more predictable bone regeneration at alveolar bone defects and to enhance dental implant osseointegration.

Periodontal Tissue Bioengineering: Is the Future Now?

Periodontitis affects nearly half of the adult population in the United States and leads to periodontium destruction, tooth loss, and tooth mobility. Novel bioengineering has become an area of interest in dentistry, as various approaches aim to regenerate attachment apparatus around diseased teeth with the use of barriers, scaffolds, bone grafts, or biologics. This article emphasizes recent findings in the fields of stem cell/gene therapy, 3-dimensional printing, and innovative scaffold designs for future applications in clinical care.

Non-Surgical Therapy for Peri-Implant Diseases: a Systematic Review.

OBJECTIVES: The purpose of this paper was to systematically evaluate the effectiveness of non-surgical therapy for the treatment of peri-implant diseases including both, mucositis and peri-implantitis lesions. MATERIAL AND METHODS: An electronic search in two different databases was performed including MEDLINE (PubMed) and EMBASE from 2011 to 2016. Human studies reporting non-surgical treatment of peri-implant mucositis and peri-implantitis with more than 10 implants and at least 6 months follow up published in English language were evaluated. A systematic review was performed to evaluate the effectiveness of the different methods of decontamination employed in the included investigations. Risk of bias assessment was elaborated for included investigations. RESULTS: Twenty-five articles were identified of which 14 were further evaluated and included in the analysis. Due to significant heterogeneity in between included studies, a meta-analysis could not be performed. Instead, a systematic descriptive review was performed. Included investigations reported the used of different methods for implant decontamination, including self-performed cleaning techniques, and professionally delivered treatment such as laser, photodynamic therapy, supra-/sub-mucosal mechanical debridement, and air-abrasive devices. Follow-up periods ranged from 6 to 60 months. CONCLUSIONS: Non-surgical treatment for peri-implant mucositis seems to be effective while modest and not-predictable outcomes are expected for peri-implantitis lesions. Limitations include different peri-implant diseases definitions, treatment approaches, as well as different implant designs/surfaces and defect characteristics.

The 1st Baltic Osseointegration Academy and Lithuanian University of Health Sciences Consensus Conference 2016. Summary and Consensus Statements: Group III - Peri-Implantitis Treatment.

INTRODUCTION: The task of Group 3 was to review and update the existing data concerning non-surgical, surgical non-regenerative and surgical regenerative treatment of peri-implantitis. Special interest was paid to the preventive and supporting therapy in case of peri-implantitis. MATERIAL AND METHODS: The main areas of interest were as follows: effect of smoking and history of periodontitis, prosthetic treatment mistakes, excess cement, overloading, general diseases influence on peri-implantitis development. The systematic review and/or meta-analysis were registered in PROSPERO, an international prospective register of systematic reviews: http://www.crd.york.ac.uk/PROSPERO/. The literature in the corresponding areas of interest was searched and reported using the PRISMA (Preferred Reporting Item for Systematic Review and Meta-Analysis) Statement: http://www.prisma-statement.org/. The method of preparation of systematic reviews of the literature based on comprehensive search strategies was discussed and standardized. The summary of the materials and methods employed by the authors in preparing the systematic review and/or meta-analysis is presented in Preface chapter. RESULTS: The results and conclusions of the review process are presented in the respective papers. The group's general commentaries, consensus statements, clinical recommendations and implications for research are presented in this article.

pH-Responsive Hydrogel With an Anti-Glycation Agent for Modulating Experimental Periodontitis.

BACKGROUND: Stimulus-responsive devices have emerged as a novel approach for local drug delivery. This study investigates the feasibility of a novel chitosan-based, pH-responsive hydrogel loaded with N-phenacylthiazolium bromide (PTB), which cleaves the crosslinks of advanced glycation end products on the extracellular matrix. METHODS: A chitosan-based hydrogel loaded with PTB was fabricated, and the in vitro release profile was evaluated within pH 5.5 to 7.4. BALB/cJ mice and Sprague-Dawley rats were used to evaluate the effects during the induction and recovery phases of periodontitis, respectively, and animals in each phase were divided into four groups: 1) no periodontitis induction; 2) ligature-induced experimental periodontitis (group PR); 3) experimental periodontitis plus hydrogel without PTB (group PH); and 4) experimental periodontitis plus hydrogel with PTB (group PP). The therapeutic effects were evaluated by microcomputed tomographic imaging of periodontal bone level (PBL) loss and histomorphometry for inflammatory cell infiltration and collagen density. RESULTS: PTB was released faster at pH 5.5 to 6.5 and consistently slower at pH 7.4. In the induction phase, PBL and inflammatory cell infiltration were significantly reduced in group PP relative to group PR, and the loss of collagen matrix was significantly reduced relative to that observed in group PH. In the recovery phase, PBL and inflammatory cell infiltration were significantly reduced, and significantly greater collagen deposition was noted in group PP relative to groups PR and PH at 4 and 14 days after silk removal. CONCLUSION: Chitosan-based, pH-responsive hydrogels loaded with PTB can retard the initiation of and facilitate the recovery from experimental periodontitis.