Stress Ulcer Prophylaxis Versus Placebo-A Blinded Pilot Randomized Controlled Trial to Evaluate the Safety of Two Strategies in Critically Ill Infants With Congenital Heart Disease.

OBJECTIVES: The routine use of stress ulcer prophylaxis (SUP) in infants with congenital heart disease (CHD) in the cardiac ICU (CICU) is controversial. We aimed to conduct a pilot study to explore the feasibility of performing a subsequent larger trial to assess the safety and efficacy of withholding SUP in this population (NCT03667703). DESIGN, SETTING, PATIENTS: Single-center, prospective, double-blinded, parallel group (SUP vs. placebo), pilot randomized controlled pilot trial (RCT) in infants with CHD admitted to the CICU and anticipated to require respiratory support for greater than 24 hours. INTERVENTIONS: Patients were randomized 1:1 (stratified by age and admission type) to receive a histamine-2 receptor antagonist or placebo until respiratory support was discontinued, up to 14 days, or transfer from the CICU, if earlier. MEASUREMENTS AND MAIN RESULTS: Feasibility was defined a priori by thresholds of screening rate, consent rate, timely drug allocation, and protocol adherence. The safety outcome was the rate of clinically significant upper gastrointestinal (UGI) bleeding. We screened 1,426 patients from February 2019 to March 2022; of 132 eligible patients, we gained informed consent in 70 (53%). Two patients did not require CICU admission after obtaining consent, and the remaining 68 patients were randomized to SUP (n = 34) or placebo (n = 34). Ten patients were withdrawn early, because of a change in eligibility (n = 3) or open-label SUP use (n = 7, 10%). Study procedures were completed in 58 patients (89% protocol adherence). All feasibility criteria were met. There were no clinically significant episodes of UGI bleeding during the pilot RCT. The percentage of patients with other nonserious adverse events did not differ between groups. CONCLUSIONS: Withholding of SUP in infants with CHD admitted to the CICU was feasible. A larger multicenter RCT designed to confirm the safety of this intervention and its impact on incidence of UGI bleeding, gastrointestinal microbiome, and other clinical outcomes is warranted.

Clinical management of vital and non-vital discolored tooth preparation stump shades: A clinical case series.

OBJECTIVE: Traditional and modern-day laboratory techniques can be used to mask vital and non-vital discolored teeth. CLINICAL CONSIDERATIONS: Two clinical case reports are presented showing different treatment approaches to differing clinical scenarios of partial coverage veneer and full coverage crown restorations, respectively. CONCLUSIONS: Feldspathic ceramics should be considered when customization of stump shade correction and equalization is required with minimum facial reduction with veneer restorations. Translucent zirconia (5 mol% Y2 O3 ) can be used to mask metal posts and core restorations on non-vital teeth using an opaquer material that is infused into the intaglio surface in the green state. CLINICAL SIGNIFICANCE: Different clinical scenarios will present to the clinician in regard to discolored stump shades where understanding what laboratory material treatment options are available that will help guide definitive restoration types and ultimately tooth preparation design.

Contemporary concepts on periodontal complications from prosthetic and restorative therapies.

The clinical outcome of every prosthetic and restorative procedure depends on the maintenance of a healthy periodontium. It is, therefore, important that the prosthodontist and restorative dentist cause no harm or permanent damage to the underlying hard and soft tissues when performing clinical procedures necessary to carry out the planned treatment. Several factors involved in these procedures have been described to have an impact on gingival health. For the present article, a selection of four of these factors are presented with the goal of evaluating the current trends and their influence on periodontal structures: (1) tooth preparation configuration and apical extension, (2) gingival tissue sulcular expansion/retraction, (3) prosthetic contours, and (4) prosthesis marginal adaptation and the consequences of excess cement remnants. Based on the available scientific evidence and clinical experience, recommendations for the practitioner are given.

A comparative analysis of dual-axis implants placed into maxillary anterior extraction sockets versus virtual planning with uniaxial implants: A simulated cone beam computed tomography study of implant length and diameter.

OBJECTIVE: The biaxial nature of the anterior maxilla poses a surgical and restorative challenge in implant dentistry. The present study sought to investigate the apical socket perforation rate (ASPR) from a simulated uniaxial implant placement and to determine the effect of implant length and diameter on ASPR when a uniaxial implant was placed compared with the orientation of the pre-existing dual-axis implant. MATERIAL AND METHOD: Cone beam computed tomography (CBCT) scans from the database of three private practices were searched for patients who received dual-axis implants within the esthetic zone in immediate tooth replacement therapy. A uniaxial implant was virtually placed using the pre-existing screw access channel of the dual-axis implant as a reference. The closest length and diameter were selected for the simulated implant. ASPR by the uniaxial implant was recorded. In addition, the affordable maximum length of a corresponding uniaxial implant that would avoid apical socket perforation was measured. RESULT: Eighty-one patients with a total of 101 dual-axis dental implants were selected for analysis. A simulated virtual surgical planning with uniaxial implants revealed high ASPR (48.51%). When the length of the uniaxial implant was reduced to 11 and 9 mm, ASPR was decreased to 41.58% and 20.79%, respectively. CONCLUSION: Dual-axis implant design effectively evades anatomical challenges in the anterior maxilla (esthetic zone). Considering the current evidence, efforts should be made to carefully consider the angular disparity between the extraction socket-alveolus complex and the future restorative emergence so that a harmonious biologic-esthetic result may be more predictably and consistently obtained.

Patient-Customized Oligonucleotide Therapy for a Rare Genetic Disease.

Genome sequencing is often pivotal in the diagnosis of rare diseases, but many of these conditions lack specific treatments. We describe how molecular diagnosis of a rare, fatal neurodegenerative condition led to the rational design, testing, and manufacture of milasen, a splice-modulating antisense oligonucleotide drug tailored to a particular patient. Proof-of-concept experiments in cell lines from the patient served as the basis for launching an "N-of-1" study of milasen within 1 year after first contact with the patient. There were no serious adverse events, and treatment was associated with objective reduction in seizures (determined by electroencephalography and parental reporting). This study offers a possible template for the rapid development of patient-customized treatments. (Funded by Mila's Miracle Foundation and others.).

The effect of implant macrogeometry in immediate tooth replacement therapy: A case series.

The concept of immediate tooth replacement therapy (ITRT) in the esthetic zone has become a viable treatment modality and widely accepted in clinical practice. However, achieving adequate primary stability that enables immediate provisional restoration and desirable space for bone-grafting with conventional tapered body implant designs is challenging. The macro-hybrid implant design with a prosthetic angle correction and body-shift feature in a singular form provides not only greater primary stability of a wider diameter implant but also circumferential gap distance both facially and interproximally preserve the labial bone plate and interdental attachment apparatus of the adjacent natural teeth thereby maintaining the interdental papilla. The present clinical series exemplifies the clinical advantages of this inverted body-shift implant design in ITRT in various clinical scenarios in (1) single tooth replacement in a Type 1 intact socket with a thin periodontal phenotype, (2) single tooth replacement in a Type 2 socket with a dentoalveolar dehiscence of the labial bone plate, and (3) multiple adjacent teeth replacement of two maxillary central incisor. CLINICAL SIGNIFICANCE: The macro-hybrid design implant with a prosthetic angle correction and body-shift feature in a singular form provides greater midfacial gap distance as well as tooth-to-implant distance to preserve the interdental attachment of the adjacent natural teeth thereby leaving the interdental papilla undisturbed, without sacrificing higher primary stability afforded by larger diameter implants.

Interdisciplinary management of recession defects on maxillary single tooth implants: Diagnosis and treatment strategies.

OBJECTIVE: One of the most common complications with dental implants placed in the smile zone is the development of mid-facial recession, creating an undesirable esthetic result. When deciding how to remediate these clinical scenarios, the question becomes whether it may be feasible to save the problematic implant or if it is more predictable to remove the implant and start all over again. However, patients may be invested emotionally, physically, and financially in the implant and remediation may be a viable option depending on the diagnosis of the specific issues at hand and multi-disciplinary clinical execution. CLINICAL SIGNIFICANCE: What is crucial to understand in order to remediate these cases is answering four separate criteria: (1) is the implant in a restorable position, (2) is the implant healthy, (3) is the implant placed at an adequate depth, and (4) are components available to restore the implant. CONCLUSIONS: Two different clinical reports are presented that demonstrate various treatment remedies when saving implants in the esthetic zone.

When to save or remove implants in the smile zone: A clinical report of maxillary lateral incisor implants in malposition.

OBJECTIVE: The following is a clinical report addressing when to save or remove implants with esthetic deficiencies in the smile zone as well as the sequence and timing of interdisciplinary treatment. CLINICAL CONSIDERATIONS: Key factors in the decision-making process in treating implants in malposition are whether the implants are (1) in a reasonable restorative position, (2) free of disease, and (3) placed with adequate depth. This clinical report encompassed periodontal corrective surgery, non-surgical soft tissue sculpting through subgingival crown contour, material selection for definitive restorations, and cementation techniques for cement-retained restorations. CLINICAL SIGNIFICANCE: Knowledge and understanding of interdisciplinary treatment planning, sequencing, and respective techniques that can be implemented when confronting implants in malposition in the smile zone will allow the interdisciplinary team to achieve the desired esthetic restorative result.

Managing restorative space, color matching, and tooth replacement with a novel implant through interdisciplinary treatment: A case report of partial anodontia and malformed teeth in the esthetic zone.

A case report of tooth agenesis and excessive intraarch space due to tooth size discrepancies and malformed teeth is presented. Interdisciplinary treatment including orthodontics, implant surgery, prosthodontics, and laboratory fabrication with dissimilar restoration and material types was used to accomplish an esthetic and functional outcome. Proper diagnosis of individual tooth width and proportion were key elements in treatment. CLINICAL SIGNIFICANCE: Knowledge and understanding of the relationships of the mandibular to maxillary anterior teeth and shade management of dissimilar restoration types will allow the interdisciplinary team to achieve the desired esthetic restorative result.

Inverted body-shift concept in macroimplant design to enhance biologic and esthetic outcomes: A clinical report.

A new implant design to increase labial plate dimension and tooth-implant distance in maxillary anterior extraction sockets over traditional tapered implant designs is presented. Generally, tapered implants are divergent and wider at the coronal aspect of the implant adjacent to the lowest bone volume. Decreasing bone around implants over time can lead to ridge collapse, recession, and a graying effect of the gingival tissues that eventually impacts esthetic outcomes adversely. This implant design incorporates a body-shift in both diameter, shape, and thread pattern and reduces the coronal portion to allow greater circumferential bone thickness to be created where it is needed most for long-term stability.

Qualitative and Quantitative Assessments of Alveolar Bone Dimension and Its Correlation with Tooth Angulation in the Anterior Maxilla for Immediate Implant Placement.

AIM AND OBJECTIVE: The aim of this paper is to ascertain the quantitative measurements of alveolar bone thickness at all maxillary anterior teeth and qualitatively demonstrate the relationship between tooth angulation (TA) and alveolar bone thickness. MATERIALS AND METHODS: Cone-beam computed tomography (CBCT) images of 189 maxillary anterior teeth were collected. Sagittal view was selected to perform the measurement on alveolar bone wall at crestal, midlevel, and palatal. TA was measured along to the tooth long axis (TLA) related to the alveolar bone housing. Spearman's correlation coefficients were conducted to test the correlation between the variables. RESULTS: The facial alveolar bone (FAB) is predominantly thin (<1 mm) at the crestal and midroot region. A significant difference was recorded in the median thickness of FAB at the midroot and apical area (p = 0.001, p = 0.021). The FAB thickness was not gradual with midroot being thinner than crestal. For the palatal alveolar bone (PAB), the thickness was increased continuously toward the apex. At all apical levels of inspected teeth, a significant negative correlation existed between TA and FAB. A positive correlation of TA was only significant at the facial crest of lateral incisor (r = 0.308). However, the canines did not correlate with the FAB, but correlated with the PAB at the apical level (r = 0.478). CONCLUSION: The FAB wall crest of maxillary anterior teeth was generally thin and not gradual with the lateral incisor being the thinnest. A significant correlation of TA existed based on different types of maxillary anterior teeth and alveolar bone level. The maxillary anterior teeth with increased buccolingual angulation were correlated with thicker bone at the apical level. CLINICAL SIGNIFICANCE: The quantitative assessment of FAB and TA in degree may serve as an anatomical index for ideal implant position.

Layperson's Esthetic Preference to the Presence or Absence of the Interdental Papillae in the Low Smile Line: A Web-based Study.

PURPOSE: To determine the layperson's esthetic preference to the visual display (presence) or lack thereof (absence) of the interdental papillae during minimum smiling or the low smile line patient type. MATERIALS AND METHODS: Two hundred lay-people were shown three-paired smile images indicative of a low gingival smile line patient type in which the vermillion border of the maxillary lip covered the mid-facial gingiva of the anterior teeth. The three images differed only with respect to [1] presence of interdental papillae, [2] absence of the interdental papilla ("black triangle"), or [3] absence of the interdental papillae (replaced with a long restorative contact area). The three images were paired in multiple groupings; group-1 consisted of a comparison of the presence of interdental papillae vs the lack of the interdental papillae "black triangle," group-2 compared the long restorative contact compared to the presence of the interdental papillae and Group-3 compared the long restorative contact replacing a missing papilla to the absence of the interdental papillae "black triangle." The comparisons were designed to determine the subjective preference of lay individuals between these groupings. RESULTS: Ninety-eight percent of lay-people demonstrated a preference to the presence of the interdental papillae in the smile (image 1) when compared to its absence ("black triangle"; image 2) with a low smile line. Seventy percent preferred the visual display of the interdental papillae, that is, pink tissues (image 1), compared to the absence of the interdental papillae replaced with a long contact area (image 3), that is, white restorative materials, when viewing a low gingival smile line. And when comparing the absence of the interdental papillae "black triangle" to a long contact area, 92% of lay-people preferred a long contact area vs the absence of the interdental papillae with a "black triangle" with a low smile line. CONCLUSIONS: The visual display [presence] of the interdental papillae, that is, pink tissues, is notably preferred to the absence of the interdental papillae when replaced by either a "black triangle" or long contact area in the commonly known low smile line. This emphasizes the need to assess the Interdental Smile Line (ie, visual display of interdental papillae during smiling) in all patients and the importance to preserve and/or re-establishment of the interdental papillae, that is, pink tissues, even in patients with a low smile line.

Layperson's preference regarding orientation of the transverse occlusal plane and commissure line from the frontal perspective.

STATEMENT OF PROBLEM: Facial asymmetries in features such as lip commissure and interpupillary plane canting have been described as common conditions affecting smile esthetics. When presented with these asymmetries, the clinician must choose the reference line with which to orient the transverse occlusal plane of the planned dental restorations. PURPOSE: The purpose of the online survey described in this study was to determine lay preferences regarding the transverse occlusal plane orientation in faces that display a cant of the commissure line viewed from the frontal perspective. MATERIAL AND METHODS: From a digitally created symmetrical facial model with the transverse occlusal plane and commissure line parallel to the interpupillary line (horizontal) and a model constructed in a previous study (control), a new facial model was created with 3 degrees of cant of the commissure line. Three digital tooth mountings were designed with different transverse occlusal plane orientations: parallel to the interpupillary line (A), parallel to the commissure line (B), and the mean angulation plane formed between the interpupillary and commissure line (C), resulting in a total of 4 images. All images, including the control, were organized into 6 pairs and evaluated by 247 selected laypersons through an online Web site survey. Each participant was asked to choose the more attractive face from each of the 6 pairs of images. RESULTS: The control image was preferred by 72.9% to 74.5% of the participants compared with the other 3 images, all of which represented a commissure line cant. Among the 3 pairs which represent a commissure line cant, 59.1% to 61.1% preferred a transverse plane of occlusion cant (B and C) compared with a plane of occlusion parallel to the interpupillary, line and 61.1% preferred a plane of occlusion parallel to the commissure line (B) compared with the mean angulation plane (C). CONCLUSIONS: Laypeople prefer faces with a commissure line and transverse occlusal plane parallel to the horizontal plane or horizon. When faces present a commissure line cant, laypeople prefer a transverse occlusal plane with a similar and coincident cant.

Simplifying optimal tooth-size calculations and communications between practitioners.

The purpose of this article is to present a simple method for determining the optimal sizes of anterior teeth. This is needed because of the frequency of anomalous and missing maxillary lateral incisors. In addition to anomalous and missing incisors, other factors that create challenges for the dentist and orthodontist when designing an esthetic and occlusally sound dentition are attrition, trauma, transposition, erosion, and caries. Optimal esthetics and occlusion require correctly sized teeth in proportion to themselves and the other teeth. Orthodontics, in partnership with restorative dentistry, allows doctors to accomplish the objectives of ideal occlusion and enhanced esthetics. Data compiled from previously published research enabled us to create simple formulae to determine optimal tooth sizes, an esthetic guide worksheet to use with collaborating dentists, and a sample written communication to accompany the completed esthetic guide worksheet. The method for establishing optimal tooth sizes is presented in a manner that allows easy memorization of the formulae and determination of the best dimensions for teeth without the use of a calculator.

Color matching strategies for non-vital discolored teeth: part 2. In-vivo bleaching options for discolored teeth preparations.

UNLABELLED: The following is a case report exemplifying the esthetic restorative and correction of a discolored substrate of a non-vital maxillary right lateral and central incisor tooth. Frequently, clinicians are presented with discolored teeth preparations after removal of a restoration and face difficult decision-making strategies in regards to materials selection, tooth preparation depth, and design. Part 2 will discuss the diagnosis and clinical bleaching treatment options when restoring non-vital discolored substrate preparations. The key is to know when such techniques should and can be applied with the associated esthetic clinical results. CLINICAL SIGNIFICANCE: Esthetic restorative correction of discolored teeth preparations can be clinically managed with an understanding of non-vital bleaching concepts and techniques along with the associated risks and rewards.

Color-matching strategies for non-vital discolored teeth: part 1. Laboratory ceramic veneer fabrication solutions.

UNLABELLED: The following is a case report exemplifying the restorative and esthetic correction of a discolored stump shade of a non-vital tooth maxillary left central incisor tooth. Treatment options are non-vital bleaching of the root canal-treated tooth or esthetic restoration through an understanding of color and layered ceramics, where the latter was employed. Proper shade communication as well as additional facial tooth preparation and reduction are key clinical requirements in order to allow the ceramist adequate room to affect a color change without sacrificing translucency or vitality of the definitive restorations. CLINICAL SIGNIFICANCE: Esthetic restorative correction of a discolored stump tooth shade can be managed with an understanding of color, shade communication, proper tooth preparation, and ceramic layering techniques.