Simplified procedures to treat periodontal intraosseous defects in esthetic areas.

Successful treatment of deep intraosseous defects in esthetic areas implies clinical improvement of the lesion consistent with long-term tooth survival as well as the preservation (or improvement) of esthetics. It is hoped that such treatment end points may be reached through procedures (which we have termed as 'simplified') that, on the one hand can be easily and successfully applied by the majority of clinicians, and, on the other hand, are well tolerated by patients in terms of postsurgical pain and discomfort, adverse events and cost. In this review, we describe the technical aspects of the simplified procedures currently available (i.e. nonsurgical therapy and the single flap approach and its variants). Also, we analyze the effect of such procedures on clinical parameters and patient-centered outcomes. While nonsurgical therapy seems to be appropriate per se in lesions with a probing depth of < 7 mm and a limited intraosseous component, severe intraosseous defects can be successfully treated using simplified surgical procedures. Overall, data support the effectiveness of simplified surgical procedures and indicate that they result in minimal esthetic impairment (i.e. post-treatment recession) and a more tolerable postoperative course when compared with conventional surgical (double flap) approaches. In particular, the single flap approach was shown to be at least as effective as traditional papilla-preservation techniques when evaluated either as a stand-alone protocol or in combination with regenerative devices. Bioactive agents have shown the most appropriate regenerative technology when used in association with simplified surgical procedures.

Alveolar ridge dimensions in mandibular posterior regions: a retrospective comparative study of dentate and edentulous sites using computerized tomography data.

PURPOSE: To evaluate ridge dimensions at edentulous, mandibular posterior sites, and contralateral dentate sites. METHODS: Computerized tomography scans of 24 patients with one fully edentulous and one fully dentate mandibular posterior region were retrospectively selected. Relative ridge position (rRP), bone height (BH), alveolar canal height (ACH), basal bone height (BBH), and bone width (BW) at 1, 3, and 5 mm apically to the most coronal point of the alveolar crest (BW1mm, BW3mm, and BW5mm, respectively) were measured at posterior dentate sites and contralateral edentulous sites. The proportion of edentulous sites with BH ≥ 9 mm and BW1mm ≥ 6 mm and/or BH ≥ 11 mm and BW3mm ≥ 6 mm was calculated. RESULTS: When compared to dentate sites, edentulous sites showed lower BH, a more apical position of the ridge, lower BW1mm, lower ACH, and similar BBH. The difference in rRP, BH, ACH, BBH, BW1mm, BW3mm, and BW5mm between edentulous and contralateral dentate sites was not significantly different between females and males. The prevalence of edentulous sites with BH ≥ 9 mm and BW1mm ≥ 6 mm and/or BH ≥ 11 mm and BW3mm ≥ 6 mm was higher in females (83.3%) compared to males (58.3%) at second premolar, while was higher in males compared to females at the first molar (83.3 vs 66.6%) and second molar (83.3 vs 75.0%). CONCLUSIONS: In the posterior mandible, edentulous sites show a reduced height and bucco-lingual ridge width compared to contralateral dentate sites. Gender seems to have a limited impact on the extent of ridge resorption following the loss of posterior mandibular teeth.

Role of Slug transcription factor in human mesenchymal stem cells.

The pathways that control mesenchymal stem cells (MSCs) differentiation are not well understood, and although some of the involved transcription factors (TFs) have been characterized, the role of others remains unclear. We used human MSCs from tibial plateau (TP) trabecular bone, iliac crest (IC) bone marrow and Wharton's jelly (WJ) umbilical cord demonstrating a variability in their mineral matrix deposition, and in the expression levels of TFs including Runx2, Sox9, Sox5, Sox6, STAT1 and Slug, all involved in the control of osteochondroprogenitors differentiation program. Because we reasoned that the basal expression level of some TFs with crucial role in the control of MSC fate may be correlated with osteogenic potential, we considered the possibility to affect the hMSCs behaviour by using gene silencing approach without exposing cells to induction media. In this study we found that Slug-silenced cells changed in morphology, decreased in their migration ability, increased Sox9 and Sox5 and decreased Sox6 and STAT1 expression. On the contrary, the effect of Slug depletion on Runx2 was influenced by cell type. Interestingly, we demonstrated a direct in vivo regulatory action of Slug by chromatin immunoprecipitation, showing a specific recruitment of this TF in the promoter of Runx2 and Sox9 genes. As a whole, our findings have important potential implication on bone tissue engineering applications, reinforcing the concept that manipulation of specific TF expression levels may elucidate MSC biology and the molecular mechanisms, which promote osteogenic differentiation.

Human mesenchymal stem cells seeded on extracellular matrix-scaffold: viability and osteogenic potential.

The development and the optimization of novel culture systems of mesenchymal osteoprogenitors are some of the most important challenges in the field of bone tissue engineering (TE). A new combination between cells and extracellular matrix (ECM)-scaffold, containing ECM has here been analyzed. As source for osteoprogenitors, mesenchymal stem cells obtained from human umbilical cord Wharton's Jelly (hWJMSCs), were used. As ECM-scaffold, a powder form of isolated and purified porcine urinary bladder matrix (pUBM), was employed. The goals of the current work were: (1) the characterization of the in vitro hWJMSCs behavior, in terms of viability, proliferation, and adhesion to ECM-scaffold; (2) the effectiveness of ECM-scaffold to induce/modulate the osteoblastic differentiation; and (3) the proposal for a possible application of cells/ECM-scaffold construct to the field of cell/TE. In this respect, the properties of the pUBM-scaffold in promoting and guiding the in vitro adhesion, proliferation, and three-dimensional colonization of hWJMSCs, without altering viability and morphological characteristics of the cells, are here described. Finally, we have also demonstrated that pUBM-scaffolds positively affect the expression of typical osteoblastic markers in hWJMSCs.

Explaining pain after lower third molar extraction by preoperative pain assessment.

PURPOSE: To evaluate whether preoperative pain sensitivity testing and emotional perception of pain could explain the level of postoperative pain after lower third molar extraction. PATIENTS AND METHODS: Twenty-three patients (16 women, 7 men) scheduled for lower third molar extraction were enrolled in the study. Patients preoperatively were submitted to a nociceptive stimulus by a cold pressor test (immersion of the hand into ice water). Preoperative pain tolerance (seconds), algosity and unpleasantness (visual analog scale), and dental anxiety (Modified Dental Anxiety Scale) were assessed. The duration of surgery was recorded (minutes). Postoperative pain ratings were taken by self-reported registrations on a 100-mm visual analog scale during the 6 days after surgery. Separate stepwise regression analyses were performed to evaluate the usefulness of preoperative scores in explaining the overall maximum postoperative pain level and postoperative pain rates at different intervals. RESULTS: Preoperative unpleasantness related to the nociceptive stimulus was found to be the best predictor of maximum postoperative pain (adjusted R(2) = 0.39, P = .001). Demographic information (age) and preoperative (dental anxiety, pain tolerance, algosity) and intraoperative (duration of surgery) factors were not correlated with postoperative pain. CONCLUSIONS: These results show that a simple preoperative test is useful to identify patients at risk of developing greater pain after third molar surgery. They are characterized by a higher level of reported pain or unpleasantness after exposure to a nociceptive stimulus. This test may be tailored to specific patient needs for postoperative treatment.

A simplified composite outcome measure to assess the effect of periodontal regenerative treatment in intraosseous defects.

BACKGROUND: To propose a novel composite outcome measure (COM) for periodontal regenerative treatment of intraosseous defects. METHODS: COM is based on the combination of clinically relevant clinical attachment level (CAL) gain (≥3 mm) and pocket closure (post-surgery probing depth [PD] ≤ 4 mm). Treatment was regarded as successful when a clinically relevant CAL gain was associated with pocket closure, and failing when either clinically relevant CAL gain and pocket closure were not achieved. The effect of the different regenerative treatments was both collectively and separately evaluated according to COM in a defect cohort accessed by Single Flap Approach (SFA). RESULTS: In the entire study cohort, the procedure resulted in a 6-month CAL gain of 3.7 ± 1.9 mm, which was clinically relevant in 71.8% of patients. Six-month residual PD was 3.7 ± 1.1 mm, with pocket closure recorded in 79.6% of patients. COM revealed a successful treatment in 60 patients (58%), and a treatment failure in 7 patients (7%). Mean CAL gain was clinically relevant for each treatment, whereas the residual PD values were consistent with pocket closure for the majority of treatment options. However, when COM was used to rate the treatment outcome of each procedure, it appeared that a successful treatment ranged from 41.5% to 77.5%, whereas treatment failure varied from 3% to 15% for different treatments. CONCLUSIONS: Compared to single probing measurements, COM seems (1) more accurate in capturing the overall benefit of the regenerative procedure and (2) to better identify which factor (CAL gain, residual pocket) mainly contributed to determine a treatment failure.

Influence of obstetric factors on osteogenic potential of umbilical cord-derived mesenchymal stem cells.

Wharton's jelly from the umbilical cord is a noncontroversial source of mesenchymal stem cells (WJMSCs) with high plasticity, proliferation rate and ability to differentiate towards multiple lineages. WJMSCs from different donors have been characterized for their osteogenic potential. Although there is large evidence of WJMSCs plasticity, recently scientific debate has focused on MSCs selection, establishing predictable elements to discriminate the cells with most promising osteoprogenitor cell potential.In the present study a comparative study between the presence of osteoblastic markers and different parameters that pertain to both the newborn and the mother was performed. Umbilical cords were collected after all patients signed the informed consent and local ethical commettee approved the study. Obstetric parameters, including baby's gender and birth weight, mother's age at delivery, gestational stage at parturition and mode of delivery were examined. After characterization and expansion, WJMSCs were analyzed for two osteoblastic markers, alkaline phosphatase (ALP) activity, and the expression level of RUNX-2 transcription factor, and for their ability to deposit mineralized matrix after osteogenic induction.We found that osteoblastic potential was not influenced by baby's gender and mode of delivery. On the contrary, the highest degree of osteoblastic potential has been shown by WJMSCs with RUNX-2 high basal levels, selected from umbilical cords of the heaviest term babies.Even if further evaluation is required, our hypothesis is that our findings may help in selecting the optimal umbilical cord donors and in collecting high potential Wharton's jelly-derived osteoprogenitors efficiently.

Milled bar-supported implant overdenture after mandibular resection: a case report.

After surgical treatment for oral cancer, patients often are affected by disfigurements, thwarted function, and psychological and social problems. Prosthodontic rehabilitation has the aim of restoring function and esthetics. Implant-supported prosthodontic rehabilitation is useful for patients with compromised residual ridge anatomy, such as patients with oral cancer following treatment. This clinical report describes the rehabilitation of a patient after mandibular resection with a milled bar-supported implant overdenture. Overdenture achieves best hygienic maintenance, easy soft tissue follow-up, and low realization cost. This rehabilitation increased prosthesis retention and stability and improved oral conditions and the patient's quality of life.

Effect of flap design and duration of surgery on acute postoperative symptoms and signs after extraction of lower third molars: A randomized prospective study.

Background. Different surgical variables are assumed to play a role in postoperative course after lower third molar extraction. The aim of study was to assess whether flap design and duration of surgery can influence acute postoperative symptoms and signs after lower third molar extraction. Methods. Twenty-five patients scheduled for lower third molar extraction were included in this study and randomly assigned to two groups in terms of flap design: group A (envelope flap) and group B (triangular flap). Swelling and trismus were assessed before and after surgery on days 0, 2 and 7. Pain was assessed for seven days after surgery. Maximum postoperative pain was chosen as the main outcome variable. ANOVA was used to assess differences between the groups regarding maximum postoperative pain, trismus and swelling at 2- and 7-day intervals. Pearson's correlation coefficient was used to assess correlation between duration of surgery and postoperative symptoms and signs. Results. No significant difference was found between the two flap designs for any postoperative symptoms and signs. The duration of surgery was found to be correlated with both trismus (r = -0.44, P = 0.04) and swelling (r = 0.59, P = 0.004) as assessed 2 days after surgery. No associations were found between duration of surgery and maximum postoperative pain and trismus and swelling at 7-day interval. Conclusion. Within the limits of the present study, the duration of surgery, and not the flap design, affected the acute postoperative symptoms and signs after lower third molar extraction.

Establishment of a 3D-dynamic osteoblasts-osteoclasts co-culture model to simulate the jawbone microenvironment in vitro.

AIMS: We aimed to establish a 3D osteoblasts/osteoclasts co-culture system requiring limited amounts of human primary cells and useful as platform to 1. recapitulate an "oral bone microenvironment" in healthy or pathological condition, and 2. produce potential implantable cell constructs for regeneration of jawbone which can be negatively affected by bisphosphonates (BPs). MAIN METHODS: Osteoblasts from normal bone chips (hOBs) or from jawbone of patients taking BPs (hnOBs) were co-cultured with monocytes (hMCs) either in static (3D-C) or dynamic (3D-DyC) condition using the RCCS-4™ bioreactor for 3weeks. Cell aggregates were characterized for viability, histological features and specific osteoclastic and osteogenic markers. KEY FINDINGS: In all tested conditions hOBs supported the formation of mature osteoclasts (hOCs), without differentiating agents or exogenous scaffolds. 3D-DyC condition associated with a ground based condition (Xg) rather than modeled microgravity (µXg) produced aggregates with high level of osteogenic markers including Osteopontin (OPN), Osterix (OSX), Runx2 and appreciable bone mineral matrix. hnOBs co-cultured with hMCs in 3D-Dyc/Xg condition generated OPN and mineral matrix positive aggregates. SIGNIFICANCE: We optimized a 3D co-culture system with a limited amount of cells preserving viability and functionality of bone cellular components and generating bone-like aggregates also by using cells from jawbone necrotic tissue. The feasibility to obtain from poor-quality bone sites viable osteoblasts able to form aggregates when co-cultured with hMCs, allows to study the development of autologous implantable constructs to overcome jawbone deficiency in patients affected by MRONJ (Medication-Related Osteonecrosis of the Jaws).

Transcription factor decoy against NFATc1 in human primary osteoblasts.

The present study describes, for the first time, the removal of the nuclear factor of activated T cells cytoplasmic 1 (NFATc1) by a decoy approach in human primary osteoblasts (hOBs). hOBs with different NFATc1 expression levels were used. The functionality of endogenous NFAT proteins in our experimental model was analyzed by monitoring the transcriptional activity on a luciferase reporter construct driven by three copies of an NFAT response element (pNFAT-TA-luc). Cell treatment with the decoy against NFATc1 resulted in a significant increase in the expression of osteoblastic markers, including ERα and ColXV. On the contrary, the expression of Runx2, which is known to not be transcriptionally regulated by NFATc1, was not altered, indicating the specificity of the decoy effect. To our knowledge, this is the first time that transcription factor decoy has been successful in hOBs to allow the investigation of the role of NFATc1 in an experimental model that, compared to the use of cell lines, more closely resembles an in vivo model. In addition, by using chromatin immunoprecipitation we found that in vivo NFATc1 is recruited on the ColXV gene promoter. The specific role of NFATc1 in osteoblast differentiation is not well understood, however, our findings reinforce the action of NFATc1 in the transcriptional program of osteoblasts, also supporting the therapeutic potential for the proper manipulation of NFATc1-mediated events in different bone disorders. At the same time, our data add important information on the regulation of the expression of ColXV, which only recently has been proposed as an osteoblastic marker.

Encapsulation of mesenchymal stem cells from Wharton's jelly in alginate microbeads.

The description of a microencapsulation procedure for Wharton's jelly mesenchymal stem cells (WJMSCs) is reported. The applied method is based on the generation of monodisperse droplets by a vibrational nozzle. An ionic alginate encapsulation procedure was utilized for the microbeads hardening. Different experimental parameters were analyzed, including frequency and amplitude of vibration, polymer pumping rate, and distance between the nozzle and the gelling bath. The produced barium-alginate microbeads were characterized by excellent morphological characteristics as well as a very narrow size distribution. The microencapsulation procedure did not alter the morphology and viability of the encapsulated WJMSCs. In addition, the current paper reports the functional properties in terms of secretive profiles of both free and encapsulated WJMSCs. The analyzed factors were members of the family of interleukins, chemokines, growth factors, and soluble forms of adhesion molecules. These experiments showed that despite encapsulation, most of the proteins analyzed were secreted both by the free and encapsulated cells, even if in a different extent. In conclusion, the described encapsulation procedure represents a promising strategy to utilize WJMSCs for possible in vivo applications in tissue engineering and biomedicine.

Implant-prosthetic rehabilitation for a patient with monolateral cleft lip and palate: a clinical report.

Cleft lip and palate (CLP) is a malformation of genetic derivation. For patients affected by CLP, procedures of guided bone regeneration by autologous bone grafting are recognized as the most effective to close oronasal communication. The residual gap of alveolar ridge, determined by the absence of 1 or more permanent teeth, can be completed by implant-prosthetic rehabilitation. This kind of rehabilitation for patients with CLP has the aim of completing dental reconstruction by avoiding sacrifice of adjacent teeth and preserving symmetric appearance. This article describes the rehabilitation of an 18-year-old patient affected by right unilateral CLP with use of a titanium implant supporting a single crown to replace the lateral incisor. The technique used was particularly helpful for this cleft case, in which a bone deficit subsisted after secondary bone grafting. An additional bone grafting procedure was performed at the time of implant placement to achieve the best functional and esthetic results.