Digitally guided root removal and simultaneous implant placement: A case study.

BACKGROUND: Encountering a retained root tip post-extraction and prior to implant placement is a possible clinical complication. There are numerous approaches for removing retained roots that may be traumatic or atraumatic. Regardless of the approach, careful treatment planning is important to minimize complications, reduce morbidity, and preserve bony structures. The aim of the current case study is to introduce a technique and digitally generated device used for identifying and atraumatically removing a retained root tip and simultaneously placing a stable dental implant. METHODS: A 63-year-old female with a history of myocardial infarction, hypertension, and acute pancreatitis presented for implant placement at site #5. Clinical examination revealed adequate interocclusal, mesiodistal, and buccolingual dimensions for implant placement. Radiographic examination using cone beam computed tomography revealed that retained root #5 interfered with implant placement. Digital planning was used to extract the root tip with minimal trauma to maintain adequate bone for simultaneous implant placement with good primary stability. RESULTS: The follow-ups at 1, 3, and 6 weeks and 4, 8, and 10 months revealed good bone preservation with an osseointegrated implant. CONCLUSIONS: Employment of digital planning to create a palatal window allowed excellent accuracy in removing the retained root while maintaining the bony foundation for a well osseointegrated dental implant. KEY POINTS: Pre-planning using cone beam computed tomography scan merged with an intraoral digital scan is necessary for precise location of a retained root and correct implant placement with excellent primary stability. A digitally planned 3D surgical guide is a useful method for extracting retained roots during implant placement to minimize bone damage. Digital planning provides a precise and minimally invasive implant surgery.

Management of vertical bony defect using novel xenogeneic/allogeneic bone graft: A case report.

BACKGROUND: Guided tissue regeneration (GTR) is a common treatment modality for correcting vertical or bony defects in furcations. Multiple materials are used in GTR with allografts and xenografts being the most widely used. Each material has distinctive properties affecting the regenerative potential. A new bone graft combination of xenogeneic/allogeneic may improve the outcome of GTR by providing space maintenance (Xenograft) and osteoinductive potential (Allograft). The aim of this case report is to evaluate the efficacy of the new combined xenogeneic/allogeneic material based on clinical and radiographic outcomes. METHODS: A 34-year-old healthy male presented with vertical bone loss interproximally between #'s 9 and 10. Clinical exam revealed 8 mm probing depth without mobility. The radiographic exam revealed a wide and deep vertical bony defect of 30%-50% bone loss. The defect was treated using a layering technique with xenogeneic/allogeneic bone graft and collagen membrane. RESULTS: The 6- and 12-month follow-ups revealed a significant reduction in probing depths and radiographic bone fill. CONCLUSIONS: GTR using a layering technique of xenogeneic/allogeneic bone graft and collagen membrane showed proper correction of a deep and wide vertical bony defect. The 12-month follow-up revealed healthy periodontium with normal probing depths and bone level.

Supernumerary tooth autotransplantation to replace missing maxillary central incisor using three-dimensional replica: A 6-year follow-up.

INTRODUCTION: Tooth autotransplantation is a viable surgical treatment option for patients with missing permanent teeth. Premolars are generally used for autotransplantation but often require extensive modifications. This case report evaluates the use of supernumerary tooth as an alternative option for premolar autotransplantation. This report shows successful supernumerary tooth autotransplantation with 6-year follow-up. METHODS: A 13-year-old male with non-contributory medical history was referred for a missing maxillary left central incisor (#9) and presence of a supernumerary tooth. The clinical and radiographic examination revealed presence of supernumerary tooth with similar dimensions to a central incisor. The treatment plan included autotransplantation of the supernumerary tooth to replace the missing central incisor (short-term) and future implant replacement of the autotransplanted tooth when jaw growth ceases (long-term). The patient and parents consented to treatment. A 3-D tooth replica was constructed based on CBCT analyses. Site #9 was prepared using split ridge technique to create a socket to house the 3-D replica. Upon achieving proper socket form, the supernumerary tooth was extracted and autotransplanted in the prepared socket. The supernumerary tooth was splinted, and the bite opened posteriorly using composite to eliminate any occlusal interferences. RESULTS: The patient was followed up clinically and radiographically. The autotransplanted supernumerary tooth integrated well within the newly created socket and remained functional at the 6-year follow-up. CONCLUSIONS: The current case presents successful management of supernumerary tooth autotransplantation with 6-year follow-up. The results show stable periodontium with satisfactory functional and aesthetic results.

Effect of guided bone regeneration on immediately placed implants: Meta-analyses with at least 12 months follow-up after functional loading.

BACKGROUND: Immediate implant placement (IIP) into fresh extraction socket is a favorable treatment option. If successfully managed, it reduces the overall treatment time, and increases patient's satisfaction. Surgical and restorative factors affect IIP success rates. In this systematic review we evaluate the effect of guided bone regeneration (GBR) at the time of IIP on crestal bone level (CBL) changes after at least 12-months of functional loading. METHODS: Reviewers conducted an independent search of the National Center for Biotechnology Information PubMed, Medline, and the Cochrane Collaboration Library from 1966 to January 2017 following the inclusion criteria. A hand search of bibliographies of reviews and clinical trials related to IIP was also performed. This study looked into CBL changes around IIP primarily and further extracted the data to conduct three meta-analysis of "IIP using GBR versus IIP without GBR", "IIP using bone graft alone versus IIP using bone graft with membrane" and "IIP using GBR versus conventional implant placement" which were further subdivided to provide more detailed information for each. Four reviewers independently assessed the study data and methodologic quality using data extraction and assessment forms. RESULTS: The electronic search identified 714 potential studies and the hand search retrieved 55 studies. Crestal bone level (CBL) changes were determined in three meta-analyses. The results revealed a mean difference in CBL changes of 0.175 ± 0.180 mm  in favor of IIP without GBR when compared with implant with GBR. However, IIP with bone graft and membrane showed better results when compared with IIP with bone graft alone [CBL changes of 0.532 ± 0.572 mm]. CBL preservation was noted in IIP with GBR versus conventional implant placement [CBL changes of - 0.001 ± 0.049 mm]. CONCLUSIONS: Meta-analyses showed minimal difference in CBL around IIP with bone graft versus without bone graft and with IIP with GBR compared with conventional implant placement. However, IIP with bone graft and membrane reported better CBL preservation compared with IIP with bone graft alone. Nonetheless, these results should be interpreted with caution because of moderate heterogeneity between studies.

Partly Deepithelialized Free Gingival Graft for Treatment of Lingual Recession.

INTRODUCTION: Gingival recession (GR) is an unhealthy root exposure that could result in sensitivity, abrasion, root caries and higher chance of plaque collection. The prevalence of GR is higher on the facial surfaces but could also affect the lingual tooth surfaces. Despite the etiology and location of GR, treatment is warranted to improve the long-term periodontal stability around the affected teeth. This case report describes the use of partly deepithelialized free gingival graft (PE-FGG) to augment lingual GR post orthodontic treatment. CASE PRESENTATION: The current report evaluates the results of PG-FGG to correct lingual recession in a 21-year-old female. The patient presented with 5 mm lingual recession on a previously orthodontically rotated tooth (#21). The recession was treated using a PE-FGG to increase keratinized gingiva (KG) and reduce root exposure. Follow-up at 24 months showed adequate root coverage and KG. CONCLUSION: The use of PE-FGG can be used to enhance KG for lingual recession with adequate root coverage.

Stabilization Techniques for Soft Tissue Grafting Around Dental Implants: Case Report.

INTRODUCTION: Implants that lack keratinized tissue (KT) have been associated with increased plaque accumulation, gingival inflammation or hue of metal showing through the tissue. Free gingival grafts (FGGs) are a predictable treatment for minimal or lack of KT. FGGs can increase the zone of KT around teeth and implants alike. Despite predictability of FGGs, stabilizing the graft around implants can be challenging, but is critical for success. Little information is available regarding ways to stabilize FGGs around implants. Acrylic or composite stents are a viable option for obtaining graft stability and support during the healing process. CASE PRESENTATION: This case report highlights the practicality of using acrylic or composite stents for FGG stabilization with successful outcomes. Two patients presented with dental implants, with minimal or lack of KT requiring soft tissue augmentation. FGGs were harvested from the palate and fitted around implant carriers allowing stabilization and adequate suturing. Custom-made acrylic or composite stabilization stents were fabricated to fit around implant carriers, which were screwed into the implant platform, and hollowed out internally to provide space for the graft. Postoperative visits showed healthy, stable zones of KT in both cases. CONCLUSION: The customized acrylic or composite stents allowed stabilization of the FGGs with successful outcome.

Full-Mouth Rehabilitation with Calvarium Bone Grafts and Dental Implants for a Papillon-Lefèvre Syndrome Patient: Case Report.

Papillon-Lefèvre syndrome (PLS) is a rare autosomal recessive disorder of keratinization associated with palmoplantar keratoderma and severe periodontitis resulting in complete edentulism in late adolescence. The pathognomonic dental features of PLS are pathologic migration, hypermobility, and exfoliation of the teeth without any signs of root resorption. It has been suggested that an effective way to treat PLS patients presenting early in the disease progression is extraction of the erupted primary dentition or hopeless permanent teeth followed by antibiotic coverage with periodontal therapy for the remaining teeth. Unfortunately, studies have shown that this regimen only temporarily delays the progression of periodontal disease and does not prevent further tooth loss and bone destruction in the long term. Post-tooth loss, atrophic ridges make conventional prosthodontic rehabilitation quite challenging, and more recently, implant-supported prostheses have been considered as a viable alternative. In a PLS patient, implant placement is complicated by inadequate bone volume; thus, bone augmentation techniques or the use of short implants is often considered. When large volumes of bone are required, parietal calvarium bone can be used to predictably reconstruct severe defects. A PLS patient aged 21 years presented a chief complaint of ill-fitting conventional complete dentures. The patient had severely atrophic ridges, requiring significant bone augmentation for an implant-supported prosthesis. The present case is the first example of bone augmentation using autogenous calvarium parietal graft followed by endosseous implant placement and prosthetic restoration in a PLS patient.

Soft Tissue Changes Around Immediately Placed Implants: A Systematic Review and Meta-Analyses With at Least 12 Months of Follow-Up After Functional Loading.

BACKGROUND: Immediate implant placement (IIP) is predictable but can lead to esthetic challenges, including midfacial recession (MFR) and papillary height (PH) loss. The aim of this systematic review is to examine the effect of IIP on MFR and PH after at least 12 months of functional loading. METHODS: Literature review of the Cochrane and MEDLINE electronic databases and hand search up to January 2016 identified eligible studies. Four reviewers independently assessed data quality and methodology. RESULTS: A total of 106 articles satisfied the inclusion criteria. Twelve studies qualified for three meta-analyses. MFR was slightly less in conventional implant placement (CIP) than in IIP, but the result was not statistically significant (mean difference [MD] -0.064 mm; P = 0.687). Similarly, there was better PH maintenance in CIPs, with statistical significance for distal PH (DPH) only (cumulative PH: MD -0.396, P = 0.010; DPH: MD -0.765, P <0.001; mesial PH [MPH]: MD -0.285, P = 0.256). MFR was slightly less in IIP with thick versus thin biotypes, but not statistically significantly different (MD -0.373, P = 0.243). Pooled data showed statistically significantly less MFR and better PH maintenance in IIP with thick biotype (MFR: MD -0.478, P <0.001; cumulative PH: MD -0.287, P <0.001; MPH: MD -0.288, P <0.001; DPH: MD -0.310, P <0.001). Non-significantly less MFR (MD 0.253, P = 0.384) and significantly better PH maintenance were found in IIP with immediate provisionalization versus conventional restoration (MD -0.519, P = 0.028). CONCLUSIONS: IIP in thick biotype and with immediate provisionalization had less MFR and better PH than IIP in thin biotype or with delayed restoration. However, these findings should be interpreted with caution due to high heterogeneity, which was calculated using comprehensive meta-analysis statistical software that took into account sample size and different treatment groups, and limited qualified studies.

Crestal bone level changes around immediately placed implants: a systematic review and meta-analyses with at least 12 months' follow-up after functional loading.

BACKGROUND: Immediate implant placement (IIP) is a successful treatment and has the advantages of reducing time and increasing patient satisfaction. However, achieving predictable esthetic results with IIP presents a challenge because of naturally occurring bone loss postextraction. Therefore, the focused question of this systematic review is: What is the effect of IIP on crestal bone level (CBL) changes after at least 12 months of functional loading? METHODS: Extensive literature review of the Cochrane and MEDLINE electronic databases and a manual search up to November 2012 identified eligible studies. Two reviewers independently assessed the study data and methodologic quality using data extraction and assessment forms. RESULTS: Electronic and manual searches identified 648 relevant publications. A total of 57 articles satisfied the inclusion criteria. Sixteen studies had test and control groups; therefore, meta-analyses could be performed. The results demonstrated better CBL preservation around IIP compared with implant placement in healed/native bone at 12 months [CBL difference of -0.242 (95% confidence interval [CI], -0.403 to -0.080; P = 0.003)]. Similarly, platform switching around IIP showed better results compared with non-platform switching (CBL difference of -0.770 [95% CI, -1.153 to -0.387; P <0.001]). There was no difference in mean CBL changes with regard to one-stage or two-stage IIP protocol (-0.017 [95% CI, -0.249 to 0.216; P = 0.85]) or the use of immediate or delayed immediate implant loading (0.002 [95% CI, -0.269 to 0.272; P = 0.99]). CONCLUSIONS: Meta-analyses showed less CBL loss around IIP compared with implant placement in healed bone. Platform-switched implants showed greater crestal bone preservation than non-platform-switched implants. There was no significant difference in CBL with one- versus two-stage placement or use of immediate versus delayed IIP loading. Although there were statistically significant differences favoring IIP, the small differences may not be clinically relevant. Although IIP showed favorable outcomes for CBL changes, these results should be interpreted with caution because of high heterogeneity among studies.

Guided bone regeneration using an allograft material: review and case presentations.

Post extraction sites may have residual ridge deformities with insufficient bone present for future implant placement. This presents a challenge to the clinician attempting to obtain optimum results. To predictably augment these areas and obtain aesthetically pleasing results, bone grafting may be required. Guided bone regeneration with an allograft material is a predictable means by which to solve this challenge. This article describes three case presentations utilizing on allograft material for bone regeneration prior to implant placement.