Ridge Preservation and Augmentation Using a Carbonated Apatite Bone Graft Substitute: A Case Series.

The newly developed mineral carbonated apatite has recently been proposed as a bone graft material for bone regenerative treatment in implant therapy. This case series details the clinical and radiographic outcomes of ridge preservation and ridge augmentation using only carbonated apatite as bone graft material for implant treatment. Twenty patients (36 sites) who required bone regeneration and implant placement were retrospectively assessed. Simultaneous carbonated apatite implant placement was performed using the simultaneous ridge preservation or augmentation approach on 24 sites in 13 patients with sufficient bone quantity for primary stabilization based on preoperative evaluation results. A staged ridge preservation or augmentation approach was used for the remaining 12 sites in seven patients with insufficient bone quantity. The mean regenerated bone height for each treatment method was as follows: simultaneous preservation, 7.4 ± 3.3 mm; simultaneous augmentation, 3.6 ± 2.3 mm; staged preservation, 7.2 ± 4.5 mm; and staged augmentation, 6.1 ± 2.7 mm. The mean regenerated bone width for each treatment method was as follows: simultaneous preservation, 6.5 ± 2.9 mm; simultaneous augmentation, 3.3 ± 2.5 mm; staged preservation, 5.5 ± 1.7 mm; and staged augmentation, 3.5 ± 1.9 mm. Ultimately, the use of carbonated apatite alone as a bone graft material in implant therapy resulted in stable and favorable bone regeneration.

Novel Flowchart Guiding the Non-Surgical and Surgical Management of Peri-Implant Complications: A Narrative Review.

Peri-implant diseases, such as peri-implant mucositis and peri-implantitis, are induced by dysbiotic microbiota resulting in the inflammatory destruction of peri-implant tissue. Nonetheless, there has yet to be an established protocol for the treatment of these diseases in a predictable manner, although many clinicians and researchers have proposed various treatment modalities for their management. With the increase in the number of reports evaluating the efficacy of various treatment modalities and new materials, the use of multiple decontamination methods to clean infected implant surfaces is recommended; moreover, the use of hard tissue laser and/or air abrasion techniques may prove advantageous in the future. Limited evidence supports additional effects on clinical improvement in antimicrobial administration for treating peri-implantitis. Implantoplasty may be justified for decontaminating the implant surfaces in the supracrestal area. Surgical treatment is employed for advanced peri-implantitis, and appropriate surgical methods, such as resection therapy or combination therapy, should be selected based on bone defect configuration. This review presents recent clinical advances in debridement methods for contaminated implant surfaces and regenerative materials for treating peri-implant bone defects. It also proposes a new flowchart to guide the treatment decisions for peri-implant disease.

Current status of Er:YAG laser in periodontal surgery.

Lasers have numerous advantageous tissue interactions such as ablation or vaporization, hemostasis, bacterial killing, as well as biological effects, which induce various beneficial therapeutic effects and biological responses in the tissues. Thus, lasers are considered an effective and suitable device for treating a variety of inflammatory and infectious conditions of periodontal disease. Among various laser systems, the Er:YAG laser, which can be effectively and safely used in both soft and hard tissues with minimal thermal side effects, has been attracting much attention in periodontal therapy. This laser can effectively and precisely debride the diseased root surface including calculus removal, ablate diseased connective tissues within the bone defects, and stimulate the irradiated surrounding periodontal tissues during surgery, resulting in favorable wound healing as well as regeneration of periodontal tissues. The safe and effective performance of Er:YAG laser-assisted periodontal surgery has been reported with comparable and occasionally superior clinical outcomes compared to conventional surgery. This article explains the characteristics of the Er:YAG laser and introduces its applications in periodontal surgery including conventional flap surgery, regenerative surgery, and flapless surgery, based on scientific evidence from currently available basic and clinical studies as well as cases reports.

Er:YAG laser-assisted comprehensive periodontal pocket therapy for residual periodontal pocket treatment: A randomized controlled clinical trial.

BACKGROUND: This study evaluated the effectiveness of a novel pocket therapy (Er:YAG laser-assisted comprehensive periodontal pocket therapy [Er-LCPT]) for residual pocket treatment, compared with conventional mechanical treatment alone, in a randomized controlled clinical trial. METHODS: Two sites in 18 patients having residual periodontal pockets of ≥5 mm depth, extant following initial active therapy, or during supportive therapy, were randomized into two groups in a split mouth design: the control group received scaling and root planing (SRP) by curette, and the test group received Er-LCPT using curette and laser. With Er-LCPT, after root debridement, inflamed connective tissue on the inner gingival surface and on the bone surface/within extant bone defects was thoroughly debrided. Furthermore, removal of proximate oral epithelium and coagulation of the blood clot in the pocket entrance were performed with laser. Clinical parameters were evaluated, before and after treatment, through 12 months. RESULTS: Both groups showed significant improvements in clinical parameters. With Er-LCPT, pocket debridement was thoroughly and safely performed, without any adverse side effects and complications, and favorable healing was observed in most of the cases. At 12 months, Er-LCPT demonstrated significantly higher probing pocket depth reduction (2.78 mm vs. 1.89 mm on average; p = 0.012, Wilcoxon signed-rank test), clinical attachment gain (1.67 mm vs. 1.06 mm; p = 0.004) as primary outcomes, and reduced BOP value (0.89 vs. 0.56; p = 0.031), compared with SRP alone. CONCLUSION: The results of this study indicate that Er-LCPT is more effective for residual pocket treatment, compared with SRP alone.

Residual periodontal pocket treatment with Er:YAG laser-assisted comprehensive periodontal pocket therapy: a retrospective study.

OBJECTIVES: Recently, the application of erbium-doped yttrium aluminum garnet (Er:YAG) laser has been increasing in periodontal therapy. In this retrospective study, we evaluated the safety and effectiveness of a novel pocket therapy using Er:YAG laser in combination with conventional mechanical scaling and root planing treatment (Er:YAG laser-assisted comprehensive periodontal pocket therapy). METHODS: Forty sites in 29 elderly patients having residual periodontal pockets of ≥ 5 mm depth were treated by curette and Er:YAG laser from 2006 to 2009. After root debridement by curette, laser irradiation was performed on the root surfaces. Then, inflamed connective tissue on the inner gingival surface and on the bone surface/within extant bone defects was thoroughly debrided by curette and laser. Furthermore, in most cases, removal of the outer epithelium and coagulation of the blood clot in the pocket entrance were additionally performed with laser. Clinical parameters were evaluated before and 3, 6, and 12 months after treatment. RESULTS: With Er:YAG laser-assisted pocket therapy, debridement of pockets was thoroughly and safely performed, and favorable clinical improvements were observed in most cases, without any adverse side effects and complications. After 1 year, probing pocket depth significantly decreased from 6.4 ± 1.4 to 3.5 ± 1.3 mm (p < 0.001, 3.0 mm reduction), and clinical attachment level significantly decreased from 7.5 ± 1.6 to 5.2 ± 1.9 mm (p < 0.001, 2.3 mm gain). CONCLUSION: The results of this study indicate that Er:YAG laser-assisted therapy is useful for the treatment of residual pockets as a minimally invasive flapless surgery. CLINICAL RELEVANCE: Er:YAG laser-assisted comprehensive pocket therapy reduces the necessity of more conventional surgical therapies.

Er:YAG Laser-Assisted Bone Regenerative Therapy for Implant Placement: A Case Series.

In order to achieve favorable ridge preservation (RP) or ridge augmentation (RA) in substantial vertical and/or horizontal bone defects and extraction sockets, a barrier membrane is usually employed. Recently, it was reported that a novel surgical technique for periodontal regenerative surgery applying Er:YAG laser (ErL) irradiation to form blood coagulation on the grafted bone surface, without using a membrane, resulted in sufficient bone regeneration in bone defects. This case series aims to present clinical and radiographic outcomes of ErL-assisted bone regenerative therapy (Er-LBRT), without use of membranes, for RP/RA before or after implant placement. In 10 cases, ErL irradiation was applied (50 mJ/pulse and 20 Hz without water spray in noncontact, defocused mode for approximately 60 seconds) to enhance the blood clot on the entire surface of the grafted bovine bone mineral before suturing. Wound healing was favorable without any postoperative complications such as wound gaping or infection of the grafted material. In all cases, dramatic bone regeneration was observed. After prosthetic treatment, peri-implant tissue and regenerated bone were stable and well-maintained during the follow-up period in each case. This novel technique of Er-LBRT without using a membrane resulted in favorable and stable RP/RA with sufficient bone regeneration for implant therapy.

Investigating the effect of antiseptic solution on the release of interleukin-6 and transforming growth factor beta 1 from human gingival fibroblasts using wound healing assays.

This in vitro study evaluated the effect of different antiseptics and different concentrations thereof in a model of wound healing using human gingival fibroblasts. The fibroblasts were rinsed with four different antiseptic solutions: sodium hypochlorite (HYP), hydrogen peroxide (H2O2), chlorhexidine digluconate (CHX), and benzalkonium chloride (BC). The effect on the release of interleukin-6 (IL-6) and transforming growth factor beta 1 (TGF-ß1) was investigated using enzyme-linked immunosorbent assays (ELISAs). In addition, the effects of the antiseptics on wound healing at 1, 12, 24, and 48 h were assessed through a wound healing assay. The viability of the fibroblasts rinsed with antiseptics was investigated with respect to the concentrations inhibiting cell growth by 50% (IC50), 25% (IC25), and ≤2% (IC2). A statistically significant increased release of IL-6 was obtained with BC IC25 and IC2 after 12, 24, and 48 h (P < 0.01). For TGF-ß1, no significant release was found for CHX IC2 after 24 and 48 h or for IC50 and IC25 after 12 h. There was no significant effect on wound healing capacity for CHX or for BC IC25 and IC2. This study demonstrated that antiseptic rinses of human gingival fibroblasts alter the release of IL-6 and TGF-ß1 and impact wound healing capacity, with both BC and CHX conferring neutral effects.

Analyzing the characteristics of rising from the bed in patients having undergone total hip arthroplasty immediately after surgery.

BACKGROUND: Immediately after patients undergo total hip arthroplasty (THA), they are often coached through the process of rising from the bed to prevent dislocation. However, motion analysis of this process, which can guide coaching methods, has not been conducted. The purpose of this study was to clarify whether there is a difference in hip joint angle, rise time, pain, and difficulty based on the method of rising from the bed in postoperative patients, immediately after THA. METHODS: Twenty patients who underwent THA were enrolled in this study. Seven days after surgery, 3-D motion analysis was performed while subjects rose from the bed using six different methods that include rising from the bed using either the affected or non-affected side either with or without assistance. Hip joint angle, rise time, pain, and difficulty were evaluated. RESULTS: In all six methods, the maximal hip joint angle of the affected side was in the safe range. The maximal hip adduction angle and adduction angle at maximum flexion of the affected side were significantly lower in patients who rose from the bed using their affected side than in those who rose using their non-affected side. There were no differences in maximal hip flexion angle, internal rotation angle, internal rotation angle at maximum flexion of the affected side, rise time, pain, or difficulty regardless of the direction of rising from the bed or the use of assistance. SIGNIFICANCE: Coaching patients to rise from the bed is better performed when using the most optimal method that takes into consideration the movement direction and patient's individuality.

In vitro and clinical evaluation of optical coherence tomography for the detection of subgingival calculus and root cementum.

This study evaluated the effectiveness of swept-source optical coherence tomography (ss-OCT) for detecting calculus and root cementum during periodontal therapy. Optical coherence tomography (OCT) images were taken before and after removal of subgingival calculus from extracted teeth and compared with non-decalcified histological sections. Porcine gingival sheets of various thicknesses were applied to the root surfaces of extracted teeth with calculus and OCT images were taken. OCT images were also taken before and after scaling and root planing (SRP) in human patients. In vitro, calculus was clearly detected as a white-gray amorphous structure on the root surface, which disappeared after removal. Cementum was identified as a thin, dark-gray layer. The calculus could not be clearly observed when soft tissues were present on the root surface. Clinically, supragingival calculus and cementum could be detected clearly with OCT, and subgingival calculus in the buccal cervical area of the anterior and premolar teeth was identified, which disappeared after SRP. Digital processing of the original OCT images was useful for clarifying the calculus. In conclusion, ss-OCT showed potential as a periodontal diagnostic tool for detecting cementum and subgingival calculus, although the practical applications of subgingival imaging remain limited.

Effective removal of calcified deposits on microstructured titanium fixture surfaces of dental implants with erbium lasers.

BACKGROUND: Recently, the occurrence of peri-implantitis has been increasing. However, a suitable method to debride the contaminated surface of titanium implants has not been established. The aim of this study was to investigate the morphologic changes of the microstructured fixture surface after erbium laser irradiation, and to clarify the effects of the erbium lasers when used to remove calcified deposits from implant fixture surfaces. METHODS: In experiment 1, sandblasted, large grit, acid etched surface implants were treated with Er:YAG laser or Er,Cr:YSGG laser at 30 to 60 mJ/pulse and 20 Hz with water spray. In experiments 2 and 3, the effects of erbium lasers used to remove calcified deposits (artificially prepared deposits on virgin implants and natural calculus on failed implants) were investigated and compared with mechanical debridement using either a titanium curette or cotton pellets. After the various debridement methods, all specimens were analyzed by stereomicroscopy (SM), scanning electron microscopy (SEM), and energy dispersive X-ray spectroscopy (EDS). RESULTS: Stereomicroscopy and SEM showed that erbium lasers with optimal irradiation parameters did not influence titanium microstructures. Compared with mechanical debridement, erbium lasers were more capable of removing calcified deposits on the microstructured surface without surface alteration using a noncontact sweeping irradiation at 40 mJ/pulse (ED 14.2 J/cm2 /pulse) and 20 Hz with water spray. CONCLUSION: These results indicate that Er:YAG and Er,Cr:YSGG lasers are more advantageous in removing calcified deposits on the microstructured surface of titanium implants without inducing damage, compared to mechanical therapy by cotton pellet or titanium curette.

A Novel Surgical Procedure for Er:YAG Laser-Assisted Periodontal Regenerative Therapy: Case Series.

The objective of this study was to evaluate an Er:YAG laser (ErL) application for periodontal regenerative surgery in angular bone defects at nine sites in six patients. Debridement was thoroughly performed using a combination of curettage with a Gracey-type curette and ErL irradiation at a panel setting of 70 mJ/pulse and 20 Hz with sterile saline spray. After applying an enamel matrix derivative and autogenous bone grafting, ErL was used to form a blood clot coagulation on the grafted bone surface at 50 mJ/pulse and 20 Hz without water spray for approximately 30 seconds. Twelve months after surgery the mean probing depth had improved from 6.2 mm to 2.0 mm, the mean clinical attachment level had reduced from 7.5 mm to 3.4 mm, and bleeding on probing had improved from (+) to (-). Mean intrabony defect depth decreased from 6.0 mm before surgery to 1.0 mm 12 months after surgery. A novel procedure for periodontal regenerative surgery applying ErL irradiation for thorough decontamination during debridement as well as blood coagulation following autogenous bone grafting seems to have achieved favorable and stable healing of periodontal pockets with significant clinical improvement and desirable regeneration of angular bone defects, including one-wall defects.

Energy output reduction and surface alteration of quartz tips following Er:YAG laser contact irradiation on soft and hard tissues in vitro.

Though the Er:YAG laser (ErL) has been used in periodontal therapy, the irradiated tip damage has not been studied in detail. In this study, the change in the energy output, surface morphology, and temperature of quartz tips was evaluated following contact irradiation. Soft tissue, calculus on extracted human teeth, and porcine bone were irradiated by ErL for 60 min at 14.2 or 28.3 J/cm(2)/pulse and 20 Hz with or without water spray. The energy output ratio declined the most in the calculus group, followed by the bone and soft tissue groups with and/or without water spray. Carbon contamination was detected in all groups, and contamination by P, Ca, and/or other inorganic elements was observed in the calculus and bone groups. The rate of energy output reduction and the degree of surface alteration/contamination is variously influenced by the targeting tissue, temperature elevation of the tip and water spray.

Periodontal and peri-implant wound healing following laser therapy.

Laser irradiation has numerous favorable characteristics, such as ablation or vaporization, hemostasis, biostimulation (photobiomodulation) and microbial inhibition and destruction, which induce various beneficial therapeutic effects and biological responses. Therefore, the use of lasers is considered effective and suitable for treating a variety of inflammatory and infectious oral conditions. The CO2 , neodymium-doped yttrium-aluminium-garnet (Nd:YAG) and diode lasers have mainly been used for periodontal soft-tissue management. With development of the erbium-doped yttrium-aluminium-garnet (Er:YAG) and erbium, chromium-doped yttrium-scandium-gallium-garnet (Er,Cr:YSGG) lasers, which can be applied not only on soft tissues but also on dental hard tissues, the application of lasers dramatically expanded from periodontal soft-tissue management to hard-tissue treatment. Currently, various periodontal tissues (such as gingiva, tooth roots and bone tissue), as well as titanium implant surfaces, can be treated with lasers, and a variety of dental laser systems are being employed for the management of periodontal and peri-implant diseases. In periodontics, mechanical therapy has conventionally been the mainstream of treatment; however, complete bacterial eradication and/or optimal wound healing may not be necessarily achieved with conventional mechanical therapy alone. Consequently, in addition to chemotherapy consisting of antibiotics and anti-inflammatory agents, phototherapy using lasers and light-emitting diodes has been gradually integrated with mechanical therapy to enhance subsequent wound healing by achieving thorough debridement, decontamination and tissue stimulation. With increasing evidence of benefits, therapies with low- and high-level lasers play an important role in wound healing/tissue regeneration in the treatment of periodontal and peri-implant diseases. This article discusses the outcomes of laser therapy in soft-tissue management, periodontal nonsurgical and surgical treatment, osseous surgery and peri-implant treatment, focusing on postoperative wound healing of periodontal and peri-implant tissues, based on scientific evidence from currently available basic and clinical studies, as well as on case reports.

Optimal Er:YAG laser irradiation parameters for debridement of microstructured fixture surfaces of titanium dental implants.

Er:YAG laser (ErL) irradiation has been reported to be effective for treating peri-implant disease. The present study seeks to evaluate morphological and elemental changes induced on microstructured surfaces of dental endosseous implants by high-pulse-repetition-rate ErL irradiation and to determine the optimal irradiation conditions for debriding contaminated microstructured surfaces. In experiment 1, dual acid-etched microstructured implants were irradiated by ErL (pulse energy, 30-50 mJ/pulse; repetition rate, 30 Hz) with and without water spray and for used and unused contact tips. Experiment 2 compared the ErL treatment with conventional mechanical treatments (metal/plastic curettes and ultrasonic scalers). In experiment 3, five commercially available microstructures were irradiated by ErL light (pulse energy, 30-50 mJ/pulse; pulse repetition rate, 30 Hz) while spraying water. In experiment 4, contaminated microstructured surfaces of three failed implants were debrided by ErL irradiation. After the experiments, all treated surfaces were assessed by stereomicroscopy, scanning electron microscopy (SEM), and/or energy-dispersive X-ray spectroscopy (EDS). The stereomicroscopy, SEM, and EDS results demonstrate that, unlike mechanical treatments, ErL irradiation at 30 mJ/pulse and 30 Hz with water spray induced no color or morphological changes to the microstructures except for the anodized implant surface, which was easily damaged. The optimized irradiation parameters effectively removed calcified deposits from contaminated titanium microstructures without causing substantial thermal damage. ErL irradiation at pulse energies below 30 mJ/pulse (10.6 J/cm(2)/pulse) and 30 Hz with water spray in near-contact mode seems to cause no damage and to be effective for debriding microstructured surfaces (except for anodized microstructures).

Histological and SEM analysis of root cementum following irradiation with Er:YAG and CO2 lasers.

Recently, the Er:YAG and CO(2) lasers have been applied in periodontal therapy. However, the characteristics of laser-irradiated root cementum have not been fully analyzed. The aim of this study was to precisely analyze the alterations of root cementum treated with the Er:YAG and the CO(2) lasers, using non-decalcified thin histological sections. Eleven cementum plates were prepared from extracted human teeth. Pulsed Er:YAG laser contact irradiation was performed in a line at 40 mJ/pulse (14.2 J/cm(2)/pulse) and 25 Hz (1.0 W) under water spray. Continuous CO(2) laser irradiation was performed in non-contact mode at 1.0 W, and ultrasonic instrumentation was performed as a control. The treated samples were subjected to stereomicroscopy, scanning electron microscopy (SEM), light microscopy and SEM energy dispersive X-ray spectroscopy (SEM-EDS). The Er:YAG laser-treated cementum showed minimal alteration with a whitish, slightly ablated surface, whereas CO(2) laser treatment resulted in distinct carbonization. SEM analysis revealed characteristic micro-irregularities of the Er:YAG-lased surface and the melted, resolidified appearance surrounded by major and microcracks of the CO(2)-lased surface. Histological analysis revealed minimal thermal alteration and structural degradation of the Er:YAG laser-irradiated cementum with an affected layer of approximately 20-µm thickness, which partially consisted of two distinct affected layers. The CO(2)-lased cementum revealed multiple affected layers showing different structures/staining with approximately 140 µm thickness. Er:YAG laser irradiation used with water cooling resulted in minimal cementum ablation and thermal changes with a characteristic microstructure of the superficial layer. In contrast, CO(2) laser irradiation produced severely affected distinct multiple layers accompanied by melting and carbonization.

Nonsurgical recovery of interdental papillae under supportive periodontal therapy.

We observed nonsurgical improvement of interdental papillae in a patient undergoing supportive periodontal therapy. The patient was a 47-year-old Japanese man presenting with widespread gingival recession at Daniele's papilla presence index level 3 and Miller Class I recession affecting the facial aspect of tooth number 42. Initial periodontal therapy for periodontitis was performed, included oral hygiene instruction, scaling and root planing, resulting in a reduction in inflammation. Use of an interdental brush was then suspended to allow the interdental papillae to recover. The type of toothbrush and tooth brushing method were checked repeatedly. Mechanical debridement was performed every 2 to 3 months. A gradual improvement was observed in recession of the interdental papillae over a period of several years together with coronal regrowth of the gingival margin.