Clinical applications of Natural Bone Morphoproteins in dentistry: a narrative review.

The need to restore bone loss in maxilla and mandible has led to find natural bone substitutes, such as fresh autogenous bone grafts. Fresh autogenous bone grafts (FABGs) have a remarkable capacity to induce new bone formation, a phenomenon called ‘osteoinduction.’ FABGs are useful in craniomaxillofacial and oral applications to restore bone deficiencies. The isolation of those proteins believed to be responsible for the osteoinductive activity of FABGs, namely Natural Bone Morphogenetic Proteins (NBMPs), led to a new era in bone regeneration. NBMPs have been approved for use in specific oral and maxillofacial applications. Clinical trials and studies of oral and craniofacial surgery have indicated that NBMPs can promote bone repair. Information about the biology, chemistry, and actions of NBMPs has called into question whether NBMPs would result in clinically useful bone induction and morphogenesis. Preclinical and specific clinical trials have indicated the efficacy of NBMPs either combined with autograft or compared with an autograft alone. In light of questions about potency and safety of NBMPs, however, additional high-level evidence is needed for specific clinical indications and appropriate patient populations that would benefit from their use.

Computer-guided implant insertion in a patient with impacted maxillary canines: case report.

The use of minimally invasive surgical techniques undoubtedly represents a huge advantage for both the clinician and the patient. This case report shows the possibility of making an implant-prosthetic rehabilitation in an upper jaw in a patient who presented dental elements 1.3 and 2.3 in bone inclusion. The use of computer-guided surgery offers us the possibility to carry out this type of implant rehabilitation without performing the extraction of the above-mentioned dental elements combined with the bone regeneration of the extraction sockets. Consequently, surgery invasiveness and post-surgery complications are reduced to a minimum. Additionally, the predictability of the methodology is evaluated with specific software that enables a comparison between what is virtually planned and what occurs in clinical practice.

Clinical outcome of a two-piece implant system with an internal hexagonal connection: a prospective study.

The purpose of this prospective clinical study was to evaluate the survival rate (SVR - i.e. fixtures still in place at the end of the observation period) and success rate (SCR - i.e. bone resorption around implant neck) of an implant system characterized by cylindrical and tapered implants, both provided with an internal hexagonal connection. In the period between January 1996 and October 2011, 52 implants with internal hexagonal connection were inserted in 21 females and 31 males, mean age 54±11 years. The mean post-surgical follow-up was 44.6±34.4 months. Several parameters were evaluated as potential outcome conditioners: age, gender, smoking, replaced tooth, periodontal disease, fixture shape (i.e. cylindrical or tapered), jaw location (i.e. maxilla or mandible), bone graft, immediate loading, post-extractive placement, type of prosthesis (i.e. single crown or bridge), edentulism, implant diameter and length. An SPSS statistical program was used and Cox regression analysis performed. SVR was 100% since no fixtures were lost. SCR, expressed through the mean marginal bone loss, was 77%. No significant differences were found, for most of the parameters analyzed, with the exception of prosthetic bridges, where implants supporting this type of rehabilitation showed a worse clinical outcome in comparison to single crown rehabilitations. Internal hexagonal connection is a reliable tool for oral rehabilitation.

Maxillary sinus by-pass with tilted implants via tapered-screw bone expanders in low density bone: one year follow -up of a case series.

In the present paper the use of tapered-screw bone expanders (TSBEs) is proposed, in combination with the placement of tilted implants in close proximity to the anterior sinus wall, solving the problem of the reduced height of the alveolar bone in the sub-antral area. The Authors named the procedure: Tilted Implant Expansion Osteotomy (TIEO). Fifteen patients (10 females and 5 males, mean age 47.8±8.15 years) with distal edentulous maxillae were enrolled in this study. For each edentulous site 2 implants were placed, the anterior implant in the area of the most anterior missing tooth while, the posterior implant, immediately in front of the maxillary sinus, with an inclined position. Adopting the aforesaid procedure, 34 cylindrical two-piece implants were placed, 17 of which were placed in tilted position, in order to by-pass the maxillary sinus. After a healing period of 4-6 months, the second stage surgery was performed. The cases were finalized by metal-ceramic cementable restorations with a variable number of elements, from 2 to 4, without any cantilever element. The post finalization follow-up was at 12 months. Survival rate was 100% since no fixtures were lost. At the one-year follow-up the clinical and radiological appearance of the soft and hard tissues was optimal and no pathological signs were recorded. TIEO is a promising surgical procedure for oral rehabilitation of maxillary edentulous sites and represents a therapeutic alternative to sinus lift techniques.

Modified connective tissue punch technique to increase the vestibular/buccal keratinized tissue on flapless implant surgery: a case series.

The aim of this article is to show a simple and predictable technique to enhance both the vestibular/buccal (V/B) gingival thickness (GT) and keratinized tissue width (KTW) improving the soft-tissue profile after flapless implant placement. The technique proposed was named Modified Connective Tissue Punch (MCTP). Fourteen patients (6 men and 8 women) aged between 35 and 69 years (mean value 48.07±13.023 years) were enrolled in this case series. Seventeen implant sites were submitted to flapless procedure. The connective punch (CP) was harvested with a motor-driven circular tissue punch and then a full-split dissection was executed, in order to create a deep pouch, beyond the mucogingival junction, on the V/B side. In this recipient site the CP was placed. The normal flapless surgical protocol was used; implants were inserted and covered with transgingival healing cap screws. GT and KTW were measured: both immediately before and after surgery; at the time of the prosthetic finalization (3-4months, respectively, for mandible and maxilla); 1 year post surgery follow-up. GT was measured at 1 mm, 2 mm and 5 mm on the V/B side, from the outline of the punch. Both KTW and GT at 1 and 2 mm can be effectively increased, while no significant effects for GT at 5 mm can be expected from this technique. Furthermore, the mean values of KTW and GT at 1 mm and 2 mm show significant increases at 3-4 months post-operative, while no further significant increments are shown at 1 year post-operative follow-up. The Authors recommend the use of the MCTP technique to reduce the number of aesthetic complications and soft tissue defects in flapless implant surgery. Longer follow-ups are needed to evaluate the stability of peri-implant tissues over time.

Retrospective study on bone-level and soft-tissue-level cylindrical implants.

The purpose of this prospective clinical study was to evaluate the survival rate (SVR - i.e. fixtures still in place at the end of the observation period) and success rate (SCR - i.e. bone resorption around implant neck) of two cylindrical implant systems. Both systems were equipped with a tapered connection, one requiring a bone-level (BL) placement, while the other a soft-tissue-level (STL) placement. In the period between January 1996 and October 2011, a total of 150 implants (76 in females and 74 in males, mean age 60±11 years) were inserted. The mean post-surgical follow-up was 84±47 months. Several parameters were evaluated as potential outcome conditioners: age, gender, diabetes, smoking, periodontitis, type of edentulism, replaced tooth, jaw location (i.e. maxilla or mandible), bone graft, immediate loading, post-extractive, type of prosthesis, implant diameter and length. An SPSS program was used for statistical analysis. Only two fixtures were lost, therefore SVR was 98.7%. SCR, expressed through the mean marginal bone loss, was 92%. The mean peri-implant bone loss was 0.121.47 mm for BL implants and 0.041.3 mm for STL implants. None of the studied variables had a statistical significant impact on SVR or SCR. Cylindrical implants are reliable for oral rehabilitation.

The influence of “conical plus octagonal” internal connection on implant survival and success rate: a retrospective study of 66 fixtures.

Implant oral rehabilitation has become one of the most successful dentistry techniques over the last 30 years. However, peri-implantitis is the most important complication in implant dentistry. Peri-implantits can be caused by inadequate implant-abutment connections (IAC). The aim of our study is to evaluate the influence of “conical plus octagonal” (i.e. I-Fix connection) on implant survival and success rate. All the implants included in this study were of a completely new type (I-Fix implants and abutments by FMD Falappa Medical Devices S.p.A. Rome, Italy). Sixty-six implants were inserted in males and females. The implants were of different diameters and lengths, inserted both in the mandible and in the maxilla with immediate or delayed loading, with guided bone regeneration (GBR), and post-extractive surgery. All implants were provided with I-Fix connection, 64 abutments using passing screws and 2 using full screws. None of the 66 implants were lost (i.e. survival rate - SVR = 100%). Cox-regression analysis demonstrated that diabetes (p=0.0074), GBR (p=0.0115), maxilla (p=0.0117) and smoking (p=0.0194) have a statistical significant impact on clinical outcome (i.e. greater bone resorption around implant neck). Our data show that I-Fix connection did not influence SVR. This finding demonstrates that I-Fix design seemed to significantly affect the survival rate of the implants in a recent meta-analysis. In spite of the limits of our study, I-Fix connection has been demonstrated to be efficient in closing the gap between implant and abutment and maintaining a good connection over time.

Non-ablative radio-frequency rejuvenation: a histological and bio-molecular report.

Radiofrequency machines for medical use are known to produce moderate clinical improvement of skin laxity without invasive procedures. Numerous equipment with different characteristics have been proposed after the introduction in 2002 of the first FDA approved device. This report is aimed to test if RF treatment is effective when performed at low frequency and low energy level. Two RF treatments were performed unilaterally 7 and 2 days before a planned eyebrow lifting surgery, with a radiofrequency device with 0.52 to 0.7 MHz frequencies, maximum energy of 200 W, used at 40% of its power. A bipolar handpiece with a diameter of 30 mm and a maximum power of 9-9.5 W was massaged along the temporal area for 10 min. Skin samples of treated and untreated sides were collected during surgery and processed for histologic examination and RT-PCR analysis, to test differences in gene activation in a panel of proteins that are relevant in extracellular matrix of dermal connective tissue. The histological examination of the samples showed that the treatment induced a loss of the typical oriented structure in the reticular dermis. The study through RT-PCR evidenced that ELN, the gene codifying for Elastine was strongly enhanced. Some collagen-tested genes (COL1A1, COL3A1 and COL9A1) were inhibited by the treatment, whereas COL2A1 and COL11 were activated. The genes responsible for Metallo-proteases (MMP) 2, 3 and 13 were depressed, while the MMP9 was stimulated. Gene codifying for Hyaluronic synthase 1 (HAS1), Hyluronidase 1 (HYAL1), Neutrophyl elastase (Elane), Desmoplakin (DSP) and GDF6 were inhibited. Insulin like growth factor (IGF1) gene activity was enhanced. RF treatment, with the tested non-ablative equipment, produced histological effects and change in DNA expression of some extracellular matrix related genes, confirming the biostimulatory role of this procedure.

Upper full arch rehabilitation with sinus by-pass with tilted implants via tapered-threaded expanders in low density bone: a clinical trial.

PURPOSE: In the present paper the use of tapered-screw bone expanders (TSBEs) is proposed, in combination with the placement of tilted implants, in close proximity to the anterior sinus wall, solving the problem of the reduced height of the alveolar bone in the sub-antral area. The Authors present a case series of full-arch rehabilitations performed with this procedure named: Tilted Implant Expansion Osteotomy (TIEO). MATERIALS AND METHODS: 12 patients (5 males and 7 females, average age 58.5 ± 8.1 years) with totally or partially edentulous maxilla were enrolled in this study. For each patient 4 implants were placed, the anterior implants in the area of lateral incisors or canines while, the posterior implants, immediately in front of the maxillary sinus, with an inclined position. Adopting the aforesaid procedure, 48 cylindrical two-piece implants were placed, 24 of which were placed in tilted position, in order to by-pass the maxillary sinus. After a healing period of 6 months, the second stage surgery was performed. The cases were finalized by means of a hybrid metal-acrylic prosthesis. The post finalization follow-up was at 12 months. RESULTS: Survival rate was 100% since none fixtures were lost. At the one-year follow up the clinical and radiological appearance of the soft and hard tissues was optimal and no pathological signs were recorded. CONCLUSION: TIEO is a promising surgical procedure for full-arch rehabilitation of maxillary edentulous sites and represents a therapeutic alternative to sinus lift techniques.

The treatment of peri-implant diseases: a new approach using hybenx® as a decontaminant for implant surface and oral tissues.

PURPOSE: The aim of the present study is to demonstrate the efficacy of HyBeNX® to decontaminate the implant surface, both in the case mucositis and severe peri-implantitis and to allow future bone regeneration. MATERIALS AND METHODS: We describe three case reports of peri-implantitis successfully treated with HyBeNX®. In our study, we have used microbiological tests to demonstrate the efficacy of HyBeNX® in decreasing bacterial load. RESULTS: The microbiological results of the clinical cases described show that there was a reduction in the total bacterial count after treatment. CONCLUSIONS: The ability of HyBeNX® to dry the surface and remove biofilm may explain the efficacy of the decontamination and subsequent clinical improvements in all three cases.

Increasing volume of vestibular soft tissues in flapless implant surgery through a modified connective punch technique: a controlled clinical trial.

PURPOSE: The aim of this article is to make a comparative assessment between the modification of the soft-tissue profile, around the healing cap screws (HCSs), following both the traditional flapless surgery (TFS) and a new modified flapless surgery, named Modified Connective Tissue Punch (MCTP) technique. MATERIALS AND METHODS: 8 patients (3M and 5F) (mean age 54.25±11.247 years) were enrolled in this study. Sixteen two-piece implants were placed on upper jaws, 2 for each patient, 8 with TFS and 8 with MCTP technique. In each patient the implants were placed in edentulous areas, of 2 or 3 adjacent teeth long. MCTP technique was performed on the front implant site (FIS) while the TFS was performed on the rear implant site (RIS). All implants were inserted and covered with healing cap screws (HCSs). Alginate impressions were carried out at the moment of the surgery, at 1 month and 4 months post-operative. Plaster models were poured and subsequently digitally scanned, in order to measure the distance between the gingival outline and the free margin of the HCS. The recorded values were analyzed with the ANOVA test. RESULTS: The use of MTCP technique, in comparison to TFS, showed a significative better outcome, in terms of vertical increments, of gingiva, on the VS toward the HCSs, during the entire observation period (p = 0.000 for all). CONCLUSION: The Authors recommend the use of MCTP technique for a better vestibular soft tissue outcome in flapless implant surgery.

Endoscopic management of the schneiderian membrane perforation during transcrestal sinus augmentation: a case report.

PURPOSE: In this article the Authors describe a procedure aimed to restore under endoscopic control, the continuity, of the Schneiderian membrane (SM) incidentally teared during a sinus lift with transcrestal approach. MATERIALS E METHODS: In a 44-year-old male, due to aforementioned complication, the SM was gently detached via transcrestal approach, with a customized small ball burnisher, in order to facilitate the placement of a collagen sponge, to close the communication with the sinus, followed by the subsequent insertion of a graft material. All the procedure was endoscopically controlled and, considering the successful grafted area elevation, was simultaneously followed by implant placement. After 6 months the second stage was performed always under endoscopic control. RESULTS: The endoscopic view of the grafted area showed a dome-shaped elevation sited on the top of the implant, the SM was apparently normal with no signs of inflammation, the antrum was empty and normally functioning. Periapical X-rays were performed: immediately after the surgery; at both 14 days and 6 months post-operative; at 6 months post prosthetic finalization. The volume of the grafted area progressively decreased over the time while its radiopacity, on the contrary, gradually increased, as expected after graft integration and remodelling. The implant was submitted to no functional load for 4 months by means of a temporary screwable acrylic crown inserted on a peek abutment and then finalized with a cementable metal-ceramic crown on a preformed titanium abutment. CONCLUSION: The Authors recommend the use of endoscope to repair the SM incidentally teared during transcrestal sinus lift.

CRESTAL SINUS LIFT USING A FLUIDO-DYNAMIC COMPUTER GUIDED PRECISE AND ATRAUMATIC TECHNIQUE.

One of the most frequent reasons for failure during the maxillary sinus floor lift operation is connected to the possibility of a rupture of the Schneiderian membrane which, if lacerated, cannot perform the function of graft containment. In order to reduce the incidence of complications it is necessary to cut the hard tissue with extreme accuracy and as little trauma as possible, while saving the soft tissue. The precision of pre-operation measures obtained through endoral x-rays, dental-scans and cone-beam CT allows us to approach and cut with delicacy the sinus cortical floor. The recent development of computer guided surgery gives the possibility of planning the operation, which reduces the risk of failure. The cortical of the maxillary sinus is reduced through the use of calibrated burs and a profiler to obtain a hole that enables both access to the maxillary sinus and, subsequently, the lifting of the Schneiderian membrane. Each stage of the operation is monitored and all the devices used pass through a custom-made template, which acts as a surgical guide. The sinus was filled using fluid biomaterial distributed through a dispenser, which had been created specifically for this technique. Due to the reduction in trauma and the fact that the process is much less invasive, this technique could be a valid alternative to the techniques known and carried out to date. Work time is reduced to less than 3 minutes in the cortical thinning operation and percussive trauma is avoided.

Treatment of a bone defect consequent to the removal of a periapical cyst with equine bone and equine membranes: clinical and histological outcome.

AIM: While deproteinized bovine bone and bovine membranes have been well studied and can yield good results when used to treat bone defects and peri-implant dehiscences, enzymatically deantigenated equine bone and equine membranes have emerged as possible alternative biomaterials. The objective of this study was the clinical and histological assessment of such materials: equine bone granules, an equine collagen membrane and an equine pericardium membrane. METHODS: Enzymatically deantigenated equine bone and an equine collagen membrane were used to restore a bone defect caused by the removal of a bone cyst in the upper anterior maxilla. After 4.5 months, an implant was placed and a bone core sample was obtained from the grafted site. Implants threads, though, were exposed. This defect was grafted with a mixture of autogenous and equine bone and covered with an equine pericardium membrane. RESULTS: Four months after implant placement the peri-implant bone levels were maintained. A prosthesis was delivered three months later providing functional and esthetic rehabilitation. Also four-year follow-up controls showed implant success. Histological analysis of the bone core revealed that the graft material had undergone remodelling, and a fair amount of newly formed vital bone was present at the time of sample collection. CONCLUSION: The deantigenated equine bone is biocompatible and undergoes osteoclastic remodelling. Both the equine collagen and pericardium membrane acted as effective barriers for guided bone regeneration.