Overlay Analysis of Cone-Beam Computed Tomography Volumes Acquired before and after Horizontal Alveolar Ridge Augmentation.

OBJECTIVE: The objective of this study was to illustrate the efficacy of a novel imaging analysis technology to capture horizontal and vertical dimensional changes following horizontal alveolar ridge augmentation (HRA). METHODS: Cone-beam computed tomography (CBCT) volumes from 65 HRA sites in 57 patients were available for evaluation, employing a three-dimensional analysis software to overlay preoperative and post-augmentation CBCT volumes. Horizontal and vertical alveolar ridge dimensional (HRD/VRD) changes were recorded considering a panel of patient-, site-, and procedure-related explanatory variables. RESULTS: VRD changes ranged from -2.9 to 3.0 mm, more than half anterior sites losing alveolar ridge height. Mean HRD increase at the 3- and 5-mm levels apical to the alveolar crest amounted to 2.3±1.6 and 2.4±1.3 mm, respectively, membrane fixation and non-resorbable membrane use associated with significantly greater gains. CONCLUSIONS: To date, studies reporting dimensional changes following HRA predominantly rely on serial in situ orofacial caliper recordings omitting vertical alterations. The protocol employed in this study allows simultaneous HRD and VRD evaluations and assures baseline and post-augmentation recordings are made at the same alveolar ridge position. Compared with in situ recording, CBCT overlay analysis may achieve a more complete characterization of dimensional changes following HRA.

Managing Antral Wall Discontinuities in Sinus Elevation Surgery.

INTRODUCTION: Schneiderian membrane perforation (SMP), which is usually readily manageable, is the most common intraoperative complication of sinus elevation surgery. Some evidence suggests that SMP is associated with increased risk for postoperative complications, including maxillary sinusitis. Antral wall discontinuity (AWD) is an acquired condition that may increase SMP likelihood and lead to larger, less-manageable perforations. CASE PRESENTATION: A generally healthy patient receiving sinus elevation surgery exhibited an AWD in the palatine process of the maxilla. The osseous defect was isolated intraoperatively, and the Schneiderian membrane was sharply dissected from the palatal connective tissue. Favorable augmentation of the maxillary sinus was noted on cone-beam computed tomography (CBCT) assessment at postoperative month 34. CONCLUSIONS: AWD (fusion of the Schneiderian membrane with the periosteum of the maxilla) is a condition identifiable on preoperative CBCT images, which may increase the incidence and severity of SMP during sinus elevation procedures. Careful assessment for integrity of antral osseous walls before surgery is essential. Presence of AWD may obligate modifications to the surgical plan, or in some cases, contraindicate sinus elevation surgery.

Adjunctive Nd:YAG Laser Irradiation for Ridge Preservation and Immediate Implant Procedures: A Consecutive Case Series.

INTRODUCTION: Whether or not laser use provides any meaningful benefit at immediate implant and ridge preservation sites remains an open question in periodontics. However, various lasers have been used in conjunction with tooth extraction and immediate implant placement. Evidence supporting adjunctive laser irradiation at immediate implant and ridge preservation sites is mostly limited to preclinical studies and a small number of case reports. CASE SERIES: Adjunctive neodymium‒doped: yttrium, aluminum, garnet (Nd:YAG) laser irradiation was used at six immediate implant sites and five ridge preservation sites. Three immediate implants were in maxillary incisor positions and three were in premolar positions, two maxillary and one mandibular. All cases exhibited favorable healing and satisfactory clinical outcomes. CONCLUSIONS: Nd:YAG laser energy application with 650-µs pulse duration consistently supported rapid clot formation and graft containment at immediate implant and ridge preservation sites. Histologic analyses and controlled clinical trials comparing ridge preservation and immediate implant procedures with and without laser use are needed. Because cellular responses and clinical outcomes may be exquisitely sensitive to irradiation parameters, studies should report materials and methods in detail.

Focus on Epithelialized Palatal Grafts. Part 3: Methods to Enhance Patient Comfort at Palatal Donor Sites.

INTRODUCTION: Postoperative discomfort is a documented complication of the epithelialized palatal graft (EPG) procedure, and the expectation of an unpleasant patient experience may cause some practitioners to avoid EPG altogether. However, EPG affords distinct advantages in a variety of clinical situations, and the postoperative discomfort associated with the procedure can be minimized. CASE SERIES: Three generally and periodontally healthy patients with gingival recession defects and minimal zones of attached gingiva received mandibular anterior EPG procedures. In all cases, collagen membranes were trimmed to fit the palatal donor sites and sutured in place. Two patients reported minimal donor site discomfort at any time point. One patient with large bilateral donor sites reported moderate palatal discomfort limited to the first postoperative week. All patients reported overall positive treatment experiences. CONCLUSIONS: Placement of a resorbable collagen membrane at large EPG harvest sites appears to limit topical irritation of the wound and may substantially improve patient comfort postoperatively. Combining local and systemic measures to minimize patient discomfort may render EPG procedures very tolerable for patients. Controlled clinical trials comparing patient-centered outcomes following EPG harvest with and without collagen membrane placement appear warranted.

Buccal bone thickness adjacent to virtual dental implants following guided bone regeneration.

BACKGROUND: Crestal bone thickness is a critical determinant of peri-implant tissue stability. This retrospective observational study sought to quantify the buccal bone thickness achieved adjacent to virtual dental implants following guided bone regeneration (GBR) surgery and evaluate the influence of patient- and procedure-related variables on buccal bone thickness. METHODS: Cone-beam computed tomography (CBCT) images acquired from patients who had undergone GBR surgery between July 1, 2012, and November 7, 2016, were used for this analysis. In all cases, the GBR procedure involved a dense polytetrafluoroethylene (dPTFE) barrier membrane and a mineralized cortical particulate freeze-dried bone allograft (FDBA). Eighty-four virtual dental implants were placed at planned locations using CBCT images from 84 patients, and the adjacent buccal bone thickness was measured at each site. The effects of sex, age, estimated baseline ridge width, number of missing teeth in site, site type (tooth-bounded versus terminal position in arch), dental arch (mandibular or maxillary), arch location (anterior or posterior), smoking status, titanium reinforcement in the membrane, membrane fixation, and tenting screw use were assessed. RESULTS: The mean post-GBR buccal bone thickness adjacent to virtual dental implants was 2.24 ± 1.01 mm. Fifty-nine of 84 virtual implants (70%) exhibited buccal bone thickness > 1.9 mm. GBR sites using membrane fixation produced significantly greater virtual implant buccal bone thickness than those without membrane fixation (2.31 ± 0.96 versus 1.15 ± 1.25 mm, P = 0.012). Virtual implant buccal bone thickness also exhibited moderate correlation with estimated initial ridge width (r = 0.43, P < 0.0001). The alveolar ridge at 81 virtual implant sites (96%) was classified as good or satisfactory, meaning dental implants were actually placed at these sites, with or without additional grafting at implant placement. CONCLUSIONS: Observations in this study suggest GBR procedures using dPTFE membranes and FDBA result in favorable ridge dimensions for dental implant placement in most cases. However, additional augmentation at implant surgery may be necessary at ≈ 30% of sites, if buccal bone thickness > 1.9 mm is intended.