Botulinum Toxin Injections as an Adjunct to Surgical Lip Repositioning For Gummy Smile Treatment.

BACKGROUND: An attractive smile depends on the proper proportion and arrangement of lip, teeth gingiva scaffold. The ideal smile is the exposure of the entire length of maxillary teeth with 1 mm gingiva. A gingival display exceeding 3 mm is unpleasant and termed ''gummy smile (GS).'' Lip repositioning is a simple surgical procedure intended to minimize the gingival display by removing a strip of mucosa and shortening the vestibular depth. Botulinum toxin injecting overactive muscles with measured quantities results in a reduction of muscle activity, relaxing the lip muscles and decreasing upward pull on the lip. There are some contraindications: patients with short lips and gingival exposures less than 3 mm. PURPOSE: This case report describes the successful management of GS of a young man. CASE REPORT: The procedures were performed and these techniques resulted in shortened vestibule and restricted the muscle pull of the elevator muscles of the lip, reducing gingival display when the patient smiles. Surgical lip repositioning can be a minimally invasive alternative to orthognathic surgery. Botulinum Toxin injections can be a useful adjunct to enhance the esthetics and improve patient satisfaction, being a more conservative and immediate nonsurgical treatment modality available. CONCLUSIONS: In this way, the clinical case report demonstrated that lip repositioning surgery combined to botulinum toxin injections promising outcomes in the GS correction. The effect showed a marked reduction in gingival display at the 4-years follow-up.

Evaluation of deviation in implants placed at different depths with a prototype surgical guide: an in vitro study.

The aim of this study was to measure the angular and linear deviations between planned and placed dental implant positions at different depths in an in vitro model. Ten dental manikins of a maxilla without the central and lateral incisors were used. The implants were placed in the tooth positions using a prototype guide based on computed tomographic scans of dental casts. The groups consisted of implants placed at varying depths according to tooth position: 1 mm deep for the right lateral incisor, 2 mm deep for the right central incisor, 3 mm deep for the left central incisor, and 4 mm deep for the left lateral incisor (n = 10 per group). After implant placement, the manikin was scanned again to compare the positioning of the implants to the planned positions. Statistical analysis evaluated the linear deviations between planned and placed implant positions at 3 points (coronal, central, and apical) as well as the angular discrepancies. The analysis showed that the depth of the implant placement proportionally affected the linear deviation of the actual position from the planned position; thus, the deeper implants showed significantly greater linear deviations (P < 0.05; 1-way analysis of variance and Tukey test). There were no statistically significant differences in the mean angular deviations of the groups. Thus, the results suggest that implants placed at greater depths present greater linear deviations than implants placed at shallower depths, but the angular deviation is not affected by implant depth.

Stability of mandibular implants with Morse taper and external hexagon connections placed under immediate loading: a longitudinal clinical study.

The aim of this study was to compare the longitudinal stability of implants with Morse taper and external hexagon connections placed in the anterior mandible and subjected to immediate functional loading. Nine patients each received 4 mandibular implants placed between the mental foramina. In each patient, 2 implants on the left side of the arch had Morse taper prosthetic connections, and 2 implants on the right side had external hexagon prosthetic connections. Mandibular overdentures and opposing removable complete dentures were placed within 72 hours after implant surgery. Clinical evaluation of the implants via magnetic transduction resonance frequency analysis was performed immediately following surgery and 3 months, 6 months, and 2 years following surgery to obtain the implant stability quotient (ISQ). The data obtained were parametric according to the Kolmogorov-Smirnov normality test. The lowest ISQ of any implant was approximately 67, representing reliable osseointegration. The only statistically significant difference between the 2 types of prosthetic connection was found in the initial period (immediately following surgery), when the external hexagon connection in the distal position presented greater stability than did the Morse taper connection in the same position on the opposite side (P < 0.05; Student t test). In intragroup comparisons, no statistically significant differences were found regarding the positions of the implants in the mandible. When the different follow-up periods were evaluated, there were statistically significant differences only in the external hexagon group, with significant reductions in stability of both mesial and distal implants at 6 months compared to other time periods (P < 0.05; Tukey test). Within the limitations of the study, it can be concluded that both Morse taper and external hexagon prosthetic connections provide good stability in an immediate functional loading protocol.

Is interdental papilla filling using hyaluronic acid a stable approach to treat black triangles? A systematic review.

PURPOSE: To evaluate the stability of interdental papilla filling using hyaluronic acid (HA) to treat black triangles in esthetic regions. METHODS: The protocol was registered in PROSPERO. Six databases (PubMed, Scopus, Embase, Lilacs, SciELO, and Web of Science) were used as primary search sources, and OpenGrey and OpenThesis were used to capture the "gray literature." Only before-after studies were included. The JBI Checklist assessed the risk of bias. Only four studies met the inclusion criteria and were considered for the analyses. The studies were published from 2010 to 2016. All studies presented a low risk of bias. Considering the studies do not have control groups, a weighted average by sample size was calculated to obtain a general estimate of the percentage of papillary filling after 6 months and the number of HA applications. RESULTS: The studies showed the percentage of papillary reconstruction after 6 months of application, the weighted average by sample size was 77.41% (SD = 20.68), with an average number of applications of 3.17 (SD = 0.31). CONCLUSION: The application of HA may be used to repair anesthetic defects in the papilla. CLINICAL SIGNIFICANCE: Interdental papilla reconstruction with injectable HA is an option of nonsurgical treatment for interdental papilla deficiencies. However, there is still concern about the quality of the evidence available, considering that studies with different experimental designs can produce contradictory results. Moreover, further understanding is required on the stability of tissue gain promoted by HA in black triangles.

Hospital Intervention in Severe Sinus Infection After Bone Graft.

This study presents the case of a patient who required antrostomy under general anesthesia to treat a sinus lift complication. The patient was a 43-year-old woman with no systemic abnormalities who underwent maxillary sinus lift surgery associated with mineralized bovine bone graft. The Schneiderian membrane was perforated during the procedure, and the rupture was treated with collagen membranes to close the wound and contain the biomaterial, preventing its dispersion. The patient developed a maxillary sinus infection 7 days after surgery. This infection was initially treated with 875 mg amoxicillin combined with 125 mg clavulanic acid. Although the initial infection did not worsen, the patient developed maxillary sinusitis. Thirty days after the onset of the initial infection, the patient underwent an intraoral surgery under local anesthesia to remove the biomaterial and clean the sinus cavity. Despite this procedure, maxillary ostial patency was still compromised, and antrostomy was performed endoscopically in a hospital setting under general anesthesia. This procedure resolved the sinus infection. Then, 12 months after hospitalization, the patient was treated with another sinus graft surgery without postoperative complications. The treatment of sinus infections caused by the graft surgery may require early and active intervention with antibiotics, graft removal, and antrostomy to prevent major complications.

Is Low-Level Laser Therapy Effective for Pain Control After the Surgical Removal of Unerupted Third Molars? A Randomized Trial.

PURPOSE: One of the main challenges after extraction of unerupted third molars is pain control, and one of the treatments for pain control is low-level laser therapy (LLLT). Thus, this study aimed to assess the effectiveness of LLLT for pain control after extraction of lower third molars. MATERIALS AND METHODS: This randomized, double-blind, split-mouth study included patients who required bilateral extraction of unerupted lower third molars. Patients received LLLT on 1 side (laser group) but not on the opposite side (control group). On the experimental side, each patient received a laser application at 5 intraoral points for 30 seconds per point. This procedure was simulated on the control side. The pain control response was assessed with a modified pain visual analog scale at the following times: immediately after surgery (T0), after laser application (T1), 24 hours after surgery (T2), 48 hours after surgery (T3), and 72 hours after surgery (T4). RESULTS: Thirty-two patients, 56.25% of whom were women, underwent extraction; the average age was 22.2 years. At the times analyzed, the laser group presented better results than the control group. As for the times, there were differences in pain scores between T0 (8.03 ± 14.87) and T3 (2.66 ± 4.23), as well as T4 (3.36 ± 7.83), in the laser group and differences between T0 (19.76 ± 26.66) and T3 (7.11 ± 10.76), as well as T4 (6.26 ± 13.14), in the control group. CONCLUSION: LLLT was effective in reducing pain after surgical removal of unerupted third molars. At T3 and T4, pain reduction in relation to T0 was noted in both groups.

Is Low-Level Laser Therapy Effective on Sensorineural Recovery After Bilateral Sagittal Split Osteotomy? Randomized Trial.

PURPOSE: When performing a sagittal osteotomy of the mandibular ramus, one must consider the risk of long-term postsurgical sensory abnormalities from lesions to the inferior alveolar nerve. One treatment for these changes is low-level laser therapy (LLLT). Thus, the aim of this research was to evaluate the effectiveness of LLLT on sensorineural recovery after split ramus osteotomy of the mandible. MATERIALS AND METHODS: This randomized, double-blinded, split-mouth design trial included patients who underwent advanced surgery of the mandible and then received LLLT on 1 side of the mandible (experimental) and a random placebo (control) treatment on the opposite site. Patients were divided into 2 groups: group 1 was treated during the short postoperative period (within 30 days) and group 2 was treated for persistent sensory abnormalities during the late postoperative period (6 months to 1 yr). Each patient received 5 LLLT and control sessions with intervals of 3 to 4 weeks between sessions. The experimental side in each patient received LLLT in the extraoral area (mandibular ramus and entire length of the inferior alveolar nerve to the mental region) and the intraoral area (mental foramen region). The control side received simultaneous placebo treatments. The sensorineural response was analyzed before the onset of treatment and after each LLLT and control session using the Semmes-Weinstein monofilament test. RESULTS: Twenty adult patients (mean age, 35.6 years; 70.0% women) showed improvement in the experimental and control sides during the follow-up period. However, the experimental side in groups 1 and 2 exhibited a marked improvement in sensorineural recovery over the course of the sessions, and group 1 had the best results. CONCLUSION: LLLT was effective in the recovery from sensorineural disorders after orthognathic surgery during the short postoperative period, particularly in the fifth session.

Use of Calcium Phosphate Cement for Repairing Bone Defects: Histomorphometric and Immunohistochemical Analyses.

This study aimed to assess the repair of surgically created bone defects filled with blood clot, autogenous bone, and calcium phosphate cement, by histomorphometric and immunohistochemical analyses. Ten adult male rabbits were used. Three bone defects were prepared with an 8-mm diameter trephine bur in the parietal region of each animal and filled with blood clot (Group BC), autogenous bone (Group AB), and calcium phosphate bone cement (Group CPC). The animals were euthanized at 40 and 90 postoperative days. The sections were subjected to histomorphometric analysis of the new bone formed inside the calvarial defects and immunohistochemical staining to determine the expression of osteocalcin (OC), osteopontin (OP), and tartrate-resistant acid phosphatase (TRAP) proteins. Histomorphometric data were analyzed statistically by analysis of variance and Tukey's post hoc test at 5% significance level. In the results at 40 and 90 days, Group AB differed significantly from Group CPC regarding the area of newly formed bone. The immunohistochemical analysis revealed expression of OP, OC, and TRAP proteins in all groups. Group AB showed prevalence of OC and OP, and lower TRAP expression. Therefore, the calcium phosphate bone cement assessed in the present study did not accelerate the protein expression dynamics during bone healing, compared with the autogenous group.

Does an Association Exist Between the Presence of Lower Third Molar and Mandibular Angle Fractures?: A Meta-Analysis.

PURPOSE: The current data suggest that the presence of lower third molars predisposes the patient to a greater risk of mandibular angle fracture. Thus, the present review sought to determine whether an association exists between the presence of a lower third molar and the occurrence of a mandibular angle fracture in adults and to assess the influence of third molar position according to the Pell and Gregory classification. MATERIALS AND METHODS: The present study was a systematic review and meta-analysis of analytical observational studies. The present review included all reports of the relationship between mandibular angle fractures and lower third molars. No restriction regarding year, language, or publication status was used. The review protocol was registered at the PROSPERO database (registration no. CRD42016047057). Electronic searches unrestricted for publication period and language were performed in the PubMed, Scopus, SciELO, and Latin American and Caribbean Health Sciences databases. Google Scholar and OpenGrey databases were used to search the "gray literature," avoiding selection and publication biases. The entire search was performed by 2 eligibility reviewers. Association and proportion meta-analyses were planned for the studies with sufficient data. The primary predictor variable was the relationship between the presence of a lower third molar and the development of mandibular angle fractures. The secondary outcome variables were the vertical and horizontal positions of the lower third molar, according to the Pell and Gregory classification and their relationship to the susceptibility to developing a mandibular angle fracture. RESULTS: The search strategies resulted in 411 studies, from which 16 were selected for qualitative and quantitative review. The association meta-analysis included all the selected studies and showed that patients with lower third molars are 3.16 times more likely to develop mandibular angle fractures. The proportion meta-analysis included 5 studies and showed that the overall rate of mandibular angle fractures was 51.58% and that positions III and C are more likely to result in fracture, with a rate of 59.84 and 63.67%, respectively. CONCLUSIONS: The results of the present study have shown that the presence of impacted third molars increases by 3.16 times the risk of mandibular angle fractures in adults, with the greatest risk present when third molars are classified as IIIC according to Pell and Gregory. The available evidence is not sufficiently robust to determine whether third molar presence or the level of impaction is the main causative factor for the occurrence of mandibular angle fractures.

Comparison of Two Screw-Retained Free Gingival Grafting Techniques.

Free gingival graft is a predictable technique for increasing the amount of attached gingiva and root coverage; however, its use is limited for cosmetic reasons. To overcome this issue, this study sought to compare 2 free gingival graft techniques that use oral screws to attach grafts. Free gingival graft was performed on teeth 44 to 46 using the traditional technique, while on the opposite side, on teeth 34 to 36, partly epithelialized free gingival grafts were performed. The partly epithelialized free gingival grafts were found to provide better cosmetic results relative to the completely epithelialized free gingival graft, and the use of stabilizing screws was found to be simple and effective.

Implant Anchorage in the Nasopalatine Canal for the Rehabilitation of Severely Atrophic Maxilla.

PURPOSE: This study aimed to describe the clinical case of implant placement in the nasopalatine canal as an aid for atrophic maxilla rehabilitation. CASE REPORT: The surgical procedure was carried out in 2 stages, the first part consisted of a surgery to lift the maxillary sinus membrane associated with the xenogeneic bone placement and the second part consisted of the surgery for the implants placement, both under local anesthesia. A number of seven osseointegrated implants were placed in the maxilla, one was anchored in the nasopalatine canal region after having its neurovascular content emptied by means of the use of drill threads of the implant system. After 5 months, the implant reopening was carried out, followed by the molding, manufacturing and placement of the protocol-type prosthesis. The case has a 4-year follow-up without any painful symptomatology. CONCLUSION: The implant placed in the nasopalatine canal region is a viable option to assist in the rehabilitation with implant-supported prostheses in atrophic maxilla.

Zygomatic Implant Subjected to Immediate Loading for Atrophic Maxilla Rehabilitation.

As life expectancy increases, a larger number of elderly people require dental health care attention for implant-supported rehabilitation, with the aim of restoring the function and aesthetics of the oral cavity. Most of these patients have lost their teeth long time ago, causing a severe bone resorption and maxillary sinus pneumatization. Therefore, the current study aims to demonstrate, through the description of the clinical case, the treatment with zygomatic implants as an option for treating severely atrophic maxillas. In this clinical study, the patient presented, in the clinical and image evaluation, severe alveolar bone atrophy, with height and thickness loss, in addition to a high-level pneumatization of the maxillary sinus, bilaterally. The classical zygomatic fixation technique was suggested, with 2 anterior conventional implants and 2 zygomatic implants in the posterior region with the placement of implant-supported prosthesis with immediate loading. The patient was monitored for 7 years and did not present pain complaints, absence of infection, or implant loss. Based on this clinical case study, it was concluded that the zygomatic implants are satisfactory options to aid the implant-supported rehabilitation of atrophic maxillas.

Block bone graft fixation (onlay): a modification of the surgical technique.

Several reconstructive methods of the alveolar ridge have been reported to make possible future rehabilitations with implants. Many of these methods come from studies done in animals, mainly rats. With this clinical practice based on scientific evidence, any experimental procedure that can be undertaken in real life is fundamental. Thus, any research that emulates as closely as possible those techniques used in humans are important. This study describes the modification of the technique for block bone graft fixation (onlay) in rats using the "lag screw"-type technique, normally used in clinical procedures for grafts in humans. The conclusion was that the execution of the described procedures minimizes interference of blood flow in the area because of the maintenance of the muscle insertion in the buckle aspect of the most anterior region of the mandible, providing better stability to the graft and better contact interface of the graft and receptor bed.

Autogenous bone grafts contamination after exposure to the oral cavity.

The purpose of this paper was to analyze specimens of autogenous bone block grafts exposed to the oral cavity after ridge reconstructions. Specimens of chronic suppurative osteomyelitis (CSO) of the jaws were used as comparison for bacterial colonization pattern. For this, 5 specimens of infected autogenous bone grafts were used and 10 specimens of CSO embedded in paraffin were stained with Brown and Brenn technique and analyzed under light microscopy. The results showed a similar colonization pattern in both situations, with the establishment of bacterial biofilm and the predominance of Gram-positive bacteria. The conclusion was that the similarity in bacterial distribution and colonization between autogenous bone grafts and CSO stresses the necessity of more invasive procedures for the treatment of the autogenous bone grafts early exposed to the oral cavity.

Guided implant surgery: what is the influence of this new technique on bone cell viability?

PURPOSE: To evaluate the effect of implant osteotomy on immediate bone cell viability, comparing guided surgery for implant placement with the classic drilling procedure. MATERIALS AND METHODS: For this study, 20 rabbits were used. The animals were divided into a guided surgery group (GG) and a control group (CG) and were then divided into 4 subgroups--subgroups 1, 2, 3, and 4--corresponding to drills used 10, 20, 30, and 40 times, respectively. All animals received 5 osteotomies in each tibia, by use of the classic drilling procedure in one tibia and guided surgery in the other tibia. The osteotomized areas were removed and processed immunohistochemically for detection of osteocalcin, receptor activator of nuclear factor κB ligand (RANKL), osteoprotegerin (OPG), and caspase 3. RESULTS: Immunohistochemical analysis showed that osteocalcin expression was initially higher in the CG and remained constant after drill reutilization. Although the expressions of RANKL and OPG were not statistically different for the GG and CG, the RANKL/OPG ratio tended to be higher for the GG. Moreover, caspase 3 expression was elevated in the GG, proportionally to the number of osteotomies, indicating an increase in the apoptosis index in the GG. CONCLUSIONS: The classic drilling procedure is more favorable to cell viability than guided surgery.

Incomplete mandibular fracture after lateralization of the inferior alveolar nerve for implant placement.

PURPOSE: The present case describes an inferior alveolar nerve lateralization for implant placement that caused mandible fracture a few days after surgery. CLINICAL REPORT: In this case, a 56-year-old female patient who had a severely atrophied jaw and showing bone height less than 7 mm from the bone crest and the mandibular canal was submitted to surgery lateralization of the inferior alveolar conducted with piezzo. Even with all postoperative care, the patient suffered an incomplete fracture of the mandible a few days after lateralization of the inferior alveolar nerve for implant placement. The patient was treated with soft diet and medications for pain and antibiotics, besides removing the implant associated with the fracture. CONCLUSION: It is suggested that this procedure may be conducted in 2 operative periods: firstly, the lateralization of the inferior alveolar; and secondly, after a period of 3 months, the implant placement in a situation of more bone stability.

Effectiveness of Hyaluronic Acid Injection for Interdental Papillae Recovery in Esthetic Areas: A Randomized Clinical Trial.

The aim of this study was to evaluate the effectiveness of hyaluronic acid (HA) injections used to reduce defects in the gingival papillae in esthetic areas. This randomized study included six patients requiring black triangle treatment in 19 defective papillae. After local anesthesia, less than 0.2 mL of HA was injected 2 to 3 mm into the tip of the deficient papilla in the apical direction. Analysis of the target regions with standardized photographs and 3D intraoral scanning (CEREC 4.5 software with RST files, Dentsply Sirona) was performed at baseline (T0) and at 1 month (T1), 2 months (T2), 3 months (T3), and 4 months (T4) after the initial application of HA. At each time period, the photographic analysis showed no statistically significant differences in linear tissue gain after HA gel application. The 3D analysis showed improvements in the vertical papillae tissue recovery at T3 (0.41 ± 0.21 mm) and T4 (0.38 ± 0.21 mm) when compared to T1 (0.13 ± 0.08 mm; P < .0001). Regarding the reconstruction of the interdental papillae, the general dimensions of the tissue in the black triangle areas showed a significant increase in size percentage at T3 (58% ± 32.9%) compared to T1 (30.41% ± 23.4%; P = .0054). Thus, the application of injectable HA was effective for filling papillae in the esthetic area. Int J Periodontics Restorative Dent 2023;43:e73-e80. doi: 10.11607/prd.5814.

Periodontal and prosthetic biologic considerations to restore biological width in posterior teeth.

The biologic width is an essential dental space that always needs to be maintained to ensure periodontal health in any dental prosthetic restorations. An iatrogenic partial fixed prosthesis constructed in lower posterior teeth predisposed the development of subgingival caries, which induced violation of the biologic width in involved teeth, resulting in an uncontrolled inflammatory process and periodontal tissue destruction. This clinical report describes a periodontal surgical technique to recover a violated biologic width in lower posterior teeth, by crown lengthening procedure associated with free gingival graft procedure, to ensure the possibility to place a modified partial fixed prosthesis in treated area. The procedure applied to recover the biologic width was crown lengthening with some modifications, associated with modified partial fixed prosthesis to achieve health in treated area. The modified techniques in both surgical and prosthetic procedures were applied to compensate the contraindications to recover biologic width by osteotomy in lower posterior teeth. The result, after 4 years under periodic control, seems to achieve the projected goal. Treating a dental diseased area is necessary to diagnose, eliminate, or control all etiologic factors involved in the process. When the traditional methods are not effective to recover destructed tissues, an alternative, compensatory, and adaptive procedure may be applied to restore the sequelae of the disease, applying a restorative method that respects the biology of involved tissues.

Maxillary bone defect reconstruction using porous polyethylene implants.

PURPOSE: The aim of this study was to evaluate the bone repair process in the maxillary sinus in monkeys treated with high-density porous polyethylene (Medpor) METHODS: Four capuchin monkeys (Cebus apella) were submitted to bilateral horizontal osteotomies in the anterior wall of the maxillary sinus and divided into 2 groups: control group, left side with no implants, and porous polyethylene group, right side with Medpor. After a period of 145 days after implant placement, the maxillae were removed for histologic and histometric analyses. RESULTS: Bone repair in osteotomized areas took place by connective tissue in 58.5% and 58.7% in the control group and the porous polyethylene group, respectively. In the contact surface with Medpor, bone repair occurred in 41.3%. CONCLUSIONS: Medpor was not reabsorbed within the period of this study and allowed bone repair surrounding it. The porous polyethylene constitutes a feasible alternative for bone defect reconstruction.

Median palatine cyst.

The median palatine cyst is a rare benign nonodontogenic lesion that attacks the median palatine suture. There is controversy about its pathogenesis; however, its origin is generally attributed to the enclavement of epithelial remnants within the palatine suture between the 2 lateral maxillary processes during their fusion in the origin of the hard palate. The purpose of this report was to relate a case of a median palatine cyst, discussing the rarity of the lesion, its pathogenesis, and the different modalities that could be used for the correct treatment of this pathologic entity.