Perio-prosthodontic pontic site management, part II: Pontic site reconstruction strategies to enhance the esthetic and biological outcomes.

OBJECTIVE: Ridge deformities are present in most patients after tooth extraction; these defects make the management of future implant and pontic sites challenging to deal with. The restorative team should be able to diagnose and treat these deformities to allow for successful outcomes. Many approaches have been described to reconstruct pontic sites, each with specific indications. This article describes the different approaches to reconstructing pontic sites and their indications to allow for a proper esthetic and biological environment for future restorations. CLINICAL CONSIDERATIONS: Depending on the severity of the defect, location, and the esthetic necessity, pontic site enhancement can be done through different approaches, some requiring soft tissue grafting, hard tissue grafting, or both. Understanding the indications of the treatment options is essential to allow the clinician to make the right therapeutic decision and achieve the best possible perio-prosthodontic outcomes. CONCLUSIONS: An adequate balance between the soft tissue and prosthetics is essential to achieve successful results on implant-supported or tooth-supported fixed dental prostheses (FDPs). Selecting the right approach to treat ridge deformities is necessary to increase treatment success, reduce over-treatment, and create a biologically sound environment for restorations. CLINICAL SIGNIFICANCE: Pontic site enhancement through reconstructive surgery will allow for esthetically pleasing and biologically stable results, allowing restorations to emulate natural structures lost after tooth extraction.

Timing implant provisionalization: Decision-making and systematic workflow.

OBJECTIVE: Provisionalization is an important step to achieve esthetic results in implant cases, and many different techniques for provisional restoration fabrication have been described. However, depending on the clinical scenario, the provisionalization strategy will require different approaches and timing. The clinician should modify the provisional restorations efficiently to reduce the number of disconnections from the implant, as repeated disconnections may have biological consequences. This article aims to schematize different scenarios requiring implant provisionalization and propose strategies to help the clinician condition the peri-implant tissues, respecting perio-prosthodontic fundamentals for soft tissue, biological, and esthetic stability. CLINICAL CONSIDERATIONS: The clinical outcomes of modern implant therapy aim to achieve results that emulate natural dentition. Different scenarios may require adjunct therapy, including hard- and soft-tissue grafting, which complicates treatment. The provisionalization strategy will vary depending on the initial condition of the tissues, the need for reconstructive procedures, and the timing of implant placement. Selecting the right strategy based on the case type is necessary to reduce treatment time and complications associated with inadequate prosthetic handling of the soft tissues. CLINICAL SIGNIFICANCE: Proper emergence profile conditioning through provisional restorations will allow for biologically sound and esthetically pleasing outcomes in implant restorations.

Perio-prosthodontic pontic site management, part I: Pontic designs and their current applications.

OBJECTIVE: Emulating natural dentition with dental implant restorations is challenging, increasing its complexity when a pontic area must be restored. Many different methods have been described to solve this problem. The pontic designs which have been proposed have specific indications and may require additional treatments, including soft tissue augmentation procedures, to increase the possibility of an esthetically pleasing and biologically tolerable outcome. Proper conditioning of the soft tissues during the interim restoration stage and adequate communication with the laboratory are also critical factors to a successful outcome. This article describes the different approaches to restoring pontic sites with different degrees of complexity, their clinical indications, and limitations viewed from a perio-prosthodontic approach. CLINICAL CONSIDERATIONS: Different clinical scenarios for pontic sites require different approaches. Missing hard and soft tissues can be replaced by surgical or prosthetic means. Understanding the clinical indications and implications of the different pontic designs allows the clinician to make good decisions when planning and treating patients that require replacement of pontic spaces leading to more successful outcomes. CONCLUSIONS: Different pontic designs have specific indications as well as biologic and esthetic prognoses. Selection of a good design, proper modifications during the provisionalization stage, and adequate communication with the dental laboratory will lead to higher chances of esthetic and biological success. CLINICAL SIGNIFICANCE: The proper pontic design allows for esthetically pleasing pontic sites which emulate natural emergence from the soft tissues while promoting biological stability.

The flat and step (F and S) pontics. Novel pontic designs for periodontally reconstructed sites.

OBJECTIVE: Fixed dental prostheses are a predictable treatment option to replace missing teeth. A periodontal-prosthodontic approach to rehabilitating those areas ensures a predictable way to achieve the desired esthetic and functional results. This is especially important in cases with high esthetic demand. An ideal esthetic result can be achieved by soft tissue overcorrection through periodontal procedures, which reduce the number of conditioning appointments of the pontic sites. Many pontic designs have been described to enhance the appearance of the restored sites. The flat (F) and step (S) pontic designs are a modification of classic pontic approaches. These designs contact the mucosa in a wide area of a previously reconstructed ridge without exerting excessive pressure, reducing the possibility of inflammation, ulceration, and facilitating cleaning. This periodontal-prosthodontic procedure aims to achieve functional and esthetic prosthodontic results in a predictable manner. CLINICAL CONSIDERATIONS: Understanding which pontic design is recommended in different clinical situations is key for a successful outcome. The F and S pontic designs are recommended to be used in a ridge with optimal soft tissue volume after periodontal reconstruction. The suggested designs provide the clinician with a solution to different clinical scenarios after the periodontal augmentation of the pontic site has been done. CONCLUSIONS: The presented pontic designs are indicated in ridges where a previous soft tissue preservation or reconstruction procedure has been done to achieve an optimal soft tissue volume. Modifications to the designs can be done in the interim stage which is later replicated into the final restoration. CLINICAL SIGNIFICANCE: The combination of periodontal and prosthodontic techniques help to predictably achieve a natural looking pontic emergence profile.

The biotransfer approach: The use of an alveolar cast die for the fabrication of the emergence profile on implant-supported interim restorations.

Maintaining natural-looking soft tissues around dental implants is one of the biggest challenges for the restorative team. To achieve this, the emergence profile of the preexisting teeth in the alveolus can be emulated rather than conditioning the soft tissue architecture arbitrarily. The biotransfer technique uses an interim restoration with a biologically driven emergence profile fabricated before the implant surgery.

Clinical outcomes of the biologically oriented preparation technique (BOPT) in fixed dental prostheses: A systematic review.

STATEMENT OF PROBLEM: The biologically oriented preparation technique is a concept with a vertical tooth preparation, gingitage, an immediate interim restoration preserving the clot, and a specific laboratory technique aiming to adapt the marginal periodontal tissue to a remodeled emergence profile of the crown. However, the published scientific evidence on this subject is limited. PURPOSE: The purpose of this systematic review was to analyze whether using the biologically oriented preparation technique leads to improved clinical outcomes in terms of probing depth, gingival inflammation index, gingival marginal stability, and fewer mechanical and biological complications. MATERIAL AND METHODS: Recommendations from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used in this systematic review. An electronic search of the MEDLINE/PubMed, EMBASE, Science Direct, Wiley Online Library, Cochrane, and ProQuest databases was made for articles published between March 2010 and July 2021 using keywords. Three reviewers selected and analyzed all articles that mentioned the biologically oriented preparation technique and met the inclusion criteria. RESULTS: A total of 6 articles met the inclusion criteria: 1 prospective randomized clinical study, 1 randomized clinical study, 1 prospective clinical study, and 3 case series. According to these studies, of all the teeth treated with the biologically oriented preparation technique, probing depth (greater than 3 mm) increased in only 2.3%, gingival inflammation was present in 22.8%, gingival recession occurred in 1.7% (decreased gingival stability), and mechanical and biological failures occurred in 4.4% of the teeth. CONCLUSIONS: Fixed dental prosthesis treatments performed following the concept of the biologically oriented preparation technique did not increase probing depth and showed a moderate rate of gingival inflammation, lower recession rates, and lower mechanical and biological failures at the 5-year follow-up. The biologically oriented preparation technique appears to be a viable alternative technique for obtaining satisfactory and stable clinical results up to 5 years. Long-term randomized clinical trials are recommended to reach more conclusions about this protocol.

The esthetic biological contour concept for implant restoration emergence profile design.

OBJECTIVE: Emergence profile design is important for stable peri-implant tissues and esthetically pleasing results with dental implant restorations, influenced by factors, such as, implant position and surrounding soft tissues. Different aspects of the emergence profile have been described, but detailed explanations of the different zones and corresponding designs are missing. This article describes the esthetic biological contour concept (EBC), differentiating important areas of the emergence profile and recommending particular designs for those zones. OVERVIEW: The EBC concept considers specific parameters for proper design of the emergence profile of implant-supported restorations. Understanding the different zones of the emergence profile and their relation to factors like implant position, implant design, and soft tissue thickness is key. The suggested guidelines are geared toward providing more stable and esthetic results when restoring dental implants in the esthetic zone. CONCLUSIONS: Each of the zones described in the EBC concept have a specific function in the design of the emergence profile. Understanding the importance and specific design features of the EBC zones facilitates esthetic and biologically sound treatment outcomes with interim and definitive implant restorations. CLINICAL SIGNIFICANCE: Proper emergence profile design supports esthetic outcomes and provides favorable biological response to implant-supported restorations.

The utilization of snap-on provisionals for dental veneers: From an analog to a digital approach.

OBJECTIVE: There are multiple treatment options to enhance a patient's smile, from conservative bleaching procedures to composite resins, porcelain veneers, or full-coverage crowns. Treating patients with porcelain veneers is a commonly used approach in esthetic dentistry. Provisional restorations for veneers can be time-consuming to make and difficult to retain. This article illustrates a technique for fabricating indirect snap-on provisional restorations for veneer cases, describing both analog and digital approaches. CLINICAL CONSIDERATIONS: The present article presents an alternative provisionalization technique using snap-on restorations for dental veneers. Application of these techniques will allow for ease of cleansability by the patient leading to healthier soft tissues before the final cementation. Delivery of veneers is more predictable with healthy soft tissue, as bleeding and inflammation may affect the bonding process. CONCLUSIONS: This technique is an effective provisionalization option in most veneer cases. This approach seems to be well accepted by patients and a good alternative in helping to maintain optimal gingival health with interim restorations before delivery. CLINICAL SIGNIFICANCE: The use of snap-on provisionals for veneer restorations will allow the clinician to have an efficient technique with better tissue response before cementation. This prevents inflammation and facilitates a controlled delivery process.

Dual-space technique for creating cement space in a cementation device for implant dentistry: A predictable chairside approach.

As residual excess cement in peri-implant tissues is a problem that can lead to implant failure, great care must be taken when delivering cement-retained crowns. Cement selection, prosthetic design, and cementation techniques can reduce the chances of having excess cement in peri-implant tissues. Multiple techniques have been described, but, in many, the cement space has been reproduced by unreliable means. The dual-space technique allows the clinician to fabricate an implant crown delivery device in which the cement space has been replicated in a predictable and straightforward manner. In this technique, light-body impression material is used to create the luting space before the fabrication of the device with bis-acryl resin.

Wear of resin teeth opposing zirconia.

STATEMENT OF PROBLEM: The use of dissimilar materials for opposing complete-mouth implant-supported prosthesis has become popular, especially when one arch is made from anatomical contour zirconia. However, the amount of wear zirconia causes on resin and other denture tooth materials is largely unknown. PURPOSE: The purpose of this in vitro study was to determine the volumetric wear of 4 commercially available resin materials used for denture teeth in complete-arch implant-supported prostheses opposed by zirconia. MATERIAL AND METHODS: A total of 32 maxillary central incisor denture teeth were evaluated (n=8): double crosslinked polymethyl methacrylate (PMMA) (DCL), nanohybrid composite resin (PHO), and computer-aided design and computer-aided manufacturing (CAD-CAM)-fabricated teeth made from crosslinked PMMA (TEL) and acrylate polymer (ZCAD). Antagonist cone-shaped specimens were milled from zirconia. Specimens were mounted in acrylic resin, polished to a flat surface by using 1200-grit SiC paper, and stored in water (37 °C for 24 hours) before exposure in a custom dual-axis wear simulator for 200 000 cycles with a vertical load of 20 N, a horizontal slide of 2 mm, and a frequency of 1 Hz. Volumetric wear was measured by using a noncontact profilometer and a superimposition software program. Data were analyzed with a 1-way analysis of variance (ANOVA) and the Tukey Honestly Significant Difference (HSD) post hoc test (α=.05). RESULTS: A statistically significant difference in volumetric wear was found between groups (P<.001), with PHO (4.3 ±1.0 mm3)

Use of Tuberosity Tissue Block for Tunneling Reconstruction of Class III Sockets With Simultaneous Implant Placement: A Case Report.

Immediate implant placement in the anterior maxilla remains a complex procedure, particularly when the cortical bone plate of the socket is not intact and a gingival recession is present. The reconstruction of both hard and soft tissues increases the complexity of these clinical scenarios. This case report describes a novel, minimally invasive technique to reconstruct class III sockets with simultaneous implant placement. Four incisions are made with a scalpel blade to create, or "draw," a square outline instead of raising a flap at the tuberosity to harvest a hard- and soft-tissue block. In addition, a tunneling approach is described to graft the site while preserving the recipient area's vascularity. Harvesting a hard- and soft-tissue block from the tuberosity in a minimally invasive manner preserves the donor site and helps to reconstruct a class III alveolus in one single appointment, thereby reducing morbidity, costs, and treatment time.

Autotransplantation of Maxillary Third Molar with Its Attached Buccal Cortical Plate Combined with a Connective Tissue Graft.

INTRODUCTION: Tooth replacement often leads to insufficient vertical volume in the recipient socket bone. The aim of this novel report is to present a successful fully guided autotransplantation of a maxillary right third molar (tooth #1) with its attached buccal plate. The procedure was combined with a palatal connective tissue graft to reconstruct a buccal hard and soft tissue defect of an irreparable maxillary right first molar (tooth #3). METHODS: A 45-year-old man complaining of pain in tooth #3 came to the clinic. Tooth #3 was non-restorable due to an extensive caries and a vertical root fracture of the mesiobuccal root, leading to a total loss of the buccal cortical plate. Guided autotransplantation of tooth #1 was completed by using 3-dimensional surgical templates for implant burs and a 3-dimensional-printed replica. After positioning the donor tooth, the cortical plate was fixed to the recipient socket with osteosynthesis screws. A connective tissue graft was also harvested to increase the band of keratinized gingiva and the thickness of the buccal soft tissue. At 6-month follow-up, the screws were removed, showing excellent regeneration throughout the buccal area. RESULTS: At 3-year follow-up, the transplanted tooth was asymptomatic, with a natural bone level and no signs of replacement or inflammatory root resorption. CONCLUSIONS: The use of a donor tooth and its attached bone cortical plate combined simultaneously with a connective tissue graft appears to improve hard and soft tissues in a single procedure.

Impacted Maxillary Canine with Curved Apex: Three-Dimensional Guided Protocol for Autotransplantation.

INTRODUCTION: Maxillary canines play a crucial role in dental and facial aspect, arch expansion, and efficient occlusion. When surgical exposure measures cannot be executed or the patient does not agree to take the treatment, autotransplantation should be considered. The aim of this case report was to describe a novel surgical technique using virtually planned three-dimensional (3D)-printed templates for guided apicoectomy and guided drilling of the recipient site for autotransplantation of an impacted maxillary canine with a curved apex. METHODS: A 42-year-old man complaining of pain and increased mobility in the maxillary left primary canine came to the clinic. Autotransplantation of the impacted canine was completed using altered methods from guided implant surgery to manufacture 3D-printed templates. After a full-thickness mucoperiosteal flap elevation, the surgical template for the guided osteotomy and apicoectomy was inserted. This 3D-printed guide allowed the clinician to perform a quick and precise removal of the curved apex, providing an atraumatic extraction of the impacted canine throughout the cyst. Three further 3D surgical guides for implant burs and a 3D replica tooth were printed to modify the recipient socket. After the final position, the tooth was semi-rigid splinted to the adjacent teeth. RESULTS: Follow-up at 2 years showed complete regeneration of the palatal defect and remodeling of the bone surrounding the maxillary canine. CONCLUSIONS: Digitally planned procedures can facilitate the complex execution of an autotransplantation, reducing the treatment chair time and the morbidity for the patient as well as increasing the predictability of the result.

Dimensional Changes in the Alveolus after a Combination of Immediate Postextraction Implant and Connective Grafting and/or Socket Shield Technique.

Immediate implant placement protocols after dental extraction have enabled a reduction in surgical phases. This procedure has increased patient satisfaction and similar survival rates to late implant placement procedures. However, placing an implant immediately after dental extraction does not counteract the physiological remodeling of alveolar bone. For this reason, additional surgical techniques have been developed, such as the placement of a connective tissue graft (CTG) or the socket shield technique (SST). Dimensional changes in the peri-implant tissues were observed after placement of immediate implants following the extraction and CTG and/or SST. A total of 26 surgical interventions were carried out in which dimensional change variables of peri-implant tissues were analyzed. The preoperative state and immediate postoperative situation were compared with the situation after one year. Measurements were taken at 3, 5, and 7 mm from the gingival margin and analyzed in this CBCT radiological study (Planmeca Promax 3D). The implant platform was used as a reference point for the measurement of changes in alveolar crest height. One year after performing either of the two techniques (CTG and/or SST), a significant increase in the gingiva thickness and vestibular cortex occurred at 5 mm (0.65 ± 1.16 mm) and 7 mm (0.95 ± 1.45 mm) from the gingival margin. Additionally, an increase in thickness of palatal bone was registered at 3 mm (0.48 ± 0.90 mm). The graft placement group showed an increase in thickness of peri-implant tissue in the vestibular area after one year, although CTG and SST groups were clinically similar. The implementation of SST revealed promising results regarding the buccal thickness of hard and soft tissues after one year. A significant increase in vestibular cortical bone thickness, as well as the overall mucosa thickness and buccal bone at 3 mm from the gingival margin, was observed. A significant reduction in the distance from the bone crest to the platform was detected in both techniques. Both techniques (CTG and SST) are appropriate to provide sufficient volume to peri-implant tissues in the vestibular area of anterior maxillary implants. Some limitations were detected, such as the lack of an aesthetic analysis or small sample size, so results should be interpreted with caution. Future studies are necessary to further evaluate the long-term predictability of these techniques.

The Impact of 3D Implant Position on Emergence Profile Design.

Implant position and soft tissue thickness have a direct influence on implant abutment design. The goal is to place the implant in the optimal spatial position to maintain the adjacent bone and soft tissues. When the implant is not placed ideally, prosthetic variations to abutments and restorations must be made, which may limit the esthetic appearance of the final restoration or alter the biologic environment of the bone and tissues. This article illustrates and explains the effect of different implant positions on the emergence profile design in order to assist the clinician with treatment planning and selection in various clinical situations.

Assessment of gingival symmetry with digital measuring tools and its reproducibility.

OBJECTIVE: The aim of this study was to investigate the accuracy of digital measuring tools to measure the position of gingival zeniths and to assess its reproducibility between different examiners. MATERIALS AND METHODS: A total of 108 subjects were photographed at the Louisiana State University School of Dentistry. The settings, positioning of the digital camera, and subjects' Frankfurt levels were standardized. A photograph was taken of the six anterior maxillary teeth of each subject, and their corresponding free gingival margins. Digital caliper measurements were taken intraorally from the zenith to the incisal edge of the right maxillary central incisor. A reference line was drawn across the screen on each image at the level of the zenith of tooth 8. Three calibrated examiners then measured the distance from the reference line to the zeniths of the other five anterior maxillary teeth. RESULTS/CONCLUSIONS: There was no statistically significant difference between the examiners regarding any of the measurements. Central incisors were at the same level in 84.24% of the subjects, and lateral incisors were within 0.5 mm of central incisors in only 58% of the subjects. Canine zeniths were within 0.5 mm of each other in 43% of the subjects. Only 28% of the subjects presented with zeniths of tooth 6 to tooth 11 within 0.5 mm of each other. Lateral incisors were at or beneath the line drawn from central incisors to cuspids in 90.8% of the subjects. Standardized digital photography taken with the aid of a stadiometer and used to evaluate esthetic parameters allowed for reproducible measurements.