Esthetic, clinical, and radiographic outcomes of two surgical approaches for single implant in the esthetic area: 1-year results of a randomized controlled trial with parallel design.

AIM: The objectives of this study were to compare (a) esthetic, (b) clinical, (c) radiographic, and (d) patient-centered outcomes following immediate (Type 1) and early implant placement (Type 2). MATERIAL AND METHODS: Forty-six subjects needing a single extraction (premolar to premolar) were randomly allocated to Type 1 or Type 2 implant placement. One year following permanent restoration, evaluation of (a) Esthetics using soft tissue positions, and the pink and white esthetic scores (PES/WES), (b) Clinical performance using probing depth, modified plaque index, and sulcus bleeding index (c) Radiographic bone level, and (d) Patient satisfaction by means of visual analogue scales (VAS) was recorded. RESULTS: Thirty-five patients completed the one-year examination (Type 1, n = 20; Type 2, n = 15). Type 1 implants lost 1.03 ± 0.24 mm (mean ± SE) of mid-facial soft tissue height while Type 2 implants lost 1.37 ± 0.28 mm (p = 0.17). The papillae height on the mesial and distal was reduced about 1 mm following both procedures. Frequency of clinical acceptability as defined by PES ≥ 6 (Type 1: 55% vs. Type 2 40%), WES ≥ 6 (Type 1: 45% vs. Type 2 27%) was not significantly different between groups (p > 0.05). Clinical and radiographic were indicative of peri-implant health. Patient-centered outcomes failed to demonstrate significant differences between the two cohorts. CONCLUSION: One year after final restoration, there were no significant differences in esthetic, clinical, radiographic, and patient-centered outcomes following Type 1 and Type 2 implant placement. At one year, patient satisfaction may be achieved irrespective of the two placement protocols.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Esthetic, clinical and patient-centered outcomes of immediately placed implants (Type 1) and early placed implants (Type 2): preliminary 3-month results of an ongoing randomized controlled clinical trial.

AIM: The objective of the study was to compare (i) esthetic, (ii) clinical and (iii) patient-centered outcomes following immediate (Type 1) and early implant placement (Type 2). MATERIAL AND METHODS: Thirty-eight subjects needing a single extraction (premolar to premolar) were randomly allocated to Type 1 or Type 2 implant placement. Three months following permanent crown insertion, evaluation of (i) esthetic outcomes using soft tissue positions, and the pink and white esthetic scores (PES/WES), (ii) clinical performance using probing pocket depth (PPD), modified plaque index (mPI) and modified sulcus bleeding index (mSBI) around each implant and (iii) patient satisfaction by means of a questionnaire using a visual analogue scale (VAS) was performed. RESULTS: Thirty-two patients completed the 3-month follow-up examination (Type 1, n = 17; Type 2, n = 15) with a 100% implant survival rate. Type 1 implants lost 0.54 ± 0.18 mm of mid-facial soft tissue height, while Type 2 implants lost 0.47 ± 0.31 mm (P > 0.05). The papillae height on the mesial and distal was reduced about 1 mm following both procedures. The PES/WES following Type 1 implant placement amounted to 13.7 ± 0.6 and 12.5 ± 0.7 in the Type 2 group (P > 0.05). PPD, mPI and mSBI were low in both groups (P > 0.05). Patient-centered outcomes failed to demonstrate any statistical difference between the two cohorts. CONCLUSION: Three months following final crown delivery, there were no significant differences in esthetic, clinical and patient-centered outcomes following Type 1 and Type 2 implant placement. On the short term, one may achieve good optimal esthetic and clinical results irrespective of these two placement protocols. These results need to be confirmed on the long term.

Bone-Level Tapered Implants for Single Tooth Replacement: Immediate vs Delayed Placement-A Multicenter Randomized Controlled, 1-Year, Non-inferiority Clinical Study.

PURPOSE: To compare the outcomes of immediate and delayed implant placement with bone-level tapered implants. MATERIALS AND METHODS: In this post-market, multicenter prospective randomized controlled study with a primary endpoint of 1 year, 53 patients were randomized to receive either immediate implant placement (test group) or delayed implant placement (control group). The mean crestal bone level changes from implant loading to 12 months postloading were measured using standardized digital periapical radiographs. Changes in facial plate thickness (as measured on CBCT images), implant success and survival, implant stability, soft tissue changes, patient-centered outcomes, and adverse events were measured to assess outcomes between the test and control treatments at 12 months postloading. RESULTS: Of the original 53 patients, 46 patients completed the study (23 in each group). Mean bone changes from loading to the 12-month follow-up were recorded with no statistically significant difference (P = .950) between the groups. The hypothesis was confirmed that immediate implant placement (test) in extraction sockets produces in similar outcomes as delayed placement (control). The test group was found to be similar to the control group (P = .022) in terms of mean changes in facial plate thickness. Implant survival and success were 95.8% in the test group and 92% in the control group. Stability in the control group was superior at the time of surgery, but there was no difference between the groups at implant loading, producing a nonsignificant P value of .563). CONCLUSIONS: This randomized controlled multicenter study showed comparable outcomes 1 year after prosthetic loading in the immediate and delayed implant placement groups.

Impact of different surgical protocols on dimensional changes of free soft tissue autografts: A randomized controlled trial.

BACKGROUND: To determine if there is a difference in the amount of shrinkage during healing of free soft tissue autografts (FSTAs) using different surgical techniques-suturing the vestibular flap margin apically to the base of the recipient bed versus leaving the flap margin free and unsutured. METHODS: Twenty-eight patients with mucogingival defects requiring FSTAs were recruited and enrolled in the study. Patients were randomized into test and control groups (14 per group) and received ≥1 FSTAs on non-molar mandibular teeth. In the test group the mucosal flap margin was sutured apically to the periosteum at the base of the graft; whereas, the mucosal flap margin in the control group was left free. Graft dimensional measurements were taken at time of surgery, then at 1, 3, and 6 months post-surgery. RESULTS: Thirty-five grafts were performed (15 test, 20 control). All FSTAs experienced vertical shrinkage after 6 months, but there was no significant difference (P = 0.51) in the mean amount of shrinkage after 6 months between the test (23.20% ± 20.88%) and control (21.10% ± 21.88%) groups. There was significantly greater horizontal shrinkage in the test (loss of 7.59% ± 10.20%) compared with the control (small gain of 0.32% ± 4.20%) group (P = 0.01). CONCLUSIONS: The findings suggest that there is similar vertical shrinkage when performing FSTA surgery when the mucosal flap margin is left free and unsutured when compared with leaving the flap margin free.

Post-surgical flap placement following osseous surgery: A short-term clinical evaluation.

BACKGROUND: The purpose of this study is to examine the relationship between immediate post-surgical flap position and subsequent probing depth measurements following osseous surgery. METHODS: Twenty-four patients treatment planned for osseous surgery after completion of initial therapy and re-evaluation were enrolled. Pressure molded stents were fabricated to serve as a reference for probing depth and relative attachment level measurements prior to surgery. After osseous recontouring was completed, flaps were sutured and compressed, and bone sounding measurements were made as designated by the stent. Patients returned at 3- and 6 months for repeat measurements of probing depth and attachment level. RESULTS: Twenty-four patients completed surgical treatment and follow-up measurements with a total of 402 treated sites. A statistically significant moderate correlation between immediate post-surgical bone sounding measurements and subsequent probing depth was found at 6 months (R = 0.56, P < 0.001). There was no significant difference between this correlation at 3 and 6 months. The probability of having 6 month probing depth ≤3 mm was 93.5% when the surgical flap was placed within 3 mm of the alveolar crest (286/306 sites) as opposed to 50% when the surgical flap was >3 mm away from the alveolar crest (48/96 sites). Interproximal sites were significantly more likely (P < 0.01) to have probing depths > 3 mm at 3 and 6 months. CONCLUSIONS: Results suggest a statistically significant relationship between immediate post-surgical flap placement and subsequent probing depths. Positioning the surgical flap more closely to the alveolar crest when performing osseous surgery resulted in shallower probing depths at 3 and 6 months.

Management of Thick and Thin Periodontal Phenotypes for Immediate Dental Implants in the Esthetic Zone: A Controlled Clinical Trial.

The goal of the study was to compare the outcome of immediate single-implant placement in esthetic sites of patients with thick or thin tissue phenotypes. Forty-one patients underwent implant surgery with guided bone regeneration including peri-implant gap and overcontour grafting. A connective tissue graft was added only for patients with a thin tissue phenotype. Twenty-six patients completed the 12-month follow-up examination (thick, n = 14; thin, n = 12). The thick-phenotype group gained 0.01 ± 1.56 mm of midfacial soft tissue height, while the thin-phenotype group lost 0.20 ± 1.14 mm (P = .21). There was no significant difference in buccal plate thickness achieved at time of uncovery, pink and white esthetic scores, radiographic bone levels, and clinical parameters between the two groups. These results suggest that when the suggested treatment protocol is followed, there are no significant differences in the outcomes of immediate implant placement for patients with different soft tissue phenotypes.

Comparison of clinical, periapical radiograph, and cone-beam volume tomography measurement techniques for assessing bone level changes following regenerative periodontal therapy.

BACKGROUND: Intraoral radiographs (IRs) provide a two-dimensional view of osseous structures, whereas cone-beam volumetric tomography (CBVT) images are viewable in three dimensions. The aim of this investigation was to compare the measurements from digital IR and CBVT images to direct surgical measurements for the evaluation of regenerative treatment outcomes. METHODS: Digital IR and CBVT images were taken prior to initial bone grafting and at the 6-month reentry surgery for 35 intrabony defects. After defect debridement, direct bony defect measurements were made with a periodontal probe. These same measurements were made on the IR and CBVT images and then compared to the direct surgical values. RESULTS: CBVT correlated strongly with surgical measurements (r = 0.89 to 0.95), whereas IRs correlated less favorably (r = 0.53 to 0.67). IR measurements were significantly less accurate compared to CBVT for all parameters investigated and underestimated surgical measurements from 0.6 +/- 2.3 mm to 1.5 +/- 2.3 mm. No significant difference for the distance from the cemento-enamel junction (CEJ) to the alveolar crest (P = 0.66 for initial measurement and P = 0.92 for reentry), defect fill (P = 0.14), or defect resolution (P = 0.09) was seen between CBVT and surgical measurements; however, there was a significant difference for the distance from the CEJ to the base of the defect, with CBVT measurements underestimating the surgical measurements by 0.5 +/- 1.1 mm for reentry (P <0.01) and 0.9 +/- 0.8 mm for the initial measurement (P <0.01). CONCLUSIONS: Overall, compared to direct surgical measurements, CBVT was significantly more precise and accurate than IRs. If supported by further research, CBVT may obviate surgical reentry as a technique for assessing regenerative therapy outcomes.

Clinical evaluation of demineralized freeze-dried bone allograft with and without enamel matrix derivative for the treatment of periodontal osseous defects in humans.

BACKGROUND: Beneficial clinical effects have been demonstrated with the addition of enamel matrix derivative (EMD) to demineralized freeze-dried bone allograft (DFDBA) compared to EMD alone. The purpose of this study was to evaluate the effectiveness of DFDBA combined with EMD compared to DFDBA alone in the treatment of intraosseous defects of chronic periodontitis. METHODS: Thirty-two patients with 41 intrabony defects > or = 3 mm were randomly assigned to one of two treatment groups. Intrabony defects were treated with DFDBA alone or in combination with EMD. Soft tissue measurements included probing depth (PD), gingival recession, and clinical attachment level (CAL). Hard tissue measurements included height of the alveolar crest, defect depth, and defect morphology. Following 6 months of healing, all measurements were repeated with the use of a surgical reentry procedure on 29 patients. Data were analyzed to determine PD reduction, CAL gain, change in recession, crestal resorption, defect fill, defect resolution, percentage of defect fill, and percentage of defect resolution. RESULTS: Analysis of soft and hard tissue measurements demonstrated a statistically significant difference from baseline within each group (P <0.001); however, there was no statistically significant difference between the groups. CONCLUSION: Both treatments were shown to be safe and effective therapy for periodontal defects; however, the addition of EMD to DFDBA provided no statistically significant improvement to the soft and hard tissue parameters measured.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Osseous Healing Around Immediate Implants Placed Using Contour Augmentation: A Prospective Case Series.

The purpose of this study was to prospectively evaluate the dimensional bone changes around implants placed immediately with buccal contour augmentation. Patients with hopeless maxillary anterior teeth were treated with extraction, immediate implant placement, and simultaneous buccal contour augmentation. Hard tissue measurements were recorded at the time of implant placement and after 3 months of healing. All implants (N = 18) successfully osseointegrated with a mean buccal bone thickness of 2.94 ± 0.21 mm (mean ± SE) at the implant platform. This was significantly greater compared to previous data on immediate implants placed without contour augmentation (2.32 ± 0.17 mm). Buccal contour augmentation in conjunction with immediate implant placement significantly increased peri-implant buccal bone thickness after 3 months of healing.

Clinical and Radiographic Evaluation of Demineralized Freeze-Dried Bone Allograft Versus Platelet-Rich Fibrin for the Treatment of Periodontal Intrabony Defects in Humans.

BACKGROUND: A wide variety of materials have been proposed for treatment of periodontal intrabony defects (IBDs); recently, platelet-rich fibrin (PRF) has been suggested as a grafting material. The aim of this study is to report changes in clinical attachment level (CAL) and bone fill of periodontal IBDs treated with demineralized freeze-dried bone allograft (DFDBA) compared with PRF in humans. METHODS: Thirty-six patients completed the study protocol. Each patient contributed a single IBD, which was randomized to receive either DFDBA or PRF. Clinical and standardized radiographic data were collected at baseline and 6 months after treatment. Primary outcome measures included: 1) radiographic bone fill as measured from the cemento-enamel junction to base of bony defect and 2) change in CAL. RESULTS: Both treatment groups had significant gains in CAL as well as bone fill, with no significant differences in outcomes between groups. DFDBA had a mean CAL gain of 1.16 ± 1.33 mm, mean clinical bone fill of 1.53 ± 1.64 mm, and mean radiographic bone fill of 1.14 ± 0.88 mm. PRF had a mean CAL gain of 1.03 ± 0.86 mm, mean clinical bone fill of 1.35 ± 1.60 mm, and mean radiographic bone fill of 1.10 ± 1.01 mm. CONCLUSION: Treatment of IBDs with either DFDBA or PRF resulted in a significant gain in CAL as well as bone fill after 6 months of healing, with no significant difference between materials.

Evaluation of demineralized bone matrix paste and putty in periodontal intraosseous defects.

BACKGROUND: Demineralized bone matrix (DBX) paste and putty are particulate demineralized bone matrices in a 2% or 4% hyaluronate carrier, respectively. The purpose of this study was to determine the effectiveness of DBX paste and putty compared to demineralized freeze-dried bone allograft (DFDBA) in the treatment of human intraosseous periodontal defects. METHODS: Sixty systemically healthy individuals between the ages of 31 and 71 years with at least one intraosseous periodontal defect of > or = 3 mm in depth and radiographic evidence of at least 40% to 50% vertical bone loss were accrued. Following initial non-surgical periodontal therapy, sites were randomly selected to receive either DBX paste, DBX putty, or DFDBA (control). Baseline and 6-month reentry soft and hard tissue parameter measurements were made by calibrated examiners. Data were analyzed within and between groups utilizing analysis of variance (ANOVA) and paired and unpaired Student t tests. RESULTS: Probing depth reductions were significantly improved in all treatment groups with DFDBA, DBX paste, and putty patients demonstrating 2.8 mm, 3.6 mm, and 2.3 mm, respectively. Attachment level gains were significantly improved from baseline for all treatment groups with DFDBA, DBX paste, and putty, respectively, demonstrating 2.4 mm, 2.9 mm, and 1.6 mm. Bone fill was similar between all groups with DBX paste, putty, and DFDBA control groups demonstrating 2.0 mm, 2.4 mm, and 2.2 mm, respectively. All groups yielded significant improvements in percent bone fill with DFDBA, DBX paste and putty, respectively, achieving 37%, 42.1%, and 50% with no significant differences between the groups. CONCLUSION: In summary, demineralized bone matrix paste, demineralized bone matrix putty, and demineralized freeze-dried bone allograft all demonstrated similar favorable improvements in soft and hard tissue parameters in the treatment of human intraosseous defects.

Lateral alveolar ridge augmentation using tenting screws, acellular dermal matrix, and freeze-dried bone allograft alone or with particulate autogenous bone.

This randomized prospective study evaluated the clinical benefits of using a corticocancellous mixture of freeze-dried bone allograft alone or in combination (1:1) with particulated autogenous bone for horizontal ridge augmentation and subsequent implant placement. Twenty-four patients with atrophic ridges received lateral ridge augmentations with particulate grafts placed around tenting screws and covered with a fixed acellular dermal matrix membrane. Thirty-three standard-diameter implants were successfully placed in 21 patients after a 24-week graft healing period. Three patients experienced early postoperative infections following the grafting procedure (12.5% of sites). At reentry, the allograft alone group showed similar average horizontal ridge width gains (3.33 ± 0.83 mm) to the combination group (3.09 ± 0.63 mm; P = .44). The mean graft resorption between baseline and reentry averaged 13.89%.

Periodontal Regeneration - Intrabony Defects: Practical Applications From the AAP Regeneration Workshop.

Focused Clinical Question: What are important considerations for selecting a predictable regenerative surgical approach for intrabony defects? Summary: The predictable regeneration of intrabony defects remains an important goal in the management of periodontitis. Clinical and histologic evidence of periodontal regeneration has been shown for multiple regenerative therapies, including bone replacement grafts, guided tissue regeneration, and biologics, when used alone or in combination. Regenerative therapies improve periodontal health, as evidenced by gains in clinical attachment level, reductions in probing depth, and gains in radiographic bone fill. Important patient-related factors (e.g., smoking) and defect/site-related factors (e.g., defect morphology and gingival biotype) can influence the potential to achieve periodontal regeneration. The regeneration of intrabony defects generally becomes more challenging with increasing loss of height, proximity, and number of bony walls. Therefore, combination therapies may be necessary to achieve predictable regeneration. Clinical improvements after regenerative therapy can be maintained over extended periods (≥10 years) with professional maintenance at appropriate intervals and adequate home care. Conclusions: Periodontal regeneration of intrabony defects is possible using a variety of regenerative strategies. Management should be coupled with an effective oral hygiene and supportive periodontal maintenance program for long-term success.

Periodontal regeneration - intrabony defects: a consensus report from the AAP Regeneration Workshop.

BACKGROUND: Treatment of intrabony defects is an important therapeutic goal of periodontal therapy. The goal of this consensus report was to critically appraise the evidence for the available approaches for promoting periodontal regeneration in intrabony defects. In addition to evaluating the effectiveness of new regenerative approaches for intrabony defects, recommendations for future research were defined for this area. METHODS: A systematic review was conducted using computerized searches of PubMed and Cochrane databases, supplemented with screening of references in original reports, review articles, and a hand search in selected journals. All searches were focused on regenerative approaches with histologic evidence of periodontal regeneration (proof of principle), clinical trials, and case reports. For purposes of analysis, change in intrabony defect fill was considered the primary outcome variable, with change in clinical attachment as a secondary outcome. The SORT (Strength of Recommendation Taxonomy) grade was used to evaluate the quality and strength of the evidence. During the consensus meeting, the group agreed on the outcomes of the systematic review, pertinent sources of evidence, clinical recommendations, and areas requiring future research. RESULTS: The systematic review, which was conducted for the consensus conference, evaluated the effectiveness of the use of biologics for the treatment of intrabony defects. Enamel matrix derivative (EMD) and recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with ß-tricalcium phosphate were shown to be efficacious in regenerating intrabony defects. The level of evidence is supported by multiple studies documenting effectiveness. The clinical application of biologics supports improvements in clinical parameters comparable with selected bone replacement grafts and guided tissue regeneration (GTR). Factors negatively affecting regeneration included smoking and excessive tooth mobility. CONCLUSIONS: Periodontal regeneration in intrabony defects is possible on previously diseased root surfaces, as evidenced by a gain in clinical attachment, decreased pocket probing depth, gain in radiographic bone height, and overall improvement in periodontal health. These clinical findings are consistent with available histologic evidence. Clinical improvements can be maintained over long periods (>10 years). Although bone replacement grafts have been the most commonly investigated modality, GTR, biologics, and combination therapies have also been shown to be effective. Future research should emphasize patient-reported outcomes, individual response differences, and emerging technologies to enhance treatment results. CLINICAL RECOMMENDATIONS: Early management of intrabony defects with regenerative therapies offers the greatest potential for successful periodontal regeneration. The clinical selection and application of a regenerative therapy or combination of therapies for periodontal regeneration should be based on the clinician's experiences and understanding of the regenerative biology and technology. This decision-making process should take into consideration the potential adverse influence of factors, such as smoking, poor oral hygiene, tooth mobility, and defect morphology, on regeneration. Management should be coupled with an effective maintenance program for long-term success.

Clinical evaluation of demineralized freeze-dried bone allograft and enamel matrix derivative versus enamel matrix derivative alone for the treatment of periodontal osseous defects in humans.

BACKGROUND: A recent study suggests that the addition of enamel matrix derivative to demineralized freeze-dried bone allograft may enhance osseoinduction. The purpose of this study was to evaluate the use of demineralized freeze-dried bone allograft (DFDBA) in combination with enamel matrix derivative (EMD + DFDBA) compared to enamel matrix derivative (EMD) alone in the treatment of human intrabony periodontal defects. METHODS: Forty patients with a total of 67 sites (intrabony defect > or = 3 mm deep) were selected to participate in this single-masked, parallel design, randomized, controlled clinical trial. Each subject received either EMD alone (34 sites) or in combination with DFDBA (33 sites). Soft tissue measurements included probing depth (PD), clinical attachment level (CAL), and recession. Hard tissue measurements included defect depth, alveolar crestal resorption, and defect morphology. Following 6 months of healing, all soft tissue measurements were repeated. Forty-nine sites (EMD + DFDBA = 26 sites, EMD alone = 23 sites) were surgically reentered. Statistical analyses were performed using unpaired and paired Student t tests. RESULTS: Analyses showed a significant improvement in soft tissue parameters for both treatment groups (P < 0.001) as compared to preoperative measurements. There were no statistical differences between treatment groups. The probing depth reduction (PDR) for the EMD + DFDBA was 3.6 +/- 0.2 mm, while the EMD alone had a PDR of 4.0 +/- 0.3 mm. The CAL gain for the EMD + DFDBA group was 3.0 +/- 0.3 mm and 3.2 +/- 0.3 mm for the EMD alone group. The mean value for bone fill in the EMD + DFDBA group was 3.7 +/- 0.2 mm (74.9%), while the EMD alone group demonstrated a mean bone fill of 2.6 +/- 0.4 mm (55.3%). While there were no significant differences between the two treatments with regards to soft tissue measurements, the combination of EMD + DFDBA therapy yielded statistically significant improvements in bone fill, crestal resorption, and percentage of sites gaining greater than 50% and 90% bone fill when compared to EMD alone (P < 0.001). CONCLUSION: The results of this study indicate that there may be an enhancement of hard tissue parameters when enamel matrix derivative is added to demineralized freeze-dried bone allograft.

Guided bone regeneration around titanium plasma-sprayed, acid-etched, and hydroxyapatite-coated implants in the canine model.

BACKGROUND: Endosseous dental implants with rough surfaces have been designed to improve early healing, especially in areas of poor bone or insufficient bone quantity. The aim of this study was to histomorphometrically assess the bone-to-implant contact on 3 different rough-surfaced implants following guided bone regeneration. METHODS: Mandibular premolars and first molars were extracted in 12 dogs, and healing was allowed for 6 months. Six implant osteotomy sites were prepared, 3 per side, followed by the creation of 7.3 mm wide by 5 mm deep surgical defects in the coronal section of the osteotomy sites. Ten-mm long titanium screw-type implants with titanium plasma-sprayed (TPS), hydroxyapatite-coated (HA), or acid-etched (AE) surfaces were placed; the surrounding defects were filled with canine demineralized freeze-dried bone allograft; implants/grafts were covered with expanded polytetrafluoroethylene membranes; and the tissue was closed. Following a healing period of 4 months, the animals were sacrificed and mandibular blocks were harvested for histomorphometric analysis. RESULTS: The mean percentage of bone-to-implant contact in the defect and non-defect areas for the different implant surfaces was: AE 16.24% defect, and 28.78% non-defect; TPS 25.08% defect, and 16.96% non-defect; and HA 48.25% defect and 26.60% non-defect. Within the defect, the mean difference in the bone-to-implant contact was significant for HA compared to TPS (P < 0.0001) and HA versus AE (P < 0.0001); TPS versus AE was not significant (P = 0.063). In the non-defect areas, the mean difference in the bone-to-implant contact was significant for AE versus TPS (P = 0.010); all other comparisons were not significant. There were 18 membrane exposures in the 72 implant sites. Data were analyzed again to assess the impact of membrane complications. Using a 1-way analysis of variance, the bone-to-implant contact was compared between the sites with and without membrane complications. No significant differences were seen in the defect areas or in the non-defect areas between the sites with and without membrane complications. CONCLUSION: In this study, the bone-to-implant contact in regenerated bone was greatest when an HA-coated implant was used.

Clinical evaluation of freeze-dried block allografts for alveolar ridge augmentation: a case series.

Various grafting materials have been used in guided bone regeneration procedures to augment alveolar ridges deficient in horizontal or vertical dimensions or both. Autogenous block grafts from intraoral and extraoral sites have been used for ridge augmentation with encouraging results. However, the risk of vascular and neurologic injury at the donor site as well as postoperative patient morbidity have been reported following these surgical procedures. The use of a cancellous block allograft could be one alternative to avoid potential donor site complications. Five deficient alveolar ridges in three patients were each grafted with a freeze-dried cancellous block allograft and a resorbable barrier membrane. Ridge measurements taken at baseline, graft placement, and a 6-month reentry surgery demonstrated an increase in alveolar ridge width from 2 to 4 mm. These gains in ridge width compare favorably with other guided bone regeneration studies, suggesting that a freeze-dried cancellous block allograft in conjunction with a resorbable membrane may be an acceptable alternative to the autogenous block graft in the treatment of compromised alveolar ridge deficiencies.

Clinical and histologic evaluation of anorganic bovine bone collagen with or without a collagen barrier.

This study evaluated an anorganic bovine-derived xenograft (Bio-Oss Collagen) in the treatment of human periodontal defects. Four patients with intrabony defects on teeth that were treatment planned for extraction were enrolled in the study. Presurgical measurements of probing depth, attachment level, and recession were recorded. The surgical procedure consisted of flap reflection, debridement of the osseous defects and root surface, placement of a notch through calculus into the root surface, topical application of a tetracycline paste to the root surface, grafting with Bio-Oss Collagen, and flap closure. Three of the eight defects examined received a resorbable collagen barrier (Bio-Gide) in addition to the bone graft. Patients were seen every 2 weeks for plaque control and review of oral hygiene measures. Six months postsurgery, clinical parameters were rerecorded prior to en bloc resection of teeth and adjacent graft sites. The majority of sites showed a favorable clinical response with respect to probing depth reduction and clinical attachment gain. Histologic analysis demonstrated new bone, cementum, and periodontal ligament coronal to the reference notch in two of the eight specimens. Two sites demonstrated new attachment, and four showed a long junctional epithelium. Periodontal regeneration is possible following a bone-replacement graft of Bio-Oss Collagen.