A root volume study of the adult dentition for ridge preservation purposes.

Ridge preservation has become a common practice to preserve the remaining alveolar bone volume after tooth extraction. The most common volume of graft material in commercially available vials is between 0.50 and 1.00 mL. The clinician must estimate how much grafting material is needed after extracting a tooth. The aim of this study is to provide the clinician with a volumetric guide for selection of graft material for ridge preservation after tooth extraction. Fifteen sets of permanent teeth, each representing a full adult dentition excluding the third molars, were selected at random from a collection of extracted teeth. Teeth were submerged in a polyvinyl siloxane impression material to record the negative impression of the root. Water was then used to fill this space and measure the root volume. For the majority of the teeth, 0.50 mL of graft material was adequate for grafting the socket. A volume greater than 0.50 mL was required to preserve the maxillary and mandibular first molars. Overestimation or underestimation of the amount of grafting material necessary postextraction may result in unnecessary expense.

Scaling and root planing vs. conservative surgery in the treatment of chronic periodontitis.

A renewed interest in conservative surgical techniques has been fueled by new technology, changes in referral patterns to periodontists and a desire to achieve periodontal health in the least invasive, most cost-efficient manner possible. Trends suggest that an increasing amount of periodontal care is being provided in the offices of general dentists. If true, it is likely that patients receiving care in these offices will be offered simpler surgical treatment modalities that do not require an extensive armamentarium. The purpose of this article was to review the effectiveness of six relatively simple surgical techniques - gingivectomy, flap debridement, modified Widman flap, excisional new attachment procedure, modified excisional new attachment procedure and laser-assisted new attachment procedure - and to compare the results obtained using these procedures with the well-known clinical benefits of scaling and root planing. The intent was to determine whether the benefits of surgical procedures in the hands of most general dentists extend beyond those of conventional nonsurgical therapy.

Subgingival scaling and root planing during minimally invasive periodontal surgery: A randomized controlled split-mouth trial.

BACKGROUND: The purpose of this randomized, controlled split-mouth study was to evaluate a videoscope as a visual adjunct to scaling and root planing when utilized in combination with minimally invasive surgery. METHODS: Twenty-five pairs (89 interproximal surfaces) of periodontally hopeless teeth planned for extraction were scaled and root planed with minimal surgical access using surgical loupes (control) or adjunctive use of a videoscope (test). Teeth were extracted with minimal trauma, stained with methylene blue, and photographed with a digital microscope for analysis. The primary outcome of residual calculus was calculated as a percentage of the total interproximal area of interest. Secondary outcomes included treatment time, as well as residual calculus according to probing depth, tooth location, and treatment date. Data were analyzed using Student's paired t-tests, two-way analyses of variance, and Spearman's correlation tests. RESULTS: Residual calculus area was 2.61% on control and 2.71% on test surfaces with no significant difference between groups. Subgroup analysis showed no difference in residual calculus between groups at moderate or deep sites. Treatment time per surface was significantly longer in the test group compared to the control group. Treatment order, tooth location, and operator experience did not significantly affect the primary outcome. CONCLUSIONS: Though the videoscope provided excellent visual access, it did not improve the efficacy of root planing for flat interproximal surfaces during minimally invasive periodontal surgery. Small amounts of calculus remain after instrumentation even with minimal surgical access and when root surfaces appear visually clean and tactilely smooth.

The application of leukocyte- and platelet-rich fibrin (L-PRF) in maxillary sinus augmentation.

BACKGROUND: Since the introduction of sinus augmentation in the 1970s the procedure has been performed with or without biomaterials. Autologous blood products (ABPs) for use in sinus augmentation was first introduced in the 2000s, to aid potentially in bone and soft tissue healing. METHODS: Three different applications of leukocyte- and platelet-rich fibrin (L-PRF) in maxillary sinus augmentation are presented in this case series. In case 1, L-PRF is used in bilateral sinus augmentation to support placement of implants to support a maxillary hybrid denture. Case 2 highlights the use of L-PRF in a complication associate with Schneiderian membrane elevation. Case 3 provides histology taken at the time of implant placement 6 months following L-PRF/xenograft sinus augmentation. RESULTS: All cases resulted in the successful placement of dental implants. In case 2, an osseodensification procedure was performed with freeze-dried bone allograft, which provided an approximate 4 mm of additional vertical height for implant placement. Histology from case 3 at 6 months post sinus augmentation demonstrated the presence of new vital bone in contact with the xenograft. CONCLUSION: To date, there is only a limited amount of evidence reporting on platelet-rich fibrin (PRF) or L-PRF use in maxillary sinus augmentation. Bone gain from either product has ranged from 3.2 to 11.8 mm, with the percentage of newly formed bone reported in case series as 33% ± 5%. Despite the lack of strong evidence, L-PRF appears to have beneficial effects on bone regeneration when used in sinus augmentation.

Evaluation of the need to prescribe opioid medication to control post-surgical pain of different periodontal/oral surgeries.

BACKGROUND: To determine the level of perceived pain after different types of periodontal/oral surgical procedures, and the differences in patients' selection of pain management, over the counter (OTC) versus opioid, based on procedure type. METHODS: Patients undergoing surgical procedures were asked to complete a pain questionnaire at four time points: 1) before surgery 2) first dose of analgesic at home, 3) 24 hours postoperatively, and 4) 72 hours postoperatively. The questionnaire consisted of numerical and descriptive scales to describe the perceived pain. RESULTS: A total of 198 patients completed the questionnaire. All surgical procedures were grouped into five major categories: bone augmentation procedures (11% BAP), teeth extractions (26% EXT), surgical implant placement (25% IP), mucogingival surgeries (21% MGS), and pocket elimination procedures (17%). IP surgery was associated with significantly less pain compared with MGS and EXT (P <0.05). There was a statistically significant difference for taking any medication based on type of surgical procedure at 24 hours (P <0.05). CONCLUSIONS: IP is associated with significantly lower perceived pain compared with EXT and MGS surgery. Analgesic consumption was generally parallel to pain perception. A considerable number of patients elected to control the post-surgical pain using OTC medication up to 72 hours. Periodontal/oral surgery procedures vary in the amount of perceived postoperative pain. Tailoring postoperative medications to the type of periodontal/oral surgery performed will help prevent overprescribing of opioids.

Periodontal wound healing with and without platelet-rich plasma: histologic observations and assessment of flap tensile strength.

BACKGROUND: Platelet-rich plasma (PRP) has been promoted as a surgical adjunct to enhance hard and soft tissue wound healing. Although anecdotally reported to be of value, the results of controlled studies examining the added effects of PRP on surgical procedures have been mixed. The purpose of this study was to test the effect of PRP on flap strength at various post-surgical time points in a minipig animal model. METHODS: Twelve Yucatan minipigs provided four sites per animal. PRP was prepared from each animal at the time of surgery. Following reflection of a mucoperiosteal flap in each quadrant, subgingival plaque and calculus were removed. Each surgical site was irrigated with sterile saline; prior to suturing, one randomly selected test quadrant in each arch was treated with PRP. Four animals were euthanized at day 14, and two animals were euthanized at 2, 7, 10, and 28 days. The flap strength in each quadrant was tested by attaching to a loop of 3-0 silk suture through the tissue; the force required to separate the flap from the tooth/bone interface was recorded for each site. A separate portion of each flap site was prepared for descriptive histologic examination, including inflammation, hemorrhage, and new bone growth. RESULTS: Flap strength was significantly less on day 2 compared to later time points, and there were no significant differences between the test and control groups. No histologic differences in healing between test and control sites were seen at any time point. CONCLUSIONS: PRP did not seem to contribute to greater flap strength at any post-surgical time point, nor was it associated with any histologic differences in wound healing in this Yucatan minipig model. The time points chosen for observation post-surgery, as well as the variability in the PRP platelet count, may have contributed to the lack of positive findings in this study.

Foreign body reaction to anorganic bovine bone and autogenous bone with platelet-rich plasma in guided bone regeneration.

BACKGROUND: Guided bone regeneration is frequently performed to augment deficient alveolar ridges. Although many materials may be used for these procedures, the outcome is usually predictable. In this report, we present an unusual reaction to a frequently used commercially available xenograft material. METHODS: A 36-year-old African American male was referred for restoration of edentulous space #8. Examination confirmed a ridge inadequate for implant placement without augmentation. A staged approach was chosen, with augmentation by a mixture of autogenous bone and anorganic bovine bone with platelet-rich plasma and a bioabsorbable collagen membrane. Healing was uneventful, although after 4 months, upon flap reflection, no regenerated hard tissue was found. The tissue at the site was submitted for histology, and the site was regrafted with an allograft/xenograft mixture and covered by a bioabsorbable collagen membrane. Wound healing was uneventful, and a histologic core was obtained at implant placement 5 months later. RESULTS: The initial histologic specimen consisted of a fibrous connective tissue matrix supporting islands of the anorganic bovine bone. The majority of the graft material demonstrated an intimate association with multinucleated foreign body-type giant cells. The histologic core obtained at the second procedure consisted of trabeculae of viable lamellar bone and associated fibrous connective tissue without a significant inflammatory cell infiltrate. Scattered particles of anorganic bovine bone were present, but no foreign body-type giant cells were identified. CONCLUSION: Failure of commonly used materials for guided bone regeneration is rare; however, different batches of materials may elicit varying immune responses in the recipient.

Ridge Preservation Procedures after Tooth Extractions: A Systematic Review.

BACKGROUND: The purpose of this systematic review was to accurately assess the procedural success of ridge preservation technique through the application of strict inclusion and exclusion criteria. DATA SOURCES: A methodical search of PubMed of the US National Library of Medicine and the Cochrane Central Register of Controlled Trials was conducted for applicable articles. Only randomized controlled trials comparing ridge preservation treatment with a nongrafting control, ten-subject minimum sample size, and three or more months of follow-up were included in our study. TYPES OF STUDIES REVIEWED: In a screening between January 1980 and September 2017, articles meeting predetermined criteria were further examined in a qualitative data analysis. A thorough search of the databases provided 1876 articles. Of these records, 174 were assessed for eligibility through the systematic employment of inclusion and exclusion criteria. RESULTS: Two records were appropriate for further data analysis. One study used a mixture of a deproteinized cancellous bovine bone and porcine collagen fibers in a block form (DBB/CF), while the other study used leukocyte-platelet-rich fibrin (L-PRF). The use of DBB/CF reduced the magnitude of vertical bone resorption, yet the study showed high risk of bias. The use of L-PRF reduced the magnitude of both the horizontal and vertical crestal bone resorption; however, the low sample size created wide standard deviations between the test and control groups. Inherent weaknesses were present in both studies. Through methodical analysis of both records, the dissimilarities prevented the conduction of a meta-analysis. IMPLICATIONS OF KEY FINDINGS: Within the limitations of this systematic review, L-PRF reduced the magnitude of vertical and horizontal bone resorption, which places L-PRF as a potential material of choice for ridge preservation procedures. CONCLUSIONS: Within the limitations and weaknesses of both studies, the use of DBB/CF prevented the vertical crestal bone resorption while the L-PRF prevented both the horizontal and vertical crestal bone resorption. More randomized controlled clinical trials are needed to eliminate all the confounding factors, which bias the outcome of ridge preservation techniques.

Clinical reliability of the "furcation arrow" as a diagnostic marker.

BACKGROUND: The radiographic entity known as the "furcation arrow" has long been used in practice even though little is known about its usefulness as a clinical indicator. The definitive study of the furcation arrow suggests that its presence on a radiograph reliably predicts furcation invasion, but this has not been confirmed in an in vivo investigation. The purpose of this study was to evaluate the furcation arrow in a clinical setting, testing the assertion that the furcation arrow image is an accurate predictor of furcation invasion. Specifically, we sought to determine the following. First, what is the prevalence of furcation arrow images in the radiographs of maxillary molars with periodontitis? Second, what is the interexaminer agreement on what constitutes a furcation arrow? Third, how does the presence or absence of a furcation arrow correlate with the true clinical status of the furcation? Fourth, what is the sensitivity and specificity of the furcation arrow as a diagnostic indicator? METHODS: Eighty-nine patients requiring surgical treatment of periodontitis in the maxillary molar regions were included in this study. Before surgery, one of five calibrated examiners viewed periapical and bitewing radiographs of the surgical site and recorded the presence or absence of a furcation arrow at each proximal furcation. Before administering anesthesia, the same examiner recorded a Hamp index value of each proximal furcation, with a second Hamp index taken after flap reflection and debridement. After surgery, each of the four remaining examiners independently reviewed the radiographs for furcation arrows. Descriptive statistical analysis was performed to correlate the appearance of the furcation arrow image to the actual degree of furcation invasion as determined by the intrasurgical Hamp index. RESULTS: A total of 164 maxillary molars were examined, providing 328 interproximal furcations; 111 (33.8%) furcations were determined at surgical debridement to have a furcation invasion of Hamp degree 1 or greater. Of the 111 furcation invasions, 43 (38.7%) were predicted by a furcation arrow image seen by at least three of the five examiners. When comparing the appearance of the radiographic image to the extent of furcation invasion, 20 of 64 (31.3%) Hamp 1 furcation invasions and 23 of 47 (48.9%) Hamp 2 and 3 furcation invasions were predicted by furcation arrows observed by at least three of five examiners. The multirater kappa statistic for interexaminer agreement on the presence or absence of the image was 0.489. The sensitivity of the furcation arrow image as a diagnostic marker was 38.7%, and the specificity was 92.2%; the positive predictive value of the image was 71.7%, and the negative predictive value was 74.6%. Of the 324 furcations used to compare clinical indices, the agreement of preanesthesia and postdebridement Hamp indices was 0% for degree 3, 83.7% for degree 2, and 98.4% for degree 1 furcation lesions. CONCLUSIONS: These data suggest that the furcation arrow has limited usefulness as a diagnostic marker of furcation invasion. The image is difficult to interpret and highly subjective and can correctly predict furcation invasions only approximately 70% of the time when present on the radiograph. In addition, when furcation invasions are truly present, the furcation arrow is seen in <40% of sites.

Palatal neurofibroma associated with localized periodontitis.

BACKGROUND: Neurofibromatosis type 1 (NF1) is the most common form of neurofibromatosis. While typically considered a dermatologic disorder, intraoral signs of neurofibromatosis occur quite commonly. This clinical entity can be confused with periodontitis because of the presence of periodontal pockets. In this report, we present the case of a palatal neurofibroma with radiographic involvement in a patient with NF1. METHODS: A 40-year-old female patient was referred from her general dentist to evaluate advanced periodontitis in the maxillary left quadrant. The patient's medical history was significant for a soft tissue lesion excised from her back 11 years previously and diagnosed as a neurofibroma. Subsequent medical examination at that time confirmed a systemic diagnosis of NF1. A comprehensive periodontal evaluation was performed, and panoramic and periapical radiographs were taken. Teeth were tested for vitality. An incisional biopsy was completed for histopathologic examination. RESULTS: The periodontal evaluation revealed the presence of 6 to 9 mm probing depths adjacent to teeth #14 and #15. Panoramic and periapical radiographs showed a circumscribed 0.8x0.9-cm unilocular radiolucency superimposed over the root of tooth #13 and extensive horizontal bone loss on the distal side of #15. Incisional biopsy confirmed the presence of a neurofibroma, and because of the extent of the lesion, the patient was referred to the Oral and Maxillofacial Surgery service for complete excision. CONCLUSIONS: Neurofibromas can cause extensive destruction of alveolar bone, mimicking periodontitis. Due to the potential systemic and genetic implications, the diagnosis of neurofibroma requires appropriate medical referral.

Combined endodontic-periodontic treatment of a palatal groove: a case report.

The palatal groove is a developmental anomaly that predisposes the tooth involved to a severe periodontal defect. When further complicated by pulp necrosis, these grooves often present a diagnostic and treatment planning challenge that requires an interdisciplinary treatment approach. This case report describes the successful collaborative management of a maxillary lateral incisor with an extensive palatal groove using a combination of nonsurgical endodontic therapy, odontoplasty, and periodontal regenerative techniques.

Post-surgical infections: prevalence associated with various periodontal surgical procedures.

BACKGROUND: Of the various adverse outcomes that may be encountered following periodontal surgery, the risk of infection stands at the forefront of concern to the surgeon, since infection can lead to morbidity and poor healing outcomes. This paper describes a large-scale retrospective study of multiple surgical modalities in a diverse periodontal practice undertaken to explore the prevalence of clinical infections post-surgically and the relationship between diverse treatment variables and infection rates. METHODS: A retrospective review of all available periodontal surgical records of patients treated in the Department of Periodontics at Wilford Hall Medical Center, San Antonio, Texas, was conducted. The sample comprised 395 patients and included 1,053 fully documented surgical procedures. Surgical techniques reviewed included osseous resective surgery, flap curettage, distal wedge procedures, gingivectomy, root resection, guided tissue regeneration, dental implant surgery, epithelialized free soft tissue autografts, subepithelial connective tissue autografts, coronally positioned flaps, sinus augmentations, and ridge preservation or augmentation procedures. Infection was defined as increasing and progressive swelling with the presence of suppuration. The impact of various treatment variables was examined including the use of bone grafts, membranes, soft tissue grafts, post-surgical chlorhexidine rinses, systemic antibiotics, and dressings. Results were analyzed using Fisher's exact test and Pearson's chi-square test. RESULTS: Of the 1,053 surgical procedures evaluated in this study, there were a total of 22 infections for an overall prevalence of 2.09%. Patients who received antibiotics as part of the surgical protocol (pre- and/ or post-surgically) developed eight infections in 281 procedures (2.85%) compared to 14 infections in 772 procedures (1.81%) where antibiotics were not used. Procedures in which chlorhexidine was used during post-surgical care had a lower infection rate (17 infections in 900 procedures, 1.89%) compared to procedures after which chlorhexidine was not used as part of post-surgical care (five infections in 153 procedures, 3.27%). The use of a post-surgical dressing demonstrated a slightly higher rate of infection (eight infections in 300 procedures, 2.67%) than non-use of a dressing (14 infections in 753 procedures, 1.86%). Despite these trends, no statistically significant relationship was found between post-surgical infection and any of the treatment variables examined, including the use of perioperative antibiotics. CONCLUSIONS: The results of this study confirm previous research demonstrating a low rate of postoperative infection following periodontal surgical procedures. Although perioperative antibiotics are commonly used when performing certain regenerative and implant surgical procedures, data from this and other studies suggest that there may be no benefit in using antibiotics for the sole purpose of preventing post-surgical infections. Further large-scale, controlled clinical studies are warranted to determine the role of perioperative antibiotics in the prevention of periodontal post-surgical infections.

Osseous surgery for crown lengthening: a 6-month clinical study.

BACKGROUND: Despite the fact that surgical crown lengthening is a commonly performed treatment, little is known about the specific surgical endpoints of the procedure or the stability of the newly attained crown height over time. Recent clinical reports have ranged across a spectrum from significant tissue rebound to remarkable stability using similar surgical techniques. The purpose of this study was to assess the stability of surgical crown lengthening procedures performed by various surgeons using specific guidelines to determine surgical endpoints. Specifically, we sought to determine the following: 1) What is the immediate increase in clinical crown height following surgery? 2) How stable is the established crown length over a 6-month period? 3) How much supporting bone is removed to establish the new crown length? 4) How does the position of the flap margin relative to the alveolar bone at surgical closure relate to the stability of crown height? METHODS: Twenty-five patients requiring crown lengthening of 43 teeth were included in this study. Clinical indices recorded at eight sites on each molar and six sites on each premolar included plaque, bleeding on probing, probing depth, and relative attachment level from a customized probing stent. Surgical measurements at the same sites included the distance from stent to alveolar bone both before and after osseous surgery and the distance from flap margin to alveolar bone after suturing. Clinical measurements were repeated at 1, 3, and 6 months after surgery. Sites were divided into three groups. All sites on teeth targeted for crown lengthening were labeled treated sites (TT). Interproximal sites on neighboring teeth were labeled adjacent (AA) if they shared a proximal surface with a treated tooth and nonadjacent (AN) if they were on the opposite side, away from the treated tooth. RESULTS: Throughout the entire 6-month healing period, descriptive statistics revealed no significant time or group differences in plaque and bleeding scores. At treated sites, the mean gain of crown height at surgery was 2.27 +/- 1.1 mm. This was reduced to 1.91 +/- 1.08 mm at 1 month, 1.69 +/- 1.02 mm at 3 months, and 1.57 +/- 1.01 mm at 6 months. At adjacent sites, the gain of crown length was 2.18 +/- 0.98 mm, 1.61 +/- 0.98 mm, 1.43 +/- 0.96 mm, and 1.30 +/- 0.96 mm at surgery, 1, 3, and 6 months, respectively. At non-adjacent sites the crown height increased 1.06 +/- 1.07 mm, 1.00 +/- 0.93 mm, 0.84 +/- 1.00 mm, and 0.76 +/- 0.85 mm, respectively. These mean measurements were significantly different for each treatment group at each time interval and appeared not to have stabilized between 3 and 6 months. The mean osseous reduction at treated, adjacent, and non-adjacent sites was 1.13 +/- 0.90 mm, 0. 78 +/- 0.75 mm, and 0.065 +/- 0.69 mm, respectively. Frequency distribution of osseous reduction demonstrated that 23.6% of treated sites had 0 mm, 44.3% had 1 mm, 25.4% had 2 mm, 6.2% had 3 mm, and less than I % had > or = 4 mm of bone removed to establish crown height More bone removal was noted at premolar than at molar sites; however, this was not statistically significant. When tissue rebound following surgery was plotted against post-surgical flap position, it was noted that the closer the flap margin was sutured to the alveolar crest, the greater the tissue rebound during the post-surgical period. This rebound ranged from 1.33 +/- 1.02 mm when the flap was sutured < or = 1 mm from the alveolar crest, to -0.16 +/- 1.15 mm when the flap was sutured > or = 4 mm from the alveolar crest. CONCLUSIONS: These data suggest that there is a significant tissue rebound following crown-lengthening surgery that has not fully stabilized by 6 months. The amount of tissue rebound seems related to the position of the flap relative to the alveolar crest at suturing. These findings support the premise that clinicians should establish proper crown height during surgery without overreliance on flap placement at the osseous crest.