Invasive cervical resorption and the oro-facial cleft patient: a review and case series.

Introduction Invasive cervical resorption (ICR) has an unknown aetiology, yet it exhibits very aggressive behaviour compared with typical external root resorption, posing a high risk of tooth loss.Aim To investigate the number of patients at the Dublin Cleft Prosthodontic Department with an oro-facial cleft who experienced ICR and to identify any possible aetiological factors.Materials and method A retrospective investigation of all oro-facial cleft patients treated at the Dublin Cleft Prosthodontic Department, St James's Hospital, Dublin. All patients' clinical and radiological records were reviewed. Patients where tooth loss became inevitable due to Class 4 ICR were analysed.Results From 588 oro-facial cleft patients, 14 (2.38%) patients with ICR were identified. Of these eight (57%) were female and six (43%) were male. Mean age at diagnosis was 28 years (range = 16-49 years). Cleft type: six (42.1%) unilateral cleft lip and palate, eight (57.9%) bilateral cleft lip and palate. Seventeen ICR affected teeth in total, with eleven (65%) maxillary central incisors, two (12%) maxillary lateral incisors, four (23%) maxillary canines, and one (7%) central, lateral and canine affected. Some, (N = 10, 71.4%) presented with ICR resulting in immediate tooth loss. Other patients (N = 4, 28.6%) developed ICR during or following prosthodontic treatment at the Cleft Centre. Tooth loss for this cohort, though not immediate, was inevitable. All had undergone fixed orthodontic appliance treatment and twelve had received dento-alveolar bone grafts. A number (N = 7, 50%) had undergone osteotomy, two (14%) had received night guard vital dental whitening and one had a history of trauma.Conclusions ICR, given its aggressive nature and ill-understood aetiology, poses significant treatment challenges. The most severe form of ICR (Class 4) leads inevitably to tooth loss. The slow-moderate progression of ICR may explain the late presentation found in this study, reinforcing the importance of long-term follow-up of this special dental care group.

Benefit of the replaceable bony window in lateral maxillary sinus augmentation: clinical and histologic study.

PURPOSE: This retrospective study demonstrates, by clinical and histologic evaluation, the benefit of the replaceable bony window as a homologous bony barrier in lateral sinus augmentation. MATERIALS AND METHODS: A total of 103 maxillary sinus augmentations were performed using a piezoelectric device and a Er,Cr:YSGG laser apparatus. The detached bony windows were repositioned over various bone grafts. Sixteen bone biopsy specimens were harvested at the time of uncovering or implant placement. RESULTS: Three sinuses developed postoperative infections (2.91%). After 6 to 8 months of healing, uncovering procedures were carried out. Radiographically, reconstruction of the lateral sinus wall was observed in all cone-beam computed tomogram. Clinically, complete bone healing between the replaceable bony window and the lateral sinus wall was observed in all cases, except for the 3 infected sinuses (100 sinuses, 97.09%). Histologically, favorable new bone formation was observed in all specimens without any fibrous connective tissue invagination. More mature bone was observed along the floor of the replaceable bony window than at the center of the graft site. CONCLUSION: This study demonstrates that the replaceable bony window acts as an osteoinductive homologous barrier membrane over various bone graft materials and accelerates new bone formation in lateral sinus augmentation.

Gengiva artificial com restauração da papila em próteses unitárias sobre implantes mal posicionados: uma alternativa estética e de fácil higienização / Artificial gingiva with papilla restoration in sigle prostheses over malpositioned implants: An aesthetic and easy to clean alternative

A reabilitação bucal com implantes tem se tornado uma ótima opção de tratamento; no entanto, implantes mal posicionados muitas vezes apresentam dificuldade em uma resolução estética favorável. O presente trabalho teve como objetivo relatar uma abordagem alternativa para uma condição clínica de posicionamento desfavorável de implantes, com um planejamento protético inicial também desfavorável. Por meio de uma caso clínico foi apresentada uma alternativa viável para essas situações, de coroas individuais sobre implante com gengiva artificial, trazendo de volta a região das papilas, demonstrando ser essa uma alternativa eficiente no que diz respeito à estética e de fácil higienização — fator importante na manutenção da saúde peri-implantar

Oral rehabilitation with implants has become a great treatment option, however, poorly positioned implants often present dificulty in a esthetically favorable resolution. This study aimed to describe an alternative approach to clinical conditions with unfavorable positioning of implants and also unfavorable initial prosthetic planning. By means of a clinical case report it was presented a viable alternative for these situations, using individual crowns over implant with artificial gingiva, giving back the poper papillae region, proving to be an effective alternative with aesthetic benefits and easy cleaning, an important factor in maintaining peri-implant health

Neuropatia pós-implante / Post-implant neuropathy

Atualmente, a utilização de implantes dentários tem sido considerada o padrão-ouro para reabilitação de arcos parcial ou totalmente edêntulos. Devido aos recursos avançados de exame por imagem, principalmente da tomografia computadorizada de feixe cônico, esses procedimentos apresentam altas taxas de sucesso; no entanto, algumas complicações trans- e pós-cirúrgicas ainda são passíveis de ocorrer, sendo uma delas a neuropatia pós-implante. A neuropatia pós-implante se trata de uma neuropatia traumática orofacial secundária a traumas diretos ou indiretos aos nervos da face, sendo os nervos alveolar inferior e lingual os mais acometidos. Essa condição pode apresentar diferentes formas clínicas, sendo elas a anestesia, parestesia, hipoestesia, hiperestesia e/ou disestesia. Por se tratar de uma complicação pouco frequente, porém de alto impacto social para o paciente e de difícil diagnóstico e tratamento, o presente artigo tem como objetivo, por meio de uma revisão de literatura dos estudos mais relevantes na área, esclarecer o que é a neuropatia pós-implante, como ela pode ser desencadeada, bem como as melhores formas de diagnóstico e tratamento.

Nowadays, the use of dental implants in partial or total edentulous arch is considered the gold standard in oral rehabilitation. This procedure has high success rates mainly due to the advanced features of radiograph exams like the cone beam computerized tomography (CBCT). However, some intra- and post-operative complication may occur. One of the possible complications is post implant neuropathy (PIN). PIN is a traumatic trigeminal neuropathy that can be due to direct or indirect nerve trauma. The most affected nerves are inferior alveolar nerve and lingual nerve. This condition can be clinically reported as anesthesia, paresthesia, hypoesthesia, hyperesthesia and/or dysesthesia. PIN is not a frequent condition but has a major impact on everyday social life and it is a very difficult pathology to diagnose and to treat. Based on that, the aim of this article is to review the most relevant studies in the field and to clarify what is PIN and what are the possible causes of it. As well as identify the best diagnostic and treatment approach.

Sinonasal complications resulting from dental treatment: outcome-oriented proposal of classification and surgical protocol.

BACKGROUND: Odontogenic sinusitis is a relevant infectious condition of the paranasal sinuses. The widespread use of dental implants and reconstructive procedures for dental implant placement has led to new types of complication. To the authors' knowledge, no publication has extensively examined sinonasal complications resulting from dental treatment, and no classification system allowing standardization and comparison of results is currently available. This study was designed to (a) analyze the results obtained from surgical treatment of complications resulting from dental procedures combining functional endoscopic sinus surgery (FESS) and an intraoral approach and (b) propose a new classification system and standardized treatment protocols for sinonasal complications resulting from dental procedures. METHODS: A total of 257 patients consecutively treated with FESS (136 in conjunction with oral surgery) were included in the study. Different clinical situations were integrated into a new classification system based on the pathogenesis and clinical aspects of each case, with the aim of identifying homogenous treatment groups. Results were evaluated for each class. RESULTS: Of the 257 patients, 254 were successfully treated with surgery performed according to the proposed protocols. Three of 257 patients required a second surgery, after which they completely recovered. Complications of implant and preimplant surgery (maxillary sinus floor elevation) showed longer recovery times. CONCLUSION: The results obtained are very encouraging. The majority of patients (254/257; 98.8%) were successfully treated with the proposed protocols. These results seem to indicate that the rationalization of surgical treatment protocols according to the initial clinical situation may significantly improve the clinical outcome.

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

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

Load-dependent heat development, thermal effects, duration, and soft tissue preservation in piezosurgical implant site preparation: an experimental ex vivo study.

PURPOSE: Piezoelectric surgery is meant to be a gentle method for implant site preparation (ISP). However, the application of load and its influence on heat development over time and effects on soft tissue are unknown. Therefore, this study sought to evaluate heat development in the bone and the duration of the procedure according to load application, as well as preservation of the sinus floor mucosa during piezoelectric ISP. MATERIALS AND METHODS: One hundred twenty implant sites (6 mm deep x 3 mm wide) were prepared in the calvaria of ex vivo pig heads using piezoelectric surgery. The load applied to the working tip was increased in 100-g intervals up to 1,000 g. The bone temperature was measured, and thermal effects were analyzed histomorphometrically. The duration of each ISP was recorded. Another 12 ISPs were performed at the lateral wall of the maxillary sinus in the vicinity of the sinus floor mucosa, and sites were checked for perforation. RESULTS: Temperature and histologic effects of heat demonstrated a significant positive correlation with the applied load. The duration of ISP was significantly negatively correlated with load application. The maximum temperature generated by piezoelectric surgery was 64.5°C (load of 901 to 1,000 g). At a load of 401 to 500 g, the average temperature was 40.2°C ± 3.3°C, the average thermal damage extended 115.9 ± 16.3 Μm beyond the ISP area, and the maximum temperature did not exceed 47°C. The average duration of ISP using this load interval was 45.5 ± 9.4 seconds. Two perforations of the sinus floor mucosa were detected. CONCLUSIONS: In the present setting, the applied load during piezoelectric ISP should not exceed 500 g to prevent temperatures above 47°C in the bony implant socket. With a load of 400 to 500 g, ISP took 40 to 50 seconds.

Comparison of flapless and conventional flap and the effect on crestal bone resorption during a 12-week healing period.

UNLABELLED: There is evidence suggesting that flapless, or minimally invasive, procedures can preserve bone vascularization because they will not disturb the periosteum of the alveolar bone. The aim of this randomized, controlled clinical trial study is to compare the effect of flapless (FL) and full-thickness flap (FT) techniques on crestal bone resorption during healing periods. METHODS: Twenty-two implants were placed by FL and FT flap in nine patients in split mouth design; each patient received two implants, except for two patients who received four implants. A periapical radiograph was taken at implant placement, as well as 6- and 12-week intervals. Crestal bone level was compared between FL and FT during these intervals and compared between intervals for each group. RESULTS: Median (IQR) crestal bone level at implant placement for the FL was 2.70 (0.60) and for the FT was 2.60 (1.20). At six weeks, median (IQR) for the FL was 3.55 (0.70) and for the FT was 3.40 (0.75). At 12 weeks, median (IQR) for the FL was 3.60 (0.30) and for the FT was 3.75 (0.85). Statistically insignificant differences were obtained between the two techniques at implant placement, as well as 6- and 12-week intervals, and were p = 0.894, p = 0.477, p = 0.755, respectively. There was a significant difference between the bone level at implant placement and at the 6-week interval for both the FL (p = 0.006) and FT (p = 0.045), whereas there was no significant difference between the bone level at 6- and 12-week intervals for the FL (p = 0.722) and for the FT (p = 0.229). Conclusions Based upon this study of nine patients with 22 implants, there was no significant difference in crestal bone resorption between FT and FL techniques during a three-month healing period. The preservation of periosteum in the FL group resulted in early progressive bone resorption.

Assessment of bone grafts placed within an oral and maxillofacial training programme for implant rehabilitation.

BACKGROUND: This study aimed to review the survival of bone grafting procedures, performed by surgical trainees and assess factors affecting survival of these bone grafts as an adjunct to implant rehabilitation. METHODS: Data were collected from patients between 2003 and 2009 receiving bone grafting. Graft failure was defined as any complete or partial graft loss, graft which had to be removed or regrafted, or was unable to have an implant placed. Implant survival rates were not assessed in this study. RESULTS: Seventy-five patients received 86 bone grafts over a period of 7 years. Overall graft survival was 87.3% with 7 complete graft failures (8.1%) and 3 partial graft failures (4.6%). All failed grafts were of the block graft type, predominately in the anterior maxilla. The main reason for failure was secondary infection. Other complications occurred in about 27% of patients. Factors significantly increasing the risk of graft failure included use of bone block augmentation (p = 0.001), mixed autogenous/bone substitute grafts (p = 0.007) and diabetes mellitus (p = 0.006). Smoking was not found to affect graft survival. CONCLUSIONS: Good results were found in a series of patients treated in an oral and maxillofacial training programme. Care should be taken in regards to planning block grafts in diabetic patients.

The maxillary sinus: challenges and treatments for implant placement.

Standard implant placement in the posterior maxilla is often limited by the lack of vertical bone height due to the pneumatization of the sinus cavity. Several techniques have been developed to enter this cavity and elevate the membrane to enable implant placement. These methods may involve the use of bone grafts and membranes, as well as concurrent implant placement. This article reviews the clinical situations in which to apply these sinus lift techniques, complications, and success rates.

An unusual complication of osteotome sinus floor elevation: benign paroxysmal positional vertigo.

Maxillary sinus floor elevation in cases of reduced vertical bone height in the posterior maxilla allows predictable implant placement. The osteotome sinus floor elevation (OSFE) technique has shorter healing and waiting times because the fixture can be placed in the implant recipient site simultaneously with the ridge augmentation. Implant site preparation is more comfortable for the patient when performed with spiral drills than with continuous malleting of the osteotomes. Membrane perforation is the most frequent complication with the OSFE technique; postoperative infection is rare. Benign paroxysmal positional vertigo (BPPV) may be a complication of OSFE and may cause stress if not identified correctly and managed properly. The available treatment options, diagnostic strategies and the pathophysiology of this unusual complication are discussed. The authors present a case in which intense BPPV developed during OSFE, focusing on dental and maxillofacial surgery as risk factors for this pathology.

Comparison of two piezoelectric cutting inserts for lateral bony window osteotomy: a retrospective study of 127 consecutive sites.

PURPOSE: The aim of the present retrospective clinical study was to compare the efficacy of two piezoelectric cutting inserts for the incidence, size, and types of sinus membrane perforations, and to evaluate their various advantages for lateral window osteotomy. MATERIALS AND METHODS: The study consisted of 127 maxillary sinus augmentation procedures performed at two centers. A bony window was made on the lateral wall of the maxillary sinus with either the piezoelectric saw or the round diamond insert and repositioned over the bone graft as a homologous bony barrier. The rate of membrane perforation during sinus augmentation between the two groups was compared and analyzed statistically by the chi-square test and the two-sample t test. RESULTS: Seven perforations were seen in the 127 maxillary sinus procedures in this study (5.51%). Six perforations in 84 cases (7.14%) occurred with the piezoelectric saw and one perforation in 43 sites (2.32%) occurred while using the round insert. No statistically significant difference was found between the rates of membrane perforation between the two inserts. CONCLUSION: The lateral bony window was created effectively with either of the two kinds of piezoelectric inserts. The membrane perforation rate was not significantly affected by the type of piezoelectric insert. The piezoelectric saw insert was more advantageous than the round diamond due to its greater precision and easier repositioning of the lateral bony window as a barrier.

Brisk, prolonged pulsatile hemorrhage during the sinus graft procedure: a case report with discussion on intra-operative hemostatic management.

The maxillary sinus graft procedure is the treatment of choice to increase the vertical bone height in the atrophic posterior maxilla to place dental implants. It is considered as a routine surgical procedure with predictable results. However, complications have been reported with this grafting procedure. With any surgical procedure, complications may arise, and the surgeon must be prepared to effectively manage the complication. In addition to detailed knowledge of the maxillofacial anatomy, recognition of surgical emergencies and its management is critical for the implant surgeon. A case of brisk, prolonged pulsatile hemorrhage during the sinus graft procedure is described, and its intra-operative management with topical Thrombin is presented.

The effect of piezoelectric use on open sinus lift perforation: a retrospective evaluation of 56 consecutively treated cases from private practices.

BACKGROUND: The lateral window approach to maxillary sinus augmentation is a well-accepted treatment option in implant dentistry. The most frequent complication reported with traditional techniques has been the perforation of the Schneiderian membrane, with perforation rates ranging from 11% to 56%. The purpose of this retrospective, consecutive case series from two private practices was to report on the rate of Schneiderian membrane perforations and arterial lacerations when a piezoelectric surgical unit was used in conjunction with hand instrumentation to perform lateral window sinus elevations. METHODS: Clinical data (Schneiderian membrane perforation, Underwood septa, and laceration of the lateral arterial blood supply to the maxillary sinus) were obtained retrospectively from two private practices and pooled for analysis. The information was collated after an exhaustive chart review. Fifty-six consecutively treated lateral window sinus lifts were performed on 50 partially or completely edentate patients. RESULTS: Zero perforations of the Schneiderian membrane occurred during the piezoelectric preparation of the lateral antrostomies, whereas two perforations were noted during subsequent membrane elevations using hand instrumentation. In both instances, membrane perforations were associated with sinus septa. The overall sinus perforation rate was 3.6%. Arterial branches of the posterior superior alveolar artery were encountered in 35 cases, and there were zero instances of arterial laceration. CONCLUSIONS: This retrospective case series from clinical private practices confirmed that a lateral window approach to sinus elevation incorporating piezoelectric technology in conjunction with hand instrumentation was an effective means to achieve sinus elevation while minimizing the potential for intraoperative complications. Further prospective and randomized controlled studies are warranted to qualify these observations.

A new method to eliminate the risk of maxillary sinusitis with zygomatic implants.

PURPOSE: A new approach for zygomatic implant placement was proposed to eliminate the risk of maxillary sinusitis related to the procedure. MATERIALS AND METHODS: A prospective study of this new approach was conducted, and consecutive patients treated between June 2007 and December 2008 were included. An extended sinus lift with retained bone window was performed, such that zygomatic implants were placed completely outside the displaced maxillary sinuses. All patients were followed up radiologically at regular intervals using cone beam computed tomography to evaluate the status of the zygomatic implants and the condition of the maxillary sinuses. RESULTS: Sixteen patients (9 women and 7 men with a mean age of 60) were treated with 37 zygomatic implants. Within the period of investigation from 6 months to 24 months, there were no failed zygomatic implants, and no instances of maxillary sinusitis were reported. CONCLUSIONS: The new approach that combined the zygomatic implant placement with the extended sinus lift procedure was predictable and fulfilled the purpose of lowering the risk of maxillary sinusitis.

Clinical outcomes of sinus floor augmentation for implant placement using autogenous bone or bone substitutes: a systematic review.

BACKGROUND: To date, there are still no clear cut guidelines for the use of autogenous bone or bone substitutes. AIM: The aim of the present review was to analyze the current literature in order to determine whether there are advantages of using autogenous bone (AB) over bone substitutes (BS) in sinus floor augmentation. The focused question was: is AB superior to BS for sinus floor augmentation in partially dentate or edentulous patients in terms of implant survival, patient morbidity, sinusitis, graft loss, costs, and risk of disease transmission? MATERIALS AND METHODS: The analysis was limited to titanium implants with modified surfaces placed in sites with 6 mm of residual bone height and a lateral wall approach to the sinus. A literature search was performed for human studies focusing on sinus floor augmentation. RESULTS: Twenty-one articles were included in the review. The highest level of evidence consisted of prospective cohort studies. A descriptive analysis of the constructed evidence tables indicated that the type of graft did not seem to be associated with the success of the procedure, its complications, or implant survival. Length of healing period, simultaneous implant placement or a staged approach or the height of the residual alveolar crest, sinusitis or graft loss did not modify the lack of effect of graft material on the outcomes. Three studies documented that there was donor site morbidity present after the harvest of AB. When iliac crest bone was harvested this sometimes required hospitalization and surgery under general anesthesia. Moreover, bone harvest extended the operating time. The assessment of disease transmission by BS was not a topic of any of the included articles. DISCUSSION AND CONCLUSION: The retrieved evidence provides a low level of support for selection of AB or a bone substitute. Clear reasons could not be identified that should prompt the clinician to prefer AB or BS.

A simple method of barrier membrane fixation for large sinus membrane tears.

Maxillary sinus grafting, a common surgical technique for adding bone to the subantral maxilla, is sometimes complicated by tears to the delicate Schneiderian membrane with which it is lined. These tears can allow migration of graft material into the sinus, as well as promote seeding of bacteria into the graft site. These tears are often mitigated by placing a barrier membrane over the tear. However, the very act of placing the graft can dislodge, or at least obscure, the position of the barrier membrane. The purpose of this report is to describe a simple method of fixing the barrier membrane by notching the lateral window in coordination with cuts in the barrier membrane. This technique has been used by the senior author (F.M.L.) for several years with consistent success.

The "dome phenomenon" associated with maxillary sinus augmentation.

AIM: This case series is aimed to report a new phenomenon, the "dome phenomenon," which was observed in infected augmented sinuses over several years. METHODS: Five patients are presented in whom sinus lift augmentation resulted in postoperative infection with inflammation and suppuration. The patients received aggressive anti-inflammatory treatment and surgical debridement of the inflamed tissue, including some grafted material performed through the lateral window of the primary procedure. RESULTS: The inflammatory condition was reversed, and the site healed clinically. Radiographically, a dome-shaped, radio-opaque tissue was observed at the superior most aspect of the grafted sinus. This "dome phenomenon" was further confirmed during dental implant placement, which indicates healing potential adjacent to the maxillary sinus membrane. CONCLUSIONS: The current report, as well as other studies and case series, suggests that there is great potential for healing and bone formation in the maxillary sinus membrane. The precise mechanism is not known. Further clinical and histologic studies are needed to understand the regenerative potential of the Schneiderian membrane.