Oronasal Fistula Closure and Defect Reconstruction: Two Case Reports Using Periodontal Plastic Surgery Principles.

OBJECTIVES: Oronasal fistulas are common sequelae following cleft lip and palate surgery and can significantly impact a patient's quality of life. They result from various factors, including surgical techniques, tissue management, and patient-specific factors. This case report explores the modern approach to oronasal fistula closure using periodontal plastic surgery principles. MATERIALS AND METHODS: The report presents two cases of patients with oronasal fistulas due to previous maxillofacial surgical intervention. These patients underwent microsurgical procedures that involved partial flap thickness preparation of the fistula areas, the use of connective tissue grafts from the palate, and meticulous suturing techniques to ensure graft integrity. The procedures were performed in stages, and postoperative care was provided. RESULTS: Both cases demonstrated successful fistula closure and graft survival. The patients reported improvements in breathing, speech, aesthetics, and quality of life. The second case also included guided bone regeneration and implant placement. CONCLUSIONS: Oronasal fistulas resulting from maxillofacial surgery can be effectively treated using periodontal plastic surgery techniques, significantly improving patients' quality of life and aesthetic outcomes. This approach represents a valuable addition to the existing repertoire of oronasal fistula closure methods.

Utilizing Individualized Titanium Frames for Protected Alveolar Bone Augmentation: A Feasibility Case Series.

Despite the various treatments proposed with barrier membranes, one of the main challenges for guided bone regeneration (GBR) is maintaining space for large defects and ensuring an adequate blood supply. The presented feasibility case series aims to introduce an original titanium frame (TF) design, customized for each defect, as a modification of well-known principles and materials for GBR to achieve an enhanced and more predictable horizontal and vertical bone augmentation. Three patients with significant horizontal defects were treated with pre-trimmed TFs to create needed space, and then a 50/50 mixture of autograft and bovine xenograft was placed and covered with a collagen membrane. After 8 months of healing, the sites were reopened, and the titanium screws were removed with the frame. An average of 8.0 ± 1.0 mm of horizontal and 3.0 ± 0.0 mm of vertical bone gain were achieved at the time of reentry and implant placement surgery. Bone core biopsy sample was obtained during the implant placement. Histomorphometric analysis revealed that 42.8% of the sample was new vital bone, 18.8% was residual bone graft particles, and 38.4% was bone marrow-like structures. After 3 to 4 months from implant placement, the implants were restored with provisional crowns and then finalized with zirconia screw-retained crowns. This case series suggests that GBR utilizing TFs with or without collagen membranes can be considered a suitable approach for horizontal and vertical bone augmentation. However, based on only three reported cases, the results should be carefully interpreted.

Tooth autotransplantation outcomes using platelet-rich fibrin: A promising approach; case study.

BACKGROUND: Autogenous tooth transplantation refers to a surgical procedure involving the relocation of a tooth within the same individual. Incorporating platelet-rich fibrin (PRF) in this procedure holds the potential to improve healing, accelerate recovery, and optimize treatment outcomes. METHODS: In this article, the authors illustrate a PRF-based approach for autogenous tooth transplantation through two case scenarios. These cases outline the surgical steps of tooth transplantation and demonstrate the potential role of PRF in enhancing soft tissue healing. Furthermore, the article provides insights from a long-term follow-up spanning over 7 years. RESULTS: Tooth transplantation in young adults is promising but depends on factors such as root development stage and donor tooth size matching. Including PRF may improve healing, at least in the short term, due to its rich concentration of growth factors and cytokines, promoting effective tissue regeneration. CONCLUSIONS: Autogenous tooth transplantation has shown to be a viable treatment option for replacing the missing dentition. Adding PRF to the autogenous tooth transplantation procedure may speed up and enhance the treatment outcome. While the favorable results of these cases might be partially attributed to the use of PRF, the contribution of PRF to the healing process of tooth transplant remains conjectural and requires validation through additional research. KEY POINTS/HIGHLIGHTS: Tooth autotransplantation can be performed in younger patients without requiring root canal treatment, while also potentially benefiting from the incorporation of platelet-rich fibrin (PRF).

Efficacy of autogenous platelet concentrates in immediate implant therapy: A systematic review and meta-analysis of prospective controlled clinical trials.

PURPOSE: To provide an overview of the outcomes of the use of autogenous platelet concentrates in immediate implant placement. MATERIALS AND METHODS: Based on an a priori protocol, a systematic search was performed of the National Library of Medicine (MEDLINE via PubMed), Embase and Scopus databases. Randomised and non-randomised controlled clinical trials on immediate implant placement including at least one study arm with use of platelet-rich fibrin or platelet-rich plasma as a gap filler between immediately placed implants and the alveolar bone were included. A random-effects meta-analysis model was built to assess the primary outcomes of marginal bone loss and probing pocket depths between test (platelet concentrates) and control (no graft or other graft materials) groups. A risk of bias assessment was performed and the Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence. RESULTS: A total of 20 trials (595 immediate implants placed in 454 individuals) were included in the meta-analytic model. Based on the data from studies with a minimum post-prosthetic loading period of 6 months after immediate implant placement, overall, the application of platelet concentrates was associated with significantly lower marginal bone loss and probing pocket depth compared to the control groups (mean difference -0.36 mm; P < 0.01 and mean difference -0.47 mm; P < 0.01, respectively). No additional benefit of application of platelet concentrates was detected regarding primary stability of immediate implants. Subgroup analysis revealed significantly lower marginal bone loss with xenogeneic bone alone compared to platelet concentrates alone as grafting material in immediate implant placement (mean difference 0.66 mm; P < 0.01). Evidence on soft tissue outcomes and aesthetic parameters was scarce. CONCLUSIONS: A low level of certainty based on the Grading of Recommendations Assessment, Development and Evaluation approach indicates superior outcomes in terms of marginal bone loss and probing pocket depth in immediate implant placement with the use of platelet concentrates versus no graft. Future research should be tailored towards a standardised protocol for preparation of platelet concentrates and inclusion of soft tissue and aesthetic outcomes as well.

Biological shaping as a conservative alternative for crown lengthening: A review.

OBJECTIVES: The perio-restorative approach to maintaining supracrestal tissue attachment (STA; formerly known as biologic width) is a fundamental goal in modern dentistry. This article aims to review the clinical impact of biologic shaping (BS) as an innovative alternative to traditional crown lengthening procedures, reflecting over two decades of clinical experience. MATERIAL AND METHODS: As a review paper, it is crucial to highlight that BS stands as a unique approach designed to optimize STA while emphasizing minimal to no removal of supporting bone. The review spans over two decades, consistently demonstrating clinical efficacy and predictability. Remarkably, BS focuses on addressing issues such as root concavities, developmental grooves, irregularities, furcation lips, and CEJ offering a remarkable level of clinical precision. RESULTS: The reviewed literature underscores that BS has consistently achieved substantial clinical success in fulfilling its objectives. This method presents a biologically sound alternative to traditional crown lengthening, placing a strong emphasis on the preservation of essential bone tissue and the establishment of durable STA. CONCLUSIONS: The results suggest that BS is a logical and biologically driven approach for maintaining STA, making it a promising alternative to traditional crown lengthening. The method offers a predictable and reproducible way to preserve bone tissue while achieving durable STA. This innovation holds great promise in the field of periodontal and restorative dentistry.

Periodontists and stem cell-based therapy for alveolar bone regeneration: A national survey.

BACKGROUND: Stem cell-based therapy for bone regeneration has received attention in medical settings but has not yet been used in clinical practice for treating alveolar bone defects. The objectives of this study were to explore whether periodontists had heard about this approach, and if so how, how interested they were to learn about it, which attitudes and behavioral intentions they had related to using stem cell-based grafting, and what they would like to know before using this approach. METHODS: Anonymous survey data were collected from 481 members of the American Academy of Periodontology (response rate: 19.41%). RESULTS: Responses showed 35.3% had heard about stem cell-based therapy, mostly from publications (9.6%) and meetings (8.3%); 76.1% wanted to learn about it through in-person continuing education (CE) courses, 68.6% in online CE courses, and 57.1% from manuals; 73% considered this approach promising; and 54.9% preferred it to traditional approaches. It was important to them that it would result in more bone volume (93%), better bone quality (90.4%), and accelerated healing (83.2%). Also, 60.1% considered it likely/very likely that they would adopt this approach, 54% that patients would prefer it, and 62.1% that it would benefit their practice. When asked what they would like to know about this approach, information about short- and long-term outcomes, cost, and logistical considerations were most frequently named. CONCLUSIONS: These findings provide the basis to develop educational interventions for periodontists about this novel approach and inform future research activities aimed to translate this approach to clinical practice.

Influence of residual pockets on periodontal tooth loss: A retrospective analysis.

BACKGROUND: Individuals enrolled in supportive periodontal therapy (SPT) can still present with tooth loss due to periodontitis (TLP). There is limited evidence on the influence of residual pockets (RPc) and a defined "threshold" at which a patient's profile is set to be at high risk for TLP in the literature. Therefore, this study aimed to assess the influence of RPc on TLP and determine the prognostic performance of RPc compared to the staging and grading of periodontitis on TLP risk. METHODS: Clinical data from 168 patients (3869 teeth) treated for periodontitis and receiving SPT for at least 10 years were evaluated in this retrospective study. TLP and the percentage of sites with RPc ≥ 5 mm or ≥6 mm per patient were collected. The prognostic performance of RPc was compared to the staging and grading of the disease on TLP using a multilevel Cox proportional hazard regression model. RESULTS: Over a median follow-up of 25 years, 13.7% of teeth were lost, 4.6% of which were due to periodontitis. Most patients with TLP had ≥1 site with RPc ≥5 mm (90.8%) or ≥6 mm (77.6%). Multivariate multilevel Cox regression revealed that patients with >15% of sites with RPc ≥5 mm had a hazard ratio of 2.34, and grade C had a hazard ratio of 4.6 for TLP compared to RPc ≤4 mm/grade A. Grading exhibited the best discrimination and model fit. CONCLUSION: Patients with RPc ≥5 mm at >15% of the sites are at risk for tooth loss. Grading and RPc ≥5 mm displayed very good predictive capability of TLP.

Auto-dentin platelet-rich fibrin matrix is an alternative biomaterial for different augmentation procedures: A retrospective case series report.

OBJECTIVES: Autologous dentin grafts derived from extracted teeth have shown promise as bone graft materials for promoting bone regeneration. This retrospective case series aimed to evaluate clinical, radiographic, and histologic outcomes of using autologous dentin matrices in various bone regeneration procedures. MATERIALS AND METHODS: This case series included 26 eligible patients and encompassed 4 socket preservation cases, 5 cases of guided tissue regeneration, 5 cases of guided bone regeneration (GBR), 10 cases of sinus augmentation procedures, 2 immediate placement implants, and 2 socket shields. Dentin grafts were prepared from extracted teeth, cleaned, and processed. These grafts were combined with platelet-rich fibrin (PRF) to create adhesive dentin matrices, then covered with collagen membranes for simultaneous guided bone augmentation cases. Cone beam computed tomography (CBCT) scans were conducted before surgery and 4 months postoperatively to assess ridge dimensions. Histologic evaluation was performed through bone core biopsies for socket preservation cases at the 4-month mark. RESULTS: A total of 42 implants were placed in 26 patients, with an average follow-up of 32 months. Notably, two implant failures occurred following lateral maxillary sinus augmentation. CBCT scans at the 4-month interval revealed bone coverage over implant platforms in the majority of cases. Histologic analysis from two cases of socket preservation demonstrated dentin granules enveloped by newly formed bone undergoing continuous remodeling. The quantitative histomorphometric assessment revealed a bone area of 42.8 ± 3.56%, a remaining graft area of 19.05 ± 4.58%, and a viable bone of 38.15 ± 7.84%. CONCLUSIONS: The utilization of autologous dentin particles mixed with PRF proved effective as an alternative to conventional bone graft materials in GBR and maxillary sinus augmentation procedures. Larger controlled clinical trials are recommended to further substantiate these findings.

3D vertical soft tissue augmentation of aesthetically compromised permanent submerged dental implants.

CASE PRESENTATION: Midfacial peri-implant soft tissue recession poses a significant challenge to achieving satisfactory aesthetic outcomes and requires a comprehensive, multidisciplinary approach. The present study describes two challenging cases in which implants were aesthetically compromised. A predictable technique was employed to manage these cases by using the implant itself as a tent to achieve 3D horizontal and vertical soft tissue building, which resulted in improved patient satisfaction. The first case involved a deep, severely buccally placed implant situated adjacent to compromised tooth structure. Horizontal and vertical soft tissue augmentation were carried out using a healing abutment to maintain the connective tissue coronal to the implant. The final fixed prosthesis was then delivered on top of the permanent submerged implant, with excellent soft tissue outcomes and a high level of patient satisfaction. The second case involved two compromised, deep, buccally placed implants that were managed by performing a permanent implant submergence technique on the maxillary left central incisor implant and augmenting the soft tissue vertically and horizontally. The final fixed prosthesis was delivered between the maxillary left lateral incisor implant and the previously prepared maxillary right central incisor, resulting in an acceptable aesthetic outcome. The technique presented managed the peri-implant soft tissue dehiscence effectively and restored the previously deficient peri-implant papillae. CONCLUSIONS: The key to treating challenging aesthetic complications encountered with implants is presurgical prosthetic preparation followed by use of a comprehensive surgical technique to optimise soft tissue thickness and height and address compromised aesthetics in a single surgical step. Use of a permanent implant submergence technique with remediation of associated defects may be a viable clinical approach that is not often explored for these types of defects.

Prevention and management of drug-induced osteonecrosis of the jaws using platelet-rich fibrin: A clinical feasibility study.

OBJECTIVE: Although a standard treatment guideline has not been established to date, various treatment modalities have been described in the literature based on the staging of medication-related osteonecrosis of the jaw (MRONJ). The aim of this case series was to describe the outcomes of surgical intervention of MRONJ cases with the adjunctive use of platelet-rich fibrin (PRF). MATERIALS AND METHODS: Thirteen patients under therapy with zoledronic acid, seven of them underwent surgical removal of necrotic bone with debridement, followed by placement of three to four PRF membranes and achieving primary closure. In six patients, PRF was used preventively to avoid MRONJ. RESULTS: The surgical treatment outcomes were successful in all patients, with a follow-up range of 12-48 months. In the presented cases, the intraoral evaluation showed excellent soft tissue healing except for one patient secondary wound healing was reported. Additionally, there was no recurrence of bone exposure in all cases. PRF membranes were comparatively effective in postsurgical pain control. CONCLUSION: The use of PRF could represent a valuable adjunct in the surgical management for advanced stages of MRONJ cases. CLINICAL RELEVANCE: This clinical case series describes the use of PRF membranes as a valuable adjunct in the surgical management of MRONJ patients, especially when treating advanced MRONJ cases. Moreover, PRF demonstrates usefulness in preventing such difficult complications from occurring.

Utilizing Individualized Titanium Frames (ITFs) for Protected Alveolar Bone Augmentation: A feasibility case series.

Despite the various barrier membranes proposed, one of the main challenges for guided bone regeneration (GBR) is space maintenance for large defects as well as ensure adequate blood supply. The presented feasibility case series aims to introduce an original titanium frame (TF) design, customized for each defect, as a modification of well-known principles and materials for GBR, for an enhanced and more predictable horizontal and vertical bone augmentation. Three patients with significant horizontal defects were treated with pre-trimmed TFs to create needed space, a 50%-50% mixture of autograft and bovine xenograft was placed, and then covered with collagen membrane. After 8 months of healing, the sites were reopened, the titanium screws were removed with the frame. An average of 8.0 ± 1.0mm horizontal and 3.0 ± 0.0mm vertical bone gain was achieved at the time of re-entry and implant placement surgery. Bone core biopsy was obtained during the implant placement. Histomorphometric analysis revealed that 42.8% of the sample was new vital bone, 18.8% was residual bone graft particles, and 38.4% was bone marrow like structures. After 3-4 months from implant placement, the implants were restored with provisional crowns and then finalized with zirconia screw-retained crowns. This case series suggests that GBR utilizing TFs with or without collagen membranes can be considered a suitable approach for horizontal and vertical bone augmentation. However, based on only three reported cases, the result should be carefully interpreted.

A decision-making tree for evaluating an esthetically compromised single dental implant.

OBJECTIVE: To develop a comprehensive decision-making tree for evaluating mid-facial peri-implant soft tissue dehiscence in the esthetic zone and provide a systematic approach for assessing various clinical case scenarios, determining appropriate treatment strategies, and considering factors such as the need for soft tissue augmentation, prosthetic changes, or implant removal. CLINICAL CONSIDERATIONS: This clinical decision tree illustrates numerous case scenarios with various esthetic complications around an esthetically compromised, but clinically healthy single implant and provides clinicians with possible solutions as a predictable map for horizontal and vertical soft tissue augmentation in order to manage different clinical circumstances. According to current evidence, the key to treating such esthetic complications is the use of an adequate pre-surgical prosthetic interdisciplinary approach with proper surgical techniques in order to optimize soft tissue dimensions and create better esthetic results. This may be accomplished through a purely surgical, combination of surgical and prosthetic, or purely prosthetic approaches. CONCLUSIONS: The present report describes a series of successfully treated peri-implant esthetic complication cases in accordance with the decision-making tree that the authors recommend in order to achieve better long-term esthetic outcomes. CLINICAL SIGNIFICANCE: The combination of adequate pre-surgical prosthetic interdisciplinary collaboration and proper surgical technique is critical in the optimization of sufficient soft tissue dimensions and contributes to a more highly esthetic result. This study demonstrates a clinical decision-making tree to provide comprehensive, effective therapy of an esthetically compromised dental implant by using one of the following approaches: purely prosthetic, purely surgical, or a combination of surgical and prosthetic with or without abutment removal.

Complete mouth rehabilitation with fixed implant-supported restoration for a patient with myasthenia gravis: A clinical report.

This clinical report describes a complete mouth fixed implant-supported rehabilitation for a patient with myasthenia gravis. Patients with myasthenia gravis may have impaired manual dexterity from progressive neuromuscular impairment. Muscle weakness and fatigue, reduced denture stability, and the inability to provide maxillary dentures with a peripheral seal have compromised the ability to wear dentures. Therefore, care is needed when providing an implant-supported prosthesis. This clinical report provides step-by-step management of a patient with myasthenia gravis, providing a complete arch implant-supported rehabilitation.

Supplement Consumption and Periodontal Health: An Exploratory Survey Using the BigMouth Repository.

BACKGROUND: Dietary supplements have been investigated for their impact on the periodontal apparatus (alveolar bone, mucosa, periodontal ligament, and cementum) and their hypothetical protective role against periodontitis. There remains a gap in the field in this area. Thus, the present study aims to examine the correlation between populations who report taking different dietary supplements and their relative periodontal health. METHODS: The BigMouth dental data repository derived from the dental Electronic Health Records (EHRs) of the University of Michigan school of dentistry was used to extract data relating to all patients who fulfilled the eligibility criteria. The prevalence of periodontitis compared to periodontal health as related to supplement consumption was assessed. RESULTS: A total of 118,426 individuals (55,459 males and 62,967 females) with self-reported consumption of the dietary supplements of interest were identified in the University of Michigan database via the BigMouth repository. Associations with the following vitamins were investigated, Vitamin B, Vitamin C, Vitamin D, Vitamin E, Multivitamins, Fish oil, Calcium, Omega 3, Saw palmetto, Zinc, Sildenafil, Flax seed, Folic acid, Garlic pills, Ginger pills, Ginko, Ginseng, Glucosamine, Iron, and Magnesium. Out of these supplements, only multivitamins and iron were found to significantly favor periodontal health, while folic acid and vitamin E significantly favored periodontitis. CONCLUSIONS: This study found a minimal association between the consumption of dietary supplements with periodontal health.

Papilla reconstruction using a vertical interproximal tunnel approach.

INTRODUCTION: Papilla reformation is one of the most difficult and elusive surgical techniques for clinicians. Although it involves similar tenets to those applied for soft tissue grafting at recession defects, crafting a small tissue in restricted space remains unpredictable. Numerous grafting techniques have been developed to correct interproximal and buccal recession, but so far, only a limited number of techniques have been prescribed for interproximal remediation. CASE PRESENTATION: This report describes in detail a modern technique (the vertical interproximal tunnel approach) for reforming the interproximal papilla and treating interproximal recession. It also documents three challenging cases of papilla loss. The first case presented Class II papilla loss and a recession type 3 gingival defect adjacent to a dental implant, managed using the vertical interproximal tunnel approach through a short vertical incision. A 6-mm increase in attachment level and almost complete papilla fill were observed in this case with this surgical technique for papilla reconstruction. The second and third cases presented Class II papilla loss between two adjacent teeth, managed using the vertical interproximal tunnel approach through a semilunar incision and achieving full papilla reconstruction. CONCLUSION: Both described incision designs for the vertical interproximal tunnel approach require technical meticulousness. When executed carefully and using the most beneficial pattern of blood supply, predictable reconstruction of the interproximal papilla can be achieved. It also helps alleviate concerns associated with inadequate flap thickness, blood supply and flap retraction.

Inverted T-shape free gingival graft for treatment of RT3 gingival recession defects: Reporting of two cases.

INTRODUCTION: One of the most challenging aspects of treating gingival recession type 3 (RT3) is reconstructing lost interdental papillae, which is directly related to the loss of interproximal bone. Free gingival graft (FGG) has been successfully used to increase the keratinized tissue width (KTW) with minimal trauma to the interdental papilla. This presented case suggests that FGG can be used for reconstruction of lost initerdental papilla creeping attachment also plays an additional role in improving the results. CASE PRESENTATION: The included two case reports suggest a novel technique using an FGG that is shaped in an inverted T-shape to achieve partial root coverage, improve the compromised interdental papilla, and increase the KTW in RT3 defects. CONCLUSIONS: This report presents a novel yet intuitive surgical technique for partial coverage of RT3 defects and reconstruction of the interdental papilla. SUMMARY: The inverted T-shape soft tissue graft may be a valuable technique for papillary reconstruction in the challenge of RT3 recessions. KEY POINTS: Why is this case new information? Reporting innovative technique with the interproximal extension of the FGG that sutured lingually with the lingual marginal gingiva. Improve interdental clinical attachment phenotype and height. More predictable root coverage because of increased vascularized interproximal bed for the graft to be survived. What are the keys to the successful management of this case? Having at least 2mm interproximal space for graft survival. Good Extension with proper fixation of the lingual part of the graft, and stabilization of the graft. What are the primary limitations to success in this case? limited capacity for perfusion and survival of the lingual extension due to limited vascularity. More investigations are necessary to confirm the validity of this technique.