Bone Volume Assessment Around Immediate Dental Implant in the Esthetic Area with Immediate Tooth-Like Single Crown Provisionalization: A Laser and Computed Tomography 1-Year Retrospective Study.

PURPOSE: To examine the remodeling process of both the soft and hard tissue components of the postextraction socket around immediately loaded dental implants after tooth extraction in maxillary esthetic areas. MATERIALS AND METHODS: Subjects underwent immediate placement of single implants in postextraction sockets without bone grafting, and their immediate provisionalization with custom tooth-like interim crowns were fabricated using digital diagnostic impressions and a dental milling machine. Intraoperative and 1-year follow-up layered scans of the postextraction sockets after implantation were acquired using a 3D optical system. In the short term, subjects underwent computed tomographic scans. Digital impressions for gingival contours, originally stored as STL (standard tessellation language) files, were converted to DICOM (Digital Imaging and Communications in Medicine) files with the implant shoulder working as a referral point, which were then superimposed to 3D radiologic images. The observed volumetric and linear outcomes were measured using a program known as DentaScan. The width of the alveolar crest at the level of the implant shoulder and marginal bone levels were acquired. Nonparametric tests were applied with a level of significance set at P < .01. RESULTS: No failure was reported after a follow-up of 1 year. Little or no inflammation of the treated areas was registered, and there were practically no signs of suppuration. The areas showed a significant reduction in the overall volumes for both soft and bone tissue, with a P value < .0001 from the baseline (0.983 ± 0.172 cm3) to the 1-year survey (0.865 ± 0.156 cm3). If the soft and bone tissue changes were separately evaluated, a significant loss (with a P value < .0001) was registered for only the bone tissues (from 0.434 ± 0.075 to 0.355 ± 0.061 cm3). Moreover, changes in gingival tissue from baseline to the 1-year survey (-0.040 ± 0.067) appeared to be significantly different from the overall volume loss (-0.118 ± 0.083 cm3). A shrinkage in width (-0.5 ± 0.7 mm) was found from baseline (12.6 ± 0.6 mm) to the 1-year follow-up (12.1 ± 0.9 mm). Marginal bone levels were 0.97 ± 0.70 mm and 0.39 ± 0.78 mm, respectively, at the mesial and distal aspects of the implants. CONCLUSIONS: The present analysis suggested that immediately customized provisionalization was effective enough to prevent both volume loss and linear shrinkage at the layers of the treated areas. Moreover, the buccal aspects seemed to be the areas most affected by the loss of volume. The mean loss in width, which amounted to roughly 0.5 mm, appeared to be negligible when compared to the overall width measured before surgery.

Electron Microscopy (EM) Analysis of Collagen Fibers in the Peri-Implant Soft Tissues around Two Different Abutments.

The design of the implant prosthesis-abutment complex appears crucial for shaping healthy and stable peri-implant soft tissues. The aim of the present animal study was to compare two implants with different healing abutment geometries: a concave design (TEST) and a straight one (CTRL). Transmission electron microscopy (TEM) was used to quantify the three-dimensional topography and morphological properties of collagen at nanoscale resolution. 2 swine were included in the experiment and 6 implants per animal were randomly placed in the left or right hemimandible in either the physiologically mature bone present between the lower canine and first premolar or in the mandibular premolar area, within tooth extraction sites. Each CTRL implant was positioned across from its respective TEST implant on the other side of the jaw. After 12 weeks of healing, 8 specimens (4 CTRL and 4 TEST) were retrieved and prepared for histological and TEM analysis. The results showed a significantly higher percentage of area covered by collagen bundles and average bundle size in TEST implants, as well as a significant decrease in the number of longitudinally oriented bundles with respect to CTRL implants, which is potentially due to the larger size of TEST bundles. These data suggest that a concave transmucosal abutment design serves as a scaffold, favoring the deposition and growth of a well-organized peri-implant collagen structure over the implant platform in the early healing phase, also promoting the convergence of collagen fibers toward the abutment collar.

Immediate Implant and Customized Healing Abutment Promotes Tissues Regeneration: a 5-year Clinical Report.

INTRODUCTION: Significant alveolar bone resorption follows tooth extraction. Immediate implant placement alone is not sufficient to prevent this phenomenon. CASE PRESENTATION: In this clinical case, a fractured upper first premolar was replaced by an immediate implant and a customized healing abutment designed on the perimeter of the extractive alveolus. After 3 months, the implant was restored. The facial and interdental  soft  tissue  was maintained with  appreciable  success after 5 years. The pre- and 5-year-post-treatment CT scans showed no bone loss. CONCLUSION: The use of an interim customized healing abutment helps preventing hard and soft tissues collapse.  This technique is very straightforward and might represent a smart preservation strategy when there is no indication for adjunctive hard or soft tissue grafting.

Immediate Implant and Customized Healing Abutment Promotes Tissues Regeneration: A 5-Year Clinical Report.

Significant alveolar bone resorption follows tooth extraction. Immediate implant placement alone is not sufficient to prevent this phenomenon. The present study aims at reporting the clinical and radiologic outcome of an immediate implant with a custom healing abutment. In this clinical case, a fractured upper first premolar was replaced by an immediate implant and a customized healing abutment designed on the perimeter of the extractive alveolus. After 3 months, the implant was restored. The facial and interdental soft tissue was maintained with appreciable success after 5 years. The pre-and 5-year post-treatment computerized tomography scans showed bone regeneration of the buccal plate. Use of an interim customized healing abutment helps prevent hard- and soft-tissue collapse and promotes bone regeneration. This technique is straightforward and may represent a smart preservation strategy when there is no indication for adjunctive hard or soft tissue grafting. Given the limited nature of this case report, further studies are needed to confirm the present findings.

Immediate implant and socket preservation using sticky bone and leukocyte-platelet-rich fibrin in the anterior maxilla: A 3-year case report.

INTRODUCTION: Immediate implant in the esthetic area is a challenging procedure. Chronic infection often contributes to extensive bone loss and acute infection often precludes a safe, clean surgery. However, it is quite common to come across failing teeth in the esthetic area, where the patient often demands a faster rehabilitation. CASE PRESENTATION: In this clinical case, a fractured upper central incisor was replaced by an immediate implant, and the perimetrical area was filled with heterologous bone blended with patient-derived leukocyte- and platelet-rich fibrin (L-PRF) in the form of sticky bone. A Maryland bridge was bonded to the adjacent teeth with the intent to guarantee minimum esthetic to the patient. After 5 months, the implant was connected to a definitive abutment and crown. The facial and interdental soft tissue was maintained with appreciable success after 2 years. The pre-treatment and 2-year- post-treatment computed tomography scans revealed marginal bone preservation. CONCLUSION: The use of sticky bone and L-PRF in immediate implant sites helps prevent hard and soft-tissue collapse and may favor faster and sounder healing. KEY POINTS: Why is this case new information? It provides support to the efficacy of immediate implant placement with simultaneous use of L-PRF. What are the keys to successful management of this case? Having L-PRF supporting wound healing. What are the primary limitations to success in this case? Having sufficient bone apical to the existing socket and at adjacent teeth.

Alveolar Bone Remodeling with or without Collagen Filling of the Extraction Socket: A High-Resolution X-ray Tomography Animal Study.

The healing process of the tooth extraction socket often leads to significant resorption of the alveolar bone, eventually causing clinical difficulties for future implant-supported rehabilitations. The aim of the present animal study was to evaluate alveolar bone remodeling after tooth extraction in a rabbit model, either with or without the use of a plain collagen plug inside the socket, by means of micro-computed tomography. The study included the micro-tomography analysis of 36 rabbits' incisor extraction sockets, either left empty or filled with a collagen plug. All animals were euthanized in a staggered manner, in order to address molecular, histologic, and radiographic analyses at different time-points, up to 90 days after surgery. The three-dimensional evaluation was carried out using micro-computed tomography technology on excised bone blocks including the alveolus and the contralateral bone. Both linear and volumetric measures were recorded: the percentage of bone volume change (ΔBV) within the region of interest was considered the primary endpoint of the study. The micro-CT analysis revealed mean volumetric changes of -58.1% ± from baseline to 3 months for the control group, and almost no bone loss for the test group, -4.6%. The sockets treated with the collagen plug showed significantly less dimensional resorption, while the natural-healing group showed an evident collapse of the alveolar bone three months after extraction surgery.

Radiographic and Histomorphologic Evaluation of the Maxillary Bone after Crestal Mini Sinus Lift Using Absorbable Collagen-Retrospective Evaluation.

BACKGROUND: After tooth extraction, the alveolar bone loses volume in height and width over time, meaning that reconstructive procedures may be necessary to perform implant placement. In the maxilla, to increase the bone volume, a mini-invasive surgery, such as a sinus lift using the crestal approach, could be performed. METHODS: A crestal approach was used in this study to perform the sinus lift, fracturing the bone and inserting collagen (Condress®). The single dental implant was placed in the healed bone after six months. RESULTS: The newly formed bone was histologically analyzed after healing. Histomorphological analyses confirmed the quality of the new bone formation even without graft biomaterials. This is probably due to the enlargement of the space, meaning more vascularization and stabilization of the coagulum. CONCLUSION: Using just collagen could be sufficient to induce proper new bone formation in particular clinical situations, with a minimally invasive surgery to perform a sinus lift.

Amino Acid-Enriched Formula for the Post-Operative Care of Extraction Sockets Evaluated by 3-D Intraoral Scanning.

BACKGROUND: Hyaluronic acid and amino acids play an important role in the wound healing process, stimulating the development of the connective tissue and the activity and proliferation of fibroblasts. The aim of the present controlled clinical study was to evaluate the clinical efficacy of a topical gel formula containing hyaluronic acid and amino acids in terms of wound closure rate, painkiller intake, and patients' reported pain and edema. METHODS: This study included patients in need of a single tooth extraction. Patients were randomized into two groups with differing post-operative care regimens. Patients in the test group used the amino acid and hyaluronic acid-based gel, while the control group did not use any product. Each parameter was measured in both groups at different time points: immediately after surgery, and after 7, 14, 30, and 60 days. RESULTS: A total of 40 patients (46.52 ± 9.84 years old) completed the observational period, and 40 extraction sockets were examined. After 7 days, the edema was significantly lower in the test group. The reported pain was lower in the test group without a significant difference, except for the first time point at 7 days. With the follow-up questionnaire, patients declared to have taken painkillers mainly during the first 7 days after surgery; however, the test group showed a lower need for painkillers than the control group. CONCLUSION: The post-operative and domiciliary use of an amino acid and hyaluronic acid-based gel for the management of soft tissue closure after tooth extraction is a valid coadjutant to reduce swelling, pain, and the need for painkillers. Additional studies are required to support the results of the present study.

The effectiveness of the information-motivation model and domestic brushing with a hypochlorite-based formula on peri-implant mucositis: A randomized clinical study.

OBJECTIVE: Management of mucositis is essential for the long-term maintenance of dental implants. This study determined the efficacy, in terms of clinical parameters, of an adjunctive domiciliary agent paired with non-surgical periodontal therapy (NSPT) for patients with peri-implant mucositis. MATERIALS AND METHODS: Patients involved in a periodontal maintenance program were randomly distributed to the domestic use of a chlorhexidine toothpaste and mouthwash (control) or a hypochlorite-based formula brushing solution (test) after diagnosis of peri-implant mucositis. A modified approach towards NSPTwas performed after 10 days of domestic use of the assigned maintenance product in both groups. Clinical and patient-related outcomes were recorded during a 90-day follow-up period. RESULTS: Forty patients completed the three-month study (20 patients per group). Both groups showed relevant clinical and patient outcome improvements after the NSPT (T2) and between T1 and T2 (p < 0 0.01), except for PPD. For the test group, the clinical improvement was significantly greater than that for the control group at the seventh-day evaluation (T1 ) in the gingival index (0-3) and FMBS (%). Favorable outcomes were maintained during the entire follow-up period. CONCLUSION: The present study showed that the modified NSPT paired with the domestic use of nitradine-based formula helps resolve peri-implant mucositis and that nitradine might represent an alternative to chlorhexidine in these cases. CLINICAL RELEVANCE: The gold standard for nonsurgical maintenance is full-mouth disinfection. A previous decontamination of the oral cavity with chlorhexidine or nitradine domiciliary for 10 days could reduce plaque and inflammation, resulting in a painless operative session. This protocol may help reduce airborne contamination and the risk of cross-infection, and during the pandemic, the protocol is safer for clinicians. In the same clinical cases, nitradine may be more efficient than chlorhexidine, and the former has no side effects such as discolouration.

Immediate restoration of fixed full-arch prostheses placed on implants in both fresh and healed sockets using the flat one-bridge technique: a 7-year retrospective study.

BACKGROUND: The aim of this retrospective study was to document the long-term clinical efficacy of a surgical-prosthetic technique (the flat one-bridge technique) involving the immediate restoration of both postextraction and nonpostextraction implants supporting full-arch restorations. METHODS: Implants were placed by adapting the axis to the available bone. Flat definitive abutments were connected during surgery and never disconnected to compensate for eventual implant disparallelism. Bone grafting was performed when needed. The patients received a screw-retained provisional restoration within 48 h of surgery and a final screw-retained prosthesis within 1 year. RESULTS: Sixty-six patients received 494 implants distributed in 75 prostheses. The median follow-up was 86 months (range 82-168 months). Only three implants had failed at the last follow-up. Implant survival was 99.6%. CONCLUSION: The flat one-bridge prosthetic protocol is a viable procedure with excellent long-term outcomes. No difference in clinical success could be observed between postextractive and nonpostextractive implants.

Effects of Non-Surgical Periodontal Treatment on Reactive Oxygen Metabolites and Glycemic Control in Diabetic Patients with Chronic Periodontitis.

BACKGROUND: Periodontal infection may contribute to poor glycemic control and systemic inflammation in diabetic patients. The aim of the present study is to evaluate the efficacy of non-surgical periodontal treatment in diabetic patients by measuring oxidative stress outcomes. METHODS: Sixty diabetic patients with periodontitis were enrolled, treated with scaling and full-mouth disinfection, and randomly prescribed chlorhexidine mouthwash, antioxidant mouthwash, or ozone therapy. Reactive oxygen metabolites (ROMs), periodontal parameters, and glycated hemoglobin were measured at baseline and then at 1, 3, and 6 months after. RESULTS: At baseline, all patients presented with pathologic levels of plasmatic ROM (388 ± 21.36 U CARR), higher than the normal population. Probing depth, plaque index, and bleeding on probing values showed significant clinical improvements after treatment, accompanied by significant reductions of plasma ROM levels (p < 0.05). At the 6-month evaluation, the mean ROM relapsed to 332 ± 31.76 U CARR. Glycated hemoglobin decreased significantly (∆ = -0.52 units) after treatment. Both the test groups showed longer-lasting improvements of periodontal parameters. CONCLUSION: In diabetic patients, periodontal treatment was effective at reducing plasma ROM, which is an indicator of systemic oxidative stress and inflammation. The treatment of periodontal infection might facilitate glycemic control and decrease systemic inflammation.

A New Approach for Lateral Sinus Floor Elevation.

The lateral sinus lift procedure has been extensively investigated and described as a reliable surgical solution aimed at facilitating implant placement and rehabilitation when the posterior upper maxilla is atrophic. The standard technique consists in a lateral antrostomy, the careful raising of the sinus membrane, and following apposition of a bone substitute between the membrane and the sinus floor. The present technical note illustrates a new conservative technique enabling lateral sinus lift without the use of bone substitutes and with predictable outcomes.

Radiological Outcomes of Bone-Level and Tissue-Level Dental Implants: Systematic Review.

Background: to assess the radiological marginal bone loss between bone-level or tissue-level dental implants through a systematic review of literature until September 2019. Methods: MEDLINE, Embase and other database were searched by two independent authors including only English articles. Results: The search provided 1028 records and, after removing the duplicates through titles and abstracts screening, 45 full-text articles were assessed for eligibility. For qualitative analysis 20 articles were included, 17 articles of them for quantitative analysis counting a total of 1161 patients (mean age 54.4 years) and 2933 implants, 1427 inserted at Tissue-level (TL) and 1506 inserted at Bone-level (BL). The survival rate and the success rate were more than 90%, except for 2 studies with a success rate of 88% and 86.2%. No studies reported any differences between groups in term of success and survival rates. Three studies showed that BL-implants had statistically less marginal bone loss (p < 0.05). Only one study reported statistically less marginal bone loss in TL-implants (p < 0.05). Conclusion: In the most part of the studies, differences between implant types in marginal bone loss were not statistically significant after a variable period of follow-up ranged between 1 and 5 years.

Extension implants in the atrophic posterior maxilla: 1-year results of a retrospective case-series.

BACKGROUND/PURPOSE: Blade implants account for one of the most debated dental implants design in scientific literature. They have been reconsidered by clinicians since their re-classification by Food and Drug Administration in 2014. MATERIALS AND METHODS: The present study aimed to evaluate the outcome of newly manufactured extension implants in the treatment of moderate atrophic posterior maxillae. All the patients enrolled in the present retrospective case series study showed a moderate bone atrophy in the posterior maxilla with a maximum residual height ranging between 4 mm and 8 mm. Implants were inserted with the aid of an electro-magnetic device, and then they covered with screws and left healing. Three months after, implants were exposed and loaded. RESULTS: Difference between the marginal bone level at the 3-month evaluation (5.57 ±â€¯0.67 mm) and that at baseline (5.67 ±â€¯0.55 mm) appeared to be not significant (p-value = 0.63). At the 12-month evaluation, the marginal bone level (4.95 ±â€¯0.45 mm) underwent significant decrease respect to baseline value as proven by significant change at marginal bone level (-0.62 ±â€¯0.51 mm with a p-value = 0.01). CONCLUSION: The results of the present study suggested a positive 12-month outcome for extension implants in the rehabilitation of the moderate atrophic maxilla, without the need of extensive reconstructive surgeries and grafting procedures.

Ozone Therapy for Oral Palatal Ulcer in a Leukaemic Patient.

Chemotherapy usually causes complications affecting several tissues such as oral mucosa. In this case report, a soft palate oral ulcer caused by chemotherapy was treated by ozone gas. This kind of treatment is known for its antimicrobial, regenerative and analgesic proprieties. The results show a complete resolution of the lesion within 2 weeks of treatment. Ozone therapy demonstrates greater effectiveness with respect to this kind of oral lesion compared to traditional therapy. Considering this evidence, ozone therapy should be considered as a useful tool for the adjuvant therapy of oral complications in oncologic patients. LEARNING POINTS: Intensive chemotherapy can have side effects, particularly affecting tissue with higher turnover. Therefore, there is a clinical need to prevent or to treat such complications.Ozone therapy could improve oral mucosa healing and have anti-inflammatory, antioxidant and antibacterial effects to prevent suprainfections. To date, there are no reported cases of oral ulcers in oncologic patients being completely resolved using ozone in the literature.Medical and dental doctors should collaborate with regards to complex patients to prevent such types of complications, discovering these clinical cases that are unknown in the literature and treating patients in a more comprehensive way.

A methodological approach to standardize and control the quality of the position and alignment of lamina implants on two-dimensional radiographs.

OBJECTIVES: We sought to validate a new method to detect the degree of correlation between simulated and real tilted blade implants as they appear on a single two-dimensional radiograph. METHODS: The angular correction factor (CF^) was defined as the coupling of two subsequent angle transformations, a set of five angular values describing the theoretical radiographic appearance of the blade implant: (1) three consecutive rotations about the axes of the blade ([Formula: see text], θ, and ψ, standing for pitch, roll, and yaw, respectively) to represent the polarization directions; (2) a two-dimensional projection defined by two angles (λ and [Formula: see text], respectively, longitude and latitude) to represent the vector of the X-ray beam intersecting the detector plate. Data of patients who received fixed prostheses supported by blade-form implants were employed to calculate a dimensional correction factor (CF°), a specific length through the major axis. The simulation of a distorted radiograph of a blade positioned in space was compared with the real radiograph. Differences in the angular measurements served as an initial test to assess the effectiveness of the method. RESULTS: In the acquired sets of periapical radiographs, mean misalignments of + 3.58° in longitude and - 0.04° in latitude were registered. The following variations were detected during the accuracy testing: the absolute error was 0.1 ± 7.5° for angle [Formula: see text]; 2.4 ± 6.7° for angle θ; - 1.0 ± 3.7° for angle ψ; 4.5 ± 8.6° for angle λ; and 2.0 ± 9.3° for angle [Formula: see text]. The linear dependence between CF° and CF^ was estimated by a robust linear regression: slope + 0.991, intercept + 0.007, and adjusted R2 0.992. CONCLUSIONS: This a posteriori analysis introduces the explicit trigonometric equations of the theoretical standard (CF^) used to describe the blade implant radiographic position and misalignment on two-dimensional radiographs.

Myofibroblast Gene Expression Profile after Tooth Extraction in the Rabbit.

After tooth extraction, the alveolar bone tends to shrink in volume, especially on the vestibular side. The role of myofibroblasts in bone remodeling has not been sufficiently investigated. The aim of the present study was to explore the gene expression related to myofibroblasts presence and activity during a 90-day healing period after tooth extraction. The study included 36 rabbits, and a single tooth extraction was performed on each rabbit. The extractive sockets were randomly distributed to natural healing or to scarification of the wound. The sacrifices were staggered in such a manner that animals contributed with sockets representing 2, 7, 15, 30, 60, and 90 days of healing. Nanostring technology was used to evaluate the expression of a wide panel consisting in 148 genes related to the activation, induction, and suppression of myofibroblasts, socket microenvironment, and autophagy. We found that the expression profile of this custom panel was time-related. The post-extractive socket was subjected to significant gene expression changes after 15 days: the genes involved in the induction of myofibroblasts were up-regulated in the first 15-day period and down-regulated during the rest of the follow-up. The study suggested that myofibroblasts play a major role in the immediate 15-day period following tooth extraction.

Mandibular Osteonecrosis Associated with Antacid Therapy (Esomeprazole).

INTRODUCTION: Osteonecrosis of the jaw has been consistently reported in the literature associated to the high-dose intravenous bisphosphonate therapy. However, osteonecrosis can also occur in patients who have other risk factors. CASE DESCRIPTION: An unusual case of ONJ in a patient being treated with esomeprazole is reported. DISCUSSION: The probable association between proton pump inhibitor intake and osteonecrosis of the jaw should alert clinicians. Collaborations between medical and dental doctor and an early diagnosis might prevent or reduce the morbidity resulting from advanced destructive lesions of the jaw bone. LEARNING POINTS: Osteonecrosis of the jaw (ONJ) can occur in patients treated with bisphosphonates and corticosteroids and is associated with oral surgical procedures involving bone.Antacid drugs commonly used to treat gastro-oesophageal reflux could affect bone metabolism although no cases of ONJ in patients using proton pump inhibitors have been reported.Medical and dental practitioners should collaborate to prevent ONJ, identify previously unreported drug interactions, and treat patients in a more comprehensive manner.

The Effect of Tapered Abutments on Marginal Bone Level: A Retrospective Cohort Study.

BACKGROUND: Early peri-implant bone loss has been associated to long-term implant-prosthetic failure. Different technical, surgical, and prosthetic techniques have been introduced to enhance the clinical outcome of dental implants in terms of crestal bone preservation. The aim of the present cohort study was to observe the mean marginal bone level around two-part implants with gingivally tapered abutments one year after loading. METHODS: Mean marginal bone levels and change were computed following radiological calibration and linear measurement on standardized radiographs. RESULTS: Twenty patients who met the inclusion criterion of having at least one implant with the tapered prosthetic connection were included in the study. The cumulative implant success rate was 100%, the average bone loss was -0.18 ± 0.72 mm, with the final bone level sitting above the implant platform most of the time (+1.16 ± 0.91 mm). CONCLUSION: The results of this cohort study suggested that implants with tapered abutments perform successfully one year after loading and that they are associated with excellent marginal bone preservation, thus suggesting that implant-connection macro-geometry might have a crucial role in dictating peri-implant bone levels.

Clinical and patient-centered outcomes post non-surgical periodontal therapy with the use of a non-injectable anesthetic product: A randomized clinical study.

AIM: The aim of this study was to determine the impact of different full-mouth decontamination (FMD) protocols on the effectiveness of an intrapocket anesthetic gel in periodontal maintenance patients. METHODS: Patients undergoing the periodontal maintenance program and with the need for FMD participated in this study. Patients were randomly allocated to non-surgical periodontal therapy (NSPT) with either a preparatory 15-day decontamination phase, including chlorhexidine mouth rinse and domiciliary hygiene instructions (modified FMD: test group), or without it (FMD: control group). In both groups, NSPT was performed with the aid of a non-injectable anesthetic gel. Clinical and patient-related outcomes were recorded during a 6-month follow-up period. RESULTS: Sixty patients completed the 6-month study. Both groups experienced relevant clinical improvements after NSPT, but the test group showed a significant change in periodontal parameters already after the initial 15-day preparatory period, and overall significantly better results in periodontal outcomes when compared with the control group at the last 6-month follow up: the gingival index was 2.07 ± 1.25 in the control group and 1.13 ± 0.51 in the test group. Less pain and dental-related anxiety were perceived by patients in the test group showing a 6-month mean visual analog scale of 2.13 ± 1.25 in the control group and 1.13 ± 0.83 in the test group. CONCLUSION: The present study suggested that the modification of the standard FMD could improve the clinical efficacy of non-injectable anesthetic, along with patients' short- and mid-term appreciation and compliance.