Patient-reported outcomes of palatal donor site healing using four different wound dressing modalities following free epithelialized mucosal grafts: A four-arm randomized controlled clinical trial.

BACKGROUND: The aim of this study was to compare the effects of four different commonly used wound dressings in improving patient reported outcomes (PROMS) after free epithelialized mucosal grafts (FEGs) harvesting. METHODS: Following 72 FEGs harvesting from 72 patients, patients were assigned into four groups. CONTROL: collagen plug + sutures (CPS); test: collagen plug with cyano-acrylate (CPC), platelet rich fibrin (PRF) + sutures, or palatal stent only (PS). Patients were observed for 14 days, with evaluation of pain level utilizing the visual analog scale, number of analgesics consumed, need for additional analgesics, amount of swelling, amount of bleeding, activity tolerance, and willingness for retreatment. RESULTS: Compared to the control group all test groups indicated significant lower pain perception (P < 0.0001), lower analgesic consumption (P < 0.0001), and higher willingness for retreatment (P < 0.0001), while no statistically significant differences among test groups were observed. There were no statistically significant differences in amount of day-by-day swelling, bleeding, and activity tolerance among four groups. Compared to other groups, the PS had the lowest overall pain scores (over the 14-day period). Palatal thickness, graft length, graft width, and graft thickness did not appear to affect patient morbidity (P > 0.05). CONCLUSIONS: All interventions significantly decreased pain perception compared to a hemostatic collagen sponge alone over the palatal donor site after FEG surgery. In the first few days after surgery, the use of a palatal stent seemed to be associated with less overall pain, pain pills consumed, and higher willingness of doing the same procedure again.

The effect of bone particle size on the histomorphometric and clinical outcomes following lateral ridge augmentation procedures: A randomized double-blinded controlled trial.

BACKGROUND: The aim of this randomized clinical trial was to clinically and histologically compare the amount and quality of bone gained after lateral ridge augmentation (LRA) procedures performed using small-particle (SP)-size (250-1000 µm) versus large-particle (LP)-size (1000-2000 µm) size corticocancellous bone allografts at 6 months following surgical intervention. METHODS: Twenty-two patients, each presenting with ridge width <5 mm were enrolled. Patients were randomly allocated to SP- and LP-size graft. The gain in ridge width at the level of the crest and 4 mm apical to the crest was assessed via a standardized procedure before grafting and at time of implant placement, using a surgical caliper and a novel digital technique using cone-beam computed tomography (CBCT). Six months following the procedure, trephine bone cores were taken from 19 augmented sites of 17 patients (14/19 sites were in the posterior mandible) who completed the study for clinical, histologic, and histomorphometric analysis. RESULTS: Seventeen patients (19 sites) completed the study. An LP-size graft resulted in greater ridge width gain at the level of the crest (LP 5.1 ± 1.7; SP 3.7 ± 1.3 mm; p = 0.0642) and 4 mm apical to the crest (LP 5.9 ± 2.2; SP 5.1 ± 1.8 mm; p = 0.4480) compared with the SP. No statistical significance for the bone density at the time of implant placement (p = 1.00) was found. Vital bone formation was more extensive in the SP compared with the LP (41.0 ± 10.1% vs. 31.4 ± 14.8%, respectively; p = 0.05). CONCLUSION: The results of the present study show a trend of higher ridge gain using LP during the bone augmentation procedure. Future research with bigger sample size should confirm the results of the present research.

Clinical applications of mucogingival therapies utilizing adjunctive autologous blood products.

BACKGROUND: Mucogingival deformities are prevalent oral conditions and can result in esthetic compromise, dentinal hypersensitivity, and an increase in radicular caries rates. Mucogingival treatments address thin periodontal phenotype and/or gingival recession defects. Although many of these grafting procedures are predictable in improving soft-tissue quality and quantity around teeth and dental implants, patients often complain of discomfort at both the donor and recipient sites. Free gingival grafts and coronally advanced flaps alone or in combination with subepithelial connective tissue graft and/or acellular dermal matrix are among the most common surgical procedures employed to achieve root coverage and enhance periodontal phenotype. Autologous blood products (ABPs) contain platelets, growth factors, leukocytes, and stem cells that contribute to cell mitosis, collagen production, and angiogenesis, leading to the healing and regeneration of hard and soft tissue. Evaluation of the adjunctive role of ABPs in mucogingival surgery and their impacts on clinical and patient-centered data is critical to achieve optimal patient-reported outcome measures based upon the current scientific evidence. METHODS: We present exemplar cases in which adjunctive ABPs were utilized in mucogingival treatment to enhance treatment outcomes. RESULTS: No adverse events were noted. Satisfactory treatment outcomes were achieved in patients with local and/or systemic compromise when mucogingival therapies were used in combination with ABPs. CONCLUSIONS: Adjunctive use of ABPs may enhance outcomes of mucogingival therapy. Utilization of adjunctive ABPs may be particularly advantageous in situations where the predictability of clinical and esthetic outcomes is limited due to anatomical and/or patient factors.

A Prospective, Randomized Controlled Pilot Trial to Compare Vestibular Incision Subperiosteal Access and Sulcular Tunnel Access Root Coverage Procedures to Treat Gingival Recession.

The aim of this randomized prospective study was to compare clinical and patient-centered outcomes of Miller Class I and II gingival recession defects treated with acellular dermal matrix (ADM) grafts and either vestibular incision subperiosteal tunneling access (VISTA) or sulcular tunnel access (STA) techniques. A total of 29 gingival recession defects in nine patients were assessed to determine clinical outcomes, including probing depth (PD), gingival recession (GR), width of keratinized tissue (KT), width of attached tissue (AT), tissue thickness at the gingival margin (TT1), and tissue thickness 4 mm apical to the gingival margin (TT2). Visual analog scale (VAS) assessment of patient-perceived pain, bleeding, swelling, and changes in activity were assessed postoperatively at 7 and 30 days, and professional assessment of postoperative esthetics using the Pink Esthetic Score (PES) was performed at 6 months. All sites demonstrated significant improvements in midfacial GR. No statistically significant differences were noted between the VISTA and STA groups for clinical or patient-centered outcomes, except for preferable midfacial AT in the VISTA sites at 6 months. These findings indicate that both surgical techniques can be used with ADM grafts to achieve improvements in root coverage, alterations in periodontal phenotype, and improved esthetics with high levels of patient satisfaction.

The Impact of Orthodontic Retainers on Gingival Recession: A Best-Evidence Review.

Retention is a critical phase of orthodontic therapy and aims to maintain occlusal stability and avoid crowding relapse. This best-evidence article reviews the effects of the different types of orthodontic retention appliances, fixed and removable, on the development and progression of gingival recession at the mandibular anterior teeth. Searched databases included PubMed, Scopus, Cochrane Library, Embase, and Dentistry and Oral Sciences. Eleven qualifying publications, including retrospective, prospective, and cross-sectional studies, were included in this review. These studies either did not demonstrate an association between orthodontic retainers and gingival recession or reported that the resulting recession defects were minimal when an association was shown. An important consideration is that recession could be a late finding following the placement of a retainer and, therefore, may be incipient or absent in short-term evaluations. Prospective studies that specifically address the role that properly positioned fixed retainers may have on gingival recession are needed before a definitive conclusion can be generalized with regard to recommended retention protocols. Factors such as duration of retainer use, number of bonded teeth, and position of fixed retainers relative to their proximity to gingival tissues are not fully elucidated but may have influencing roles on gingival recession. The use of retainers should be based on orthodontic indications to maintain a stable dental arch form, esthetics, and occlusion. Effective oral hygiene and follow-up regimens remain the gold standard in maintaining periodontal health and preventing gingival recession.

The new periodontal disease classification: Level of agreement on diagnoses and treatment planning at various dental education levels.

PURPOSE/OBJECTIVES: Using the periodontal diseases classification published in 2018, this study evaluated the level of agreement among predoctoral and postgraduate students of different education levels and specialties in the diagnosis and treatment planning of periodontal conditions. METHODS: Second-year (D2) and fourth-year (D4) dental students, postgraduate orthodontic students (OS), and periodontology students (PS) were presented with an anonymous survey of 10 cases, each with five choices of diagnosis and seven therapeutic approaches. The cases included a patient summary, photographs, radiographs, periodontal charting, and ranged from health to periodontitis. Consensus diagnosis, used as a gold standard, was established between two experienced periodontists. Diagnosis and treatment choices for each case were compared across educational groups using Fisher's exact test. The level of agreement among educational groups was assessed using a multirater kappa coefficient. RESULTS: The survey was completed in 2020 with a 72.4% overall response rate (57-D2, 45-D4, 17-OS, and 12-PS). The overall level of agreement on diagnosis was fair (κ = 0.24, p <.0001) with PS showing the most agreement (κ = 0.55, p <.0001). There were tendencies to prioritize stage over grade and extent in assigning diagnoses and to overdiagnose disease severity and underdiagnose localized periodontitis. Nonsurgical periodontal therapies had the highest overall agreement (κ = 0.63 for scaling/root planing and κ = 0.44 for maintenance, p <.0001). Response distribution per case and per level of education indicated that PS more consistently agreed with the gold standard than any other group. CONCLUSIONS: OS, D2, and D4 students demonstrated inferior agreement levels compared to PS, successfully recognized health from disease, suggested appropriate treatment plans, and tended to overdiagnose milder periodontal conditions.

A 5-Year Retrospective Analysis of Biologic and Prosthetic Complications Associated With Single-Tooth Endosseous Dental Implants: Practical Applications.

FOCUSED CLINICAL QUESTION: What are the key considerations of the incidence and timing for single-tooth implant complications, including early failure, biological complications, and prosthetic complications? SUMMARY: Single-tooth dental implants have been shown to have a high overall survival rate, but implant complications affect patient satisfaction and may lead to costly and/or time-consuming repair and revision. Assessing the incidence and types of biologic and prosthetic complications and the timing of such complications is helpful so that the underlying causes can be addressed during the treatment planning process. Furthermore, identification of patient demographics, patient-, implant-, and site-specific factors associated with such complications may allow for more comprehensive risk assessment during treatment planning. CONCLUSIONS: Overall, dental implants have a high survival rate. Identification of the incidence of both biologic and prosthetic complications and minimizing their impact in patients with dental implants is critical to overall implant success. Utilization of careful treatment planning and dental implant fixtures, surgical protocols, and prosthetic designs that reduce complication rates can improve patient acceptance and outcomes. Further research is necessary to fully assess complication rates and risk factors.

The impact of anatomic, patient and surgical factors on membrane perforation during lateral wall sinus floor elevation.

OBJECTIVES: This retrospective study aimed to evaluate the influence of anatomical, patient and surgical factors on the occurrence of membrane perforation (MP) during lateral window sinus floor elevation (LWSFE). MATERIAL AND METHODS: A review of LWSFE patient records between 2014 and 2019 accounted for MP occurrence, window surface area (WSA), intravenous sedation use, osteotomy instrument type and clinician experience. Preoperative cone beam computed tomography (CBCT) scans were analyzed for lateral wall thickness (LWT), LFM and LAM angles formed between lateral and medial walls at the floor and anterior wall, respectively, sinus width at 5-, 10- and 15-mm (LM-5, LM-10 and LM-15) from the floor, residual bone height (RBH), sinus pathologies, septa and arterial anastomoses. The generalized estimating equation (GEE) approach with a sandwich variance-covariance estimator was used to evaluate the associations with MP. RESULTS: MP occurred in 25.74% of 202 LWSFE procedures (166 patients). Mean 1.6 mm-LWT, 3.2 mm-RBH, 95°-LFM, 75.5°-LAM, 12 mm-LM-5, 20.79% septa, 16.83% arterial anastomosis, 37.62% sinus pathology and 29.21% intravenous sedations, 85.24% WSA ≥ 40 mm2 and 57% >10 procedures/clinician were reported. Greater MP rates were encountered as follows: 38.3% (LWT ≥ 1.5 mm), 38% (LFM < 90°), 59.6% (LAM < 70°), 45.4% (LM-5 < 10 mm) and 36.4% (WSA ranged > 80 mm2 ), with statistically significant associations with all these outcomes (p < .05). The presence of pathologies was also associated with MP (p = .013). Associations between MP and the presence of septa and arterial anastomoses, age/gender, right/left sinus, RBH, clinician's experience, instrument type and intravenous sedation use could not be demonstrated. CONCLUSIONS: MP is significantly associated with thicker lateral walls, narrower sinuses, larger windows and existing sinus pathology.

Management of a Large Artery During Maxillary Sinus Bone Grafting: A Case Report.

INTRODUCTION: Branches of the posterior superior artery (PSA) are often found within the lateral wall of the maxillary sinus. Most vessels are small and laceration of the blood vessel during sinus augmentation is not uncommon. Such lacerations can result in intra-surgical bleeding complicating the augmentation procedure, otherwise they are typically non-life threatening. The purpose of the present case report is to document a maxillary sinus floor augmentation procedure involving displacement of large artery from its bony canal using a piezoelectric device. CASE PRESENTATION: A maxillary sinus floor augmentation procedure was performed in a 58-year-old healthy female planned for a future implant supported fixed prosthesis. The preoperative computed tomography scan revealed a bony canal within the lateral maxillary sinus wall of the alveolar ridge. The artery tracing obvious on the lateral wall was elevated along with the Schneiderian membrane without any complication or hemorrhage using a piezoelectric device system. The postoperative healing was uneventful. CONCLUSION: Elevation of a large diameter PSA branch with the Schneiderian membrane significantly minimizes the risk of vessel laceration and hemorrhagic complications.

Clinical Decision Making for Primary Peri-Implantitis Prevention: Practical Applications.

FOCUSED CLINICAL QUESTION: When planning dental implant therapy, what risk-reduction strategies allow practitioners to select patients, sites, and restorative plans that decrease the incidence of peri-implant disease? SUMMARY: With a marked increase in the number of patients receiving dental implants to treat partial or complete edentulism, it follows that the prevalence of peri-implant mucositis and peri-implantitis have increased. Risks associated with implant therapies may vary based upon underlying local, environmental, surgical, patient, prosthetic, and fixture-related factors. Furthermore, an emphasis on preventative measures and maintenance should be undertaken to avoid development and progression of peri-implant diseases. Thorough risk assessment, proper treatment planning, and early diagnosis and intervention are critical in the absence of definitive data of long-term success of treatments for peri-implant condition. Given the difficulty in intervention once peri-implantitis is established, identification of risk factors and development of treatment plans to address those factors before dental implant therapy is critical to the long-term health and success of dental implants. CONCLUSIONS: A patient-centered, evidence based approach to dental implant treatment planning to reduce the risk for peri-implantitis should be undertaken. Systematic diagnosis of disease state(s) and evaluation of the etiologic and modifying risk factors for peri-implant diseases can yield more optimal outcomes to reduce peri-implantitis rates.

The Effect of Dental Implant Collar Design on Crestal Bone Loss at 1 Year After Implant Placement.

The aim of this randomized, prospective study was to compare clinical and radiographic outcomes of microtextured implants with two different collar designs at 1 year postplacement. A total of 69 implants were assessed in 58 patients for site, patient-specific, and clinician-experience variables. Overall implant survival was 94.9%. A statistically significant preservation of crestal bone was observed in the microgrooved-collar group. Narrow implant diameter was associated with a statistically significant increase in crestal bone loss. Collar design and implant diameter may be important in limiting adverse esthetic and bone loss outcomes during initial function.

Changes in Keratinized Tissue Width Following Connective Tissue Grafts and Diode Laser- vs Blade-Gingivoplasty.

The objectives of this study were to clinically and histologically assess the capacity of bilaminar subepithelial connective tissue grafts (SCTGs) alone or in combination with gingivoplasty (Gv) to increase the keratinized gingiva width (KGW) in contralateral mandibular sites lacking KG (10 patients, 42 sites). The effects of Gv timing (1 vs 2 months) and technique (blade vs laser) were also evaluated. SCTGs alone resulted in mean KGW increase of 0.1 to 0.7 mm. Laser-Gv significantly increased KGW by an additional 1.9 mm at 4 months postabrasion as opposed to 0.9 mm achieved with blade-Gv. Histologically, laser-treated sites displayed parakeratinization with more pronounced rete pegs than observed in blade-abraded sites.

Glycemic control among patients with physician-managed type 2 diabetes.

Outcomes for treatment, overall oral health status, and periodontal disease progression in patients with type 2 diabetes mellitus (T2DM) have been associated with glycemic control as measured by hemoglobin A1c (HbA1c) levels. Due to the high prevalence of T2DM among patient populations in the United States, this study sought to assess baseline levels of glycemic control for patients with a known diagnosis of T2DM who were under the care of a physician and to identify management solutions for these patients. All patients included in this study were prescreened to ensure that they were dentate, had been diagnosed with T2DM at least 3 months previously, were under the care of a physician for diabetes management, and had no changes to their diabetes-related medications for 3 months or more (N = 822). The patients meeting those criteria were then screened in person, and those who had moderate to severe chronic periodontitis, had at least 20 teeth, and met other inclusion/exclusion criteria were qualified to participate in the study (N = 214). After the patients fasted, a whole blood sample was drawn and subjected to HbA1c testing. The mean (SD) HbA1c for the qualified patients was 7.76% (1.79%), and the values ranged from 5.1% to 18.8%. Among the 214 qualified individuals, 150 (70.1%) had HbA1c values greater than 6.5%. Of these 150 patients, 80 (53.3%, or 37.4% of the total screened sample) presented with HbA1c values greater than 8.0%. The majority of patients with periodontitis and physician-managed T2DM did not meet ideal standards for glycemic control. Dental healthcare providers should consider consultation and/or advanced screening for diabetic patients seeking dental care.

Clinical and Patient-Centered Outcomes Following Treatment of Multiple Gingival Recessions Using Acellular Dermal Matrix Allografts.

The aim of this case series was to evaluate clinical and patient-centered outcomes when treating multiple recessions (Miller Class I, II, and III) affecting five or more teeth in a single procedure using acellular dermal matrix in 18 eligible participants (mean of 7.4 ± 1.7 recessions/patient). Low mean visual analog scale pain scores (0.7 ± 0.8) and analgesic consumption (2.3 ± 2.5 tablets) were reported from days 0 to 6 postoperatively. Mean baseline recession depth was 2.1 ± 1 mm. At 1 year postsurgery, mean percent root coverage was 87.1% ± 18.3%, and complete root coverage was achieved in 61.7% of recessions with statistically significant differences between smokers and nonsmokers.

Creation of a Zone of Immobile Connective Tissue with Acellular Dermal Matrix Allografts.

Acellular dermal matrix allografts (ADMs) have been hypothesized to create a zone of immobile connective tissue (ICT) extending apical to the mucogingival junction (MGJ). This 12-month prospective randomized trial investigated the presence of ICT after the use of two commercially available ADMs with coronally advanced flaps in the treatment of Miller Class I and II recession defects. This study demonstrated that the use of either type of ADM resulted in predictable root coverage and a zone of ICT extending apical to the MGJ by 1.88 to 2.69 mm. Hence, minimal keratinized gingival width should not preclude the use of ADMs.

Enhancement of the Regenerative Potential of Anorganic Bovine Bone Graft Utilizing a Polyglutamate-Modified BMP2 Peptide with Improved Binding to Calcium-Containing Materials.

Autogenous bone is the gold standard material for bone grafting in craniofacial and orthopedic regenerative medicine. However, due to complications associated with harvesting donor bone, clinicians often use commercial graft materials that may lose their osteoinductivity due to processing. This study was aimed to functionalize one of these materials, anorganic bovine bone (ABB), with osteoinductive peptides to enhance regenerative capacity. Two peptides known to induce osteoblastic differentiation of mesenchymal stem cells were evaluated: (1) DGEA, an amino acid motif within collagen I and (2) a biomimetic peptide derived from bone morphogenic protein 2 (BMP2pep). To achieve directed coupling of the peptides to the graft surface, the peptides were engineered with a heptaglutamate domain (E7), which confers specific binding to calcium moieties within bone mineral. Peptides with the E7 domain exhibited greater anchoring to ABB than unmodified peptides, and E7 peptides were retained on ABB for at least 8 weeks in vivo. To assess the osteoinductive potential of the peptide-conjugated ABB, ectopic bone formation was evaluated utilizing a rat subcutaneous pouch model. ABB conjugated with full-length recombinant BMP2 (rBMP2) was also implanted as a model for current clinical treatments utilizing rBMP2 passively adsorbed to carriers. These studies showed that E7BMP2pep/ABB samples induced more new bone formation than all other peptides, and an equivalent amount of new bone as compared with rBMP2/ABB. A mandibular defect model was also used to examine intrabony healing of peptide-conjugated ABB. Bone healing was monitored at varying time points by positron emission tomography imaging with (18)F-NaF, and it was found that the E7BMP2pep/ABB group had greater bone metabolic activity than all other groups, including rBMP2/ABB. Importantly, animals implanted with rBMP2/ABB exhibited complications, including inflammation and formation of cataract-like lesions in the eye, whereas no side effects were observed with E7BMP2pep/ABB. Furthermore, histological analysis of the tissues revealed that grafts with rBMP2, but not E7BMP2pep, induced formation of adipose tissue in the defect area. Collectively, these results suggest that E7-modified BMP2-mimetic peptides may enhance the regenerative potential of commercial graft materials without the deleterious effects or high costs associated with rBMP2 treatments.

Healing Time for Final Restorative Therapy After Surgical Crown Lengthening Procedures: A Review of Related Evidence.

Focused Clinical Question In healthy patients who receive surgical crown lengthening, how much healing time should be allowed for the positional changes of the gingival margin before final restoration? Clinical Scenario A 59-year-old woman presented to the University of Alabama at Birmingham School of Dentistry in August 2011 for replacement of her existing porcelain-fused-to-metal crowns on the maxillary anterior teeth for esthetic reasons. Clinical examination revealed a diagnosis of developmental mucogingival deformity manifested by gingival excess in the maxillary anterior sextant. An esthetic evaluation was performed and identified excessive gingival display attributable to short clinical crowns and excluded vertical maxillary excess and short or hypermobile upper lip as etiologic factors. After signing a written informed consent, the patient underwent an esthetic crown lengthening procedure to correct this mucogingival deformity, followed by prosthodontic rehabilitation. The patient and restoring dentist were concerned with the healing time that should elapse before the teeth were permanently restored. Figures 1 through 5 illustrate the initial presentation of the patient, surgical crown lengthening procedure, and final restorations.