Successful Regenerative Therapy of Periodontal Defects Associated With Tongue Piercing: A Clinical Report.

Oral piercing habits are associated with various degrees of complications. Tongue piercing increases the risk of gingival recession and infrabony defects, subsequently leading to localized periodontitis. In the case presented, the patient had persistent swelling and suppuration around her mandibular anterior teeth attributed to tongue piercing jewelry that was placed approximately 12 years prior. Intraoral examinations revealed a localized deep pocket, purulent discharge, swelling, plaque accumulation, bleeding on probing, gingival recession, and teeth mobility. The patient was diagnosed with localized stage III, grade C periodontitis. Following full-mouth debridement and the placement of an extracoronal lingual splint, minimally invasive, papillae-sparing incisions were made, and regenerative therapy with bone allograft and collagen membrane was used to manage the infrabony defects. During the 18-month postoperative follow-up, complete soft-tissue healing was observed along with a significant reduction in pocket depth and the absence of bleeding on probing or suppuration. Radiographic evaluation showed evidence of bone fill. The reported case demonstrates how careful diagnosis and treatment planning are crucial for managing different periodontal defects and emphasizes the importance of proficient periodontal management, which can save teeth that would otherwise be extracted and replaced with implant therapy or fixed bridgework.

Proposal regarding potential causes related to certain complications with dental implants and adjacent natural teeth: Physics applied to prosthodontics.

PURPOSE: Complications can and do occur with implants and their restorations with causes having been proposed for some single implant complications but not for others. METHODS: A review of pertinent literature was conducted. A PubMed search of vibration, movement, and dentistry had 175 citations, while stress waves, movement, and dentistry had zero citations as did stress waves, movement. This paper discusses the physics of vibration, elastic and inelastic collision, and stress waves as potentially causative factors related to clinical complications. RESULTS: Multiple potential causes for interproximal contact loss have been presented, but it has not been fully understood. Likewise, theories have been suggested regarding the intrusion of natural teeth when they are connected to an implant as part of a fixed partial denture as well as intrusion when a tooth is located between adjacent implants, but the process of intrusion, and resultant extrusion, is not fully understood. A third complication with single implants and their crowns is abutment screw loosening with several of the clinical characteristics having been discussed but without determining the underlying process(es). CONCLUSIONS: Interproximal contact loss, natural tooth intrusion, and abutment screw loosening are common complications that occur with implant retained restorations. Occlusion is a significant confounding variable. The hypothesis is that vibration, or possibly stress waves, generated from occlusal impact forces on implant crowns and transmitted to adjacent teeth, are the causative factors in these events. Since occlusion appears to play a role in these complications, it is recommended that occlusal contacts provide centralized stability on implant crowns and not be located on any inclined surfaces that transmit lateral forces that could be transmitted to an adjacent tooth and cause interproximal contact loss or intrusion. The intensity, form, and location of proximal contacts between a natural tooth located between adjacent single implant crowns seem to play a role in the intrusion of the natural tooth. Currently, there is a lack of information about the underlying mechanisms related to these occurrences and research is needed to define any confounding variables.

The Influence of a Single Infrapositioned Anterior Ankylosed Tooth or Implant Supported Restoration In Smile Attractiveness.

OBJECTIVES: To investigate the influence of a single infrapositioned ankylosed tooth or implant supported restoration, in smile attractiveness. MATERIAL AND METHODS: A series of 48 digital modified images, simulating a varying degree of infraposition(from 0.25 to 2.0 mm, with a step of 0.25 mm), was created for each one of the maxillary anterior tooth, by altering the full-portrait image of a smiling male adult, in medium and high smile lines. For the model with the high smile line, also a series of 24 digital modified images simulating infraposition of a single anterior tooth with a restored incisal edge was created. Smile attractiveness for each one of the images was evaluated from 160 participants (80 dentists and 80 laypersons), implementing a visual analog scale. RESULTS: For the images with the high smile line, an infraposition ≥ 0.25mm in central incisor's region and ≥ 0.5mm in the region of the lateral incisor or the canine, had a negative effect on the perceived smile attractiveness both for the dentists and the laypersons. Regarding the medium smile line, an infraposition ≥ 0.5mm in central and lateral incisor's region, had a negative effect on the perceived smile attractiveness for both groups of observers. In the area of the canine, infraposition ≥ 0.5mm for the dentists and ≥ 0.75mm for the laypersons, had a negative impact on the smile attractiveness. CONCLUSIONS: Even a minor infraposition of a single maxillary anterior ankylosed tooth or implant supported restoration, can reduce the perceived attractiveness of the face. Infraposition in canine's area can be better tolerated in a medium, compared to a high smile line. In patients with a high smile line prosthetic intervention in order to restore the incisal edge of an infrapositioned tooth, without to harmonize the gingival contour, can be beneficial for the lateral incisor, ineffective for the central incisor and unfavorable for the canine.

A Paradigm Shift Using Scan Bodies to Record the Position of a Complete Arch of Implants in a Digital Workflow.

The use of conventional scan bodies (SBs) with an intraoral scanner (IOS) to capture the position of a complete arch of dental implants has proven to be challenging. The literature is unclear about the accuracy of intraoral scanning techniques using SBs that are connected vertically to multiunit abutments (MUAs) for numerous adjacent implants in the same arch. Recently, there has been a paradigm shift from vertical SBs to horizontal SBs, which are positioned perpendicular to the long axis of the MUAs. Most IOSs available today can capture these horizontal SBs, called scan gauges (SGs), with better accuracy and consequently acquire the position of multiple adjacent implants using an effective scan path, thus reducing stitching and the number of images. The key to implementing this novel technology is to strategically arrange the SGs to optimize horizontal overlap of multiple adjacent SGs without touching each other. By superimposing two high-resolution intraoral scans of the SGs, an artificial intelligence (AI) algorithm is employed to produce a calibrated digital best-fit model on which a passive complete-arch prosthesis can be designed and fabricated. The advantages and disadvantages of SBs and SGs are discussed, and a case report using a digital workflow is presented.

Subcrestal Implantoplasty for Treating Peri-implantitis With Regenerative Care-How Deep Should Treatment Go?

Used to treat implants failing due to peri-implantitis, implantoplasty has traditionally been performed in conjunction with a resective approach or to smooth the portion of the dental implant above the bone to facilitate oral hygiene efforts. This article demonstrates the use of implantoplasty to decontaminate the implant surface both above and below the crest of bone in an attempt to reosseointegrate the failing implant; to the authors' knowledge this is the first time in the literature that implantoplasty was used in this manner and demonstrated potential regenerative efficacy.

Selective Serotonin Reuptake Inhibitors and Dental Implant Failure: A Systematic Review and Meta-Analysis.

Selective serotonin reuptake inhibitors (SSRI) are commonly prescribed to treat mental health disorders, and previously published literature, although scarce, has shown a significant association between SSRI use and dental implant failure. This systematic review and meta-analysis aimed to examine whether such an association exists and, if so, to determine its strength. Reviewers performed an extensive search of the literature, last accessed in June 2022 in PubMed/Medline, Embase, and Cochrane databases using MeSH terms. Retrospective and prospective observational cohort and experimental studies evaluating the role of SSRI on dental implant failure among individuals ≥18 years of age, with a minimum follow-up of 6 months after implant placement, were deemed eligible. The search yielded a total of 6 eligible studies, all retrospective cohorts. Statistical analyses were performed using the statistical software R 4.1.3. Results showed higher implant failure rates among SSRI users vs non-SSRI users at both the patient level (5.6%-19.6% vs 1.9%-8.0%) and the implant level (5.6%-12.5% vs 1.9%-5.8%). The pooled relative risk (RR) of implant failure was more than double among SSRI users at the patient level (pooled RR: 2.44, 95% confidence interval [CI]: 1.68-3.55, P < .01) and at the implant level (pooled RR: 2.34, 95% CI: 1.74-3.15, P < .01) compared with non-SSRI users. DerSimonian and Laird estimates showed homogeneity of the studies (I2 = 0%, P > .05), and funnel plots and Egger's test determined no publication bias across all selected studies at both patient and implant levels. In conclusion, SSRI use is significantly associated with higher implant failure. Providers should be aware of this association and educate patients on the risk of implant therapy when obtaining informed consent.

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.

Frequency of screw-retained angulated screw channel single crown following immediate implant placement and provisionalization in the esthetic zone: A cone beam computed tomography study.

OBJECTIVE: The purpose of this cone beam computed tomography (CBCT) study was to determine the frequency percentage of screw-retained crown using angulated screw channel (ASC) abutment for single immediate implant placement and provisionalization (IIPP) in the esthetic zone. METHODS: The CBCT images of 200 patients without disease and without metal restorations in maxillary anterior teeth were evaluated. The mid-sagittal-sectional CBCT images of maxillary anterior teeth (#6-#11) were created in an implant planning software, screen-captured, and transferred to a presentation program. Template of tapered implants with diameter of 3.5 mm (for central and lateral incisors) and 4.3 mm (for central incisors and canines) and lengths of 13, 15, and 18 mm were applied to the sagittal images to identify the IIPP cases. To qualify for IIPP, the implant must engage >35% bone with at least 1 mm of surrounding bone and no perforations. The IIPP cases were further divided into straight screw channel (IIPPSSC) abutment or 25-degree angulated screw channel abutment (IIPPASC), based upon its restorability. The frequency percentages of possible IIPP, IIPPSSC, and IIPPASC were reported and compared among all maxillary anterior teeth. RESULTS: A total of 1200 maxillary anterior teeth sagittal images from 200 patients (88 male and 112 female) with a mean age of 51.3 years (range 20-83 years) were evaluated in this study. The overall frequency percentages of IIPP, IIPPSSC, and IIPPASC possibility were 84% (74%-92%), 14% (10%-24%), and 75% (66%-87%), respectively. CONCLUSION: Within the limitations of this CBCT study, 90% of single IIPP in the esthetic zone can be restored with screw-retained crown when utilizing ASC. In addition, the possibility of using a screw-retained restoration following IIPP increases about five times with ASC abutment compared to the SSC abutment.

A comparative analysis of dual-axis implants placed into maxillary anterior extraction sockets versus virtual planning with uniaxial implants: A simulated cone beam computed tomography study of implant length and diameter.

OBJECTIVE: The biaxial nature of the anterior maxilla poses a surgical and restorative challenge in implant dentistry. The present study sought to investigate the apical socket perforation rate (ASPR) from a simulated uniaxial implant placement and to determine the effect of implant length and diameter on ASPR when a uniaxial implant was placed compared with the orientation of the pre-existing dual-axis implant. MATERIAL AND METHOD: Cone beam computed tomography (CBCT) scans from the database of three private practices were searched for patients who received dual-axis implants within the esthetic zone in immediate tooth replacement therapy. A uniaxial implant was virtually placed using the pre-existing screw access channel of the dual-axis implant as a reference. The closest length and diameter were selected for the simulated implant. ASPR by the uniaxial implant was recorded. In addition, the affordable maximum length of a corresponding uniaxial implant that would avoid apical socket perforation was measured. RESULT: Eighty-one patients with a total of 101 dual-axis dental implants were selected for analysis. A simulated virtual surgical planning with uniaxial implants revealed high ASPR (48.51%). When the length of the uniaxial implant was reduced to 11 and 9 mm, ASPR was decreased to 41.58% and 20.79%, respectively. CONCLUSION: Dual-axis implant design effectively evades anatomical challenges in the anterior maxilla (esthetic zone). Considering the current evidence, efforts should be made to carefully consider the angular disparity between the extraction socket-alveolus complex and the future restorative emergence so that a harmonious biologic-esthetic result may be more predictably and consistently obtained.

Clinical outcomes of retention of the buccal root section combined with immediate implant placement: A systematic review of longitudinal studies.

INTRODUCTION: Immediate implant placement in conjunction with partial extraction therapy has been shown to result in functional osseo- and dento-integration with partial preservation of the periodontal ligament (PDL) in humans. Strategic buccal root retention for PDL preservation is a biologically driven procedure that maintains alveolar ridge dimensions and esthetics, while allowing for implant placement. The aim of this study was to conduct a systematic review of longitudinal clinical outcomes of PDL-mediated ridge preservation in conjunction with implant placement in adults, compared with conventional immediate implant placement with total extractions. The primary outcome for this study was marginal bone level (MBL) changes after strategic buccal root retention implant placement techniques. MATERIALS AND METHODS: To address a predefined PICOS question, a systematic search of randomized clinical trials and cohort studies with at least 10 participants per group and a minimum 12-month follow-up was conducted. A two-phase systematic selection strategy, data extraction, and risk of bias assessment, was performed independently and in duplicate. Randomized trials were quantitatively analyzed in a meta-analysis. RESULTS: Ten human studies fulfilled the predefined criteria and were included; three clinical trials and seven cohort studies, for a total of 506 patients and 587 implants. PDL-mediated implant placement of single-rooted periodontally healthy teeth was found to reduce marginal peri-implant bone loss and buccal plate changes as compared to conventional immediate implants across studies, while implant survival and success rates were comparable between the two procedures. A meta-analysis found that bone changes were significantly less when retention of the buccal root section was performed as compared to total extractions (standardized mean difference: [-4.53, -0.11]); the three clinical trials were, however, largely heterogeneous (I2 : 93.1%; Q = 28.98, p < 0.001). CONCLUSION: Strategic retention of the buccal root section has a benefit in terms of dimensional ridge stability over conventional immediate implantation when implemented in carefully selected cases of single-rooted teeth.

Strategies for implant surface decontamination in peri-implantitis therapy.

Peri-implantitis is an infectious disease that leads to progressive bone loss. Surgical therapy has been advocated as a way of halting its progression and re-establishing peri-implant health. One of the most challenging but crucial tasks in the management of peri-implantitis is biofilm removal to achieve reosseointegration and promote the reduction of peri-implant pockets. A wide variety of strategies have been used for implant surface decontamination. Mechanical means have been demonstrated to be effective in eliminating calculus deposits and residual debris; however, the presence of undercuts and the grooves and porosities along the roughened implant surface make it difficult to achieve an aseptic surface. In conjunction with mechanical measures, use of chemical adjuncts has been advocated to dilute bacterial concentrations, destroy the bacteria's organic components and eliminate endotoxins. Pharmacological adjuncts have also been recommended to diminish the bacterial load. Other strategies, such as use of lasers, implantoplasty and electrolysis, have been suggested for implant surface decontamination to promote predictable clinical and radiographic outcomes.

Remediation of a Failed Lateral Window Sinus Augmentation via a Palatal Approach: Rationale and Case Report.

Maxillary sinus elevation by the lateral window approach has been shown to be a highly predictable surgical procedure for increasing bone volume in the posterior maxilla. There are occasions, however, where this procedure may be difficult or impossible to perform in a highly predictable manner. There are many presurgical conditions and anatomical features that can make lateral window access difficult, leading to an increase in intraoperative complications and procedural failures. These complicating factors include complex internal sinus anatomy (multiple septa, anteroposterior septa), a narrow available window space, a thin or absent labial plate on adjacent teeth, and the presence of a root apex in the proposed window area, or it may be due to iatrogenically created defects, such as a previous failed sinus elevation, a healed oroantral fistula, or defects created by difficult extractions. While not frequently used or routinely reported in the literature, the palatal window approach may negate many of these obstacles. When it is reported, success rates are similar to those of lateral window procedures, and as an added advantage, postoperative morbidity is dramatically reduced, allowing the patient to wear a removable appliance immediately after surgery. There are, however, anatomical limitations that dictate when this procedure can be used. This case report is unique in that many of the lateral window complicating factors are present, and the palatal anatomy proved ideal for performing the technique.

Ridge Augmentation in a Site of a Previous Implant Failure Using Tenting Screws With Allograft and Collagen Membrane.

Rehabilitation of a severely resorbed mandibular posterior ridge with implants poses a challenge to the clinician. Several techniques to address this challenge have been described in the literature. This case report describes the successful vertical and horizontal bone augmentation of a site of a previous implant failure with severe vertical and horizontal ridge deficiencies using tenting screws, cortico-cancellous particulate bone allograft, and a resorbable collagen membrane. A bone core was obtained at the time of implant placement, 8 months postoperatively, and histological findings showed the highest concentration of lamellar bone at the apical third; a 50-50% graft and lamellar bone proportion in the middle third; and a higher concentration of bone allograft at the coronal third of the bone core. Successful implant placement was achieved at the site. This case report demonstrates the effective use of tenting screws for vertical and horizontal bone augmentation and consequent implant placement in a severely resorbed ridge in the posterior mandible.

Evaluation of Dimensional Changes and Ridge Contour Around Ovate Pontics Inserted Immediately After Extraction with Alveolar Ridge Preservation in the Esthetic Zone.

Alveolar ridge preservation (ARP) is indicated to attenuate anatomic and physiologic changes following tooth extraction. A properly contoured ovate pontic placed immediately into an extraction socket may be adequate to maintain alveolar ridge architecture for improved esthetic results. This prospective clinical study evaluated the ability of immediately placed ovate pontics in conjunction with ARP to attenuate postextraction tissue dimensional changes in the esthetic zone and maintain alveolar ridge contour. Ten patients (11 sites) completed the study. All subjects received a combination of socket grafting with allogeneic particulate graft material and socket sealing with an ovate pontic provisional restoration. A set of clinical linear and volumetric outcomes were assessed after a 6-month healing period. At 6 months postoperative, the linear measurements for the mean ridge dimensional loss were 0.9 ± 0.6 mm (range: 0.2 to 1.8 mm) in height and 1.4 ± 0.6 mm (range: 0.1 to 2.4 mm) in width. The mean volumetric tissue loss observed was 24.4 ± 15.4 mm3 (range: 2.6 to 50.1 mm3) at 3 months postoperative and 32.2 ± 14.2 mm3 (range: 3.8 to 50.5 mm3) at 6 months postoperative. Resorption pattern assessment showed the overall cervical area to have less resorption than the apical areas at 6 months postoperative, with the least amount of resorption in the midbuccal cervical section. When compared to the data of a previous pilot study, no statistically significant difference was seen between the dimensional losses when using ovate pontics with and without ARP. This may be evidence that the use of an ovate pontic provisional restoration immediately after extraction effectively attenuates postextraction dimensional changes.

The effect of implant macrogeometry in immediate tooth replacement therapy: A case series.

The concept of immediate tooth replacement therapy (ITRT) in the esthetic zone has become a viable treatment modality and widely accepted in clinical practice. However, achieving adequate primary stability that enables immediate provisional restoration and desirable space for bone-grafting with conventional tapered body implant designs is challenging. The macro-hybrid implant design with a prosthetic angle correction and body-shift feature in a singular form provides not only greater primary stability of a wider diameter implant but also circumferential gap distance both facially and interproximally preserve the labial bone plate and interdental attachment apparatus of the adjacent natural teeth thereby maintaining the interdental papilla. The present clinical series exemplifies the clinical advantages of this inverted body-shift implant design in ITRT in various clinical scenarios in (1) single tooth replacement in a Type 1 intact socket with a thin periodontal phenotype, (2) single tooth replacement in a Type 2 socket with a dentoalveolar dehiscence of the labial bone plate, and (3) multiple adjacent teeth replacement of two maxillary central incisor. CLINICAL SIGNIFICANCE: The macro-hybrid design implant with a prosthetic angle correction and body-shift feature in a singular form provides greater midfacial gap distance as well as tooth-to-implant distance to preserve the interdental attachment of the adjacent natural teeth thereby leaving the interdental papilla undisturbed, without sacrificing higher primary stability afforded by larger diameter implants.

Interdisciplinary management of recession defects on maxillary single tooth implants: Diagnosis and treatment strategies.

OBJECTIVE: One of the most common complications with dental implants placed in the smile zone is the development of mid-facial recession, creating an undesirable esthetic result. When deciding how to remediate these clinical scenarios, the question becomes whether it may be feasible to save the problematic implant or if it is more predictable to remove the implant and start all over again. However, patients may be invested emotionally, physically, and financially in the implant and remediation may be a viable option depending on the diagnosis of the specific issues at hand and multi-disciplinary clinical execution. CLINICAL SIGNIFICANCE: What is crucial to understand in order to remediate these cases is answering four separate criteria: (1) is the implant in a restorable position, (2) is the implant healthy, (3) is the implant placed at an adequate depth, and (4) are components available to restore the implant. CONCLUSIONS: Two different clinical reports are presented that demonstrate various treatment remedies when saving implants in the esthetic zone.

Outcomes of a 1-Year Prospective Single-Arm Cohort Study Using a Novel Macro-Hybrid Implant Design in Extraction Sockets: Part 1.

A novel macro-hybrid implant design was introduced to afford high apical primary stability and more coronal space to preserve the circumferential extraction socket architecture. This study presents 1-year data from a prospective single-arm cohort study. The data was distilled based on the following criteria: (1) single-tooth immediate tooth replacement therapy (ITRT) in the maxillary anterior and premolar regions in intact (Type 1) extraction sockets that were (2) treated with the dual-zone grafting technique. The clinical and radiographic outcomes of 48 ITRT implants were evaluated. The mean ± SD labial plate dimension changes were 0.33 ± 0.41 mm at the implant abutment interface (L1) and 0.34 ± 0.40 mm at 5.0 mm below (L2). The mean labial plate dimension (thickness) at the 1-year recall was 2.27 ± 0.88 mm (L1) and 1.95 ± 0.95 mm (L2). At ITRT, the ridge contour at the free gingival margin and 3.0 mm below it were 7.54 ± 0.93 mm and 9.44 ± 2.36 mm, respectively; after final restoration delivery, the corresponding values were 7.45 ± 0.95 mm and 10.23 ± 2.30 mm, respectively. The peri-implant soft tissue thickness (PISTT) at the time of implant-level impression-making was 3.29 ± 0.73 mm, with an average Pink Esthetic Score of 12.79. A macro-hybrid implant design showed high levels of primary stability (~60 Ncm), stable ridge contour at 1 year, a labial plate dimension between 1.5 and 2.0 mm, and PISTT > 3.0 mm, which may be a critical factor in providing stable, long-term esthetic outcomes.

A New Definition of Attached Gingiva Around Teeth and Implants in Healthy and Diseased Sites.

There is a need to modify the definition of attached gingiva (AG) as it applies to healthy and diseased teeth and implants. There are two parts to this new definition: Part A is when the biologic width is supracrestal (epithelial attachment and gingival fibers) and is attached to a healthy tooth or tissue-level implant, and the zone of AG is measured from the base of the sulcus to the mucogingival junction (MGJ); Part B is when the biologic width is subcrestal-as with infrabony defects on periodontally involved teeth, periodontally involved tissue-level implants, and bone-level implants placed at or below the bone crest-and the zone of AG is measured from the bone crest (not the base of the sulcus) to the MGJ. Further, what the AG is actually attached to around teeth and different types of implants, and the clinical significance of these differences, are thoroughly discussed.

When to save or remove implants in the smile zone: A clinical report of maxillary lateral incisor implants in malposition.

OBJECTIVE: The following is a clinical report addressing when to save or remove implants with esthetic deficiencies in the smile zone as well as the sequence and timing of interdisciplinary treatment. CLINICAL CONSIDERATIONS: Key factors in the decision-making process in treating implants in malposition are whether the implants are (1) in a reasonable restorative position, (2) free of disease, and (3) placed with adequate depth. This clinical report encompassed periodontal corrective surgery, non-surgical soft tissue sculpting through subgingival crown contour, material selection for definitive restorations, and cementation techniques for cement-retained restorations. CLINICAL SIGNIFICANCE: Knowledge and understanding of interdisciplinary treatment planning, sequencing, and respective techniques that can be implemented when confronting implants in malposition in the smile zone will allow the interdisciplinary team to achieve the desired esthetic restorative result.

The Relationships Between Tooth-Supported Fixed Dental Prostheses and Restorations and the Periodontium.

PURPOSE: To search the literature and to critically evaluate the findings on the periodontal outcomes of restorations and tooth-supported fixed prostheses. MATERIALS AND METHODS: PubMed was searched according to a systematic methodology, previously reported, but updated to include a larger database. Filters applied were: Case reports, clinical trial, review, guideline, randomized controlled trial, meta-analysis, systematic reviews, and English. A narrative review was then synthesized to discuss periodontal outcomes related to restorations and tooth-supported fixed prostheses. Relevant data was organized into four sections: Direct restorations, indirect restorations, biologic width or supracrestal tissue attachment and tooth preparation/finish line design. RESULTS: While increased gingival index, bleeding on probing, probing depth and clinical attachment loss have been associated with subgingival restorations, intracrevicular margins do not cause periodontal diseases. Inflammation and bone loss occur, for both direct and indirect restorations, only with large overhangs. Different restorative materials are associated with different clinical responses when placed in the gingival sulcus or within the epithelial and connective tissue attachments. When the connective tissue attachment is removed, histological changes occur causing its apical shift and subsequent re-establishment. Gingival displacement during impression procedures can cause gingival recession. Emergence profile can have a range of values, not associated with periodontal diseases. Periodontal response appears to be clinically not different when compared among different finish line designs. CONCLUSIONS: Contemporary procedures and materials used for the placement and fabrication of tooth-supported restorations and fixed prostheses are compatible with periodontal health when adequate patient education and motivation in self-performed oral hygiene are present. Periodontal diagnostic criteria should be thoroughly reviewed before fixed restorative treatments are planned and executed.