Biologically-oriented Alveolar Ridge Preservation.

BACKGROUND: A recent systematic review failed to identify one approach for alveolar ridge preservation with superior outcomes. The present case series aimed to evaluate the dimensional changes of sites undergoing Biologically-oriented Alveolar Ridge Preservation (BARP). METHODS: The sockets were filled with a collagen sponge up to 4-5 mm from the most coronal extensions of the crest. Xenograft particles were placed to fill the coronal part. In cases with a compromised buccal/lingual bone, an additional collagen sponge was interposed between the residual cortical bone plate and the mucoperiosteal flap. A collagen sponge was placed to cover the graft. RESULTS: The study population consisted in 10 extraction sites. Mean change in bone width and vertical ridge position as observed from BARP to re-entry for implant placement were 1.3 mm (14.4%) and 0.6 mm, respectively. The mean distance between buccal and lingual flap healing by secondary intention shifted from 4.9 mm immediately after BARP to 1.8 mm at 2 weeks. No marked differences in the dimensional changes of alveolar ridge were observed between sites with intact or deficient buccal bone plate. All implants were successfully loaded at 2-3 months after placement. In one case, bone augmentation was required. CONCLUSIONS: The stratification of materials proposed in BARP-technique and the additional use of a resorbable device to stabilize graft particles at the buccal aspect provided the conditions for maintaining the ridge dimensions following tooth extraction comparable to the other technique of ARP, restricting the use of graft material to the most coronal portion of the socket.

Tooth loss in complying and non-complying periodontitis patients with different periodontal risk levels during supportive periodontal care.

OBJECTIVES: To evaluate yearly tooth loss rate (TLR) in periodontitis patients with different periodontal risk levels who had complied or not complied with supportive periodontal care (SPC). MATERIALS AND METHODS: Data from 168 periodontitis patients enrolled in a SPC program based on a 3-month suggested recall interval for at least 3.5 years were analyzed. For patients with a mean recall interval within 2-4 months ("compliers") or > 4 months ("non-compliers") with different PerioRisk levels (Trombelli et al. 2009), TLR (irrespective of the cause for tooth loss) was calculated. TLR values were considered in relation to meaningful TLR benchmarks from the literature for periodontitis patients either under SPC (0.15 teeth/year; positive benchmark) or irregularly complying with SPC (0.36 teeth/year; negative benchmark). RESULTS: In both compliers and non-compliers, TLR was significantly below or similar to the positive benchmark in PerioRisk level 3 (0.08 and 0.03 teeth/year, respectively) and PerioRisk level 4 (0.12 and 0.18 teeth/year, respectively). Although marked and clinically relevant in non-compliers, the difference between TLR of compliers (0.32 teeth/year) and non-compliers (0.52 teeth/year) with PerioRisk level 5 and the negative benchmark was not significant. CONCLUSION: A SPC protocol based on a 3- to 6-month recall interval may effectively limit long-term tooth loss in periodontitis patients with PerioRisk levels 3 and 4. A fully complied 3-month SPC protocol seems ineffective when applied to PerioRisk level 5 patients. CLINICAL RELEVANCE: PerioRisk seems to represent a valid tool to inform the SPC recall interval as well as the intensity of active treatment prior to SPC enrollment.

A Simplified Procedure for Biologically Oriented Alveolar Ridge Preservation: Clinical and Histological Findings From a Case Report.

INTRODUCTION: A recent systematic review failed to identify one approach for alveolar ridge preservation (ARP) with superior outcomes compared with the others. The present case report presents a novel, simplified technique for ARP, namely the Biologically-oriented Alveolar Ridge Preservation (BARP), based on socket grafting and sealing. CASE PRESENTATION: After extraction of tooth #19, the socket was filled with a collagen sponge up to 4-5 mm from the most coronal extension of the bone crest (deep collagen layer). A bovine-derived xenograft was placed on top of the collagen sponge to fill the coronal part of the socket (graft layer). Socket sealing was then performed by placing a collagen sponge over the exposed portion of the graft (superficial collagen layer), and the wound healed by secondary intention. At implant insertion (4 months after ARP), limited reduction in bone width and no vertical change in ridge height were observed. Histological analysis of a biopsy specimen retrieved during implant site preparation showed a gradient ranging from interconnected trabeculae of mature, lamellar bone in the apical portion to cancellous bone incorporating a modest number of remodeled graft granules in the central portion. In the coronal portion, non-mineralized tissue with sparse isles of newly formed cancellous bone and residual graft granules was found. CONCLUSION: The present case report indicates that BARP might provide ideal conditions for preserving the pre-existing alveolar ridge dimensions following tooth extraction while restricting any potential interference of the graft biomaterial with bone healing dynamics to the coronal part of the socket.

Peri-implant tissue conditions at implants treated with Sub-periosteal Peri-implant Augmented Layer technique: A retrospective case series.

OBJECTIVES: To assess peri-implant tissue conditions on the short term in patients receiving the Sub-periosteal Peri-implant Augmented Layer (SPAL) technique and in patients with adequate thickness (≥2 mm) of the peri-implant buccal bone plate (PBBP) at placement. METHODS: Patients where either a dehiscence defect or thin PBBP at implant placement was corrected by SPAL technique (SPALdehiscence and SPALthin groups, respectively) and patients presenting a residual PBBP thickness ≥2 mm at implant placement (control group) were retrospectively selected. The number of peri-implant sites positive to bleeding on probing (BoP) at 6 months following prosthetic loading was the primary outcome. Also, height of keratinized mucosa, marginal soft tissue level, Plaque Index, peri-implant probing depth, suppuration on probing, and interproximal radiographic bone level (RBL) were evaluated. RESULTS: Thirty-four patients (11 in the SPALdehiscence group, 11 in the SPALthin group, and 12 in the control group) were included. In each SPAL group, 10 patients (90.9%) showed peri-implant tissue thickness ≥2 mm at the most coronal portion of the implant at uncovering. The prevalence (number) of BoP-positive sites was 2, 1, and 0 in the SPALdehiscence , SPALthin , and control groups, respectively. RBL amounted to 0.3 mm in the SPALdehiscence group, 0.2 mm in the SPALthin group, and 0 mm in the control group. CONCLUSION: After 6 months of prosthetic loading, patients treated with SPAL technique show limited peri-implant mucosal inflammation in association with shallow PD and adequate KM. At implants receiving SPAL technique, however, interproximal RBL was found apical to its ideal position.

A simplified soft tissue management for peri-implant bone augmentation.

PURPOSE: This case series illustrates a simplified soft tissue management, namely, the subperiosteal peri-implant augmented layer (SPAL), to increase hard and soft tissue dimensions at the most coronal portion of an implant. MATERIALS AND METHODS: Twenty-seven implants in 16 patients presenting either a buccal bone dehiscence or a thin (< 1 mm) buccal cortical bone plate (BCBP) were consecutively treated. Briefly, a split-thickness flap (namely, the mucosal layer) was raised on the buccal aspect. Then, the periosteal layer was elevated from the bone crest. A full-thickness flap was elevated on the oral aspect. After implant site preparation, a xenograft was used to fill the space between the periosteal layer and the BCBP and/or exposed implant surface and, if present, to completely correct the bone dehiscence. The periosteal layer was sutured to the oral flap. The mucosal layer was coronally advanced and sutured to submerge both the graft and the implants. At 3 to 6 months, a re-entry procedure for implant exposure was performed. RESULTS: Healing was uneventful, with no signs of infection in all cases. A wound dehiscence was observed in three implants in two patients at 2 weeks postsurgery. Out of 15 implants showing an initial bone dehiscence, 12 implants (80%) showed a complete resolution, with a subperiosteal tissue thickness (SPTT) at the time of re-entry of 3.1 ± 1.0 mm. Three implants presented a residual dehiscence of 1 mm (two implants) or 2 mm (one implant), with a SPTT of at least 2 mm. Out of 12 implants showing a thin BCBP at implant placement, 10 implants (90%) revealed a SPTT ≥ 2 at the time of re-entry. Two implants revealed a SPTT of 1 mm. CONCLUSION: The SPAL technique represents a valuable simplified surgical approach associated with a low rate of complications in the treatment of peri-implant bone dehiscence and in the horizontal augmentation of peri-implant tissue thickness.

Alveolar ridge dimensions in mandibular posterior regions: a retrospective comparative study of dentate and edentulous sites using computerized tomography data.

PURPOSE: To evaluate ridge dimensions at edentulous, mandibular posterior sites, and contralateral dentate sites. METHODS: Computerized tomography scans of 24 patients with one fully edentulous and one fully dentate mandibular posterior region were retrospectively selected. Relative ridge position (rRP), bone height (BH), alveolar canal height (ACH), basal bone height (BBH), and bone width (BW) at 1, 3, and 5 mm apically to the most coronal point of the alveolar crest (BW1mm, BW3mm, and BW5mm, respectively) were measured at posterior dentate sites and contralateral edentulous sites. The proportion of edentulous sites with BH ≥ 9 mm and BW1mm ≥ 6 mm and/or BH ≥ 11 mm and BW3mm ≥ 6 mm was calculated. RESULTS: When compared to dentate sites, edentulous sites showed lower BH, a more apical position of the ridge, lower BW1mm, lower ACH, and similar BBH. The difference in rRP, BH, ACH, BBH, BW1mm, BW3mm, and BW5mm between edentulous and contralateral dentate sites was not significantly different between females and males. The prevalence of edentulous sites with BH ≥ 9 mm and BW1mm ≥ 6 mm and/or BH ≥ 11 mm and BW3mm ≥ 6 mm was higher in females (83.3%) compared to males (58.3%) at second premolar, while was higher in males compared to females at the first molar (83.3 vs 66.6%) and second molar (83.3 vs 75.0%). CONCLUSIONS: In the posterior mandible, edentulous sites show a reduced height and bucco-lingual ridge width compared to contralateral dentate sites. Gender seems to have a limited impact on the extent of ridge resorption following the loss of posterior mandibular teeth.

Sub-periosteal peri-implant augmented layer technique for horizontal bone augmentation at implant placement.

In the present study, a novel surgical technique, namely the sub-periosteal peri-implant augmented layer (SPAL), to increase hard and soft tissue dimensions at the most coronal portion of an implant will be thoroughly described. The surgical buccal access at the time of implant placement first consisted of a split-thickness flap to raise the most superficial mucosal layer, followed by the elevation of the periosteal layer which was detached from the buccal cortical bone plate (BCBP). A full-thickness flap was elevated on the oral aspect. A xenograft was used to fill the space between the periosteal layer and the BCBP, and the periosteal layer was sutured to the oral flap. The mucosal layer was coronally advanced and sutured to submerge both the graft and the implants. At implant uncovering at 4 months, an increase in the thickness (>2 mm) of the buccal peri-implant tissues was observed. A free gingival graft was used to enhance the dimensions of buccal keratinized mucosa. The SPAL technique may represent a surgical option for the horizontal augmentation of peri-implant tissue thickness.

Clinical efficacy of a chlorhexidine-based mouthrinse containing hyaluronic acid and an antidiscoloration system in patients undergoing flap surgery: A triple-blind, parallel-arm, randomized controlled trial.

OBJECTIVES: To evaluate the postsurgery gingival healing as well as plaque, gingival inflammation and staining levels following the use of a 0.2% chlorhexidine (CHX) solution with or without antidiscoloration system (ADS) and 0.2% hyaluronic acid (HA). METHODS: Patients undergoing flap surgery at sites with an intact or reduced but healthy periodontium participated in a parallel-arm RCT. After surgery, patients used the assigned mouthrinse (CHX + HA + ADS or CHX) for 21 days. At days 7 and 21, the healing process was evaluated at experimental teeth using a composite index, namely the Gingival Healing Index (GHI). GHI score was obtained as the sum of the scores related to the severity of wound dehiscence (score 1-3) and the profile of the buccal and oral aspects of the papilla (score 1-3). Therefore, GHI ranged from 2 (worst quality of healing) to 6 (optimal quality of healing). Plaque Index (PlI), Gingival Index (GI), angulated bleeding score (AngBS), and tooth and tongue staining were also assessed. RESULTS: In both groups, GHI assumed values of 5 or 6 at both days 7 and 21 in ≥50% of patients, and low median values of PlI, GI, AngBS and staining were observed during the 21-day period. Except for a significantly lower GI in CHX group at day 7, no other significant intergroup differences were found. CONCLUSIONS: Postsurgery plaque control based on either CHX or CHX + HA + ADS mouthrinses results in optimal plaque control and quality of early gingival healing along with limited tooth and tongue staining.

Patient-reported outcomes of implant placement performed concomitantly with transcrestal sinus floor elevation or entirely in native bone.

AIM: Based on the hypothesis that maxillary sinus floor elevation with a transcrestal approach (tSFE) does not increase the morbidity of implant surgery, the study evaluated the patient-reported outcomes as well as the type and incidence of complications when implants are placed either concomitantly with tSFE (performed according to Trombelli et al. 2008, 2010a,b) or entirely in native bone. METHODS: Data from the record charts of patients undergone implant placement for single-tooth rehabilitation in the posterior maxilla were retrospectively obtained from four clinical centers. Cases for tSFE group were included if they showed an extent of sinus lift ≥4 mm concomitantly to implant placement. Cases for N group were included when implant placement was performed entirely in native bone. Patient-reported outcomes had been assessed using 100-mm visual analog scales (postoperative pain, VASpain ) and visual rating scales (level of discomfort, VRSdiscomfort ; willingness to undergo the same surgery, VRSwillingness ). The dose of analgesics had been self-recorded. RESULTS: A convenience sample of 14 patients and 17 patients (contributing with one implant site each) treated with tSFE and N, respectively, was obtained for this study. Membrane perforation occurred in 1 tSFE case, without compromising the completion of the procedure. VASpain remained low (<12) in both groups. A tendency of VASpain to decrease with time was observed in both groups. The area under the curve for VASpain (AUCpain ), indicating the level of pain experience through the first week following surgery, was 18.0 (IR: 8.5-85.0) and 11.5 (IR: 4.5-18.5) in tSFE and N groups, respectively, with no significant inter-group differences (P = 0.084). The dose of analgesics was similarly low between groups. No significant inter-group difference in VRSdiscomfort and VRSwillingness was observed. CONCLUSIONS: Implant placement performed either concomitantly with tSFE (according to Trombelli et al. 2008, 2010a,b) or entirely in native bone is associated with limited incidence of complications, low postoperative pain and medication and are both well tolerated.

Ridge Dimensions of the Edentulous Mandible in Posterior Sextants: An Observational Study on Cone Beam Computed Tomography Radiographs.

AIMS: To evaluate the ridge dimensions of posterior sextant in totally edentulous mandibles. MATERIAL AND METHODS: Cone beam computed tomography scans of 136 patients were retrospectively included for analysis. At sites corresponding to the second premolar (site a) and the mesial and distal root of first molar (sites b and c, respectively), bone height (BH) and bone width (BW) were measured. RESULTS: BH significantly decreased from site a (11.20 ± 4.03 mm) to site c (10.28 ± 3.33 mm). Males showed a significantly higher BH compared with females at all sites (P < 0.001), No significant impact of age on BH was found. BW increased from coronal to apical at all sites. At all height levels, BW increased from mesial to distal (BWc > BWb > BWa). CONCLUSIONS: BH decreased from mesial to distal, whereas BW showed an increase. Sex showed a significant impact on BH, with males having on average a 2.8 mm greater height than females, but not on BW. Age did not significantly influence the dimensions of the residual bone crest.

Early postoperative healing following buccal single flap approach to access intraosseous periodontal defects.

AIM: This study aims to evaluate the early postoperative healing of papillary incision wounds and its association with (1) patient/site-related factors and technical (surgical) aspects as well as with (2) 6-month clinical outcomes following buccal single flap approach (SFA) in the treatment of intraosseous periodontal defects. METHODS: Forty-three intraosseous defects in 35 patients were accessed with a buccal SFA alone or in combination with a reconstructive technology (graft, enamel matrix derivative (EMD), graft + EMD, or graft + membrane). Postoperative healing was evaluated at 2 weeks using the Early Wound-Healing Index (EHI). RESULTS: EHI ranged from score 1 (i.e., complete flap closure and optimal healing) to score 4 (i.e., loss of primary closure and partial tissue necrosis). SFA resulted in a complete wound closure at 2 weeks in the great majority of sites. A significantly more frequent presence of interdental contact point and interdental soft tissue crater, and narrower base of the interdental papilla were observed at sites with either EHI > 1 or EHI = 4 compared to sites with EHI = 1. No association between EHI and the 6-month clinical outcomes was observed. CONCLUSIONS: At 2 weeks, buccal SFA may result in highly predictable complete flap closure. CLINICAL RELEVANCE: Site-specific characteristics may influence the early postoperative healing of the papillary incision following SFA procedure. Two-week soft tissue healing, however, was not associated with the 6-month clinical outcomes.

Explaining pain after lower third molar extraction by preoperative pain assessment.

PURPOSE: To evaluate whether preoperative pain sensitivity testing and emotional perception of pain could explain the level of postoperative pain after lower third molar extraction. PATIENTS AND METHODS: Twenty-three patients (16 women, 7 men) scheduled for lower third molar extraction were enrolled in the study. Patients preoperatively were submitted to a nociceptive stimulus by a cold pressor test (immersion of the hand into ice water). Preoperative pain tolerance (seconds), algosity and unpleasantness (visual analog scale), and dental anxiety (Modified Dental Anxiety Scale) were assessed. The duration of surgery was recorded (minutes). Postoperative pain ratings were taken by self-reported registrations on a 100-mm visual analog scale during the 6 days after surgery. Separate stepwise regression analyses were performed to evaluate the usefulness of preoperative scores in explaining the overall maximum postoperative pain level and postoperative pain rates at different intervals. RESULTS: Preoperative unpleasantness related to the nociceptive stimulus was found to be the best predictor of maximum postoperative pain (adjusted R(2) = 0.39, P = .001). Demographic information (age) and preoperative (dental anxiety, pain tolerance, algosity) and intraoperative (duration of surgery) factors were not correlated with postoperative pain. CONCLUSIONS: These results show that a simple preoperative test is useful to identify patients at risk of developing greater pain after third molar surgery. They are characterized by a higher level of reported pain or unpleasantness after exposure to a nociceptive stimulus. This test may be tailored to specific patient needs for postoperative treatment.

Alveolar ridge dimensions in maxillary posterior sextants: a retrospective comparative study of dentate and edentulous sites using computerized tomography data.

AIM: To compare the alveolar ridge dimensions between edentulous sites and contralateral dentate sites of maxillary posterior sextants in the same individuals. MATERIALS AND METHODS: Computerized tomography scans of 32 patients with one fully edentulous and one fully dentate maxillary posterior sextants were analyzed. RESULTS: When compared with dentate sextants, edentulous sextants showed (i) a lower bone height (BH) at second premolar, first molar and second molar sites, which was associated with a more coronal position of the maxillary sinus floor at second premolar site; (ii) a more apical position of the ridge at second premolar and second molar sites; (iii) a lower bone width (BW)(1 mm) at first and second premolar sites, and a lower BW(3 mm) at all sites, (iv) a lower, although not significant, prevalence of premolar and molar sites with BH ≥8 mm and BW(1 mm) ≥6 mm. CONCLUSIONS: The edentulous sextants in the posterior maxilla showed a reduced height and width of the ridge when compared with contralateral dentate sextants. The reduced vertical dimensions observed in edentulous sextants were variably associated with ridge resorption as well as sinus pneumatization.

Ridge dimensions of the edentulous posterior maxilla: a retrospective analysis of a cohort of 127 patients using computerized tomography data.

OBJECTIVES: to evaluate the edentulous ridge dimensions of maxillary posterior sextants with a tridimensional radiographic technique. The influence of the presence/absence of teeth adjacent to the edentulous site on the dimensions of the edentulous ridge was also evaluated. MATERIAL AND METHODS: computerized tomography (CT) scans of 127 patients (65 males and 62 females; mean age: 55.2 ± 10.1 years) with at least one missing tooth in the maxillary posterior sextants were analyzed. On CT cross sections, bone height (BH), bone width (BW) at 1, 3, and 7 mm from the most coronal point of the alveolar crest (BW(1 mm) , BW(3 mm) , and BW(7 mm) , respectively) and the relative vertical ridge position (rVRP) were assessed at the first premolar, second premolar, first molar and second molar edentulous sites. RESULTS: the results of the study indicate that (i) the maxillary sinus was radiographically evident in about 50% of first premolar sites and 90-100% of second premolar and molar sites; (ii) BH showed a significant decrease from first premolar to molar sites; (iii) BW(1 mm) was higher at second molar site compared with the first and second premolar sites, BW(3 mm) and BW(7 mm) were higher at each molar site compared with each premolar site; (iv) the proportion of sites with BH ≥ 8mm and BWI mm ≥ 6mm was 28.3%, 18.4%, 8.0% and 18.2% [corrected] at first premolar, second premolar, first molar and second molar sites, respectively. The absence of teeth adjacent to the edentulous site negatively affected rVRP, but not BH and BW. CONCLUSIONS: The results of the study indicate that at premolar and molar sites, [corrected] the dimensions of the alveolar crest may call for bone augmentation procedures for proper implant placement in a substantial amount of edentulous patients. When both mesial and distal tooth adjacent to the edentulous site are absent, the placement of implants of adequate dimensions may be more challenging due to a more apical position of the alveolar ridge compared with sites where both adjacent teeth are present.

Single flap approach with and without guided tissue regeneration and a hydroxyapatite biomaterial in the management of intraosseous periodontal defects.

BACKGROUND: The single flap approach (SFA) is a minimally invasive procedure designed for periodontal reconstructive procedures of intraosseous periodontal defects characterized by a dominant unilateral, buccal or oral, extension. This study evaluates the adjunctive effect of guided tissue regeneration (GTR) combined with a hydroxyapatite (HA) biomaterial in the management of intraosseous periodontal defects accessed with SFA compared to SFA alone. METHODS: Twenty-four intraosseous defects (in 24 patients) were randomly allocated to treatment with SFA or SFA + HA/GTR. Clinical outcomes were assessed 6 months post-surgery. RESULTS: Five sites in the SFA + HA/GTR group showed incomplete closure at week 2, which resolved spontaneously. There were no statistically significant or clinically meaningful differences in mean (+/-SD) clinical attachment gain (4.7 +/- 2.5 versus 4.4 +/- 1.5 mm), probing depth reduction (5.3 +/- 2.4 versus 5.3 +/- 1.5 mm), and gingival recession increase (0.4 +/- 1.4 versus 0.8 +/- 0.8 mm) between the SFA + HA/GTR and SFA groups. CONCLUSIONS: SFA with and without HA/GTR seems to be a valuable minimally invasive approach in the treatment of deep intraosseous periodontal defects. Under the present experimental conditions, the additional HA/GTR protocol offers no significant adjunctive effect.