Application of "10 Keys" Checklist and Partial Extraction Techniques to Optimize Esthetic Outcome for Adjacent Implants in the Esthetic Zone.

Placing immediate implants in the esthetic zone area poses significant challenges. Implants should be placed with consideration to hard and soft tissue management to optimize long term implant and cosmetic success. In this case report, two maxillary central incisors were extracted in two different time points, separated by 5 years because of horizontal root fractures. Implants were placed according to immediate single-tooth guidelines, using two different surgical and loading approaches, as risk assessment factors changed in the time between first immediate placement (#8) and second immediate placement (#9). These techniques included Partial Extraction Therapy (PET), the use of allograft and growth factors, connective tissue graft (CTG), platelet rich fibrin (PRF) and immediate and conventional loading. These were grouped as the "10 keys", a checklist used to pursue long term success. After 6-year and 1-year follow-up, radiographic and clinical results were satisfactory.

Periodontal regeneration risk assessment in the treatment of intrabony defects.

BACKGROUND: Regenerative approaches performed in periodontics seems to be efficient in treating intrabony defects. There are, however, many factors that may affect the predictability of the regenerative procedures. The present article aimed to propose a new risk assessment tool for treating periodontal intrabony defects by regenerative therapy. METHODS: Different variables that could affect the success of a regenerative procedure were considered based on their impact on (i) the wound healing potential, promoting wound stability, cells, and angiogenesis, or (ii) the ability to clean the root surface and maintain an optimal plaque control or (iii) aesthetics (risk for gingival recession). RESULTS: The risk assessment variables were divided into a patient, tooth, defect, and operator level. Patient-related factors included medical conditions such as diabetes, smoking habit, plaque control, compliance with supportive care, and expectations. Tooth-related factors included prognosis, traumatic occlusal forces or mobility, endodontic status, root surface topography, soft tissue anatomy, and gingival phenotype. Defect-associated factors included local anatomy (number of residual bone walls, width, and depth), furcation involvement, cleansability, and number of sides of the root involved. Operator-related factors should not be neglected and included the clinician's level of experience, the presence of environmental stress factors, and the use of checklists in the daily routine. CONCLUSIONS: Using a risk assessment comprised of patient-, tooth-, defect- and operator-level factors can aid the clinician in identifying challenging characteristics and in the treatment decision process.

7 Keys for Treatment of Periodontal Intrabony Defects.

Although technique-sensitive, periodontal regeneration seems efficient in treating intrabony defects; nonetheless, complete success can be difficult to attain. Seven keys for successful periodontal regeneration of intrabony defects, presented herein, encapsulate an evidence-based treatment planning and surgical protocol for achieving predictable outcomes. Utilizing a step-by-step approach, the seven keys offer periodontists a checklist for treating intrabony defects and include protocols for the planning, surgical, and postoperative phases of the treatment. This article describes the use of the seven keys checklist to achieve predictable regenerative outcomes at short-term and long-term follow-ups. A case report demonstrates the application of these seven keys.

Short-Term Case Reports Demonstrating the Use of Volume-Stable Collagen Matrix.

A proper diagnostic and treatment planning process for dental implant rehabilitations should include a checklist of key factors to help clinicians avoid potential complications. Such a checklist should encompass evaluation of the soft- and hard-tissue volume buccal to each implant, as this has been shown to aid in maintaining marginal bone levels long-term. Thus, as part of surgical planning, a decision to augment the soft tissue should be considered. The autogenous palatal graft has long been considered the "gold standard" for soft-tissue augmentation; however, the benefits of this approach should be weighed against the potential complications associated with a secondary surgical site as well as the patient's desire for as pain-free an experience as possible. The volume-stable collagen matrix (VSCM) is a promising material with favorable healing characteristics and volume thickness maintenance of up to 3 years in current literature. This article presents two cases that demonstrate the clinical advantages of a VSCM over the use of autogenous palatal grafts as part of the authors' "10 Keys" principles of augmenting the volume and thickness of peri-implant tissues.

Application of the 10 Keys for Replacement of Multiple Teeth in the Esthetic Zone.

Ten keys for successful esthetic-zone single immediate implants encapsulate in an evidence-based manner the treatment planning and replacement of single hopeless teeth in the maxillary anterior sextant. These include two treatment-planning, five surgical, and three prosthetic keys, which, collectively, aim to minimize soft- and hard-tissue complications for an optimal esthetic implant restoration. The Straightforward, Advanced, and Complex (SAC) classification is designed to aid clinicians in the treatment planning of dental implant cases. As per this classification, cases are stratified by the degree of surgical and restorative risk and complexity for both the surgical and prosthetic phases of treatment. A technique-sensitive and skill-demanding task, the replacement of multiple adjacent teeth in the esthetic zone poses significant challenges for clinicians and is considered a complex SAC procedure surgically and restoratively. This article presents a case report on the replacement of multiple adjacent teeth in the esthetic zone, demonstrating the use of 10 key principles to achieve an optimal esthetic outcome.

Long-term Case Reports Demonstrating Use of Porcine Collagen Matrix to Augment Width and Thickness of Keratinized Gingiva.

Gingival augmentation therapy is intended to create a healthy band of attached keratinized tissue to inhibit further gingival recession, facilitate plaque control, and improve patient comfort. Although an effective treatment for gingival augmentation procedures, the often-used autogenous epithelialized palatal graft has several drawbacks, including the need for a second surgical site to harvest the graft, the risk of such complications as damage to neurovascular tissue and poor healing of the donor site, and potential color and texture discrepancies of the grafted site. The use of a resorbable xenogeneic collagen-based matrix may be considered as a treatment alternative to augment soft tissue. The authors describe the application of such a graft that is made from purified porcine type I and type III collagen and processed without the addition of chemical cross-linkers. Two cases are presented that demonstrate the clinical advantages of this material compared to autogenous palatal grafts when augmenting the width and thickness of attached keratinized gingiva.

Group 1 ITI Consensus Report: The influence of implant length and design and medications on clinical and patient-reported outcomes.

OBJECTIVES: The aim of Working Group 1 was to address the influence of different local (implant length, diameter, and design) and systemic (medications) factors on clinical, radiographic, and patient-reported outcomes in implant dentistry. Focused questions on (a) short posterior dental implants (≤6 mm), (b) narrow diameter implants, (c) implant design (tapered compared to a non-tapered implant design), and (d) medication-related dental implant failures were addressed. MATERIALS AND METHODS: Four systematic reviews were prepared in advance of the Consensus Conference and were discussed among the participants of Group 1. Consensus statements, clinical recommendations, and recommendations for future research were based on structured group discussions until consensus was reached among the entire expert Group 1. The statements were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Short implants (≤6 mm) revealed a survival rate ranging from 86.7% to 100%, whereas standard implant survival rate ranged from 95% to 100% with a follow-up from 1 to 5 years. Short implants demonstrated a higher variability and a higher Risk Ratio [RR: 1.24 (95% CI: 0.63, 2.44, p = 0.54)] for failure compared to standard implants. Narrow diameter implants (NDI) have been classified into three categories: Category 1: Implants with a diameter of <2.5 mm ("Mini-implants"); Category 2: Implants with a diameter of 2.5 mm to <3.3 mm; Category 3: Implants with a diameter of 3.3 mm to 3.5 mm. Mean survival rates were 94.7 ± 5%, 97.3 ± 5% and 97.7 ± 2.3% for category 1, 2 and 3. Tapered versus non-tapered implants demonstrated only insignificant differences regarding clinical, radiographic, and patient-reported outcomes. The intake of certain selective serotonin reuptake inhibitors and proton pump inhibitors is associated with a statistically significant increased implant failure rate. The intake of bisphosphonates related to the treatment of osteoporosis was not associated with an increased implant failure rate. CONCLUSIONS: It is concluded that short implants (≤6 mm) are a valid option in situations of reduced bone height to avoid possible morbidity associated with augmentation procedures; however, they reveal a higher variability and lower predictability in survival rates. Narrow diameter implants with diameters of 2.5 mm and more demonstrated no difference in implant survival rates compared to standard diameter implants. In contrast, it is concluded that narrow diameter implants with diameters of less than 2.5 mm exhibited lower survival rates compared to standard diameter implants. It is further concluded that there are no differences between tapered versus non-tapered dental implants. Certain medications such as selective serotonin reuptake inhibitors and proton pump inhibitors showed an association with a higher implant failure rate.

Systematic review of clinical and patient-reported outcomes following oral rehabilitation on dental implants with a tapered compared to a non-tapered implant design.

BACKGROUND: Dental implants are available in different shapes. AIMS: This systematic review aims to address whether tapered compared to non-tapered implants demonstrate similar clinical and patient-reported outcomes. The review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. MATERIALS & METHODS: We searched electronic databases including MEDLINE through PubMed and the Cochrane Central Register of Controlled Trials for randomized clinical trials (RCT) that compare tapered versus non-tapered implants with at least 10 treated participants and a minimum mean follow-up time of 3 years. There were no restrictions to a particular treatment indication or outcome measures. Two authors independently conducted screening, risk of bias assessment, and data extraction of eligible trials in duplicate. We applied the Cochrane risk of bias assessment tool to consider risk of bias. RESULTS: We identified 18 different RCTs, of which three reported outcomes at 3 years or greater. The three trials described the results of 245 participants with 388 implants at 3 years, from the initially 306 participants with 494 implants at baseline. The three trials compared, respectively, two, two, and three different commercially available implant brands and reported only clinically insignificant differences. We judged all three trials to be at moderate risk of bias. The low number and heterogeneity of RCTs did not allow for meta-analyses. DISCUSSION AND CONCLUSION: Appropriate professional judgment in clinical decision making must include a comprehensive diagnosis of the patient's jawbone quality and quantity and consideration of osteotomy protocol in accordance with the patient's treatment preferences, where the shape of the dental implant is only one contributory factor.

10 Keys for Successful Esthetic-Zone Single Implants: Importance of Biotype Conversion for Lasting Success.

The concept of 10 keys for successful esthetic-zone single immediate implants is an evidenced-based summary for the treatment planning and replacement of a hopeless tooth in the maxillary anterior sextant. It includes two treatment-planning, five surgical, and three prosthetic keys. These keys are aimed at minimizing soft- and hard-tissue complications to achieve an optimal long-term esthetic implant restoration. Based on the 10 keys, which were described in a prior publication and are reiterated herein, the management of an immediate implant in the esthetic zone is considered a complex SAC procedure (SAC = straightforward, advanced, and complex). The present article highlights the importance of connective tissue grafting as part of the 10 keys and its role in biotype conversion and esthetic success that endures.

10 Keys for Successful Esthetic-Zone Single Immediate Implants.

The 10 keys for successful esthetic-zone single immediate implants encapsulate in an evidencebased manner the treatment planning and replacement of single hopeless teeth in the maxillary anterior sextant. These include 2 treatment-planning, 5 surgical, and 3 prosthetic keys, which, collectively, aim to minimize soft- and hard-tissue complications for an optimal esthetic implant restoration. The straightforward, advanced, and complex (SAC) classification was designed to aid clinicians in the treatment planning of dental implant cases. Cases are stratified by the degree of surgical and restorative risk and complexity for both the surgical and prosthetic phases of treatment. Based on the 10 keys, the management of an immediate implant in the esthetic zone is considered a complex SAC procedure. As described in this article, a complex SAC procedure requires careful patient selection and treatment planning, along with precise execution by skillful clinicians, to achieve successful results.

Single-Tooth Implant Restorations in Fresh Extraction Sockets of the Maxillary Esthetic Zone: Two-Year Results of a Prospective Cohort Study.

In this prospective study, 15 patients received 15 variable-thread tapered implants placed in fresh extraction sites in the maxillary esthetic zone and immediately were provisionalized out of occlusion. Of the 15 patients, 11 completed their 2-year follow-up. At 2 years, the success and cumulative survival rates were both 100%, and the mean bone level gain was 0.83 mm. Soft tissue assessment showed no zero esthetic scores, improved papilla indices, and low bleeding on probing and plaque accumulation. Overall, the study implants showed excellent hard tissue, soft tissue, and esthetic outcomes, indicating a healthy tissue response in single-tooth extraction sites in the maxillary esthetic zone.

Clinical and radiologic outcomes after submerged and transmucosal implant placement with two-piece implants in the anterior maxilla and mandible: 3-year results of a randomized controlled clinical trial.

PURPOSE: The aim of this investigation was to evaluate the 3-year outcomes regarding crestal bone level, clinical parameters, and patient satisfaction, following submerged and transmucosal implant placement for two-piece implants in the anterior maxilla and mandible. MATERIALS AND METHODS: Patients requiring dental implants for single-tooth replacement in the anterior maxilla or mandible were enrolled in a randomized, controlled, multicenter clinical trial. The implants were randomized at placement to either submerged or transmucosal healing, with final restorations placed after 6 months. Radiographic and clinical parameters were recorded after 1, 2, and 3 years; a questionnaire was also used to assess patient satisfaction. A two-sided, unpaired T-test (significance level p ≤ .05) was used to statistically evaluate the differences between the two groups. RESULTS: A total of 106 patients were included in the 3-year analysis. The mean change in crestal bone level from implant placement to 3 years was 0.68 ± 0.98 mm (p < .001) and 0.58 ± 0.77 mm (p < .001) in the submerged and transmucosal groups, respectively; the differences between the groups were not significant. Clinical parameters remained stable throughout the study, with no significant differences between the groups, and patient satisfaction was good or excellent for over 90% of subjects in both groups. CONCLUSIONS: The results demonstrate excellent clinical and radiographic conditions after 3 years for implants supporting single-tooth restorations, regardless of whether a submerged or transmucosal surgical technique was used.

Custom abutments alone will not eliminate the clinical effects of poor cementation techniques around dental implants.

With proper planning, placement, prosthetic treatment, and maintenance, dental implants have been shown to be a predictable and reliable treatment option with a high success rate. Clinicians who place cement-retained implant restorations, however, should be aware of the potential and sometimes irreversible biological complications associated with residual excess cement and should be prepared to consider using different practices that may reduce the problem. The present case reports describe the use of custom abutments to restore deeply placed implants with the intent of minimizing residual excess cement.

Radiographic appearance of commonly used cements in implant dentistry.

Cement-retained restorations allow for a conventional fixed partial denture approach to restoring dental implants. However, inadequate removal of excess cement at the time of cementation may introduce a severe complication: cement-induced peri-implantitis. Radiopaque cements are more easily detected on radiographs and should improve the recognition of extravasated cement at the time of insertion. The purpose of this study was to evaluate the radiopacity of commercially available cements in vitro. Eighteen different cements commonly used for luting restorations to implants were tested at both 0.5- and 1.0-mm thicknesses. The cements examined were zinc oxide eugenol, zinc oxide, zinc polycarboxylate, zinc phosphate, resin-reinforced glass ionomer, urethane resin, resin, and composite resin. Two samples of each cement thickness underwent standardized radiography next to an aluminum step wedge as a reference. The mean grayscale value of each of the nine 1-mm steps in the step wedge were used as reference values and compared to each of the cement samples. Temp Bond Clear (resin), IMProv (urethane resin), Premier Implant Cement (resin), and Temrex NE (resin) were not radiographically detectable at either sample thickness. Cements containing zinc were the most detectable upon radiographic analysis. There are significant differences in the radiopacity of many commonly used cements. Since cementinduced peri-implantitis can lead to late implant failure, cements that can be visualized radiographically may reduce the incidence of this problem.

Assessing image-guided implant surgery in today's clinical practice.

As implant dentistry has progressed, greater emphasis has been placed on natural-looking tooth replacement, minimally invasive techniques, and better cost efficiencies, with implant positioning being guided by the desired prosthetic outcome. Image-guided surgery is a technique that merges preoperative diagnostic imaging with computer-based planning tools to facilitate surgical and restorative plans and procedures. This article discusses the intricacies of guided implant surgery, including 3-dimensional presurgical planning and the challenges of maintaining guide stability during surgical execution.

Implant-supported single tooth restoration in the aesthetic zone: transmucosal and submerged healing provide similar outcome when simultaneous bone augmentation is needed.

AIM: The aim of this study was to compare the clinical outcomes after 2 years with bone level implants placed to restore a single missing teeth that needed simultaneous augmentation and were treated with a transmucosal or submerged approach. METHODS: This study analyzed a subset of patients included in an ongoing prospective multicenter randomized clinical trial (RCT) involving12 centers where patients were to be followed-up to 5 years after loading. Of the 120 implants that were placed in the original study, and randomly assigned to submerged or non-submerged healing, 52 needed simultaneous augmentation (28 women patients and 24 men patients, between 23 and 78 years of age). Twenty-seven of them received implants with submerged healing (AuS), while in 25 patients the implants were inserted with a non-submerged protocol (AuNS). At the 2-year follow-up visit, radiographic crestal bone level changes were recorded as well as soft tissue parameters included Pocket probing depth (PPD), bleeding on probing (BoP) and clinical attachment level (CAL) at teeth adjacent to the implant site. RESULTS: After 2 years a small amount of bone resorption was found in both groups (0.37 ± 0.49 mm in the AuS group and 0.54 ± 0.76 in the AuNS group; P < 0.001). There was no statistically significant difference between AuS Group and AuNS group for PPD (2.5 vs. 2.4 mm), BOP (BOP + sites: 8.8% vs. 11.5%) and CAL (2.8 vs. 2.4 mm) at the 2-year follow-up visit. CONCLUSIONS: When a single implant is placed in the aesthetic zone in conjunction with bone augmentation for a moderate peri-implant defect, submerged and transmucosal healing determine similar outcome, hence there is no need to submerge an implant in this given clinical situation.

Immediate and early loading of chemically modified implants in posterior jaws: 3-year results from a prospective randomized multicenter study.

BACKGROUND: There is a lack of well-designed prospective, randomized clinical trials evaluating the efficacy of immediate and early loading of implants placed in the partially edentulous posterior maxilla or mandible. PURPOSE: The aim of this study was to evaluate crestal bone level changes over 3 years following immediate or early loading of Straumann implants with a chemically modified surface (SLActive®, Institut Straumann AG, Basel, Switzerland) placed in the posterior maxilla and mandible. MATERIALS AND METHODS: Subjects received temporary restorations immediately or 28 to 34 days after surgery, with permanent restorations placed at 20 to 23 weeks. Bone level changes were measured by comparison of standardized radiographs taken on the day of implant placement and 5, 12, 24, and 36 months thereafter. RESULTS: Two hundred thirty-nine of two hundred sixty-six patients (89.9%) completed the trial. Implant survival rates were 97.4% and 96.7% in the immediate and early loading groups, respectively (p = not significant). Over 36 months, the mean bone level change for immediately loaded implants was 0.88 ± 0.81 mm versus 0.57 ± 0.83 mm for the early-loaded group (p < .001). After adjusting for a slight difference in initial placement depth, the time of loading had no significant influence on bone level change. CONCLUSIONS: Changes in crestal bone level occurred mostly during the first 5 months postloading. After this bone remodeling period, crestal bone level was stable up to 36 months. Implants with a chemically modified surface are safe and predictable for immediate and early loading in the posterior maxilla and mandible.

Incidental findings from a retrospective study of 318 cone beam computed tomography consultation reports.

PURPOSE: Cone beam computed tomography (CBCT) is a three-dimensional radiographic technique used in planning implant therapy to help clinicians determine the volume and dimension of bone available for implant placement, and CBCT images potentially depict coincident findings. MATERIALS AND METHODS: Three hundred eighteen patients received CBCT scans prior to receiving implants, which were interpreted by blinded board-certified oral and maxillofacial radiologists. All incidental findings were defined as non-tooth-related pathologies or abnormalities. These findings were categorized and analyzed using descriptive statistics. RESULTS: The patients ranged in age from 16 to 91 years (mean age for men, 64.73 ± 15.05 years; for women, 62.47 ± 15.83 years). Controlling for age, men were 2.13 times more likely to have sinus pathology than women. Patients over age 65 were 5.01 times more likely to demonstrate vascular pathology (eg, carotid artery calcification) than patients ages 41 to 65; the likelihood versus patients ages 16 to 40 was 13.39. Women were 2.63 times more likely to display brain pathology (eg, pineal or pituitary calcifications). Controlling for gender, patients ages 41 to 65 were 3.17 times more likely to exhibit condylar pathology (eg, degenerative changes) than patients ages 16 to 40. Similarly, patients above age 65 were 3.53 times more likely to show condylar pathology than patients ages 16 to 40, and women were 1.61 times more likely to have condylar pathology than men. Versus patients ages 16 to 40, patients ages 41 to 65 were 17.69 times more likely to show signs of vertebral pathology (eg, degenerative disc changes) and patients over age 65 were 28.67 times more likely to display vertebral pathology. CONCLUSION: CBCT scans frequently reveal non-tooth-related pathologies and/or abnormalities in the head and neck region. Therefore, comprehensive review of the entire CBCT image set is necessary.

Submerged and transmucosal healing yield the same clinical outcomes with two-piece implants in the anterior maxilla and mandible: interim 1-year results of a randomized, controlled clinical trial.

OBJECTIVES: To test whether or not transmucosal healing at two-piece implants is as successful as submerged placement regarding crestal bone levels and patient satisfaction. MATERIAL AND METHODS: Adults requiring implants in the anterior maxilla or mandible in regions 21-25, 11-15, 31-35 or 41-45 (WHO) were recruited for this randomized, controlled multi-center clinical trial of a 5-year duration. Randomization was performed at implantation allowing for either submerged or transmucosal healing. Final reconstructions were seated 6 months after implantation. Radiographic interproximal crestal bone levels and peri-implant soft tissue parameters were measured at implant placement (IP) (baseline), 6 and 12 months. Patient satisfaction was assessed by a questionnaire. A two-sided t-test (80% power, significance level α=0.05) was performed on bone-level changes at 6 and 12 months. RESULTS: One hundred and twenty-seven subjects were included in the 12-month analysis (submerged [S]: 52.5%, transmucosal [TM]: 47.2%). From IP to 6 months, the change in the crestal bone level was -0.32 mm (P<0.001) for the S group and -0.29 mm (P<0.001) for the TM group. From IP to 12 months, bone-level changes were statistically significant in both groups (S -0.47 mm, P<0.001; TM -0.48 mm, P<0.001). The mean differences of change in the bone levels between the two groups were not statistically significant at either time point, indicating the equivalence of both procedures. For both groups, very good results were obtained for soft tissue parameters and for patient satisfaction. CONCLUSIONS: Transmucosal healing of two-piece implants is as successful as the submerged healing mode with respect to tissue integration and patient satisfaction within the first 12 months after IP.

Regenerative Treatment for Recession Defects Using Purified Human Platelet-Derived Growth Factor-BB, Particulate Grafts, and Coronally Repositioned Flaps.

INTRODUCTION: Recession defects are typically characterized by loss of periodontal attachment, including gingiva, periodontal ligament, alveolar bone, and cementum. Numerous techniques have been developed for treatment of these defects using soft-tissue grafting procedures with autogenous and allograft materials that generally heal with root coverage and repair of the defects. This case presentation illustrates a technique using a particulate carrier saturated with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and coronally advanced gingival flaps to cover recession defects. Additionally, other scientific evidence from previous studies suggests that this technique may lead to periodontal regeneration, including cementum, periodontal ligament, and alveolar bone over previously exposed roots, which might be preferable to other methods that lead to periodontal repair. CASE PRESENTATION: This article illustrates a technique to coronally position flaps in combination with rhPDGF-BB-saturated particulate graft material. Results show significant root coverage with excellent color and texture match to adjacent tissues. Additionally, the alveolus appeared thicker than non-treated areas, suggesting appositional augmentation of the sites. Human histologic investigation of this technique in other studies confirms that periodontal regeneration can occur with this technique. CONCLUSIONS: Coronally positioned flaps over rhPDGF-BB-soaked human freeze-dried bone allograft, termed "recession regeneration," can result in significant root coverage with excellent esthetics, even in demanding cases. Surgical reentry of one case shows significant regeneration of buccal alveolar bone over the previously exposed root surfaces, consistent with periodontal regeneration that is not ordinarily observed with other root coverage techniques unless biologic modifiers or cell occlusive barrier membranes are used.