Clinical evaluation of Laser-Assisted New Attachment Procedure® (LANAP®) surgical treatment of chronic periodontitis: a retrospective case series of 1-year results in 22 consecutive patients.

PURPOSE: Treatment for periodontitis has evolved over the years as new technologies have become available. Currently, lasers seem attractive as a treatment modality, but their effectiveness needs to be verified. The purpose of this project was to evaluate Laser Assisted New Attachment Procedure® (LANAP®) surgery as a single treatment modality. METHODS: As part of a mandatory training program for periodontists and other dentists, 22 consecutive patients diagnosed with moderate to severe periodontitis (probing depth [PD] up to 11 mm) were treated with the LANAP® surgical approach using a 1064-nm Nd:YAG laser as part of a multi-step protocol. Following single-session active therapy, they were entered into a maintenance program. Their clinical status was re-evaluated at 12-18 months following surgery. RESULTS: All 22 patients completed the 12- to 18-month follow-up. PD, clinical attachment level, and furcation (FURC) showed substantial improvement. Recession was minimal (mean, 0.1 mm), while 93.5% of PD measurements were 3 mm or less at re-evaluation. Furthermore, 40% of grade 2 FURC closed clinically. CONCLUSIONS: Within the limits of this case series, LANAP® was found to be an effective, minimally invasive, laser surgical therapy for moderate to advanced periodontitis.

Bacterial reduction effect of four different dental lasers on titanium surfaces in vitro.

Compare the effectiveness of selected dental lasers for decontamination of machined titanium surfaces in vitro. Seventy-two sterile machined surface titanium discs were individually inoculated with strains of Streptococcus mutans (Sm), Streptococcus oralis (So), Aggregatibacter actinomycetemcomitans (Aa), or all three bacteria together (MIX) at 34.0° C, 20.8% O2 and 5% CO2 for 12 h. After incubation, the discs were divided into six groups: 1) no treatment, 2) 0.12% chlorhexidine gluconate (CHX), and 3) 10,600 CO2, 4) 810 nm diode, 5) 2780 nm Er,Cr:YSGG, 6) 1064 nm Nd:YAG laser groups. After treatment, any remaining viable bacteria were liberated from the discs via sonication, transferred onto brain heart infusion (BHI) agar plates for culturing, and colony-forming units (CFUs) were recorded. Statistical analysis was performed. There were statistically significantly differences (SSD) (p < 0.01) in bacterial reduction of discs individually inoculated with Aa between the Er,Cr:YSGG and Nd:YAG lasers. There was also a SSD (p < 0.01) lower effect with the MIX with the Er,Cr:YSGG compared with all other modalities. Bacterial reduction with the CO2 was better (p < 0.001) than treatment with CHX or the Er,Cr:YSGG laser on killing of So. Although all modalities of treatment showed a mean of 98% or greater viable bacterial reduction, the most consistent bacterial reduction of all titanium discs was with the Nd:YAG laser (100%).

Evaluation of Different Dental Lasers' Ability to Congeal Pooled Blood: An In Vitro Study.

Most dental lasers claim that they can aid in hemostasis during oral and periodontal surgery. To date, there are no studies that compare different lasers' ability to congeal pooled blood. The aim of the study was to see if there was a difference in dental lasers' ability to congeal pooled human blood in vitro. Whole blood was collected from donors, with 0.5 mL (premolar socket volume for all tests) aliquoted into microcentrifuge tubes. Different dental lasers (810-nm diode, 940-nm diode, 1,064-nm Nd:YAG, 2,790-nm Er,Cr:YSGG, 2,940-nm Er:YAG, and 10,600-nm CO2) were applied to the whole blood for 0, 15, 30, and 45 seconds. The sample tubes were centrifuged, and the supernatant color was scored to assess the degree of congealing. Additional samples of blood were tested for time needed for maximum congealing and temperature change. Analysis of supernatant colors showed that there were significant differences in the degrees of congealing for the 810-nm diode, 940-nm diode, and 2,790-nm Er,Cr:YSGG lasers when compared to the 1,064-nm Nd:YAG, 2,940-nm Er:YAG, and 10,600-nm CO2 lasers, but not within those groupings. Additionally, the 1,064-nm Nd:YAG laser increased the temperature of the blood samples more than the other lasers and had a shorter time for maximum congealing. There were differences in the dental lasers' ability to congeal pooled human blood in an in vitro model. Nd:YAG, Er:YAG, and 10,600-nm CO2 lasers were able to achieve a greater degree of congealing at an earlier time point. The Nd:YAG laser produced the most heat and was the fastest to complete coagulation.

Limitations and options using resorbable versus nonresorbable membranes for successful guided bone regeneration.

OBJECTIVE: Deficient bony ridges often complicate the implant treatment plan. Several treatment modalities are used to regenerate bone, including guided bone regeneration (GBR). The purpose of this study was to summarize the knowledge on different types of membranes available and currently used in GBR procedures in a staged approach or with simultaneous implant placement. The primary role of the membranes is to exclude epithelial and connective tissue cells from the wound area to be regenerated, and to create and maintain the space into which pluripotential and osteogenic cells are free to migrate. DATA SOURCES: A literature search was performed for articles that were published in English on the topic. A selected number of studies were chosen in order to provide a review of the main characteristics, applications, and outcomes of the different types of membranes. Resorbable membranes are made of natural or synthetic polymers like collagen and aliphatic polyesters. Collagens are the most common type used. They have similar collagen composition to the periodontal connective tissue. Other materials available include human, porcine, and bovine pericardium membranes, human amnion and chorion tissue, and human acellular freeze-dried dermal matrix. Nonresorbable membranes used in GBR include dense-polytetrafluoroethylene (d-PTFE), expanded-polytetrafluoroethylene (e-PTFE), titanium mesh, and titanium-reinforced polytetrafluoroethylene. CONCLUSIONS: The most common complication of nonresorbable membranes is exposure, which has detrimental effect on the final outcome with both types of membranes. For vertical bone augmentation procedures, the most appropriate membranes are the nonresorbable. For combination defects, both types result in a successful outcome.

A Novel Treatment Decision Tree and Literature Review of Retrograde Peri-Implantitis.

BACKGROUND: Although retrograde peri-implantitis (RPI) is not a common sequela of dental implant surgery, its prevalence has been reported in the literature to be 0.26%. Incidence of RPI is reported to increase to 7.8% when teeth adjacent to the implant site have a previous history of root canal therapy, and it is correlated with distance between implant and adjacent tooth and/or with time from endodontic treatment of adjacent tooth to implant placement. Minimum 2 mm space between implant and adjacent tooth is needed to decrease incidence of apical RPI, with minimum 4 weeks between completion of endodontic treatment and actual implant placement. The purpose of this study is to compile all available treatment modalities and to provide a decision tree as a general guide for clinicians to aid in diagnosis and treatment of RPI. METHODS: Literature search was performed for articles published in English on the topic of RPI. Articles selected were case reports with study populations ranging from 1 to 32 patients. Any case report or clinical trial that attempted to treat or rescue an implant diagnosed with RPI was included. RESULTS: Predominant diagnostic presentation of a lesion was presence of sinus tract at buccal or facial abscess of apical portion of implant, and subsequent periapical radiographs taken demonstrated a radiolucent lesion. On the basis of case reports analyzed, RPI was diagnosed between 1 week and 4 years after implant placement. Twelve of 20 studies reported that RPI lesions were diagnosed within 6 months after implant placement. A step-by-step decision tree is provided to allow clinicians to triage and properly manage cases of RPI on the basis of recommendations and successful treatments provided in analyzed case reports. It is divided between symptomatic and asymptomatic implants and adjacent teeth with vital and necrotic pulps. CONCLUSIONS: Most common etiology of apical RPI is endodontic infection from neighboring teeth, which was diagnosed within 6 months after implant placement. Most common findings, radiographically and clinically, are lesions around implant apex and sinus tract. A small number of implants did not improve with treatment. Decision tree provides a path to diagnose and treat lesions to facilitate their management. Further studies are needed to focus on histologic data around periapical microbiota to establish specific etiology and differential diagnoses compared with marginal peri-implantitis and other implant-related conditions.

Lasers in minimally invasive periodontal and peri-implant therapy.

Laser therapy has the potential to be an effective, minimally invasive procedure in periodontal therapy. The aim of the present review was to survey the relevant literature on the clinical application of lasers as a minimally invasive treatment for periodontitis and peri-implant disease. Currently, there are a large number of published clinical studies and case reports that evaluate the adjunctive use of diode, carbon dioxide, neodymium-doped yttrium aluminium garnet (Nd:YAG), erbium-doped yttrium aluminium garnet (Er:YAG) and erbium, chromium-doped: yttrium, scandium, gallium, garnet (Er,Cr:YSGG) lasers or antimicrobial photodynamic therapy for nonsurgical and minimally invasive surgical treatment of periodontal pockets. These procedures are expected not only to control inflammation but also to provide biostimulation effects with photonic energy. Recent meta-analyses did not show statistically significant differences in pocket reduction and clinical attachment gain compared with mechanical debridement alone, although limited positive effects of adjunctive laser therapy were reported. At present, systematic literature approaches suggest that more evidence-based studies need to be performed to support the integration of various laser therapies into the treatment of periodontal and peri-implant diseases. The disparity between previous statistical analyses and individual successful clinical outcomes of laser applications might reveal the necessity of developing optimal laser-treatment modalities of different wavelengths and better-defined indications for each protocol.

Periodontal and peri-implant wound healing following laser therapy.

Laser irradiation has numerous favorable characteristics, such as ablation or vaporization, hemostasis, biostimulation (photobiomodulation) and microbial inhibition and destruction, which induce various beneficial therapeutic effects and biological responses. Therefore, the use of lasers is considered effective and suitable for treating a variety of inflammatory and infectious oral conditions. The CO2 , neodymium-doped yttrium-aluminium-garnet (Nd:YAG) and diode lasers have mainly been used for periodontal soft-tissue management. With development of the erbium-doped yttrium-aluminium-garnet (Er:YAG) and erbium, chromium-doped yttrium-scandium-gallium-garnet (Er,Cr:YSGG) lasers, which can be applied not only on soft tissues but also on dental hard tissues, the application of lasers dramatically expanded from periodontal soft-tissue management to hard-tissue treatment. Currently, various periodontal tissues (such as gingiva, tooth roots and bone tissue), as well as titanium implant surfaces, can be treated with lasers, and a variety of dental laser systems are being employed for the management of periodontal and peri-implant diseases. In periodontics, mechanical therapy has conventionally been the mainstream of treatment; however, complete bacterial eradication and/or optimal wound healing may not be necessarily achieved with conventional mechanical therapy alone. Consequently, in addition to chemotherapy consisting of antibiotics and anti-inflammatory agents, phototherapy using lasers and light-emitting diodes has been gradually integrated with mechanical therapy to enhance subsequent wound healing by achieving thorough debridement, decontamination and tissue stimulation. With increasing evidence of benefits, therapies with low- and high-level lasers play an important role in wound healing/tissue regeneration in the treatment of periodontal and peri-implant diseases. This article discusses the outcomes of laser therapy in soft-tissue management, periodontal nonsurgical and surgical treatment, osseous surgery and peri-implant treatment, focusing on postoperative wound healing of periodontal and peri-implant tissues, based on scientific evidence from currently available basic and clinical studies, as well as on case reports.

Histologic evaluation of an Nd:YAG laser-assisted new attachment procedure in humans.

This report presents histologic results in humans following a laser-assisted new attachment procedure (LANAP) for the treatment of periodontal pockets. Six pairs of single-rooted teeth with moderate to advanced chronic periodontitis associated with subgingival calculus deposits were treated. A bur notch was placed within the pocket at the clinically and radiographically measured apical extent of calculus. All teeth were scaled and root planed with ultrasonic and hand scalers. One of each pair of teeth received treatment of the inner pocket wall with a free-running pulsed neodymium:yttrium-aluminum-garnet (Nd:YAG) laser to remove the pocket epithelium, and the test pockets were lased a second time to seal the pocket. After 3 months, all treated teeth were removed en bloc for histologic processing. LANAP-treated teeth exhibited greater probing depth reductions and clinical probing attachment level gains than the control teeth. All LANAP-treated specimens showed new cementum and new connective tissue attachment in and occasionally coronal to the notch, whereas five of the six control teeth had a long junctional epithelium with no evidence of new attachment or regeneration. There was no evidence of any adverse histologic changes around the LANAP specimens. These cases support the concept that LANAP can be associated with cementum-mediated new connective tissue attachment and apparent periodontal regeneration of diseased root surfaces in humans.

Calculus removal with diamond-coated ultrasonic inserts in vitro.

BACKGROUND: Efficient calculus removal is a primary goal in periodontal therapy. Diamond-coated ultrasonic inserts (DIs) offer promise for improved scaling and were evaluated in vitro. METHODS: Extracted human teeth with moderate to severe calculus had areas of calculus ( approximately 5 x 5 mm) delineated with small burs. Each calculus area was treated under 2.5x magnification to the point of visible root cleanliness with sharp Gracey curets (hand instruments [HIs]), plain ultrasonic inserts (PIs), or ultrasonic inserts with fine-grit diamond coating; the latter two were used in a magnetostrictive ultrasonic instrument at a medium power setting. Each curet or insert was used for four teeth and then replaced by a new instrument. The time needed to clean each tooth/surface was recorded. The total area treated and the area of the residual calculus were calculated using an imaging analysis program. RESULTS: The mean time required for clinical calculus removal was 29.7 seconds for DIs, 91.9 seconds for PIs, and 49.8 seconds for HIs (all P <0.0001 from each other). Overall, the mean percentage of residual calculus was 6.3% for DIs, 5.4% for PIs, and 3.1% for HIs (significant differences between HIs and the other treatments). CONCLUSIONS: In vitro calculus removal was faster with DIs, followed by HIs and PIs. More residual calculus was found with the DIs; however, the 1% to 3% difference (93.7% clean versus 94.6% clean versus 96.9% clean with DIs, PIs, and HIs, respectively) does not seem to be clinically significant.

Evaluation of allogeneic bone graft substitute for treatment of periodontal osseous defects: 6-month clinical results.

This article is an initial clinical evaluation of the use of Puros, a specially processed allogeneic bone graft substitute, for treatment of periodontal osseous defects. Nine patients with chronic periodontitis contributed 1 osseous defect each. Clinical and surgical measurements were taken at the time of the initial grafting and 6 months later at the time of a surgical re-entry. On average, probing depth improved by 3 mm, and there was 2.5 mm bone fill. Resorption of the alveolar crest was minimal. All cases healed satisfactorily, and at the time of re-entry only 1 case required re-treatment. Puros appears to be a useful and beneficial material for the treatment of proximal type human periodontal defects.

Periodontal regeneration with peptide-enhanced anorganic bone matrix in particulate and putty form in dogs.

BACKGROUND: Peptide-enhanced (using the peptide 15 [P-15] synthetic peptide) anorganic bone matrix (ABM) particulate (PPart) grafts have demonstrated clinical and histologic success in human periodontal defects. Dispersion of ABM/P-15 in sodium hyaluronate carrier (PPutty) improves the handling properties of the graft material. The healing of ABM/P-15 particulate and ABM/P-15 putty was compared in critical-sized fenestration defects in 16 mongrel dogs. METHODS: After full thickness flap reflection, 7 mm diameter fenestrations were made with a trephine in the mid-root of both maxillary canines in each dog. Bone, periodontal ligament, and cementum were removed as completely as possible with hand root planing within the trephine-produced notches. By random allocation, each defect was filled with PPart or PPutty, and the flaps were closed with sutures. One dog contributing two defects served as a negative control. Block sections were retrieved at 3 and 8 weeks for histologic processing. Three 6-mu step serial sections in the center of the defects were used for analysis. Parameters measured included the original length of the wound, linear amount of periodontal regeneration including new cementum, bone and connective tissue, and area measurements of new bone and remaining particles. PPutty and PPart results were compared for significant differences using the Wilcoxon rank sum test. RESULTS: Clinical healing was uneventful in all cases. There was no evidence of inflammation or adverse tissue reactions with either material. The controls showed minimal regeneration at the periphery of the defect. Histomorphometric evaluation of the grafted defects revealed the following: at 3 weeks, there was minimal new bone formation (occupying 4.2% of the grafted area for the PPutty and 1.2% for the PPart). The grafted particles occupied 21.2% and 35.6% of the area for the PPutty and PPart, respectively (P = 0.039). At 8 weeks, there was a tendency for greater new bone formation compared to 3 weeks with both materials. There was significantly more new bone with the PPutty (49.3%) compared to the PPart (14.8%) (P = 0.045). The grafted particles occupied 7.9% and 17% of the grafted area for the PPutty and PPart, respectively (no significant difference). There were no significant differences for any of the linear measurements. ABM/P-15 PPutty had superior handling characteristics. CONCLUSIONS: Both ABM/P-15 materials yielded satisfactory healing and resulted in the greater regeneration of fenestration defects in dogs at 8 weeks compared to controls. In addition, AMB/P-15 putty resulted in more bone formation compared to ABM/P-15 particulate.

Effect of locally delivered doxycycline hyclate on human fibroblast attachment to subgingival calculus.

BACKGROUND: Clinical studies using locally applied doxycycline hyclate (DHV) have demonstrated significant probing depth reduction and gain in clinical attachment as a monotherapy without scaling and root planing. The mechanism for this attachment level gain to the non-root planed tooth is not understood. The purpose of this study was to investigate the effect of locally applied doxycycline hyclate on human gingival fibroblast attachment to subgingival calculus on contaminated root surfaces. METHODS: Two separate experiments were performed, both on subgingival calculus. In experiment 1, teeth with subgingival calculus were treated with either doxcycycline hyclate in bioabsorbable vehicle (DHV) or with vehicle control (VC) in vivo. In experiment 2, teeth with subgingival calculus were treated with DHV, VC, scaling and root planing (SRP), or no treatment in vitro. The amount of cell attachment to calculus-covered root surfaces was quantitatively compared using a fluorescent dye assay and epifluorescence microscope. Values for cell attachment are presented as the mean standard deviation of the mean. The data were evaluated using Student t test. RESULTS: In both experiments, there was no statistically significant difference in fibroblast attachment in the DHV, VC, or no treatment groups (P >0.05). The SRP group showed significantly more cellular attachment to tooth surfaces formerly covered by subgingival calculus than all other groups (P <0.001). In general, more cells attached to cementum than to calculus. Root chips that showed no attachment to the subgingival calculus also had no cells attached to the adjacent cemental root surface. CONCLUSION: The addition of doxycycline hyclate in a bioabsorbable vehicle used as a locally delivered drug did not enhance the initial cellular attachment of human gingival fibroblasts to subgingival calculus or contaminated root surfaces.

Outer membrane vesicles from Porphyromonas gingivalis affect the growth and function of cultured human gingival fibroblasts and umbilical vein endothelial cells.

BACKGROUND: The purpose of this study was to examine the effects of outer membrane vesicles (OMV) obtained from Porphyromonas gingivalis (Pg) on the growth and function of human gingival fibroblasts (HGF) and human umbilical vein endothelial cells (HUVEC). METHODS: OMV were obtained from a cell-free growth medium of Pg ATCC 33277 by 40% NH2SO4 precipitation and ultracentrifugation. Cell proliferation was measured by 3H-thymidine incorporation into growing HGF and HUVEC. Endothelial cell function was determined by their capacity to form a network of capillary tubes on an extracellular matrix (ECM). RESULTS: Proliferating HGF and HUVEC demonstrated a significant dose-dependent inhibition of 3H-thymidine uptake when cultured with 0 to 40 microg/ml of OMV protein. HGF and HUVEC showed an IC50 of growth of about 9.0 microg/ml and 4.5 microg/ml of OMV protein, respectively. Capillary tube formation by HUVEC cultured on an ECM was suppressed by 70% to 80% with 5 microg/ml OMV protein after 18 hours of incubation. The presence of proteolytic enzymes in the OMV did not contribute to capillary tube disruption, since blocking enzyme activity with specific inhibitors did not reduce the suppression of capillary tube formation. After heating at 90 degrees C for 5 minutes, OMV significantly lost their capacity to suppress capillary tube formation. CONCLUSIONS: OMV significantly inhibit the proliferation of cultured HGF and HUVEC in a dose-dependent manner. OMV suppressed the capillary tube formation by cultured HUVEC. The factor(s) appeared to be a protein and not endotoxin because its inhibitory activity was markedly reduced by heat inactivation. These studies suggest that OMV contribute to chronic periodontitis by suppressing cell proliferation and revascularization in periodontal tissues.

Root surface removal and resultant surface texture with diamond-coated ultrasonic inserts: an in vitro and SEM study.

BACKGROUND: A new diamond-coated ultrasonic insert has been developed for scaling and root planing, and it was evaluated in vitro for the amount of root surface removed and the roughness of the residual root surface as a result of instrumentation. METHODS: 48 extracted single-rooted human teeth were ground flat on one root surface and mounted (flat side up) in PVC rings of standard height and diameter with improved dental stone. Each tooth surface was treated with either a plain ultrasonic insert (PI), an ultrasonic insert with a fine grit diamond coating (DI) or sharp Gracey curettes (HI). The mounted teeth were attached to a stepper motor which drove the teeth in a horizontal, reciprocal motion at a constant rate. The thickness from the flattened bottom of the ring to the flattened tooth surface was measured before and after 10, 20, and 30 instrumentation strokes for each root surface with each of the experimental instruments. A number of treated teeth were randomly selected for examination with SEM and a profilometer. Statistical analysis (analysis of co-variance) was performed to compare the amounts of tooth structure removed among the 3 instruments and t-test was used to compare the roughness of the treated root surfaces. RESULTS: The mean depth of root structure removed was PI 10.7 microm, HI 15.0 microm, and DI 46.2 microm after 10 strokes; and PI 21.6 microm, HI 33.2 and DI 142.0 microm after 30 strokes, respectively. On average, 0.9 microm, 1.3 microm, and 4.7 microm of root surface was removed with each stroke of PI, HI and DI, respectively. PI and HI were not different from each other for all the stroke cycles, while DI was significantly different from PI and HI for all the stroke cycles (p<0.0001). Analysis with the profilometer showed that the smoothest surface was produced by the PI followed by the HI. The DI produced a surface that was significantly rougher than the surface produced by the PI or HI. CONCLUSION: These results suggest that diamond-coated ultrasonic instruments will effectively plane roots, and that caution should be used during periodontal root planing procedures. Additionally, the diamond-coated instruments will produce a rougher surface than the plain inserts or the hand curettes.

Comparative evaluation of decalcified and non-decalcified freeze-dried bone allografts in rhesus monkeys. I. Histologic findings.

BACKGROUND: Controversy exists regarding the relative merits of decalcified (DFDBA) and non-decalcified (FDBA) freeze-dried bone allografts when used in periodontal or other oral surgical procedures. METHODS: Under typical sedation, six rhesus monkeys had nylon mesh cylinders containing either DFDBA or FDBA implanted into surgically created vertical grooves on the facial aspects of all posterior quadrants. Each quadrant received three cylinders containing one type of bone, plus one empty cylinder (E) as negative control, and the full thickness flaps were closed to completely cover the cylinders. Cylinders were retrieved at 1, 2, and 3 months and processed for histologic evaluation. Photomicrographs taken at 8x were randomly evaluated using a histometric grid point counting technique for new bone and old bone within the chambers, and the data were analyzed with analysis of variance plus post-tests. RESULTS: The nylon chambers and their contents were well-tolerated by the tissues. FDBA chambers contained more new bone and total bone than either the DFDBA or E chambers at all time periods (P <0.05). DFDBA was not statistically significantly different than E at any time period. FDBA had less old bone than DFDBA at 3 months (P<0.05). FDBA and DFDBA had more total bone (grafted plus new) present than E at all time periods (P<0.05). CONCLUSION: These results suggest that FDBA may stimulate earlier, more rapid, and more substantial new bone formation than DFDBA in a monkey jaw defect model system.

A multicenter study evaluating the sensitization potential of enamel matrix derivative after treatment of two infrabony defects.

BACKGROUND: Several studies reported some success toward regeneration in infrabony defects using enamel matrix derivative (EMD). Clinically and statistically significant improvements in probing depth reduction, clinical attachment levels, and bone fill have been demonstrated. This multi-center study evaluated the potential for sensitization to EMD in a subgroup of periodontal patients treated at least twice with at least 2 months between treatments. METHODS: Three hundred seventy-six (376) patients in 11 university-based postgraduate periodontics programs and five private practices were selected. Surgeries were performed on infrabony defects. Following reflection of mucoperiosteal flaps and debridement of the root surface and defect, root conditioning (either citric acid pH = 1 or 24% EDTA) was performed and the site was irrigated with sterile saline. Enamel matrix derivative was reconstituted and applied to the exposed root surface and the bony defect. Flaps were sutured and pressure applied for 5 minutes. The second test defect was treated in a similar manner at least 8 weeks after the first surgery. The patient was given a diary card where any subjective adverse events (erythema, swelling, itching, headache, root hypersensitivity, or pain) were recorded at weeks 1 and 2 post-surgery. In addition, objective adverse events (gingival inflammation, ulcers, abscess, cratering, and lesions) were recorded by the investigator on an adverse event form. RESULTS: No clinical adverse reactions to multiple applications of EMD were noted. Of 376 patients, two were referred to a dermatologist for evaluation, but neither had signs indicating any adverse events due to EMD treatment. Instead their reactions were classified as a small local abscess and tinea cruris. The single immunoassay performed (on the patient with a small local abscess) did not demonstrate any EMD-reactive antibodies, neither IgE nor IgG. Other subjective/objective reactions that occurred during this study were of the type that are commonly experienced by patients immediately following periodontal surgery, but were not related to EMD. They included headache, swelling, itching, pain, and root hypersensitivity. CONCLUSIONS: This study demonstrated a lack of clinical adverse reactions following two separate applications of EMD. Any subjective/objective adverse reactions experienced by the patient were typical complications following routine periodontal surgery and were not directly related to the use of enamel matrix derivative.

Immediate Dental Implant Placement in Sockets Augmented With HTR Synthetic Bone.

PURPOSE: The purpose of this article is to present the results of using immediate implant placement in combination with HTR synthetic bone socket grafting to achieve a predictable restorative result. MATERIAL AND METHODS: Twenty-three hydroxylapatite-coated cylinder implants (Spline, CenterPulse Dental, Carlsbad, CA) were placed into fresh extraction sockets in 19 patients. In each case, HTR synthetic bone (Bioplant, Inc., South Norwalk, CT) was used to fill any voids remaining in the sockets and to augment the facial aspect of the ridge. The restorative phase was initiated approximately 6 months after implant placement. Conventional impression techniques were used and porcelain-fused-to-metal crowns were selected as the final restorations. RESULTS: The prosthetic outcome was evaluated as generally favorable. Only 4 (17%) of the dental implants required an angled abutment. The gingival contour was excellent in 61% and good in 35% of the cases. The emergence profile was evaluated as class I (full papilla) in 37% and class II, III, and IV in 21% each. CONCLUSIONS: The clinical results of this study demonstrate that immediate implant placement in combination with HTR synthetic bone grafting of residual socket voids and crestal deformities is a predictable procedure and provides a good base for successful prosthetic reconstruction. Adequate gingival contour and favorable emergence profile can be expected when combining immediate implant placement and HTR grafting material.