Peri-implant radiographic bone level and associated factors in Spain.

OBJECTIVES: To evaluate radiographic bone level (RxBL) at dental implants and its associated factors in Spain. MATERIAL AND METHODS: This cross-sectional study was performed by a network of sentinel dentists from regions of Spain. RxBL was defined as the distance from the implant shoulder to the first clearly visible contact between the implant surface and the bone. Radiographic measurements were performed by two trained and experienced periodontists. Implant and patient data were also collected. Descriptive, bivariate, discriminative and multivariate analyses were done. RESULTS: A total of 49 sentinel dentists provided data 275 patients. Mean RxBL from 474 implants (5-13 years) was 1.87 mm (range: 0.00-13.17 mm). Statistically significant associations between RxBL and clinical output variables (bleeding on probing, oedema, plaque, probing depth, suppuration, keratinized tissue) were found. In the multiple regression analysis, statistically significant associations for RxBL were found for smoking habit, implant diameter, years of follow-up and type of prosthesis (p < 0.01). CONCLUSIONS: Peri-implant RxBL ranged from 0 to 13.17 mm. It was significantly associated with clinical output variables and with some potentially predictor variables, at patient- (smoking >10 cigarettes/day) and implant- (diameter, years of follow-up, Toronto bridge) levels.

Connective Tissue Grafts with Nonincised Papillae Surgical Approach for Periodontal Reconstruction in Noncontained Defects.

This case report presents the preliminary results of combining a modification of the nonincised papillae surgical approach (NIPSA), attempting to improve outcomes in the treatment of teeth with advanced periodontal support loss. The modification added a connective tissue graft (CTG) in the buccal aspect of these unfavorable cases caused by deep buccal bone dehiscence, soft tissue deficiencies, or tooth malposition (especially when positioned outside the bony contour). Deep, intrabony, noncontained defects affecting the maxillary incisors were treated in four patients. At the 1-year follow-up, all cases showed an improvement in the marginal soft tissue with considerable reductions in periodontal pocket depth and gains in clinical attachment. NIPSA plus CTG seem to improve clinical outcomes in deep, noncontained intrabony defects.

Supra-alveolar attachment gain in the treatment of combined intra-suprabony periodontal defects by non-incised papillae surgical approach.

AIM: To assess the effectiveness of non-incised papillae surgical approach (NIPSA) in periodontal reconstructive surgery of combined intra-suprabony defects. MATERIALS AND METHODS: Patients with deep periodontal defects treated with NIPSA (n = 20) were analysed. Defects were treated with enamel matrix derivative plus xenograft. Clinical outcomes were assessed before surgery and at 12 months. Wound closure was assessed one week post-surgery. Supra-alveolar attachment gain (SUPRA-AG) was recorded at 12 months post-surgery. RESULTS: Non-incised papillae surgical approach showed significant improvements in clinical attachment gain (5.9 ± 2.38 mm; p < 0.001), recession reduction (0.25 ± 0.44; p < 0.05) and tip of the papillae coronal displacement (0.4 ± 0.5; p < 0.05). It also showed complete wound closure of the apical mucosal incision in the 85% of the cases, with no interproximal tissue necrosis. SUPRA-AG (1.9 ± 1.74) showed a positive tendency, associated with complete intrabony defect resolution. CONCLUSIONS: Non-incised papillae surgical approach promoted primary intention healing, wound stability and space provision for optimal periodontal reconstruction, preserving supra-alveolar soft tissue integrity.

Adherence to supportive periodontal treatment.

Like any other chronic disease, periodontal disease can be treated, but not eradicated. Personal maintenance of periodontal health requires the continuous elimination of bacterial accumulation at the gingival level, which demands periodical professional assistance. Of upmost importance is the patient being able to actively follow the counsel of the care providers. Thus, patient compliance, adherence, and persistence are paramount for the long-term success of periodontal therapy. Unfortunately, in medicine as well as in dentistry, most studies show that, sooner rather than later, an unacceptable percentage of patients quit maintenance care. However, different studies have shown that there are behavioral techniques which may significantly improve the degree of motivation, compliance and persistence of patients with oral hygiene and supportive periodontal treatment. The right interval between maintenance visits has not been determined yet, but should be implemented according to patient needs, which do not necessarily coincide with the standard three-month interval historically accepted as adequate. Adherence to periodontal maintenance results in reduction of plaque and bleeding on probing, and potentially slowing down or halting the disease progression. Finally, based on numerous retrospective studies, patient compliance could be considered a disease-modifying factor positively affecting tooth survival. However, a lack of randomized clinical trials means this last statement is still open to question.

Cellular therapy in periodontal regeneration.

Periodontitis is a chronic inflammatory condition leading to destruction of the tooth supporting tissues, which if left untreated may cause tooth loss. The treatment of periodontitis mainly aims to arrest the inflammatory process by infection control measures, although in some specific lesions a limited periodontal regeneration can also be attained. Current regenerative approaches are aimed to guide the cells with regenerative capacity to repopulate the lesion and promote new cementum and new connective tissue attachment. The first phase in periodontal tissue regeneration involves the differentiation of mesenchymal cells into cementoblasts to promote new cementum, thus facilitating the attachment of new periodontal ligament fibers to the root and the alveolar bone. Current regenerative approaches limit themselves to the confines of the lesion by promoting the self-regenerative potential of periodontal tissues. With the advent of bioengineered therapies, several studies have investigated the potential use of cell therapies, mainly the use of undifferentiated mesenchymal cells combined with different scaffolds. The understanding of the origin and differentiation patterns of these cells is, therefore, important to elucidate their potential therapeutic use and their comparative efficacy with current technologies. This paper aims to review the in vitro and experimental studies using cell therapies based on application of cementoblasts and mesenchymal stem cells isolated from oral tissues when combined with different scaffolds.

Treatment trends in periodontics.

This volume of Periodontology 2000, entitled "Treatment Trends in Periodontics", evaluates the importance of nonsurgical periodontal therapy and defines its role as the key etiologic treatment of the disease. The need for scaling and root planing is mandatory step during the initial phase of therapy, as is self-care by the patient. Only after reevaluation of the outcome achieved by nonsurgical procedures should surgery be considered, and the concept of "critical probing depth" is emphasized. The chapters in this volume discuss different aspects of periodontal surgery, including regeneration and plastic periodontal procedures, and, looking toward the future, cell therapy in periodontics is explored. The impact of periodontal therapy on systemic diseases is reviewed, and the role of occlusion in periodontal disease is revisited and discussed. Topics on implants include their placement in fresh extraction sockets, socket healing with or without implant placement, and research on osseointegration. The important topic of maintenance care of teeth and implants for long-term therapeutic success is thoroughly evaluated, as is the efficacy of dentifrices in oral hygiene. The editors convey a nutshell review of the concepts of what periodontal treatment should entail, based on scientific evidence generated during half-a-century of work in periodontics.

Periodontal reconstructive surgery of deep intraosseous defects using an apical approach. Non-incised papillae surgical approach (NIPSA): A retrospective cohort study.

BACKGROUND: The objective of this study was to compare a minimally-invasive surgical technique (MIST) and a non-incised papilla surgical approach (NIPSA) in periodontal reconstructive surgery of deep intraosseous defects. METHODS: Data on 30 patients with a deep intraosseous defect treated with MIST (n = 15) or NIPSA (n = 15) were analyzed retrospectively. All patients met the same inclusion criteria and were treated following the same protocol, except for the surgical management of soft tissue (MIST versus NIPSA). Clinical parameters at baseline and at 1-year post-surgery, early healing at 1 week, and postoperative pain were assessed. RESULTS: NIPSA and MIST resulted in significant clinical attachment gain (CAG) (P < 0.001) and probing depth reduction (PDr) (P < 0.001) at 1-year post-surgery. However, NIPSA resulted in significantly lower recession of the tip of the interdental papilla compared with MIST (P < 0.001). Smoking negatively influenced early healing in both techniques (P < 0.05). CONCLUSIONS: NIPSA and MIST both resulted in significant improvements in clinical parameters. NIPSA showed significant soft tissue preservation. NIPSA may represent a promising papillae preservation technique in the treatment of intraosseous periodontal defects.

Prevalence and risk indicators of peri-implant diseases in Spain.

AIM: To evaluate the prevalence of peri-implant diseases in Spain, as well as the associated risk indicators. MATERIAL AND METHODS: This is a cross-sectional study using a network of sentinel dentists, who randomly selected 10 patients with implants (placed, at least, 5 years before), which were clinically and radiographically evaluated. Case definitions were established for peri-implant mucositis [bleeding on probing (BOP) and no bone level ≥2 mm] and peri-implantitis (BOP plus bone level ≥2 mm). Potential predictor variables, at univariate and multivariate levels, were explored by means of binary logistic regression. RESULTS: A total of 49 sentinel dentists provided complete data from 474 implants in 275 patients. At implant level, prevalences for peri-implant mucositis and peri-implantitis were 27% (95% confidence interval [CI] 22-32) and 20% (95% CI: 15-24), respectively, with 17% of implants (14-21) with bone level ≥2 mm without BOP. At patient level, prevalences were 27% (22-32), 24% (19-29) and 18% (13-22), respectively. In the multiple regression analysis, statistically significant associations for peri-implantitis (p < 0.10) were found for gender, peri-implant supportive therapy, implant location, diameter and surface, type of prosthesis and access to interproximal hygiene. CONCLUSIONS: In this representative subject sample across Spain, the prevalence of peri-implant diseases was high (51%).

Nonincised Papillae Surgical Approach (NIPSA) in Periodontal Regeneration: Preliminary Results of a Case Series.

A new surgical approach has been developed to optimize the preservation of the gingival margin and papillae when treating periodontal defects. The flap is raised by one mucosal incision far away from the marginal tissues. This case series reports on the effectiveness of a nonincised surgical approach (NIPSA) in conjunction with a hydroxyapatite-based graft biomaterial and enamel matrix derivative in treating intrabony defects. Ten defects in 10 patients were treated. The follow-up period ranged from 6 to 18 months (mean: 10.8 ± 4.7 months). Probing pocket depth was 9.6 ± 2.3 mm before surgery and 2.3 ± 0.5 mm postsurgery. Clinical attachment level (CAL) decreased from 10.4 ± 2.7 mm to 3.1 ± 0.87 mm postsurgery. The gingival papilla height, keratinized tissue width, and buccal gingival margin remained stable over time. No wound dehiscence was recorded. Mean Early Healing Index was 1.5 ± 0.7. Results show a substantial CAL gain, limited postsurgical shrinkage, minimal morbidity, and early healing.

Coverage of Buccal Tissue Dehiscences on Endosseous Implants: Decision-Making Process and Case Report.

INTRODUCTION: Dehiscences on facial aspects of implants are an esthetic concern and, just as importantly, may make maintaining adequate home-care measures and implant health more difficult, especially when bordered by inadequate and mobile soft tissue margins. CASE PRESENTATION: This report describes a new approach, the laterally rotated flap, and a tunnel subepithelial connective tissue graft, used to correct soft tissue dehiscences and gain keratinized mucosa on endosseous implants. Soft tissues were maintained in a stable condition 3 years after treatment. CONCLUSIONS: Although there are few controlled clinical studies that support any surgical technique for covering dehiscences on implants, some results show a tendency for improvement. The techniques presented in this case report provided promising results.

A Latin American perspective of periodontology.

Periodontal diseases occur worldwide, and Latin American populations are significantly affected by different manifestations of periodontal disease. The interest in periodontics and periodontal therapy first developed in the early 1930s in the southernmost countries of Latin America, and spread, as the years went by, throughout the region. Today, periodontal research is vibrant in Latin America. The aim of this volume of Periodontology 2000 was to present an overview of the periodontal research currently being performed in different countries of Latin America. The epidemiology of periodontal diseases in adults, children and adolescents, and the pathogenesis of such diseases (including microbiological characteristics and risk factors), are discussed. The role of systemic antibiotic therapy and the effect of smoking are discussed in relation to the progression and the treatment of periodontitis. In addition, the benefit of lasers in periodontal therapy is evaluated. Latin American research groups have been active in exploring new venues of regenerative periodontal treatment, addressing the role of cementum proteins, growth factors and oral mesenchymal stem cells in tissue engineering. Finally, basic research to study cancerization is reported.

17beta-estradiol promotes cementoblast proliferation and cementum formation in experimental periodontitis.

BACKGROUND: Periodontitis is a chronic inflammatory condition that leads to the destruction of the tooth-supporting tissues. Its treatment includes the arrest of the inflammatory process and, in some circumstances, the restoration of the lost anatomy and function, including the formation of new cementum, periodontal ligament (PDL), and bone. With this goal, we investigated the effects of low concentrations of 17beta-estradiol on human cementoblast proliferation and its possible regenerative potential in vivo. METHODS: Human cementum-derived cells obtained from a healthy human premolar were isolated and characterized by immunocytochemistry. Cell proliferation assays were performed to test the effects of 100 nM 17beta-estradiol and enamel matrix derivative (EMD). Three-wall intrabony periodontal defects were created in beagle dogs. After 1 month of plaque accumulation, 0.225 mg 17beta-estradiol impregnated in a collagen sponge was applied to randomly selected defects (test group), whereas a collagen sponge impregnated in a culture medium was applied to the control group. After 3 months, specimens were obtained, and tissue regeneration was assessed by histometric analysis. RESULTS: Cells spreading out from human tooth-layer explants were able to form cell colonies, produce a mineral matrix, and express osteocalcin, indicating they were cementoblast-like cells. In contrast, PDL fibroblasts did not express osteocalcin. 17beta-estradiol, but not EMD, increased the rate of human cementoblast cell proliferation in vitro by 2.5-fold. Histometric results from the treated periodontal defects revealed that 17beta-estradiol promoted the formation of 2.94 mm of new cementum, (45% of the defects) compared to 1.54 mm of new cementum in the control group (28% of the defects). Furthermore, the test group showed an inhibition of epithelial downgrowth and a gain of new connective tissue attachment. CONCLUSION: 17beta-estradiol promoted human cementoblast cell proliferation in vitro and periodontal regeneration in an experimental periodontitis model.

Detection of Porphyromonas gingivalis and Streptococcus intermedius in chronic periodontitis patients by multiplex PCR.

A Multiplex PCR assay for the detection of Porphyromonas gingivalis and Streptococcus intermedius in chronic periodontitis is presented. A total of 180 samples from 65 adults with untreated periodontitis and 17 healthy volunteers were taken and processed in a simple boiling step. Cell lysates were used as DNA source for multiplex PCR assays. Primers were designed from 16S rRNA gene sequences from the GenBank-EMBL database showing specificity for target pathogens. This multiplex PCR system could detect 8.2 P gingivalis and S. intermedius cells. In untreated periodontitis patients, only 78.5% were positive for one or both bacteria; 37% were positive for P gingivalis only, 17% for S. intermedius and 24.5% for both. P. gingivalis was detected in 23.5% of healthy volunteers, while S. intermedius was not detected in the same patients. The distribution of these bacteria was related to the periodontal probing depth, while 95.23% of patients with pockets wih 6 to 7 mm deep were positive for either or both, only 70.45% of of them with 4 to 5 mm pockets were positive.

Extracellular matrix expression and periodontal wound-healing dynamics following guided tissue regeneration therapy in canine furcation defects.

AIM: Temporal and spatial expression pattern of extracellular matrix (ECM) components in furcation defects following guided tissue regeneration (GTR) compared with open-flap debridement (OFD). MATERIAL AND METHODS: In 21 dogs, mandibular second and fourth pre-molars were treated with one non-resorbable and three different resorbable membranes. Third pre-molars were treated by OFD. After 2, 4, 8 weeks and 3, 6, and 12 months, tissues were analysed by immunohistochemistry for collagen I (Col-I) and III (Col-III), fibronectin (FN), bone sialoprotein (BSP), and osteopontin (OPN). RESULTS: At 2 weeks, the defect was mainly occupied by FN+ granulation tissue (GT), which was sequentially replaced by new connective tissue expressing FN, Col-I, and increasingly Col-III. Following superficial resorptions by OPN+ osteoclasts and odontoclasts, cementum and bone formation ensued with strong expression of BSP and OPN along bone and tooth surfaces. Deposition of Col-I, FN, BSP and OPN+ cementoid and osteoid became evident after 4 weeks. Extrinsic fibres of cementum and bone stained intensely for Col-III. The newly formed periodontal ligament expressed FN, Col-I, and Col-III, but no BSP or OPN. CONCLUSIONS: The spatial ECM expression was similar for OFD and the different GTR methods, although the timing and quantity of ECM expression were influenced by wound stabilization and inflammatory reactions.

Effect of mechanical and antiseptic therapy on peri-implant mucositis: an experimental study in monkeys.

OBJECTIVES: This experiment was performed to evaluate clinically and histologically the effect of mechanical therapy with or without antiseptic therapy on peri-implant mucositis lesions in nine cynomolgus monkeys. MATERIAL AND METHODS: Two ITI titanium implants were inserted into each side of the mandibles. After 90 days of plaque control and soft tissue healing, a baseline clinical examination was completed. Peri-implant lesions were induced by placing silk ligatures and allowing plaque to accumulate for 6 weeks. The clinical examination was then repeated, and the monkeys were randomly assigned to three treatment groups: group A, mechanical cleansing only; group B, mechanical cleansing and local irrigation with 0.12% chlorhexidine (CHX) and application of 0.2% CHX gel; and group C, control, no treatment. The implants in treatment groups A and B were treated and maintained according to the assigned treatment for two additional months. At the end of the maintenance period, a final clinical examination was performed and the animals were sacrificed for biopsies. RESULTS: The mean probing depths (PD) values at mucositis were: 3.5, 3.7, and 3.4 mm, and clinical attachment level (CAL) = 3.8, 4.1, and 3.9 mm for treatment groups A, B and C, respectively. The corresponding values after treatment were: PD = 1.7, 2.1, and 2.5 mm, and CAL=2.6, 2.6, and 3.1 mm. ANOVA of mean changes (Delta) in PD and CAL after treatment showed no statistical difference between the treatment groups. Comparison of the mean changes in PD and CAL after treatment yielded statistical differences between the control and treatment groups P < 0.01. According to the t-test, no statistical difference was found between treatment groups A and B for the PD reduction but there was a significant difference for the CAL change, P < 0.03. Group A had significantly more recession and less CAL gain than group B. Non-parametric tests yielded no significant differences in modified plaque index (mPlI) and gingival index (GI) after treatment between both treatment groups. Frequencies and percent distributions of the mPlI and GI scores changed considerably for both treatment groups when compared with the changes in the control group after treatment. With regard to the histological evaluation, no statistical differences existed between the treatments for any linear measurement. The proportion of inflammation found in the mucosal tissues of the control implants was greater than the one found for both treatment groups, P < 0.01. More importantly, both treatment groups showed a similar low proportion of inflammation after 2 months of treatment. CONCLUSIONS: Within the limitations of this experiment, and considering the supportive plaque control rendered, it can be concluded that for pockets of 3-4 mm: (1) mechanical therapy alone or combined with CHX results in the clinical resolution of peri-implant mucositis lesions, (2) histologically, both treatments result in minimal inflammation compatible with health, and (3) the mechanical effect alone is sufficient to achieve clinical and histologic resolution of mucositis lesions.

Enamel matrix derivative and coronal flaps to cover marginal tissue recessions.

BACKGROUND: Correcting recession defects is one of the goals of periodontal therapy, and the efficacy and predictability of the various techniques are important considerations for both patients and clinicians. Several reports have examined the outcome of gingival recession treatment by means of coronally positioned flaps (CPF) and enamel matrix derivative (EMD). The purpose of this study was to clinically evaluate the use of EMD in association with CPF to cover localized gingival recessions compared to CPF alone. METHODS: Twenty-two patients with Miller Class I or II gingival recessions >2 mm were included. One recession from each patient was treated in the study. Two treatments were randomly assigned: coronally positioned flap with EMD (test) and coronally positioned flap alone (control). Clinical parameters measured at baseline and 1, 6, and 12 months included gingival index, plaque index, probing depth, clinical attachment level, vertical and horizontal recession, and width of keratinized gingiva. RESULTS: At 12 months, both treatment modalities showed significant root coverage, gain in clinical attachment, and gain in width of keratinized gingiva (P <0.05). Vertical recessions were reduced from 2.68 +/- 1.63 mm to 0.36 +/- 0.60 mm in the test group and from 2.31 +/- 1.52 mm to 0.90 +/- 0.95 mm in the control group. Horizontal recessions decreased from 4.27 +/- 2.06 mm to 0.77 +/- 0.87 mm in the test group and from 3.68 +/- 1.91 mm to 1.72 +/- 1.31 mm in the control group. Changes in keratinized gingiva went from 3.81 +/- 1.95 mm to 4.63 +/- 2.15 mm in the test group and from 3.31 +/- 1.81 mm to 3.27 +/- 1.80 mm in the control group. When both treatments were compared at 12 months, there was a significant difference in vertical tooth coverage and gain in keratinized gingiva in favor of the experimental group (P <0.05). The average percentage of root coverage for test and control groups was 88.6% and 62.2%, respectively. CONCLUSIONS: The coronally positioned flap alone or with EMD is an effective procedure to cover localized gingival recessions. The addition of EMD significantly improves the amount of root coverage.

Localized gingival recessions treated with the original envelope technique: a report of 50 consecutive patients.

BACKGROUND: The surgical techniques used to treat gingival recession have changed considerably in the last 50 years. The envelope technique described nearly 20 years ago still offers an excellent alternative for the problem of recession. The purpose of this retrospective study is to show the results of 115 recession sites treated in 50 patients using the envelope technique. METHODS: One hundred-fifteen consecutive procedures were performed in 50 patients in a private practice in the last 5 years using the envelope technique. Briefly, the teeth are scaled, a split thickness flap is performed around the recession, a subepithelial connective tissue graft is harvested from the palate and placed over the recession, and sutured with 6-0 silk. Four cases representing different types of recession will be reviewed and all cases will be analyzed. RESULTS: In general, this surgical method provided excellent root coverage and an increased amount of keratinized gingiva. The complete root coverage mean was 85%, 65%, and 16% for recession Class I, II, and IV, respectively. CONCLUSION: The cases support the use of the envelope technique to treat different types of single and multiple recessions.

Coronally positioned flap with or without enamel matrix protein derivative for the treatment of gingival recessions.

PURPOSE: To evaluate, histometrically, the healing of gingival recessions treated by coronally positioned flaps associated with enamel matrix protein derivative (EMD-Group) and to compare it to that obtained with coronally positioned flaps alone (CPF-Group). METHODS: Five mongrel dogs were used. Gingival recessions were surgically created on the buccal aspect of the upper cuspids. The defects (5 x 7 mm) were exposed to plaque accumulation for 3 months. After a preparation period, the contralateral defects were randomly assigned to each group. After 3 months of healing, the dogs were sacrificed and the blocks were processed. The histometric parameters evaluated included: gingival recession, length of epithelium, new connective tissue attachment and new bone. RESULTS: The gingival recession was -0.1 +/- 0.2 mm for the EMD-Group and -0.8 +/- 1.3 mm for the CPF-Group (P = 0.17). The extension of the epithelium was 1.2 +/- 1.0 mm for the EMD-Group and 1.3 +/- 0.7 mm for the CPF-Group (P = 0.89). The new connective tissue attachment was 4.8 +/- 0.7 in the EMD-Group and 4.0 +/- 1.4 in the CPF-Group (P = 0.22). The new bone was 0.1 +/- 1.8 mm and -0.5 +/- 1.4 mm in the EMD-Group and CPF-Group, respectively (P = 0.50). Histologically, the defect coverage observed was 98.2% for the EMD-Group and 85.8% for the CPF-Group.

Immediate replacement of single upper posterior teeth: a report of cases.

BACKGROUND: The immediate replacement of upper molar teeth with implants poses a significant challenge to the clinician because of its sinus involvement. PURPOSE: The purpose of this article is to report a protocol in which single molar teeth are replaced immediately with implants, minimizing the need for other surgical procedures. MATERIALS AND METHODS: This protocol has been employed in eight cases. Briefly, the teeth are extracted atraumatically, the sockets evaluated, an osteotomy performed following the direction of the socket, and a wide diameter implant placed using the socket walls and sinus floor to anchor it. A grafting material is placed when the space between implant and socket wall is considerably large. Three cases are reviewed here, and all eight are summarized. RESULTS: All cases have excellent soft and hard tissue healing after 6 months. Furthermore, the overall time needed to restore the cases has been considerably reduced and the need for sinus management eliminated. CONCLUSION: The cases presented support the use of the described protocol in the placement of implants in maxillary molar areas without any other sinus procedures.