Complications and treatment errors in implant positioning in the aesthetic zone: Diagnosis and possible solutions.

Incorrect implant positioning can lead to functional and aesthetic compromise. Implant positioning errors can occur in three dimensions: mesiodistal, corono-apical, and orofacial. Treatment solutions to manage adverse outcomes through positioning errors require an understanding of the underlying conditions and of those factors that may have led to the error being committed in the first place. These types of complications usually occur because of human factors. If errors do occur with adverse aesthetic outcomes, they are difficult and sometimes impossible to correct. Connective tissue grafts to reverse recession defects are only feasible in defined situations. The option to remove and replace the implant may be the only recourse, provided the removal process does not further compromise the site. Error in judgment by the clinician.

Alveolar ridge preservation and early implant placement at maxillary central incisor sites: A prospective case series study.

PURPOSE: To assess whether alveolar ridge preservation (ARP) with 90% deproteinized bovine bone mineral in a 10% collagen matrix (DBBMC) and resorbable type I/III porcine collagen matrix (CM) maintains sufficient bone volume for early implant placement 8-10 weeks after extraction of maxillary central incisors. MATERIALS AND METHODS: In this case series study of 10 consecutively enrolled patients, sockets of maxillary single central incisors requiring extraction and early implant placement were grafted with DBBMC/CM. Ridge dimensions were measured pre-extraction and just prior to implant placement. RESULTS: Alveolar ridge preservation maintained sufficient bone volume for implants to be placed in all sites. Compared to pre-extraction, there was a significant reduction in the orofacial dimensions of the ridge (1.4 ± 1.07 mm; 13.2% reduction) and bone (0.7 ± 0.67 mm; 9.3%) at the coronal midfacial region. A significant reduction in apicocoronal height of the crestal bone at midfacial (1.2 ± 0.78 mm) and palatal aspects was observed. On CBCT, a statistically significant reduction in alveolar ridge area occurred (10.9 ± 13.42 mm2 ; 12.2% reduction). To optimize aesthetic outcomes, 9/10 sites required additional low volume grafting at the coronal region, whereas one site required more extensive grafting due to a facial bone dehiscence. At 1-year, the implant survival rate was 100% and median Pink Esthetic Score (PES) was 10 (range 9-13). CONCLUSIONS: ARP using DBBMC/CM maintains sufficient bone volume for early implant placement 8.9 ± 0.97 weeks later, with a 100% survival rate 1 year after restoration.

Health-Promoting Strategies for the Aging Brain.

As the world's population ages and people live longer, the changes in the aging brain present substantial challenges to our health and society. With greater longevity come age-related diseases, many of which have direct and indirect influences on the health of the brain. Although there is some degree of predictable decline in brain functioning with aging, meaningful cognitive decline is not inevitable and is perhaps preventable. In this review, we present the case that the course of aging-related brain disease and dysfunction can be modified. We present the evidence for conditions and risk factors that may contribute to cognitive decline and dementia and for interventions that may mitigate their impact on cognitive functioning later in life, or even prevent them and their cognitive sequelae from developing. Although much work remains to be done to meet the challenges of the aging brain, strategies to promote its health have been demonstrated and offer much promise, which can only be realized if we mount a vigorous public health effort to implement these strategies.

Memory and Brain Amyloid and Tau Effects of a Bioavailable Form of Curcumin in Non-Demented Adults: A Double-Blind, Placebo-Controlled 18-Month Trial.

OBJECTIVE: Because curcumin's anti-inflammatory properties may protect the brain from neurodegeneration, we studied its effect on memory in non-demented adults and explored its impact on brain amyloid and tau accumulation using 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile positron emission tomography (FDDNP-PET). METHODS: Forty subjects (age 51-84 years) were randomized to a bioavailable form of curcumin (Theracurmin® containing 90 mg of curcumin twice daily [N = 21]) or placebo (N = 19) for 18 months. Primary outcomes were verbal (Buschke Selective Reminding Test [SRT]) and visual (Brief Visual Memory Test-Revised [BVMT-R]) memory, and attention (Trail Making A) was a secondary outcome. FDDNP-PET signals (15 curcumin, 15 placebo) were determined in amygdala, hypothalamus, medial and lateral temporal, posterior cingulate, parietal, frontal, and motor (reference) regions. Mixed effects general linear models controlling for age and education, and effect sizes (ES; Cohen's d) were estimated. RESULTS: SRT Consistent Long-Term Retrieval improved with curcumin (ES = 0.63, p = 0.002) but not with placebo (ES = 0.06, p = 0.8; between-group: ES = 0.68, p = 0.05). Curcumin also improved SRT Total (ES = 0.53, p = 0.002), visual memory (BVMT-R Recall: ES = 0.50, p = 0.01; BVMT-R Delay: ES = 0.51, p = 0.006), and attention (ES = 0.96, p < 0.0001) compared with placebo (ES = 0.28, p = 0.1; between-group: ES = 0.67, p = 0.04). FDDNP binding decreased significantly in the amygdala with curcumin (ES = -0.41, p = 0.04) compared with placebo (ES = 0.08, p = 0.6; between-group: ES = 0.48, p = 0.07). In the hypothalamus, FDDNP binding did not change with curcumin (ES = -0.30, p = 0.2), but increased with placebo (ES = 0.26, p = 0.05; between-group: ES = 0.55, p = 0.02). CONCLUSIONS: Daily oral Theracurmin may lead to improved memory and attention in non-demented adults. The FDDNP-PET findings suggest that symptom benefits are associated with decreases in amyloid and tau accumulation in brain regions modulating mood and memory.

Proceedings of the 6th ITI Consensus Conference.

The 6th ITI Consensus Conference was held in Amsterdam on 17-19 April 2018. In preparation for the conference, 21 systematic reviews were written. They were divided into five main topics in dental implantology-surgery, prosthodontics, patient-reported outcomes, complications/risk and digital technologies. Based on these review papers, the working groups prepared consensus statements, clinical guidelines and recommendations for future research.

The relationship between facial bone wall defects and dimensional alterations of the ridge following flapless tooth extraction in the anterior maxilla.

PURPOSE: To evaluate the relationship between defects of the facial socket wall at extraction and dimensional changes 8 weeks later in maxillary central and lateral incisor sockets. MATERIALS AND METHODS: A total of 34 consecutive patients requiring single tooth implants in the anterior maxilla (27 central and 7 lateral incisors) were evaluated. Orofacial external ridge, bone dimensions and the location of the socket bone crest were measured at extraction and again 8.5 ± 2.91 weeks later. The status of the facial bone wall was recorded at the same time points. RESULTS: At extraction, 16 of 34 sites (47%) had intact facial bone. There were fenestration defects at 9 of 34 sites (26.5%) and dehiscence defects at 9 of 34 sites (26.5%). A significant reduction (P < 0.001) in the external orofacial ridge dimension occurred (mesial 1.4 ± 1.30 mm or 12.1%, facial 2.5 ± 1.46 mm or 22.2%, distal 1.1 ± 0.83 mm or 10.5%), with greatest change at dehiscence (3.3 ± 1.80 mm or 28.4%) and fenestration sites (2.8 ± 1.40 mm or 24.9%). A significant reduction in orofacial bone dimension occurred (mesial 0.8 ± 0.80 mm or 9.3%, P < 0.001; facial 1.2 ± 1.03 mm or 18.3%, P < 0.001; distal 0.4 ± 0.65 mm or 5.5%, P < 0.01). Vertical resorption of the bone crest was most marked at the mid-facial aspect (1.4 ± 1.94 mm, P < 0.001). Initial fenestration defect sites demonstrated the greatest vertical dimensional change (2.9 ± 2.67 mm; P = 0.008). Of 16 sites with initially intact facial bone, 9 sites (56.3%) developed dehiscence defects after 8 weeks. Of the 9 initial sites with fenestration defects, 5 (55.6%) turned into dehiscence defects. All 9 sites with initial dehiscence defects healed with persistence of the dehiscence. CONCLUSIONS: Eight weeks after flapless extraction of maxillary central and lateral incisors, a reduction in the orofacial dimensions of the ridge was observed due to resorption of the facial bone of the socket. Tooth type (maxillary central incisor) and thin tissue phenotype significantly influenced the outcomes. The dimensional alterations were most pronounced at sites that initially had fenestration and dehiscence defects of the facial bone.

Psychological well-being and regional brain amyloid and tau in mild cognitive impairment.

OBJECTIVES: To determine whether psychological well-being in people with mild cognitive impairment (MCI), a risk state for Alzheimer disease (AD), is associated with in vivo measures of brain pathology. METHODS: Cross-sectional clinical assessments and positron emission tomography (PET) scans after intravenous injections of 2-(1-{6-[(2-[F18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile (FDDNP), a molecule that binds to plaques and tangles, were performed on middle-aged and older adults at a university research institute. Volunteers were aged 40-85 years with MCI (N = 35) or normal cognition (N = 29) without depression or anxiety. Statistical analyses included general linear models, using regional FDDNP-PET binding values as dependent variables and the Vigor-Activity subscale of the Profile of Mood States (POMS) as the independent variable, covarying for age. The POMS is a self-rated inventory of 65 adjectives that describe positive and negative feelings. RESULTS: Scores on the POMS Vigor-Activity subscale were inversely associated with degree of FDDNP binding in the posterior cingulate cortex (r = -0.35, p = 0.04) in the MCI group but not in the control group. CONCLUSION: Psychological well-being, as indicated by self-reports of greater vigor and activity, is associated with lower FDDNP-PET binding in the posterior cingulate cortex, a region involved in emotional regulation, in individuals with MCI but not in those with normal cognition. These findings are consistent with previous work indicating that deposition of brain amyloid plaques and tau tangles may result in noncognitive and cognitive symptoms in persons at risk for AD.

Healthy behavior and memory self-reports in young, middle-aged, and older adults.

BACKGROUND: Previous research has shown that healthy behaviors, such as regular physical exercise, a nutritious diet, and not smoking, are associated with a lower risk for Alzheimer's disease and dementia. However, less is known about the potential link between healthy behaviors and mild memory symptoms that may precede dementia in different age groups. METHODS: A daily telephone survey (Gallup-Healthways Well-Being Index) of US residents yielded a random sample of 18,552 respondents ranging in age from 18 to 99 years, including 4,423 younger (age 18-39 years), 6,356 middle-aged (40-59 years), and 7,773 older (60-99 years) adults. The questionnaire included demographic information and the Healthy Behavior Index (questions on smoking, eating habits, and frequency of exercise). General linear models and logistic regressions were used in the analysis. RESULTS: Older adults were more likely to report healthy behaviors than were middle-aged and younger adults. Reports of memory problems increased with age (14% of younger, 22% of middle-aged, and 26% of older adults) and were inversely related to the Healthy Behavior Index. Reports of healthy eating were associated with better memory self-reports regardless of age, while not smoking was associated with better memory reports in the younger and middle-aged and reported regular exercise with better memory in the middle-aged and older groups. CONCLUSIONS: These findings indicate a relationship between reports of healthy behaviors and better self-perceived memory abilities throughout adult life, suggesting that lifestyle behavior habits may protect brain health and possibly delay the onset of memory symptoms as people age.

Maxillary sinus floor elevation and grafting with deproteinized bovine bone mineral: a clinical and histomorphometric study.

OBJECTIVES: This study evaluated the histomorphometric and clinical outcomes of maxillary sinus floor elevation using deproteinized bovine bone mineral (DBBM). MATERIAL AND METHODS: Maxillary sinuses with a residual vertical height of <5 mm were augmented with DBBM alone before implant placement 9 months later. At the time of implant surgery, trephine samples were removed and histological and histomorphometric analyses were performed to examine the percentage of bone and residual graft using point counting and software-aided analysis. Patients were recalled for clinical and radiographic examination up to 3 years later. RESULTS: Twenty-five patient specimens were analysed. The percentages of regenerated bone and residual graft material were 19% and 40%, respectively. Software-aided analysis was comparable to point counting. Twelve patients attended for clinical follow-up. Implants placed into this regenerated bone exhibited success and survival rates of 100% after an average follow-up of 3 years. The average vertical height gained was 7.9 mm. CONCLUSIONS: The use of DBBM alone in maxillary sinus floor elevation is a predictable method to gain vertical bone height in the posterior maxilla.

Remifentanil: a review of its use in electroconvulsive therapy.

OBJECTIVE: The primary objectives were to review studies that used remifentanil in electroconvulsive therapy (ECT) and to determine whether remifentanil has potential advantages over other anesthetics. MATERIALS AND METHODS: The author reviewed 12 original studies obtained through a MEDLINE database search that examined remifentanil as an anesthetic in patients receiving ECT. RESULTS: Remifentanil was associated with longer seizure durations when used as the sole anesthetic or as an adjunct when the primary anesthetic dose was lowered. Individual studies reported higher postictal suppression index and lower initial seizure thresholds and less rise in seizure thresholds with remifentanil. Data on hemodynamic effects were mixed but suggested favorable effects with remifentanil when seizure duration was not prolonged. CONCLUSIONS: Studies support the use of remifentanil in ECT, particularly in patients with brief seizures, high seizure thresholds, and postictal hemodynamic instability. Broad variability in study design, selection and dosing of anesthetics, electrode placement, and limited examination of potentially relevant variables such as age, sex, concomitant medications; and stimulus parameters attenuate the certainty of these results. Advantages in safety and efficacy over other anesthetics remain undetermined. Further study of remifentanil in ECT is warranted, given the methodological limitations and exclusion of important outcomes in the current literature.

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.

Treatment of a patient with dementia and inappropriate sexual behaviors with citalopram.

Inappropriate sexual behaviors (ISBs) associated with dementias and their treatment have not been commonly reported in the medical literature. This report presents an elderly male patient with moderately severe dementia and incident onset of ISBs who was treated with citalopram (20-mg daily) and subsequently displayed a reduction in ISBs. A review of the literature suggests that ISBs may be underrecognized and undertreated, and therefore should be actively monitored and treated.

Transmucosal healing around peri-implant defects: crestal and subcrestal implant placement in dogs.

OBJECTIVE: This study was designed to evaluate the transmucosal healing response of implants placed with the junction of the smooth surfaces, either crestal or subcrestal, into simulated extraction defects after healing periods of 1 and 3 months. MATERIALS AND METHODS: A total of 23 Straumann SP v3.3 mm NN, SLA 10 mm implants were placed in the mandibular premolar regions of three greyhound dogs 3 months after the teeth were removed. Five control implants were placed at the crestal bone level, and test implants with surgically created peri-implant defects of 1.25 mm wide x 5 mm depth were placed either at the crestal (nine implants) or at the 2 mm subcrestal (nine implants) bone level. Implants on the right side were placed 1 month before the dogs were sacrificed, and implants on the left side were placed 3 months before sacrifice. All dogs had daily plaque control following surgery and were sacrificed 3 months after implant placement for histological and histometric analyses. RESULTS: Mesial-distal ground sections of the control and test implant specimens showed a greater %BIC in the coronal defect region after 3 months of healing. This healing response was incomplete for the test implants compared with the control implants after a 1-month healing period. The histometric measurements for test implants placed at the crestal bone level or 2 mm subcrestal with surgically created peri-implant defects were more coronal or closer to the implant margin compared with the control implants. Additionally, the degree of osseointegration between the newly formed bone and the implant surface was similar between the test implants. CONCLUSION: Peri-implant defects of 1.25 mm width healed with spontaneous bone regeneration around implants placed transmucosally at crestal or 2 mm subcrestal with a high degree of osseointegration after a 3-month healing period.

Immediate implant placement postextraction without flap elevation.

BACKGROUND: The aim of this retrospective study was to assess soft tissue and esthetic outcomes at single-tooth immediate implants placed without flap elevation in maxillary central and lateral incisor sites. METHODS: Photographic records of 85 consecutive patients with immediate single-tooth implants in maxillary central and lateral incisors that were placed without elevation of surgical flaps were selected. The change in mucosal level was expressed as a percentage of the length of the reference central incisor. RESULTS: Significant recession of the mesial papilla (-6.2% +/- 6.8%), distal papilla (-7.4% +/- 7.5%), and facial mucosa (-4.6% +/- 6.6%) between surgical placement and 1 year was observed (P <0.001). Recession was greater for implants placed facially within the extraction socket compared to those placed lingually (P = 0.009). Sites with gingival margins initially coronal achieved mucosal levels close to the line of symmetry with the contralateral tooth. Sites initially level or apical failed to reach the line of symmetry and remained receded. For sites with initially level gingival margins, recession >10% occurred at six of 25 thin biotype sites compared to two of 19 thick biotype sites. Acceptable outcomes were achieved in the majority of sites; between 10% and 20% of sites had suboptimal esthetic results. CONCLUSIONS: Immediate implant placement without elevation of surgical flaps is associated with recession of the marginal mucosa that may fall within the threshold of visually detectable change. The orofacial position of the implant shoulder and the tissue biotype are important contributory factors.

Clinical and esthetic outcomes of implants placed in postextraction sites.

PURPOSE: The aim of this review was to evaluate the clinical outcomes for the different time points of implant placement following tooth extraction. MATERIALS AND METHODS: A PubMed search and a hand search of selected journals were performed to identify clinical studies published in English that reported on outcomes of implants in postextraction sites. Only studies that included 10 or more patients were accepted. For implant success/survival outcomes, only studies with a mean follow-up period of at least 12 months from the time of implant placement were included. The following outcomes were identified: (1) change in peri-implant defect dimension, (2) implant survival and success, and (3) esthetic outcomes. RESULTS AND CONCLUSIONS: Of 1,107 abstracts and 170 full-text articles considered, 91 studies met the inclusion criteria for this review. Bone augmentation procedures are effective in promoting bone fill and defect resolution at implants in postextraction sites, and are more successful with immediate (type 1) and early placement (type 2 and type 3) than with late placement (type 4). The majority of studies reported survival rates of over 95%. Similar survival rates were observed for immediate (type 1) and early (type 2) placement. Recession of the facial mucosal margin is common with immediate (type 1) placement. Risk indicators included a thin tissue biotype, a facial malposition of the implant, and a thin or damaged facial bone wall. Early implant placement (type 2 and type 3) is associated with a lower frequency of mucosal recession compared to immediate placement (type 1).

Ridge preservation techniques for implant therapy.

PURPOSE: The aim of this review was to evaluate the techniques and outcomes of postextraction ridge preservation and the efficacy of these procedures in relation to subsequent implant placement. MATERIALS AND METHODS: A MEDLINE/PubMed search was conducted and the bibliographies of reviews from 1999 to March 2008 were assessed for appropriate studies. Randomized clinical trials, controlled clinical trials, and prospective/retrospective studies with a minimum of five patients were included. RESULTS: A total of 135 abstracts were identified, from which 53 full-text articles were further examined, leading to 37 human studies that fulfilled the search criteria. Many different techniques, methodologies, durations, and materials were presented in the publications reviewed, making direct comparison difficult. CONCLUSIONS: Despite the heterogeneity of the studies, it was concluded that ridge preservation procedures are effective in limiting horizontal and vertical ridge alterations in postextraction sites. There is no evidence to support the superiority of one technique over another. There is also no conclusive evidence that ridge preservation procedures improve the ability to place implants.

Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures.

Early implant placement is one treatment option for implant therapy following single-tooth extraction in the anterior maxilla. The surgical technique presented here is characterized by tooth extraction without flap elevation, a 4- to 8-week soft tissue healing period, implant placement in a correct three-dimensional position, simultaneous contour augmentation on the facial aspect with guided bone regeneration using a bioabsorbable collagen membrane combined with autogenous bone chips and a low-substitution bone filler, and tension-free primary wound closure. The surgical step-by-step procedure is presented with a case report. In addition, the biologic rationale is discussed.

FDDNP-PET Tau Brain Protein Binding Patterns in Military Personnel with Suspected Chronic Traumatic Encephalopathy1.

BACKGROUND: Our group has shown that in vivo tau brain binding patterns from FDDNP-PET scans in retired professional football players with suspected chronic traumatic encephalopathy differ from those of tau and amyloid aggregate binding observed in Alzheimer's disease (AD) patients and cognitively-intact controls. OBJECTIVE: To compare these findings with those from military personnel with histories of mild traumatic brain injury(mTBI). METHODS: FDDNP-PET brain scans were compared among 7 military personnel and 15 retired players with mTBI histories and cognitive and/or mood symptoms, 24 AD patients, and 28 cognitively-intact controls. Nonparametric ANCOVAs with Tukey-Kramer adjusted post-hoc comparisons were used to test for significant differences in regional FDDNP binding among subject groups. RESULTS: FDDNP brain binding was higher in military personnel compared to controls in the amygdala, midbrain, thalamus, pons, frontal and anterior and posterior cingulate regions (p < 0.01-0.0001). Binding patterns in the military personnel were similar to those of the players except for the amygdala and striatum (binding higher in players; p = 0.02-0.003). Compared with the AD group, the military personnel showed higher binding in the midbrain (p = 0.0008) and pons (p = 0.002) and lower binding in the medial temporal, lateral temporal, and parietal regions (all p = 0.02). CONCLUSION: This first study of in vivo tau and amyloid brain signals in military personnel with histories of mTBI shows binding patterns similar to those of retired football players and distinct from the binding patterns in AD and normal aging, suggesting the potential value of FDDNP-PET for early detection and treatment monitoring in varied at-risk populations.