Clinical Efficacy of Tooth-Bone Graft: A Systematic Review and Risk of Bias Analysis of Randomized Control Trials and Observational Studies.

PURPOSE: The objective of this systematic review was to assess the clinical efficacy of the tooth-bone graft as a bone substitute in the oral and maxillofacial region in humans as compared to ungrafted sites and other bone substitutes. MATERIALS AND METHODS: Databases were electronically and manually searched up to January 2017 to identify animal and human studies and a risk of bias analysis and descriptive statistics was performed. RESULTS: Eighteen animal controlled trials (401 animals), 4 human randomized controlled trials, 1 cohort study, and 3 controlled trials (184 patients) were included. Graft processing was highly heterogeneous. 71.42% clinical and 55.56% animal studies reported no significant difference between tooth-bone graft and controls. Histologically, a dentin-bone complex was reported. A low risk of bias was noted in only 50% of the randomized controlled trials and 63.33% animal study entries. An independent analysis of 6 high-quality case reports (350 patients) revealed complications in 18.86% cases. CONCLUSION: Tooth-bone graft demonstrated no added benefits over conventional graft materials. Absence of standardized processing and heterogeneous study results limit its use in clinical practice. Until long-term studies determine its success, clinicians are recommended to use it with caution because of high variability in resorption time (2-24 weeks) and a risk of graft dehiscence (12.96%-34.38%).

Comparison of clinical periodontal status among habitual smokeless-tobacco users and cigarette smokers.

AIM: Investigating the comparative effect of cigarette smoking and smokeless-tobacco use on periodontal health. BACKGROUND: There is a dearth of studies comparing the effects of smoking and smokeless tobacco on periodontal health. Smokeless tobacco is emerging as a major public health hazard, but is often neglected as a risk factor by many clinicians. MATERIALS AND METHODS: A cross-sectional study of 286 subjects was conducted. The participants were divided into mutually exclusive groups (i.e. any subject who had the habit of both smoking as well as smokeless tobacco usage was excluded from the study), as follows: a smoking group (SG; n=121); a smokeless-tobacco group (ST; n=81); and a non-tobacco-consuming group (NT; n=84). Data were obtained using a questionnaire and by clinical examination. The Periodontal Disease Index (PDI) and Oral Hygiene Index-Simplified (OHI-S) were used to clinically evaluate the periodontal and dental health status of the subjects. Multivariate analysis was performed to identify statistical correlations. RESULTS: The Plaque Index was higher in the ST group than in the SG group and was statistically significantly higher in the ST group than in the NT group. Probing depth and gingival inflammation (components of the PDI) were also higher in the ST group than in the SG and NT groups, but this was not statistically significant. CONCLUSIONS: Within the limits of the study, and for this study population, the impact on the periodontium as a result of smokeless tobacco use appeared to be comparable with that of smoking tobacco. The results of this study affirm the need to consider smokeless tobacco as a possible contributory factor to periodontal disease, in addition to smoking, and to counsel patients accordingly. Further randomised clinical trials are necessary to validate the long-term impact of smokeless tobacco on periodontal disease.

The effect of nutrition on periodontal disease: a systematic review.

The link between nutrients and periodontal disease has not been clearly established. A PubMed and Cochrane database literature search was conducted. The published research reveals only a possible relationship between vitamins and minerals and periodontal disease. Vitamin E, zinc, lycopene and vitamin B complex may have useful adjunct benefits. However, there is inadequate evidence to link the nutritional status of the host to periodontal inflammation. More randomized controlled trials are needed to explore this association.

Cone Beam Computed Tomography Analysis of Posterior-Superior Alveolar Canal from a Fixed Reference Point: Implications for Sinus Floor Elevation Procedure through Lateral Approach.

Objective: Sinus floor elevation is commonly done in the maxillary posterior region prior to dental implant placement. This study primarily aimed at assessing the location of the posterior superior alveolar artery (PSAA) canal on cone beam computed tomography (CBCT) scans and its relation to the alveolar ridge and maxillary sinus from a fixed reference point. Material and Methods: A total of 226 edentulous maxillary molar sites were included in this retrospective analysis. The distance from the PSAA to the sinus floor (SF), alveolar crest (AC) and a fixed reference point, that is, the roof of sinus (RS) were measured. The alveolar bone height (ABH), thickness of the crestal keratinized mucosa (CKM) and thickness of Schneiderian membrane (SM) were also evaluated. Results: 54 sites (23.89%) were excluded from the study. The SF, AC, RS and ABH values averaged at 11.91 mm ± 3.63 mm, 16.05 mm ± 3.96 mm, 25.32 mm ± 7.13 mm and 4.93 mm ± 4.27 mm respectively. SF and AC was higher in second molar than first molar region (p < 0.001), but RS did not show significant difference (p = 0.85). CKM and SM averaged at 2.02 mm ± 0.68 mm and 1.31 mm ± 0.81 mm respectively. Conclusion: The PSAA can be visualized in CBCT scans with a prevalence of 76.11% and may not be detected when adherent to the sinus membrane. This study stresses on the need for a CBCT, prior to sinus surgeries through lateral approach, to assess the PSAA.

Squamous cell carcinoma in association with dental implants: an assessment of previously hypothesized carcinogenic mechanisms and a case report.

Although dental implants have seen tremendous clinical success over the past few decades, there are some worrying reports in literature describing squamous cell carcinoma (SCC) in close association with dental implants. This article also provides a critical assessment of the published literature relating to the presence of carcinoma in association with dental implants, analyzing the previously published and hypothesized carcinogenic responses to an implant, to try and come to a conclusion regarding the plausibility and clinical risk for cancer formation in association with dental implants. An unusual case of an SCC noted in close proximity to a dental implant is also presented. A systematic search was conducted using Medline (PubMed), Cochrane Database, and Google Scholar with the search terms "cancer," "squamous cell carcinoma," "dental implant," "SCC," "peri-implantitis," "oral cancer," and "implantology" and using multiple combinations using Boolean operators "or" and "and." The search was not limited to dental literature; orthopedic and biomedical literature was also included. The results were then hand screened to pick out the relevant articles. In total, 14 previous published reports were found, where 24 dental implants were reported to be associated with SCC. Not all the reported patients had a history of cancer, but contributory factors such as smoking were found. An analysis of the biological plausibility of previously proposed carcinogenic mechanisms, such as corrosion, metallic ion release, and particulate debris, did not support the etiologic role for dental implants in cancer development, and the standardized incidence ratio was found to be extremely low (0.00017). Peri-implantitis should be assessed cautiously in patients receiving implants who have a previous history of cancer. Dental implants are a safe treatment modality based on the published data, and any change in surgical protocol is not mandated.

A Clinical Guide for Treatment of Dental Cervical Lesions Through a Restorative, Surgical, or Combination Approach: A Proposed Evidence-Based Algorithm.

The incidence of dental cervical carious and noncarious lesions is common, and often these are treated with a restorative material without due attention paid to the amount of exposed cementum/enamel, level of interproximal bone, and final desired esthetic result. This article is intended to provide clinicians an evidence-based clinical decision tree for treating such lesions through a restorative, surgical, or combination approach such that the optimum functional and cosmetic result is achieved.

Long-term evaluation (7 years) of coronally advanced flap with (CAF) and without (e-CAF) vertical release incisions using a subepithelial connective tissue graft in the treatment of multiple recession-type defects.

OBJECTIVES: The objective of this retrospective study was to compare the 7-year outcomes of coronally advanced flap with vertical incisions (CAF) and the envelope type of flap (e-CAF), using a subepithelial connective tissue graft (SCTG) in the treatment of multiple recession defects. METHOD AND MATERIALS: Twenty-two patients (13 CAF and 9 e-CAF) with at least two adjacent recession defects in the esthetic zone contributed to a total of 50 sites (29 CAF and 21 e-CAF). Complete root coverage (CRC), mean root coverage (MRC), and keratinized tissue (KT) width were recorded over the course of the study. RESULTS: In the short term (8 months), CRC, MRC, and KT outcomes were similar between the groups (P > .05). However, at the 3-year follow-up, the e-CAF group displayed significantly higher KT, MRC (100%), and CRC (100% at both tooth- and patient-levels) than the CAF group (MRC 91.43%; CRC 79.31% at tooth-level and 69.23% at patient-level). Similarly, at the 7-year follow-up, statistically significantly superior KT, MRC (94.24%), and CRC (87.71% at tooth-level and 77.78% at patient-level) values were recorded for the e-CAF group compared to the CAF group (MRC 68.98%; CRC 31.03% at tooth-level and 15.38% at patient-level). CONCLUSIONS: Despite similar treatment outcomes recorded by both surgical procedures in the short term, sites treated with e-CAF showed better stability of the gingival margin and superior KT width in the medium (3 years) and long term (7 years).

Holding up the oral health safety net: the role of National Health Service Corps alumni dentists in North Carolina.

BACKGROUND: Access to oral health care among low income populations is a growing problem. The National Health Service Corps (NHSC) might increase the supply of dentists motivated to provide services for this population. OBJECTIVE: To determine if North Carolina dentists who began a service obligation with the NHSC in 1990-1999 continued to provide care for underserved populations and if they differ from non-NHSC alumni primary care dentists who started practice in the state during that same period. METHODS: All 19 NHSC alumni and 50 comparison dentists were surveyed by mail. NHSC alumni also responded to selected items in a telephone follow-up interview. The two groups were compared using difference of means tests and multivariate contingency tables. RESULTS: National Health Service Corps alumni were more likely to be African-American (38%vs. 10%), work in safety net practices (84%vs. 23%), and see more publicly insured patients (60%vs. 19%) than comparison dentists. Yet their job satisfaction was comparable to non-NHSC alumni dentists. Analyses suggested that current practice in safety net settings is affected by dentists' race, altruistic motivations and previous NHSC participation. CONCLUSION AND POLICY IMPLICATION: Targeted recruitment of African-American dentists and others wanting to work in underserved communities could amplify the effectiveness of the financial incentive of NHSC loan repayment and induce dentists to remain in 'safety net' settings.

The Graft Infusion Technique (GIT) for Treatment of Peri-Implantitis Defects: Case Series.

Peri-implantitis is a site-specific infectious disease that causes an inflammatory process in soft tissues, and bone loss around an osseointegrated implant in function. Several techniques with non-surgical or surgical debridement and decontamination followed by ongoing supportive therapy or regeneration of the peri-implant bone defects have been proposed in the literature. However, the literature is still unclear on an effective protocol for implant surface decontamination or the appropriate choice of regenerative materials. This case series describes a surgical technique to treat peri-implantitis osseous defects using a mixture of deproteinized bovine bone mineral with 10% porcine collagen (DBBM-C) in a block form, soaked in an appropriate antibiotic. The use of this combination provides advantages such as good graft adaptability along with localized antibiotic release without the use of systemic antibiotics. Thus, this technique might be an effective method to treat amenable peri-implantitis defects. Additionally, the proposed algorithm also allows for customized culture based antibiotic loading. To the best of the authors' knowledge, this is the first case series documenting this technique for peri-implantitis defects. Long-term studies with controlled samples would be necessary for further evaluation.

Evaluating Mouse Fibroblast Interaction with Implant Surfaces in a 3D Microenvironment.

PURPOSE: Previous studies assessing fibroblast interactions with implants have mainly relied on measurements such as cell migration, gene expression, and cell adhesion. For these studies, testing cellular behavior at the implant surface was done by imaging the cell-implant interface using standard microscopy techniques in 2D tissue culture dishes. The true behavior of cells relative to the implant can best be assessed in a more physiologic 3D microenvironment. MATERIALS AND METHODS: The embedding of the implant disks in 3D collagen gels was standardized with labeled fibroblasts to allow the imaging of fibroblast morphology and behavior when proximal to or binding to the implant disks. This allowed comparison of the behavior of laser-microgrooved and machined implant disk surfaces quantitatively in an in vitro 3D microenvironment. RESULTS: This in vitro imaging assay revealed for the first time in a 3D microenvironment setting the statistically significant impact laser-microgrooved disk surfaces have on both cell adherence and recruitment of cells in proximity to the disk. It also allowed visualization of membrane protrusivity and cytoskeletal organization in cells adherent to the implant disk. CONCLUSION: This assay provides a simple and effective way of observing cell behavior on and around the implant disk surface in a more physiologic 3D setting. Within the limits of this study, it revealed that the laser-microgrooved implant surface demonstrates significant superiority in fibroblast recruitment and binding in a 3D microenvironment.

Quantitative Assessment of the Edentulous Posterior Maxilla for Implant Therapy: A Retrospective Cone Beam Computed Tomographic Study.

AIM: Dimensional changes of the alveolar bone are often noted in horizontal and vertical planes as a sequel to tooth extraction, particularly in the maxillary posterior region due to alveolar bone resorption combined with pneumatization of the sinus. The aim of this retrospective study was to quantitatively assess the maxillary residual alveolar ridge using cone beam computed tomography (CBCT) scans. MATERIALS AND METHODS: A total of 349 edentulous sites from 250 CBCTs were evaluated. The apico-coronal bone height and bucco-palatal crest width were measured in sagittal and coronal slices, respectively. Additionally, the obliqueness of the sinus floor at the edentulous sites was also evaluated. RESULTS: One hundred and twelve (55.45%) of the molar and 74 (54.42%) of the premolar sites had a horizontal ridge dimension < 6 mm, whereas 137 (67.83%) of the molar and 61 (44.86%) of the premolar sites showed an apico-coronal height < 8 mm. Furthermore, 183 (54.14%) of the evaluated sites had an oblique sinus floor morphology. CONCLUSION: Additional augmentative procedures are thus required in a high percentage of the population at the edentulous maxillary posterior site for rehabilitation using a standard dimension implant. This study stresses on the need for a three-dimensional CBCT prior to implant surgery for proper treatment planning.

Osseodensification -- A systematic review and qualitative analysis of published literature.

The recently introduced technique of osseodensification for dental implant involves the use of special drills (Densah) run in a counter-clockwise direction at the osteotomy site. It is claimed that this causes expansion of the osteotomy site, and increases density of the bone in immediate vicinity of the osteotomy. We reviewed published papers on the primary stability attained using this drilling technique. As a secondary finding, the bone to implant contact (BIC) and the bone area fraction occupancy (BAF) was also compared between the conventional drilling protocol and the osseodensification protocol, among these articles. A Systematic search was performed in PubMed-Medline, Embase and Google Scholar for clinical/animal studies up to November 2018. A total of 12 articles, from a database of 132 articles, consisting of 8 animal histologic studies, 2 human based clinical studies, 1 case series and 1 case report were assessed. 10/12 articles measured the insertion torque values, 7/12 articles measured the BIC and 6/12 articles estimated the BAF between the two techniques. Quality assessment of 8 studies performed using ARRIVE guidelines showed that 6/8 studies had a high score. An average increase in the insertion torque, BIC and BAF was noted in the osseodensification group as compared to the conventional drilling group. Since most of these studies are non-clinical, it can be inferred that osseodensification is an efficient way to enhance primary stability of implants in low density bone in an animal model. However, extrapolation to long term clinical success cannot be ascertained until further evidence becomes available.

Three-Dimensional Alveolar Bone Assessment of Mandibular First Molars with Implications for Immediate Implant Placement.

The aim of this retrospective study was to evaluate the alveolar dimensions of the mandibular molar using cone beam computed tomography (CBCT) for immediate implant placement. The width of buccal (WB) and lingual (WL) bone; width of interradicular bone 2 and 4 mm apical to the furcation and at the apex (IRB2, IRB4, and IRBA, respectively); and distance to the inferior alveolar nerve from the furcation (IAN-F) and mesial (IAN-M) and distal (IAN-D) roots were evaluated from CBCT records of 126 subjects (200 mandibular first molars). Mean WB (0.84 ± 0.39 mm) and WL (2.71 ± 1.17 mm) measurements showed significant differences (P = .003). Differences between IAN-F, IAN-M, and IAN-D measurements averaged at 14.14 ± 2.57 mm, 4.31 ± 1.06 mm, and 4.61 ± 1.02 mm, respectively. IRB2, IRB4, and IRBA dimensions were 1.93 ± 0.65 mm, 2.54 ± 0.9 mm, and 4.46 ± 1.91 mm, respectively. The findings of the study demonstrate the alveolar bone morphology of the mandibular first molar and the need for CBCT scans for proper treatment planning for immediate implant placement.

In Vitro Surface Testing Methods for Dental Implants-Interpretation and Clinical Relevance: A Review.

More than 2,000 dental implant options are estimated to be available for any given clinical situation. Because many implants have claims that are substantiated mainly on the basis of in vitro studies, it is prudent for clinicians to understand the interpretation of such studies and possible clinical relevance. In vitro tests can be segregated as surface analysis tests and mechanical assessment tests. With a wide variation of methodologies used and results achieved by different implant manufacturers, practitioners may find it difficult to judge the clinical significance of in vitro tests. This article provides an overview, including limitations, of the in vitro implant analysis tests implant companies routinely perform, ranging from older methods involving mechanical testing and surface microscopy to more recent tests such as atomic force microscopy (AFM) studies and gene expression tests, to assist clinicians when choosing an implant system. Having identified the limitations of in vitro testing methods, the current evidence indicates that scanning electron microscopy may be useful in providing insight on the role of implant surface topography. AFM, single cell tests, 3D imaging, and gene expression tests could be useful for assessment of cellular and physio-biochemical properties. 3D finite element analysis may help in the evaluation of mechanical properties of dental implants. Clinicians are encouraged to correlate the findings of in vitro tests with robust animal histologic studies and well-designed, high-quality clinical research to ascertain optimum clinical results.

New directions in host modulation for the management of periodontal disease.

BACKGROUND: New strategies for periodontal disease management have been emerging as more is learned about the role of the host response. Our increasing understanding of inflammation and its resolution has opened the door to the study of new periodontal treatment strategies. This commentary examines periodontal disease in light of a new understanding of the role of inflammation in disease expression, thus setting the stage for the development of new prevention and treatment strategies of a widespread disease. METHODS: We examined current publications and focused on articles relating to anti-inflammatory and pro-resolution mechanisms in periodontal disease. RESULTS: Recent research has examined the inflammatory and resolution cascade in greater detail while looking at endogenous and exogenous mediators that can be utilized to achieve therapeutic end-points. The possible introduction of "resolution indices" for drug testing warrants a new look at pharmacologic agents that might have been overlooked for their beneficial effects in periodontal disease treatment. CONCLUSION: The emerging awareness of inflammation and its control in periodontal disease management underscores the importance of exploring inflammatory pathways and mediators, thus exploring new ways to control inflammation. This direction of research promises a new era in drug discovery and therapeutics for periodontal disease treatment.

Modulation of the host inflammatory response in periodontal disease management: exciting new directions.

BACKGROUND: New strategies for periodontal disease management have been emerging as more is learned about the role of the host response. Our increasing understanding of inflammation and its resolution has opened the door to the study of new periodontal treatment strategies. This review examines periodontal disease in the light of a new understanding of the role of inflammation in disease expression thus setting the stage for the development of new prevention and treatment strategies of a widespread disease. METHODS: We examined current publications and focused on articles relating to anti-inflammatory and pro-resolution mechanisms in periodontal disease. RESULTS: Recent research has examined the inflammatory and resolution cascade in greater detail while looking at endogenous and exogenous mediators that can be utilised to achieve therapeutic end-points. The possible introduction of 'resolution indices' for drug testing warrants a new look at pharmacologic agents that might have been overlooked for their beneficial effects in periodontal disease treatment. CONCLUSION: The emerging awareness of inflammation and its control in periodontal disease management underscores the importance of exploring inflammatory pathways and mediators, thus exploring new ways to control inflammation. This direction of research promises a new era in drug discovery and therapeutics for periodontal disease treatment.

The use of digital volume tomography in imaging an unusually large composite odontoma in the mandible.

The odontoma is the most common of all odontogenic tumors. Digital volume tomography (DVT) provides a major advantage of decreased radiation and cost-effectiveness, as compared to a conventional computed tomography. There is no known published report utilizing this DVT analysis for assessing and localizing on odontomo. The purpose of this case report was to document the use of digital volume tomography to assess an unusually large composite odontoma in the mondible. Tomographic sections revealed expansion of the buccol cortex and occasional thinning of both the buccol and lingual cortical plates, although there was no pronounced clinically detectable cortical expansion. The sections further demonstrated enomel ond dentin in on irregular mass bearing no morphologic similority to rudimentary teeth. This case highlights the importance of early diagnosis and intervention for treating on odontoma while demonstrating the value of tomographic imaging as on aid to diagnosis.

Long-Term Outcomes of Coronally Advanced Tunnel Flap (CATF) and the Envelope Flap (mCAF) Plus Subepithelial Connective Tissue Graft (SCTG) in the Treatment of Multiple Recession-Type Defects: A 6-Year Retrospective Analysis.

This study evaluated the 6-year results of the subepithelial connective tissue graft (SCTG) plus envelope-type flap (modified coronally advanced flap; mCAF) or coronally advanced tunnel flap (CATF) in the treatment of multiple recessions. Thirty-six patients with at least two adjacent recessions were included. Complete root coverage (CRC), mean root coverage (MRC), and keratinized tissue (KT) width were recorded over the course of the study. Both groups presented similar CRC, MRC, and KT outcomes between the 1-year and 6-year follow-ups. MRC decreased from 96.90% to 94.16% for mCAF, and from 89.56% to 83.10% for CATF. Both surgical techniques were similarly efficient in treating multiple recessions in the short term, and in maintaining the stability of therapy in the medium and long term.

Long-term follow-up and tomographic assessment of an intrabony defect treated with enamel matrix derivative.

BACKGROUND: Enamel matrix derivative (EMD) has an extensive documentation of use in the treatment of periodontal defects. Digital volume tomography (DVT) has been in use in dental medicine since the late 1990s, with a major advantage of decreased radiation and cost-effectiveness compared to conventional computed tomography (CT). To the best of our knowledge, there is no peer-reviewed report documenting long-term tomographic assessment of an intrabony defect treated with EMD alone. METHODS: In this case report, we document the long-term response of an isolated intrabony defect treated with flap surgery plus EMD and monitored for 30 months with a DVT scan. We also compare clinical and radiographic findings for the defect at 7 and 30 months postoperatively. RESULTS: With regenerative treatment, significant improvements in probing depth (PD), clinical attachment level (CAL), and bleeding on probing (BOP) were observed both short and long term. No recession occurred, and papillary heights were maintained throughout the monitoring period. Although intraoral radiography suggested bone fill at the defect site at 7 months, DVT confirmed that the intrabony defect was eliminated at 30 months. CONCLUSIONS: Treatment of an intrabony defect with surgery plus EMD demonstrated excellent bone fill as assessed with conventional radiographic and tomographic examinations performed over 30 months. Larger studies are needed to further assess the use of DVT imaging as an appropriate adjunctive diagnostic tool for evaluating the responses of intrabony defects to regenerative techniques.

Controlled Palatal Harvest Technique for Harvesting a Palatal Subepithelial Connective Tissue Graft.

Subepithelial connective tissue grafts (SCTGs) have been extensively used to augment soft-tissue volume on dental implants and natural teeth. The authors present a technique called the controlled palatal harvest (CPH) to obtain SCTGs. CPH provides an alternative to the trap-door and single-incision techniques currently utilized. The objective of this article is to describe this harvesting technique for SCTGs. A case report is presented in which the CPH technique was successfully used to obtain a SCTG. Contrary to current techniques where the SCTG is usually taken from the palatal (bone) side, this technique involves the dissection of a thick split-thickness flap in which the graft is harvested from the raised flap. Further, an L-shaped incision (with an anterior release) improves visibility and dexterity during dissection of the connective tissue graft. This technique enables the operator to maintain a certain minimum overlying flap thickness, and excellent control is ensured over the thickness of the harvested SCTG. The thickness of theremaining connective tissue overlying the palatal can also be controlled by the operator. Thus, the chances of leaving behind a thin tissue covering the palatal bone are reduced, minimizing necrosis and flap sloughing, which further improves grafting success. While the CPH can be used as an alternative to currently employed conventional harvest techniques, it may require greater operator skill. To the best of the authors' knowledge, this is the first report that documents such a technique.