Immediate Oral Rehabilitation With Quad Zygomatic Implants: Ultrasonic Technique vs Conventional Drilling.

Inserting zygomatic implants is a challenging surgery and requires special care and great precision. Piezoelectric surgery offers several advantages: more precise bone cutting with improved intraoperative visibility and a low temperature increase. The aim of this case-control study was to evaluate whether ultrasonic instruments can be as effective as standard drilling instruments for zygomatic implant surgery in terms of clinical outcomes. Ninety-two patients with atrophic maxilla were included in the study. Implant sites were prepared with the ultrasonic technique (test group = 47 patients) or traditional drilling (control group = 45 patients). In total, 368 zygomatic implants were inserted (202 with the extrasinus technique, 77 with the sinus slot technique, and 89 with the Brånemark technique). Complete arch provisional prostheses were delivered 3 to 5 hours after the surgical operations. The mean follow-up after surgery was 24 months (range = 12-32 months). The primary outcome evaluations were based on implant survival rates and postoperative complications. Operative time and surgeon's stress were evaluated as secondary outcomes. Implant survival rate was 100% in the test and 98.89% in the control group. Postoperative complications were seen in 9 patients (4 in the test and 5 in the control group); the difference was not statistically significant. Operative time was longer in the test group; however, surgeons were more comfortable using ultrasonic instruments. Within the limitations of this preliminary study, the ultrasonic technique was a feasible alternative to traditional drilling for zygomatic implant surgery.

Socket Preservation Using a Biomimetic Nanostructured Matrix and Atraumatic Surgical Extraction Technique.

OBJECTIVE: The aim of the present study was to evaluate the efficacy of biomimetic composite bone substitute composed of equine collagen I and Mg-hydroxyapatite in improving socket preservation after tooth extraction in humans. METHODS: Thirty-two patients were subjected to a single tooth extraction, performed without elevation of the full-thickness flap. In each patient, socket was grafted with the bone substitute and specimens were retrieved 2 months after surgery and processed for histological observations. The clinical outcome variables were healing index, visual analog score for pain, postsurgery complications, and patient satisfaction evaluated through a questionnaire. RESULTS: No adverse reaction or infection occurred, in which healing index averaged 5.8 (range 4-7). Pain scores were lower. The patients' questionnaire outcomes were unanimously in favor of the test treatment. At low-power magnification, it was possible to see a portion of native bone with small marrow spaces and many areas of bone remodeling. At high-power magnification, it could be observed that small newly formed trabeculae originated from the preexisting bone and bone spicules in the middle of the defect. CONCLUSION: Grafting the postextraction socket with composite bone substitute may improve the healing process by accelerating socket closure and tissue maturation. Such a product demonstrated excellent biocompatibility as no inflammatory reaction could be detected histologically and was well accepted by patients.

Efficacy of Anti-Inflammatory and Analgesic of Superpulsed Low Level Laser Therapy After Impacted Mandibular Third Molars Extractions.

The purpose of this study was to evaluate anti-inflammatory and analgesic efficacy of superpulsed low level laser therapy (SLLLT) after bilateral extraction of impacted mandibular third molars. Many studies in the literature show the anti-inflammatory and analgesic efficacy of laser therapy after oral surgery.The authors report the preliminary results of 25 patients who underwent bilateral extraction of mandibular eighths included in a single surgery. This is a split-mouth study, a site was randomized chosen to be treated with SLLLT at T0, 24 hours and 48 hours with a GaAs laser diode, whereas the other surgical site was evaluated as control. The suture was removed at 7 days and healing was controlled at 14 days. During the sessions were monitored and recorded the pain, using visual analog scale, and oedema with the visual analog scale and cephalometric measurements of cutaneous points (TR-GO, GO-CA, GO-SP, GO-PO). Each patient received only antibiotic prophylaxis and analgesic therapy as needed.Results indicate that in the treated site SLLLT determines a reduction in pain and swelling statistically significant compared with the control site (P < 0.05). The authors found that the effectiveness of laser therapy is in the first 5 days after surgery, showing a significant reduction of pain and swelling in the treated site than the control site.This study suggests that the SLLLT has a potential in reducing the postoperative discomfort after impacted third molar extractions, due to a reduction in postoperative pain and swelling. Superpulsed low level laser therapy has no side effects and is well tolerated by patients. It also seems to have a role in reducing the intake of drugs.

Effects of Superpulsed, Low-Level Laser Therapy on Neurosensory Recovery of the Inferior Alveolar Nerve.

OBJECTIVE: The purpose of this investigation was to evaluate the therapeutic efficacy of superpulsed, low-level laser therapy (SLLLT) on neurosensory recovery of the inferior alveolar nerve (IAN) after oral surgical injury. BACKGROUND DATA: A survey of the literature reveals the uncertainty of outcomes for the surgical management of IAN injury and the efficacy of low-level laser therapy in the treatment of IAN injury. METHODS: In this study, the authors report the results for SLLLT in 57 patients affected by paresthesia of the lip, chin, gingival, and buccal regions. Each patient was subjected to 10 laser treatments, once a week, with a GaAs diode laser. Clinical neurosensory tests (soft touch, 2-point discrimination, pin prick, thermal test) and the visual analogue scale were used before every treatment to evaluate the extent of neurosensory recovery. RESULTS: The authors' results demonstrate that 83.3% of the patients had a significant neurosensory recovery, as evident in the objective and subjective tests. CONCLUSION: The results reported in this study indicate that SLLLT has the potential to improve neurosensory recovery in patients with IAN paresthesia.

Adjunctive Effect of Autologus Platelet-Rich Fibrin to Barrier Membrane in the Treatment of Periodontal Intrabony Defects.

BACKGROUND AND AIM: Autologous platelet-rich fibrin (PRF) and barrier membranes in the treatment of intrabony defects in chronic periodontitis patients have shown significant clinical benefits. This study evaluates the additive effect of autologous PRF in combination with a barrier membrane versus the use of barrier membrane alone for the treatment of intrabony defects in chronic periodontitis patients. METHODS: A randomized split-mouth design was used. Sixteen patients with 32 paired intrabony defects were included. In each patient 1 defect was treated using a resorbable collagen membrane along with PRF (test group) and the other defect by guided tissue regeneration alone (control group). The following clinical parameters were measured at baseline and after 9 months: plaque index, modified sulcus bleeding index, probing pocket depth, clinical attachment level, and gingival marginal level. The radiographic defect depth was also assessed at baseline and after 9 months. RESULTS: Test group showed a statistically significant improvement for probing depth (P = 0.002), clinical attachment level (P = 0.001), and radiographic defect depth (P < 0.001) after 9 months as compared with the control sites. Radiographic defect depth reduction was 58.19 ±â€Š13.24% in the test group as compared with 24.86 ±â€Š9.94% reduction in the control group. CONCLUSIONS: The adjunctive use of PRF in combination with barrier membrane is more effective in the treatment of intrabony defects in chronic periodontitis as compared with barrier membrane alone.

Surgical treatment of denture-induced fibrous hyperplasia with plasma rich in growth factors.

Denture-induced fibrous hyperplasia is a fibrous connective tissue lesion that commonly occurs in oral mucosa in patients showing important alveolar ridge atrophy. In this study, we propose Plasma Rich in Growth Factors (PRGF) to overcome constrains of traditional surgical treatment. Herein, we demonstrated that PRGF represents an autologous source of growth factors able to reduce the healing time of the alveolar mucosa and the discomfort of those patients. These properties are the result of PRGF's precise biological features that result in the following: reduction of duration and intensity of postsurgical pain, acceleration of re-epithelialization of the wound, and reduction of bleeding events and of edema. In conclusion, we showed that using PRGF on patients affected by denture-induced fibrous hyperplasia allows a short healing time, thereby reducing complications and overall improving their quality of life. The aims of this study were to evaluate the influence of PRGF-ENDORET on secondary re-epithelialization in vestibuloplasty after excision of denture irritation fibrous hyperplasia, with an explorative randomized case control trial with 10 patients, 5 patients treated with PRGF and 5 patients with traditional hemostasis, and to analyze differences with simple surgery, considering postoperative rapidity of re-epithelialization, comfort, and discomfort of patients, pain, swelling, and infections.

Temporomandibular joint disorders treated with articular injection: the effectiveness of plasma rich in growth factors-Endoret.

The objective of this study was to evaluate the effectiveness of the temporomandibular joint (TMJ) osteoarthritis treatment through articular injections of plasma rich in growth factors (PGRF)-Endoret. Thirteen patients (median age, 47.64 y; SD, 7.51; range, 40-64 y; male-female ratio, 2:11) with osteoarthritis of TMJ associated to chronic pain have been selected. They were treated with articular injections of PRGF-Endoret, measuring the maximum mouth opening and pain level before the first injection (t0), 30 days after just before the second (t1), and after 6 months (t2). Data were analyzed using the paired Student's t-test data. The visual analogue scale score at t0 is 7.69 (range, 4-10; SD, 1.9), whereas that at t1 is 1.54 (range, 0-5; SD, 1.74) and that at t2 is 0.23 (range, 0-2; SD, 0.65). These differences in the results are statistically highly significant (P < 0.0001 comparison t0-t1 and t0-t2 and P < 0.01 comparison t1-t2). In terms of maximum mouth opening, it reduced from 30.15 mm at t0 (range, 26-40 mm; SD, 4.44) to 37.54 mm at t1 (range, 31-51 mm; SD, 5.10), with an increase of 7.38 mm (range, 4-11 mm; SD, 2.02) and a highly significant difference (P < 0.0001). At t2, it was 39.54 mm (range, 34-51; SD, 4.55) with an increase of 9.38 mm (range, 5-12 mm; SD, 2.21) compared with t0 and that of 2.00 mm compared with t1. Both differences in the results are statistically significant (P < 0.0001 and P < 0.01, respectively). The articular injections of PRGF-Endoret represent a very efficient method to control pain and to improve the TMJ mobility.

Rehabilitation with 4 zygomatic implants with a new surgical protocol using ultrasonic technique.

When the residual bone crest cannot allow the placement of standard implants, the treatment for complete arch rehabilitation of severely atrophic maxillae can be performed with 4 zygomatic implants (ZIs) and immediate function with predictable results in terms of aesthetics, function, and comfort for the patient. However, even if ZIs' rehabilitations showed a good success rate, this surgery is difficult and need a skillful operator. Complications in this kind of rehabilitation are not uncommon; the main difficulties can be related to the reduced surgical visibility and instrument control in a critical anatomic area. All the surgical protocols described in the literature used drilling techniques. Furthermore, the use of ultrasonic instruments in implant surgery compared with drilling instruments have shown advantages in many aspects of surgical procedures, tissues management, enhancement of control, surgical visualization, and healing. The aim of this study was to report on the preliminary experience using ultrasound technique for ZIs surgery in terms of safety and technical improvement. Ten consecutive patients with severely atrophic maxilla have been treated with 4 ZIs and immediate complete arch acrylic resin provisional prostheses. The patients were followed up from 30 to 32 months evaluating implant success, prosthetic success, and patient satisfaction with a questionnaire. No implants were lost during the study period, with a 100% implant and prosthetic success rate. Within the limitations of this preliminary study, these data indicate that ultrasonic implant site preparation for ZIs can be a good alternative to the drilling technique and an improvement for the surgeon.

Conservative treatment with plasma rich in growth factors-Endoret for osteoradionecrosis.

OBJECTIVES: Osteoradionecrosis (ORN) is the worst long-term complication due to radiotherapy to the head and neck and is defined as an area of exposed necrotic oral bone, with failure to heal for at least 3 months. In most cases, ORN is associated with oral surgery procedures involving the jaw bone. The aim of this study was to evaluate the safety and effectiveness of a biological approach for ORN treatment. METHODS: A series of 10 patients with ORN were treated by debridement of necrotic bone using an ultrasound device followed by application of plasma rich in growth factors (PGRF)-Endoret to improve and accelerate soft-tissue healing. Patients were followed clinically and radiographically up to 12 months. Pain was assessed in the first week postsurgery using a visual analogue scale (VAS). Maturation and quality of tissue healing was assessed using a modified healing index. RESULTS: All cases were successfully treated. No intraoperative or postoperative complications occurred. Clinical and radiographic evaluations showed no signs of persistent infection or exposed bone up to 12 months of follow-up. The maturity and quality of the regenerated tissues was excellent, surgical wounds always achieving complete closure. VAS scores and trismus were very low in all patients, which did not take analgesics since the third day after surgery. CONCLUSIONS: PRGF-Endoret is beneficial, as an adjunct to surgical treatment of osteoradionecrosis, for predictable enhancement of tissue vascularization and epithelialization in patients with a history of head and neck radiotherapy.

Failure risk estimates after dental implants placement associated with plasma rich in growth factor-Endoret in osteoporotic women under bisphosphonate therapy.

There is disagreement as to whether it is safe to place implants in patients under bisphosphonates (BPs) therapy owing to the risk for developing BP-related osteonecrosis of the jaws (BRONJ). The American Association of Oral and Maxillofacial Surgeons recommends that dental implants should be avoided in oncologic patients treated with intravenous BPs. Conversely, for patients receiving oral BPs, dental implant placement is not explicitly contraindicated even if a cautious approach is suggested. The aim of the current study was to assess the risk level as related to adverse events such as implant failure and BRONJ in a large cohort of osteoporotic patients submitted to implant placement and concomitant application of plasma rich in growth factor (PGRF)-Endoret. The clinical charts of 235 middle-aged women under oral BPs therapy for osteoporosis, who underwent positioning of 1267 dental implants, were reviewed. The implants were always positioned in association with PRGF-Endoret. The outcomes were implant failure and BRONJ. A model based on personal risk factors distribution was used for risk assessment. Sixteen implants were lost in 16 patients up to 120 months of follow-up, leading to a survival of 98.7% and 93.2% on an implant basis and patient basis, respectively. No cases of BRONJ were reported. In line with the current literature, the present data show that the risk for developing BRONJ associated to dental implant surgery remains low for patients receiving oral BPs. The use of procedures that could enhance and support healing, such as platelet concentrates, should be recommended.

Efficacy of plasma-rich growth factor in the healing of postextraction sockets in patients affected by insulin-dependent diabetes mellitus.

PURPOSE: To evaluate the efficacy of plasma-rich growth factor (PRGF) in improving socket healing after tooth extraction in diabetic patients. MATERIALS AND METHODS: This was a split-mouth study in which each patient also served as the control: the study socket was treated with PRGF, whereas the control socket underwent natural healing. The outcome variables were the Healing Index, residual socket volume, visual analog scale score, postsurgical complications, and outcome of a patient questionnaire. The investigation considered the impact of hyperglycemia, glycated hemoglobin, End Organ Disease Score, and smoking habits. Follow-up included 4 postextraction checkups over a 21-day period. Pairs of correlated continuous variables were analyzed with the Wilcoxon test, independent continuous variables with the Mann-Whitney test, and categorical variables with the χ(2) test or Fisher test. RESULTS: From January 2012 to December 2012, 34 patients affected by insulin-dependent diabetes mellitus underwent contemporary bilateral extractions of homologous teeth. The treatment-versus-control postoperative comparison showed that PRGF resulted in significantly smaller residual socket volumes and better Healing Indices from days 3 to 14. The patients' questionnaire outcomes were unanimously in favor of PRGF treatment. The small sample of patients with glycemia values of at least 240 mg/dL showed worse Healing Index and minor socket decreases. CONCLUSION: PRGF application after extraction improved the healing process in diabetic patients by accelerating socket closure (epithelialization) and tissue maturation, proving the association between PRGF use and improved wound healing in diabetic patients.

Bleeding rate during oral surgery of oral anticoagulant therapy patients with associated systemic pathologic entities: a prospective study of more than 500 extractions.

PURPOSE: Oral anticoagulant therapy (OAT) patients have international normalized ratio (INR) safety windows for oral surgery, the lower limit of which is determined by the thromboembolic risk, with the upper limit typically 3.0. We sought to assess whether these limits will also be true with comorbidities that favor bleeding, such as diabetes, liver disease, and chronic renal failure. MATERIALS AND METHODS: The study was designed for 500 consecutive extractions. Patients with an INR greater than 3.0 were switched to heparin and used as controls. The primary outcome was the incidence of bleeding with the need for reoperation, in connection with 3 principal predictors: the INR, reasons for OAT, and comorbidity type. Continuous variables were analyzed using the Mann-Whitney U test and categorical variables using χ2 or Fisher's exact test. Statistical significance was set at P < .05. The reliability of the INR as a bleeding predictor was assessed using receiver operating characteristic (ROC) curves. RESULTS: Extractions in patients receiving OAT without comorbidities had a success rate of 99.7% against severe bleeding. Despite equivalent INR values, patients with comorbidities had a significantly lower rate (81.3%, P < .001). For these patients, the ROC curve procedure indicated lower INR upper limits, 2.8 for mechanical heart prosthesis subjects and 2.3 for all others. Among the comorbidities, diabetes was associated with the greatest frequency of bleeding (31%) compared with liver disease (15%) and kidney failure (11%). CONCLUSIONS: Patients with comorbidities should be advised to bring their INR within narrower safety windows (upper limit of 2.5 to 2.8 for mechanical prosthesis and 2.0 to 2.3 otherwise) or be switched to heparin. Alternatively, we propose applying to the socket, a platelet-rich growth factor preparation to foster hemostasis.

A split-mouth randomized clinical trial to evaluate the performance of piezosurgery compared with traditional technique in lower wisdom tooth removal.

PURPOSE: The surgical removal of mandibular third molars is frequently accompanied by significant postsurgical sequelae, and different protocols have been described to decrease such adverse events. The aim of this study was to investigate the performance of piezosurgery compared with traditional rotating instruments during mandibular third molar removal. PATIENTS AND METHODS: A single-center, randomized, split-mouth study was performed using a consecutive series of unrelated healthy patients attending the Oral Surgery Unit of the University of Turin for surgical removal of bilateral mandibular third molar teeth. Each patient was treated, at the same appointment, using bur removal on 1 side of the mandible and a piezoelectric device on the contralateral side. The primary outcomes reported were postoperative pain, objective orofacial swelling, and surgical duration; secondary outcomes were gender, age, and possible adverse events. Analysis of variance or paired t test was used as appropriate to test any significant differences at baseline according to each treatment subgroup, and categorical variables were analyzed by χ(2) test. RESULTS: The study sample consisted of 100 otherwise healthy patients. The mean pain evaluation reported by patients who underwent surgery with piezosurgery was significantly lower than that reported after bur (conventional) removal, reaching statistical difference after 4 days (P = .043). The clinical value of orofacial swelling at day 7, normalized to baseline, was lower in the piezosurgery group (P < .005). The average surgical duration was significantly shorter in the bur group than in the piezosurgery group (P < .05). Three patients having bur removal developed short-term complications (2 dry sockets and 1 temporary paraesthesia), which totally resolved by 4 weeks. CONCLUSIONS: To date, this prospective investigation is the largest reported split-mouth study on piezosurgery for lower third molar tooth removal. This study also compared surgeons with different degrees of experience. It is evident that using a piezoelectric device can enhance the patient experience and decrease postoperative pain and swelling.

A simple score for evaluation of the complexity of third-molar extractions.

OBJECTIVES: This article proposes a simple preoperative score to evaluate the complexity of tooth extractions of the third mandibular molar and to estimate the time involved. STUDY DESIGN: We consider 11 factors (demographic, anatomic, and radiologic) that favor the surgery and that can be identified through standard clinical and radiologic examinations. The number of favorable factors (NFF) relative to each patient constitutes his/her score. The analysis of 1500 extractions performed by various surgeons with experience from 2 to 25 years evidences a quadratic inverse correlation between NFF and the time required for the surgery. RESULTS: The shape of the time distribution suggests the existence of 3 major classes of patients characterized by time of 4 to 10 minutes, 11 to 20 minutes, and 21 to 40 minutes. The corresponding NFF brackets, as identified by their frequency distributions and validated by the receiver operating characteristic curve method, are 5 to 11 (mean [SD], 6.8 [1.6]), 2 to 4 (3.3 [1.3]), and 0 to 1 (0.8 [1.0]), respectively. CONCLUSIONS: Our results show the good performance of this score as a predictor of the surgical time and its applicability in daily practice regardless of operator experience, background, and level of surgical ability.

Third-molar extraction with ultrasound bone surgery: a case-control study.

PURPOSE: The aim of this case-control study was to evaluate the postoperative period and healing between 2 surgical methods (traditional and ultrasound bone surgery) that are used for mandibular third-molar extraction. PATIENTS AND METHODS: Fifteen patients with impaction of both of the lower third molars and indications for their extractions were used in this study. Bilateral-mandibular third-molar extractions were performed at the same surgical time: traditional surgery with burrs was used on 1 side (control site), and ultrasound surgery was used on the other side (test [T] site). After surgery, the patients were examined at 7 and 14 days and at 1 and 3 months to evaluate tissue healing. The following was assessed at every follow-up: pain, trismus, swelling, and alveolar bone level. RESULTS: The study included 15 patients, and 30 mandibular third-molar extractions were performed. We found only 1 postoperative complication: 1 patient had alveolitis in the control site. Complete recoveries without any complications were reported in all of the patients at the T sites. CONCLUSIONS: Complete recoveries without any complication were reported in all patients at the T sites. The only disadvantage of the piezoelectric technique was the length of operation time, which was increased by approximately 8 minutes; however, this effect was offset by reducing the morbidity. CLINICAL RELEVANCE: Our preliminary study showed that Piezosurgery is an excellent tool for reducing the risk of complications and improving the postoperative period.

Can plasma rich in growth factors improve healing in patients who underwent radiotherapy for head and neck cancer? A split-mouth study.

OBJECTIVES: The objective of this study was to identify surgical protocols that can improve mucosal healing and postextraction socket closure in patients who underwent radiation therapy for head and neck cancer. METHODS: The study was designed as a prospective split-mouth trial on 20 patients who needed bilateral paired dental extractions. On the side directly impacted by radiation, chosen to be the study side, the sockets were filled with plasma rich in growth factors (PRGF), whereas, on the other side (control), they were allowed to undergo natural healing. Outcome variables were residual socket volume (RSV), healing index (HI), pain, and postsurgical complications as measured at the 2 sides at the 4 follow-up sessions (up to 30 days after the extraction). Continuous variables were analyzed with Wilcoxon (when matched) or Mann-Whitney (when independent) test; categorical variables, with Chi-squared or Fisher test. Statistical significance was set at P < 0.05. Correlation was estimated with Pearson linear correlation coefficient. RESULTS: The PRGF side showed statistically significant better values for RSV and HI at all checkups and no postoperative complications. The control side had a slower healing and 2 cases of bone exposure, which were successfully cured with PRGF application. The RSV on the 21st day after the extraction was correlated with the dose received but not with the time since radiotherapy. CONCLUSIONS: Plasma rich in growth factors proved to be effective in the management of patients with a history of head and neck radiotherapy, accelerating and fostering mucosal healing and avoiding postextraction bone exposures.

Patient-based assessment of tooth extraction with ultrasonic dental surgery.

BACKGROUND: The aim of this study was to compare the postoperative period and healing of 2 methods used for simple tooth extraction: traditional and ultrasonic bone surgery. The clinical healing of the sockets and psychologic acceptance of the ultrasonic bone surgery were also evaluated. METHODS: Two hundred patients requiring bilateral maxillary or mandibular extractions were enrolled. The extractions of the 2 teeth were performed in the same surgical session. The extraction on 1 side was performed using traditional surgery (control site), whereas ultrasonic surgery was used on the other side (test site). The patients were clinically screened at 1, 7, 14, and 21 days. RESULTS: A total of 200 patients (115 women and 85 men), with a mean age of 54.8 years (range, 40-65 y), provided 400 extraction sites. The time required to perform the tooth extractions was longer at the test site than at the control site, although this difference did not reach statistical significance. CONCLUSIONS: The piezoelectric extraction technique also provided the best surgical healing results, as evidenced by the integrity of the alveolar walls and surrounding soft tissues. In addition, the patients responded positively to ultrasonic surgery and preferred it to traditional surgery for both the surgical and postsurgical phases. CLINICAL IMPLICATION: Our preliminary study showed that Piezosurgery is an excellent tool for reducing the risk for complications and for improving the clinical healing and postoperative period in particular. The use of ultrasound reduces trauma to the adjacent bone and soft tissues during the tooth extraction.

Tooth extractions in intravenous bisphosphonate-treated patients: a refined protocol.

PURPOSE: The aim of this prospective hospital-based study was to refine a surgical protocol for tooth extractions in patients with a history of intravenous use of a potent bisphosphonate by modifying a previously reported protocol to produce a significantly shortened operating time. PATIENTS AND METHODS: Prospective patients with a follow-up of at least 4 months were included. Tooth extractions were performed without a vestibular split-thickness flap; healing was stimulated by filling the extraction site with autologous plasma rich in growth factors (PRGF System, BTI Biotechnology Institute, Vitoria, Spain). Local and systemic infection control was obtained with dental hygiene and antibiotic therapy. RESULTS: Sixty-three patients participated in the study. Two hundred two tooth extractions were performed. Differences between the present and previous protocols (the previous protocol used a vestibular flap) were analyzed and the surgical time proved significantly shorter for the present approach (P = .00). CONCLUSIONS: The proposed surgical protocol appears to be a better choice for patients treated with intravenous bisphosphonates who need tooth extraction, because it seems to be faster and simpler than the previously reported successful protocol.

Oral mucosa produces cytokines and factors influencing osteoclast activity and endothelial cell proliferation, in patients with osteonecrosis of jaw after treatment with zoledronic acid.

OBJECTIVES: The intravenous injection of bisphosphonates, currently used as treatment for osteoporosis, bone Paget's disease, multiple myeloma, or bone metastases, can cause jaw bone necrosis especially in consequence of trauma. The present research aimed to clarify the mechanisms underlying bone necrosis, exploring involvement of the oral mucosa "in vivo." PATIENTS AND METHODS: Specimens of oral mucosa were removed from bisphosphonate-treated patients with or without jaw bone necrosis. In mucosa specimens, expression was evaluated of: cytokines involved in the inflammatory process, factors involved in osteoclast activity, i.e., receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin, a factor involved in cell proliferation, namely hydroxymethylglutaryl coenzyme A reductase, and a factor involved in angiogenesis, namely vascular endothelial growth factor (VEGF). RESULTS: Interleukin (IL)-6 and the RANK/osteoprotegerin ratio were significantly elevated in mucosa from patients with versus without jaw necrosis, whereas hydroxymethylglutaryl coenzyme A reductase and VEGF were significantly decreased. CONCLUSIONS: Our results suggest that mucosa, stimulated by bisphosphonate released from the bone, can contribute to the development of jaw necrosis, reducing VEGF, and producing IL-6 in consequence of hydroxymethylglutaryl coenzyme A reductase reduction. In turn, IL-6 stimulates osteoclast activity, as shown by the increased RANKL/osteoprotegerin ratio. CLINICAL RELEVANCE: The results of this study suggest the importance of evaluating during bisphosphonate treatment the production of IL-6, RANKL, osteoprotegerin, and VEGF, in order to monitor the jaw osteonecrosis onset. To avoid repeated mucosa excisions, the determination of these factors could be carried out in crevicular fluid.

Changes in implant stability using different site preparation techniques: Osseodensification drills versus piezoelectric surgery. A multi-center prospective randomized controlled clinical trial.

INTRODUCTION: Implant stability is influenced by bone density, implant design, and site preparation characteristics. Piezoelectric implant site preparation (PISP) has been demonstrated to improve secondary stability compared with conventional drilling techniques. Osseodensification drills (OD) have been recently introduced to enhance both bone density and implant secondary stability. The objective of the present multi-center prospective randomized controlled trial was to monitor implant stability changes over the first 90 days of healing after implant bed preparation with OD or PISP. METHODS: Each patient received two identical, adjacent or contralateral implants in the posterior maxilla. Following randomization, test sites were prepared with OD and control sites with PISP. Resonance frequency analysis was performed immediately after implant placement and after 7, 14, 21, 28, 60, and 90 days. Implants were then restored with single screw-retained metal-ceramic crowns and followed for 12 months after loading. RESULTS: Twenty-seven patients (15 males and 12 females; mean age 63.0 ± 11.8 years) were included in final analysis. Each patient received two identical implants in the posterior maxilla (total = 54 implants). After 1 year of loading, 53 implants were satisfactorily in function (one failure in test group 28 days after placement). Mean peak insertion torque (40.7 ± 12.3 Ncm and 39.5 ± 10.2 Ncm in test and control group, respectively) and mean implant stability quotient (ISQ) value at baseline (71.3 ± 6.9 and 69.3 ± 7.6 in test and control group, respectively) showed no significant differences between the two groups. After an initial slight stability decrease, a shift to increasing ISQ values occurred after 14 days in control group and after 21 days in test group, but with no significant differences in ISQ values between the two groups during the first 90 days of healing. CONCLUSION: No significant differences in either primary or secondary stability or implant survival rate after 1 year of loading were demonstrated between implants inserted into sites prepared with OD and PISP.