localized management of the sinus floor (LMSF) technique

Placement of implants in the severely atrophic posterior maxilla using localized management of the sinus floor: a preliminary study.

Winter AA, Pollack AS, Odrich RB
Int J Oral Maxillofac Implants. 2002 Sep-Oct;17(5):687-95.

PURPOSE: This retrospective study investigated whether or not implants can be placed successfully without sinus grafts in atrophic posterior maxillary ridges with < or = 4 mm of bone utilizing the localized management of the sinus floor technique as described by Bruschi and coworkers. MATERIALS AND METHODS: Fifty-eight implants were placed in 34 consecutive patients with an average vertical height of 2.87 mm of residual bone under the sinus. The implants were placed at the time the sinus membrane was elevated. RESULTS: The sinus was "raised" an average of 9.12 mm without benefit of bone grafts or membranes. The success rate after 22 months of loading was 91.4%. DISCUSSION: The localized management of the sinus floor (LMSF) technique permits osseointegration of titanium implants by an endosteal-periosteal continuum that is unhindered by the need of graft material to resorb. CONCLUSION: This preliminary study demonstrated that it is possible to place implants in an atrophic alveolar ridge with < or = 4 mm of bone without the need for a traditional sinus graft.

Evaluation of Long-Term Implant Success

Devorah Schwartz-Arad,* ­Ran Herzberg, and ­Liran Levin­
Journal of Periodontology
2005, Vol. 76, No. 10, Pages 1623-1628

Implant success criteria, regarding marginal bone loss and other parameters, were first suggested in 1986 and today are still frequently referred to as the gold standard for implant success. However, according to the recent abundance of data on marginal bone loss and a better understanding of bone and soft tissue behavior around the implant neck and body, these criteria are inaccurate for the wide variety of implant systems. The purpose of this article is to review some of the relevant literature regarding marginal bone loss and to propose guidelines for a novel approach to evaluate the long-term success of implants regarding marginal bone loss. Four hypothetical patterns of implant marginal bone loss after the first year are suggested: a low-rate marginal bone loss over the years (Albrektsson's pattern); low-rate marginal bone loss in the first few years followed by a rapid loss of bone support; high-rate marginal bone loss in the first few years followed by almost no bone loss; and continuous high-rate marginal bone loss leading to a complete loss of bone support.

Treatment of peri-implantitis by the Vector® system: A pilot study

Karring ES, Stavropoulos A, Ellegaard B, Karring T. Treatment of peri-implantitis by the Vector® system. A pilot study.
Clin. Oral Impl. Res. 16, 2005; 288–293

To compare the effectiveness of treatment of peri-implantitis with a novel ultrasonic device, the Vector® system, with that of subgingival debridement with carbon fiber curettes.

Material and methods:
The study, comprising 11 patients with at least two screw type implants with bleeding on probing (BOP), probing pocket depth (PPD)5 mm, and at least 1.5 mm radiographic bone loss and exposed implant threads, was carried out as a single blind randomized clinical trial. At baseline one randomly chosen implant in each patient was treated by the Vector® system (test) while the other implant (control) was treated by submucosal debridement with a carbon fiber curette. After 3 months, the same treatments were repeated. Plaque, BOP, and PPD were recorded on all implant surfaces at baseline, and after 3 and 6 months. Bone levels were recorded on radiographs taken prior to the start of the study, and after 6 months. Results:
Oral hygiene around both test and control implants was improved at 3 and 6 months compared with baseline. At 6 months, four of the Vector®-treated sites, and only one site treated with curettes, had stopped to bleed. In neither the test nor the control group, were there any differences between baseline and 6 months regarding PPD and bone levels.

Conclusion: Although there was a greater reduction in the number of sites with BOP following treatment with the Vector® system than following instrumentation with carbon fiber curettes, there was no significant difference between the two methods.

Efficiency of subgingival calculus removal with the Vector™-system compared to ultrasonic scaling and hand instrumentation in vitro

Andreas Braun, Felix Krause, Matthias Frentzen, Søren Jepsen
Journal of Periodontal ResearchVolume 40 Issue 1 Page 48 - February 2005

Objective: The recently introduced Vector™-system (Duerr Dental, Bietigheim-Bissingen, Germany) is recommended to be used in conjunction with different insert tips and irrigation fluids. The aim of the study was to assess subgingival calculus removal depending on the mode of operation and to compare the results to conventional methods for root debridement.
Methods: Sixty extracted human teeth with calculus on the root surface were treated in an artificial periodontal pocket model using six methods: Vector™-system with metal probe insert (VPP) or metal curette insert (VPC), both used with polishing fluid, Vector™-system with metal probe insert (VAP) or metal curette insert (VAC), both used with abrasive fluid, EMS-ultrasonic system (U) and hand instrument (Gracey curette). Photographs of the root surface were taken at intervals of 10 s and calculus removal was assessed using a surface analysis software until the root surfaces were cleaned completely. Analysis of variances (ANOVA) of the ranks with subsequent comparison of mean ranks and calculation of homogeneous groups (Scheffé) were used for statistical analysis.
Results: Employing the hand instrument, highest efficiency could be observed (0.340 mm2/s). Calculus removal with the Vector™-system and metal probe insert (VPP: 0.036 mm2/s; VAP: 0.067 mm2/s) was less effective (p <> 0.05).
Conclusion: The present in vitro study indicates that the efficiency of calculus removal with the Vector™-system is significantly dependent on the selection of inserts and irrigation fluids.

Socket Augmentation: Rationale and Technique.

Implant Dentistry. 13(4):286-296, 2004.Wang, Hom-Lay DDS, MSD *; Kiyonobu, Koichi DDS, PhD +; Neiva, Rodrigo F. DDS ++

The consequences of exodontia include alveolar bone resorption and ultimately atrophy to basal bone of the edentulous site/ridges. Ridge resorption proceeds quickly after tooth extraction and significantly reduces the possibility of placing implants without grafting procedures. The aims of this article are to describe the rationale behind alveolar ridge augmentation procedures aimed at preserving or minimizing the edentulous ridge volume loss. Because the goal of these approaches is to preserve bone, exodontia should be performed to preserve as much of the alveolar process as possible. After severance of the supra- and subcrestal fibrous attachment using scalpels and periotomes, elevation of the tooth frequently allows extraction with minimal socket wall damage. Extraction sockets should not be acutely infected and be completely free of any soft tissue fragments before any grafting or augmentation is attempted. Socket bleeding that mixes with the grafting material seems essential for success of this procedure. Various types of bone grafting materials have been suggested for this purpose, and some have shown promising results. Coverage of the grafted extraction site with wound dressing materials, coronal flap advancement, or even barrier membranes may enhance wound stability and an undisturbed healing process. Future controlled clinical trials are necessary to determine the ideal regimen for socket augmentation.

Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects

Cochrane Review. The Cochrane Library, Issue 4, 2005
Esposito M, Grusovin MG, Coulthard P, Worthington HV

Background: Periodontitis is a chronic infective disease of the gums caused by bacteria present in dental plaque. This condition induces the breakdown of the tooth supporting apparatus until teeth are lost. Surgery may be indicated to arrest disease progression and regenerate lost tissues. Several surgical techniques have been developed to regenerate periodontal tissues including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). EMD is an extract of enamel matrix and contains amelogenins of various molecular weights. Amelogenins are involved in the formation of enamel and periodontal attachment formation during tooth development.

Objectives: To test whether EMD is effective, and to compare EMD versus GTR, and various BG procedures for the treatment of intrabony defects.
Search strategy: We searched the Cochrane OHG Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Several journals were handsearched. No language restrictions were applied. Authors of RCTs identified, personal contacts and the manufacturer were contacted to identify unpublished trials. Most recent search: May 2005.

Selection criteria: RCTs on patients affected by periodontitis having intrabony defects of at least 3 mm treated with EMD compared with open flap debridement, GTR and various BG procedures with at least 1 year follow up. The outcome measures considered were: tooth loss, changes in probing attachment levels (PAL), pocket depths (PPD), gingival recessions (REC), bone levels from the bottom of the defects on intraoral radiographs, aesthetics and adverse events. The following time-points were to be evaluated: 1, 5 and 10 years.

Data collection and analysis: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI). It was decided not to investigate heterogeneity, but a sensitivity analysis for the risk of bias of the trials was performed.

Main results: Ten trials were included out of 29 potentially eligible trials. No included trial presented data after 5 years of follow up, therefore all data refer to the 1-year time point. A meta-analysis including eight trials showed that EMD treated sites displayed statistically significant PAL improvements (mean difference 1.2 mm, 95% CI 0.7 to 1.7) and PPD reduction (0.8 mm, 95% CI 0.5 to 1.0) when compared to placebo or control treated sites, though a high degree of heterogeneity was found. Significantly more sites had < 2 mm PAL gain in the control group, with RR 0.48 (95% CI 0.29 to 0.80). Approximately six patients needed to be treated (NNT) to have one patient gaining 2 mm or more PAL over the control group, based on a prevalence in the control group of 35%. No differences in tooth loss or aesthetic appearance as judged by the patients were observed. When evaluating the only two trials at a low risk of bias in a sensitivity analysis, the effect size for PAL was 0.6 mm, which was less than 1.2 mm for the overall result. Comparing EMD with GTR (five trials), GTR showed a statistically significant increase of REC (0.4 mm) and significantly more postoperative complications. No trials were found comparing EMD with BG.

Authors' conclusions: One year after its application, EMD significantly improved PAL levels (1.2 mm) and PPD reduction (0.8 mm) when compared to a placebo or control, however, the high degree of heterogeneity observed among trials suggests that results have to be interpreted with great caution. In addition a sensitivity analyses indicated that the overall treatment effect might be overestimated. The actual clinical advantages of using EMD are unknown. With the exception of significantly more postoperative complications in the GTR group, there was no evidence of clinically important differences between GTR and EMD.
Citation: Esposito M, Grusovin MG, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects.

The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003875.pub2. DOI: 10.1002/14651858.CD003875.pub2.

Microsurgical Approach to Periodontal Regeneration

Dr. Pierpaolo Cortellini & Maurizio S. Tonetti Journal of Periodontology 76:3, 341-350

Background: Improvements in flap design and soft tissue manipulation are considered key elements in improving the outcomes of regenerative periodontal surgery. Improved visual acuity and better soft tissue handling resulting from the application of a microsurgical approach hold great promise to further improve predictability of periodontal regeneration. The aim of this study was to preliminarily evaluate the outcomes of a microsurgical approach in the regenerative therapy of deep intrabony defects.
Methods: This patient cohort study involved 26 patients with one deep interdental intrabony defect each. They were treated with periodontal regeneration using guided tissue regeneration membranes. Defects were accessed with previously described papilla preservation flaps performed with the aid of an operating microscope and microsurgical instruments. A stringent plaque control regimen was enforced in all the patients during the 1-year observation period. Outcomes included evaluation of the complete primary closure of the interdental space (closure), gains in clinical attachment (CAL), and reductions in probing depths (PD).
Results: Closure was achieved in all treated defects and was maintained in 92.3% of cases for the entire healing period. Associated gains in CAL were 5.4 ± 1.2 mm on average, corresponding to a CAL gain of 82.8 ±14.7% of the initial intrabony component of the defect. Average PD reduction was 5.8 ±1.4 mm and was associated with minimal increase in gingival recession (0.4 ±0.7 mm).

The modified papilla preservation technique

Int J Periodontics Restorative Dent. 1996 Dec;16(6):546-59.

The modified papilla preservation technique with bioresorbable barrier membranes in the treatment of intrabony defects. Case reports.
Cortellini P, Pini Prato G, Tonetti MS.
A new surgical approach for interproximal regenerative procedures has been utilized in conjunction with bioresorbable barrier membranes in the treatment of deep intrabony defects. The purpose of this study was to test the effectiveness of the modified papilla preservation technique in obtaining and maintaining primary closure of the interdental space over bioresorbable membranes. Ten patients (10 sites) with optimal plaque control were treated according to the modified papilla preservation technique. Baseline probing attachment level and probing pocket depth were 10.1 +/- 1.9 mm and 8.9 +/- 2.4 mm, respectively. The intrabony component of the defects was 6.5 +/- 1.7 mm. Polylactic acid barrier membranes were positioned just coronal to the interproximal bone crest. Primary closure over the membranes was obtained in 100% of the cases. In two cases only a slight dehiscence of the interproximal tissues was observed after 2 weeks. Healing was uneventful in all the treated sites. Probing attachment level gains of 4.5 +/- 0.9 mm and a probing pocket depth reduction of 5.8 +/- 2.3 mm were observed at 1 year. It can be concluded that the modified papilla preservation technique is a suitable alternative for interproximal regenerative procedures in conjunction with bioresorbable barrier membranes.

J Periodontol. 1995 Apr;66(4):261-6.

The modified papilla preservation technique. A new surgical approach for interproximal regenerative procedures.
Cortellini P, Prato GP, Tonetti MS.
A modification of the papilla preservation technique has been applied to achieve primary closure of the interproximal tissue over barrier membranes placed coronal to the alveolar crest. Fifteen patients with deep intrabony interproximal defects were treated. Defects had a probing attachment level loss of 9.9 +/- 3.2 mm and a recession of the gingival margin of 1.7 +/- 1.6 mm. The depth of the intrabony component was 5.5 +/- 2.9 mm; while the suprabony component was 5.9 +/- 2.0 mm. Titanium-reinforced teflon membranes were placed 1.3 +/- 0.7 mm from the cemento-enamel junction, 4.5 +/- 1.6 mm coronal to the interproximal alveolar bone crest. Primary closure over the interproximal portion of the membrane was obtained in 93% of cases. In 73% of the cases complete coverage of the membrane was maintained until its removal at 6 weeks. These data indicate that the modified papilla preservation technique can be successfully applied to obtain primary closure of the interdental space in regenerative procedures with barrier membranes.

Principles and mechanisms of peri-implant soft tissue healing

The long-term clinical and esthetic success of implant-supported restorations is determined by osseointegration and optimal remodeling of peri-implant soft tissues. Complications of soft-tissue management are often caused by fibrotic regeneration of oral mucosa after multiple surgical procedures. Knowledge of the proliferative processes in wound healing is necessary to attain adequate soft-tissue conditions. Successful reconstruction of peri-implant soft tissues is feasible even in fibrotic conditions when appropriate surgical techniques are selected. The pleiotropic proliferative cytokine TGF-b is involved in the regulation of all phases of wound healing and tissue remodeling. The isoform TGF-b1 is a cytokine associated with the development of fibrotic tissue. Overexpression of TGF-b1 causes scarring and fibrosis, and results in limited clinical success of intraoral soft-tissue management. Experimental therapeutic approaches with neutralizing antibodies to block TGF-b1 resulted in less scarring and a reduction of fibrosis. Further molecular biologic research of cell-matrix-cytokine interactions in wound healing will provide highly specific antifibrotic therapeutic approaches in the future.
Stefan Schultze-Mosgau, Markus B. Blatz, Falk Wehrhan, DMD, Karl Andreas Schlegel, Michael Thorwart, Stefan Holst. (Quintessence Int 2005;36:759?69)

Complications with Surgical Procedures Utilizing Connective Tissue Grafts

Randall J. Harris, DDS / Richard Miller, DDS / Laura Harris Miller, DDS / Christopher Harris, DDS

The goal of this study was to evaluate the incidence and severity of the complications that occur after connective tissue grafts are used. Five hundred consecutively treated patients, for whom connective tissue grafts were used for root coverage or gingival augmentation, were included in this study. Complications did occur, but the rates and intensities seemed clinically acceptable. There was no pain reported in 81.4% of the patients, no bleeding in 97.0% of the patients, no infection in 99.2% of the patients, and no swelling in 94.6% of the patients. None of the factors evaluated in this study were associated with a statistically significant increase in the rate or intensity of complications. These factors included: age, sex of patient, smoking status, purpose of the graft (ie, for root coverage or for gingival augmentation), size of the recipient area, and the location of the defect being treated. Based on the results of this study, the incidence and severity of complications seemed to be clinically acceptable. (Int J Periodontics Restorative Dent 2005;25:449-59.)