October 6, 2017
Is ridge preservation or augmentation at periodontally
compromised extraction sockets safe?
Preserving or augmenting the alveolar ridge at periodontally compromised sockets appears safe after a thorough removal of the infectious source. The finding is part of a study published online Aug. 30 in Journal of Clinical Periodontology.
Researchers designed the study to estimate the safety of ridge preservation or augmentation in periodontally compromised extraction sockets. The researchers conducted a chart review of patients who were subject to ridge preservation or augmentation at periodontally compromised sockets at Seoul National University Dental Hospital (SNUDH) in Seoul, South Korea. They included only patients subject to extraction of periodontally compromised teeth followed by immediate ridge preservation or augmentation without flap elevation.
After the patient received anesthetic at the extraction sites, the affected teeth were removed and saline irrigation was performed after debridement. The procedure was performed using surgical curettes until it was thought that the socket was clearly free from inflammatory tissue. The extraction sockets were then filled with a bone biomaterial and covered using a barrier membrane or left alone with an open flap. Extraction sites entry points were sutured in an “X” manner to protect and prevent the escape of the biomaterial and membrane.
Patients were prescribed antibiotics and nonsteroidal anti-inflammatory therapy 5 to 7 days after ridge preservation or augmentation. Sutures were removed after 1 to 2 weeks, and additional antibiotics were prescribed to patients with inflammatory symptoms. Patients were examined 1 week later, and if inflammatory signs persisted, the implanted biomaterials were removed.
Researchers considered a site a periodontally compromised extraction socket when teeth had a greater than degree 2 mobility, greater than 8 millimeters probing depth, and apically narrowing bone destruction, as well as when teeth had a periapical lesion greater than 4 mm radiographically and a negative response to an electric pulp test with periodontal characteristics as noted above.
Extracted data included self-reported patient demographics of age, sex, tobacco smoking, hypertension, diabetes mellitus, osteoporosis, hepatitis, tuberculosis, ridge preservation or augmentation location (maxillary-anterior or -posterior, mandibular-anterior or -posterior), and indication (periodontal or combined endodontic-periodontal).
If symptoms of increased local swelling with or without suppuration did not subside after the course of additional medication, implanted biomaterials were removed and the patient was categorized as having a reinfection.
The chart review identified 10,060 patients subject to tooth extractions at the SNUDH Department of Periodontics, from 2011 through 2015. The final sample of 297 patients with periodontitis included 172 men and 125 women, aged 22 through 86 years. A total of 43 patients were smokers, 28 had diabetes, 66 had hypertension, 2 had tuberculosis, 9 had hepatitis, and 9 had osteoporosis.
From the final sample, 8 patients exhibited inflammatory symptoms that required additional treatment. Within this group, reinfection occurred in 2 patients and led to required removal of implanted biomaterials. The ridge preservation or augmentation safety rates before and after complication management was 97.3% and 99.3%, respectively. The final ridge preservation or augmentation safety rate for periodontally compromised extraction sockets was 99.3%.
“When a ridge preservation/augmentation is attempted immediately after tooth extraction in periodontally compromised sockets,” the authors concluded, “a proper protocol includes conventional debridement/decontamination and saline irrigation stimulating an early wound healing localized inflammatory reaction.”
Read the original study here.
Consulting Editor: Tapan Koticha, BDS
Diplomate, American Board of Periodontology
Director, Graduate Periodontics
University of Oklahoma Health Sciences Center, College of Dentistry
Reduction of maxillary sinus changes after ridge preservation
Ridge preservation using bovine-derived xenograft might reduce sinus pneumatization along with minimizing crestal bone resorption, according to a study published online July 26 in Clinical Implant Dentistry and Related Research.
The authors designed the study to compare maxillary sinus and alveolar crest dimensional changes before and after tooth extraction with or without socket preservation. They identified 132 dental files for patients who underwent extraction of either the maxillary second premolar, first molar, or second molar between July 1996 and March 2016 at the Rambam Health Campus in Haifa, Israel. Of these, 42 underwent tooth extractions only and 21 underwent tooth extraction with socket preservation using demineralized bovine bone xenograft.
The standard surgical protocol included atraumatic extraction, socket debridement, and primary closure of the soft tissues.
The study group comprised 21 patients (14 women and 7 men) aged 31 to 80 years. The control group comprised 42 patients (27 women and 15 men) aged 30 to 85 years. In cases that included multiple extractions, 1 site per patient was randomly chosen. A total of 3 patients exhibited minor complications after tooth extraction, 1 had severe postoperative pain, and 2 experienced prolonged bleeding.
The researchers superimposed panoramic radiographs from before and about 1 year after extraction and matched them using a fixed reference unit. Researchers performed the following measurements in the midline of the tooth site: distance of the bone crest to the sinus floor, distance of the sinus floor to the sinus roof, and the sagittal circumference of the sinus.
In the study group, extraction sites were 42.8% first molars, 38.1% second molars, and 19.1% second premolars, while in the control group, 50%, 26.2%, and 23.8% of the extraction sites were of first molars, second molars, and second premolars, respectively. Median follow-up period between baseline and after extraction radiographs was 7 months (range, 6-11 months) in the study group and 9 months (range, 6-36 months) in the control group.
The mean increase in the distance from the sinus floor to the sinus roof before and after extraction was 0.30 millimeters (standard error (SE], 60.10) in the study group and 1.30 mm (SE, 60.27) in the control group (P = .0221). The mean reduction in the distance from the bone crest to the sinus floor was 0.32 mm (SE, 60.09) in the study group and 1.26 mm (SE, 60.28) in the control group (P = .0019), and the mean increase in the sinus sagittal circumference was 37.34 mm (SE, 66.10) and 125.95 mm (SE, 615.60), respectively (P = .0001).
Observing that these changes were clinically appreciable and statistically significant, the authors concluded that ridge preservation reduced both the maxillary sinus pneumatization and crestal bone resorption.
Read the original article here.
Alveolar ridge preservation using allografts and xenografts
Allografts and xenografts are both suitable materials to preserve the alveolar ridge, according to a study published online Aug. 1 in Clinical Implant Dentistry and Related Research.
The authors designed the randomly controlled trial to compare clinically and histologically the use of xenografts and allografts in alveolar ridge preservation after 6 months of healing.
The authors randomized 20 volunteers in need of extraction of a single-root tooth before implant installation into 2 groups at the Periodontology Specialist Clinic of the Universidad Nacional de Colombia, Bogota, Columbia. They evaluated full-mouth plaque, full-mouth bleeding on probing, and periodontal probing in the full dentition, including pocket depth, gingival marginal, and attachment level measurements. They also obtained intraoral radiographs before tooth extraction.
The study focused on 2 materials: a demineralized freeze-dried cortical bone allograft and a well-known deproteinized bovine bone mineral xenograft embedded in 10% porcine collagen.
After tooth extraction, customized stents were made with grooves to guide the probe placement to make the measurements at the mesial (m), central (c), and distal (d) aspects, respectively. The stents measured the vertical distance between the stent (S) and the top of the buccal wall (C) at the mesial (S-Cm), center (S-Cc), and distal (S-Cd) aspects. They performed horizontal measurements on the total ridge width 1 millimeter below the top of the crest and the thickness of the buccal bony wall, 1 mm below the top of the bony crest. After 6 months, the authors obtained cone-beam computer tomographic images from each patient for implant treatment planning.
The clinical differences in horizontal and vertical dimensions between the extractions and the biopsy harvesting were calculated for S-Cm, S-Cc, S-Cd, and top of the crest. Three sections representing the central part of each biopsy were used for the histologic analysis.
Both groups showed shrinkage of bone dimensions. At mesial, center, and distal sites, the vertical changes in dimension were 20.6, 0.5, and 20.1 mm for the allograft and 21.1, 20.4, and 20.9 mm for the xenograft. The horizontal changes in dimensions were 21.4 mm for the allograft and 22.6 mm for the xenograft. New bone and residual graft material were 25.5610.1% and 33.869.4% at the allograft and 35.3616.8% and 22.2613.4% at the xenograft sites. None of the differences was statistically significant.
“Slight similar changes for both groups were seen for variations in attachment level at teeth adjacent to the extraction site,” the authors concluded. “This suggested that both procedures may be clinically suitable for maintaining the alveolar ridge.”
Read the original article here.
Molar extraction site healing with and without ridge preservation
Significantly more ridge height reduction occurs in molar extraction sites without ridge preservation (RP), and most ridge width loss is localized to the buccal aspect. Ridge width loss does not significantly decrease when RP is performed, but the loss is evenly distributed between facial and lingual aspects of the extraction site. The findings are from a study published in the March issue of Journal of Periodontology.
Researchers designed the parallel, 2-arm randomized clinical trial to determine dimensional alveolar changes radiographically and changes in the soft tissue encountered after molar extraction with and without RP. The study also measured the need for RP in molar sites to successfully place a restoratively driven dental implant as a molar replacement, specifically on the influence of the buccal bone thickness on alveolar ridge dimensional change.
A total of 40 patients undergoing treatment in the graduate periodontics clinic at the University of Texas Health Science Center at San Antonio, San Antonio, Texas, were enrolled from January 2014 through May 2015, with the last follow-up completed in November 2015. All patients were referred for a single-molar extraction and treatment planned for tooth replacement with a dental implant.
Alginate impressions were made to fabricate a customized stent for each participant. After extraction, patients in the control group received an absorbable collagen sponge that was placed into the socket. Patients in the test group had their sockets filled incrementally with mineralized cortical freeze-dried bone allograft, which was condensed to the bony crest of the extraction walls. The graft was covered with a dense polytetrafluoroethylene membrane trimmed and positioned to contain the bone graft by extending roughly 3 millimeters beyond the buccal and lingual bony crests.
A cone-beam computed tomographic scan was obtained within 72 hours of extraction and again at 3 months with the radiographic stent in place. A dental implant of 4.7 mm, 4.8 mm, or 5.0 mm in diameter was placed according to recommendations provided by the manufacturer, and bone grafting was completed if implant placement in a restoratively driven position left more than 4 square mm of the implant surface exposed.
Vertical measurements were made over the mesial root and distal root aspects of the socket at the same distances from the edges of the marker from baseline and final scans. Crestal height measurements made at these 6 points (mesial, midpoint, and distal over both buccal and lingual crests) on the baseline and final scans were used to determine vertical ridge changes. Horizontal changes were calculated from differences between the baseline and final measurements at 3 mm, 5 mm, and 7 mm from the highest crest at the coronal slices corresponding to the middle of the mesial and distal roots and the socket midpoint.
Researchers found significantly greater loss in alveolar ridge height in molar sites allowed to heal without RP on the buccal aspect of the socket (with RP, –1.12 to 1.60 mm; without RP, –2.60 to 2.06 mm, P = .01). No significant difference in ridge width loss was found between groups. Two-thirds ridge width reduction was experienced on the buccal aspect in sites without RP, but width loss was evenly distributed between buccal and lingual aspects when RP was performed. Bone grafting at time of placement was required in 25% of implants in the group without RP versus 10% of implants in the RP group.
Read the original article here.
AAP publishes proceedings from best evidence consensus meeting on cone-beam computed tomography
The American Academy of Periodontology recently published its first-ever “best evidence consensus” (BEC) proceedings on the topic of cone-beam computed tomography (CBCT). The proceedings are the result of the AAP’s inaugural BEC meeting, a model of scientific inquiry rooted in the best available published research and expert opinion.
The panel of over 10 periodontists who participated in the BEC meeting determined that CBCT has diverse applications for both dental implant therapy and periodontal-orthodontic therapy and should be used when the benefit to the patient outweighs the risk. The use of CBCT in dental implant and periodontal-orthodontic cases can not only assist in planning a safer approach to treatment, but also facilitate interdisciplinary communication. For patients with periodontitis, 2D full-mouth radiographs combined with clinical probing remain the gold standard; however, CBCT may be beneficial in certain advanced cases. Click here to read the report in the Journal of Periodontology.
AAP installs new president, officers in Boston
Steven R. Daniel, DDS, a periodontist in Murfreesboro, Tenn., was installed as the American Academy of Periodontology’s president during its 103rd Annual Meeting, held Sept. 9-12, 2017, in Boston. Other newly installed officers include President-elect Richard T. Kao, DDS, PhD; Vice President Bryan J. Frantz, DMD, MS; and Secretary/Treasurer James G. Wilson, DMD. Terrence J. Griffin, DMD, will act as the Academy’s immediate past president. Click here to learn more.
Available for download: clinical and scientific papers from the AAP
The American Academy of Periodontology has developed a suite of resources to be used as guidelines for dentists dealing with periodontal health issues. These resources include disease classifications, AAP-commissioned reviews, parameters of care, position papers, consensus papers/clinical recommendations, and Academy statements.
View and download these materials by clicking here.
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