Aryan Eghbali

Immediate single‐tooth implants in the anterior maxilla: 3‐year results of a case series on hard and soft tissue response and aesthetics

PURPOSE The objective of this prospective study was to assess the overall outcome of immediate single implant treatment in the anterior maxilla after a 3-year observation period. MATERIAL AND METHODS Thirty consecutively treated patients with a thick gingival biotype, ideal gingival level/contour and intact socket walls at the time of tooth extraction were treated for single-tooth replacement in the aesthetic zone by two experienced clinicians. Treatment included minimal mucoperiosteal flap elevation, immediate implant placement (NobelReplace TiUnite(®)), insertion of a grafting material between the implant and the socket wall and connection of a screw-retained provisional restoration. The latter was replaced by a cemented crown 6 months thereafter. Patients were clinically and radiographically re-examined after 3 years to assess implant survival, complications and hard and soft tissue conditions. The aesthetic outcome was objectively rated using the Pink Esthetic Score (PES) and White Esthetic Score (WES) by a blinded clinician who had not been involved in the treatment. RESULTS Twenty-five patients could be re-evaluated after 3 years. One early implant failure had occurred resulting in an implant survival rate of 96%. Radiographic examination yielded on average 1.13 mm mesial, respectively 0.86 mm distal bone loss. The clinical conditions showed fairly low peri-implant plaque (18%) and bleeding (24%) and mean probing depth was 3.17 mm. Mean mesial/distal papilla shrinkage and midfacial soft tissue recession in reference to the pre-operative status accounted for 0.05, 0.08 and 0.34 mm, respectively. Between the 1- and 3-year reassessment mesial papillae showed significant re-growth (0.36 mm; p=0.015). Advanced midfacial recession (>1 mm) was found in 2/25 (8%) cases. Five (21%) cases were aesthetic failures (PES<8 and/or WES<6) and 5/24 (21%) showed an (almost) perfect outcome (PES≥12 and WES≥9). The remainder (14/24 or 58%) demonstrated acceptable aesthetics. CONCLUSIONS The proposed strategy seems a valuable and predictable treatment option for well-selected patients in the mid-long term as shown by almost full papillary re-growth and a low risk for advanced midfacial recession.

Single Implant Treatment in Healing Versus Healed Sites of the Anterior Maxilla: An Aesthetic Evaluation

PURPOSE The aim was to compare and document in detail the aesthetic outcome of single implant treatment in healing sites (early implant placement) with fully healed sites (conventional implant placement) of the anterior maxilla. MATERIALS AND METHODS A cross-sectional study in patients who had been treated by two periodontists and two prosthodontists in 2006 and 2007 was conducted. Surgical treatment involved standard flap elevation without releasing incisions and restorative procedures included cemented crowns in all patients. Only straightforward single implant treatments using Nobelreplace tapered TiUnite® implants (Nobel Biocare, Göteborg, Sweden) in healing sites (6-8 weeks following tooth extraction) and fully healed sites (≥6 months following tooth extraction) were considered with both neighboring teeth present and without the need for hard and/or soft tissue grafting. The aesthetic outcome was objectively rated using the pink esthetic score (PES) and white esthetic scrore (WES) by a blinded clinician who had not been involved in the treatment. Patients rated aesthetics by means of visual analogue scales. RESULTS Twenty-one out of 22 early and 25/27 conventional implant treatments were available for aesthetic evaluation after on average two and a half years of function (range 17-41 months). There were no significant differences for any of the criteria between the treatment concepts. Overall, papillae were most easy to satisfy, whereas alveolar process and tooth color most difficult. A thin-scalloped biotype was associated with low distal papillae (p=.041) and alveolar process deficiency (p=.039). Twenty-six percent of the cases were aesthetic failures (PES<8 and/or WES<6) and 13% showed an (almost) perfect outcome (PES≥12 and WES≥9). The remainder (61%) demonstrated acceptable aesthetics. There was no significant correlation between objective and subjective ratings. CONCLUSIONS Early and conventional single implant treatment yielded comparable aesthetic outcome. Albeit all treatments had been performed by experienced clinicians and only straightforward cases had been selected, 1 out of 4 cases were aesthetic failures and only a strict minority showed perfection. Research is required on the aesthetic outcome of alternative surgical procedures especially in high-risk patients with a thin-scalloped biotype.

The gingival biotype assessed by experienced and inexperienced clinicians

AIM A recent cluster analysis has identified three gingival biotypes among 100 periodontally healthy subjects based on different combinations of morphometric data related to maxillary front teeth and surrounding soft tissues. Patients with a thin-scalloped biotype are considered at risk because they have been associated with a compromised soft tissue response following surgical and/or restorative therapy. Hence, an accurate identification of these high-risk patients is warranted. The purpose of the present study was to evaluate the precision of simple visual inspection as a method to identify the gingival biotype by experienced and inexperienced clinicians. MATERIAL AND METHODS Fifteen clinicians (five Restorative Dentists, five Periodontists and five Students) were invited to assess the gingival biotype (thin-scalloped, thick-flat, thick-scalloped) of 100 periodontally healthy subjects based on clinical slides. Cluster analysis on these subjects was used as the gold standard and the accuracy in identifying the gingival biotype was determined using percentile agreement and kappa statistics. Intra- and inter-examiner reliability were also calculated. RESULTS The gingival biotype was accurately identified only in about half of the cases irrespective of the clinicians experience. The thick-flat biotype was mostly recognized especially by experienced clinicians (> or =70% of the cases). Nearly half of the thin-scalloped cases were misclassified. The intra-examiner repeatability was fair to substantial (kappa: 0.328-0.670) and the inter-examiner reproducibility was slight to moderate (kappa: 0.127-0.547). CONCLUSIONS Simple visual inspection may not be considered a valuable method to identify the gingival biotype as nearly half of the high-risk patients are overlooked.

Four Modalities of Single Implant Treatment in the Anterior Maxilla: A Clinical, Radiographic, and Aesthetic Evaluation

PURPOSE To document the outcome of single implants in the anterior maxilla following four routine treatment modalities when performed by experienced clinicians in daily practice using the same implant system and biomaterials. MATERIAL AND METHODS A retrospective study in patients who had been treated by two periodontists and two prosthodontists in 2006 and 2007 was conducted. The four treatment modalities practically covered every clinical situation and included standard implant treatment (SIT), immediate implant treatment (IIT), implant treatment in conjunction with guided bone regeneration (GBR), and implant treatment in grafted bone (BGR) harvested from the chin. All implants were installed via flap surgery. Patients were clinically and radiographically examined. Complications were registered and the aesthetic outcome (pink esthetic score [PES] and white esthetic score [WES]) was rated. A blinded clinician who had not been involved in the treatment performed all evaluations. Patients aesthetic satisfaction was also registered. RESULTS One hundred four out of 115 eligible patients (44 SIT, 28 IIT, 18 GBR, and 14 BGR) received at least one single NobelReplace tapered TiUnite® (Nobel Biocare, Göteborg, Sweden) implant in the anterior maxilla and were available for evaluation. Clinical parameters (implant survival: 93%, mean plaque level: 24%, mean bleeding on probing: 33%, and mean probing depth: 3.2 mm) and mean bone level (1.19 mm) did not differ significantly between treatment modalities. Postoperative complications were more common following GBR/BGR (>61%) when compared with SIT/IIT (<18%) (p < .001). BGR was in 4/14 patients associated with permanent sensory complications at the donor site. Technical complications occurred in 9/104 patients. SIT and IIT showed similar soft tissue aesthetics (PES: 10.07 and 10.88, respectively), however major alveolar process deficiency was common (>15%). PES was 9.65 for GBR. BGR showed inferior soft tissue aesthetics (PES: 9.00; p = .045) and shorter distal papillae were found following GBR/BGR (p = .009). Periodontal disease (odds ratio [OR]: 13.0, p < .001), GBR/BGR (OR: 4.3, p = .004), and a thin-scalloped gingival biotype (OR: 3.7, p = .011) increased the risk for incomplete distal papillae. WES was 7.98 for all patients considered. Poor agreement was found between objective and subjective aesthetic ratings. CONCLUSIONS All treatment modalities were predictable from a clinical and radiographic point of view. However, advanced reconstructive surgery, especially BGR, increased the risk for complications and compromised aesthetics. Research is required on the prevention and minimally invasive treatment of buccal bone defects at the time of tooth loss to avoid complex therapy.

Ultrasonic Assessment of Mucosal Thickness around Implants: Validity, Reproducibility, and Stability of Connective Tissue Grafts at the Buccal Aspect

PURPOSE (1) To assess validity and reproducibility of mucosal thickness (MT) registration by means of an ultrasonic device and (2) to determine the MT stability of connective tissue grafts (CTGs) when applied at the buccal aspect of single implants demonstrating alveolar process deficiency. MATERIALS AND METHODS For the validity assessment, four human cadaver edentulous maxillae were used to determine MT at 100 different sites. Soft tissue thickness as recorded with the ultrasonic device was compared with MT as registered with Micro-CT (UGent, Ghent, Belgium), taking the latter as gold standard. For the reproducibility assessment, 50 duplicate ultrasonic registrations were used. For the clinical part, 10 non-smoking patients with a single implant were included. All demonstrated alveolar process deficiency and had been provided with a provisional screw-retained crown at the time of inclusion. Following an intrasulcular incision at the buccal aspect, a CTG was inserted to thicken soft tissues. MT was assessed at t0 (before CTG), t1 (immediately after CTG), t2 (suture removal), t3 (permanent crown installation), and t4 (9 months after CTG). RESULTS There was a strong correlation between ultrasonic and Micro-CT measurements (r = 0.89, p < .001). However, the former significantly underrated MT by 0.13 mm (p = .030). There was a strong correlation between duplicate ultrasonic recordings (r = 0.99, p < .001). Seven females and three males were included in the clinical study with a mean age of 52. MT significantly increased by 0.92 mm between t0 and t1 (p = .005). Between t3 and t4, there was a slight, yet significant decrease of 0.15 mm (p = .047). CONCLUSION The ultrasonic device can be used as a non-invasive, reliable, and reproducible method to evaluate MT. Using this technology around single implants demonstrated that CTG may substantially thicken the peri-implant mucosa with acceptable stability over a 9-month period.

Single Implant Treatment in Healing versus Healed Sites of the Anterior Maxilla: A Clinical and Radiographic Evaluation

PURPOSE The aim was to document the Nobelreplace tapered TiUnite® (Nobel Biocare, Göteborg, Sweden) implant system used by experienced clinicians in daily practice for replacing single maxillary anterior teeth and to compare the clinical and radiographic outcome between implants installed in healing sites (early implant placement) and fully healed sites (conventional implant placement) after on average two and a half years of function. MATERIAL AND METHODS A cross-sectional study in patients who had been treated by two periodontists and two prosthodontists in 2006 and 2007 was conducted. Surgical treatment involved standard flap elevation without releasing incisions and restorative procedures included cemented crowns in all patients. Only straightforward single implant treatments in healing sites (6-8 weeks following tooth extraction) and fully-healed sites (≥6 months following tooth extraction) were considered with both neighboring teeth present and without the need for hard and/or soft tissue grafting. Clinical and radiographic analyses of all implants were performed by a blinded clinician who had not been involved in the treatment. RESULTS Forty-nine of the 53 eligible single implants (22 early and 27 conventionally placed implants) in 44/48 patients were available for scrutiny. There was no significant difference in implant survival between early (95%) and conventionally (93%) installed implants (p = 1.000). Mean bone level to the implant-abutment interface was 1.25 and 1.02 mm for early and conventional implant placement, respectively (p = .220). In spite of fairly low plaque levels (26%), overall peri-implant bleeding was quite prevalent (36%). Mean peri-implant probing depth was 3.3 mm. Five restorations had experienced technical complications. CONCLUSIONS Single Nobelreplace tapered TiUnite® implants installed in healing as well as in healed sites of the anterior maxilla are predictable. Both strategies seem equally successful in terms of implant survival, bone remodeling, clinical response, and risk for complications.

Horizontal stability of connective tissue grafts at the buccal aspect of single implants : a 1-year prospective case series

AIM To clinically evaluate the horizontal stability of a connective tissue graft (CTG) at the buccal aspect of single implants (1); to compare actual gingival thickness between thin and thick gingival biotype (2). MATERIALS AND METHODS Periodontally healthy non-smoking patients with a single implant in the anterior maxilla (15-25) were selected for a prospective case series. All demonstrated a horizontal alveolar defect and were in need of contour augmentation by means of CTG for aesthetic reasons. Patients were enrolled 3 months after implant surgery and had been provided with a provisional screw-retained crown. CTG was inserted in the buccal mucosa via the envelope technique using one intrasulcular incision. An ultrasonic device was used to evaluate mucosal thickness (MT) at the buccal aspect. MT was assessed at t0 (before CTG), t1 (immediately after CTG), t2 (2 weeks after CTG = suture removal), t3 (3 months after CTG = permanent crown installation) and t4 (1 year after implant placement). The gingival biotype was categorized as thin or thick based on the transparency of a periodontal probe through the soft tissues while probing the buccal sulcus of the contra-lateral tooth. Gingival thickness (GT) was measured at the contra-lateral tooth using the same ultrasonic device. RESULTS Thirty-seven patients (19 men, 18 women; mean age 38) met the selection criteria and consented to the treatment. Mean soft tissue gain immediately after CTG was on average 1.07 mm (SD 0.49). What remained of this tissue gain after 1 year was on average 0.97 mm (SD 0.48; 90.5%). Hence, mean soft tissue loss amounted to 0.10 mm (SD 0.23; 9.5%; p = 0.015) with no significant difference between patients with a thin or thick biotype (p ≥ 0.290). Patients with a thin biotype had a mean GT of 1.02 mm (SD 0.21), whereas GT was on average 1.32 mm (SD 0.31) in subjects with a thick biotype (p = 0.004). CONCLUSION Connective tissue graft substantially thickens the peri-implant mucosa with acceptable stability over a 1-year period.

Relationship between buccal bone and gingival thickness revisited using non‐invasive registration methods

OBJECTIVE To determine the relationship between buccal bone and soft tissue thickness at teeth in the premaxilla by means of non-invasive registration methods. MATERIALS AND METHODS Buccal bone thickness at central incisors, lateral incisors and canines was measured at five reference points (1-5 mm from the top of the alveolar crest) on CB-CT scans of 21 patients. The corresponding buccal gingival thickness was measured by the use of an ultrasonic device. Spearmans correlation coefficient was calculated to assess the correlation between buccal bone and soft tissue thickness at each tooth type. RESULTS Mean buccal bone thickness (SD) at central incisors, lateral incisors and canines was 1.07 mm (0.34 mm), 1.16 mm (0.54 mm) and 0.98 mm (0.37 mm), respectively. For central incisors, 68% of all sites had a thickness <1 mm and 32% had a thickness between 1.0 and 2.0 mm. At lateral incisors, 44% demonstrated buccal bone thickness between 0 and 1.0 mm, 48% between 1.0 and 2.0 mm and 8% ≥2 mm. For canines, 57% of the sites were <1 mm thick; 41% were between 1.0 and 2.0 mm thick, and 2% demonstrated ≥2 mm thickness. Mean gingival thickness (SD) at central incisors, lateral incisors and canines was 1.37 mm (0.32 mm), 1.33 mm (0.32 mm) and 1.08 mm (0.25 mm), respectively. The correlation between buccal bone and soft tissue thickness was moderately positive (ρ = 0.406; P < 0.001). CONCLUSIONS A thin buccal bone wall (<1 mm) may be expected in over half of the central incisors and canines. The correlation between buccal bone and soft tissue thickness was moderately positive.

Marginal and apical bone stability after staged sinus floor augmentation using bone condensing implants with variable-thread design: a two-dimensional analysis

Studies on the vertical stability of augmented bone after sinus lifting differ substantially. In addition, long healing periods are usually advocated prior to implant installation. The purpose of this case series study was to evaluate the changes in bone height after sinus lifting with a bovine-derived xenograft and to evaluate the clinical outcome of bone condensing implants installed after a short healing period. Patients treated during the years 2010-2013 were re-examined using peri-apical radiographs to evaluate the changes in augmented bone height (BH) and marginal bone loss (BL). Fifty-seven of 70 eligible subjects (28 male and 29 female, mean age 56 years) attended for reassessment. Data were available for 53 sinus lifts and 105 implants installed after a mean healing period of 4.6±1.5 months. Implant survival was 99% after a mean time in function of 19±9 months. Baseline BH, BH at implant placement, and final BH were on average 3.87±1.74mm, 13.75±2.12mm, and 13.11±2.12mm, respectively (P<0.001). Mean BL was 0.51±0.65mm. Only limited resorption is to be expected after sinus lifting in the short term. A bone condensing implant can be used in the early healing phase with successful outcomes in terms of implant survival and bone adaptation.

Patient-Reported Outcomes After Lateral Wall Sinus Floor Elevation: A Systematic Review

Objectives: The aim of this systematic review is to assess patient-reported outcome measures (PROMs) after a sinus lift elevation by means of a lateral approach. Material and Methods: An electronic search was performed to search for eligible publications reporting PROMs after a lateral wall sinus lift procedure. Selected articles were further scrutinized and underwent a quality check before inclusion in a final study pool. Results: The electronic search provided us with 2444 articles of which 98 were further examined through a full-text analysis. Of these 98 studies, 11 were selected based on our inclusion and exclusion criteria. Results on a different number of PROMs were examined and compared: pain, edema, ability to eat, ability to work, phonetics, daily activities, bleeding, bruising, ability to sleep, bad breath, patient preference, and Oral Health Impact Profile-14 (OHIP-14). Methods of evaluation were 3- to 5-point scales, visual analog scale scores, and OHIP-14 questionnaires. Evaluation time points differed between 1 single evaluation time to a daily registration during 1 week. Conclusions: A general peak in discomfort could be noticed on day 1 postoperatively with a general decline thereafter. Severe morbidity or discomfort occurred but not in most patients.