International Journal of Periodontics & Restorative Dentistry 5/2014 An international reputation for high-quality editorial content and unparalleled color illustrations has created a loyal following for this elegantly produced journal. Uniquely presented articles encompass the relationship between a healthy periodontium and precise restorations, as well as the integration of implants with comprehensive treatment planning. Providing clinically relevant information for your daily practice is the main focus of this often-cited journal. The journal's web edition provided by the publishing Quintessence branch in Chicago, USA, can be found at This rss-feed covers the latest table of contents including the abstracts. en Quintessence Publ. Comp. Inc. 2014-09-15 International Journal of Periodontics & Restorative Dentistry 5/2014 Editorial: Tribute to Morton Amsterdam Weisgold, Arnold<br>Page 599 - 599 The Connective Tissue Graft Wall Technique and Enamel Matrix Derivative to Improve Root Coverage and Clinical Attachment Levels in Miller Class IV Gingival Recession Zucchelli, Giovanni / Mazzotti, Claudio / Tirone, Federico / Mele, Monica / Bellone, Pietro / Mounssif, Ilham<br>Page 600 - 609<br>The case reports in this article describe a surgical approach for improving root coverage and clinical attachment levels in Miller Class IV gingival recessions. Two gingival recessions affecting maxillary and mandibular lateral incisors associated with severe interdental hard and soft tissue loss were treated. The surgical technique consisted of a connective tissue graft (CTG) that was placed below a coronally advanced envelope flap and acted as a buccal soft tissue wall of the bony defect treated with enamel matrix derivative (EMD). No palatal/lingual flap was elevated. In the first clinical case, 6 months after surgery a ceramic veneer was placed to correct tooth extrusion and improve the overall esthetic appearance. One year after the surgery in both cases, clinically significant root coverage, increase in buccal keratinized tissue height and thickness, improvement in the position of the interdental papilla, and clinical attachment level gain were achieved. The radiographs demonstrate bone fill of the intrabony components of the defects. This report encourages a novel application of CTG plus EMD to improve both root coverage and regenerative parameters in Miller Class IV gingival recessions. Radiographic Comparison of Different Concentrations of Recombinant Human Bone Morphogenetic Protein with Allogenic Bone Compared with the Use of 100% Mineralized Cancellous Bone Allograft in Maxillary Sinus Grafting Froum, Stuart J. / Wallace, Stephen / Cho, Sang-Choon / Khouly, Ismael / Rosenberg, Edwin / Corby, Patricia / Froum, Scott / Mascarenhas, Patrick / Tarnow, Dennis P.<br>Page 610 - 620<br>The purpose of this study was to radiographically evaluate, then analyze, bone height, volume, and density with reference to percentage of vital bone after maxillary sinuses were grafted using two different doses of recombinant human bone morphogenetic protein 2/acellular collagen sponge (rhBMP-2/ACS) combined with mineralized cancellous bone allograft (MCBA) and a control sinus grafted with MCBA only. A total of 18 patients (36 sinuses) were used for analysis of height and volume measurements, having two of three graft combinations (one in each sinus): (1) control, MCBA only; (2) test 1, MCBA + 5.6 mL of rhBMP-2/ACS (containing 8.4 mg of rhBMP-2); and (3) test 2, MCBA + 2.8 mL of rhBMP-2/ACS (containing 4.2 mg of rhBMP-2). The study was completed with 16 patients who also had bilateral cores removed 6 to 9 months following sinus augmentation. A computer software system was used to evaluate 36 computed tomography scans. Two time points where selected for measurements of height: The results indicated that height of the grafted sinus was significantly greater in the treatment groups compared with the control. However, by the second time point, there were no statistically significant differences. Three weeks postsurgery bone volume measurements showed similar statistically significant differences between test and controls. However, prior to core removal, test group 1 with the greater dose of rhBMP-2 showed a statistically significant greater increase compared with test group 2 and the control. There was no statistically significant difference between the latter two groups. All three groups had similar volume and shrinkage. Density measurements varied from the above results, with the control showing statistically significant greater density at both time points. By contrast, the density increase over time in both rhBMP groups was similar and statistically higher than in the control group. There were strong associations between height and volume in all groups and between volume and new vital bone only in the control group. There were no statistically significant relationships observed between height and bone density or between volume and bone density for any parameter measured. More cases and monitoring of the future survival of implants placed in these augmented sinuses are needed to verify these results. Analysis of Select Facial and Dental Esthetic Parameters Nold, Sarah L. / Horvath, Sebastian D. / Stampf, Susanne / Blatz, Markus B.<br>Page 622 - 629<br>This clinical study examined objective smile parameters in the natural anterior dentition. Standardized intraoral and extraoral photographs were taken of 106 Caucasian adults (54 women, 52 men) with a healthy dentition. The following parameters were analyzed: correlation of dental and facial midline, upper lip position and curvature, relationship of the maxillary anterior incisal curve with lower lip, number of teeth displayed in a smile, distance between maxillary anterior teeth and lower lip, slope of tooth, and lip arc. The simple frequency distribution of measured variables revealed an average smile with coinciding dental and facial midlines, an average smile line, and a straight upper lip curvature. With an average smile, the maxillary anterior teeth did not touch the lower lip, teeth were displayed up to the second premolar, and the maxillary anterior incisal curve was parallel to the lower lip. Oval was the most prevalent tooth form. A slope of 9 degrees was detected for the mean tooth arc and 13 degrees for the mean lip arc. The outcomes of this clinical study provide a quantifiable frame for esthetic evaluation, treatment planning, and restoration fabrication. Soft Tissue Contour Changes at Immediate Implants: A Randomized Controlled Clinical Study Cardaropoli, Daniele / Gaveglio, Lorena / Gherlone, Enrico / Cardaropoli, Giuseppe<br>Page 630 - 637<br>In 52 patients, single anterior teeth were extracted and replaced by immediate implants. The peri-implant gap was left either untreated (control) or was grafted and covered with a membrane (test group). After 12 months the horizontal bone resorption was significantly lower in the test group (test sites: 0.69 ± 0.68 mm, 8.13%; control sites: 1.92 ± 1.02 mm, 21.62%; P = .001), and there was less reduction in ridge height (test sites: 0.58 ± 0.77 mm; control sites: 1.69 ± 1.74 mm; P = .004). Ridge preservation considerably limited the amount of horizontal and vertical soft tissue alterations when compared with implant placement alone. Bone Dimensions in the Posterior Mandible: A Retrospective Radiographic Study Using Cone Beam Computed Tomography. Part 2- Analysis of Edentulous Sites Braut, Vedrana / Bornstein, Michael M. / Kuchler, Ulrike / Buser, Daniel<br>Page 638 - 647<br>A precise radiographic evaluation of the local bone dimensions and morphology is important for preoperative planning of implant placement. The purpose of this retrospective study was to analyze dimensions and morphology of edentulous sites in the posterior mandible using cone beam computed tomography (CBCT) images. This retrospective radiographic study measured the bone width (BW) of the mandible at three locations on CBCT scans for premolars (PM1, PM2) and molars (M1, M2): at 1 mm and 4 mm below the most cranial point of the alveolar crest (BW1, BW2) and at the superior border of the mandibular canal (BW3). Furthermore, the height (H) of the alveolar process (distance between the measuring points BW1 and BW3), as well as the presence of lingual undercuts, were analyzed. A total of 56 CBCTs met the inclusion criteria, resulting in a sample size of 127 cross sections. There was a statistically significant increase from PM1 to M2 for the BW2 (P < .001), which was not present for BW1 and BW3 values. For the height of the alveolar process, the values exhibited a decrease from PM1 to M2 sites. Sex was a statistically significant parameter for H (P = .001) and for BW1 (P = .03). Age was not a statistically significant parameter for bone width (BW1: P = .37; BW2: P = .31; BW3: P = .51) or for the height of the alveolar process (P = .41) in the posterior mandible. Overall, 73 (57.5%) edentulous sites were evaluated to be without visible lingual undercuts; 13 (10.2%) sites exhibited lingual undercuts classified as influential for implant placement. Precise evaluation of the alveolar crest by cross-sectional imaging is of great value to analyze vertical and buccolingual bone dimensions in different locations in the posterior mandible. In addition, CBCTs are valuable to diagnosing the presence of and potential problems caused by lingual undercuts prior to implant placement. Treatment of Noncarious Cervical Lesions by a Subepithelial Connective Tissue Graft Versus a Composite Resin Restoration Leybovich, Martin / Bissada, Nabil F. / Teich, Sorin / Demko, Catherine A. / Ricchetti, Paul A.<br>Page 648 - 654<br>This study compared two treatments for mild noncarious cervical lesions (NCCLs): a subepithelial connective tissue graft (CTG) versus a Class V composite resin restoration (CRR). Twenty-six sites with NCCLs were randomly assigned to be treated by CTG or CRR. Periodontal health parameters and dentinal hypersensitivity (DH) were recorded at baseline and 3 months postoperatively. Esthetics was also evaluated at 3 months. Results showed a significant improvement in all periodontal health parameters in the CTG treatment. The CTG treatment attained a mean 82% defect coverage with 75% of sites achieving complete coverage. Patients rated the CTG treatment to be significantly more esthetic (P = .03), while a clinician panel did not see an esthetic difference (P = .86). There was no difference in DH reduction between the two treatments (P = .81). In conclusion, the CTG treatment is superior to the CRR treatment for NCCLs based on periodontal health parameters. From a patient point of view, the CTG is the more esthetic treatment. Factors Affecting the Outcome in the Immediate Loading Rehabilitation of the Maxilla: A 6-year Prospective Study Pera, Paolo / Menini, Maria / Bevilacqua, Marco / Pesce, Paolo / Pera, Francesco / Signori, Alessio / Tealdo, Tiziano<br>Page 656 - 665<br>This prospective study reports the 6-year outcomes for patients rehabilitated with an immediate loading protocol of the maxilla (Columbus Bridge Protocol). In this study, 164 implants were inserted in 37 patients and loaded within 24 to 36 hours. Four implants failed during the first 6 months. At the 6-year follow-up, a mean bone loss of 1.52 mm was found. Significantly (P < .0083) less bone loss was found next to tapered implants compared with cylindric implants and next to machined collar implants compared with full acid-etched implants (P < .0083). No significant differences in bone loss were found in tilted versus upright implants or in mesial versus distal implant sites. In addition, there were no significant differences relating to either the degree of abutment angulation or the reason for tooth loss. Vertical Bone Growth Following Autotransplantation of the Developing Maxillary Third Molar to Replace a Retained Mandibular Permanent Molar: A Case Report Plakwicz, Paweł / Czochrowska, Ewa Monika / Milczarek, Anna / Zadurska, Małgorzata<br>Page 666 - 671<br>A retained permanent mandibular first molar caused arrested development and a defect of the alveolar bone in a 16-year-old girl. Extraction of the ankylosed tooth was immediately followed by autotransplantation of the developing maxillary third molar. At the 3-year follow-up examination the interproximal bone level at the autotransplanted molar was equal to that of the neighboring teeth. Cone beam computed tomography showed bone at the labial aspect of the transplant. The eruption of the autotransplanted tooth stimulated vertical alveolar bone development and repaired the bone defect. Additionally, there was closure of the posterior open bite that was initially present at the ankylosed molar site. Quantitative Three-Dimensional Methodology to Assess Volumetric and Profilometric Outcome of Subepithelial Connective Tissue Grafting at Pontic Sites: A Prospective Pilot Study González-Martín, Oscar / Veltri, Mario / Moráguez, Osvaldo / Belser, Urs C.<br>Page 672 - 679<br>The aim of this study was to describe a technique for the assessment of soft tissue volumetric and profilometric changes. The technique has been applied at the alveolar contour of mild to moderate horizontal ridge defects after soft tissue augmentation at pontic sites. A quantitative three-dimensional (3D) analysis based on laser scanning was used for the measurement of volume gain and horizontal changes of alveolar profile 5 months after a subepithelial connective tissue graft using a pouch approach in five patients. All the surgical sites healed uneventfully. A mean soft tissue volume increase of 35.9 mm3 was measured 5 months after the grafting procedure. The linear measurements showed that, in the area where the augmentation was performed, the distance between the preoperative vestibular profile and the postoperative one ranged from 0.16 to 2 mm. The described quantitative measurements based on 3D laser scanning appear to be an effective method for assessment of soft tissue changes in future studies. Additionally, within the limitation of a small sample size, the present data suggest that the investigated surgical technique can be considered when corrections of mild to moderate alveolar horizontal ridge atrophies at maxillary lateral incisor edentulous gaps are necessary. Impacted Canine Extraction by Ridge Expansion Using Air Scaler Surgical Instruments: A Case Report Agabiti, Ivo / Bernardello, Fabio / Nevins, Myron / Wang, Hom-Lay<br>Page 680 - 687<br>The presence of an impacted tooth interferes with ideal implant placement. In such cases, atraumatic extraction is recommended in order to avoid difficult and complex bone regeneration procedures. In the present case report, a novel surgical approach to extract a horizontally impacted canine using an edentulous ridge expansion (ERE) technique and air scaler surgical devices is described. A 74-yearold female patient had a maxillary left horizontally impacted canine. The tooth was extracted after elevating a partial-thickness flap and performing an ERE technique using air scaler surgical instruments. The impacted tooth was fragmented through the breach created in the expanded ridge, and the fragments were carefully removed. A suitably sized implant was placed at the time of surgery. The treated site healed without complication. The implant was integrated, successfully restored, and stable after a 3-year follow-up period. This case report demonstrates a novel surgical approach to extract an impacted canine through ridge expansion, using air scaler surgical devices that allow implant placement in an ideal position. Color Stability of Shade Guides After Autoclave Sterilization Schmeling, Max / Sartori, Neimar / Monteiro, Sylvio / Baratieri, Luiz<br>Page 688 - 693<br>This study evaluated the influence of 120 autoclave sterilization cycles on the color stability of two commercial shade guides (Vita Classical and Vita System 3D-Master). The specimens were evaluated by spectrophotometer before and after the sterilization cycles. The color was described using the three-dimensional CIELab system. The statistical analysis was performed in three chromaticity coordinates, before and after sterilization cycles, using the paired samples t test. All specimens became darker after autoclave sterilization cycles. However, specimens of Vita Classical became redder, while those of the Vita System 3D-Master became more yellow. Repeated cycles of autoclave sterilization caused statistically significant changes in the color coordinates of the two shade guides. However, these differences are considered clinically acceptable. Prospective Observational Study of the Early Loading of Nanostructured Calcium Phosphate-Coated Tapered Implants in the Mandible and Maxilla Kim, Young-Kyun / Yun, Pil-Young / Kim, Sung-Bum / Ahn, Kyo-Jin / Lee, Hyo-Jung / Yi, Yang-Jin / Kim, Su-Gwan<br>Page 694 - 703<br>The purpose of this study was to evaluate the prospective clinical results of early loading. Implants were inserted in 11 maxillae (group I, 23 implants) and 12 mandibles (group II, 19 implants). Six months after prosthetic loading, several factors were investigated. Significant differences between the primary and secondary stability were not observed in groups I and II. The primary stability in the mandible was 81.1 implant stability quotient (ISQ), which was significantly higher than the 73.3 ISQ value observed in the maxilla (P = .003). The survival rates were 100% in group I and 94.7% in group II for 9 and 10.4 months, respectively. The marginal bone loss was 0.07 mm in group I and -0.07 mm in group II. After the placement of nanostructured calcium phosphate- coated implants, excellent primary and second stability was obtained. Platelet-Rich Plasma Combined with Decalcified Freeze-Dried Bone Allograft for the Treatment of Noncontained Human Intrabony Periodontal Defects: A Randomized Controlled Split-Mouth Study Agarwal, Ashish / Gupta, Narindra Dev<br>Page 704 - 711<br>The aim of the present randomized split-mouth clinical trial was to compare plateletrich plasma (PRP) combined with a demineralized freeze-dried bone allograft (DFDBA) to DFDBA with a saline solution in the treatment of noncontained human periodontal intrabony defects. Forty-eight noncontained interproximal intrabony defects in 24 healthy nonsmoking patients diagnosed with chronic periodontitis were randomly assigned to the test group (PRP/DFDBA) or the control group (DFDBA/saline). Clinical (probing pocket depth, clinical attachment level [CAL], and gingival recession [REC]) and radiographic (bone fill, defect resolution, and alveolar crest resorption) measurements were made at baseline and at a 12-month evaluation. Compared with baseline, 12-month results indicated that both treatment modalities resulted in significant changes in all clinical and radiographic parameters. However, the test group exhibited statistically significantly greater changes compared with the control group in CAL (3.15 ± 0.50 versus 2.40 ± 0.61 mm), REC (0.54 ± 0.59 versus 1.23 ± 0.47 mm), bone fill (3.02 ± 0.50 versus 2.37 ± 0.47 mm), and defect resolution (3.29 ± 0.53 versus 2.69 ± 0.38 mm). Findings indicate that a combination of PRP and DFDBA is more effective than DFDBA with saline for the treatment of noncontained intrabony defects. Rehabilitation of the Atrophic Posterior Mandible with Short (4-mm) Implants: A Case Report Pistilli, Roberto / Barausse, Carlo / Checchi, Luigi / Felice, Pietro<br>Page 712 - 718<br>This case report describes a successful implant-prosthetic rehabilitation of an atrophic posterior mandible with 4-mm-long implants. The patient refused to undergo any reconstructive surgery, and because the available bone up to the inferior alveolar nerve was only 5 mm or less, the patient received four implants of 4-mm length. Four months after implant placement, a provisional prosthesis was put in place; after another 4 months, this was then in turn replaced with a definitive prosthesis. The use of such short implants allows a fixed prosthetic solution without the need for vertically augmenting the mandibular bone. This procedure considerably reduces intra- and postoperative patient discomfort compared with reconstructive surgery for the placement of longer implants. The follow-up time was 1 year after implant loading. A Follow-Up Study of up to 5 Years of Metal-Ceramic Crowns in Maxillary Central Incisors for Different Gingival Biotypes Tao, Jianxiang / Wu, Ying / Chen, Jianrong / Su, Jiansheng<br>Page 85 - 92<br>The objective of this prospective clinical study was to evaluate the outcomes of metal-ceramic crown restorations in maxillary central incisors for different gingival biotypes in a Chinese population. One hundred single metal-ceramic crowns were fabricated for 100 patients (50 for thin gingival type and 50 for thick gingival type) from April 2007 to October 2007 and evaluated according to the World Dental Federation criteria at baseline and annually at all follow-up examinations for 5 years. Gingival recession was recorded at the same time, as well. The failure-free rate over the 5-year clinical trial for thin gingival type (78.0%) was significantly lower than that for thick gingival type (94.0%; P = .02). Seven crowns were ranked as failures because of esthetic problems in patients with a thin gingival type. The restored teeth with a thin gingival type exhibited more gingival recession (1.09 ± 0.22 mm) than the control teeth (0.31 ± 0.16 mm; P = .01). Gingival biotype had a significant effect on the outcomes of metal-ceramic crown restorations in maxillary central incisors. Stress Distribution in Reduced Periodontal Supporting Tissues Surrounding Splinted Teeth Kurgan, Şivge / Terzioglu, Hakan / Yılmaz, Burak<br>Page 93 - 101<br>The aim of this study was to analyze the distribution of occlusal stresses for splinted and nonsplinted mandibular anterior incisors and to compare different splinting materials. A mandibular model was generated from a patient's computed tomography scan using three-dimensional (3D) software. The mandibular model presented with four periodontally compromised incisors and two canines with optimal bone support (two-thirds crown-root ratio). Three different splint materials (composite resin, metal-reinforced, and fiber-reinforced) were selected. Vertical and transverse loads were applied, and stress levels around the periodontal structures and splint materials were analyzed with 3D finite element analysis. The results showed that when bone levels around teeth decreased, the stress on the canine increased. Tested splinting materials were successful in stress distribution, and metal was better than the other splinting materials at distributing the stresses.