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Dental extractions are commonly performed in general veterinary practice for a variety of reasons. Owing to a lack of education in veterinary dentistry, veterinary surgeons often struggle with a consistently successful approach to tooth extraction. Without such education the occurrence of complications associated with tooth extraction will increase, including root fracture, jaw fracture and the formation of oronasal communications. A consistent approach, using a few well-practiced techniques, will allow for fewer complications and less frustration. This article aims to cover some of those basic techniques.

Retrospective study of jaw osteonecrosis treatment in patients using the "Krokodil" drug from 2009 to 2013. On the territory of the former USSR countries there is widespread use of a self-produced drug called "Krokodil". Codeine containing analgesics ("Sedalgin", "Pentalgin" etc), red phosphorus (from match boxes) and other easily acquired chemical components are used for synthesis of this drug, which used intravenously. Jaw osteonecrosis develops as a complication in patients who use "Krokodil". The main feature of this disease is jawbone exposure in the oral cavity. Surgery is the main method for the treatment of jaw osteonecrosis in patients using "Krokodil". 40 "Krokodil" drug addict patients with jaw osteonecrosis were treated. Involvement of maxilla was found in 11 patients (27.5%), mandible in 21 (52.5%), both jaws in 8 (20%) patients. 35 Lesions were found in 29 mandibles and 21 lesions in 19 maxillas. Main factors of treatment success are: cessation of "Krokodil" use in the pre- (minimum 1 month) and postoperative period and osteonecrosis area resection of a minimum of 0.5 cm beyond the visible borders of osteonecrosis towards the healthy tissues. Surgery was not delayed until sequestrum formation. In the mandible marginal or segmental resection (with or without TMJ exarticulation) was performed. After surgery recurrence of disease was seen in 8 (23%) cases in the mandible, with no cases of recurrence in the maxilla. According to our experience in this case series, surgery is the main method for the treatment of jaw osteonecrosis in patients using "Krokodil". Cessation of drug use and jaw resection minimize the rate of recurrences in such patients.

This study evaluated use of a solid-state laser to avoid the flap technique and suturing. An Er:YAG laser was used in 26 consecutive patients referred for osseous crown lengthening in 32 posterior teeth. The distance from the planned restoration margin to the alveolar crest (B) satisfied a 3-mm dentogingival complex. No tissue necrosis and no significant change in the distance from the gingival margin to B or probing depth were detected at 3 and 6 months. Minimally invasive Er:YAG laser surgery decreases the time needed to establish the gingival margin necessary for definitive restoration.

The success of autogenous tooth transplantation depends on the vitality of the periodontal ligament attached to the donor tooth, and its viability decreases when it is exposed extraorally. This report describes the case of a 16-year-old patient in whom a rapid prototyped tooth model was performed using cone-beam technology and a surgical template guide for autotransplantation as an effective technique for a critical time-based procedure.

Excessive gingival display (EGD) has a negative impact on a pleasant smile. Minimally invasive therapeutic modalities have become the standard treatment in many dentistry fields. Therefore, the aim of this study is to compare the clinical outcomes of open-flap (OF) and minimally invasive flapless (FL) esthetic crown lengthening (ECL) for the treatment of EGD.A split-mouth randomized controlled trial was conducted in 28 patients presenting with EGD. Contralateral quadrants received ECL using OF or FL techniques. Clinical parameters were evaluated at baseline and 3, 6, and 12 months post-surgery. The local levels of receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) were assessed by enzyme-linked immunosorbent assay at baseline and 3 months. Patients' perceptions regarding morbidity and esthetic appearance were also evaluated. Periodontal tissue dimensions were obtained by computed tomography at baseline and correlated with the changes in the gingival margin (GM).Patients reported low morbidity and high satisfaction with esthetic appearance for both procedures (P0.05). RANKL and OPG concentrations were increased in the OF group at 3 months (P0.05). Probing depths were reduced for both groups at all time points, compared with baseline (P0.05). There were no differences between groups for GM reduction at any time point (P0.05).FL and OF surgeries produced stable and similar clinical results up to 12 months. FL ECL may be a predictable alternative approach for the treatment of EGD.

Previous studies on crown lengthening (CL) report contradictory results regarding stability of crown length gained at the time of surgery. The "3-mm rule" has dictated the amount of alveolar bone to be removed during CL surgery for decades. With the current understanding of wide variations in supracrestal gingival tissue (SGT) dimensions, bone removal can be customized to the situation. The purpose of this study is to assess alterations in periodontal tissue levels 6 months after CL surgery and to evaluate factors that may influence stability of CL achieved over time.Sixty-four patients requiring CL surgery on 64 teeth are included in this study. Clinical parameters were recorded along six surfaces of treated tooth and neighboring teeth. Sites were labeled as treated sites, adjacent sites, and non-adjacent sites. Bone was reduced based on the minimal amount of tooth structure required for restorative purpose and SGT dimensions at each site. Patients were re-evaluated at 3 and 6 months.Significant soft-tissue rebound (0.77 ± 0.58 mm) was observed 6 months after CL surgery. This rebound was found to be significantly correlated with periodontal biotype (r = 0.325, P = 0.000) and post-suturing flap position (r = -0.601, P = 0.000). SGT was not reestablished to its preoperative dimensions by the end of 6 months (P = 0.001).Crown length gained during surgery significantly decreased 6 months post-surgery. Suturing the flap ≤3 mm from the osseous crest and thick-flat biotype were associated with greater tissue rebound.

Ameloblastic fibroodontoma (AFO) is a rare entity of mixed odontogenic tumors and frequently arises from posterior portion of the maxilla or mandible in first two decades of life. Herein, a 35-year-old woman with a noncontributory medical history who presented with a progressive left maxillary toothache, left maxillary first molar tooth mobility, and swelling in the left maxillary molar area for the last 2 months was reported. Radiologically, a tumor that originated from periapical area of the second mature molar teeth of maxilla was seen and additively unerupted tooth was not detected. The histopathologic examination revealed AFO. The patient is disease-free for five years after treated with limited segmental alveolectomy combining with Caldwell-Luc procedure.

Purpose Close proximity of the inferior alveolar nerve (IAN) to mandibular third molars (MTMs) may result in nerve injury during the extraction of third molars. Alternative surgical techniques, such as coronectomy, have been suggested to decrease this risk. This study examined a new alternative technique, the pericoronal ostectomy (PO), that is intended to decrease IAN injury in high-risk cases. Patients and Methods This prospective clinical cohort study consisted of 14 patients with 17 MTMs in close relation to the IAN. All patients were subjected to 2- and 3-dimensional preoperative radiographic evaluations. Selected patients with mesioangular and vertical bone impactions were treated by the staged PO technique. An institutional review board approval from the University of the Pacific was given to this study. Results Because of the PO procedure, all 17 high-risk MTMs in the study erupted to a more occlusal position away from the danger zone of the IAN and were eventually removed (mean distance of eruption, 2.0 mm). Three patients reported a transient neurosensory deficit, 2 with the IAN and 1 with a lingual nerve. All 3 had a full resolution of symptoms within 3 months of the postoperative period. Conclusion The PO technique appears to be an additional viable alternative technique to extraction of MTMs in intimate proximity to the IAN.

Purpose Ostectomies, performed by different methods, are often necessary in oral and maxillofacial surgery. Rotatory and reciprocating devices are most frequently used but have disadvantages, such as noise, vibration, and the potential for inducing thermal damage. Laser systems are interesting alternatives to these procedures. We analyzed bone healing in a rat model after mandibular ostectomy with a surgical bur or noncontact erbium:yttrium-aluminum-garnet laser using different energy levels. Materials and Methods Four groups of 5 rats each underwent ostectomy of the bone cortical of the mandibular body, with irrigation, using a surgical bur or erbium:yttrium-aluminum-garnet laser with different energy parameters. A metal plate was used for morphologic standardization of the cavities. The samples collected after 7, 14, 45, 60, and 90 days were analyzed by optical microscopy. Results The ostectomies performed with surgical burs resulted in bone healing from the cortical endosteum and remaining trabecular bone. The cortical endosteum was repaired after 45 days, followed by bone remodeling. After laser irradiation, healing involved bone neoformation from the external cortical surface and endosteum. Surface regions with thermal damage were observed after laser treatment in the 3 conditions used up to day 60, followed by bone remodeling. Conclusions Laser ostectomies resulted in a thin layer of thermal damage. Bone healing was faster when surgical burs were used, with similar results reached after 90 days.

Patients with impacted ectopic canines often present to Orthodontic and Oral and Maxillofacial units, with 85% being displaced palatally. Current orthodontic opinion suggests that the creation of adequate space ultimately allows the spontaneous eruption of most impacted canines, but we are often requested to operate to facilitate their eruption. There are several approaches, techniques that vary depending on whether orthodontically assisted or spontaneous eruption is expected. There are few publications that describe either the techniques or their merits. We have used a gingival-sparing technique for more than 10 years in this unit. To determine current practice, we carried out a national postal survey of consultant oral and maxillofacial surgeons and staff grade/associate specialists. A total of 564 questionnaires were sent, and 353 replies were received (63%). There was considerable variation in the design of mucosal flaps used for exposure of the canines. Only 9% of clinicians avoided the gingival margin of the adjacent erupted teeth during operation. We describe this unit's practice of sparing the gingival margins, and highlight the merits of this technique.

All-on-4 treatment is facilitated by bone reduction to create prosthetic restorative space, establish maximum anterior posterior spread of implants, and to avoid pneumatized sites. Unlike a reduction alveloplasty for denture placement, the All-on-4 shelf enables optimal surgical prosthetic management of implant placement for the fixed hybrid prosthesis.

Purpose Calcium sulfate (CaS) is a simple, biocompatible material with a very long, safe clinical history in several different fields of medicine. CaS is a rapidly resorbing material that leaves behind a calcium phosphate lattice, which promotes bone regeneration and hemostasis. The aim of this study was to perform a clinical evaluation of a possible hemostatic effect of calcium sulfate hemihydrate (CaSO 4 ), commonly known as plaster of Paris, in the surgical and orthodontic treatment of impacted teeth. Materials and Methods Forty-three patients with 66 impacted cuspids and premolars were enrolled in this study. The gap between teeth and bone was filled with several layers of CaS cement. Each layer was put in place and was compressed with a dry gauze. The outer layer was then hardened with a potassium sulfate solution. After hardening, the CaS excess was removed, and a bracket was applied to the surface of the tooth. Results In no case was a separation of the bracket by the surface of the tooth observed. Conclusions These results seem to confirm the usefulness of the hemostatic effect of CaS in this procedure.

In an attempt to help produce guidelines for the use of soft tissue punches, this animal study was undertaken to examine the effects of soft tissue punch size on the healing of peri-implant tissue in a canine mandible model.Bilateral, edentulous, flat alveolar ridges were created in the mandibles of 6 mongrel dogs. After a 3-month healing period, 3 fixtures (diameter 4.0 mm) were placed on each side of the mandible using 3-mm, 4-mm, or 5-mm soft tissue punches. After subsequent healing periods of 3 weeks and 3 months, the peri-implant mucosa was evaluated using clinical, radiologic, and histometric parameters, which included gingival index, bleeding on probing, probing pocket depth, marginal bone loss, and vertical dimension measurements of the peri-implant tissues.The results obtained showed significant differences (P.05) between the 3-mm, 4-mm, and 5-mm tissue punch groups for the length of the junctional epithelium, probing depth, and marginal bone loss at both 3 weeks and 3 months after implant placement. When the mucosa was punched with a 3-mm tissue punch, the length of the junctional epithelium was shorter, the probing depth was shallower, and less crestal bone loss occurred than when using a tissue punch with a diameteror=4 mm.The results show that the size of the soft tissue punch plays an important role in achieving optimal healing. The findings support the use of a tissue punch slightly narrower than the implant itself to obtain better peri-implant tissue healing around flapless implants.

Purpose The aim of this study was to compare root development after transplantation of teeth into surgically created sockets or into fresh extraction sites. Patients and Methods The sample consisted of 62 patients with a total of 64 transplanted immature third molars. All transplants were at root development stages 3 to 4. In 22 cases, a new socket was created by means of burs. Forty-two teeth transplanted into a fresh extraction site served as controls. Postoperative root development was determined on intraoral radiographs taken immediately after transplantation and at the final follow-up. For all transplants, extraoral storage time and number of trials were recorded during transplantation. Results No significant intergroup differences were observed at root development stage 3. In contrast, at root development stage 4 transplantations to surgically created sockets showed a significantly lower final root length (P = .025) and root length increment (P = .038) than transplants in the control group. In addition, a significant correlation was determined in the prepared socket group at developmental stage 4 between root length increment and extraoral storage time (r = −0.910, r2 = 0.828, P < .001) or number of trials in the recipient socket (r = −0.775, r2 = 0.601, P < .001). Conclusions Teeth at advanced developmental stages transplanted to surgically created sockets show an impaired postoperative root development. A possible explanation might be damage of Hertwig's epithelial root sheath during the transplantation procedure.

Objective: The effects on periodontal tissues of adjacent second molars after semi-impacted mandibular third molar surgery were evaluated. The influence of flap design was studied. Methods: Twenty volunteers randomly underwent the three-cornered flap technique (group A) or the distal wedge flap technique (group B). The periodontal probing depth was measured by using a ‘Williams’-type probe just prior to surgery and three months post-operatively. Six sites, mesio-buccal, buccal, disto-buccal, disto-lingual, lingual and mesio-lingual, around the second molar were selected for measurement. Kruskal–Wallis test and Dunn test (post hoc) were used. Significance level was set at 5%. Results: There were no complications (oedema, alveolitis, etc.) in any of the patients of the study. The results showed that both methods caused shallow pocket depth (P > 0.05) and there were no statistically significant differences between the flap techniques (P > 0.05). Flap design was not an important factor affecting the periodontal status of the second molar. Conclusion: The decision to use any of the various flap designs for access to mandibular third molars should be based on operator preference rather than on the assumption that periodontal health of the adjacent second molar will be improved.

Alveolar ridge augmentation using intraoral autogenous block grafts to augment localized alveolar ridge defects before implant placement is a predictable method. However, large severely atrophic edentulous segments may require extraoral donor sites. The purpose of this study was to evaluate the effectiveness of using intraoral cortical block grafts in combination with particulate human mineralized allograft, in a "tenting" fashion, to augment large atrophic alveolar ridge defects for implant placement.This prospective case study evaluated augmentation in 10 consecutive patients with severely resorbed alveolar ridges missing a minimum of 4 adjacent teeth. Before augmentation, all grafted sites were deemed inadequate for placement of a standard 4-mm-diameter implant. Horizontal ridge augmentation was performed using autologous membranous cortical bone grafts from an oral donor site to tent out the soft tissue matrix and periosteum for the adjacent particulate allograft. The ridges were clinically evaluated 4 to 5 months after augmentation, and 42 implants were placed at that time.Implants were successfully placed at all grafted sites 4 to 5 months after the original graft date. Clinical evaluation of the grafted sites upon re-entry revealed uniform ridge anatomy. All edentulous segments had at least 2 implants placed of at least 4.0 mm diameter. In all, 42 implants were placed into grafted sites in the 10 patients. Implants were checked for osseointegration by using a counter torque of 35 N.cm. One implant failed to integrate. Mean follow-up was 22 months after implant placement. All augmented ridges had retained their functional and esthetic integrity at 1 year after original augmentation.Tenting of the periosteum and soft tissue matrix using a cortical bone block maintains space and minimizes resorption of the particulate allograft volume. In addition, bridging the cortical blocks with particulate bone avoids unaesthetic ridge defects between cortical block grafts in larger ridge defects. The result was a more uniform and esthetic alveolar ridge, capable of maintaining an implant-supported prosthesis. The technique offers predictable functional and esthetic reconstruction of large-volume defects without extensive amounts of autogenous bone. This offers a superior functional and esthetic result than with either cortical or particulate grafting alone.

This is the second paper in this two-part series. Paper one provided an overview of managing gingival tissue excess and paper two will focus on increasing clinical crown height to facilitate restorative treatment. Crown lengthening is a surgical procedure aimed at the removal of gingival tissue with or without adjunctive bone removal. The different types of procedure undertaken will be discussed over the two papers. In order to provide predictable restorations, care must be taken to ensure the integrity of the margins. If this is not taken into account it can lead to an impingement on the biologic width, which may in turn lead to chronic inflammation resulting in recession or the development of periodontal problems which can be hard to manage. Clinical Relevance: This paper aims to reinforce the need for thorough diagnosis and treatment planning and provides an overview of the various procedures that can be undertaken.

Crown lengthening surgery aims to increase the amount of supragingival tooth tissue by resection of the soft and/or hard tissues to enable otherwise unrestorable teeth to be restored by increasing the retention and resistance forms of the teeth. Restoration of the worn dentition may require significant prosthodontic knowledge and skill. A prosthodontist should be involved from the beginning of the management of the patient. A number of key stages should be considered for correct management. Although the periodontist may guide the prosthodontist with regards to what may or may not be possible surgically, the overall treatment plan should be prosthodontically driven. Clinical Relevance: Toothwear of the anterior dentition provides a unique challenge to restore not only function but also to manage the aesthetic demands of the patient. To ensure that the correct outcome is reached, clinicians should be familiar with the normal anatomical proportions and relationships to enable planning and treatment to take place.

This is the first article in a two-part series which aims to provide an overview of the different techniques used to increase clinical crown height. In the first paper, the focus will be on the management of patients who present with gingival tissue excess. The different aetiologies are discussed and illustrated with clinical cases, following which a range of procedures that may be employed in the management of these patients are presented. With an increasingly ageing population, more patients are taking regular medications prescribed from their general medical practitioner, and so having a working knowledge of the specific drugs that may cause gingival enlargement is essential. Clinical Relevance: When patients with gingival tissue excess present in primary or secondary care, a clinician must have a good knowledge of the possible causes of the condition, as well as an idea of how the patient may be managed.

BACKGROUND: The aim of this study was to assess soft-tissue re-growth following Fibre Retention Osseous Resective Surgery (FibReORS) or Osseous Resective Surgery (ORS) over a 12-month healing period. MATERIAL AND METHODS: Thirty patients with chronic periodontitis showing persistent periodontal pockets at posterior natural teeth after cause-related therapy were enroled. Periodontal pockets were associated with infrabony defect ?3�mm; 15 patients were randomly assigned to FibReORS (test group) and 15 to ORS (control group). Measurements were performed by a blind and calibrated examiner. Soft-tissue rebound after flap suture was monitored by changes in gingival recession at 1-, 3-, 6-, and 12- month follow-up. Multilevel analysis considering patient, site, and time levels was performed. RESULTS: Greater osseous resection during surgery and higher post surgical gingival recession was observed in the ORS group. The mean amount of soft-tissue rebound following surgery was 2.5�mm for ORS-treated sites and 2.2�mm for FibReORS-treated sites. Approximately 90% of the coronal re-growth was detectable after 6�months for both procedures. The interaction between ORS and time of observation showed a higher soft-tissue rebound after 12�months (p�=�0.0233) for ORS-treated sites. CONCLUSIONS: Both procedures showed a similar coronal soft-tissue re-growth with a significant higher recession reduction for ORS-treated sites. Significant clinical stability of the gingival margin is obtained 6�months after surgery for both procedures.

AIM The aim of this split-mouth clinical trial was to compare the effectiveness of Apically Positioned Flap with Fibre Retention Osseous Resective Surgery (FibReORS) or Osseous Resective Surgery (ORS) in the treatment of periodontal pockets associated with intrabony defects ≤ 3 mm at posterior natural teeth. MATERIALS AND METHODS Twenty-six posterior sextants requiring osseous resective surgery were selected in 13 chronic periodontitis patients: 13 sextants were randomly assigned to ORS and 13 to FibReORS. Clinical evaluation of probing depth (PD), gingival recession and clinical attachment level was performed at baseline, 6 and 12 months postoperatively. Periapical radiographs were taken prior and after surgical treatment, at 6- and 12-month follow-up. RESULTS Ostectomy amounted to 1.0 ± 0.3 mm in the ORS group and to 0.4 ± 0.2 mm in the FibReORS group. At 12-month examination PD changes did not significantly differ between the experimental groups. ORS group showed significantly (p < 0.001) greater clinical attachment loss (2.2 ± 1.0 mm versus 1.0 ± 0.6 mm), radiographic bone resorption (0.43 ± 0.08 mm versus 0.13 ± 0.09 mm) and post-operative patient discomfort compared to FibReORS. CONCLUSION FibReORS resulted in similar PD reduction, but less ostectomy, clinical attachment loss and patient morbidity compared to ORS.

Myofibroma is a solitary myofibroblastic proliferative neoplasm occurring predominantly in infants and children. Myofibroma rarely arises in the oral and maxillofacial region. We report a case of myofibroma of the mandibular gingiva in a 15-year-old girl. She noticed a gradual swelling in the right mandibular molar region 1 month previously and was referred to our hospital. A soft elastic mass arising in the right molar gingiva, measuring 1.2×1.0-cm, was recognized. An incisional biopsy of the mass yielded a diagnosis of myofibroma. Because the tumor grew rapidly after the biopsy, excision of the tumor with alveolectomy of the mandibular molar region was performed. She has no evidence of recurrence 3 years 9 months after surgery.

Recently, there has been much research done into the regenerative potential of materials used in oriental medicine. In several studies, evidence was found that these materials have an effect on bone regeneration. Among these materials, safflower seeds are of particular interest as they have been used for the treatment of blood stasis, bone fracture, and osteoporosis in traditional Korean medicine. In addition, they are known to have anti-inflammatory effects. The objective of this study is to evaluate the periodontal tissue regenerative effects of a bioabsorbable barrier membrane (polylactide glycolic acid electro-spun non-woven membrane) containing safflower seed extracts applied to surgically created 1-wall intrabony defects in beagle dogs.One-wall intrabony defects were surgically created bilaterally at the mesial and distal sides of the mandibular second premolars and mesial side of the fourth premolars. These defects were randomly assigned either to the surgical control group which received a flap operation only or to one of two experimental groups consisting of defects which received a guided tissue regenerative procedure with either a bioabsorbable membrane (PLGA) or a bioabsorbable membrane containing safflower seed extracts (SSE/PLGA). The dogs were sacrificed 8 weeks after the operation, and a comparative histological examination was done.The new cementum formation was 2.49+/-0.41 mm in the surgical control group, 3.22+/-0.35 mm in the PLGA group, and 3.67+/-0.82 mm in the SSE/PLGA group. The extent of new cementum formation in barrier groups was significantly different from the surgical control group (P0.05). The amount of intrabony cementum was 1.75+/-0.06 mm, 2.40+/-0.33 mm, and 2.70+/-0.81 mm for the surgical control group, the PLGA group, and the SSE/PLGA group, respectively; the amount of infrabony cementum in the barrier groups was significantly different from the surgical control group (P0.05). The value of the suprabony cementum was 0.73+/-0.48 mm, 0.82+/-0.21 mm, and 0.97+/-0.09 mm for the surgical control group, the PLGA group, and the SSE/PLGA group, respectively, with no significant differences being observed among the treatments. The amount of new alveolar bone formation was 1.74+/-0.25 mm, 2.36+/-0.30 mm, and 2.64+/-0.74 mm for the surgical control group, the PLGA group, and the SSE/PLGA group, respectively, with a significant difference exhibited between the surgical control group and other groups (P0.05). Superficial root resorption was often observed, but ankylosis was not present.Our results suggest that surgical application of polylactide glycolic acid non-woven membrane with or without safflower seed extract could promote the regeneration of alveolar bone and cementum in intrabony periodontal defects.

Purpose Lingual nerve damage following lower third molar surgery remains a clinical problem. The traditional approach in the United States has been a buccal approach avoiding exposure or surgery on the lingual side of the crest of the ridge. An alternative technique is to deliberately expose the lingual tissues and retract the lingual nerve lingually before tooth removal. This study reports a trial of this technique. Materials and methods Patients had removal of their lower third molars carried out using a technique that raises a lingual flap in addition to a buccal flap and places a specially designed lingual retractor to ensure that the lingual nerve is held out of the surgical field. This technique was used in cases where the crown of the tooth had to be sectioned or when distal bone needed to be removed. Results Two hundred fifty patients were treated by this method. There were 4 cases of transient lingual paresthesia, presumably caused by traction pressure from the retractor. Three of these cases were mild and resolved within 3 weeks. The fourth case had more profound paresthesia, but still resolved within 2 months. There were no cases of permanent nerve damage, and in many cases removal of the third molar was simplified by the superior access. Conclusion Lingual retraction for third molar removal improves access to the surgical site and can simplify third molar removal. In this prospective study there were no cases of permanent lingual nerve injury.

Despite the fact that surgical crown lengthening is a commonly performed treatment, little is known about the specific surgical endpoints of the procedure or the stability of the newly attained crown height over time. Recent clinical reports have ranged across a spectrum from significant tissue rebound to remarkable stability using similar surgical techniques. The purpose of this study was to assess the stability of surgical crown lengthening procedures performed by various surgeons using specific guidelines to determine surgical endpoints. Specifically, we sought to determine the following: 1) What is the immediate increase in clinical crown height following surgery? 2) How stable is the established crown length over a 6-month period? 3) How much supporting bone is removed to establish the new crown length? 4) How does the position of the flap margin relative to the alveolar bone at surgical closure relate to the stability of crown height?Twenty-five patients requiring crown lengthening of 43 teeth were included in this study. Clinical indices recorded at eight sites on each molar and six sites on each premolar included plaque, bleeding on probing, probing depth, and relative attachment level from a customized probing stent. Surgical measurements at the same sites included the distance from stent to alveolar bone both before and after osseous surgery and the distance from flap margin to alveolar bone after suturing. Clinical measurements were repeated at 1, 3, and 6 months after surgery. Sites were divided into three groups. All sites on teeth targeted for crown lengthening were labeled treated sites (TT). Interproximal sites on neighboring teeth were labeled adjacent (AA) if they shared a proximal surface with a treated tooth and nonadjacent (AN) if they were on the opposite side, away from the treated tooth.Throughout the entire 6-month healing period, descriptive statistics revealed no significant time or group differences in plaque and bleeding scores. At treated sites, the mean gain of crown height at surgery was 2.27 +/- 1.1 mm. This was reduced to 1.91 +/- 1.08 mm at 1 month, 1.69 +/- 1.02 mm at 3 months, and 1.57 +/- 1.01 mm at 6 months. At adjacent sites, the gain of crown length was 2.18 +/- 0.98 mm, 1.61 +/- 0.98 mm, 1.43 +/- 0.96 mm, and 1.30 +/- 0.96 mm at surgery, 1, 3, and 6 months, respectively. At non-adjacent sites the crown height increased 1.06 +/- 1.07 mm, 1.00 +/- 0.93 mm, 0.84 +/- 1.00 mm, and 0.76 +/- 0.85 mm, respectively. These mean measurements were significantly different for each treatment group at each time interval and appeared not to have stabilized between 3 and 6 months. The mean osseous reduction at treated, adjacent, and non-adjacent sites was 1.13 +/- 0.90 mm, 0. 78 +/- 0.75 mm, and 0.065 +/- 0.69 mm, respectively. Frequency distribution of osseous reduction demonstrated that 23.6% of treated sites had 0 mm, 44.3% had 1 mm, 25.4% had 2 mm, 6.2% had 3 mm, and less than I % hador = 4 mm of bone removed to establish crown height More bone removal was noted at premolar than at molar sites; however, this was not statistically significant. When tissue rebound following surgery was plotted against post-surgical flap position, it was noted that the closer the flap margin was sutured to the alveolar crest, the greater the tissue rebound during the post-surgical period. This rebound ranged from 1.33 +/- 1.02 mm when the flap was suturedor = 1 mm from the alveolar crest, to -0.16 +/- 1.15 mm when the flap was suturedor = 4 mm from the alveolar crest.These data suggest that there is a significant tissue rebound following crown-lengthening surgery that has not fully stabilized by 6 months. The amount of tissue rebound seems related to the position of the flap relative to the alveolar crest at suturing. These findings support the premise that clinicians should establish proper crown height during surgery without overreliance on flap placement at the osseous crest.

Objectives: This pilot study was designed to test whether biochemical markers of bone turnover in washes of periosteal or trabecular alveolar bone surfaces could be correlated with increases in bone density of an adjacent healing implant socket. Methods: Ten subjects had a canula inserted into the alveolar crest and sterile phosphate-buffered saline was washed over the periosteal and trabecular surfaces and collected. Surgical flaps were reflected, 5 mm diameter bone cores were removed from the bone wash site, and standardized radiographs were taken. The sites were allowed to heal for 12 weeks, and radiographs were repeated. Bone washes of the healing sites were also collected after 2 and 12 weeks. Washes were analysed for bone turnover markers osteocalcin (OC; radioimmunoassay) and C-terminal telopeptide of Type 1 collagen (ICTP; enzyme-linked immunosorbent assay (ELISA)), and blood component albumin (ALB; ELISA). Changes in bone density during healing were determined by radiographic absorptiometry. Results: OC/ALB and ICTP/ALB ratios were higher for trabecular than periosteal washes at baseline (p0.01). Trabecular OC/ALB and ICTP/ALB were inversely correlated with increasing bone density of the healing bone core socket (r=−0.72, p=0.03; Pearson's correlation coefficient). Conclusions: Biochemical markers of bone turnover in bone washes of specific alveolar bone sites may prove helpful in predicting how the bone density will increase around healing dental implants.

The objective of this study was to histologically evaluate periodontal healing following flap surgery in intrabony periodontal defects to determine the influence of the number of bone walls on periodontal regeneration.One-, 2-, and 3-wall intrabony periodontal defects were surgically produced at the proximal aspect of mandibular premolars in either right or left jaw quadrants in six beagle dogs. Mucoperiosteal flaps were positioned and sutured to their presurgery position following defect preparation. The animals were euthanized at 8 weeks post-surgery, and block sections of the defect sites were collected for histologic and histometric analysis.Bone and cementum regeneration was positively correlated to the number of bone walls limiting the intrabony periodontal defects. The junctional epithelium averaged (+/- SD) 1.5 +/- 0.2, 1.2 +/- 0.3, and 0.9 +/- 0.2 mm for the 1-, 2-, and 3-wall defects, respectively, with the 3-wall defects being significantly different from the 1-wall defects (P0.05). Cementum regeneration averaged 1.2 +/- 0.6, 2.0 +/- 0.6, and 2.8 +/- 0.5 mm for the 1-, 2-, and 3-wall defects, respectively; all groups were significantly different from each other (P0.05). Bone regeneration averaged 1.5 +/- 0.5, 1.7 +/- 0.6, and 2.3 +/- 0.5 mm for the 1-, 2-, and 3-wall defects, respectively, with the 3-wall defects being significantly different from the 1-wall defects (P0.05).The results suggest that the number of bone walls is a critical factor determining treatment outcomes in intrabony periodontal defects. One- and 3-wall intrabony defects appear to be reproducible models to evaluate candidate technologies for periodontal regeneration.

Objective The development of biomaterials for secondary bone grafting to the alveolar cleft, recombinant human morphogenetic protein-2 (rhBMP-2) may have great potential to promote osseous regeneration. The purpose of this study was to investigate the osteoinductive activity of low-dose rhBMP-2 (10 μg/100 μL) and the biological response of newly generated bone to orthodontic stimulation, compared with previous results using high-dose rhBMP-2 (40 μg/100 μL). Method After extraction of the maxillary first premolars, bone defects were surgically created in eight adult beagle dogs using a 5-mm-diameter trepan bar. The rhBMP-2 with a PLGA/gelatin sponge complex (PGS) made of gelatin and polylactic acid polyglycolic acid copolymer was immediately implanted. The osteoinductive activity of rhBMP-2 and tooth movement into the newly generated bone was evaluated based on histological and morphometric examination. Results Dramatic histological and morphometric differences were found in the time course of bone remodeling between low- and high-dose rhBMP-2. The onset of bone remodeling occurred significantly earlier in low-dose rhBMP-2. During experimental tooth movement, in contrast to high-dose rhBMP-2, with which root resorption occurred, only partial cementum resorption occurred on the pressure side with low-dose rhBMP-2. Conclusion These results indicated that the proper dosage of rhBMP-2 should be determined for successful clinical application.

Previous surgical crown lengthening studies have investigated positional changes of the free gingival margin but not the biological width. Histological studies utilizing animal models have shown that postoperative crestal resorption allowed reestablishment of the biological width. However, very little work has been done in humans. Therefore, the purpose of this study was to evaluate the positional changes of the periodontal tissues, particularly the biological width, following surgical crown lengthening in human subjects.Twenty-three (23) patients who needed surgical crown lengthening to gain retention necessary for prosthetic treatment and/or to access caries, tooth fracture, or previous prosthetic margins entered the study. The following parameters were obtained from line angles of treated teeth (teeth requiring surgical crown lengthening) and adjacent teeth with adjacent and non-adjacent sites: plaque and gingival indexes, free gingival margin, probing depth, attachment level, bone level, direct bone level, and biological width. During surgery, the bone level was reduced based on the future prosthetic margin and predetermined biological width; flaps were placed at the bony crest. Patients were examined at baseline and at 3 and 6 months postoperatively.Eighteen patients completed the study. Overall, the amount of bone resected was 1 to 5 mm. At 90% of treated sites,or = 3 mm of bone was removed. At 3 months, the apical displacement of the free gingival margin at non-adjacent, adjacent, and treated sites was 2.46 +/- 0.25 mm, 2.68 +/- 0.20 mm, and 3.07 +/- 0.16 mm, respectively. There was no significant change in the position of the free gingival margin from 3 to 6 months. The biological width at all sites was smaller at 3 and 6 months compared to baseline (P0.05) except for the treated sites, which were not significantly different from baseline at 6 months.During surgical crown lengthening, the bone level was lowered for placement of the prosthetic margin and reestablishment of the biological width. The biological width, at treated sites, was reestablished to its original vertical dimension by 6 months. In addition, a consistent 3 mm gain of coronal tooth structure was observed at the 3- and 6-month examinations.

Objectives: To evaluate the significance of mandibular bone invasion by gingival carcinoma revealed by reformatted dental CT images as a prognostic indicator of cervical metastasis. Methods: Thirty-two patients with squamous cell carcinoma of the lower gingiva were examined by dental CT. Cervical metastases and survival rates of these patients were analysed in relation to their clinical characteristics, histologic grading based on gingival biopsy, and mandibular bone invasion using reformatted dental CT imaging diagnoses prior to surgery. The dental CT images were classified into four types: Class I, no bone invasion; Class II, invasion confined to the alveolus; Class III, invasion extending between the alveolus and the mandibular canal; and Class IV, invasion beyond the mandibular canal. Results: Logistic multivariate regression analysis showed that bony invasion identified on dental CT images was a significant prognostic factor in cervical metastases (P=0.028). The 5year overall survival rates of Classes I, II, III, and IV were 100% (n=9), 76.2% (n=9), 71.4% (n=7), and 28.6% (n=7), respectively. Conclusions: The evaluation of mandibular bone invasion using dental CT images is useful as a prognostic indicator of cervical metastasis for patients with gingival carcinoma. Dentomaxillofacial Radiology (2002) 31, 339‐343. doi:10.1038/sj.dmfr.4600726

Purpose Although treatment of cleft lip and cleft palate is becoming standardized, treatment of alveolar cleft remains controversial. Thus, preclinical animal work remains necessary to improve clinical outcome. This study established an alveolar cleft model in the rat. Materials and Methods Maxillary first molars were extracted to create a 4- × 4- × 3-mm complete alveolar cleft on the right and left sides in 25 8-week-old Sprague-Dawley rats. The left cleft was filled with bone wax and the right side remained untreated. Animals were sacrificed at 0, 4 and 8 weeks after surgery. Harvested alveolar cleft samples were evaluated by micro-computed tomographic and histologic analyses. Results The healing rate and osteoblast activity of the left cleft were less than those of the right cleft. Conclusion This model of a critical-size alveolar cleft can be used efficiently for the therapeutic evaluation of novel techniques for the treatment of alveolar cleft.

The aim of the present study was to evaluate the effect of periodontal dressing on post-operative pain and swelling after surgical crown lengthening.A blind, randomized, clinical trial was carried out with 36 patients. Following surgical crown lengthening, the individuals were randomly allocated to the periodontal dressing group (PDG) and control group (CG, non-placement of periodontal dressing). Pain and discomfort were analyzed using a visual analog scale (VAS), verbal scale (VS) and the number of analgesics consumed in 7 days post-operatively. Post-operative infection, stability of the gingival margin and type of healing were also evaluated.The PDG had a significantly higher percentage of responses of 'strong pain' on the VS in the first day post-operatively (33.3% vs 5.3%, p = 0.03) and greater pain on the first and second days post-operatively based on the VAS. Moreover, a significant difference between groups was found regarding gingival swelling after 7 days. However, gingival recession was found in 57.8% of the sites in the CG and only 5.5% of sites in the PDG. No change in condition was found among individuals with conjunctive tissue/bone exposure in the CG in the immediate post-operative period and 80% of the patients in the PDG had healing by first intention after 7 days.The use of periodontal dressing seems to be preferable following surgical crown lengthening with connective tissue/bone exposure. However, adequate post-operative analgesic strategies should be employed due to the possibility of intense pain in the first 24 hours.

The correction of diastemas in the anterior region with composite resin is considered to be practical and conservative. Harmony between the restorative material and the periodontium is necessary to achieve satisfactory functional and esthetic results. Whenever excessive gingiva occurs in the interproximal region, removal is necessary to avoid excessively contoured restorations. A predictable technique is described to conservatively remove interproximal tissue in situations in which crown lengthening is required to treat bilateral diastemas. A surgical template based on the diagnostically waxed cast was produced to serve as a reference during periodontal surgery.

OBJECTIVE: To propose and evaluate a novel surgical approach with minimal trauma, termed interseptal bone reduction, combined with the use of a conventional orthodontic fixed appliance to accelerate canine retraction. MATERIALS AND METHODS: A split-mouth design study was conducted in 18 female subjects (mean age, 21.9 years) whose bilateral upper first premolars were extracted and who subsequently received canine distalization. The extraction socket on the experimental side was deepened, and interseptal bone distal to the maxillary canine was reduced in thickness using a surgical bur; conventional extraction was performed on the control side. The canines were then distalized using elastomeric chains on both the labial and palatal sides, with a net force of 150 g. The extent of canine movement and rotation was determined from study models, and the angulation was analyzed based on lateral cephalograms. RESULTS: A Wilcoxon signed rank test demonstrated that the extent of canine movement in the mesio-distal direction after 3 months was significantly greater on the experimental side than on the control side (5.4 and 3.4 mm, respectively, P = .002). However, there was no statistically significant difference in canine angulation or rotation after 3 months between the experimental and control sides. CONCLUSIONS: In combination with the use of conventional orthodontic appliances, interseptal bone reduction can enhance the rate of canine movement when interseptal bone is sufficiently reduced in both thickness and depth following surgical criteria.

Root coverage procedures using subgingival soft tissue grafts or guided tissue regeneration have attracted much interest within the past 2 decades. Recently, acellular dermal matrix allograft (ADMA) has been introduced as a substitute for palatal donor tissue in gingival augmentation procedures. This study was undertaken to examine the potential of ADMA to be used as a substitute for autogenous connective tissue graft material in a root coverage procedure in a case with moderate gingival recession combined with reduced keratinized attached gingiva. After thorough root planing and conditioning of the root surface with a saturated solution of tetracycline-HCl, a trapezoidal mucoperiosteal flap was raised and the papillae were de-epithelialized. The exposed bone surrounding the exposed root surface was perforated with a No. 2 round drill, and the exposed root and surrounding bone were covered by ADMA. The allograft was stabilized by 5-0 vicryl sutures. The flap was coronally positioned to completely cover the ADMA. Healing was uneventful. Eight-month observations and measurements showed root coverage of more than 3.5 mm (80%), a gingival margin that was harmonious with the neighboring teeth, and an increase of the zone of keratinized attached gingiva, from 1 to 3 mm. Within the limitations of these clinical observations, it is suggested that ADMA may be a possible substitute to free autogenous connective tissue grafts and/or bioabsorbable barrier membranes. Further clinical and histological studies are necessary to understand the healing process of this surgical wound.

The relationship between probing attachment changes in treated periodontal pockets and the prevalence of selected periodontal pathogens was assessed in 10 patients with adult periodontitis 1 year following randomized therapy. All patients had at least 1 tooth in each quadrant with an inflamed pocket of probing depth > or =5 mm and clinical attachment loss and harbored at least one of the following 3 major periodontal pathogens: Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, or Bacteroides forsythus. The number of target organisms per site was determined preoperatively; at 1 week; and at 1, 3, 6, and 12 months postoperatively utilizing DNA probes. The following clinical parameters were measured and recorded preoperatively and at 1, 3, 6, and 12 months post-treatment: gingival fluid flow, gingival index, plaque index, probing depth, probing attachment level, gingival recession, and bleeding on probing. One quadrant in each patient was randomly assigned to 1 of the following 4 treatments: 1) scaling and root planing; 2) pocket reduction through osseous surgery and apically-positioned flap; 3) modified Widman flap; and 4) modified Widman flap and topical application of saturated citric acid at pH 1 for 3 minutes. All 4 treatments were rendered in one appointment using local anesthesia. No postoperative antibiotics were used, but patients rinsed with 0.12% chlorhexidine for the first 3 months postoperatively and received a prophylaxis every 3 months. This investigation revealed: 1) 30.0% of the sites were infected by at least 1 species at 3, 6, and 12 months postoperatively. 2) Failing sites were infected by a high number of both Pg and Bf These sites had a mean of 24.2+/-9.0 x 10(3) Pg and 93.1+/-42.0 X 10(3) Bf while stable sites had a mean of 6.8+/-0.5 x 10(3) Pg and 7.2+/-1.2 x 10(3) Bf (P = 0.06 and P = 0.05, respectively). 3) The infected sites lost significantly more mean clinical attachment at 12 months (1.5+/-0.5 mm compared to a loss of 0.2+/-0.3 mm for uninfected sites, P = 0.017). 4) The infected sites had a significantly greater BOP (67+/-14% versus 25+/-8% for uninfected sites at 12 months, P = 0.012). 5) The choice of treatment modality did not affect the prevalence of the target species at 1 year post-treatment. These results suggest that prevalence of microbial pathogens negatively affects the 1 year outcome of periodontal surgical and nonsurgical therapy.

Objective. The purpose of this study was to answer the following two questions: (1) Can hydroxyapatite cement in combination with demineralized freeze dried bone feasibly augment the dimension of an atrophic edentulous canine mandible? (2) What is the histologic fate of an augmentation graft composed of hydroxyapatite cement and demineralized freeze dried bone placed on the surface of an atrophic edentulous canine mandible? Study Design. Each of four mixed-breed canines (weighing 50 to 60 pounds) underwent bilateral mandibular dental extraction (canine to second molar) and radical alveolectomy. After 4 months of healing, a bilateral subperiosteal mandibular augmentation graft was put into place, with hydroxyapatite cement/demineralized freeze dried bone on the surface of one hemimandible and porous granular hydroxyapatite and demineralized freeze dried bone on the surface of the other hemimandible. The animals were killed after functioning on a soft diet for 9 months, and the grafted hemimandibles were harvested. Results. Both hydroxyapatite cement and granular hydroxyapatite grafts appeared to augment the edentulous atrophic canine mandible. On histologic exam, the hydroxyapatite cement grafts showed osteoconduction and subperiosteal and endosteal osteonal bone formation, whereas the granular hydroxyapatite grafts showed only osteoconduction. Neither graft material showed chronic or acute inflammation. Conclusion. Hydroxyapatite cement can function feasibly as a mandibular augmentation device. The histologic fate of hydroxyapatite cement is different from that of granular hydroxyapatite. It has a fate comparable to autograft or allograft cortical bone grafts.

Objectives. Bone defects are a challenge for the dental clinician. As widely accepted in guided tissue regeneration, physically halting soft connective tissue proliferation into bone allows for bone regeneration. This concept is the “osteopromotion principle.” The aim of this study was to assess the osteopromoting effect of calcium sulfate as a barrier. Study design. Forty male Sprague-Dawley rats were used. Mucoperiosteal flaps were raised bilaterally at buccal and lingual aspects of the mandible to expose the angles. Next, 5 mm through-and-through bony defects were created bilaterally. On the test side, sterile medical grade prehardened calcium sulfate disks were applied both lingually and buccally to cover the defect. The control side defects were left uncovered. All flaps were sutured closed. Observation times were 3, 9, 18, and 22 weeks. Results. Histologic analysis demonstrated that at 3 weeks all test sites showed partial or complete bone healing. Similar findings were reported for all observation times. The control group showed no bone growth at 3 and 9 weeks and partial bone healing at 18 and 22 weeks. Conclusions. This study indicates that calcium sulfate barriers can exclude connective tissues, allowing bone regeneration during healing.

An improved understanding of the differentiation of periodontal ligament cells could facilitate the development of new treatment approaches for overcoming the loss of specialized cell types caused by periodontitis. To study healing of wounded periodontal tissues and the differentiation of mineralizing connective tissue cells in periodontal ligament, we have examined the influence of wound size and collagen implantation on the regeneration of periodontium and on immunohistochemical staining for osteopontin and bone sialoprotein. Four groups of Wistar rats were wounded by drilling through the alveolar bone and by extirpation of the periodontal ligament. Wounds were 0.6 or 1.8 mm in diameter and defects were either implanted with collagen gels or were treated without implants. Rats were killed at 1 wk or 2 months after wounding and tissue sections were stained with monoclonal antibodies against rat osteopontin and bone sialoprotein. Collagen implants strongly increased staining for osteopontin and bone sialoprotein in defects at 1 wk. By 2 months alveolar bone healed completely regardless of the wound size but in large defects, periodontal ligament width was significantly reduced with or without implants. In large wounds at 2 months, collagen implants inhibited bone regeneration and there was stronger staining for osteopontin and bone sialoprotein in the bone replacing the implant, indicating that collagen prolonged bone remodelling. We conclude that implantation of exogenous collagen affects alveolar bone healing but does not preserve the width of the regenerated periodontal ligament. Therefore collagen does not appear to contribute to homeostasis in the periodontium following wounding.

Regular discussions between the Departments of Oral Surgery and Orthodontics at Göteborg University have resulted in a modified operative technique for impacted maxillary canines, called transalveolar transplantation. After exposure of the operation field, large amounts of bone are removed, avoiding damage to the surface of the cementum and the periodontal membrane. Throughout the surgical procedure the tooth is kept in the alveolar process and then finally gently moved to its desired position. Orthodontic fixation is used to stabilize, not to immobilize, the tooth. So far 101 maxillary canines have been autotransplanted in 85 patients (11-76 years old) with an observation period of 1-17 years. Transalveolar transplantation is considered a good alternative for impacted maxillary canines, provided that the treatment planning is discussed by an orthodontist and an oral surgeon together and the treatment is performed with meticulous surgical techniques and adequately functioning orthodontic fixation and used in patients with proper oral hygiene.

Autotransplantation is a well-known method used in oral surgery. However, risk of failure, most commonly resulting from root resorption of the transplanted tooth or ankylosis, is quite high. Piezosurgery with specific device tip vibration frequencies enables selective tissue cutting, and therefore, tooth buds or teeth can easily be removed from bones with little injury to periodontal fibers or bud follicles.

Maxillary permanent incisors impaction is not a frequent case in dental practice, but its treatment is challenging because of its importance to facial esthetics. Supernumerary teeth are the main cause of impaction of upper incisors. Supernumerary teeth when present can cause both esthetic and pathologic problems. Early detection of such teeth is most important if complications are to be avoided. In this reported case, the orthopantamogram of a 9-year-old boy revealed two impacted supernumerary teeth in the maxillary anterior region, which was interfering with the eruption of the permanent central incisors. The impacted supernumerary teeth were surgically removed, 11 was repositioned in the arch as it was situated very high in the arch, close to the nasal floor. Twenty-one erupted spontaneously but orthodontic force was applied over 11 to bring it into the occlusion and alignment was achieved with 0.014 mm NiTi wire.