Injertos óseos en bloque intraorales tipo onlay: estudio de los tejidos duros y blandos periimplantarios

Los injertos óseos en bloque intraorales tipo onlay son una opción terapéutica para incrementar tanto la anchura como la altura del proceso alveolar para la posterior colocación de los implantes dentales. La colocación simultánea del implante con el injerto óseo permitiría acortar el tiempo de tratamiento y evitar un segunda cirugía, sin embargo aunque se ha descrito ampliamente en el aumento vertical, son escasos los estudios en el tratamiento del aumento horizontal. Por otro lado, diversos procedimientos se han utilizado para la atrofia vertical de los sectores posteriores de la mandíbula atrófica, sin embargo las complicaciones relacionadas con los procedimientos de aumento ha hecho que revisiones sistemáticas recientes valoren positivamente la alternativa de los implantes dentales cortos. Además la valoración de los tejidos blandos así como de la satisfacción del paciente es fundamental para considerar el éxito del tratamiento y son escasos los estudios que aportan datos al respecto. OBJETIVO: El objetivo de esta tesis fue evaluar la tasa de complicaciones postoperatorias, el éxito del injerto, el estado de los tejidos duros y blandos periimplantarios, así como la evaluación de la satisfacción del paciente, tras un mínimo de 3 años tras la carga protésica. METODOLOGÍA: El presente trabajo de investigación se dividió en dos apartados claramente diferenciados en función de si la atrofia ósea era de la anchura o de la altura del proceso alveolar, pues las situaciones iniciales entre pacientes no serían comparables. Se realizó un estudio clínico retrospectivo controlado no aleatorizado entre enero de 2005 y diciembre de 2010 en la Unidad de Cirugía Bucal de la Universitat de València. Para el estudio del aumento horizontal se seleccionaron pacientes rehabilitados con implantes dentales que hubieran recibido injertos óseos en bloque intraorales tipo onlay debido a una atrofia horizontal del proceso alveolar. Grupo 1: Pacientes con implantes dentales colocados de forma simultánea con el injerto. Grupo 2: Pacientes con implantes dentales colocados de forma diferida a la cirugía del injerto óseo. Para el estudio del aumento vertical, se seleccionaron pacientes con una atrofia vertical de los sectores posteriores de la mandíbula (7-8 mm de hueso disponible sobre el canal mandibular) que hubieran recibido injertos óseos en bloque intraorales tipo onlay e implantes diferidos de longitud convencional (longitud mínima 10 mm) o implantes dentales cortos (con una longitud de 5,5 mm) sobre hueso nativo. Grupo 1: Pacientes tratados con injertos óseos autólogos en bloque tipo onlay. Grupo 2: Pacientes con implantes cortos. En ambos apartados, atrofia horizontal y atrofia vertical, se revisaron los registros clínicos, fotográficos y radiográficos de todos los pacientes, y se evaluaron retrospectivamente al año y tras un seguimiento de 3 años de la carga protésica. Al año de la carga se evaluaron las complicaciones relacionadas con el procedimiento de aumento, el éxito del injerto y la supervivencia, éxito y pérdida ósea marginal de los implantes. Pasados 3 años de la carga protésica se evaluó nuevamente la supervivencia, éxito y pérdida ósea marginal de los implantes, así como el estado de los tejidos blandos periimplantarios y la satisfacción del paciente con el tratamiento recibido. RESULTADOS Y CONCLUSIÓN: La colocación diferida fue más predecible que el procedimiento simultáneo de los implantes al presentar una menor pérdida ósea marginal así como una mayor proporción de implantes en estado de salud periimplantaria. Mientras que no hubo diferencias en el número de complicaciones, la tasa de éxito del injerto o el grado de satisfacción del paciente. Respecto al aumento vertical de los sectores posteriores de la mandíbula con injertos en bloque, el grupo del aumento óseo mostró un mayor número de complicaciones que los implantes cortos, mientras que no hubo diferencias estadísticamente significatives ni para la tasa de supervivencia y de éxito ni para la media de pérdida ósea. Los tejidos blandos periimplantarios evidenciaron un estado de salud periimplantario, y la satisfacción global de los pacientes fue elevada. BIBLIOGRAFÍ BÁSICA: 1. Esposito M, Grusovin MG, Coulthard P, Worthington H V. The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants. 2006;21:696–710. 2. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral implants. Clin Oral Implants Res. 2006;17 Suppl 2:136–59. 3. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington H V, Coulthard P. Interventions for replacing missing teeth: horizontal and vertical bone augmentation techniques for dental implant treatment. Cochrane Database Syst Rev. 2009;CD003607. 4. Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg. 2014;43:606–25. 5. Rocchietta I, Fontana F, Simion M. Clinical outcomes of vertical bone augmentation to enable dental implant placement: a systematic review. J Clin Periodontol. 2008;35:203–15. 6. Peñarrocha-Diago MM, Aloy-Prósper A, Peñarrocha-Oltra D, Guirado JLC, Peñarrocha-Diago MM. Localized lateral alveolar ridge augmentation with block bone grafts: simultaneous versus delayed implant placement: a clinical and radiographic retrospective study. Int J Oral Maxillofac Implants. 2013;28:846–53. 7. Peñarrocha-Oltra D, Aloy-Prósper A, Cervera-Ballester J, Peñarrocha-Diago MM, Canullo L, Peñarrocha-Diago MM. Implant treatment in atrophic posterior mandibles: vertical regeneration with block bone grafts versus implants with 5.5-mm intrabony length. Int J Oral Maxillofac Implants. 2014;29:659–66. 8. Cordaro L, Amadé DS, Cordaro M. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement. Clin Oral Implants Res. 2002;13:103–11. 9. Felice P, Cannizzaro G, Barausse C, Pistilli R, Esposito M. Short implants versus longer implants in vertically augmented posterior mandibles: a randomised controlled trial with 5-year after loading follow-up. Eur J Oral Implantol. 2014;7:359–69. 10. Chiapasco M, Zaniboni M, Rimondini L. Autogenous onlay bone grafts vs. alveolar distraction osteogenesis for the correction of vertically deficient edentulous ridges: a 2-4-year prospective study on humans. Clin Oral Implants Res. 2007;18:432–40. 11 Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Esthetic outcome and tissue stability of maxillary anterior single-tooth implants following reconstruction with mandibular block grafts: a 5-year prospective study. Int J Oral Maxillofac Implants. 2013;28:270–80. 12. Meijndert L, Meijer HJA, Stellingsma K, Stegenga B, Raghoebar GM. Evaluation of aesthetics of implant-supported single-tooth replacements using different bone augmentation procedures: a prospective randomized clinical study. Clin Oral Implants Res. 2007;18:715–9

Dental implants with versus without peri-implant bone defects treated with guided bone regeneration

Background: The guided bone regeneration (GBR) technique is highly successful for the treatment of peri-implant bone defects. The aim was to determine whether or not implants associated with GBR due to peri-implant defects show the same survival and success rates as implants placed in native bone without defects. Material and Methods: Patients with a minimum of two submerged dental implants: one suffering a dehiscence or fenestration defect during placement and undergoing simultaneous guided bone regeneration (test group), versus the other entirely surrounded by bone (control group) were treated and monitored annually for three years. Complications with the healing procedure, implant survival, implant success and peri-implant marginal bone loss were assessed. Statistical analysis was performed with non-parametric tests setting an alpha value of 0.05. Results: Seventy-two patients and 326 implants were included (142 test, 184 control). One hundred and twenty-five dehiscences (average height 1.92±1.11) and 18 fenestrations (average height 3.34±2.16) were treated. At 3 years post-loading, implant survival rates were 95.7% (test) and 97.3% (control) and implant success rates were 93.6% and 96.2%, respectively. Mean marginal bone loss was 0.54 (SD 0.26 mm) for the test group and 0.43 (SD 0.22 mm) for the control group. No statistically significant differences between both groups were found. Conclusions: Within the limits of this study, implants with peri-implant defects treated with guided bone regeneration exhibited similar survival and success rates and peri-implant marginal bone loss to implants without those defects. Large-scale randomized controlled studies with longer follow-ups involving the assessment of esthetic parameters and hard and soft peri-implant tissue stability are neede

The outcome of intraoral onlay block bone grafts on alveolar ridge augmentations: a systematic review

Aim: The purpose of this study was to systematically review clinical studies examining the survival and success rates of implants placed with intraoral onlay autogenous bone grafts to answer the following question: do ridge augmentations procedures with intraoral onlay block bone grafts in conjunction with or prior to implant placement influence implant outcome when compared with a control group (guided bone regeneration, alveolar distraction, native bone or short dental implants.)? Material and Method: An electronic data banks and hand searching were used to find relevant articles on vertical and lateral augmentation procedures performed with intraoral onlay block bone grafts for dental implant therapy published up to October 2013. Publications in English, on human subjects, with a controlled study design –involv- ing at least one group with defects treated with intraoral onlay block bone grafts, more than five patients and a minimum follow-up of 12 months after prosthetic loading were included. Two reviewers extracted the data. Results: A total of 6 studies met the inclusion criteria: 4 studies on horizontal augmentation and 2 studies on vertical augmentation. Intraoperative complications were not reported. Most common postsurgical complications included mainly mucosal dehiscences (4 studies), bone graft or membrane exposures (3 studies), complete failures of block grafts (2 studies) and neurosensory alterations (4 studies). For lateral augmentation procedures, implant survival rates ranged from 96.9% to 100%, while for vertical augmentation they ranged from 89.5% to 100%. None article studied the soft tissues healing. Conclusions: Survival and success rates of implants placed in horizontally and vertically resorbed edentulous ridges reconstructed with block bone grafts are similar to those of implants placed in native bone, in distracted sites or with guided bone regeneration. More surgical challenges and morbidity arise from vertical augmentations, thus short implants may be a feasible optio

Replantation of a maxillary second molar after removal of a third molar with a dentigerous cyst: Case report and 12-month follow-up

The aim of this study was to describe the replantation of a maxillary second right molar, which had been removed for surgical reasons in order to remove a dentigerous cyst associated with the adjacent third molar, and the case's 12-month follow-up. A 51-year-old man presented swelling in the right maxillary area. Radiographic examination showed a large radiolucency in close proximity to the third molar, suggesting a follicular cyst. The third molar was extracted and the cyst underwent curettage. The second molar had to be extracted to enable complete removal of the cyst and to achieve primary closure of the wound, which would have been impossible without repositioning the molar. With this objective, extraoral endodontic treatment was performed, the root-end was resected and prepared with ultrasonic retrotips, and root-end filling was accomplished with MTA before the molar was replanted. At the 12-month follow-up, the tooth showed no clinical signs or symptoms, probing depth was no greater than 3 mm and radiographic examination showed no evidence of root resorption or periapical lesion

Distal probing depth and attachment level of lower second molars following surgical extraction of lower third molars : a literature review

A review of the literature is made to evaluate factors that influence probing depth and attachment level on the distal aspect of the lower second molar (L2M) following extraction of a lower third molar (L3M). The PubMed database was searched for studies published between 1997 and March 2009 using the following keywords: mandibular third molar, distal periodontal defect, distal probing depth, distal attachment level, flap design. Randomized prospective studies, with a minimum follow-up of three months for which the full text could be obtained, and that indicated the attachment level and/or probing depth on the distal surface of the L2M in both the preoperative and postoperative periods were included. In the studies obtained, flap design had no influence on distal probing depth or distal attachment level of the L2M following extraction of an L3M. Curettage of the distal radicular surface of the L2M, together with oral hygiene control by the dentist, reduced probing depth values. Various authors recommend bone regeneration techniques in patients with a distal periodontal defect prior to extraction. The placing of membranes (resorbable or nonresorbable) is not justified; however, the use of demineralized bone powder or platelet-rich plasma gel reduces the distal probing depth and attachment level of the L2M

Bone regeneration using particulate grafts : an update

Objective: A review is made of the publications on bone regeneration using particulate grafts, with an evaluation of the success of implants placed in such regenerated areas. Material and Method: A Medline search using different key words was made of the articles published between 1999-2009 involving at least two patients subjected to grafting with autologous, homologous or xenogenic bone, non-bony substitutes, or a combination of these grafts for the placement of dental implants. Studies involving block grafting were excluded. A total of 11 studies were evaluated. Results: These grafts are indicated in cases of small or peri-implant bone defects such as dehiscences and fenestrations, with the possibility of combining a barrier membrane. However, some authors have used particulate block grafts to secure vertical or horizontal increments of the alveolar process. In most of these cases, graft healing until implant placement lasted 6-9 months. The most frequent complications in the receptor zone were wound dehiscences with exposure of the membrane. In almost all cases, prosthetic loading of the implants took place more than three months after their placement. The implant survival rate varied from 90.9% to 100%, with an implantation success rate of 85.7% to 100%. Conclusions: Although our sample is small, due to the difficulty of finding homogeneous studies, it can be concluded that particulate grafts are effective in correcting localized defects of the alveolar process. The complications of particulate grafting are few, and the success rate of implants placed in the reconstructed areas varies from 85.7% to 100%

Effect of a single initial phase of non-surgical treatment of peri-implantitis : abrasive air polishing versus ultrasounds. A prospective randomized controlled clinical study

Non-surgical treatment of peri-implantitis includes a correct mechanical debridement of the implant surface to reduce the inflammation and recondition the soft tissues. The aim of the study was to evaluate the results of a single phase of non-surgical therapy by comparing the effect of curettes and ultrasounds versus curettes and abrasive air polisher (Air-Flow) in the peri-implant tissue conditions, and patient satisfaction. A double-blind randomized and controlled prospective clinical study was conducted on patients in peri-implant maintenance phase diagnosed of peri-implantitis treated in the Oral Surgery Unit of the Stomatology Department of the Faculty of Medicine and Dentistry of the University of Valencia, between September of 2017 and May of 2018. They were divided into 2 groups: Group 1: curettes and ultrasounds, and Group 2: curettes and Air-Flow. The clinical and radiological baseline parameters were evaluated after 3-weeks of treatment, as well as patient satisfaction. The sample included 34 patients. Group 1 (17 patients, 38 implants) and Group 2 (17 patients, 32 implants). All the variables improved statistically significantly after treatment in both groups, with the exception of recessions and keratinized mucosa and bone loss that did not vary. When comparing both groups, the type of treatment did not influence the majority of the variables, with the exception of the plaque index (p=0.011) and modified bleeding index from the palatine (p=0.048), which reduced statistically significant in the group 2, as well as the patient satisfaction which was higher in the group 2 (p<0.001). An initial phase of non-surgical treatment achieves an improvement of the peri-implant clinical parameters, thought the method of debridement used seems not to influence

Non surgical predicting factors for patient satisfaction after third molar surgery

Background: In the third molar surgery, it is important to focus not only on surgical skills, but also on patient satisfaction. Classically studies have been focused on surgery and surgeon’s empathy, but there are non-surgical factors that may influence patient satisfaction. Material and Methods: A cross-sectional study was performed on 100 patients undergoing surgical extractions of impacted mandibular third molars treated from October 2013 to July 2014 in the Oral Surgery Unit of the University of Valencia. A questionnaire (20 questions) with a 10-point Likert scale was provided. The questionnaire assessed the ease to find the center, the ease to get oriented within the center, the burocratic procedures, the time from the first visit to the date of surgical intervention, waiting time in the waiting room, the comfort at the waiting room, the administrative staff (kindness and efficiency to solve formalities), medical staff (kindness, efficiency, reliability, dedication), personal data care, clarity in the information received (about the surgery, postoperative care and resolution of the doubts), available means and state of facilities. Outcome variables were overall satisfaction, and recommendation of the center. Statistical analysis was made using the multiple linear regression analysis. Results: Significant correlations were found between all variables and overall satisfaction. The multiple regression model showed that the efficiency of the surgeon and the clarity of the information were statistically significant to overall satisfaction and recommendation of the center. The kindness of the administrative staff, available means, the state of facilities and the comfort at the waiting room were statistically significant to the recommendation of the center. Conclusions: Patient satisfaction directly depends on the efficiency of the surgeon and clarity of the clinical information received about the procedure. Appreciation of these predictive factors may help clinicians to provide optimal care for impacted third molar surgery patients

Marginal bone loss in relation to platform switching implant insertion depth: an update

A review is made, analyzing marginal bone loss in relation to the depth of implant insertion with platform switching, according to the position of the neck (supracrestal, crestal or subcrestal), and evaluating survival of the implants. A PubMed search was made of the studies in animals and humans published between 2005 and 2011, specifying platform insertion depth (supracrestal, crestal or subcrestal) and registering marginal bone loss from the time of prosthetic restoration to the end of follow-up (minimum 6 months). A total of 30 studies were included. The bone loss associated with implants placed at supracrestal level was slightly smaller than in the case of implants placed at subcrestal level, though statistical significance was not reached. The mean marginal bone loss values were 0.0 mm to 0.9±0.4 mm for the implants with the neck located at supracrestal level; 0.05 mm to 1.40±0.50 mm for those at subcrestal level; and 0.26±0.22 mm to 1.8±0.39 mm for those in a crestal location, after 6-60 months of follow-up. The survival rate was 88.6-100% for the implants with the neck positioned at crestal level, versus 98.3- 100% below the crest, and 100% above the crest. The heterogeneity of the studies (surgical technique, platform surface texture, radiographic measurement techniques, etc.) made it difficult to establish a relationship between marginal bone loss and the supracrestal, crestal or subcrestal location of platform switching

Patient compliance to postoperative instructions after third molar surgery comparing traditional verbally and written form versus the effect of a postoperative phone call follow-up a : a randomized clinical study

The understanding and adherence to postoperative care instructions may be influenced by how they are presented by the professional interfering the recuperation process after surgery. The aim of this study was to evaluate the effect of a postoperative phone call follow-up compared with a traditional verbally and written instructions regarding compliance of postoperative recommendations after third molar surgery; and secondly, to discover the main points of non-compliance. A randomized clinical study was performed including patients that underwent surgical extraction of an impacted mandibular or maxillary third molar in the Oral Surgery Unit of the University of Valencia from January 2016 to January 2017. Patients were randomly assigned to one of three different test groups according to how the post-operative instructions were delivered: brief written instructions, written extended instructions or brief written instructions plus a phone call follow-up at 3-day postoperative period. Patients were interviewed about their adherence to the instructions one week after surgery. The significance level was set at p<0.05. The higher score of compliance was found to the phone call follow-up group (p=0.001). No statistically significant differences were found between brief written group and the group that received written extended instructions. In the phone call follow-up group all variables assessed to the compliance were fulfilled. To brief written and written extended instructions groups, the main points of non-compliance were hygiene and smoking (p<0.001, p=0.026, respectively), and tended towards significance for chlorhexidine rinses and antibiotic, analgesic and anti-inflammatories medication prescribed. Telephone call follow-up can promote patient adherence to postoperative recommendations after third molar surgery. The main factors of non-compliance were not maintain a proper hygiene and not smoking, followed by not performing chlorhexidine rinses and not following medication prescribed