Estudio de la rehabilitación del maxilar atrófico con implantes zigomáticos. Comparación del protocolo Branemark vs el Zigoma Quad

Esta tesis es el estudio prospectivo de 82 pacientes con maxilares atróficos rehabilitados mediante 169 implantes zigomáticos y 198 implantes convencionales (124 alveolares y 74 pterigoideos) para su rehabilitación protésica entre los años 1999 y 2015. Los pacientes han sido intervenidos por el Dr. Guillermo Raspall y el Dr. Javier Mareque. Desde que Branemark, en la década de los 70, presentara su experiencia en el tratamiento de pacientes con edentulismo mediante la colocación de implantes endoóseos, la rehabilitación con implantes pasó a ser uno de los procedimientos más frecuentes y habituales en la práctica diaria. Es por ello, que la implantología oral ha ido convirtiéndose progresivamente en el método de elección en rehabilitación oral (Branemark y cols., 1977). Por otro lado, el tratamiento implantológico convencional, en ciertos casos, no puede aplicarse en la mandíbula atrófica de algunos pacientes, debido a una avanzada reabsorción ósea y/o a la presencia de unos senos maxilares extensos, llevando a unas cantidades inadecuadas de tejido óseo para el anclaje de los implantes. En este estudio valoramos diversos factores como el sexo, la edad, la causa del edentulismo y los distintos esquemas implantológicos. En la revisión bibliográfica se describen conceptos básicos de la implantología y las diferentes alternativas existentes para afrontar el problema del edentulismo maxilar avanzado. A lo largo de esta serie el protocolo de rehabilitación ha sufrido una modificación, la primera mitad de la serie los pacientes fueron rehabilitados acorde al protocolo planteado inicialmente por el Dr. Branemarck con 2 implantes zigomáticos y 4 ó 6 implantes alveolares y/o pterigoideos; en la segunda mitad de la serie los pacientes fueron rehabilitados con 2 implantes zigomáticos por lado sin implantes anteriores ni posteriores. Hay más mujeres que hombres en nuestra muestra (52 versus 30) y sus edades medias son similares en torno a los 57 años. Las razones que condujeron a los pacientes a la pérdida dental son en su mayoría patologías dentales generales: caries y enfermedad periodontal. La tasa global de éxito en la osteointegración de los implantes en la técnica quad y la clásica depende de la técnica utilizada, y es superior en la técnica QUAD. El éxito de los implantes zigomáticos aisladamente en cada protocolo quirúrgico es muy elevada. La tasa de éxito en la osteointegración en la técnica quad fue del 99% y en la técnica clásica del 95%. El esquema rehabilitador clásico (1 implante zigomático por lado y 4 implantes anteriores) presenta como principal complicación la pérdida de los implantes anteriores. El esquema de cigoma cuádruple no presenta pérdidas de implantes. El esquema rehabilitador QUAD (2 implantes zigomáticos por lado) tiene menores complicaciones y permite la carga inmediata sin aumentar la tasa de fracaso. La morbilidad y complicaciones de los casos rehabilitados con implantes zigomáticos es baja (3,26%) y se concentran en la sinusitis y en el fracaso de los implantes alveolares anteriores.MedicinaOdontologí

Mandibular ameloblastoma : reconstruction with iliac crest graft and implants

The ameloblastoma is a bening odontogenic tumor. The treatment planning in young persons is still not clear. We describe a case report of a young boy who was treated in our unit and we review the different aproaches for this type of lesions, which nowadays still not clear in this patients

Direct oral anticoagulants and its implications in dentistry : a review of literature

Four novel direct oral anticoagulants (DOACs) named dabigatran, rivaroxaban, edoxaban and apixaban have been recently introduced to overcome some of the drawbacks of existing anticoagulants. They have less interactions and do not require routine monitoring. However, there is not enough scientific data about the protocol to apply in these patients on DOACs undergoing dental treatment. Thus is necessary to evaluate the potential bleeding risk of these drugs, the possibility of thromboembolic events occurring if they are withdrawn or the need to change to heparin previously. A comprehensive search of the PubMed, Scopus and ISI Web of Science databases was conducted to identify studies that evaluated the relationship between direct oral anticoagulants and dental procedures. The quality of the reported information was assessed following the PRISMA statement. Eleven studies that met the inclusion criteria were included in the review: 2 randomized clinical trials, 3 prospective studies, 3 retrospective studies, 2 case series and 1 case report. DOACs are safe drugs in terms of bleeding. The possible postoperative bleeding complications are manageable with conventional haemostasis measurements. The bridging approach with heparin does not seem to be recommended. Consensus among the professionals involved in the management of the patient is fundamental in invasive dental treatments and in complex patients

Envelope approach for onlay bone grafting : preliminary surgical and prosthetic results

Minimally invasive surgery principles have been applied to preprosthetic-implant surgery, and an adequate presurgical planning reduces morbidity in both harvesting and stabilization of the bone grafts. Objective: A new ?envelope? approach for onlay bone grafting at the alveolar process is presented, this avoids releasing incisions yet allowing adequate reconstruction of the defective site. Study design: To be included in the study the patient had to have an antero-posterior defect of the alveolar crest. Patient age and sex, location of the defect, type and size of graft, and complications appeared during follow up were recorded. Results: Ten consecutive patients (4 men and 6 women) have been succesfully treated with this technique between June/2006 and February/2008. Eight defects were located at the anterior maxilla (between canines), and the remaining two at the anterior mandible (between canines). Four patients received bone grafts harvested from the chin, and the remaining six patients received bone grafts from the mandibular body. Mean size of the graft was: width 11,5mm (range 8 to 17), height 14,7mm (range 9 to 18), depth 4,3mm (range 3 to 6). Conclusion: This technique improves vascularization of the mucoperiosteal flap and avoidance of releasing incisions which has an aesthetic impact in patients with gingival smile

Effect of intra-alveolar placement of 0.2% chlorhexidine bioadhesive gel on the incidence of alveolar osteitis following the extraction of mandibular third molars. A double-blind randomized clinical trial

Alveolar osteitis (AO) is a common complication after third molar surgery. One of the most studied agents in its prevention is chlorhexidine (CHX), which has proved to be effective. Objectives: The aim of this randomized double-blind clinical trial was to evaluate the efficacy of 0.2% bioadhesive chlorhexidine gel placed intra-alveolar in the prevention of AO after the extraction of mandibular third molars and to analyze the impact of risk factors such as smoking and oral contraceptives in the development of AO. Study Design: The study was a randomized, double-blind, clinical trial performed in the Ambulatory Surgery Unit of Hospital Vall d’Hebron and was approved by the Ethics Committee. A total of 160 patients randomly received 0.2% bioadhesive gel (80 patients) or bioadhesive placebo (80 patients). Results: 0.2% bioadhesive chlorhexidine gel applied in the alveolus after third molar extraction reduced the incidence of dry socket by 22% compared to placebo with differences that were not statistically significant. Smoking and the use of oral contraceptives were not related to higher incidence of dry socket. Female patients and the difficulty of the surgery were associated with a higher incidence of AO with statistically significant differences. 0.2% bioadhesive chlorhexidine gel did not produce any of the side effects related to chlorhexidine rinses. Conclusions: A 22% reduction of the incidence of alveolar osteitis with the application of 0.2% bioadhesive chlorhexidine gel compared to placebo with differences that were not statistically significant was found in this clinical trial. The lack of adverse reactions and complications related to chlorhexidine gel supports its clinical use specially in simple extractions and adds some advantages compared to the rinses in terms of duration of the treatment and reduction of staining and taste disturbance

Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol

Background: Partial ankyloglossia is a limitation which restricts the possibility of protrusion and elevation of the tip of the tongue due to the shortness of either the lingual frenulum or the genioglossus muscles or both. The principal objective of this paper is to present our protocol of action for the treatment of ankyloglossia. The specific objectives are to study patients with ankyloglossia treated by the Service of Maxillofacial Surgery and the Service of Speech Therapy of our pediatric Hospital, describe the diagnostic procedures, the pre-surgical intervention, the surgical technique undertaken and the post-surgical rehabilitation taking into account the level of collaboration of the patients, and finally, describe the surgical complications and the referral of patients. Material and Methods: This is a descriptive study of healthy patients, without any diagnosis of syndrome, ranging between 4 and 14 years that have been surgically treated and rehabilitated post-surgery within a period of 2 years. Results: 101 frenectomies and lingual plasties have been performed and patients have been treated following the protocol of action that we hereby present. After the surgical intervention, the degree of ankyloglossia has been improved, considering correction in 29 (28%) of the patients (95% CI: 20%, 38%), reaching, with the post-surgical orofacial rehabilitation, a correction of 97 (96%) of the participants (95% CI: 90%, 98%). Conclusions: The chosen surgical technique for moderate-severe ankyloglossia in our centre is the frenectomy and lingual plasty. The myofunctional training begins one week before the surgical intervention so that the patients learn the exercises without pain

A novel trephine design for sinus lift lateral approach. Case report

Various techniques are described in the literature, either by crestal or lateral approach. Sinus augmentation has a high percentage of success, but presents a number of intraoperative and postoperative complications. The most frequent complication is the Schneiderian membrane perforation with a percentage of perforations between 11% and 56% according to authors. The aim of this study is to describe another membrane approach technique for the sinus lateral wall osteotomy that minimizes the risk of Schneiderian membrane perforation. We present a case of a 50 year old patient attended the University Dental Clinic (UDC) of International University of Catalonia for implant and crown treatment due to the loss of a right maxillary first molar. To insert an implant in position 1.6 a computerized tomography (CT) was requested to determine with greater accuracy the quantity of residual crestal bone. It showed a height of 5 mm and width of 8 mm. The lateral osteotomy was performed with a (SLA KIT® -Neobiotech) trephine mounted in the same implant handpiece with which the field for the implant and the implant itself were prepared. It can be concluded that in the case described, the use of trephine drills of the SLA system mounted in a handpiece allows better access to lateral approach due to its perpendicular position relative to the sinus wall minimizing the membrane perforation risk

Relation between bone density and primary implant stability

Aims: This study aims to relate bone density in Hounsfield units (Hu) with the primary implant stability measured by insertion torque (Ncm) and resonance frequency analysis (ISQ). Materials and Methods: Ten patients were included in this study. A total of 54 implant sites were provided from 10 computerized tomography scans. The computerized tomography scan was used for the preoperative evaluation of bone density for each patient. The bone mean density around planned implants was determined with Physioplanet TM software. Bone quality according resistance to drilling, insertion torque and resonance frequency measurements were recorded. Results: A statistically significant relationship was observed between bone quality density and location with ISQ values. Conclusions: This research demonstrates a strong relationship between the bone density values from computerized tomography and the location in the maxillaries. A correlation exists between bone quality, according to the Lekholm and Zarb classification, and Hu computerized tomography values. The primary implant stability measured with resonance frequency analysis depends on bone density values, bone quality and implant location

Marginal changes at bone-level implants supporting fixed screw-retained partial implant prostheses with or without intermediate standardised abutments: 1-year results of a randomised controlled clinical trial

Objective: To compare marginal changes at bone- level implants restored with screw- retained implant prosthesis with or without intermediate standardised abutments, after 1 year of follow-up.Materials and Methods: Thirty- six partially edentulous patients received 72 implants. Each patient received 2 implants and a 2- to 4- unit screw- retained implant- prosthesis. The test group received implants consisting of a screw- retained prosthesis connected directly to the implant shoulder, while the prostheses in the control group were con-nected through a 3- mm standardised intermediate abutment. Clinical and radiological data were recorded at baseline and at 3, 6 and 12 months in follow-up visits.Results: At 12 months, the marginal bone loss was 0.17 ± 0.24 mm for the test group (19 patients) and 0.09 ± 0.15 mm for the control group (17 patients), with no statistically significant differences (p> .05). The mean probing pocket depth was 2.96 mm ± 0.46 for the test group and 2.86 ± 0.62 mm for the control group. The test and control groups showed bleeding on probing levels of 18.86 ± 14.12% and 13.73 ± 17.66%, re-spectively. All patients scored below 25% on the plaque index levels.Conclusions: Restoration of bone- level implants with fixed screw- retained partial prostheses with or without intermediate abutments presented similar radiographic and clinical outcomes after 1 yearS

Aplicación de la "toxina botulínica A" en el tratamiento del síndrome aurículo-temporal

Consultable des del TDXTítol obtingut de la portada digitalitzadaEl síndrome aurículo-temporal, también conocido como síndrome de Frey, es una entidad clínica caracterizada por presentar sudoración en la región preauricular coincidiendo con las comidas. Este cuadro aparece en algunos pacientes que han sido sometidos a parotidectomías, generalmente por tumoraciones benignas, debido a una reinervación aberrante de las fibras parasimpáticas colinérgicas que inervaban las glándulas parótidas, un periodo variable de alrededor de 6 meses es lo que tardan las terminales nerviosas en alcanzar la piel, sinaptando a nivel de la dermis liberando la acetilcolina a este nivel. Esto produce en el momento de la ingesta enrojecimiento (por vasodilatación cutánea) y sudoración (por activación de las glándulas sudoríparas ecrinas) en la región preauricular. En el presente estudio, se ha seleccionado una población de pacientes afectos de síndrome de Frey y se les ha propuesto entrar en estudio para determinar la utilidad de la toxina botulínica A para su tratamiento. Los pacientes que aceptaron entrar en el estudio, fueron sometidos a un cuestionario y se les realizó el test de Minor, para cuantificar y delimitar la afectación inicial. En los pacientes en los que se objetivó un síndrome de Frey significativo, se llevó a cabo la inyección intradérmica de toxina botulínica A. La dosis utilizada fue de 10 unidades/cm². Los pacientes fueron sometidos a un estrecho seguimiento durante las semanas siguientes a la inyección. No se observaron efectos secundarios ni reacciones adversas en ningún paciente. En torno al quinto día post-inyección los pacientes presentaron una desaparición total de la sudoración coincidente con las comidas en la zona afecta. Los pacientes se mantuvieron asintomáticos un periodo variable de tiempo, cuya media ha sido de diez y seis meses. En comparación con las diversas alternativas quirúrgicas (interposición de colgajos o de materiales aloplásticos) y no quirúrgicas (medicamentos varios, Iontoforesis o radioterapia) disponibles en la actualidad para el tratamiento del cuadro, el tratamiento con toxina botulínica A se ha mostrado como un tratamiento que sitúa a esta modalidad terapéutica al frente del arsenal terapéutico disponible. Conclusiones 1. La inyección intradérmica de toxina botulínica A es un método efectivo para controlar los síntomas de sudoración y enrojecimiento presentes en el síndrome aurícula-temporal establecido. 2. La inyección a altas dosis de toxina botulínica A en la región afectada no ha desencadenado, ni a nivel local, ni a nivel sistémico, efectos secundarios. 3. Se trata de un procedimiento de fácil aplicación en la consulta médica sin necesidad de ingreso, ni de hacer uso de las instalaciones quirúrgicas, ya que posee un carácter claramente ambulatorio. 4. La técnica presenta una baja morbilidad, ya que en ningún casos se produjeron efectos adversos durante, ni como consecuencia de la inyección. 5. Se trata de una técnica reproducible y protocolizable, y además una vez finalizado el efecto puede repetirse. 6. La duración del efecto libre de sudoración aplicando una dosis de 10 U/ cm² fue de 16 meses de media.The auricular-temporal syndrome also known as Frey's síndrome or gustatory sweatting is carachterized for presentting sweatting in the preauricular region during meals. This pathology appears in some patients that have been operated of a parotid tumour, generally because of benign tumours, due to the aberrant reinervation of parasympathetic cholinergic fibbers that normally innervated the parotid gland. An average time of six months after the surgery, which is the time needed for the nerves to reach the skin and establish a new synapses in the dermis, allowing acetylcholine into the synapses at this level. During meals patients experience flushing (due to vasodilatation) and sweating (because of the activation of the sweat glands located on the dermal part of the skin) on the preauricular region. In this study, we reviewed the patients that had been operated of a parotid tumour, and we selected the patients who presented the auricular-temporal syndrome, they were asked to join the study with botullinum toxin A. The patients that accepted to join the study, were asked to answer a questionnaire and we carried a Minor's test in all of them in order to quantify the surface of skin affected. In the patients that we observed a clinical significant Frey's syndrome we proceeded to the intradermal injection of botullinum toxin A. The dose used was of 10 IU/cm². The patients were followed during the weeks after the injection. Neither secondary effects nor adverse reactions were observed. The fifth day after day after the injection the sweating and flushing disappeared in all the patients when the Minor's test was carried out. Patients stayed free of symptoms for an average time of sixteen months. Comparing our results with the surgical and nonsurgical procedures that can be nowadays performed in order to solve the Frey's syndrome, the treatment with botullinum toxin A has shown a better result and no complications. Conclusions 1. The intradermal injection of botullinum toxin A is an effective method to control the symptoms of sweating and flushing on the preauricular region on those patients affected of auricular-temporal syndrome. 2. The injection with high doses of botullinum toxin A in the affected region has not developed any adverse effect, either locally or systemically. 3. It's a procedure that can be easily carried on the consultations, without need of sleeping in the hospital, and also without having to make use of the operation room. 4. This technique showed a very low morbidity, none of the cases developed any secondary effects during or after the injection. 5. The technique can be reproduced easily and standardized, and once finished the effect the technique can be repeated again. 6. The time free of symptoms with the dose of 10 IU/ cm² was of an average of 16 months