Socket augmentation: rationale and technique

The consequences of exodontia include alveolar bone resorption and ultimately atrophy to basal bone of the edentulous site/ridges. Ridge resorption proceeds quickly after tooth extraction and significantly reduces the possibility of placing implants without grafting procedures. The aims of this article are to describe the rationale behind alveolar ridge augmentation procedures aimed at preserving or minimizing the edentulous ridge volume loss. Because the goal of these approaches is to preserve bone, exodontia should be performed to preserve as much of the alveolar process as possible. After severance of the supra- and subcrestal fibrous attachment using scalpels and periotomes, elevation of the tooth frequently allows extraction with minimal socket wall damage. Extraction sockets should not be acutely infected and be completely free of any soft tissue fragments before any grafting or augmentation is attempted. Socket bleeding that mixes with the grafting material seems essential for success of this procedure. Various types of bone grafting materials have been suggested for this purpose, and some have shown promising results. Coverage of the grafted extraction site with wound dressing materials, coronal flap advancement, or even barrier membranes may enhance wound stability and an undisturbed healing process. Future controlled clinical trials are necessary to determine the ideal regimen for socket augmentation.     

Biopsy technique: the pathological considerations.

As the dental profession moves toward additional emphasis in detection of disease and sophistication in diagnosis, biopsy is being used with increasing frequency as a diagnostic tool. This article states and elucidates simple ground rules that govern the rationale of surgical sampling of pathologic tissue. The three most common deficiencies that hamper interpretation (tissue artifact, inadequate clinical information, and inappropriate tissue sampling) are discussed, and the biopsy approach to various types of clinical lesions is reviewed.     

Mineralized bone allograft-plug socket augmentation: rationale and technique

BACKGROUND: Socket augmentation allows clinicians to preserve alveolar bone height. This, in turn, could maintain adjacent soft tissue (papillae) height to promote optimal implant esthetics. MATERIALS AND METHODS: A new regimen for the socket augmentation technique (the mineralized bone allograft-plug technique) is introduced. It uses solvent-preserved mineralized cancellous allografts to fill the sockets up to 1-2 mm below the bone crest. This is covered with a bioabsorbable collagen wound dressing (CollaPlug; Zimmer Dental, Carlsbad, CA). Illustrations to demonstrate the technique are introduced. A case treated with this approach is presented. RESULTS: This technique is easy to perform with minimal trauma. Both clinical observation and histological results showed excellent bone formation. CONCLUSION: Our clinical experience, as well as histologic data, suggest that the mineralized bone allograft-plug is a suitable technique for socket augmentation.     

Mucogingival pouch flap for sandwich bone augmentation: technique and rationale

This article introduces a novel flap design, mucogingival pouch flap (MPF), to enhance the clinical outcome of sandwich bone augmentation. MPF uses a pouch flap reflection via mucogingival junction extension incisions to provide an improved graft retention, minimized membrane exposure, preserved papilla dimension, and soft tissue camouflage for improved esthetics.There are 4 implant-associated buccal dehiscence defects in 3 patients treated with sandwich bone augmentation technique in conjunction with MPF. All cases yielded an adequate new bone thickness of 1.5-3.5 mm as well as a height of 84% to 100% at 6 months. Rationales, indications, contraindications, advantages, and disadvantages for MPF designs are further discussed.     

Hydroxylapatite-coated dental implants. Biologic rationale and surgical technique

Implant prosthodontics now offers our patients more benefits than conventional prosthetics. Considerations of bone biology, occlusal principles, occlusal materials, implant design, implant biomaterials, patient health profile, patient bone density and quality, site classification, manufacture quality and ethics, and operator efficiency all go into the prognosis and affect our final product. Emerging biomaterials help the clinician, in certain areas, to achieve a more predictable result. The time-tested principle--such as unloaded healing, atraumatic gentle surgical placement, and machined components--are carried along into the new systems that are being developed for clinical use. The use of the HA-coated cylinder has proved to be of extreme value in these past 5 years. It is another step closer to the ideal implant system.     

Gingival depigmentation for aesthetic purposes using erbium:YAG laser: rationale and technique

Melanin, carotene and hemoglobin are the most common natural pigments contributing to the normal color of the gums. Although physiologic and ethnic melanin pigmentation is not a medical problem, complains about "black gums" are common. Gingival depigmentation has been carried out using surgical, chemical, electrosurgical and cryosurgical procedures. Recently, Laser Ablation has been recognized as one of the most effective, pleasant and reliable techniques. Effective depigmentation of the gingival requires removal of all or most of the melanocytes from the basal layer of the gingival epithelium. Using non-specific radiation means ablation of all the epithelial cell layers, as well as connective tissue rete pegs, leaving behind only remnants of the epithelial rete ridges. CO2, Nd:YAG and Erbium:YAG lasers, meeting most of these requirements and being available in the dental office, seems to be the lasers of choice for this procedure. Five patients (3 F; 2 M) who were referred to the TAUSDM for cosmetic therapy of "black gums" were treated using Erbium-YAG laser. The laser beam was set up at 850 mj/10 pulses per second producing peak power of 2.13 kwand peak power density of 30.43 kw/sq/cm. The beam was defocused to produce a 3 mm diameter circle, thus reducing the beam penetration while increasing the treated surface. Using the "brush" technique, 800-2,000 pulses were required per patient, with an average of 500-1,100 pulses per 1 sq.cm, depending on the thickness of the epithelium and the intensity of the pigmentation. Treatment required only topical anesthesia. Healing was uneventful and required no supportive therapy. Three months follow up has shown no repigmentation in any of the patients. Patients' evaluation analysis showed that the results were pleasing; no pain was experienced during lasing as well as during healing. Two patients were interupted by the lasing burning smell, which may be reduced or eliminated by operating a power suction during the procedure.     

"Sandwich" bone augmentation technique: rationale and report of pilot cases

The aim of this article is to present a new technique for augmentation of deficient alveolar ridges and/or correction of osseous defects around dental implants. Current knowledge regarding bone augmentation for treatment of osseous defects prior to and in combination with dental implant placement is critically appraised. The "sandwich" bone augmentation technique is demonstrated step by step. Five pilot cases with implant dehiscence defects averaging 10.5 mm were treated with the technique. At 6 months, the sites were uncovered, and complete defect fill was noted in all cases. Results from this pilot case study indicated that the sandwich bone augmentation technique appears to enhance the outcomes of bone augmentation by using the positive properties of each applied material (autograft, DFDBA, hydroxyapatite, and collagen membrane). Future clinical trials for comparison of this approach with other bone augmentation techniques and histologic evaluation of the outcomes are needed to validate these findings.     

Immediate stabilization at stage II of zygomatic implants: rationale and technique.

The severely resorbed maxilla presents a challenge for the maxillofacial surgeon and the restorative dentist planning implant restorations. The Zygomatic implant, as introduced by Br?nemark, allows for the surgical placement of implants to restore resorbed maxillae without major grafting procedures. A minimum of 2 implants in the anterior maxilla are used in conjunction with 1 implant in each zygoma to support a prosthesis. Fabricating a passive bar to connect the implants at phase II surgery may require 1 to 2 days. With the adhesive abutment cylinder luting technique, a rigid framework can be delivered within 1 hour of uncovering the implants. This approach saves considerable time over conventional techniques and allows for the restoration of severely resorbed maxillae in an efficient and routine manner. The technique also eliminates the necessity for a technician to be available on-site for the procedure.     

A predictable precision cast for multi-unit screw-retained implant prosthesis: rationale and technique

The aim of this article is to describe a technique derived from the premachined cylinder luting technique with the goal to predictably fabricate a highly precise master cast. An impression can be taken directly at implant level or, with some technique modification, at the abutment level. Concurrently, multiple techniques can be employed to fabricate the final framework with the assurance that a framework that fits the cast will fit in the mouth. This predictability improves the workflow of the restoring dentist and laboratory technician since multiple framework try-ins and adjustments are eliminated.     

Begg-edgewise diagnosis-determined totally individualized orthodontic technique: foundations, description, and rationale

This article presents an appliance system designed to facilitate efficient treatment by the use of the biomechanical approach considered most suitable by the orthodontist for the individual patient. The system described uses narrow, single brackets with 0.022 X 0.028 inch edgewise arch wire slots and 0.020 X 0.020 inch vertical slots for various auxiliaries. There are five brackets that differ only in the torque of the arch wire slot-0 degree, 5 degrees, 10 degrees, 15 degrees, and 20 degrees. Thus, an appropriate bracket can be selected for any tooth in any situation. The brackets and bonding pads are small in all dimensions to ensure optimal appearance and interbracket arch wire spans and minimal lip and cheek irritation. This also lessens occlusal interference, enamel surface involved in bonding, and problems with gingival proximity and oral hygiene. The basic buccal tubes are conventional 4.5 mm long, 0.022 X 0.028 inch torqued edgewise tubes. A buccal tube assembly with a similar additional rectangular tube carried diagonally at a 15 degree angle across the buccal surface of the basic tube (its mesial end pointing gingivally) is used in extraction cases with deep overbites or moderate-to-severe anchorage requirements. The angulated outer tube carries the main (working) arch wire during the bite-opening and retraction phases of treatment. A rectangular sectional wire in the inner tube and second premolar bracket locks the molar and premolar teeth together so that neither can tip independently. As a unit they provide anchorage for bite opening and retraction. The gingivally positioned and angulated outer tube directs the arch wire out of danger of distortion from mastication and provides a built-in biteopening effect. The molar and premolar teeth, in effect, become a single large tooth with its center of resistance (CR) further mesial than the CR of the molar. Sectional wires result in a more favorable system of moments created by arch wires and elastics. This delivers more intrusive force to the incisors with less tendency to tip the anchor units. The appliance provides the orthodontist with an extensive range of options in treatment mechanics--from anchorage conservation and rapid movement of limited tipping by light forces to translation or stabilization with precise three-dimensional control.