An interdisciplinary approach to treatment planning in implant dentistry

The practice of implant dentistry requires an interdisciplinary approach that integrates the knowledge, skills, and experience of all the disciplines of dentistry into a comprehensive treatment plan. The team must examine the anticipated restorative site to determine the suitability of the existing hard and soft tissues for implant placement. Deficiencies in hard and soft tissue, which prevent ideal implant placement, must be recognized and addressed to ensure a more predictable esthetic outcome. This article outlines a comprehensive interdisciplinary treatment philosophy designed for developing the foundation of optimal esthetics in implant dentistry. Cases are presented to illustrate the utility of interdisciplinary treatment in which specialists are recruited to enhance and improve a patient's dental function and esthetics.     

Is dental erosion really a problem?

Dental erosion is the non-carious dental substance loss induced by direct impact of exogenous or endogenous acids. It results in a loss of dental hard tissue, which can be serious in some groups, such as those with eating disorders, in patients with gastroesophageal reflux disease, and also in persons consuming high amounts of acidic drinks and foodstuffs. For these persons, erosion can impair their well-being, due to changes in appearance and/or loss of function of the teeth, e.g., the occurrence of hypersensitivity of teeth if the dentin is exposed. If erosion reaches an advanced stage, time- and money-consuming therapies may be necessary. The therapy, in turn, poses a challenge for the dentist, particularly if the defects are diagnosed at an advanced stage. While initial and moderate defects can mostly be treated non- or minimally invasively, severe defects often require complex therapeutic strategies, which often entail extensive loss of dental hard tissue due to preparatory measures. A major goal should therefore be to diagnose dental erosion at an early stage, to avoid functional and esthetic impairments as well as pain sensations and to ensure longevity of the dentition.     

Interdisciplinary cooperation in dentistry

The treatment of complex dental problems often requires the involvement of different disciplines in dentistry. Referral of the patient from one dentist or dental-specialist to the other in these cases is not uncommon. It is known as multidisciplinary treatment. In dentistry today treatment planning and treatment of complex dental problems are done as a team, working together, as an interdisciplinary team.     

Cone beam computed tomography: third eye in diagnosis and treatment planning

Orthodontic treatment of adult patients with complex dental problems is done in interdisciplinary teams where different specialists of dental medicine have to manage a vast quantity of data. In such complicated cases good diagnostic tools and easy communication are essential Computer science has an increasing impact in almost every aspect of the orthodontic practice, research and education. Within the past decade, technology termed "cone beam computed tomography" (CBCT) has evolved that allows 3-D visualization of the oral and maxillofacial complex from any plane. With the development of Cone Beam Computed Tomography, there has been a drastic reduction in radiation exposure to the patient, which allows its use for safely obtaining three dimensional images of the craniofacial structures. This should allow the clinician to visualize the hard and soft tissues of the craniofacial region from multiple perspectives, which could have far-reaching implications for treatment planning in orthodontics and orthognathic surgery. This paper shall discuss in detail the principles of the cone beam computed tomography and its applications in the field of orthodontics.     

Profilocephalometric analysis: a combination of the cephalophotometric and the architectural-structural craniofacial analyses

A number of cephalometric analyses are presently being used in the assessment of dentofacial deformities. These cephalometrics are mostly based on hard tissue assessment alone, although a few methods using soft tissue only or partially hard and partially soft tissues exist. Most of the analyses use angular and linear measurements, although some are based mainly on measurements of relationships. When the various cephalometric analyses are compared, considerable inconsistency comes to light; so much so, that cephalometrics sometimes cannot be considered as a primary diagnostic tool. A combination of two relationship analyses, one based on soft tissue assessment and one based on hard tissue assessment, incorporating the craniofacial complex, is presented to provide a higher degree of diagnostic accuracy. This combination analysis is based on only a few critical hard tissue landmarks of the cranial base that are used for the total assessment of the facial hard, dental, and soft tissues. This has eliminated inappropriate landmarks and lines that existed in each of the original analyses. The cephalophotometric and architectural-structural craniofacial analyses have been adjusted accordingly and renamed the profilocephalometric analysis.     

Recombinant human bone morphogenetic protein-2 for peri-implant bone regeneration: a case report

Background: Currently, clinicians have a limited treatment arsenal in the repair of peri‐implant defects. The aim of the present report is to present the clinical results of treating a dental implant using recombinant human bone morphogenetic protein (rhBMP)‐2 in an elderly patient. Methods: A 75‐year‐old man presented for routine dental prophylaxis. Clinical and radiographic examination revealed significant loss of attachment and bone loss around an implant replacing the maxillary left first molar. The patient did not report any symptoms, and the implant showed no signs of mobility. Because of the severity of the defect, regenerative treatment using a combination of rhBMP‐2 and freeze‐dried bone allograft was used. Results: The patient was followed for 80 weeks postoperatively. By 28 weeks, significant probing depth reduction and radiographic bone fill was observed, and the original implant crown was replaced. From 28 weeks postoperatively to 80 weeks, no significant clinical or radiographic changes were observed. Conclusions: rhBMP‐2 represents a potential therapeutic modality for severe peri‐implant hard tissue loss. Future studies should examine parameters, such as surgical technique, to maximize the rhBMP‐2‐driven regenerative outcomes.     

Optimizing esthetics for implant rehabilitation in maxillary lateral incisors aplasia: multidisciplinary considerations and 7 years follow-up case report

Especially in the esthetic zone the management of dental agenesis is best achieved by an interdisciplinary team approach. The realisation of individually optimized rehabilitation outcomes is depending foremost on early diagnosis and the coordination of appropriate orthodontic, prosthodontic and oral-maxillofacial surgical handling options. Due to modern reconstruction techniques the final completion with single-tooth implants meanwhile represents the treatment of choice, independent of initial situations with local hard and soft tissue deficiencies. Prerequisites for esthetically optimized long-lasting results of implant-supported restorations are the establishment of a stable bone foundation and soft tissue profile as well as the proper 3-dimensional implant placement.     

Video imaging: techniques for superimposition of cephalometric radiography and profile images

Computerized video imaging techniques that enable superimposition of cephalometric radiographs and tracings on the image of the soft tissue profile are presented. This superimposition allows visualization of the underlying skeletal and dental hard tissues as they relate to the profile and permits surgical planners to be more cognizant of the limitations that the teeth and occlusion present as the esthetic treatment goals are defined. Step-by-step treatment planning of a patient is used to demonstrate the techniques.     

Multiple dentoalveolar traumatic injury: a case report (3 years follow up)

Abstract –  Dental trauma with children and adolescents is a serious dental public health problem. Traumatic injuries on permanent teeth are common, and dramatic episodes can occur during childhood. Cases of dental avulsions and reimplantations, dentoalveolar fractures, several forms (lateral, extrusive and intrusive) of luxations, concussion, subluxation, gingival lacerations and hard, pulpal dental tissue lesions have been extensively reported. This case report presents the therapy for severe trauma caused by multiple traumatic injuries to the dentoalveolar complex of a patient.     

A survey of dental and oral trauma in south-east Queensland during 1998

BACKGROUND: This project investigated the aetiology of dental and oral trauma in a population in south-east Queensland. The literature shows there is a lack of dental trauma studies which are representative of the general Australian population. METHOD: Twelve suburbs in the south-east district of Queensland were randomly selected according to population density in these suburbs for each 25th percentile. All dental clinics in these suburbs were eligible to participate. Patients presenting with dental and oral trauma were eligible to participate. RESULTS: A total of 197 patients presented with dental/oral trauma over a 12 month period. The age of patients ranged from 1-64 years whilst the most frequently presenting age group was 6-10 years. There was a total of 363 injured teeth with an average of 1.8 injured teeth per patient. Males significantly outnumbered females in the incidence of trauma. CONCLUSIONS: The highest frequency of trauma occurred in the 6-10 year age group. Most injuries in this group occurred while playing or riding bicycles. In the next most prevalent trauma group, 16-20 years, trauma occurred as a result of fighting and playing sport. Overall, males significantly outnumbered females by approximately 1.8:1.0. The majority of injuries in the deciduous dentition were to periodontal tissues. In the secondary dentition most injuries were to hard dental tissue and pulp.     

Restoring Function and Aesthetics in a Class II Division 1 Patient with Amelogenesis Imperfecta: A Clinical Report

Amelogenesis imperfecta (AI) encompasses a complicated group of hereditary conditions that cause developmental alterations in the structure of the enamel in the absence of a systemic disorder. AI primarily affects the quality and/or quantity of dental enamel, and it may affect all or only some of the teeth in the primary and/or permanent dentition. This clinical report describes the oral rehabilitation of a 21-year-old man diagnosed with hypomaturation-type AI. He presented with discolored and mutilated teeth. Cephalometrically, the patient has skeletal class II malocclusion due to mandibular deficiency considered as a result of maxillary constriction. The interdisciplinary approach was followed because of the complex needs of the patient. The aim of treatment was to restore aesthetics, improve malocclusion and masticatory function. Aesthetic and functional expectations were met with metal ceramic restorations. In this report, the interdisciplinary approach for a patient with AI and a malocclusion is described.     

Tissue engineering: from research to dental clinics

Tissue engineering is an interdisciplinary field that combines the principles of engineering, material and biological sciences toward the development of therapeutic strategies and biological substitutes that restore, maintain, replace or improve biological functions. The association of biomaterials, stem cells, growth and differentiation factors has yielded the development of new treatment opportunities in most of the biomedical areas, including Dentistry. The objective of this paper is to present the principles underlying tissue engineering and the current scenario, the challenges and the perspectives of this area in Dentistry. SIGNIFICANCE: The growth of tissue engineering as a research field has provided a novel set of therapeutic strategies for biomedical applications. Indeed, tissue engineering may lead to new strategies for the clinical management of patients with dental and craniofacial needs in the future.     

A predoctoral clinical geriatric dentistry rotation at the University of the Pacific School of Dentistry

Predoctoral dental students from University of the Pacific School of Dentistry provide initial and yearly dental evaluations for participants of On Lok Senior Health Services on site at On Lok centers. Student dentists also complete some dental procedures including denture fabrication, adjustments and repairs, hard and soft relines, scaling/root planing, polishing, and limited restorative treatments. A wide range of age-prevalent oral conditions such as candidiasis and xerostomia are identified and treated or managed. Students may also be called upon to present patient needs weekly to a member of the interdisciplinary team for discussion. Students periodically review instructions and devices for oral health care with the On Lok staff. The program is intended to be mutually beneficial to the participants of On Lok and Pacific student dentists. While the majority of comprehensive and emergency services are provided by On Lok staff dentists and contract specialists, the student dentist program has broadened the scope of the oral health program at On Lok and has been well integrated with the other day services. Meanwhile, Pacific students gain experience identifying and managing the complex social, economic, and health needs of frail elders in San Francisco.     

Dental manifestations associated with Seckel syndrome type II: a case report

Seckel syndrome is a rare form of primordial dwarfism that is characterized by short stature, skeletal defects, mental retardation, and characteristic facial features such as microcephaly, micrognathia, and a bird-head appearance. Dental findings include hypodontia, enamel hypoplasia, crowding, and Class II malocclusion. The purpose of this paper was to report the case of a female patient with Seckel syndrome type II and describe her orodental manifestations. She presented with interesting dental findings, including gingival hyperplasia, recession and ulceration, significant crowding, and early exfoliation of the primary dentition with accelerated eruption of the permanent dentition. The patient received comprehensive dental care under general anesthesia, and hard and soft tissue samples were collected for histologic analysis. The patient was followed for over 3 years.     

Piezoelectric distraction osteogenesis in the atrophic maxillary anterior area: a case report

The reconstruction of a maxillary anterior dentoalveolar defect in patients with trauma has been a challenge for surgeons. Extensive loss of bone and teeth in the anterior maxilla presents a complex problem for reconstruction. This is owing to the difficulty in achieving complete closure using overlying soft tissue. Tension-free sutures cannot be used after a large bone graft because the overlying soft tissue on severe bone defects of the anterior maxilla is often deficient and is attached to the underlying atrophic bone by scarring. Distraction osteogenesis provides a method to regain both hard tissue and soft tissue without any grafting. We describe a patient who had severe maxillary anterior bony defects that were restored by means of piezoelectric distraction osteogenesis, followed by dental implant placement. Clinical, radiological, and histological results showed that the reconstruction was successful.     

Fixed prosthodontic rehabilitation in a wear patient with Fabry's disease

Fabry's disease is an uncommon X-linked metabolic disorder that leads to abnormal accumulation of glycosphingolipids in the body resulting in a variety of systemic disorders. Few reports have addressed dental findings and management of these patients. This clinical report describes the fixed prosthodontic rehabilitation of an adult male patient with Fabry's disease, who presented with generalized severe wear of the dentition. In addition to numerous systemic morbidities, the patient also presented with intraoral angiokeratomas, telangiactasias, anterior diastemata, bimaxillary prognathism, and other oral findings known to be prominent in these patients. The patient was managed by an interdisciplinary team of dental specialists in close coordination with his nephrologist. The prosthodontic treatment included restorations on all teeth, except mandibular anterior teeth, and the patient was restored with a partial group function scheme of occlusion. At the 3.5-year follow-up appointment, the patient's oral health and integrity of the restorations remained stable. This is the first clinical report describing the prosthodontic management of a patient with Fabry's disease. Unique features related to this patient's fixed prosthodontic treatment include accommodation to complex medical problems, management of maxillary diastemata, and choice of occlusal scheme.     

Alveolar ridge preservation in the esthetic zone

In the esthetic zone, in the case of tooth extraction, the clinician is often confronted with a challenge regarding the optimal decision‐making process for providing a solution using dental implants. This is because, after tooth extraction, alveolar bone loss and structural and compositional changes of the covering soft tissues, as well as morphological alterations, can be expected. Ideally, the therapeutic plan starts before tooth extraction and it offers three options: spontaneous healing of the extraction socket; immediate implant placement; and techniques for preserving the alveolar ridge at the site of tooth removal. The decision‐making process mainly depends on: (i) the chosen time‐point for implant placement and the ability to place a dental implant; (ii) the quality and quantity of soft tissue in the region of the extraction socket; (iii) the remaining height of the buccal bone plate; and (iv) the expected rates of implant survival and success. Based on scientific evidence, three time‐periods for alveolar ridge preservation are described in the literature: (i) soft‐tissue preservation with 6–8 weeks of healing after tooth extraction (for optimization of the soft tissues); (ii) hard‐ and soft‐tissue preservation with 4–6 months of healing after tooth extraction (for optimization of the hard and soft tissues); and (iii) hard‐tissue preservation with > 6 months of healing after tooth extraction (for optimization of the hard tissues).     

Intraoral piezosurgery: preliminary results of a new technique.

The piezosurgery instrument, developed in 1988, uses a modulated ultrasonic frequency that permits highly precise and safe cutting of hard tissue. Nerves, vessels, and soft tissue are not injured by the microvibrations (60 to 200 mm/sec), which are optimally adjusted to target only mineralized tissue. The selective and thermally harmless nature of the piezosurgery instrument results in a low bleeding tendency. In addition, the instrument can be used in operations requiring either local or general anesthesia. The precise nature of the instrument allows exact, clean, and smooth cut geometries during surgery. The difference in time requirement for surgical procedures using the piezosurgery instrument in comparison with the conventional drill is negligible. Postoperatively, excellent wound healing, with no nerve and soft tissue injuries, is observed. It is apparent that the range of application of piezosurgery is not limited to minor operations. Because of its highly selective and accurate nature, with its cutting effect exclusively targeting hard tissue, its use may be extended to more complex oral surgery cases, as well as to other interdisciplinary problems.     

Temporal sequence of hard and soft tissue healing around titanium dental implants

The objective of the present review was to summarize the evidence available on the temporal sequence of hard and soft tissue healing around titanium dental implants in animal models and in humans. A search was undertaken to find animal and human studies reporting on the temporal dynamics of hard and soft tissue integration of titanium dental implants. Moreover, the influence of implant surface roughness and chemistry on the molecular mechanisms associated with osseointegration was also investigated. The findings indicated that the integration of titanium dental implants into hard and soft tissue represents the result of a complex cascade of biological events initiated by the surgical intervention. Implant placement into alveolar bone induces a cascade of healing events starting with clot formation and continuing with the maturation of bone in contact with the implant surface. From a genetic point of view, osseointegration is associated with a decrease in inflammation and an increase in osteogenesis‐, angiogenesis‐ and neurogenesis‐associated gene expression during the early stages of wound healing. The attachment and maturation of the soft tissue complex (i.e. epithelium and connective tissue) to implants becomes established 6–8 weeks following surgery. Based on the findings of the present review it can be concluded that improved understanding of the mechanisms associated with osseointegration will provide leads and targets for strategies aimed at enhancing the clinical performance of titanium dental implants.     

Supraoccluding cobalt-chrome onlays in the management of amelogenesis imperfecta in children: a 2-year case report.

Children suffering from the inherited dental anomaly amelogenesis imperfecta frequently present with sensitive, discolored teeth and decreased lower facial height. The aim of treatment is to reduce sensitivity while maintaining the maximum amount of hard tissue possible until the patient reaches an age at which advanced restorative techniques can be used to rehabilitate the dentition. A case is presented in which amelogenesis imperfecta in the mixed dentition was managed by the placement of adhesive cast restorations. These restorations have been in place for 2 years.