Ultrasonographic Tissue Perfusion in Peri-implant Health and Disease

High-Frequency Ultrasound Characterization of Periodontal Soft Tissues Pre- and Post-Bacterial Inoculation

OBJECTIVE

Current diagnostic methods of inflammatory periodontal diseases, e.g., visual evaluation, periodontal probing, and radiographs, are either subjective or insensitive. Intra-oral high-frequency ultrasound was investigated to quantify inflammation by detecting tissue dimensional and perfusion changes.

METHODS

A cohort of 15-month-old mini-pigs, 4 female/male each, was analyzed. Pre-molars (PM) 3 and 4, as well as first molars (M1), were scanned. In bi-weekly time intervals all 4 quadrants were randomly enrolled and bacterial injection followed each quadrant scan in a weekly fashion. Soft tissue dimensions were obtained from B-mode images and statistically analyzed to identify correlations to inoculation time, i.e., response to bacterial loading, tooth type and sex, using analysis of variance and regression analysis. Color flow velocity and power-weighted color pixel density was obtained and statistically analyzed analogous to soft tissue.

RESULTS

Soft tissue thickness increased significantly post-inoculation at 1 and 2 mm below the free gingival margin for both genders and all observed teeth. The significance lasted for weeks 2, 4 and 6, except for female M1s (4 weeks). Color flow velocity was significantly higher compared with baseline for 6 weeks, except for male PM4 (2 weeks). Color flow power did not show significance for PM3 and 4, only in M1 (except male week 4). Significance also extended to tooth type and sex.

CONCLUSION

Periodontal tissue dimension and color flow velocity increased in correlation to bacterial inoculation. Further studies are needed to obtain an understanding of the underlying biology observed here. Eruption of dentition may have been a confounding factor for inflammation interpretation.

In vivo periodontal ultrasound imaging via a hockey-stick transducer and comparison to periodontal probing: a proof-of-concept study

OBJECTIVE

The objective of this study is to evaluate a compact ultrasound transducer to image anatomical biomarkers for periodontal diagnosis of teeth, including difficult-to-reach posterior teeth.

MATERIALS AND METHODS

A 9-MHz hockey-stick transducer was used to image 53 premolars, 30 molars, and 79 incisors and canines from 13 subjects. The alveolar bone crest (ABC), cementoenamel junction (CEJ), and gingival margin (GM) were identified by ultrasound imaging. The image-based distances between these anatomic landmarks were measured for iABC (ABC to CEJ), iGR (GM to CEJ) and iGH (ABC to GM). The measurements were compared to corresponding parameters obtained from clinical examination. The measurements were also used to assess periodontal health and were compared with clinical diagnosis.

RESULTS

The average iGR measurements were - 1.12 mm (i.e., 1.12 mm above the CEJ) for gingivitis and Stage I periodontitis, and - 0.56 mm for Stage III periodontitis, demonstrating a significant increase in gingival recession in patients with severe periodontitis (Student t-test, unpaired, two-tailed, p < 0.0001). The iGH measurements distinguished gingivitis, Stage I periodontitis group, and the Stage III periodontitis group (unpaired, two-tailed t-test, p < 0.05 for PPD, and p = 0.05 for iGH).

CONCLUSION

Non-invasive periodontal ultrasound imaging can be used to stratify subjects with differing periodontal disease severity. The clinical parameters obtained from ultrasound imaging with the hockey-stick transducer are reproducible.

CLINICAL RELEVANCE

The compact ultrasound transducer can be used as a screening tool for patients affected by periodontitis for clinical examination and treatment.

Introduction of "MAPS" wound healing index and its correlation with guided bone regeneration outcome

METHODS

The MAPS score was introduced to evaluate the bioMechanical, Aesthetic/Anatomical, Pathophysiologic, and Subject-related parameters for the healing assessment of 20 patients who underwent GBR in the posterior mandible retrospectively. Intraoral photography was taken at 3-, 10-, 21 days, and 5 months, resulting in 80 follow-up visits. Two independent examiners evaluated the photos giving scores for each timepoint and tested against horizontal bone gain (CBCT) for predictability.

RESULTS

Cohen's Kappa values showed high intra- and inter-examiner agreement. Pearson's correlation showed an inverse correlation between baseline bone width and bone changes at a 3 mm level (R2 = 0.23). The higher M, A, and P values at any time point were associated with higher bone gain. The 10-day MAPS score turns out the most predictive of bone gain (RMSE 1.32, R2 0.75). In addition, increasing the average P score by 1 point at 10 days is associated with an increase in bone gain of 1.23 (p=.057).

CONCLUSION

The MAPS score improves consistently over the 5-month healing period. However, no statistically significant difference is observed between the scores at 21 days and 5 months, reflecting the clinical healing pattern for GBR. The overall MAPS score correlated with bone changes after GBR procedures, indicating its potential for estimating hard tissue regenerative outcomes.

Characterization of oral biomarkers during early healing at augmented dental implant sites

AIM

The aim of this study is to assess early wound healing expression of local angiogenic biomarkers following connective tissue graft (CTG) at dental implant sites.

METHODS

Twenty-eight subjects with single dental implants exhibiting a soft tissue dehiscence were included and randomly treated with CTG, either with coronally advanced flap (CAF) or with tunnel technique (TUN). Peri-implant crevicular fluid (PICF) was collected at the midfacial and midlingual aspect of the implant sites at baseline and at 3, 7, 14, 30, and 90 days after the surgical intervention. The expression of angiogenin (ANG), fibroblast growth factor-2 (FGF-2), platelet-derived growth factor (PDGF), tissue inhibitor of metalloproteinases-2 (TIMP-2), and vascular endothelial growth factor (VEGF) was investigated over a period of 3 months. Patient-reported outcomes, clinical measurements, and ultrasonography scans at multiple time points were also evaluated.

RESULTS

The longitudinal regression revealed a significant difference in the expression of VEGF and TIMP-2 between CAF- and TUN-treated sites over 3 months (p = .033 and p = .004, respectively), whereas no significant differences were observed for ANG, FGF-2 and PDGF between the two groups. At 7 days, a direct correlation was observed between ANG levels and ultrasonographic color velocity in the CAF group (p < .001) and between ANG levels and ultrasonographic color power in the TUN group (p = .028). VEGF levels and ultrasonographic mean perfused area of the CTG were significantly correlated at the 7-day time point (p < .001 for both CAF and TUN). The expression of VEGF at 7 days was directly associated with mucosal thickness gain at 1 year (p < .001 for both groups). Early TIMP-2 expression showed an inverse correlation with time to recovery (p = .002). TIMP-2 levels at 3 months exhibited inverse correlations with mean dehiscence coverage (p = .004) and the rate of complete dehiscence coverage (p = .012).

CONCLUSION

PICF biomarkers can be used to monitor early wound healing events following soft tissue grafting at implant sites. VEGF and TIMP-2 showed correlations with the 1-year clinical and volumetric outcomes, as well as with post-operative patient-reported outcomes and Doppler Ultrasonographic tissue perfusion-related parameters.

Intraoral perfusion assessment using endoscopic hyperspectral imaging (EHSI)- first description of a novel approach

OBJECTIVES

This study aimed to establish a method to detect and quantify mucosal malperfusion intraorally using state-of-the-art Endoscopic Hyperspectral Imaging (EHSI). For this purpose, mucosal ischemia was selectively induced by intraligamentary anesthesia (ILA) with and without + epinephrine using a standardized protocol.

MATERIALS AND METHODS

EHSI was performed using a novel endoscopic hyperspectral imaging system. Parameters assessed were Tissue Oxygen Saturation (StO2 [%]), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI). Fifty-seven healthy subjects received ILA using Articaine 4% with (ILA+) and without (ILA-) epinephrine at a dosage of 1:200,000 administered mesially and distally to the target tooth 42 (Universal No. 26). Mucosal perfusion was assessed using EHSI for 45 min post-injection.

RESULTS

After ILA+, a distinct ischemia of the mucosa was already clinically apparent after 30 s with significant reduction of THI and StO2 by an average of 57% (p < 0.001) and 7% (p < 0.040) compared to baseline values. Persistent hypoperfusion of the oral mucosa was observed throughout the monitoring period, exhibiting a gradual resolution at the 30-minute mark, and nearing baseline perfusion approximately 45 min post-injection. There was no papillary necrosis after ILA + injection.

CONCLUSION

EHSI is suitable to adequately detect and visualize actual perfusion of the intraoral mucosa. The study revealed that LA with epinephrine (1:200,000) induce temporary hypoxia in the dental papilla but without causing severe ischemia.

CLINICAL RELEVANCE

EHSI will enable promising applications in the future, i.a. success monitoring of periodontal therapies, intraoral free flap monitoring and the assessment of cancer margins.

Ultrasonography-Guided Dental Implant Surgery: A Feasibility Study

OBJECTIVE

To evaluate the feasibility of ultrasound-image-based computer-assisted implant planning and placement.

MATERIALS AND METHODS

Intraoral scans, cone-beam computerized tomography (CBCT), and ultrasound (US) scans with a custom positioning device were acquired in nine patients. Prosthetic-driven surgical guides were planned and fabricated based on ultrasound images and intraoral scans. Implants were then placed. Postoperative implant position was obtained intra-surgically by intraoral scan. Aside from the ultrasound-based plan, conventional implant planning was performed by the same operator on a pre-surgical CBCT for comparison. Linear deviations between ultrasound and CBCT-planned implant positions were measured and compared with the intra-surgical implant position, and the position deviations between two consecutive plannings were performed on the same CBCT by the same operator. The linear deviation between the 3D scan surface of the edentulous region and the ultrasonographic soft tissue profile segmentation was also assessed with reverse-engineering software. Means, standard deviations, and root mean square differences (RMSD) were calculated for every variable.

RESULTS

All the ultrasound-planned implants were successfully placed, and no complications were recorded. The mean deviations in angles, shoulders, and apexes were 5.27 ± 1.75° (RMSD: 5.53°), 0.92 ± 0.26 mm (RMSD: 0.95 mm), and 1.41 ± 0.61 mm (RMSD: 1.53 mm), respectively, between the US and CBCT-planned implants; 2.63 ± 0.43° (RMSD: 2.66°), 1.16 ± 0.30 mm (RMSD: 1.19 mm), and 1.26 ± 0.27 mm (RMSD: 1.28 mm) between the planned implant and intra-surgically recorded positions; and 2.90 ± 1.36° (RMSD: 3.18°), 0.65 ± 0.27 mm (RMSD: 0.70 mm), and 0.99 ± 0.37 mm (RMSD: 1.05 mm) between two consecutive CBCTs planning performed by the same operator. The mean deviation between the 3D surfaces of model scans and ultrasound-derived soft tissue profile in the edentulous area was 0.19 ± 0.08 mm.

CONCLUSIONS

Ultrasound-guided implant surgery represents a feasible non-ionizing alternative to conventional static guided implant surgical protocols for implant placement in sites with favorable characteristics.

Peri-Implant Health and Perfusion Parameters in Patients After Microvascular Jaw Reconstruction: A Clinical Cohort Study

INTRODUCTION

The aim of this study was to evaluate perfusion parameters and clinical features of healthy implants and implants affected by peri-implant disease in patients who had undergone microvascular jaw reconstruction.

METHODS

A total of 25 patients with 92 implants placed in microvascular transplants were included. Of these, 68 implants showed healthy peri-implant tissue, 12 were affected by peri-implant mucositis, and 12 were diagnosed with peri-implantitis. Peri-implant perfusion was measured mesially and distally at the implant shoulder using laser Doppler flowmetry and tissue spectrophotometry (LDF-TS), followed by a clinical evaluation, including measurement of probing depths, bleeding on probing (BOP), plaque index, biotype, type of implant, the restoration and the presence of keratinized tissue. Perfusion parameters were compared between the healthy implants and the implants with peri-implant disease based on the conventional BOP-based diagnosis of peri-implantitis, and the associations between the perfusion values and clinical measurements were analyzed. Optimal cut-off values for predicting peri-implantitis were calculated with receiver operating characteristics.

RESULTS

The mean relative amount of hemoglobin and mean blood flow were significantly different between healthy implants and implants with peri-implant mucositis and peri-implantitis (p = 0.003 and p = 0.002, respectively). However, there are interindividual differences that appear to influence blood flow values as well. When a linear mixed regression model was applied, including the patient as a random variable, the difference in blood flow was no longer statistically significant (p = 0.400). Still, the optimal cut-off value of mean blood flow for predicting peri-implantitis was determined to be > 46.5 AU (AUC = 0.788; p < 0.001; CI = 0.695-0.881; sensitivity = 1.00, specificity = 0.60).

CONCLUSION

Implants in microvascular flaps are particularly vulnerable to peri-implant disease. Risk factors are the lack of keratinized peri-implant tissue, fixed restorations, bone-level implants, and high plaque levels. As a noninvasive and objective method, LDF-TS can contribute to risk assessment by evaluating perfusion parameters and help detect the early onset of peri-implant disease.

Tissue Perfusion and Biomarkers Assessment Following Root Coverage Procedures

AIM

To assess tissue perfusion changes and wound healing biomarker levels after root coverage procedures with coronally advanced flap in combination with the cross-linked xenogeneic collagen matrix (CCMX), loaded either with a placebo or recombinant human platelet-derived growth factor-BB (rhPDGF).

METHODS

This study was designed as a secondary analysis from a previously published clinical trial, and it assessed the tissue perfusion changes over 6 months around multiple gingival recession defects, treated with either with CCMX alone (control) or with CCMX + rhPDGF (test). High frequency Doppler ultrasonography (HFUS) scans were obtained at sites of interest at baseline, 2 weeks, 3 months, and 6 months after surgery. Dynamic tissue perfusion measurements (DTPMs) were performed at the midfacial, interproximal, and transverse aspects of the teeth by an operator, blinded to treatment allocation, using a software package. The expression of different wound healing biomarkers from the gingival crevicular fluid was also assessed.

RESULTS

The regression analyses showed similar tissue perfusion changes between the two groups throughout the majority of the 6 months. DTPMs at 2 weeks showed the test group to have significantly higher perfusion relief intensity (pRI, p < 0.001), mean perfused area (pA, p < 0.001), mean blood flow intensity (FImean, p = 0.021), and total blood flow intensity (FItot, p = 0.021) at the graft region of interest (ROI) compared to control sites. The test sites also exhibited significantly greater pA (p = 0.033) and blood flow intensity "blue" (FIblue, meaning flow away from the transducer, p = 0.035) at the level of the flap compared to the control sites. At 2 weeks, FIblue of the graft was directly correlated with the final mean root coverage (p = 0.008) and complete root coverage (p = 0.003). FImean and FItot of the graft exhibited a direct correlation with volume gain at 6 months (p = 0.031 for both parameters). The final GT gain was correlated to the early DTPMs (pA and FIblue) of the graft and the flap. The two groups exhibited different expressions of IL-1β, PDFG-BB, and VEGF over 3 months, with the 1-week levels of PDGF-BB that were associated with time to recovery.

CONCLUSIONS

HFUS allowed exquisite assessment of tissue perfusion occurring at the entire surgical reconstructive regions and also within the flap and the graft. Sites treated with CCMX + rhPDGF exhibited higher DTPMs, primarily within the graft and flap ROIs at the 2-week timepoint compared to sites augmented with CCMX + saline. Early DTPMs at the graft and flap ROIs showed associations with PROMs and the final clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04462237.

High-Frequency Ultrasound for Detecting Periodontal Inflammation: A Preclinical Diagnostic Accuracy Study

AIM

Ultrasonography (US) has shown accuracy in imaging healthy periodontium. This study aims to evaluate the feasibility and accuracy of US for estimating dimensions of inflamed periodontium induced by ligature and bacteria.

METHODS

Periodontal tissues of maxillary as well as mandibular premolars and molars in six female mini pigs were treated with ligature and three strains of bacteria for 4-10 weeks. Before euthanization, the periodontium was imaged with US. After euthanization, cone-beam computed tomography (CBCT) scans and histology were performed. Soft and hard tissue measurements by calibrated and masked examiners from US, CBCT, and histology were statistically compared.

RESULTS

Seventy-one histological samples with corresponding CBCT and US scans were available for analysis. Overall, there was a good to excellent agreement between histology and US (ICC: 0.77-0.96) for parameters such as Soft Tissue Thickness (STT), Gingival Recession, Crestal Bone Thickness (CBT), and the bone-to-cemento-enamel junction (B-CEJ) distance. However, discrepancies were observed for STT at 3 mm below the CEJ and Soft Tissue Height (STH) (ICC: 0.44 and 0.54, respectively). CBCT showed lower agreement with histology, particularly for thin CBT (< 1 mm), with an ICC of 0.20, compared to 0.90 for US vs. histology. CBCT failed to identify crestal bone in 14 cases when the crestal bone was thin. Notably, CBCT results differed more from histological measurements than US in assessing B-CEJ and thin CBT.

CONCLUSION

US demonstrated substantial potential as a transformative tool for periodontal diagnostics, exhibiting high agreement with histology in determining critical parameters. Compared to CBCT, US offered advantages, particularly in cases with thin crestal bone.

Dental Ultrasonography for Visualizing Osteoimmune Conditions and Assessing Jaw Bone Density: A Narrative Review

Despite the widespread use of ultrasonography (US) in medical diagnostics, there is no similar US device available for visualizing jawbone density. This study is a narrative review of the possible applications of US in dentistry. This review is divided as follows: (a) Pulse-echo ultrasonography: the applications offer new perspectives for periodontal and peri-implant assessment. (b) Through-transmission alveolar US (TTAU): this technique was a novel imaging modality until 2004, when TTAU devices were last available. Quantitative US scaling made the device useful for diagnosing chronic inflammatory conditions in the jaw. (c) Ultrasound transmission velocity (UTV): in 2008, this technique was introduced in German university dental clinics to analyze the mechanical properties of the jawbone without translating the scientific findings into a practical device. (d) Trans-alveolar US device (TAU): the growing importance of "osteoimmune focal bone marrow defects" has led practitioners to develop a new TAU device. The attenuation of US was used for imaging of jawbone density. (e) Patients who benefit from TAU-guided jawbone surgery: research has shown remarkable results in specific disease cases. This review concludes that US has been undervalued as a diagnostic tool in dentistry. The new TAU-n unit offers the opportunity to change this in the future.

Doppler ultrasonographic evaluation of tissue revascularization following connective tissue graft at implant sites

AIM

To assess the Doppler ultrasonographic tissue perfusion at dental implant sites augmented with connective tissue graft (CTG) using coronally advanced flap (CAF) or tunnel technique (TUN).

MATERIALS AND METHODS

Twenty-eight patients presenting with isolated healthy peri-implant soft-tissue dehiscence (PSTD) were included in this randomized clinical trial. PSTDs were treated with either CAF + CTG or TUN + CTG. Ultrasound scans were taken at baseline, 1 week, 1 month, 6 months and 12 months. Tissue perfusion at the mid-facial, mesial and distal aspects of the implant sites was assessed by colour Doppler velocity (CDV) and power Doppler imaging (PDI). Early vascularization of the graft and the flap at 1 week and at 1 month were evaluated via dynamic tissue perfusion measurements (DTPMs), including flow intensity (FI), mean perfusion relief intensity (pRI) and mean perfused area (pA).

RESULTS

Regression analysis did not reveal significant differences in terms of mid-facial CDV and PDI changes between CAF and TUN over 12 months (p > .05), while significant differences between the two groups were observed at the interproximal areas (p < .001 for both CDV and PDI changes). Higher early DTPMs were observed at the TUN-treated sites in terms of mean FI of the graft (p = .027) and mean FI (p = .024) and pRI of the flap (p = .031) compared with CAF-treated sites at 1 week. Assessment of the FI direction showed that CTG perfusion at 1 week and at 1 month mainly occurred from the flap towards the implant/bone. Early tissue perfusion outcomes were found to be associated with the 12-month mean PSTD coverage and mucosal thickness gain.

CONCLUSIONS

Doppler ultrasonography shows tissue perfusion changes occurring at implant sites augmented with CTG. The main differences in tissue perfusion between CAF and TUN were observed at the interproximal sites, with early perfusion associated with clinical and volumetric outcomes at 12 months.

Overview of Wearable Healthcare Devices for Clinical Decision Support in the Prehospital Setting

Prehospital medical care is a major challenge for both civilian and military situations as resources are limited, yet critical triage and treatment decisions must be rapidly made. Prehospital medicine is further complicated during mass casualty situations or remote applications that require more extensive medical treatments to be monitored. It is anticipated on the future battlefield where air superiority will be contested that prolonged field care will extend to as much 72 h in a prehospital environment. Traditional medical monitoring is not practical in these situations and, as such, wearable sensor technology may help support prehospital medicine. However, sensors alone are not sufficient in the prehospital setting where limited personnel without specialized medical training must make critical decisions based on physiological signals. Machine learning-based clinical decision support systems can instead be utilized to interpret these signals for diagnosing injuries, making triage decisions, or driving treatments. Here, we summarize the challenges of the prehospital medical setting and review wearable sensor technology suitability for this environment, including their use with medical decision support triage or treatment guidance options. Further, we discuss recommendations for wearable healthcare device development and medical decision support technology to better support the prehospital medical setting. With further design improvement and integration with decision support tools, wearable healthcare devices have the potential to simplify and improve medical care in the challenging prehospital environment.

Soft tissue elasticity at teeth and implant sites. A novel outcome measure of the soft tissue phenotype

AIM

To assess ultrasonographic tissue elasticity at teeth and implant sites and its variation after peri-implant soft tissue augmentation with a connective tissue graft (CTG).

METHODS

Twenty-eight patients, each contributing with one clinically healthy dental implant exhibiting a soft tissue dehiscence (PSTD), were included. Implant sites were augmented with CTG and monitored over 12 months. Ultrasonographic strain elastography, expressed as strain ratios (SR1, SR2, and SR3, respectively) was assessed at baseline, 6-, and 12-month, and compared with the corresponding contralateral homologous natural tooth. SR1 assessed the strain/elasticity of the midfacial coronal portion of the soft tissue in comparison to the natural tooth crown/implant-supported crown, SR2 evaluated the strain of the midfacial coronal soft tissue in relation to the one of the alveolar mucosa, while SR3 depicted the strain of the midfacial soft tissue in relation to the interproximal soft tissue on the transverse ultrasound scan.

RESULTS

SR1 in natural dentition and at implant sites was 0.20 ± 0.08 and 0.30 ± 0.14, respectively (p = .002), indicating that the coronal portion of the soft tissue around teeth is generally more elastic than its counterpart around dental implants. Soft tissue augmentation with CTG promoted an increased stiffness of the midfacial coronal portion of the soft tissue over 12 months (p < .001 for SR1, SR2, and SR3). Strain ratios at the 12-month time points were significantly higher than the values observed at 6 months (p < .001). Regression analysis demonstrated that strain elastography ratios in natural dentition were significantly associated with keratinized gingiva width, and gingival thickness. At implant sites, SR1 was significantly associated with keratinized mucosa width and mucosal thickness (p < .001 for both correlations), SR2 was significantly associated with keratinized mucosa width (p = .013), and SR3 was significantly associated with the surgical technique performed in combination with CTG (p = .022).

CONCLUSION

Ultrasound strain elastography captures and quantifies tissue elasticity and its changes after soft tissue augmentation. A different baseline tissue elasticity was observed between teeth and dental implants in the most coronal aspect of the soft tissue. The main factors affecting tissue elasticity-related outcomes were the keratinized tissue width, and mucosal thickness.

Echo-intensity characterization at implant sites and novel diagnostic ultrasonographic markers for peri-implantitis

AIM

To apply high-frequency ultrasound (HFUS) echo intensity for characterizing peri-implant tissues at healthy and diseased sites and to investigate the possible ultrasonographic markers of health versus disease.

MATERIALS AND METHODS

Sixty patients presenting 60 implants diagnosed as healthy (N = 30) and peri-implantitis (N = 30) were assessed with HFUS. HFUS scans were imported into a software where first-order greyscale outcomes [i.e., mean echo intensity (EI)] and second-order greyscale outcomes were assessed. Other ultrasonographic outcomes of interest involved the vertical extension of the hypoechoic supracrestal area (HSA), soft-tissue area (STA) and buccal bone dehiscence (BBD), among others.

RESULTS

HFUS EI mean values obtained from peri-implant soft tissue at healthy and diseased sites were 122.9 ± 19.7 and 107.9 ± 24.7 grey levels (GL); p = .02, respectively. All the diseased sites showed the appearance of an HSA that was not present in healthy implants (area under the curve = 1). The proportion of HSA/STA was 37.9% ± 14.8%. Regression analysis showed that EI of the peri-implant soft tissue was significantly different between healthy and peri-implantitis sites (odds ratio 0.97 [95% confidence interval: 0.94-0.99], p = .019).

CONCLUSIONS

HFUS EI characterization of peri-implant tissues shows a significant difference between healthy and diseased sites. HFUS EI and the presence/absence of an HSA may be valid diagnostic ultrasonographic markers to discriminate peri-implant health status.

Ultrasound identification of the cementoenamel junction and clinical correlation through ex vivo analysis

Accurately identifying periodontal landmarks via acoustic imaging is increasingly important. Here, we evaluated the accuracy of cementoenamel junction (CEJ) identification using ultrasound by comparing it to clinical methods in 153 extracted human teeth. The distance between the CEJ to a reference point was measured using two clinical methods (visual examination and tactile sensation) as well as ultrasound imaging. Statistical analyses were performed across all teeth and sub-groups, including tooth types (incisors, cuspids, and molars/premolars), and two classifications: A- vs. B- (visually detectable or undetectable CEJ, respectively); and CL-S vs. CL-D (shallow or deep cervical lesions). In A- or CL-S teeth, ultrasound measurements highly agreed with clinical measurements, showing a 1.72-mm 95% CI for A- and 1.99-mm 95% CI for CL-S compared to visual examination, and a 1.77-mm 95% CI for A- and a 2.10-mm 95% CI for CL-S compared to tactile sensation, respectively. For 80% of A- and 76% of CL-S teeth, the difference between ultrasound and visual examination was within ± 20%. For 81% of A- and 80% of CL-S teeth, the difference between ultrasound and tactile sensation was within ± 20%. The variance of ultrasound versus clinical CEJ identifications showed a significant correlation (r = 0.6607) to the cervical lesion depth. The errors between ultrasound and clinical measurements show no significant bias across different tooth types.

Analyses of gingival papilla blood flow via color doppler flow imaging and micro-flow imaging in patients with advanced periodontitis: a clinical pilot study

BACKGROUND

Research investigating the potential link between gingival microvascular blood flow and inflammatory status is scarce. This study aims to assess color doppler flow imaging (CDFI) and micro-flow imaging (MFI) as tools for the assessment of gingival papilla blood flow (GPBF) and to examine their diagnostic utility as a noninvasive means of detecting gingival bleeding.

METHODS

CDFI and MFI were used to assess the GPBF grade (0-4) of 140 anterior gingival papilla sites in advanced periodontitis patients. Correlations between GPBF grades and periodontal characteristics were examined, and diagnostic performance as a means of predicting bleeding on probing (BOP) was examined using receiver operating characteristic curves.

RESULTS

GPBF grades 0 and 1 assessed by the MFI were 14.29% and 15.71% respectively, lower than the 28.57% and 24.29% assessed by the CDFI. In contrast, MFI detected a higher frequency of GPBF grade 2 sites (40.71%) relative to CDFI (22.14%). The CDFI and MFI provided consistent results in 62.14% of the sites, while the MFI demonstrated higher ratings in rest 37.86% of the sites. A significant positive correlation was detected between GPBF grade and the modified gingival index (MGI), bleeding index (BI), BOP, and probing depth (PD). It showed high accuracy for CDFI or MFI to diagnosing BOP with a sensitivity of 80.51% and 96.43% and a specificity of 77.27% and 57.14%, respectively. Area under the receiver operator characteristic curve values when predicting BOP based on the GPBF grade determined using CDFI and MFI approaches 0.887 (95% CI 0.833-0.942) and 0.917 (95% CI 0.862-0.972), respectively, and there were no significant differences between these values (Z = - 1.502, p = 0.133).

CONCLUSIONS

Both MFI and CDFI can be employed for the evaluation of GPBF, and MFI is better suited to detecting mild inflammation. Trial registration ChiCTR2200066021 (Date of registration: 22/11/2022).

The use of digital technologies in peri-implant soft tissue augmentation - A narrative review on planning, measurements, monitoring and aesthetics

OBJECTIVE

To identify the different uses and modalities of digital technologies to diagnose, plan and monitor peri-implant soft tissue conditions and aesthetics.

METHODS

A comprehensive narrative review of pertinent literature was conducted, critically appraising key digital technologies that may assist peri-implant soft tissue augmentation and assessment. An electronic search on four databases including studies published prior to 1st July 2023 was performed and supplemented by a manual search.

RESULTS

Predominantly, tools such as cone beam computed tomography (CBCT), intraoral scanning (iOS), intraoral ultrasonography and digital spectrophotometry were commonly to assess and monitor peri-implant soft tissues. The main clinical and research applications included: (i) initial assessment of mucosal thickness, supra-crestal tissue height and keratinized mucosa width, (ii) evaluation of peri-implant soft tissue health and inflammation, (iii) monitoring profilometric changes and midfacial mucosal margin stability over time and (iv) aesthetic evaluation through colour assessment. While evidence for some digital tools may be limited, the integration of digital technologies into peri-implant soft tissue management holds great promise. These technologies offer improved precision, comfort and speed in assessment, benefiting both patients and clinicians.

CONCLUSION

As digital technologies progress, their full potential in peri-implant soft tissue augmentation and their value will become more evident with ongoing research. Embracing these innovations and their potential benefits is recommended to ensure that during progress in implant dentistry, patient care is not hindered.

The current role and future potential of digital diagnostic imaging in implant dentistry: A scoping review

OBJECTIVES

Diagnostic imaging is crucial for implant dentistry. This review provides an up-to-date perspective on the application of digital diagnostic imaging in implant dentistry.

METHODS

Electronic searches were conducted in PubMed focusing on the question 'when (and why) do we need diagnostic imaging in implant dentistry?' The search results were summarised to identify different applications of digital diagnostic imaging in implant dentistry.

RESULTS

The most used imaging modalities in implant dentistry include intraoral periapical radiographs, panoramic views and cone beam computed tomography (CBCT). These are dependent on acquisition standardisation to optimise image quality. Particularly for CBCT, other technical parameters (i.e., tube current, tube voltage, field-of-view, voxel size) are relevant minimising the occurrence of artefacts. There is a growing interest in digital workflows, integrating diagnostic imaging and automation. Artificial intelligence (AI) has been incorporated into these workflows and is expected to play a significant role in the future of implant dentistry. Preliminary evidence supports the use of ionising-radiation-free imaging modalities (e.g., MRI and ultrasound) that can add value in terms of soft tissue visualisation.

CONCLUSIONS

Digital diagnostic imaging is the sine qua non in implant dentistry. Image acquisition protocols must be tailored to the patient's needs and clinical indication, considering the trade-off between radiation exposure and needed information. growing evidence supporting the benefits of digital workflows, from planning to execution, and the future of implant dentistry will likely involve a synergy between human expertise and AI-driven intelligence. Transiting into ionising-radiation-free imaging modalities is feasible, but these must be further developed before clinical implementation.

Evaluation of peri-implant perfusion in patients who underwent avascular augmentation or microvascular reconstruction using laser Doppler flowmetry and tissue spectrophotometry: a prospective comparative clinical study

OBJECTIVES

The aim of this study was to evaluate the peri-implant perfusion, such as oxygen saturation, the relative amount of hemoglobin, and blood flow, in implants placed in pristine bone and avascular and microvascular grafts using a non-invasive measurement method.

MATERIALS AND METHODS

A total of 58 patients with 241 implants were included. Among them, 106 implants were based in native bone (group I), 75 implants were inserted into avascular bone grafts (group II), and 60 implants were placed in microvascular bone grafts (group III). Gingival perfusion was measured using laser Doppler flowmetry and tissue spectrophotometry (LDF-TS). Implants with signs of gingival inflammation were excluded to analyze healthy implant perfusion in different bony envelopes.

RESULTS

The mean values for oxygen saturation, relative hemoglobin levels, and blood flow did not differ significantly between the groups (p = 0.404, p = 0.081, and p = 0.291, respectively). There was no significant difference in perfusion between implants that were surrounded by mucosa and implants based within cutaneous transplants (p = 0.456; p = 0.628, and p = 0.091, respectively).

CONCLUSION

No differences in perfusion were found between implants inserted into native bone and implants involving bone or soft tissue augmentation. However, implants based in avascular and microvascular transplants showed higher rates of peri-implant inflammation.

CLINICAL RELEVANCE

Peri-implant perfusion seems to be comparable for all implants after they heal, irrespective of their bony surroundings. Although perfusion does not differ significantly, other factors may make implants in avascular and microvascular transplants vulnerable to peri-implant inflammation.

Nonionizing diagnostic imaging modalities for visualizing health and pathology of periodontal and peri-implant tissues

Radiographic examination has been an essential part of the diagnostic workflow in periodontology and implant dentistry. However, radiographic examination unavoidably involves ionizing radiation and its associated risks. Clinicians and researchers have invested considerable efforts in assessing the feasibility and capability of utilizing nonionizing imaging modalities to replace traditional radiographic imaging. Two such modalities have been extensively evaluated in clinical settings, namely, ultrasonography (USG) and magnetic resonance imaging (MRI). Another modality, optical coherence tomography (OCT), has been under investigation more recently. This review aims to provide an overview of the literature and summarize the usage of USG, MRI, and OCT in evaluating health and pathology of periodontal and peri-implant tissues. Clinical studies have shown that USG could accurately measure gingival height and crestal bone level, and classify furcation involvement. Due to physical constraints, USG may be more applicable to the buccal surfaces of the dentition even with an intra-oral probe. Clinical studies have also shown that MRI could visualize the degree of soft-tissue inflammation and osseous edema, the extent of bone loss at furcation involvement sites, and periodontal bone level. However, there was a lack of clinical studies on the evaluation of peri-implant tissues by MRI. Moreover, an MRI machine is very expensive, occupies much space, and requires more time than cone-beam computed tomography (CBCT) or intraoral radiographs to complete a scan. The feasibility of OCT to evaluate periodontal and peri-implant tissues remains to be elucidated, as there are only preclinical studies at the moment. A major shortcoming of OCT is that it may not reach the bottom of the periodontal pocket, particularly for inflammatory conditions, due to the absorption of near-infrared light by hemoglobin. Until future technological breakthroughs finally overcome the limitations of USG, MRI and OCT, the practical imaging modalities for routine diagnostics of periodontal and peri-implant tissues remain to be plain radiographs and CBCTs.

Diagnostic methods/parameters to monitor peri-implant conditions

The diagnostic accuracy of clinical parameters, including visual inspection and probing to monitor peri-implant conditions, has been regarded with skepticism. Scientific evidence pointed out that primary diagnostic tools (chairside) seem to be highly specific, while their sensitivity is lower compared with their use in monitoring periodontal stability. Nonetheless, given the association between pocket depth at teeth and implant sites and the aerobic/anaerobic nature of the microbiome, it seems plausible for pocket probing depth to be indicative of disease progression or tissue stability. In addition, understanding the inflammatory nature of peri-implant diseases, it seems reasonable to advocate that bleeding, erythema, ulceration, and suppuration might be reliable indicators of pathology. Nevertheless, single spots of bleeding on probing may not reflect peri-implant disease, since implants are prone to exhibit bleeding related to probing force. On the other side, bleeding in smokers lacks sensitivity owing to the decreased angiogenic activity. Hence, the use of dichotomous scales on bleeding in the general population, in contrast to indices that feature profuseness and time after probing, might lead to false positive diagnoses. The definitive distinction between peri-implant mucositis and peri-implantitis, though, relies upon the radiographic evidence of progressive bone loss that can be assessed by means of two- and three-dimensional methods. Accordingly, the objective of this review is to evaluate the existing clinical and radiographic parameters/methods to monitor peri-implant conditions.

Risk indicators for gingival recession in the esthetic zone: A cross-sectional clinical, tomographic, and ultrasonographic study

BACKGROUND

To evaluate the risk indicators associated with midfacial gingival recessions (GR) in the natural dentition esthetic regions.

METHODS

Cone-beam computed tomography (CBCT) results of thirty-seven subjects presenting with 268 eligible teeth were included in the cross-sectional study. Clinical measurements included presence/absence of midfacial GR; the depth of the midfacial, mesial, and distal gingival recession; the recession type (RT); keratinized tissue width (KT); and attached gingiva width (AG). Questionnaires were utilized to capture patient-reported esthetics and dental hypersensitivity for each study tooth. Buccal bone dehiscence (cBBD) and buccal bone thickness (cBBT) were measured on the CBCT scans. High-frequency ultrasonography was performed to assess gingival thickness (GT) and buccal bone dehiscence (uBBD). Intraoral optical scanning was obtained to quantify the buccolingual position of each study site (3D profile analysis). Multilevel logistic regression analyses with generalized estimation equations were performed to assess the factors associated with the conditions of interest.

RESULTS

The presence of midfacial GR was significantly associated with the history of periodontal treatment for pocket reduction (OR 7.99, p = 0.006), KT (OR 0.62, p < 0.001), cBBD (OR 2.30, p = 0.015), GT 1.5 mm from the gingival margin (OR 0.18, p = 0.04) and 3D profile 1 mm from the gingival margin (OR 1.04, p = 0.001). The depth of midfacial GR was significantly correlated to previous history of periodontal treatment (OR 0.96, p = 0.001), KT (OR -0.18, p < 0.001), presence of bone fenestration (OR 0.24, p = 0.044), and cBBD (OR 0.43, p < 0.001). The depth of midfacial GR was also the only factor associated with patient-reported esthetics (OR -3.38, p = 0.022), while KT (OR 0.77, p = 0.018) and AG (OR 0.82, p = 0.047) were significantly correlated with patient-reported dental hypersensitivity.

CONCLUSIONS

Several risk indicators of midfacial and interproximal GR in the esthetic region were identified. The use of imaging technologies allowed for detection of parameters associated with the conditions of interest, and, therefore, their incorporation in future clinical studies is advocated. Ultrasonography could be preferred over CBCT for a noninvasive assessment of periodontal phenotype.

A systematic review of oral wound healing indices

Wound healing monitoring for abnormality identification and intervention is crucial to securing a successful surgical outcome. Indices have been used to summarize the degree of healing. Given the increasing frequency of regenerative procedures which preserve dentition and implant stability, and the higher esthetic demands, an appraisal of the available indices is needed to identify the current knowledge gap. This study aimed to systematically review published oral wound healing indices and scores.

MATERIALS AND METHODS

A complete literature electronic search in 5 databases was conducted by two reviewers. A combination of keywords related to oral wound healing was used.

RESULTS

A total of 11 articles were included in the evaluation of various procedures (conventional periodontal procedures, guided tissue regeneration, soft tissue reconstruction procedures, and tooth extractions), at different time points (1 day to 12 weeks), with a focus on diverse clinical signs and symptoms. Frequently evaluated parameters included wound dehiscence/epithelialization (91%), tissue color (redness) (73%), suppuration (55%), swelling/edema (55%), and hemostasis (55%). Other less commonly used parameters include esthetics-related and patient-centered outcomes.

CONCLUSION

The available indices evaluate a diverse group of subjective clinical signs and symptoms to estimate the underlying biological healing events and assess the degree of clinical success. The majority of the included indices are not validated. Quantitative and objective subclinical parameters including blood perfusion, biomaterial stability, and completeness of epithelialization, are needed for customized wound healing care and better outcome prediction.

Use of ultrasound imaging for assessment of the periodontium: A systematic review

The objective of this study was to systematically review the literature regarding diagnostic applications of ultrasound imaging for evaluation of the periodontium in humans. The search was conducted on Medline, EMBASE, Web of Science, Scopus, Cochrane, and PubMed up to April 3, 2023. The studies included were exclusively human studies that assessed the periodontium with ultrasound (US) imaging (b-mode). Outcomes measured included alveolar bone level, alveolar bone thickness, gingival thickness, and blood flow quantification. References were imported to Covidence. Two reviewers conducted phases 1 and 2. The JBI risk assessment tool for cross-sectional studies was used. Extracted data included the transducer and measurements used and the study's outcomes. The search yielded 4892 studies after removing duplicates. From these, 25 studies were included and selected for extraction. Included studies retrieved outcomes from US examinations of the periodontal tissues. From the selected studies, 15 used US on natural teeth, 4 used US on implants, 2 used US on edentulous ridges, and 4 used color flow/power in US to evaluate the blood flow. The results of the present systematic review suggest that US might be a feasible and valuable diagnostic tool for the periodontium, with the potential to complement shortfalls of current radiographic technologies.

Novel Flowchart Guiding the Non-Surgical and Surgical Management of Peri-Implant Complications: A Narrative Review

Peri-implant diseases, such as peri-implant mucositis and peri-implantitis, are induced by dysbiotic microbiota resulting in the inflammatory destruction of peri-implant tissue. Nonetheless, there has yet to be an established protocol for the treatment of these diseases in a predictable manner, although many clinicians and researchers have proposed various treatment modalities for their management. With the increase in the number of reports evaluating the efficacy of various treatment modalities and new materials, the use of multiple decontamination methods to clean infected implant surfaces is recommended; moreover, the use of hard tissue laser and/or air abrasion techniques may prove advantageous in the future. Limited evidence supports additional effects on clinical improvement in antimicrobial administration for treating peri-implantitis. Implantoplasty may be justified for decontaminating the implant surfaces in the supracrestal area. Surgical treatment is employed for advanced peri-implantitis, and appropriate surgical methods, such as resection therapy or combination therapy, should be selected based on bone defect configuration. This review presents recent clinical advances in debridement methods for contaminated implant surfaces and regenerative materials for treating peri-implant bone defects. It also proposes a new flowchart to guide the treatment decisions for peri-implant disease.

The feasibility of ultrasonography for the measurement of periodontal and peri-implant phenotype: A systematic review and meta-analysis

BACKGROUND

Screening ultrasonography was proposed for monitoring periodontal soft tissues in the early 1960s, owing to its nonionizing, real-time, and cost-effective properties. Studies have provided convincing preliminary evidence for the use of ultrasound (US) in implant dentistry.

PURPOSE

To assess the feasibility of ultrasonography (US) for measuring the buccal thickness of periodontal and peri-implant tissues. The secondary objective was to evaluate the reliability of US measurements compared to classic techniques, such as CBCT and directly measurements.

MATERIALS AND METHODS

An electronic literature search was conducted by three independent reviewers through February 2023. The inclusion criteria were articles investigating at least five patients/cadavers with US measurements in periodontal or peri-implant buccal tissues. Compliance with methodological reporting standards and risk of bias was assessed using EULAR and QUADAS-C tools, respectively. Random-effects meta-analysis was conducted, using Bland-Altman analysis. Certainty of the evidence was assessed using GRADE.

RESULTS

The final selection included 12 studies examining 458 patients and 13 cadavers, with a total of 226 implants, 1958 teeth and 60 edentulous sites. The body of evidence was assessed as partially compliant with methodological reporting standards for US studies and had an unclear to high risk of bias. Meta-analysis of five comparative studies showed no evidence of clinically significant bias between US and direct measurements (very low certainty), and between US and CBCT (very low certainty) for soft-tissue thickness. Likewise, for bone thickness, there is no evidence of clinically significant bias between US and CBCT (low certainty).

CONCLUSIONS

Compared to the CBCT and direct measurements, ultrasonography might be a reliable approach for monitoring on periodontal and peri-implant phenotype. However, there is uncertainty about estimates of the actual effect, so further standardized and larger sample size of clinical research is needed.

Utility of Ultrasonography for Diagnosing and Differentiating Periapical Granuloma from Radicular Cyst

RATIONALE AND OBJECTIVES

This study aimed to investigate the reliability and accuracy of high-resolution ultrasonography (US) for diagnosing periapical lesions and differentiating radicular cysts from granulomas.

MATERIALS AND METHODS

This study included 109 teeth with periapical lesions of endodontic origin from 109 patients scheduled for apical microsurgery. Ultrasonic outcomes were analyzed and categorized after thorough clinical and radiographic examinations using US. B-mode US images reflected the echotexture, echogenicity, and lesion margin, while color Doppler US assessed the presence and features of blood flow of interested areas. Pathological tissue samples were obtained during apical microsurgery and subjected to histopathological examination. Fleiss' κ was used to measure interobserver reliability. Statistical analyses were performed to assess the diagnostic validity and the overall agreement between US and histological findings. The reliability of US compared to histopathological examinations was assessed based on Cohen's κ.

RESULTS

The percent accuracy of US for diagnosing cysts, granulomas, and cysts with infection based on histopathological findings was 89.9%, 89.0%, and 97.2%, respectively. The sensitivity of US diagnoses was 95.1% for cysts, 84.1% for granulomas, and 80.0% for cysts with infection. The specificity of US diagnoses was 86.8% for cysts, 95.7% for granulomas, and 98.1% for cysts with infection. The reliability for US compared to histopathological examinations was good (κ = 0.779).

CONCLUSION

The echotexture characteristics of lesions in US images correlated with their histopathological features. US can provide accurate information on the nature of periapical lesions based on the echotexture of their contents and the presence of vascularity. It can help improve clinical diagnosis and avoid overtreatment of patients with apical periodontitis.

A conceptual review on reconstructive peri-implantitis therapy: Challenges and opportunities

OBJECTIVES

The current strategies to reconstruct lost peri-implant tissues due to the disease have been largely unpredictable. The aim of this conceptual review is to discuss relevant biological and biomechanical challenges of applying reconstructive means to treat peri-implantitis. Additionally, opportunities to improve treatment predictability are presented.

MATERIAL AND METHODS

A narrative review was conducted to fulfill the aim.

RESULTS

The four interrelated negative conditions hampering effective reconstruction are: inferior tissue perfusion, unfavorable bone topography, ineffective surface treatment, and unstable wound. First, peri-implant tissues resemble scars with reduced cellularity and vascularity, coupled with the absence of the periodontal ligament plexuses and the avascular implant and biomaterials, maintaining primary closure is a challenge, which is critical for regeneration. Second, defect morphology and bone topography surrounding implants determine the reconstructive potential. Unfortunately, noncontained defects are frequently encountered, with a combination of suprabony (horizontal bone loss) and infrabony (vertical usually involving circumferential bone loss) defects. Third, current attempts for implant surface decontamination are insufficient due to inaccessible macrostructure and rough surfaces in the micro-scale. Histologic evaluation has shown bacteria aggregation and calcified deposits around implants. Lastly, wound stability is difficult to achieve due to inherent soft tissue biomechanical quality and quantity deficiencies and mobile bone particulates. Opportunities to tackle the abovementioned challenges include the use of novel imaging technologies, such as high-frequency dental ultrasound and laser speckle imaging to evaluate tissue perfusion, soft tissue quality/quantity, and bone topography pre-surgically. The use of the operating microscope could allow better visualization and removal of etiologic factors. Strategies to improve soft tissue quality may include preoperative control of soft tissue inflammation and the potential use of biologics. Methods such as fixation to stabilize the biomaterials could be beneficial.

CONCLUSIONS

A more nuanced understanding of the current challenges and opportunities can lead to more effective preoperative and postoperative care protocols, ultimately improving the success rate of reconstructive procedures.

Echo intensity and gray-level co-occurrence matrix analysis of soft tissue grafting biomaterials and dental implants: an in vitro ultrasonographic pilot study

OBJECTIVE

To characterize different allogeneic and xenogeneic soft tissue graft substitutes and to assess their echo intensity and grayscale texture-related outcomes by using high-frequency ultrasonography (HFUS).

METHODS

Ten samples from each of the following biomaterials were scanned using HFUS: bilayered collagen matrix (CM), cross-linked collagen matrix (CCM), multilayered cross-linked collagen matrix (MCCM), human-derived acellular dermal matrix (HADM), porcine-derived acellular dermal matrix (PADM), collagen tape dressing (C) and dental implants (IMPs). The obtained images were then imported in a commercially available software for grayscale analysis. First-order grayscale outcomes included mean echo intensity (EI), standard deviation, skewness, and kurtosis, while second-order grayscale outcomes comprised entropy, contrast, correlation, energy and homogeneity derive from the gray-level co-occurrence matrix analysis. Descriptive statistics were performed for visualization of results, and one-way analysis of variance with Bonferroni post-hoc tests were performed to relative assessments of the biomaterials.

RESULTS

The statistical analysis revealed a statistically significant difference among the groups for EI (p < .001), with the group C showing the lowest EI, and the IMP group presenting with the greatest EI values. All groups showed significantly higher EI when compared with C (p < .001). No significant differences were observed for energy, and correlation, while a statistically significant difference among the groups was found in terms of entropy (p < 0.01), contrast (p < .001) and homogeneity (p < .001). IMP exhibited the highest contrast, that was significantly higher than C, HADM, PADM, CCM and CM.

CONCLUSIONS

HFUS grayscale analysis can be applied to characterize the structure of different biomaterials and holds potential for translation to in-vivo assessment following soft tissue grafting-related procedures.

Comparison of morbidity at the donor site and clinical efficacy at the recipient site between two different connective tissue graft harvesting techniques from the palate: A randomized clinical trial

Background

This study was conducted to compare the pain levels in patients and the clinical efficacy of grafts obtained using two techniques, namely de-epithelialized gingival graft (DGG) and subepithelial connective tissue graft (SCTG), in combination with coronally advanced flap (CAF) for the treatment of multiple adjacent gingival recessions.

Methods

Twelve patients were treated using DGG+CAF on one side and SCTG+CAF on the other. The patients' pain levels at the surgical site, the number of analgesics taken on days 3 and 7, the mean root coverage (MRC), the percentage of complete root coverage (CRC), color match, and gingival thickness (GT) at the graft recipient site were evaluated 6 months after surgery.

Results

The total number of analgesics taken during the 7-day period after surgery and pain levels at the surgical site from day 3 to day 7 were significantly higher in the DGG+CAF group compared to the SCTG+CAF group (P=0.001). In the 6-month follow-up, color match and CRC were significantly higher in the SCTG+CAF group, while GT was significantly higher in the DGG+CAF group. There was no significant difference in MRC between the two groups.

Conclusion

The pain and analgesic consumption levels were higher in the DGG+CAF group compared to the SCTG+CAF group, and the recipient site had a weaker color match. However, this technique can lead to a greater increase in the thickness of the grafted area.

Preliminary Experience in Transducer Preparation for Intraoral Imaging

Intraoral scanning must meet a stringent infection control standard because of contact with the oral mucosa. A preparation protocol is thus presented for increased inquiries about intraoral scanning requirements. Materials required for such a preparation include: a single-use bubble-free gel packet, a gel standoff pad, and a transducer probe cover. Postscan reprocessing of the ultrasound transducer requires high-level disinfection. Examples for proper and improper use are provided as well as limitations of this preparation protocol and recommendations for future development. This guidance meets the current infection control standard and may guide the user to obtain consistent ultrasound image quality.

Keratinized mucosa width assessment at implant sites using high-frequency ultrasonography

BACKGROUND

The aim of this study was to describe the application of high-frequency ultrasonography (HFUS) for assessing keratinized mucosa (KM) width at implant sites.

METHODS

KM width was measured at 28 implant sites exhibiting a peri-implant soft tissue dehiscence at baseline and 12 months after soft tissue augmentation. KM width assessment was performed with a periodontal probe [clinical assessment (clKM)] and with HFUS, based on the echointensity of the keratinized epithelium compared to the adjacent structures. KM width measurements on ultrasound scans were performed linearly (lnKM) and along the soft tissue profile [surface distance (sdKM)].

RESULTS

No statistically significant differences were observed between clKM, lnKM, and sdKM at baseline, while at 12 months, sdKM (5.313 ± 1.188 mm) was significantly higher than clKM (3.98 ± 1.25 mm) and lnKM (4.068 ± 1.197 mm) (P < 0.001 for both comparisons). A linear relationship between mucosal thickness (MT) and the difference between sdKM and lnKM was observed. In 95.2% of cases with MT > 2.51 mm, the discrepancy between sdKM and lnKM was at least 1 mm.

CONCLUSIONS

HFUS is a noninvasive and valuable tool for measure KM width at implant site. Evaluating KM width along the soft tissue profile as a surface distance may improve the accuracy of the assessment.

Overview of Ultrasound in Dentistry for Advancing Research Methodology and Patient Care Quality with Emphasis on Periodontal/Peri-implant Applications

BACKGROUND

Ultrasound is a non-invasive, cross-sectional imaging technique emerging in dentistry. It is an adjunct tool for diagnosing pathologies in the oral cavity that overcomes some limitations of current methodologies, including direct clinical examination, 2D radiographs, and cone beam computerized tomography. Increasing demand for soft tissue imaging has led to continuous improvements on transducer miniaturization and spatial resolution. The aims of this study are (1) to create a comprehensive overview of the current literature of ultrasonic imaging relating to dentistry, and (2) to provide a view onto investigations with immediate, intermediate, and long-term impact in periodontology and implantology.

METHODS

A rapid literature review was performed using two broad searches conducted in the PubMed database, yielding 576 and 757 citations, respectively. A rating was established within a citation software (EndNote) using a 5-star classification. The broad search with 757 citations allowed for high sensitivity whereas the subsequent rating added specificity.

RESULTS

A critical review of the clinical applications of ultrasound in dentistry was provided with a focus on applications in periodontology and implantology. The role of ultrasound as a developing dental diagnostic tool was reviewed. Specific uses such as soft and hard tissue imaging, longitudinal monitoring, as well as anatomic and physiological evaluation were discussed.

CONCLUSIONS

Future efforts should be directed towards the transition of ultrasonography from a research tool to a clinical tool. Moreover, a dedicated effort is needed to introduce ultrasonic imaging to dental education and the dental community to ultimately improve the quality of patient care.

Coronally advanced flap versus tunnel technique for the treatment of peri-implant soft tissue dehiscences with the connective tissue graft: A randomized, controlled clinical trial

AIM

To evaluate the efficacy of coronally advanced flap (CAF) versus tunnel technique (TUN) in covering isolated mid-facial peri-implant soft tissue dehiscences (PSTDs).

MATERIALS AND METHODS

Twenty-eight participants presenting with isolated non-molar implants exhibiting PSTDs were enrolled and randomized to receive either CAF or TUN, both with a connective tissue graft (CTG). The primary outcome of the study was the percentage of mean PSTD coverage at 12 months. Secondary endpoints included the frequency of complete PSTD coverage, changes in keratinized mucosa width (KMW) and horizontal mucosal thickness (MT), as assessed with transgingival probing, 3D optical scanning and ultrasonography, professional aesthetic evaluation and patient-reported outcome measures (PROMs).

RESULTS

At 12 months, the mean PSTD coverage of the CAF and TUN groups was 90.23% and 59.76%, respectively (p = .03). CAF-treated sites showed a substantially higher frequency of complete PSTD coverage (p = .07), together with significantly greater gain of KMW (p = .01), increase in MT (p = .02), volumetric gain (p < .01) and professional aesthetic outcomes (p = .01). Both interventions showed an improvement in patient-reported aesthetics and a reduction of the anxiety related to the appearance of the implant compared to baseline, with the CAF group obtaining significantly higher scores (p = .03 for both PROMs).

CONCLUSIONS

CAF + CTG resulted in superior PSTD coverage outcomes, greater gain in KMW and MT, and better PROMs than TUN + CTG for the treatment of isolated PSTDs (ClinicalTrials.gov NCT03498911).

Alveolar ridge preservation: Complications and cost-effectiveness

Alveolar ridge preservation is routinely indicated in clinical practice with the purpose of attenuating postextraction ridge atrophy. Over the past two decades numerous clinical studies and reviews on this topic have populated the literature. In recent years the focus has primarily been on analyzing efficacy outcomes pertaining to postextraction dimensional changes, whereas other relevant facets of alveolar ridge preservation therapy have remained unexplored. With this premise, we carried out a comprehensive evidence-based assessment of the complications associated with different modalities of alveolar ridge preservation and modeled the cost-effectiveness of different therapeutic modalities as a function of changes in ridge width and height. We conclude that, among allogeneic and xenogeneic bone graft materials, increased expenditure does not translate into increased effectiveness of alveolar ridge preservation therapy. On the other hand, a significant association between expenditure on a barrier membrane and reduced horizontal and vertical ridge resorption was observed, though only to a certain degree, beyond which the return on investment was significantly diminished.

Ultrasound Imaging of the Periodontium Complex: A Reliability Study

Background

Ultrasonography is a noninvasive, low-cost diagnostic tool widely used in medicine. Recent studies have demonstrated that ultrasound imaging might have the potential to be used intraorally to assess periodontal biomarkers.

Objectives

To evaluate the reliability of interlandmark distance measurements on intraoral ultrasound images of the periodontal tissues.

Materials and Methods

Sixty-four patients from the graduate periodontics (n = 33) and orthodontics (n = 31) clinics were recruited. A 20 MHz handheld intraoral ultrasound transducer was used to scan maxillary and mandibular incisors, canines, and premolars. Distances between the alveolar bone crest and cementoenamel junction (ABC-CEJ), gingival thickness (GT), and alveolar bone thickness (ABT) were measured by 3 raters. The intercorrelation coefficient (ICC) and mean absolute deviation (MAD) were calculated among and between the raters. Raters also scored images according to quality.

Results

The ICC scores for intrarater reliability were 0.940 (0.932-0.947), 0.953 (0.945-0.961), and 0.859 (0.841-0.876) for ABC-CEJ, GT, and ABT, respectively. The intrarater MAD values were 0.023 (±0.019) mm, 0.014 (±0.005) mm, and 0.005 (±0.003) mm, respectively. The ICC scores for interrater reliability were 0.872 (95% CI: 0.836-0.901), 0.958 (95% CI: 0.946-0.968), and 0.836 (95% CI: 0.789-0.873) for ABC-CEJ, GT, and ABT, respectively. The interrater MAD values were 0.063 (±0.029) mm, 0.023 (±0.018) mm, and 0.027 (±0.012) mm, respectively.

Conclusions

The present study showed the high reliability of ultrasound in both intrarater and interrater assessments. Results suggest there might be a potential use of intraoral ultrasound to assess periodontium.

Vertical soft tissue augmentation to treat implant esthetic complications: A prospective clinical and volumetric case series

INTRODUCTION

Challenging implant esthetic complications are often characterized by implant malpositioning and interproximal attachment loss of the adjacent teeth. However, limited evidence is available on the treatment of these conditions. The aim of this study was to evaluate the clinical, volumetric, and patient-reported outcome following treatment of peri-implant soft tissue dehiscences (PSTDs) exhibiting interproximal attachment loss on adjacent teeth, performed through vertical soft tissue augmentation with implant submersion.

METHODS

Ten subjects with isolated PSTD in the anterior maxilla characterized by adjacent dentition exhibiting interproximal attachment loss were consecutively enrolled and treated with horizontal and vertical soft tissue augmentation, involving crown and abutment removal, two connective tissue grafts, and submerge healing. Clinical outcomes of interest included mean PSTD coverage, mean PSTD reduction, clinical attachment level (CAL) gain at the implant and adjacent sites and soft tissue phenotype modifications at 1 year. Optical scanning was used for assessing volumetric changes. Professional assessment of esthetic outcomes was performed using the Implant Dehiscence coverage Esthetic Score (IDES), while patient-reported esthetic assessment involved a 0-10 visual analogue scale.

RESULTS

The mean PSTD depth reduction and mean PSTD coverage at 1 year were 2.25 mm, and 85.14%, respectively. A mean keratinized tissue width (KTW) gain of 1.15 mm was observed, while the mean gain in mucosal thickness (MT) was 1.58 mm. A mean CAL gain of 1.45 mm was obtained at the interproximal aspect of the adjacent dentition at 1 year. Greater linear dimensional (LD) changes were observed at the midfacial aspect of the implant compared to the interproximal sites. The mean final IDES was 6.90 points, while patient-reported esthetic evaluation was 8.83 points.

CONCLUSIONS

The present study demonstrated that vertical soft tissue augmentation with a submerged healing is an effective treatment approach for the treatment of challenging PSTDs with adjacent dentition exhibiting interproximal attachment loss. This technique can be effective in resolution of esthetic complications in most cases, providing a substantial gain in interproximal attachment levels at the adjacent dentition.

PDGF-BB-enriched collagen matrix to treat multiple gingival recessions with the tunneled coronally advanced flap

BACKGROUND

With technological advancements in reconstructive periodontology, traditional protocols for the treatment of gingival recessions (GRs) can be challenged. This manuscript presents preliminary findings of a novel minimally-invasive approach for the regenerative treatment of multiple adjacent GR defects.

METHODS

Two healthy adults were treated as part of this study. Multiple adjacent GRs in both subjects (1 in the mandible, and 1 in the maxilla) were treated employing a tunneled coronally advanced flap (TCAF) design, with the application of a cross-linked collagen matrix (CCM) that was enriched with recombinant human platelet-derived growth factor-BB (PDGF-BB) that was also applied on the prepared root surfaces. Clinical, ultrasonographic, esthetic, and patient-reported outcomes were observed at approximately 6- and 18-month time points.

RESULTS

All sites healed uneventfully after the treatments. Complete root coverage was achieved and maintained throughout the follow-up observations, from 6 to 18 months. Patients reported minimal discomfort and reduction of dentinal hypersensitivity at the augmented sites. The areas augmented with CCM + PDGF-BB revealed an increased soft tissue thickness relative to baseline (pretreatment) measures, as well as reduction in the level of the facial bone dehiscences.

CONCLUSION

This article describes the success of two cases of a novel minimally invasive regenerative approach for the treatment of multiple adjacent GR defects by the TCAF, using a CCM loaded with PDGF-BB. This approach offers potential as a minimally-invasive method to repair multiple adjacent GRs.

Soft tissue features of peri‐implant diseases and related treatment

BACKGROUND

The need for soft tissue grafting at implant sites for preventing and treating peri-implant diseases is a currently investigated and debated topic.

PURPOSE

The aim of this manuscript is to explore the inflammatory mechanisms at the peri-implant soft tissue compartment, to distinguish the structural components of the peri-implant soft tissue phenotype and their role on peri-implant health, and to appraise the clinical indications and expected outcomes of soft tissue augmentation procedures at peri-implant diseased sites.

MATERIALS AND METHODS

This narrative review depicts the inflammatory biomarkers and mediators in the peri-implant crevicular fluid utilized to diagnose peri-implant disease and that have been shown to be associated with peri-implant soft tissue phenotype modification and disease resolution. The impact of the peri-implant soft tissue phenotype, involving keratinized mucosa (KM) width, attached mucosa (AM), mucosal thickness (MT), and supracrestal tissue height (STH), on peri-implant health, esthetic, patient's comfort and disease prevention are discussed. The manuscript also illustrates the use of ultrasonography for the detection of peri-implant health/disease and the evaluation of the treatment outcomes following surgical therapies.

RESULTS

Current evidence indicates that soft tissue phenotype modification at implant sites with inadequate KM width, AM and MT can be beneficial for promoting peri-implant health and improving patient's comfort and hygiene procedures. Treatment approaches and outcomes from the available literature on soft tissue phenotype modification in combination with conventional techniques at sites with peri-implant mucositis or peri-implantitis are presented and discussed in detail.

CONCLUSIONS

Soft tissue grafting can be beneficial in preventing and treating peri-implant diseases. Clinical recommendations based on the disease, soft tissue phenotype characteristics and bone defect morphology are provided for a comprehensive hard- and soft-tissue-oriented treatment of peri-implant disease.

Recombinant human platelet-derived growth factor improves root coverage of a collagen matrix for multiple adjacent gingival recessions: A triple-blinded, randomized, placebo-controlled trial

AIM

To evaluate the efficacy of recombinant human platelet-derived growth factor (rhPDGF)-BB combined with a cross-linked collagen matrix (CCM) for the treatment of multiple adjacent gingival recession type 1 defects (MAGRs) in combination with the coronally advanced flap (CAF).

MATERIALS AND METHODS

Thirty patients were enrolled in this triple-blind, randomized, placebo-controlled trial and treated with either CAF + CCM + rhPDGF, or CAF + CCM + saline. The primary outcome was mean root coverage (mRC) at 6 months. Complete root coverage, gain in gingival thickness (GT), keratinized tissue width, volumetric and ultrasonographic changes, and patient-reported outcome measures were also assessed. Mixed-modelling regression analyses were used for statistical comparisons.

RESULTS

At 6 months, the mRC of the CCM + rhPDGF and CCM alone groups were 88.25% and 77.72%, respectively (p = .02). A significant gain in GT was consistently observed for both treatment arms, and more so for the patients receiving the matrix containing rhPDGF through time (0.51 vs. 0.80 mm, on average, p = .01). The rhPDGF + CCM treated patients presented greater volume gain, higher soft tissue thickness, and a superior aesthetic score.

CONCLUSION

rhPDGF enhances the clinical, volumetric, and aesthetic outcomes of MAGRs above the results achieved with CAF + CCM alone (ClinicalTrials.gov NCT04462237).

The Forefront of Dentistry-Promising Tech-Innovations and New Treatments

KNOWLEDGE TRANSFER STATEMENT

This article discusses innovations in technology and treatments that have enormous potential to revolutionize our dental care, including novel concepts in electronic health records, communication between dentists and patients, biologics around diagnosis and treatment, digital dentistry, and, finally, the real-time optimization of information technology. The early implementation and validation of these innovations can drive down their costs and provide better dental and medical services to all members of our society.

High-resolution ultrasonography of gingival biomarkers for periodontal diagnosis in healthy and diseased subjects

OBJECTIVE

To determine the capacity of ultrasonographic image-based measurements of gingival height and alveolar bone level for monitoring periodontal health and disease.

METHODS

Sixteen subjects were recruited from patients scheduled to receive dental care and classified as periodontally healthy (n = 10) or diseased (n = 6) according to clinical guidelines. A 40-MHz ultrasound system was used to measure gingival recession, gingival height, alveolar bone level, and gingival thickness from 66 teeth for comparison to probing measurements of pocket depth and clinical attachment level. Interexaminer variability and comparison between ultrasound measurements and probing measurements was performed via Bland-Altman analysis.

RESULTS

Gingival recession and its risk in non-recessed patients could be determined via measurement of the supra- and subgingival cementoenamel junction relative to the gingival margin. Interexaminer bias for ultrasound image analysis was negligible (<0.10 mm) for imaged gingival height (iGH) and 0.45 mm for imaged alveolar bone level (iABL). Diseased subjects had significantly higher imaging measurements (iGH, iABL) and clinical measurements (probing pocket depth, clinical attachment level) than healthy subjects (p < 0.05). Subtraction of the average biologic width from iGH resulted in 83% agreement (≤1 mm difference) between iGH and probing pocket depth measurements.

CONCLUSIONS

Ultrasonography has an equivalent diagnostic capacity as gold-standard physical probing for periodontal metrics while offering more detailed anatomical information.

Dental diagnosis for inlay restoration using an intraoral optical coherence tomography system: A case report

PATIENTS

The patient was a 32-year-old man who underwent amalgam restoration of the mandibular right second molar. An amalgam restoration fracture was diagnosed by intraoral optical coherence tomography (OCT), and pulp exposure was examined during cavity preparation. Subsequently, a definitive ceramic restoration was fabricated, and the marginal fit in the oral cavity was evaluated using the OCT system.

DISCUSSION

The existing OCT system cannot acquire images inside the oral cavity because of the large probe size. However, the proposed intraoral OCT system can access the prostheses in the mandibular right second molar. Therefore, dental diagnosis for restoration treatment with dental prosthesis fracture, marginal gap, and pulp exposure after tooth preparation is possible using the proposed intraoral OCT system.

CONCLUSIONS

The use of the intraoral OCT system improved dental diagnosis by allowing the dentist to confirm quantitative values through cross-sectional images, rather than that by determining a treatment plan after visual dental diagnosis.

Prevalence and risk indicators of midfacial peri-implant soft tissue dehiscence at single site in the esthetic zone: A cross-sectional clinical and ultrasonographic study

BACKGROUND

Esthetic complications of dental implants in the esthetic zone can have a major negative impact on patients' quality of life and perception of implant therapy. The aim of the present study was to evaluate the prevalence of peri-implant soft tissue dehiscence (PSTD) and the clinical and ultrasonographic risk indicators for this condition.

METHODS

Subjects with one or more healthy single dental implants in the esthetic area were identified and recruited. Clinical and ultrasonographic measurements, including PSTD class and subclass, pocket depth, keratinized mucosa width (KMW), mucosal thickness (MT) at 1 mm and 3 mm, buccal bone distance (BBD) and buccal bone thickness, were evaluated in healthy implants and implants with PSTD.

RESULTS

153 subjects with a total of 176 dental implants were included. The prevalence of PSTD was 54.2% and 56.8% on a patient and implant level, respectively. The most frequent type of PSTD was the one characterized by having both an implant-supported crown longer than the clinical crown of the homologous tooth and a visible abutment/implant fixture exposed to the oral cavity. The multi-variate analysis showed that the presence of an adjacent implant, a longer time of the implant in function, limited MT, reduced KMW and increased BBD were significantly associated with the presence of a PSTD.

CONCLUSIONS

PSTDs are common findings in the esthetic region. Several risk indicators for this condition, such as presence of an adjacent implant, increased time in function of the implant, higher BBD, lower KMW and MT were identified. This article is protected by copyright. All rights reserved.