Erythritol powder airflow for the treatment of peri-implant mucositis: A randomized controlled clinical trial

OBJECTIVES

Peri-implant mucositis is a biofilm-related, reversible inflammatory disease that can evolve into peri-implantitis if not adequately treated. The aim of the present randomized controlled clinical trial was to evaluate the efficacy of air-abrasive powder as compared to chlorhexidine (CHX) for the treatment of peri-implant mucositis, in terms of clinical and patient-reported outcomes (PROMs) and occurrence of peri-implantitis 12 months after treatment.

METHODS

In the control group, full-mouth calculus and plaque removal was performed with ultrasound and manual devices, and a 1.0% CHX gel was applied; in the test group, supra- and subgingival biofilm removal was performed using erythritol powder with a dedicated nozzle and calculus removal was performed with ultrasonic instruments if needed. Bleeding and plaque indexes, peri-implant probing depth and tissue level were measured at 1 week, and 1, 3, 6 and 12 months after treatment, while PROMs were evaluated up to 7 days after treatment.

RESULTS

Among 80 included implants, 70 were analysed at 12 months follow-up (30 in the test group, 40 in the control group, and 20 subjects). Success rates (implant-level) in terms of bleeding index were significantly different between the test (96.7%) and control group (92.5%); as for PROMs, only taste sensation was significantly better in the test group. The test group was significantly correlated to the smallest changes in peri-implant probing depth between baseline and 3 months.

CONCLUSIONS

The study showed that both treatment strategies are effective. This suggests that the use of air-abrasive powders could be used as an alternative biofilm removal method instead of adjunctive treatments with antiseptics.

A Proposal for a Multidisciplinary Integrated Oral Health Network for Patients Undergoing Major Orthopaedic Surgery (IOHN-OS)

The passing of the years of life physiologically leads to the accumulation of changes in tissues in the oral cavity, influencing dentition, chewing and swallowing mechanisms, and the oral microbiota. Some diseases and medications can aggravate oral symptoms and negatively influence eating behaviours, increasing the likelihood of becoming malnourished. This could make older individuals more vulnerable to complications when undergoing major orthopaedic surgery. Hidden infection foci in the oral cavity are a recognised cause of post-operative periprosthetic joint infections. Dysfunctional oral problems might also compromise feeding after surgery when good nutrition represents a fundamental aspect of a proper recovery. To manage these shortcomings, in this article, the authors hypothesise a multidisciplinary path of care named the Integrated Oral Health Network applied to major Orthopaedic Surgery (IOHN-OS). This peri-operative initiative would include pre-operative oral health screening and risk management by a dental team, patient education programmes before and after surgery, and bedside gerodontology actions like oral care and meal and eating support for fragile individuals. The IOHN-OS has the potential to reshape the concept of suitability for major orthopaedic surgery and generate momentum for designing community-based surveillance programmes that can keep the mouths of older subjects healthy for a long time.

The Correlation between Intraorifice Distance and the Anatomical Characteristics of the Second Mesiobuccal Canal of Maxillary Molars: A CBCT Study

Introduction

Missing anatomy is one of the main causes of endodontic failures, and accurate knowledge of teeth anatomy is a prerequisite for adequate root canal treatment. The aim of the present cone beam computed tomography (CBCT) study was to describe the anatomical characteristics of the mesiobuccal (MB) root canals of maxillary molars and to understand if a correlation exists between the position of the canal orifices and the anatomical features of the root.

Methods

For the purposes of the study, a total of 100 CBCT scans of maxillary molars with two MB canals were selected and studied. The features of root canal anatomy of the MB root of the same teeth were analyzed and recorded (root length, confluence, and Vertucci classification). The distance between MB1 and MB2 orifices and the palatal orifice were recorded, as well as the distance between the orifices and the line joining the palatal orifice and the others. A statistical analysis was performed by providing descriptive measures, the measure of the correlation between different parameters, and the influence of some of these measures on the presence of a confluence between MB1 and MB2.

Results

It resulted that the most frequent configuration is type II Vertucci. The length measured on the sagittal plane was significantly correlated to the presence of a confluence in the MB root. When the root length was higher than 14.56 mm, the confluence is three times more frequent than when the length is lower (OR = 3.635). The area under the curve (AUC) of the receiver operator characteristic (ROC) curve for length on the sagittal plane was 0.632 (P=0.036).

Conclusions

The presence of a confluence between the MB canals of maxillary molars is correlated to the length of the root that could be measured on the sagittal plane and to the distance between the canal orifices. The relative position of the root canal orifices in relation to anatomic landmarks needs to be further explored.

The influence of implant position and of prosthetic characteristics on the occurrence of peri-implantitis: a retrospective study on periapical radiographs

OBJECTIVE

The present retrospective study aimed to investigate the influence of malposition on the occurrence of peri-implantitis.

MATERIALS AND METHODS

The study included clinical records of systemically healthy patients with single and partial implant-supported rehabilitations and at least 1-year post-loading follow-up. The parameters collected included implant-related factors, patient-related factors, site-related factors, and prosthesis-related factors. The radiographic measurements were taken by using a dedicated software and the diagnosis of peri-implantitis was made based on all the available clinical and radiographic data. Descriptive statistics were provided for all variables. Following an exploratory approach, an implant-level analysis of factors influencing the occurrence of peri-implantitis was done through a multilevel multivariate logistic regression (mixed).

RESULTS

A total of 180 implants belonging to 90 subjects were randomly selected. Malposition showed no statistically significant association with the occurrence of peri-implantitis. According to the multi-level analysis, the parameters that were significantly associated with peri-implantitis included presence / history of periodontitis (OR = 5.945, 95% CI: 1.093 - 32.334, P = 0.039) and presence of an emergence profile angle ≥ 45° (OR = 9.094, 95% CI: 2.017 - 40.995, P = 0.005).

CONCLUSIONS

Implant malposition, as defined following Buser's criteria (2004), did not influence the occurrence of peri-implantitis in the selected cohort. Conversely, history of periodontitis and presence of a prosthetic emergence profile with an angle ≥ 45° were correlated to an increased risk of peri-implantitis.

CAD-CAM Titanium Meshes for GBR: A Case Series with Preliminary Histological Analysis

Titanium has been proposed as a mesh material for GBR since the nineties. To overcome difficulties in shaping and adaptation to the defect, digital elaboration techniques were introduced to digitally print meshes capable of fitting the bone perfectly, reproduced through the CT scan of the patient. Five patients were included in this case series. CBCT data of patients were acquired and sent to the producer of the titanium mesh. 3-dimension regenerative surgery was performed with titanium meshes and a mix of Demineralized Bovine Bone Matrix (DBBM) and Autologous bone (1:1 ratio). Radiographic measures were evaluated on paraxial sections of the CBCT through a dedicated software. When possible, regenerated bone samples were obtained at implant insertion time. Four out of five regenerated areas healed without local and systemic complications. One mesh was removed after two months and two weeks because of exposition. Mean vertical bone gain was 4.3 ± 1.5 mm (range 2.5 - 7 mm). Two histologic samples were obtained. In sample n.1, Bone Tissue Area and Graft Material Area were respectively 44.4% and 12.5%. In sample n.2, the same parameters were 15.6% and 16.9% respectively.

Efficacy of biomaterials for lateral bone augmentation performed with guided bone regeneration. A network meta-analysis

Bone regeneration is often required concomitant with implant placement to treat a bone fenestration, a dehiscence, and for contouring. This systematic review assessed the impact of different biomaterials employed for guided bone regeneration (GBR) simultaneous to implant placement on the stability of radiographic peri-implant bone levels at ≥12 months of follow-up (focused question 1), as well as on bone defect dimension (width/height) changes at re-assessment after ≥4 months (focused question 2). Only randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared different biomaterials for GBR were considered. A Bayesian network meta-analysis (NMA) was performed using a random-effects model. A ranking probability between treatments was obtained, as well as an estimation of the surface under the cumulative ranking value (SUCRA). Overall, whenever the biological principle of GBR was followed, regeneration occurred in a predictable way, irrespective of the type of biomaterial used. A lower efficacy of GBR treatments was suggested for initially large defects, despite the trend did not reach statistical significance. Regardless of the biomaterial employed, a certain resorption of the augmented bone was observed overtime. While GBR was shown to be a safe and predictable treatment, several complications (including exposure, infection, and soft tissue dehiscence) were reported, which tend to be higher when using cross-linked collagen membranes.

Effectiveness of root resection techniques compared with root canal retreatment or apical surgery for the treatment of apical periodontitis and tooth survival: A systematic review

BACKGROUND

To manage apical periodontitis in root filled maxillary and mandibular molars, root resection techniques may be employed to avoid the loss of the tooth.

OBJECTIVES

The objectives of the study were to systematically analyse the effectiveness of root resection techniques (root resection/crown resection/root amputation) for the management of apical periodontitis with non-surgical root canal retreatment or apical surgery by the evaluation of clinical and patient-related outcomes (PROMS), in human experimental studies and longitudinal studies.

METHODS

An electronic literature search in PubMed, MEDLINE via OVID interface, EMBASE and Cochrane Central, supplemented by a manual hand search of the grey literature, was performed up to 25th September 2021. Randomized controlled trials, comparative clinical trials and observational studies reporting on the outcome (tooth survival and patient-reported outcome measures with a minimum follow-up of 1 year) of root resection techniques for treating apical periodontitis were identified. The risk of bias was evaluated using the Newcastle-Ottawa scale.

RESULTS

From a total of 2098 reports, 36 were considered for further screening. Three retrospective studies, published between 2018 and 2020, were included in this systematic review. A high heterogeneity in terms of protocols, study design and the reported outcomes were observed. The risk of bias was scored as low to moderate. These three studies consisted of data from 305 resected teeth, from 254 patients, with a follow-up period of 1-16.8 years. Overall, 151 teeth were extracted during the follow-up period. In these studies, root resection treatment was carried out on 42 teeth exclusively for endodontic reasons. One of these studies reported 12 out of 23 teeth lost at follow-up. None of the studies reported on PROMS.

DISCUSSION

Although root resection techniques may be used for treating teeth with apical periodontitis, the data are limited. Furthermore, the studies are very heterogeneous and associated with high risk of bias.

CONCLUSIONS

Given the current level of available evidence, it is not possible to recommend, or dismiss, root resection techniques for managing apical periodontitis.

REGISTRATION

PROSPERO database (CRD42021260306).

Endodontic Surgery of the Palatal Root of a Maxillary Molar Associated with Simultaneous Management of a Maxillary Sinus Lesion

This case report describes a particular application of endodontic microsurgery with a palatal approach in the presence of a radiopaque lesion inside the maxillary sinus. The patient presented complaining of pain related to the first maxillary molar and events of nasal obstruction and facial pain in the cheek and nasal area. The endodontic orthograde treatment and retreatment were done, respectively, 7 and 4 years earlier. The cone-beam computed tomography (CBCT) scan taken before the treatment showed two separate lesions: one associated with the palatine root of the molar and another one inside the maxillary sinus. The patient agreed to solve both problems in one surgical step: endodontic surgery of the palatine root with palatal access with the simultaneous asportation of a lesion from the maxillary sinus floor. Complete bone healing of the periapical area and the maxillary sinus was visualized on intra-oral radiographs, and CBCT was taken one year after the treatment. As far as the authors know, no one in literature has ever described this approach and solved in such a conservative way both the problems at the tooth and in the maxillary sinus.

Effect of Guided Tissue Regeneration on the Success of Surgical Endodontic Treatment of Teeth with Endodontic-Periodontal Lesions: a Systematic Review

BACKGROUND

Endodontic-periodontal lesions may need surgical approach and the application of guided tissue regeneration (GTR) to be treated by a combined approach.

OBJECTIVES

The aim of the present study was to evaluate the effects of GTR on the success (clinical and radiological healing) of teeth with endodontic-periodontal lesions treated by modern surgical endodontic treatment, by means of a systematic review of the literature.

METHODS

An exhaustive electronic (Medline, Embase and Scopus searched from inception to August 2020) and manual literature search combined with strict inclusion and exclusion criteria was undertaken to identify any clinical (prospective case series or comparative trials) studies that assessed the added benefit of GTR in modern surgical endodontic treatment of teeth with endodontic-periodontal lesions. The success of the treatment was assessed based on radiographic healing and clinical evaluations. The risk of bias of the identified studies was evaluated using the Cochrane's collaboration RoB 2.0 tool and the Joanna Briggs Institute (JBI) critical appraisal tools.

RESULTS

A systematic literature search for eligible reports retrieved three randomized controlled trials (RCTs) and one prospective single arm study with a total of 125 teeth in 125 subjects. One of the RCTs has a low risk of bias, while the other two raised some concerns, using the RoB 2.0 tool. Due to the heterogeneity of the results, it was not possible to perform a comparative meta-analysis and the results are presented in a narrative manner and by calculating pooled outcomes. Pooling together the data from all the included studies, the reported outcome was of complete healing in 58.4% of all cases, of scar tissue formation / incomplete healing in 24% of cases, of uncertain healing in 12.8% of cases, and of failure in 4.8% of all analyzed teeth, with a follow-up ranging from 12 to 60 months.

CONCLUSIONS

The scientific evidence about the use of GTR in modern surgical endodontic treatment of endodontic-periodontal lesion is sparse, and the available results are derived from very heterogeneous studies, thus not permitting to clarify which is the most effective treatment option in these cases, also due to the absence of studies comparing GTR versus no GTR.

Mechanical resistance of a 2.9 mm diameter dental implant with a Morse-taper implant-abutment connection

Among the complications that can occur at dental implants, the fracture of any implant component is a relatively infrequent but clinically relevant problem. Due to their mechanical characteristics, small diameter implants are at higher risk of such complication. The aim of this laboratory and FEM study was to compare the mechanical behavior of a 2.9 mm and a 3.3 mm diameter implant with a conical connection under standard static and dynamic conditions, following the ISO 14801:2017. Finite element analysis was performed to compare the stress distribution on the tested implant systems under a 300 N, 30° inclined force. Static tests were performed with a load cell of 2 kN; the force was applied on the experimental samples at 30° with respect to the implant-abutment axis, with an arm of 5.5 mm. Fatigue tests were performed with decreasing loads, at 2 Hz frequency, until three specimens survived without any damage after 2 million cycles. The emergence profile of the abutment resulted the most stressed area in finite element analysis, with a maximum stress of 5829 MPa and 5480 MPa for 2.9 mm and 3.3 mm diameter implant complex respectively. The mean maximum load resulted 360 N for 2.9 mm diameter and 370 N for 3.3 mm diameter implants. The fatigue limit was recorded to be 220 N and 240 N respectively. Despite the more favorable results of 3.3 mm diameter implants, the difference between the tested implants could be considered clinically negligible. This is probably due to the conical design of the implant-abutment connection, which has been reported to present low stress values in the implant neck region, thus increasing the fracture resistance.

Use of an antiseptic rinse (NanArgol) for the oral hygiene maintenance of subjects with fixed appliances: A randomized clinical trial

BACKGROUND

The risk of periodontal diseases development increased in patients with malocclusion undergoing orthodontic treatment. Thus, the aim of this study was to examine the efficacy of the use of adjunctive rinses with nano-Argentum to standard oral hygiene regimen in subjects wearing fixed orthodontic appliances.

MATERIALS AND METHODS

Eighty patients were observed for 1 year. They were divided in two groups: in test group patients were instructed to rinse with non-ionic colloidal silver solution according to protocol for 6 months as an adjunct to standard; in control group the patients followed the standard oral hygiene regimen. Index of efficiency of oral hygiene (PHPm), community periodontal index (CPI) and papillary-marginal-alveolar index (PMA) were evaluated before treatment and after 1 and 6 months. For statistics analysis, Mann-Whitney, Kruskal-Wallis tests and Pearson criterion were used.

RESULTS

Baseline hygiene levels in two groups had no differences. Oral hygiene indices were significantly lower in the test group in comparison with control after 1 month (PHPm = 0.38 ± 0.18 and 1.19 ± 0.45, respectively, p < 0.01; PMA = 11.78 ± 8.5 and 47.25 ± 20.9, respectively, p < 0.05; CPI = 0.65 ± 0.53 and 1.53 ± 0.77, respectively, p < 0.01) and 6 months (PHPm = 0.5 ± 0.2 and 1.2 ± 0.4, respectively, p < 0.01; PMA = 11.62 ± 19.6 and 66.33 ± 27.9, respectively, p < 0.01; CPI = 0.63 ± 0.73 and 1.68 ± 0.78, respectively, p < 0.01).

CONCLUSIONS

The use of the test solution as an adjunct to standard oral hygiene provided a significant beneficial effect in terms of oral hygiene in patients undergoing orthodontic treatment.

Immediate implant positioning using tooth-derived bone substitute material for alveolar ridge preservation: Preliminary results at 6 months

OBJECTIVES

In the present study we evaluated the effectiveness of the use of a novel autologous bone substitute derived directly from processing the extracted tooth in the upper premolar area to preserve a suitable esthetic score and functionality.

MATERIAL AND METHODS

Fourteen bone-level implants with platform switching were inserted in 12 patients immediately after atraumatic extraction of premolars for restorative or endodontic reasons. The implant buccal bone gap was filled using autologous tooth extracted-derived material. Clinical and radiographic parameters, including Pink Esthetic Score (PES) were evaluated at 6 months.

RESULTS

A total of 10 patients accounting for 11 implants were included. PES showed a suitable esthetic result, and all the implant-prosthetic rehabilitation reported full satisfaction for masticatory function, phonetics, and aesthetics. Bone levels were stable and not affected by implant location, lesion type, or bone quality.

CONCLUSION

Radiographically the autologous bone substitute used appears stable in the surgical site and there is good continuity between the autologous bone and the graft. No adverse effects such as periodontal inflammation, infection, or graft rejection was reported.

Connective tissue graft versus xenogeneic collagen matrix for soft tissue augmentation at implant sites: a randomized-controlled clinical trial

OBJECTIVES

The purpose of this randomized clinical trial (RCT) is to compare xenogeneic collagen matrix (XCM) versus subepithelial connective tissue graft (SCTG) to increase soft tissue thickness at implant site.

MATERIALS AND METHODS

The study was a randomized, parallel-group controlled investigation. Thirty patients underwent buccal soft tissue thickness augmentation at the stage of implant placement by two different methods: SCTG (control group) and XCM (test group). Primary outcome was the amount of buccal soft tissue thickness gain, 3 months after the intervention. Secondary outcomes were the operation time, the amount of keratinized mucosa (KM), pain syndrome (PS), and patients' quality of life (QL). Histologic evaluation was also performed.

RESULTS

The amount of soft tissue thickness gain was 1.55±0.11 mm in SCTG group, and 1.18±0.11mm in XCM group. The difference between the SCTG and XCM was -0.366 (-0.66 to -0.07; p=0.016). Operation time with XCM was 8.4 (3.737 to 13.06) min shorter than that with the SCTG (p=0.001). KT, PS, and QL for both groups were not statistically significantly different at any time point (p>0.05). At histological examination, the general picture in both groups was similar. No significant differences between the studied groups in most indices, except for the average and maximum formation thickness, cellularity of the basal, mitotic activity and also maximum length of rete ridges.

CONCLUSION

Within limitations, this study demonstrates that the use of SCTG provides a statistically significant superior soft tissue thickness gain than XCM for soft tissue augmentation procedures around implants.

CLINICAL RELEVANCE

XCM can be used as the method of choice for increasing the thickness of soft tissues.

The effect of the use of proton pump inhibitors, serotonin uptake inhibitors, anti-hypertensive, and anti-inflammatory drugs on clinical outcomes of functional dental implants: a retrospective study

OBJECTIVE

The present retrospective study investigated the effect of chronic intake of proton pump inhibitors, selective serotonin uptake inhibitors, anti-inflammatory, and anti-hypertensive drugs on the survival of dental implants and on the occurrence of peri-implantitis.

MATERIALS AND METHODS

Survival analyses for implant failure and peri-implantitis were performed patient level for each drug subcategory and for risk factors. The HR for each drug was calculated with adjusted models as compared to a control group made of subjects not assuming the specific drug. Multilevel logistic regression was used to explore the influence of implant-level and patient-level variables on the outcomes.

RESULTS

A total of 270 subjects receiving 1118 dental implants were included, with a mean follow-up time of 5.19 ± 4.22 years. After 10 years, the survival rate was 86.9% (patient level) and, according to survival analysis, 61.3% of subjects were free from peri-implantitis. The use of anti-inflammatory medicines produced a significant effect (P = 0.04) on peri-implantitis as compared to subjects not using the drug, with a 2.7 year drop of the mean survival time. The HR was slightly above the level of significance in a semi-adjusted model (P = 0.058). The multilevel analysis found a significant effect on the entire sample and not when considering only subjects with implants with more than 1 year follow-up.

CONCLUSIONS

We found a possible relationship between anti-inflammatory drugs use and the occurrence of peri-implantitis in the examined cohort of patients, and no correlation for the other drugs.

Tooth as graft material: Histologic study

Background

An effective regenerative protocol is key to reestablish and maintain the hard and soft tissue dimensions over time. The choice of the graft material and its properties also could have an impact on the results. To prevent alveolar ridge dimensional changes, since numerous graft materials have been suggested and in the past years, a growing interest in teeth material has been observed as a valuable alternative to synthetic biomaterials.

Aim

The aim of the study was to explore the histomorphometric outcomes of tooth derivative materials as used as bone substitute material in socket preservation procedure.

Methods

After alveolar socket preservation (ASP) procedures using autologous demineralized tooth as graft material prepared by means of an innovative device, was evaluated. A total of 101 histological samples, from 96 subjects, were analyzed by evaluating the total amount of bone (BV), residual tooth material (residual graft, TT), and vital bone (VB). The section from each sample was then split in nine subsections, resulting in 909 subsections, to allow statistical comparison between the different areas.

Results

It was not noticed a statistically significant difference between maxillary and mandibular sites, being the amount of VB in upper jaw sites 37.9 ± 21.9% and 38.0 ± 22.0% in lower jaw sites and the amount of TT was 7.7 ± 12.2% in maxilla and 7.0 ± 11.1% in mandibles. None of the other considered parameters, including defect type and section position, were statistically correlated to the results of the histomorphometric analysis.

Conclusions

ASP procedure using demineralized autologous tooth‐derived biomaterial may be a predictable procedure to produce new vital bone potentially capable to support dental implant rehabilitation.

Frequency and anatomic variability of the mandibular lingual foramina: a cone-beam CT study

Background

To evaluate the distribution of lingual foramina (LF) and their correlation with demographic characteristics and mandible width, shape, and bone thickness in Caucasian Italian patients subjected to cone-beam CT (CBCT).

Methods

CBCTs were reviewed to assess the number of all LF, midline and lateral LF. We also assessed the relationship of the number of lateral LF with gender and mandibular width, shape, and bone thickness using the Chi Square test. A p value < 0.05 was considered statistically significant.

Results

Three-hundred patients (180 males; age range: 21–87 years) were included. The highest frequency per patient was of 2 LF (97/300, 32.3%), followed by 3 (81/300, 27%) and 4 (53/300, 17.7%). No LF were observed in 2/300 patients (0.7%), while the highest number was of 8 LF in one patient. The highest frequency of midline LF per person was of 2 LF (57.3%, 172/300), while the highest number per person was 5 LF in one patient (0.3%). The highest frequency of midline LF located above and below the genial tubercle was of 1 in 197/300 patients (65.7%) and in 169/300 patients (56.3%), respectively. Concerning lateral LF, the highest frequencies were of 0 (113/300, 37.7%) and of 1 (112/300, 37.3%). We did not observe any significant difference of the number of midline and lateral LF based on gender (P = .438 and P = .195, respectively) or mandible width (P = .069 and P = .114, respectively). The mandible shape was normal in 188 cases, with facial constriction in 42, lingual constriction in 54, and hour glass constriction in 16. The mean bone thickness was 10.76 mm in the symphysis, 10.92 mm in the right hemiarches, and 10.68 in the left hemiarches. No significant differences in the distribution of LF were observed also based on mandibular shape and bone thickness (both with P > .05).

Conclusions

We have shown the high variability of number and anatomic distribution of LF in an Italian group of patients subjected to CBCT without reporting any association with gender and mandible width, shape, and bone thickness.

Comparative Study of Deproteinized Bovine Bone Mineral and Bovine Bone Mineral Enriched with a Polymer and Gelatin in Maxillary Sinus Floor Elevation Procedures

The aim of this histomorphometric study was to compare the outcome of sinus floor augmentation procedures using bovine bone mineral and a xenograft enriched with gelatin and a polymer. In 20 patients a single sinus floor elevation procedure with a lateral window approach was performed. In half of the patients, sinuses were grafted with a deproteinized bovine bone mineral-DBBM (control group)-while in the remaining 10, a xenograft enriched by polymer and gelatin-NBS (test group)-was applied. In the DBBM group, histomorphometric analysis revealed 23.14 ± 10.62% of lamellar bone, 19.43% ± 9.18% of woven bone, 23.35% ± 6.04% of osteoid, 17.16% ± 6.13% of biomaterial particles, and 16.93% ± 9.78% of medullary spaces. In the NBS group, histomorphometric analysis found 39.64% ± 12.02% of lamellar bone, 16.28% ± 7.75% of woven bone, 17.51% ± 4.87% of osteoid, 12.72% ± 5.36% of biomaterial particles, and 13.84% ± 6.53% of medullary spaces. Differences between groups for proportion of lamellar bone (P = .004) and osteoid (P = .0287) were statistically significant. Inflammatory infiltration was appreciated only in the NBS group. The enriched xenograft showed a statistically significant higher proportion of lamellar bone and osteoid; however, this was accompanied by an accentuated inflammatory infiltrate.

Fungal species in endodontic infections: A systematic review and meta-analysis

Fungal infections are common on oral mucosae, but their role in other oral sites is ill defined. Over the last few decades, numerous studies have reported the presence of fungi, particularly Candida species in endodontic infections, albeit in relatively small numbers in comparison to its predominant anaerobic bacteriome. Here, we review the fungal biome of primary and secondary endodontic infections, with particular reference to the prevalence and behavior of Candida species. Meta-analysis of the available data from a total of 39 studies fitting the inclusion criteria, indicate the overall weighted mean prevalence (WMP) of fungal species in endodontic infections to be 9.11% (from a cumulative total of 2003 samples), with 9.0% in primary (n = 1341), and 9.3% in secondary infections (n = 662). Nevertheless, WMP for fungi in primary and secondary infections which were 6.3% and 7.5% for culture-based studies, increased to 12.5% and 16.0% in molecular studies, respectively. The most prevalent fungal species was Candida spp. The high heterogeneity in the reported fungal prevalence suggests the need for standardized sampling, and speciation methods. The advent of the new molecular biological analytical platforms, such as the next generation sequencing (NGS), and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF), that enables identification and quantitation of a broad spectrum of hitherto unknown organisms in endodontic infections should radically alter our understanding of the endodontic mycobiome in the future. Candida spp. appear to be co-pathogens with bacteria in approximately one in ten patients with endodontic infections. Hence, clinicians should comprehend the importance and the role of fungi in endodontic infections and be cognizant of the need to eradicate both bacteria and fungi for successful therapy.

Evaluation of mental foramen and inferior alveolar nerve canal and its relationship to adjacent anatomical landmarks using cone-beam computer tomography

The objective of the research was to evaluate the location, size, variability, and morphologic features of mental foramen (MF) and the inferior alveolar nerve canal (IAN) on cone-beam CT. We evaluated the morphologic findings of mental foramen (MF) and inferior alveolar nerve (IAN) canal of 88 mandibular hemiarches of 65 Caucasian subjects (35 males, 30 females; age range 25-75 years) using cone beam CT. The most common horizontal position of MF was type 3 (53.4%), followed by type 4 (39.8%), type 1 (2.3%), type 2 (2.3%), and type 5 (2.3%). Regarding the vertical position, in 71.6% of cases (63/88) we found type 3 position, followed by type 2 (22.7%) and type 1 (5.7%). MF presented as oval in 51.1% and round in 42%, with double oval and triple foramens having been observed in 5.7% and 1.1% respectively. In 36.9% of cases, we found an anterior loop of the IAN. The mean depth of MF was 6.12±1.65mm; width and height were 3.7±0.83mm and 3.14±0.78mm. Width and height of the IAN distal to MF were 2.27±0.53mm and 2.74±0.51mm, while those of the incisive nerve canal mesial to MF were 1.37±0.44mm and 1.54±0.58mm, respectively. An increase in the width of MF was correlated to oval shape (r=0.45; P < 0.01), and there was a low but significant correlation (r=0.23; P < 0.05) between the round shape of MF and the size of the IAN. MF shape appears to be correlated to MF width and size of the IAN. The individual anatomical variability of this structure is a factor that must be considered when dealing with mandibular surgery.

Cutaneous and oral comorbidities in patients with geographic tongue: a multicenter multidisciplinary cross-sectional observational study

Geographic tongue (GT) represents a localized type of psoriasis inversa and its burden of dermatological and oral comorbidities frequently conditions its severity and diagnosis. Currently, no epidemiological studies have evaluated GT muco-cutaneous comorbidities. We aimed to study oral and dermatological comorbidities in a large sample of GT patients. In this multicenter, cross-sectional study, involving 4 primary referral centers in Italy, we evaluated adult GT patients, who were assessed by board certified dermatologists and dentists for 5 months and collected demographics and medical history. GT was evaluated using Hume's classification together with Geographic tongue severity index (GTASI) to score its severity. The prevalence of oral and dermatological comorbidities was recorded. In the sample we enrolled 137 GT patients (M/F= 5:1) with a mean age of 48,2 ± 14,7 yoa and 33.6% had GT family history. The clinical evaluation found 96 (70.1%) GT type I, 7 (5.1%) type II, 13 (9.5%) type IIIa, 19 (13.9%) type IIIb, 2 (1.5%) type IV, following Hume's classification. The mean GTASI score was 23,7 ± 14,2 and the vast majority displayed a severe form of GT. Eighty-nine patients had oral comorbidities (burning mouth syndrome, caries, parulid and lichen planus) and 80 had dermatological concurrent conditions (plaque psoriasis, inverse psoriasis and atopic dermatitis). In GT patients, both dermatological and dental evaluation should be mandatory to identify previously undiagnosed mucocutaneous comorbidities.

Geographic tongue clinical response in moderate-to-severe psoriatic patients undergoing secukinumab: a real-life, multicenter retrospective observational study

Geographic tongue (GT), a form of inverse psoriasis, is frequently linked to plaque psoriasis. The objective of the study is to evaluate IL-17 blocker (secukinumab) effect on GT severity. This reallife, multicenter, retrospective observational pilot study evaluated patients with plaque psoriasis and concomitant GT that started in label treatment with secukinumab. Patients were evaluated twice (T0=baseline and T1=after 16 weeks) by a dentist and a dermatologist collecting data on cutaneous Psoriasis Area Severity Index (PASI) and oral statuses using Hume's classification of the Geographic Tongue Severity Index (GTASI). Twenty-nine psoriatic patients with GT treated with secukinumab were enrolled for the study. Seventeen patients display type I GT, 6 type II and 6 type III with an overall GTASI of 25.52±9.57 at the baseline (T0). No correlation was found between delta GTASI and delta PASI (r=-0.27, p=0.1551). GTASI decrement from T0 to T1 was statistically significant ([95%CI -26.64 to -19.56], t=-13.36, p<0.0001). Secukinumab may enter in GT therapeutic armamentarium as the first biologic IL-17 blocker in patients with concomitant moderate-to-severe plaque psoriasis.

Effect of concentrated growth factors on quality of life of patients undergoing implant therapy: a cohort study

Pain, bad taste, and impaired daily activity after implant therapy are common sequelae. Concentrated growth factors (CGF) are a platelet concentrate with a favourable effect on wound healing, but there is still no evidence regarding its potential benefits for reducing postoperative pain and symptoms. Therefore, aim of this prospective comparative study was to determine the effect of CGF on quality of life (QoL) of patients after implant therapy. Fifty-two consecutive patients with one missing mandibular molar were included in the study and alternatively assigned to two groups. Control group received standard implant treatment, and test group received CGF associated with implants. Standard periapical radiographs were taken before and after procedure. Post-operative care consisted of 0.2% chlorhexidine digluconate solution twice daily for 10 days. A QoL questionnaire (OHIP-14) for bad taste, pain and limitation in daily activities was filled and returned one week post-operatively. Daily pain was also assessed through Visual Analogue Scale (VAS) on a 1-100 scale. Parametric test (chi-square) was performed to compare the results of the questionnaire between the two groups using STATA statistical software. All patients correctly filled and returned the questionnaire. Significantly higher proportions of patients of test group reported no bad taste, pain, and limited activity, (24/26, 13/26, and 25/26, respectively) respect to control. Postoperative pain with VAS score was significantly lower in the test group on day 1, 2, and 3 as compared to control. CGF positively influenced QoL when associated with implant rehabilitation of mandibular molars, minimizing post-operative discomfort.

Persistence of postoperative pain due to extrusion of endodontic obturator plastic carrier: A report of two cases treated with a periradicular microsurgical approach

The aim of the present study was to describe two clinical cases showing postoperative pain associated with the use of plastic carrier obturation system and apical bone fenestration. The patients were treated by surgical access and apicoectomy through a modern technique (using magnification and microsurgical approach), thus removing the direct contact between obturation material and submucosal connective tissue. The surgical interventions were carried on without the occurrence of any complication. Postsurgical adverse sequelae were negligible. After few weeks from the surgery, all symptoms disappeared. Radiographic healing was observed after 48 months. The presence of apical bone fenestration could be the cause of persistent pain after root canal treatment. The contact between plastic carrier and submucosal connective tissue could be the direct cause of spontaneous pain even in absence of periapical infection. Since the clinical diagnosis could be difficult, the use of tridimensional radiology could be justified. Surgical approach, by the removal of the contact between the carrier and connective tissues, can be considered a viable option to treat these particular affections.

Microsurgical endodontic treatment of the upper molar teeth and their relationship with the maxillary sinus: a retrospective multicentric clinical study

PURPOSE

To assess the clinical and radiographic success rate of microsurgical endodontic treatment of upper molar teeth in relationship with the maxillary sinus, with 12 months follow-up.

METHODS

Patients treated with microsurgical endodontic treatment of upper molar teeth in the period between 2017 and 2019 were recruited from two dental clinics according to specific selection criteria. The outcomes were determined based on clinical and radiographic results taken three, six and 12 months post-operatively, compared with those taken immediately before and after surgery. Clinical and radiographic outcomes were recorded. The distance between the most apical part of the root and of the lesion to the maxillary sinus was measured on CBCT images before the surgery. Patient-related outcomes were recorded.

RESULTS

Out of 35 patients evaluated, 21 were selected according with the selection criteria for a total of 27 roots and 29 canals treated. After 12 months, 18 patients showed a complete healing whereas three demonstrated incomplete healing. Consequently, the success rate in this study was 85.7% after one year. In 28.5% (6 patients) there was a perforation of the Schneiderian membrane that didn't seem to affect the outcome. All patients kept the molar one year later. The pain level decreased significantly over the time during the first week after surgery.

CONCLUSION

Microsurgical Endodontic treatment of the upper molar teeth should be considered a valid and predictable treatment option even in case of Schneiderian membrane perforation. Future clinical studies with a larger sample size are needed to compare the results obtained.

Medium- and Long-Term Survival Rates of Implant-Supported Single and Partial Restorations at a Maximum Follow-up of 12 Years: A Retrospective Study

PURPOSE

To present medium- and long-term biologic outcomes of implant-supported single-tooth restorations and fixed partial dentures and to analyze their correlations with prosthesis and patient characteristics.

MATERIALS AND METHODS

The records of patients treated with implant-supported fixed restorations between 2004 and 2019 reporting the presence or absence of peri-implantitis and/or implant failure were analyzed. The cumulative survival rate (%) over time was calculated, as well as the cumulative prevalence of units free of peri-implantitis.

RESULTS

A total of 344 implants in 112 patients were included, with a mean follow-up period of 5.3 ± 4.0 years after loading. The cumulative survival rates for implants supporting single crowns and fixed partial dentures were 98.11% and 100% after 5 years, respectively, and 97.43% and 98.96% after 10 years, with an overall survival rate of 91.69% after 12 years. At the patient level, the implant survival rates were 95.42%, 92.73%, and 85.31% at 5, 10, and 12 years, respectively. The cumulative rate of implants free from peri-implantitis was 87.46% at the implant level and 72.39% at the patient level. Implant and prosthesis characteristics did not affect the long-term occurrence of implant failure or peri-implantitis. The development of peri-implantitis was statistically correlated with patient smoking habits, but not with history of periodontitis or with diabetes mellitus.

CONCLUSION

Implants supporting single crowns and fixed partial dentures showed relatively high medium- and long-term survival rates that were not influenced by the implant or prosthesis characteristics, including the retention method. As for patient characteristics, only smoking was correlated with the occurrence of peri-implantitis.

Applications of deep learning in dentistry

Over the last few years, translational applications of so-called artificial intelligence in the field of medicine have garnered a significant amount of interest. The present article aims to review existing dental literature that has examined deep learning, a subset of machine learning that has demonstrated the highest performance when applied to image processing and that has been tested as a formidable diagnostic support tool through its automated analysis of radiographic/photographic images. Furthermore, the article will critically evaluate the literature to describe potential methodological weaknesses of the studies and the need for further development. This review includes 28 studies that have described the applications of deep learning in various fields of dentistry. Research into the applications of deep learning in dentistry contains claims of its high accuracy. Nonetheless, many of these studies have substantial limitations and methodological issues (e.g., examiner reliability, the number of images used for training/testing, the methods used for validation) that have significantly limited the external validity of their results. Therefore, future studies that acknowledge the methodological limitations of existing literature will help to establish a better understanding of the usefulness of applying deep learning in dentistry.

The Influence of Residual Alveolar Bone Height on Graft Composition after Maxillary Sinus Augmentation Using Two Different Xenografts: A Histomorphometric Comparative Study

AIM

To evaluate the hypothesis of a correlation between the preoperative residual alveolar bone height (RBH) and graft maturation after maxillary sinus floor augmentation procedures using two different bone substitutes.

METHODS

A total of 20 patients who underwent unilateral maxillary sinus floor augmentation with either mineralized deproteinized bovine bone (DBBM) or a xenograft enriched with polymer and gelatin (NBS) were included in this prospective study. Six months after sinus surgery, bone biopsies were harvested with a 3.2 mm diameter trephine bur, prior to dental implant placement. Histomorphometric analysis was performed, and the results were correlated with the individual RBH. Implants were loaded after 5 months of insertion, and 1-year implant success and marginal bone level change were assessed.

RESULTS

RBH was 2.17 ± 1.11 mm (range 0.5-3.5 mm) and 2.14 ± 0.72 mm (range 0.5-3.0 mm) in the NBS and DBBM group, respectively. The biopsy analyses for the DBBM group showed woven bone increases by 5.08% per 1-mm increment of RBH; medullary spaces decreased by 9.02%, osteoid decreased by 4.4%, residual biomaterial decreased by 0.34%, and lamellar bone increased by 5.68% per 1-mm increase of RBH. In the NBS group, samples showed woven bone increases by 8.08% per 1-mm increase of RBH; medullary spaces decreased by 0.38%; osteoid increased by 1.34%, residual biomaterial decreased by 0.58%, and lamellar bone decreased by 5.50% per 1-mm increase of RBH. There was no statistically significant difference in the correlation between RBH and lamellar bone, woven bone, and osteoid, independently of the material used. Implant success was 100% in both groups, and marginal bone loss was 1.02 ± 0.42 mm in DBBM and 0.95 ± 0.31 mm in the NBS group after the 1-year follow-up.

CONCLUSION

In spite of the absence of significance, the observed trend for woven bone to increase and medullary spaces to decrease when RBH increases deserves attention. Residual bone dimension might be a determinant in the bone graft maturation after maxillary sinus augmentation.

Influence of teeth anatomical characteristics on the efficacy of manual toothbrushing manoeuvres

Purpose

The aim of the study was to investigate the efficacy of two toothbrushing techniques on the amount of plaque accumulation and to evaluate how the changes were correlated to the anatomical characteristics of the anterior maxillary arch.

Methods

Thirty subjects of both genders were included, they were asked not to brush for 12 h. Afterwards, they were asked to manually brush the left side of their maxillary arch with the modified Bass technique and the right side adopting the roll technique. The comparison of photographs taken before and after the manoeuvres, using a plaque disclosing agent, allowed the researchers to measure the changes in plaque accumulation measured using the Quigley and Hein plaque scoring classification. Linear regression analysis was used to evaluate the correlation between such changes and the teeth and arch anatomical characteristics.

Results

A mean reduction of 9.6 ± 5.2% considering both arches after brushing was observed. The changes in plaque accumulation were not different between the two techniques. The length of the line obtained joining the contact point between the central incisors and the contact point between the second premolar and the first molar on the left side and the distance between that line and the lateral incisor on the same side positively correlated to the decrease in the plaque scores (P = 0.046 and P = 0.044, respectively).

Conclusion

Both tested techniques were effective in plaque removal in the anterior maxillary arches. However, the research for the anatomical factors influencing the amount of efficacy of the toothbrushing manoeuvres was inconclusive. We can hypothesise that the adoption of one adequate technique could be more important than the teeth characteristics.

Influence of Diabetes on Implant Failure and Peri-Implant Diseases: A Retrospective Study

Diabetes is an important modifying factor of periodontitis, but its association with peri-implant diseases has not been fully explored and the existing literature reports controversial results. The aim of this retrospective study was to evaluate the influence of diabetes on peri-implantitis and implant failure. Smoking status, history of periodontal disease, presence of diabetes, diabetes type, therapy and glycaemia levels were collected in a total of 204 subjects treated with 929 implants, with a mean follow-up time of 5.7 ± 3.82 years after loading. Odds ratio (OR) for diabetes as a direct cause of peri-implantitis and implant failure were calculated, adjusted for smoking status and history of periodontitis. Nineteen patients were diabetic and most of them presented a good control of the disease at the time of surgery. The overall patient-level prevalence of peri-implantitis was 11.3%. Among diabetic patients, one developed peri-implantitis, whereas one experienced multiple implant failures. The calculated ORs, adjusted for smoking status and periodontitis, were not statistically significant. The results revealed no association between diabetes and peri-implantitis or implant failure coherently with the existing scientific literature. The actual influence of hyperglycemia on implant failure is still uncertain and new studies with larger cohorts of patients are needed.

Biofilm Formation on Dental Implant Surface Treated by Implantoplasty: An In Situ Study

Peri-implantitis is a biofilm-related disease whose characteristics are peri-implant tissues inflammation and bone resorption. Some clinical trials report beneficial effects after implantoplasty, namely the surgical smoothening of the implant surface, but there is a lack of data about the development of the bacterial biofilm on those smoothened surfaces. The aim of this study is to evaluate how implantoplasty influences biofilm formation. Three implants with moderately rough surfaces (control) and three implants treated with implantoplasty (test) were set on a tray reproducing the supra- and sub-gingival environment. One volunteer wore this tray for five days. Every 24 h, plaque coverage was measured and, at the end of the period of observartion, the implant surfaces were analyzed using scanning electron microscopy and confocal laser scanning microscopy. The proportion of implant surface covered with plaque was 65% (SD = 7.07) of the control implants and 16% (SD = 0) of the test implants. Untreated surfaces showed mature, complex biofilm structures with wide morphological diversity, and treated surfaces did not show the formation of mature biofilm structures. This study supports the efficacy of implantoplasty in reducing plaque adhesion and influencing biofilm formation. These results can be considered a preliminary proof of concept, but they may encourage further studies about the effects of implantoplasty on biofilm formation.

Comparative analysis of methods to increase the amount of keratinized mucosa before stage-two surgery: a randomized controlled study

OBJECTIVES

The aim of the present randomized controlled clinical trial was to evaluate the outcomes of the use of free gingival graft (FGG), of a collagen matrix and of vestibuloplasty to increase the amount of keratinized attached mucosa (KM) before healing abutment placement.

METHOD AND MATERIALS

The study was a randomized, parallel-group controlled investigation. All patients were treated to increase the KM width before placement of implant-supported prostheses. The implants were placed 3 to 6 months before the interventions. Three techniques were tested: an apically positioned flap (control group), FGG (test group 1), and use of a collagen matrix (test group 2). Biopsy was performed during healing abutment placement by means of a mucotome.

RESULTS

A total of 63 patients were recruited and treated, and 58 were available for follow-up visits. After 4 weeks, the KM width gain was 1.93 ± 0.85 mm, 4.85 ± 1.11 mm, and 3.03 ± 0.58 mm, respectively, for control group, test group 1, and test group 2. Postoperative pain was significantly higher in the FGG group than in the others. Edema and hyperemia decreased gradually during the first week without significant differences among groups.

CONCLUSION

Despite the limitations of the study, it was found that FGG was the most effective technique to augment the amount of KM in sites of implant placement. The use of a collagen matrix could be a viable alternative to diminish the intervention's impact on patients' postoperative quality of life.

Hard and soft tissue changes in the rehabilitation of the anterior maxilla with triangular shape neck implants: a retrospective clinical study with a one-year follow up

Aim of this retrospective study was to evaluate the one-year clinical and radiographic outcomes of implants with a triangular shaped neck inserted immediately after tooth extraction in esthetic zones. Patients in which immediate postextraction implants were placed and restored in the anterior maxilla, who underwent a Cone Beam Computed Tomograpy (CBCT) at baseline and after 12-16 months were included. The socket was preserved using deproteinized bovine bone to fill the buccal gap, and a resorbable collagen membrane. One-year implant survival and prosthesis success were evaluated. Hard and soft tissue stability was assessed by measuring various parameters on CBCT images. Clinical evaluation was also performed and Pink Esthetic Score (PES) assessed. Data from baseline and one-year follow-up were statistically compared using paired tests and a significance threshold of p=0.05. Twenty patients (13 males, 7 females, mean age 50.42±11.35 years) were included. Each contributed with one implant. No implant was lost. A significant improvement in PES was detected. Excellent hard and soft tissue preservation was observed after one year of function. Immediate placement of implants with a triangular shaped neck after tooth extraction, can be a suitable solution even for areas with a high aesthetic demand, such as the anterior maxilla.

Anatomical factors associated with gender recognizability: A study on intraoral standardized photographs

AIM

The aim of this research was to evaluate the possibility of identifying the sex of 1 subject through visual assessment of a frontal photograph of dentition, and to investigate if some morphological characteristics are related to sex determination.

METHODS

5 expert dentists, 5 non-expert dentists and 5 laypeople were made to watch 100 intraoral photographs for 5 seconds each and to establish their sex. The responses of the participants and the baseline characteristics of photographed dentitions were analyzed.

RESULTS

The proportion of right answers was 56.0% ± 8.2% in the group of expert dentists, 65.0% ± 6.0% in the group of non-expert dentists and 58.6% ± 4.5% in the group of non-expert people. The round shape of maxillary central incisors was related to the female gender (P = .006). The male condition was correlated with poor oral hygiene for 4 observers. Female sex perception was correlated with round morphology of upper central incisors for 3 observers.

CONCLUSION

No difference in the ability to determine the sex was registered among groups, suggesting that sex perception is not strongly influenced by the characteristics of dentition.

Surgically-oriented anatomical study of mandibular premolars: A CBCT study

Background

The knowledge of root canal anatomy and of the anatomical relationship should be considered mandatory when planning surgical endodontics. The aim of the study was to investigate the anatomical features of mandibular premolars, evaluating their relationship with mental nerve.

Material and Methods

CBCT scans were evaluated recording the number of roots, root canal configuration and the relationship with mental nerve of 100 mandibular premolars. After simulating a resection of 3 mm of the root, the shape and the number of canals, and the distance to the buccal and lingual bone plate and to the mental foramen was evaluated.

Results

The one root - one canal configuration was the most common configuration. The mental foramen was located at the level of MSPs in 40% cases, and it was between MSP and MFP in 46% of cases. The distance between the apex and the vestibular plate was lower than the distance to the lingual one.

Conclusions

We found a significant heterogeneity in the anatomy of mandibular premolars. CBCT could be considered important when planning surgical endodontics in this region. Key words:Cone-Beam Computed Tomography, bicuspid, root canal, root canal therapy, apicoectomy, mandibular nerve.

Enamel matrix derivative for the treatment of partially contained intrabony defects: 12-month results

BACKGROUND

The aim of the study was to evaluate the use of enamel matrix derivative (EMD) alone or in association with deproteinized bovine bone mineral (DBBM) for the treatment of partially contained intrabony defects.

METHODS

A total of 20 two-walled intrabony defects belonging to nine patients were included. Ten defects were treated with EMD alone (test group 1) and the other 10 were treated with EMD and DBBM (test group 2), applying either modified papilla preservation technique or simplified papilla preservation technique.

RESULTS

Twelve months after surgery, in the test group 1, PD was 2.8 ± 0.8 mm, REC was 2.3 ± 2.4 mm and CAL was 5.0 ± 2.8 mm, significantly reduced from baseline values (P < 0.05). Likewise, in test group 2, PD, REC and CAL reduced to 3.0 ± 0.7 mm, 3.9 ± 1.5 mm and 6.9 ± 1.1 mm respectively, from baseline values at 12 months (P < 0.05). No significant differences between groups were found.

CONCLUSIONS

The results showed that the use of EMD alone and the use of a combination of EMD and DBBM for the treatment of partially contained defects showed comparable clinical and radiographic outcomes after 12 months.