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The recently introduced 2017 World Workshop on the classification of periodontitis, incorporating stages and grades of disease, aims to link disease classification with approaches to prevention and treatment. Periodontitis is characterized by progressive destruction of the tooth-supporting apparatus. Its primary features include the loss of periodontal tissue support manifest through clinical attachment loss (CAL) and radiographically assessed alveolar bone loss, presence of periodontal pocketing and gin­gival bleeding. If untreated, it may lead to tooth loss, although it is preventable and treatable in the majority of cases. The objective of the narrative review presented in this Module was to report the S3 Level Clinical Practice Guideline (CPG) for the treatment of Stage I-III periodontitis revealed during the EFP 2020 Workshop. The treatment of stage III periodontitis should be carried out in an incremental manner, first by achieving the goal’s obtained during the first and second step of therapy. The third step of therapy is, therefore, aimed at treating those sites non-responding adequately to the second step of therapy with the purpose of getting access to deep pocket sites, or aiming at regenerating those lesions, that add complexity in the management of periodontitis with intrabony lesions. In the presence of deep residual pockets (PPD ≥6 mm) in patients with Stage III periodontitis after the first and second steps of periodontal therapy, it was sug­gested performing access flap surgery. Regenerative and conservative surgical therapy resulted in improved clinical out-comes (higher CAL gain) compared with resective surgery in the majority of studies. The aims of periodontal regeneration are to obtain: An increase in the periodontal attachment and bone of a severely compromised tooth; a decrease in pocket depth; no, or a minimal, increase in gingival recession. Teeth with deep pockets associated with deep intrabony defects are considered a clinical challenge. Nevertheless periodontal surgery (re­generative management) is beyond the scope and competence of education in general dental practice. Dental curricula include knowledge and familiarity with the approach but are not designed to provide competence to conduct such treatment. Therefore, turns out to be fundamental a proper understanding of the basic bio­logic mechanisms involved in periodon­tal wound repair and regeneration requires assessment of the macroscopic, microscopic, cellular and molecular components of the healing process. Afterwards, clinicians should select a specific biomaterial to be used to promote regeneration at intrabony defects based on clinical and scientific evidence. It is therefore necessary to choose a regenerative strategy out of a panel of options to treat a given defect. Anatomical considerations related to the width of the interdental space advise on the choice of the preferred flap design to access the interdental area. Location and configuration of the intrabony defect advise on the possibility to: Minimize flap extension; raise a single flap or the need to fully elevate the interdental papilla. The adoption of a clinical strategy for optimal application of materials and surgical approach could increase the efficacy of periodontal regeneration and provide improved clinical outcomes.

Wound management after periodontal surgery must follow specific timing and procedures, in order to allow proper healing of hard and soft tissues. At each post-surgical check-up appointment, the clinician should polish the treated area to minimize the inflammatory reactions where the patient cannot yet perform the usual home oral hygiene maneuvers. It is also essential giving to the patient appropriate post-operative instructions based on the type of surgery performed and the wound maturation. Usually, after an osseous resective surgery the sutures are removed at seven days, and already from the following week the patient gradually resumes home procedures. After a regenerative surgery, on the other hand, particular attention must be paid to the complete closure of the surgical wound before giving the patient new instructions for the home maneuvers, which will resume in a much more gradual and delicate way. At the end of active therapy, whether surgical or non-surgical, the patient undergoes a new re-evaluation by the periodontist in order to establish the new baseline parameters as a reference point during supportive periodontal therapy. The main objective of the latter is to prevent recurrence of periodontal disease in patients previously treated with active therapy, in order to keep the bacterial load and consequent inflammation low, and thus avoid the progression of the disease and the possible tooth loss. Many studies have shown that a system of hygiene recalls and personalized supportive therapy allow the long-term tooth maintenance in periodontal patients. There are different systems to establish a risk profile of disease progression in an individualized way for each patient, to determine frequency and modality of the supportive therapy necessary to maintain stable the attachment levels obtained during active therapy. With these methods the clinician can easily identify patients who have a worse periodontal prognosis and can thus implement personalized therapeutic strategies to control individual risk factors. The tools used during supportive therapy are the same used during the phases of diagnosis, instruction for home oral hygiene maneuvers, and non-surgical therapy. It is important to choose minimally invasive tools, which allow not to damage the cleansed dental substance in the repetition of the sessions. The actual operative session includes several phases which aim to check the periodontal status and re-motivate the patient where he is in difficulty in home oral hygiene maneuvers, to eliminate the residual supra and subgingival calculus and plaque, to treat dentinal hypersensitivity with specific products and to diagnose any new oral pathologies (caries, soft tissue diseases, periodontal recurrences), also through the use of radiological investigations. Adjuvant systems such as lasers, photodynamic therapy and topical antimicrobial agents have shown through the literature no additional benefit in the supportive therapy session compared to mechanical therapy alone. In conclusion, supportive care must be an integral part not only of periodontal therapy, but of the patient’s whole dental therapy. In fact, it is essential that the patient is made aware of the risks, but above all of the benefits that regularity in the frequency of recalls can give, also from a systemic point of view due to the numerous correlations between oral health and general health.

ERIODONTAL DIAGNOSIS In the light of a recent opinion poll carried out on behalf of the Italian Society of Periodontology and Implantology (SIdP), the need to consolidate the inclusion of periodontal diagnosis, as a routine component, in the dental examination appears essential. The related diagnostic process is based on information obtained from medical and dental history, clinical, radiographic and laboratory tests. The purposes of this procedure are: to evaluate the presence of periodontal diseases, the related risk factors, and to quantify the severity and extent of the induced tissue damage. In periodontology the diagnostic process is indicated by the term “periodontal evaluation” and consists of three parts: clinical examination, radiographic exams and laboratory diagnostic tests; in turn, the clinical examination involves the collection of the anam nesis and the physical examination with the compilation of a special periodontal charting. In particular, during the visit, three types of anamnesis are collected: physiological, medical and dental/periodontal ones; then the execution of the physical examination involves the completion of: intraoral inspection, periodontal probing, registration of periodontal indices, periodontal phenotype evaluation, dental mobility, teeth migrations and occlusal analysis. Specifically, periodontal probing is an essential clinical procedure in the diagnostic path of periodontal diseases allowing evaluation of tissue destruction and the differential diagnosis between gingivitis and periodontitis, by means of periodontal biometric parameters. Periodontal evaluation implies, after the physical examination, the execution of radiographic exams; the rx techniques commonly used are three: intraoral radiographs, orthopantomography and computed tomography. The elective method is intraoral radiography which, in patients with suspected periodontitis with pathological probing depths and loss of clinical attachment in multiple dental sites, results in the execution of a complete systematic intraoral radiographic examination. The laboratory tests complete the periodontal evaluation; they are divided into two broad categories, generic and specific: the former assess the patient’s systemic conditions on the basis of anamnestic histories, the second, optional, is divided into microbiological, genetic, immune and biochemical. CLASSIFICATION OF PERIODONTAL DISEASES In the joint American Academy of Periodontology and European Federation of Periodontology World Workshop in 2017, a new classification was introduced to update the pre-existing one from 1999, adapting it to the evolution of scientific evidence and overcoming some unresolved issues. The main innovations include: the introduction of peri-implant diseases, a clear definition of gingival health at a histological and clinical level, the distinction of gingivitis into only two cat egories based on the presence or absence of bacterial biofilm, the abolition of a distinction between chronic and aggressive periodontitis and the adoption of a multilevel framework of staging and grading of periodontitis, the replacement of the terms occlusal trauma and biological width with those of traumatic occlusal force and supracrestal attached tissue respectively, a new classification of gingival recessions. In this Module we analyze in detail the World Workshop proceedings regarding biofilm-inducted gingivitis and periodontitis, from the definition of health and related clinical cases, to the staging and grading model

The aim of the narrative review pre-sented in this Module is to illustrate the indications and the operative steps of modern non regenerative periodontal surgical techniques with particular focus on osseous resective surgery. The authors made a selection of the available scientific literature from classic articles to the most current trends, in order to provide the scientific basis and to guide the clinician in choosing the correct surgical approach. The clinical practice guidelines (S3 lev-el) for treatment of stage I-III periodontitis published by the European Federation of Periodontology (EFP), in 2020, give an indication for osseous resective surgery in cases with deep residual pockets (PD ≥6 mm) in patients with stage III periodontitis after an adequate non-surgical therapy has been com-pleted, keeping in mind the potential risk of increase in gingival recession af-ter this type of procedure. In fact, osseous resective surgery modifies the bony support altered by periodontal disease through reshaping of the alveolar process without removing supporting bone or through the removal of part of the alveolar bone. The aim of this surgical technique is to obtain minimal probing depths and positive osseous and gingival architecture, that will allow and ease the patient in performing correct oral hygiene maneuvers. The present review describes the operative steps of the technique, starting from an accurate presurgical evalua-tion that will consider quality and quantity of the keratinized tissue, probing depth and anatomy. The incision and flap decision are carefully described, flap elevation is made, and through os-teoplasty and ostectomy maneuvers the profile of the hard tissues is re-shaped to obtain positive osseous ar-chitecture in a more apical position compared to the presurgical condition. Finally, the soft tissues are repositioned apically or at the bone crest. A modification to traditional osseous resective surgery is that of osseous surgery with fibre retention. This technique allows for a more conservative approach and can reduce post-surgi-cal recession and discomfort for the patient. It is based on the notion that supra crestal connective tissue fibres embedded into radicular cement are always present (even in diseased peri-odontium) on average about 1 to 2 mm coronally to the base of the defect. For this reason, through this ap-proach, the base of the defect is no longer made of mineralized tissue but it’s moved coronally at the level of the connective tissue attachment. The coronal shift of the most apical portion of the defect allows for a more conservative osseous resection. In conclusion, osseous resective surgery is a very effective surgical procedure in the elimination of periodontal pockets. Today it is used mostly to treat shallow intraosseous defects in non esthetic areas and in perio-prosthetic cases (such as clinical crown lengthening procedures). Having a good understanding of the rationale and of the operative steps of this surgical technique constitute the basis of every periodontal surgery.

Non-surgical periodontal therapy is the treatment that aims at removal of the etiological and risk factors of periodontitis, with the aim of preventing further damage to the periodontium and im­proving the clinical condition of the patient suffering from periodontitis. It consists of several phases, which include the plaque control, the professional removal of bacterial plaque and its retentive factors in the supragingival and subgingival areas. The purpose of this narrative review is to illustrate, in the light of the current guidelines for the treatment of periodontitis, the essential steps to obtain the preservation or restoration of a healthy periodontal condition. The patient’s plaque control is one of the fundamental aspects of periodontal therapy and strongly affects its short and long-term success. There are different ways to obtain the patient’s collaboration and his active participation in therapy, the so-called adherence. This process must be accompanied with personalized, effective and achievable oral hygiene measures. The main characteristics of the tools for plaque control are illustrated (manual or electric toothbrushes, dental floss or interproxi­mal brush etc.) and their indications to guide dental professionals in the choice of suggestions to the patient. For the removal of the supra and subgingival plaque, the principles are illus­trated according to a modern orienta­tion of mini-invasiveness. Manual or mechanical instruments, micro-powder jets, have precise characteristics that are illustrated to help understanding the advantages and disadvantages or limitations of each of them. Historically, the use of curettes was associated with the removal of large amounts of root cement, which was believed to be colonized by bacteria and toxins. The current orientation involves the removal of plaque and calculus (because it is re­tentive of plaque), without intentional removal of the root cement. The instruments, in the light of different objectives, take on other functions, with often integrated therapies performed with the different tools to optimize the advantages of each of them. Mechanical tools are efficient means for remov­ing supragingival calculus and can be used, with the right precautions for use, even in the subgingival area where they are effective, especially in areas that are difficult to access. Additional therapies are illustrated, in accordance with the literature, if they produce an effective advantage over non-surgical periodontal therapy alone, recommending the most appropriate conditions and timing. The objectives of non-surgical periodontal therapy are also illustrated, such as the reduction of plaque indexes, inflammation and the probing depth, necessary to achieve the stability of periodontal health. The objectives of the therapy also include an improvement in the quality of life perceived by the patient, who shortly after execution shows less discomfort and better masticatory function. Finally, the limits of non-surgical periodontal therapy are clarified which, while obtaining sub­stantial improvements in the patient’s clinical condition by itself, must be integrated into a broader program of periodontal therapy, sometimes including also surgical phases, and is always fol­lowed by periodontal support therapy that aims at long-term maintenance.

Recent publications have reported high prevalence of C. parapsilosis sensu stricto in oral cavity niches. Our research group performed a pilot study in 2017 which showed that of the psilosis complex, C. parapsilosis sensu stricto is the species most frequently isolated from oral cavity niches. Under inflammatory conditions, the probability of recovering it is almost four times higher, and it displays higher biofilm-forming capacity in-vitro, differing significantly from isolates of the same species obtained in conditions of eubiosis. This led us to hypothesize that an oral environment in dysbiosis overregulates virulent genes, promoting a more pathogenic phenotype. Accordingly, we decided to reevaluate the in-vitro biofilm formation assay using a larger sample, under two nutritional conditions, using colorimetric methods for quantification. In addition, the results obtained were validated by imaging techniques. For both clinical conditions (eubiosis and dysbiosis), high biofilm forming phenotype predominated with both reading methods, and for both nutritional conditions tested. XTT showed significant difference between absorbance values for isolates from buccal dysbiosis and eubiosis (p=0.0025). C. parapsilosis sensu stricto cells that colonize oral cavity niches are basically strong biofilm formers, regardless of in vitro growing conditions. However, the oral cavity in dysbiosis probably promotes virulence in this species due to inheritable epigenetic modifications.

Obiettivo: In questo lavoro intendiamo valutare la qualità della vita e il grado di distress dei caregiver di pazienti affetti da demenza afferenti presso il Centro di Riferimento Regionale Demenze Senili-Alzheimer - Unità Valutativa Alzheimer, dell’A.S.P. di Palermo. Metodi: L’assessment si compone di una batteria testo-logica che comprende i seguenti tests: Relative Stress Scale, Caregivere Burden Inventory, Neuropsychiaric Inventory, Short Form-36 Healty Survey. Risultati: Dall’analisi dei dati emerge che il grado di stress del caregiver risulta proporzionale al numero di anni di accudimento del paziente. Inoltre i caregiver di sesso femminile dedicano un numero sensibilmente maggiore di ore rispetto ai caregiver di sesso maschile e ricevono minor supporto, riferendo una compromissione maggiore sulla sfera emotiva e sulla vita socio-relazionale. Conclusioni: La demenza essendo una patologia con una sintomatologia variegata e complessa che inficia inesorabilmente la salute del soggetto richiede un interessamento globale e totalizzante del caregiver con notevoli ripercussioni sulla sua salute fisica e psichica. Ciò evidenzia la necessità di un supporto

Objective: the aim of our study was to evaluate the role of stressful events, lifestyles and various socio-environmental factors in the beginning of ischemic cardiac diseases, together with cardiovascular factors. Materials and methods: 64 patients with recent cardiac ischemia and 64 controls matched 1:1, according to their sex and age, have been evaluated. The study required the filling in of clinico-anamnestic reports and the evaluation of stressful events, using the Holmes Rahe scale. Results: in the 44% of the patients who had a heart ischemia, an emotional striking event occurred few day before, with a 28% incidence of work and family problems. The mean score of the Holmes Social Readjustment Rating Scale was statistically significantly higher among cases (p

Obiettivo. Considerati la diffusione e l’incremento dei comportamenti aggressivi e violenti, specie quelli che trovano come radicale comune la mancanza di un’effettiva motivazione e l’efferatezza, la nostra ricerca si è posta l’obiettivo di rintracciare gli indicatori e i segni predittivi di tali comportamenti. La letteratura, inoltre, dimostra che gli indicatori e i segni predittivi di maggiore affidabilità sono quelli legati alle invarianti strutturali (per esempio le strategie difensive, la capacità di controllo degli impulsi). Metodi. È stato realizzato, con un piano di ricerca trasversale, uno studio clinico di confronto reclutando un gruppo di adolescenti (26 soggetti di sesso maschile) con disturbo della condotta (F91.8), un gruppo di pazienti (29 soggetti di sesso maschile) con disturbo borderline di personalità (F60.31), un gruppo di detenuti (34 soggetti di sesso maschile) con disturbo antisociale di personalità (F60.2). È stato adoperato un protocollo comprendente, per il reclutamento, l’«Intervista clinica strutturata per il DSM-IV asse II» e i questionari «Indicatori della condotta aggressiva» e il «Profile of mood states» (POMS) esclusivamente destinati al gruppo di adolescenti; il «Defense mechanisms inventory» (DMI). Risultati. I gruppi messi a confronto hanno prodotto prestazioni significativamente differenti in ordine alle misure difensive prevalentemente adoperate e allo sfondo psichico emozionale di partenza. Conclusioni. Sono stati selezionati un profilo in cui l’aggressività e la violenza sono supportate da iporesponsività emozionale e un profilo in cui queste sono legate a un’impulsività clinicamente significativa. Abbiamo così isolato alcuni indicatori e predittori clinici dell’aggressività e della violenza e identificato, secondo i parametri dei reattivi utilizzati, i profili maggiormente a rischio.

The primary goal of periodontal therapy is the removal of supra and subgingival bacterial deposits by mechanical debridement consisting in scaling and root-planing (SRP) using manual or power-driven instruments. The complete removal of bacteria and their toxins from periodontal pockets is not always achieved with conventional mechanical treatment. The use of lasers as an adjunctive therapy for periodontal disease may improve tissue healing by bactericidal and detoxification effects. The aim of this study was to compare the effectiveness of Diode laser used as adjunctive therapy of SRP to that of SRP alone for non surgical periodontal treatment in patients with chronic periodontitis. Nineteen pairs of teeth with untreated chronic periodontitis were selected in 13 patients and randomly treated by SRP alone (control group) or by SRP + laser irradiation (test group). Clinical measurements (PPD, CAL, BOP, GI, PI) were performed before treatment at baseline (T0) and at T1 (after 4 weeks), T2 (8 weeks), T3 (12 weeks), T4 (6 months). Subgingival plaque samples were taken at baseline and after treatment and examined for 8 periopathogens bacteria using PCR technique. The present study showed that the additional treatment with diode laser may lead to a slightly improvement of clinical parameters, whereas no significant differences between test and control group in reduction of periodontopathogens were found.

Leiomyomas are uncommon in the oral cavity and rare on gingiva. They account only for 0.42% of all soft tissue lesions in the oral cavity. We present an extremely rare case of leiomyoma localized to the attached gingival, simulating an epulis in a healthy 14-year-old boy. The tumour was described at the clinical and instrumental level; moreover, its histopathological phenotype was depicted. The treatment of the choice was the radical excision. The wound was closed by surgical dressing with 2-0 silk suture.The post-operative course was uneventful. The surgical wound healed in one week with normal scarring. Finally, the problems of differential diagnosis with other tumours of the oral cavity and the most appropriate therapeutic procedures are discussed.

The aim of this scoping review was to summarise current knowledge about the effects of bone anabolic drugs on periodontitis, in order to identify new therapeutic strategies for preventing disease progression and reducing tooth loss. A technical expert panel (TEP) was established of 11 medical specialists, including periodontists and bone specialists that followed the PRISMA-ScR model to perform the scoping review and considered for eligibility both pre-clinical and clinical studies published in the English language up to September 2020. 716 items were initially found. After duplicate removal and screening of articles for eligibility criteria, 25 articles published between 2001 and 2019 were selected. Only studies concerning teriparatide, strontium ranelate, sclerostin antibodies and DKK1 antibodies met the eligibility criteria. In particular, only for teriparatide were there both clinical studies and experimental studies available, while for other bone anabolic drugs only animal studies were found. Available evidence about the use of bone anabolic drugs in periodontology demonstrates beneficial effects of these agents on biological pathways and histological parameters involved in periodontal tissue regeneration that suggest relevant clinical implications for the management of periodontitis.

The presence of a double-tooth requires specific complex management due to the need for differential diagnosis and following treatment choices. The aim of this report was to present a rare case of a geminated mandibular lateral incisor, treated with an orthodontic approach. A Caucasian 10.9-year-old girl presented a lower right double-tooth incisor, with a class 1 molar and a class 2 cuspid tendency on both sides. The upper arch was constricted as shown by bilaterally tendencies to cross-bite, a slightly lower midline deviation was reported and a lack of space for all four permanent cuspids was confirmed also by the panoramic X-ray. In the lower arch, there was a severe crowding of about 14 mm and a buccally ectopic left canine. Overbite was normal and Overjet minimally increased. The double-tooth was identified like a geminated tooth, for the presence of one root and one pulp canal of increased size, as shown by the radiographic examinations. The anomalous tooth was managed with an orthodontic approach associated with a progressive stripping to reshape the crown. A two-phase treatment plan was performed, based on first maxillary expansion and lip bumper and then fixed appliances, in order to achieve a proper occlusion and a better aesthetic.

Aim of the present study was to investigate the bacterial adhesion to titanium (Ti) implant surfaces, different for composition and topographic features. Grade 4 and 5 turned (T-4, T-5,) and mildly acid-etched (MA-4, MA-5) Ti 6 × 1 mm disks were topographically analyzed by scanning electronic microscopy and 3D profilometry. Bacterial cultures (Streptococcus sanguinis) were in vitro seeded and, after two and six hours, adherent bacteria were quantified by colony-forming unit (CFU) counting. Ti samples were also exposed to the oral environment of six periodontally healthy volunteers and, after 12 h, the formed biofilm was evaluated by CFU counting. Inter-group differences were tested by the Mann–Whitney U-Test (α = 0.05). MA surfaces were significantly rougher than T ones, whereas no difference between grade 4 and grade 5 disks was detected. Significantly higher in vitro bacterial adhesion for MA than T disks was shown at two and six hours. Significantly higher values of CFU counting for MA than T surfaces and for grade 5 than grade 4 disks were found at the 12 h-ex vivo test. Bacterial adhesion showed to be sensitive to both Ti surface topography and composition, with possible implications on peri-implant tissue health maintenance.

The objectives of this study were to assess gingival recessions (GR) and periodontal status in patients previously treated with non-extraction orthodontic treatment and retention at a follow-up of a minimum of two years after the end of treatment. Data from patients aged between 16 and 35 years with a previous non-extraction orthodontic treatment and at least 2 years of retention and full records before and after treatment were collected. The casts were digitalized using the 3Shape TRIOS® intraoral scanner and the Viewbox4 software was used for the measurements. The following parameters were scored: inclination of the lower and upper incisors (IMPA and I^SN) and anterior crowding (Little index). The included patients were recalled for a clinical periodontal follow-up examination and the following parameters were evaluated: buccal and lingual GR (mm) of incisors and canines, bleeding of probing score, plaque score, and gingival phenotype. The digital cast analysis showed a mean Little index of 7.78 (SD 5.83) and 1.39 (SD 0.79), respectively, before and after treatment. The initial and final cephalometric analyses showed an I^SN of 103.53° and 105.78° (SD 7.21) and IMPA of 91.3°and 95.1°, respectively. At the follow-up periodontal visits, the patients showed an overall low oral hygiene with bleeding at probing in 66.6% and plaque in the anterior area in 76.2% of patients. From the total examined 240 teeth of the frontal sextants, three patients had GR (from 1 to 6.5 mm): in the upper arch two at canines and one at central incisor, whereas in the lower arch two at central and one at lateral incisors. The gingival phenotype was thick in 55% of cases. The lingual-to-lingual retainers at follow-up were present in 61.9% of patients. A slight increased risk for buccal GR development was found only in correlation with the presence of fixed retainer and thin gingival phenotype mainly in patients with gingivitis. Thus, non-extraction orthodontic treatment performed with controlled forces and biomechanics seems to not affect the development of GR or the periodontal health after retention.

Prevention of alveolar bone resorption after tooth extraction may be useful for implant rehabilitation of the edentulous site minimizing the future need for bone augmentation procedures. A number of studies have investigated the efficacy of autologous platelet concentrates for the preservation of the alveolar bone volume after tooth extraction. Although encouraging results have been published, the available data are still controversial. The aim of the present systematic review was to assess the effect of platelet concentrates on alveolar socket preservation after tooth extraction. A literature search was carried out up to September 2017 for prospective controlled trials in which a test group using exclusively a platelet concentrate was compared with a control group in which extraction sockets were left to heal spontaneously. Seven controlled clinical trials published between 2010 and 2016 were included. A total of 320 extractions (170 tests and 150 controls) in 190 patients was considered. A great heterogeneity was found in terms of study design, methodological aspects, and outcome evaluation. For this reason, a quantitative analysis followed by meta-analysis was not possible, and only a descriptive analysis on the role of platelet concentrates in alveolar socket preservation was carried out. There is growing evidence that platelet concentrates may be advantageously used in postextraction sites, mainly to improve soft tissue healing and to reduce postoperative symptoms. Data about their potential in preserving the alveolar bone volume are still scarce and controversial, although recently encouraging results have been presented using more reliable and accurate evaluation technologies, such as the computed tomography. Further, well-designed and methodologically standardized investigations are strongly demanded to reach a higher level of evidence on this topic.

Several treatment modalities have been proposed to regenerate bone, including guided bone regeneration (GBR) where barrier membranes play an important role by isolating soft tissue and allowing bone to grow. Not all membranes biologically behave the same way, as they differ from their origin and structure, with reflections on their mechanical properties and on their clinical performance. Collagen membranes have been widely used in medicine and dentistry, because of their high biocompatibility and capability of promoting wound healing. Recently, collagen membranes have been applied in guided bone regeneration with comparable outcomes to non-resorbable membranes. Aim of this work is to provide a review on the main features, application, outcomes, and clinical employment of the different types of collagen membranes. Comparisons with non-resorbable membranes are clarified, characteristics of cross-linked collagen versus native collagen, use of different grafting materials and need for membrane fixation are explored in order to gain awareness of the indications and limits and to be able to choose the right membrane required by the clinical condition.

Statement of problem How the properties of the implant-abutment unit may affect the peri-implant soft-tissue seal, whose stability is considered key to safeguarding the implant from bacterial contamination and preserve peri-implant health conditions, is unclear. Purpose The purpose of this systematic review and meta-analysis of animal studies was to investigate whether material and surface properties of transmucosal implant components can influence the peri-implant soft-tissue adhesion at a histological level. Material and methods An electronic and hand search was conducted until August 2019. Histological animal studies comparing soft-tissue response to abutment or transmucosal collar with different materials and/or surface characteristics were selected by 2 independent reviewers. Risk of bias in individual studies was evaluated. Histomorphometric data on the dimension of the peri-implant attachment were recorded, and a quantitative synthesis by a meta-analysis was performed. Risk of bias in individual studies was evaluated in accordance with the Systematic Review Centre for Laboratory Animal Experimentation Risk of Bias tool. Results Eighteen relevant studies out of 1187 were identified, none with a low risk of bias for all domains. Data from only 4 studies could be meta-analyzed. Comparable results in terms of peri-implant attachment dimensions between test and control groups were found, except for a significantly higher apical junctional epithelium to coronal bone to implant (ajE-CBI) distance for chemically modified acid-etched compared with titanium machined surfaces. Non–meta-analyzable and/or qualitative results highlighted some improved properties also for microgrooved and oxidized surfaces. Conclusions Limited data from animal studies suggest that some characteristics of the transmucosal implant components may affect peri-implant soft-tissue adhesion and stabilization but do not allow definitive conclusions. Future research should improve study design to increase the availability of comparable and suitable data on this topic.

The combination of enamel matrix derivative (EMD) with an autogenous bone graft in periodontal regeneration has been proposed to improve clinical outcomes, especially in case of deep non-contained periodontal defects, with variable results. The aim of the present systematic review and meta-analysis was to assess the efficacy of EMD in combination with autogenous bone graft compared with the use of EMD alone for the regeneration of periodontal intrabony defects. A literature search in PubMed and in the Cochrane Central Register of Controlled Trials was carried out on February 2019 using an ad-hoc search string created by two independent and calibrated reviewers. All randomized controlled trials (RCTs) comparing a combination of EMD and autogenous bone graft with EMD alone for the treatment of periodontal intrabony defects were included. Studies involving other graft materials were excluded. The requested follow-up was at least 6 months. There was no restriction on age or number of patients. Standard difference in means between test and control groups as well as relative forest plots were calculated for clinical attachment level gain (CALgain), probing depth reduction (PDred), and gingival recession increase (RECinc). Three RCTs reporting on 79 patients and 98 intrabony defects were selected for the analysis. Statistical heterogeneity was detected as significantly high in the analysis of PDred and RECinc (I2 = 85.28%, p = 0.001; I2 = 73.95%, p = 0.022, respectively), but not in the analysis of CALgain (I2 = 59.30%, p = 0.086). Standard difference in means (SDM) for CALgain between test and control groups amounted to -0.34 mm (95% CI -0.77 to 0.09; p = 0.12). SDM for PDred amounted to -0.43 mm (95% CI -0.86 to 0.01; p = 0.06). SDM for RECinc amounted to 0.12 mm (95% CI -0.30 to 0.55. p = 0.57). Within their limits, the obtained results indicate that the combination of enamel matrix derivative and autogenous bone graft may result in non-significant additional clinical improvements in terms of CALgain, PDred, and RECinc compared with those obtained with EMD alone. Several factors, including the surgical protocol used (e.g. supracrestal soft tissue preservation techniques) could have masked the potential additional benefit of the combined approach. Further well-designed randomized controlled trials, with well-defined selection criteria and operative protocols, are needed to draw more definite conclusions. The combination of enamel matrix derivative (EMD) with an autogenous bone graft in periodontal regeneration has been proposed to improve clinical outcomes, especially in case of deep non-contained periodontal defects, with variable results. The aim of the present systematic review and meta-analysis was to assess the efficacy of EMD in combination with autogenous bone graft compared with the use of EMD alone for the regeneration of periodontal intrabony defects. A literature search in PubMed and in the Cochrane Central Register of Controlled Trials was carried out on February 2019 using an ad-hoc search string created by two independent and calibrated reviewers. All randomized controlled trials (RCTs) comparing a combination of EMD and autogenous bone graft with EMD alone for the treatment of periodontal intrabony defects were included. Studies involving other graft materials were excluded. The requested follow-up was at least 6 months. There was no restriction on age or number of patients. Standard difference in means between test and control groups as well as relative forest plots were calculated for clinical attachment level gain (CALgain), probing depth reduction (PDred), and gingival recession increase (RECinc). Three RCTs reporting on 79 patients and 98 intrabony defects were selected for the analysis. Statistical heterogeneity was detected as significantly high in the analysis of PDred and RECinc (I-2 = 85.28%, p = 0.001; I-2 = 73.95%, p = 0.022, respectively), but not in the analysis of CALgain (I-2 = 59.30%, p = 0.086). Standard difference in means (SDM) for CALgain between test and control groups amounted to -0.34 mm (95% CI -0.77 to 0.09; p = 0.12). SDM for PDred amounted to -0.43 mm (95% CI -0.86 to 0.01; p = 0.06). SDM for RECinc amounted to 0.12 mm (95% CI -0.30 to 0.55. p = 0.57). Within their limits, the obtained results indicate that the combination of enamel matrix derivative and autogenous bone graft may result in non-significant additional clinical improvements in terms of CALgain, PDred, and RECinc compared with those obtained with EMD alone. Several factors, including the surgical protocol used (e.g. supracrestal soft tissue preservation techniques) could have masked the potential additional benefit of the combined approach. Further well-designed randomized controlled trials, with well-defined selection criteria and operative protocols, are needed to draw more definite conclusions.

Single tooth implant restorations in the aesthetic area are a demanding challenge. If a complete osseointegration is mandatory, the final result has to result in a higher standard of biomimetic and soft tissue health among natural teeth. This outcome is traditionally pursued by cementing crowns over individualized abutments. However, in recent years, the need for controlling peri-implant health and the preference towards a retrievable solution has led to an increase in screw-retained crowns, which is not always applicable when the implant axis is not ideal. In the aesthetic area, the use of a novel technical solution represented by the angled screw channel (ASC) of the abutment has been proposed in order to match the advantages of the screwed solution with the aesthetic demands. The aim of this study was to compare ASC crowns to cemented crowns (CC) in single implant restorations using the white esthetic score (WES) and pink esthetic score (PES) at the crown delivery and at a follow-up of a minimum of 2 years. Peri-implant health and marginal bone loss (MBL) were also evaluated. The mean follow-up was 44.3 months, with a mean MBL of 0.22 mm in the ASC group and 0.29 mm in the CC group. The total WES/PES score was 16.6 for ASC, compared with 17.3 for CC at baseline, and 16.2 and 17.1, respectively, at follow-up. Both of the groups reached a high WES/PES, and this was maintained over time, without signs of peri-implant diseases or bone loss, regardless of the choice of connection. In conclusion, ASC can be adopted in cases where the implant axis is not ideal, with aesthetic and functional results that are comparable to implants restored by cemented crowns.

Background. Several locally administered antimicrobials have been studied in the literature as adjunctive or primary treatments for periodontitis and peri-implantitis with conflicting results. Objective. The aim of this study was twofold: (1) the formulation of a controlled-release material containing metronidazole and doxycycline; (2) an in vitro evaluation of its antibacterial properties against planktonic and biofilm species involved in periodontal and peri-implant diseases. Methods. Doxycycline (10 mg/ml) and metronidazole (20 mg/ml) were incorporated into a hydroxyethylcellulose-polyvinylpyrrolidone-calcium polycarbophil gel. Three milliliters of gel were dialyzed against Dulbecco's phosphate-buffered saline for 13 days. Antibiotics release at 3, 7, 10, and 13 days was determined spectroscopically. The inhibitory activity of the experimental gel was tested against A. actinomycetemcomitans, S. sanguinis, P. micra, and E. corrodens with an agar diffusion test, an inactivation biofilm test, and a confocal laser scanning microscope study (CLSMS) for S. sanguinis up to 20 days. Results. After 13 days, the released doxycycline was 9.7% (at 3 days = 1.2 mg; 7 days = 0.67 mg; 10 days = 0.76 mg; 13 days = 0.29 mg), while metronidazole was 67% (30 mg, 6.8 mg, 2.5 mg, and 0.9 mg at the same intervals). The agar diffusion test highlights that the formulated gel was active against tested microorganisms up to 312 h. Quantitative analysis of biofilm formation for all strains and CLSMS for S. sanguinis showed a high growth reduction up to 13 days. Conclusions. The in vitro efficacy of the newly formulated gel was confirmed both on planktonic species and on bacterial biofilm over a period of 13 days. The controlled-release gel containing metronidazole and doxycycline had an optimal final viscosity and mucoadhesive properties. It can be argued that its employment could be useful for the treatment of periodontal and peri-implant diseases, where conventional therapy seems not successful. Background. Several locally administered antimicrobials have been studied in the literature as adjunctive or primary treatments for periodontitis and peri-implantitis with conflicting results. Objective. The aim of this study was twofold: (1) the formulation of a controlled-release material containing metronidazole and doxycycline; (2) an in vitro evaluation of its antibacterial properties against planktonic and biofilm species involved in periodontal and peri-implant diseases. Methods. Doxycycline (10 mg/ml) and metronidazole (20 mg/ml) were incorporated into a hydroxyethylcellulose-polyvinylpyrrolidone-calcium polycarbophil gel. Three milliliters of gel were dialyzed against Dulbecco's phosphate-buffered saline for 13 days. Antibiotics release at 3, 7, 10, and 13 days was determined spectroscopically. The inhibitory activity of the experimental gel was tested against A. actinomycetemcomitans, S. sanguinis, P. micra, and E. corrodens with an agar diffusion test, an inactivation biofilm test, and a confocal laser scanning microscope study (CLSMS) for S. sanguinis up to 20 days. Results. After 13 days, the released doxycycline was 9.7% (at 3 days = 1.2 mg; 7 days = 0.67 mg; 10 days = 0.76 mg; 13 days = 0.29 mg), while metronidazole was 67% (30 mg, 6.8 mg, 2.5 mg, and 0.9 mg at the same intervals). The agar diffusion test highlights that the formulated gel was active against tested microorganisms up to 312 h. Quantitative analysis of biofilm formation for all strains and CLSMS for S. sanguinis showed a high growth reduction up to 13 days. Conclusions. The in vitro efficacy of the newly formulated gel was confirmed both on planktonic species and on bacterial biofilm over a period of 13 days. The controlled-release gel containing metronidazole and doxycycline had an optimal final viscosity and mucoadhesive properties. It can be argued that its employment could be useful for the treatment of periodontal and peri-implant diseases, where conventional therapy seems not successful.

Introduction. Orofacial clefts are congenital malformations characterized by an incomplete shaping of structures that separate the nasal from the oral cavity and can affect the right, left, or both sides. The aim of the present study is to assess, with clinical, radiographical, and histological evaluations, the efficacy of piezoelectric devices compared to traditional rotating instruments in the bone harvesting in patients with history of cleft. Materials and Methods. We have conducted a retrospective analysis on 20 patients with a history of orofacial clefts that were operated on from February 2014 to June 2017. The patients were divided into two groups: Group R in which bone graft was harvested using a burr and Group P in which the bone graft was obtained by a piezoelectric device. After a healing period of 8 months from the grafting procedure, clinical and radiographic evaluations were performed. Results and Discussion. The use of the piezoelectric devices in bone harvesting allows a slight improvement in the final volume. This supports a faster integration into the receiving site. Conclusions. The use of piezoelectric device in patients with history of orofacial cleft that needed bone graft represents a method to be taken into consideration because it has interesting advantages. Introduction. Orofacial clefts are congenital malformations characterized by an incomplete shaping of structures that separate the nasal from the oral cavity and can affect the right, left, or both sides. The aim of the present study is to assess, with clinical, radiographical, and histological evaluations, the efficacy of piezoelectric devices compared to traditional rotating instruments in the bone harvesting in patients with history of cleft. Materials and Methods. We have conducted a retrospective analysis on 20 patients with a history of orofacial clefts that were operated on from February 2014 to June 2017. The patients were divided into two groups: Group R in which bone graft was harvested using a burr and Group P in which the bone graft was obtained by a piezoelectric device. After a healing period of 8 months from the grafting procedure, clinical and radiographic evaluations were performed. Results and Discussion. The use of the piezoelectric devices in bone harvesting allows a slight improvement in the final volume. This supports a faster integration into the receiving site. Conclusions. The use of piezoelectric device in patients with history of orofacial cleft that needed bone graft represents a method to be taken into consideration because it has interesting advantages.