Maxillary Anterior Region Research Articles

A Comparative Evaluation of Efficacy of Local Infiltration of Sodium Bicarbonate Buffered Local Anesthesia with Epinephrine Vs Non-Buffered La with Epinephrine: A Clinical Study

Background: The aim of the study was to compare the efficacy of local infiltration of sodium bicarbonate buffered local anaesthesia with epinephrine vs non- buffered local anaesthesia with epinephrine.  Method: Patients having periapical infection in the maxillary anterior and premolar region were selected for the study. A total of 50 patients were included in the study. In group A, 8.4% sodium bicarbonate buffered 2% Lignocaine with 1:80,000 adrenaline was used for local infiltration for extraction. In group B, 2% Lignocaine with 1:80,000 adrenaline (non-buffered) was used for local infiltration for extraction. The onset of anesthesia, was compared between group A and group B. Data was tabulated and statistical analysis was carried out using paired t-test.  Result: The inter-group difference in onset of anesthesia,was assessed using paired t-test and highly significant difference was found between group A and group B (p≤0.05).  Conclusion: Significant improvement seen in onset of anesthesia and duration of anesthesia.

Optimizing Treatment for Severe-Early Childhood Caries: The Role of Groper’s Appliance

Severe-Early Childhood Caries (S-ECC), often leading to serious health issues if left untreated, possesses a great restorative challenge to the pediatric dentist. This case report discusses a comprehensive management of S-ECC in a 5-year-old female patient with high dental caries risk. The patient presented with multiple carious lesions, root stumps, and fenestrated roots, necessitating a staged intervention. Treatment involved restorations with glass ionomer cement, pulpectomy followed by omega loop post build-up on anterior tooth and stainless-steel crowns on posterior teeth. Additionally, extractions were performed and Groper’s appliance was inserted for esthetic rehabilitation and space maintenance on maxillary anterior and posterior regions, respectively. Following completion of the planned treatment, overall risk assessment measured low. This case report emphasizes the importance of rehabilitative interventions in S-ECC, showcasing Groper's appliance as a viable and effective treatment option.

Impact of Two Implant-Abutment Connection Types on Crestal Bone Stability: A 3-Year Comparative Split-Mouth Clinical Trial.

This prospective, preliminary controlled clinical trial investigates the comparative effectiveness of platform-switching (PS) versus traditional butt-joint or platform-matching (PM) implant-abutment connections on peri-implant crestal bone stability. Utilizing a split mouth design, 10 systemically healthy patients (n= 20 implants) had adjacent non-restorable maxillary anterior teeth replaced with two different implants (butt-joint connections and platform-switching interfaces). Patients underwent alveolar ridge preservation, followed by implant placement: platform-matching implants were inserted at crestal bone level, and platform-switching implants were placed 1mm subcrestally. Customized Zirconia crowns were then fabricated for both systems. Outcome measures included bleeding on probing (BOP), probing pocket depth (PPD), and marginal bone loss (MBL), which were evaluated through standardized periapical radiographs over 3-year timeframe. Results showed significantly higher initial MBL in the PM group (0.86 ± 0.13 mm) compared to the PS group (0.34±0.29 mm) [p value: p<0.01]. Moreover, at the three-year follow-up, the crestal bone levels remained above the implant shoulder until the third year of the study for the PS subcrestal group (PS: -0.15±0.39 mm) and slightly below the implant platform in the PM crestal group (PM: 0.55±0.19). After 3 years, the PS group also exhibited lower mean BOP percentages (12%) than the butt-joint group (17%). This study suggests that subcrestal placement with PS and internal connections can provide better long-term peri- implant bone preservation, thereby potentially improving implant success and aesthetic outcomes in the anterior maxillary region.

Evaluation of canalis sinuosus and accessory canal morphology by cone-beam computed tomography.

To evaluate canalis sinuosus (CS) and accessory canalis sinuosus (AC) morphology and their relationship with the impacted canine on cone-beam computed tomography (CBCT) images. The diameter and location of the CS, its distance from the nasal cavity (NC-CS), its distance from the buccal cortical plate (BC-CS), and its distance from the alveolar ridge crest (AR-CS) were evaluated on 1000 CBCT scans. The prevalence and termination of AC and the presence of impacted canines were also evaluated. CS was detected in 89 (8.9%) of 1000 CBCTs. The mean CS diameter was found as 1.34 ± 0.53mm. No statistically significant difference was found between gender, age, direction, and CS presence and diameter. CS was most frequently seen in regions 11 (23.6%) and 13 (23.6%). The average NC-CS, BC-CS, and AR-CS length was 6.14, 6.06 and 4.35mm, respectively. AC was detected in 22 patients (24.71%). There was no statistically significant difference between the presence of AC and gender, age, CS diameter, NC-CS, BC-CS, and AR-CS distance. BC-CS length and AR-CS length were statistically significantly higher in patients with impacted canines. It should be kept in mind that the CS diameter, NC-CS, BC-CS, and AR-CS distance may increase in the presence of an impacted canine and the integrity of the neurovascular structure should be preserved. The fact that the CS is often localized in the palatial region requires a detailed evaluation of the anterior maxillary region with three-dimensional imaging methods.

Measurement of Anterior Maxillary Alveolar Ridge Dimension and Assessment of Sagittal Root Position by Cone Beam Computerized Tomography (CBCT)

Maxillary anterior region is the implant site that may require the most rigorous pre-operative assessment as it will have a direct influence on aesthetic outcome and stability of the dental implant. In the present study, CBCT (cone beam computerized tomography) images were used to evaluate alveolar ridge dimension in the maxillary anterior region. This observational radiographic study was done at Nepal Medical College Teaching Hospital. The width of the alveolar bone was measured from the labial cortex to the palatal cortex of the maxillary anterior teeth in mm at the alveolar crest (L1), mid-root (L2), and apical root region (L3) for each tooth. Alveolar height was also measured from the alveolar crest to the floor of the nasal fossa. The Sagittal Root Position (SRP) of the maxillary anterior teeth was also assessed. Results showed that the maximum width of the alveolar bone was seen at L3 of canine and lateral incisor showed least width of alveolar bone width at L1. Maximum alveolar bone height was seen in canines. Males were seen to have increased width of the alveolar bone as compared to the females in all anterior teeth. The most frequent sagittal root position was class I which was seen in 270 (51.4%) of the total teeth examined, which was followed by class IV observed in 210 (40%) of the teeth examined. It could be concluded that for maxillary anterior region, additional regeneration therapy maybe required since class I is the most frequent SRP observed.

Effect of Needle Insertion Angle on Pain During Labial Infiltration Anesthesia of the Anterior Maxilla: A Randomized Clinical Trial.

This study aimed to assess the effect of needle insertion angle on pain during labial infiltration anesthesia in the anterior maxillary region. In this parallel-design randomized clinical trial, participants were randomly assigned to four groups for labial infiltration anesthesia of the anterior maxilla. Local anesthesia was performed with needle orientation parallel to the longitudinal axis of the tooth using a conventional syringe (Syringe-0), needle at α angle with a conventional syringe (Syringe-α), computer-controlled local anesthetic delivery (CCLAD) device parallel to the longitudinal axis of the tooth (CCLAD-0), and CCLAD at α angle (CCLAD-α). The heart rate (HR), blood pressure (BP), and respiratory rate (RR) of participants were measured before needle insertion, immediately after needle insertion, and immediately after the injection by a vital signs monitor. The level of pain experienced by participants was quantified using a numerical rating scale (NRS). Data were analyzed by repeated-measures ANOVA and regression models (α = 0.05). Thirty-six participants aged from 21 to 60 years, with a mean age of 35.36 years were recruited. The mean pain scores were 7.44, 4.67, 2.89, and 0.67 in groups Syringe-0, Syringe-α, CCLAD-0, and CCLAD-α, respectively (p < 0.001). Age and sex had no significant effect on pain scores (p = 0.914 and p = 0.702, respectively). The four groups had no significant difference in vital signs (p > 0.05). Injection at an α angle and the application of CCLAD can be used in clinical practice to decrease the pain experienced by participants during labial infiltration anesthesia of the anterior maxilla. Iranian Registry of Clinical Trials: IRCT20230719058849N1.

Immediate Implantation with Autologous Mineralized Dentin Graft versus Deproteinized Bovine Bone as Space-Filling Substitute in Maxillary Anterior Zone: Retrospective Radiological and Clinical Study.

Background/Objectives: Various bone substitutes have been recommended to augment the horizontal gap following immediate implantation. The purpose of this study was to compare the effectiveness of an autogenous mineralized dentin graft or a deproteinized bovine bone in horizontal gap augmentation following immediate implant placement in the maxillary anterior region. Methods: A total of 110 patients underwent tooth extraction followed by immediate implant placement. The patients were divided into two groups. The first group received an autogenous mineralized dentin graft (the test group) while the second group received a deproteinized bovine bone (the control group) to augment the horizontal gap. Preoperative (T0), immediate postoperative (T1), and 1-year postoperative (T2) cone beam computed tomography scans were taken from all the patients. Linear measurements were recorded 1 mm (R1) and 5 mm (R2) points apical to the implant platform at both T1 and T2 time intervals. Pink Esthetic Scores and prosthetic complications were evaluated as well. Results: There were 57 patients with a mean age of 45.42 ± 9.86 (range 24-63 years) selected as the test group and 53 patients with a mean age of 40.28 ± 11.69 (range 20-63 years) as the control group. The mean reduction in the buccal bone plate at R1 was 6.39 ± 3.78% in the test group and 6.99 ± 5.01% in the control group (p > 0.05). The mean reduction in the buccal bone plate at R2 was 5.46 ± 4.98% in the test group and 6.77 ± 7.60% in the control group (p < 0.05). The PES and prosthetic-related complications were shown to be negligible between the groups (p > 0.05). Conclusions: The efficiency of using an autogenous mineralized dentin graft for horizontal gap augmentation showed similar results in comparison to using a deproteinized bovine bone in relation to buccolingual socket reduction following immediate implantation.

Reconstruction of Pathology Induced Anterior Maxillary Defect: A Case Report

A cyst is defined as a pathologic cavity lined by epithelium. Nasopalatine duct cysts (NPDC) are of non-odontogenic origin arising from epithelial remnants from two embryonic nasopalatine ducts. These cysts may form anywhere along the ducts’ course, which runs from posterior palatal midline to the soft tissue palatine papilla also known as the incisive papilla. NPDC often develop between the 4th and 5th decades of life with men being affected more than women (2:1 ratio). They are typically asymptomatic but present with palatal swelling in the anterior maxillary region. Larger cysts may create a labial expansion in addition to a midpalate expansion which is usually compressible due to resorption of bone beneath the mucosa. Radiography often shows a well demarcated round or pear-shaped radiolucency superimposed on the incisive canal, tooth displacement or divergence of roots may be observed. This pathology is usually greater than 6mm in size which differentiates it from the incisive canal. Differential diagnoses often include a periapical granuloma or radicular cyst from nonvital central incisors, however a palatal radiolucency and expansion represents a NPDC until proven otherwise. Typical treatment includes enucleation and curettage with low recurrence rates.

Clinical and Radiographic Evaluation of Soft Tissue and Bone Status in Immediate Loaded Implants Placed Following Their Extraction in the Maxillary Anterior Region.

In the maxillary anterior region, teeth extraction leads to significant soft and hard tissue changes. Immediate implant placement following extraction aims to reduce bone loss and overall treatment time. However, it may result in adverse soft tissue changes impacting esthetics. This study evaluates the clinical and radiographic outcomes of immediately loaded implants in the maxillary anterior region, focusing on soft tissue preservation and bone status. This study, conducted from April 2022 to August 2024 at the Department of Oral and Maxillofacial Surgery, Ragas Dental College and Hospital, included 10 immediately loaded implants in seven patients. Following atraumatic extraction, implants were placed and loaded with functional provisional crowns fabricated using three-dimensional (3D) rapid prototyping models. Parameters such as crestal bone loss, buccal and palatal bone width, and interdental papilla thickness were evaluated preoperatively and postoperatively using radiographsand clinical assessments. The study found significant crestal bone loss at both mesial and distal sites over time, with the greatest loss observed at the three-month follow-up. Buccal and palatal bone width showed no significant differences preoperatively and postoperatively. Interdental papilla thickness and overall pink esthetic scores also showed no significant differences between preoperative and postoperative evaluations. Immediate implant placement in the maxillary anterior region, using 3D rapid prototyping for custom splint fabrication, demonstrated effective preservation of soft tissue profile and bone architecture. This approach provides functional and esthetic benefits, although careful monitoring of crestal bone loss is necessary.

Long-Term Assessment (5 to 19-Year Follow-up) of the Incisal Level Changes in Single Implants Placed in the Anterior Maxillary Region. An Observational Clinical Study.

Long-Term Assessment (5 to 19-Year Follow-up) of the Incisal Level Changes in Single Implants Placed in the Anterior Maxillary Region. An Observational Clinical Study.

Primordial odontogenic tumor of the maxilla: A case report

A primordial odontogenic tumor (POT) consists of an ellipsoidal mass of dental papilla-like myxoid connective tissue entirely enveloped in an intricate membrane of the ameloblastic epithelium. This case has been particularly interesting due to its unique identity and rare nature. A 5-year-old boy came to the ENT department of a tertiary care hospital complaining of left facial swelling for the past three months. In contrast with clinical, radiological, and histological investigations and following the WHO definition, it was confirmed as a Primordial odontogenic tumor of the maxilla. The ideology and genetic makeup of this disease are still idiopathic and in the early developing phase. The clinical, radiologic, microscopic, and IHC features in this case suggest POT in an infrequent location of the anterior maxillary region.

Non-Surgical Treatment of Residual Cyst in Maxillary Anterior Region of an 11-year-old Patient: A Case Report

We aim to report a case of residual cyst in an 11-year-old male patient, which was treated by marsupialization as a conservative alternative to surgical enucleation. An 11-year-old male patient reported to our department with a painless swelling of approximately 1.5x1 cm in size intraorally, both in the maxillary right buccal and palatal region for about 1 month. On fine needle aspiration, a yellow-coloured highly viscous fluid was observed which on histopathological examination revealed an infected cyst. This along with the clinical examination and history confirmed the diagnosis of a residual cyst. Marsupialization was chosen as a conservative treatment due to the size of the cyst and the age of the patient. Weekly follow-up and dressing change were carried out for 6 months which lead to a complete resolution of the cyst with continuous normal development of the occlusion. No adverse effects such as fever, infection, or pus discharge were seen at any time during treatment. We have been able to design a treatment protocol which has provided us with a nonsurgical solution for large cystic lesions in growing patients without adverse effects for the complete duration of treatment. Marsupialization should be considered as a treatment option for large residual cysts, especially in pediatric patients. Key Words - Marsupialization, Maxilla, Mixed dentition, Residual cyst

Management of a Maxillary Radicular Cyst in a Patient with Gilbert Syndrome: A Rare Case Report

Gilbert syndrome is a rare benign autosomal genetic disorder characterized by reduced activity of glucuronyl transferase, leading to decreased clearance of bilirubin and occasional mild jaundice in the absence of hepatic injury or hemolysis. Diagnosis involves clinical and laboratory investigations as part of differential diagnosis, with genetic analysis providing additional confirmation. Oral manifestations of Gilbert syndrome exist but often go unnoticed. Drugs metabolized by this enzyme need to be considered along with stress management in patients undergoing surgical procedures. This case report of a 24-year-old male diagnosed with a radicular cyst in the maxillary anterior teeth region, who incidentally exhibited Gilbert syndrome, also highlights perioperative management considerations for such patients.

Assessment of variations in the nasopalatine canal on CBCT: considerations from an anatomical point of view.

The nasopalatine canal (NPC) is one of the most significant anatomical markers in the anterior maxillary region. Its location is quite important, especially for implant placement. Therefore, the purpose of this study was to use cone-beam computed tomography (CBCT) to evaluate the morphology, size, and anatomic variations of the NPC. A total of 150 individual CBCT images were assessed in various sections to evaluate the dimensions, morphology, and extent of the NPC. Reformatted sagittal images were chosen to classify the shape and course of the canal. The Student's t-test, the χ² test, and Pearson correlation coefficients were used. The NPC was longer in males than in females, and the mediolateral diameter of the canal was greater in older adults. In sagittal sections, the canal predominantly exhibits a cylindrical shape, while a spindle shape is the least common. In coronal sections, a single shape is most frequently observed, with a Y-shape being the least common. Regarding the orientation of the canal, slanted canals are more prevalent, whereas vertically curved canals are rare. Typically, 2 canal openings are observed, with 4 openings being the least common. The current study highlights the challenges associated with identifying the anatomical appearance and variations of the NPC. Consequently, possessing a thorough understanding of this anatomy is essential before undertaking any surgical procedures, such as implant placement. This knowledge helps prevent complications such as nerve injury-related loss of sensation, bleeding due to blood vessel injury, and the development of a nasopalatine duct cyst following trauma to the canal during surgery.

Cosmetic Makeover of Periodontally Compromised Patients using Flexible Gingival Mask and Porcelain Laminate Veneers: Report of Two Cases

Chronic periodontal disease can lead to advanced gingival tissue loss that can result in problems with esthetics, phonetics, food impaction and tooth sensitivity. One of the most difficult problem encountered in the management of periodontal disease is loss of interdental papillae which leaves unsightly “black triangles” between the teeth. The first step in the management of these problems is surgical correction of the defect. In cases where mucogingival surgery is unpredictable due to generalized recession and loss of large volume of gingival tissue, removable gingival prosthesis is an excellent alternative to correct the deformities remaining after the control of destructive periodontal disease specially in the maxillary anterior region. Gingival prostheses may be fixed or removable. It can be made from a range of materials like acrylic, silicones, porcelain- based materials and flexible resin denture material. This report describes two clinical situations in which combined periodontal/prosthodontic rehabilitation was done for patients with advanced periodontal disease. Accurately fitting flexible gingival prostheses and porcelain laminate veneers were fabricated to restore advanced gingival tissue loss in esthetic area following periodontal flap surgery. The flexible gingival masks not only help to achieve excellent cosmetic results but also reinstate the functional and psychological wellbeing of the patient.

Comparative Evaluation of Hard- and Soft-tissue Changes in Immediate Implant Placement Using Flapless Approach with and without Demineralized Freeze-dried Bone Allograft Clinically and Radiographically Using Cone-beam Computed Tomography

Abstract Objectives: The present study evaluated hard- and soft-tissue changes in immediate implants using flapless approach with and without demineralized freeze-dried bone allograft (DFDBA) clinically and radiographically using cone-beam computed tomography (CBCT). Materials and Methods: Thirty-two sites in patients requiring immediate implants in the maxillary anterior region including the premolars were grouped according to the treatment provided with (test group) or without (control group) DFDBA. Plaque index, probing depth, soft-tissue assessment using Testori Esthetic Score (TS), and ridge width were recorded at baseline and postoperatively at 6 and 12 months, while crestal bone height (CBH), buccal bone thickness (BBT), jump space (JS), and gingival thickness were evaluated using CBCT at baseline and 12 months. Results: Considerable differences among the different time lines and the groups in favor of the test group were prominently seen on the midfacial aspects at 12 months, with CBH values of −0.28 ± 0.17 mm in the test group as compared to −0.78 ± 0.34 in the control group (P &lt; 0.0001). The JS was maximum on the buccal aspects being 1.42 ± 0.87 mm in the test group and 1.12 ± 0.81 mm in the control group which reduced at 12 months to 0.13 ± 0.35 mm and 0.73 ± 0.79 mm, respectively. Conclusion: Immediate implants with DFDBA augmentation using a flapless protocol demonstrated reduced CBH with resolution of JS and increased BBT, especially at the coronal aspects which influence the tissue stability and overall esthetics.

Single-piece zirconia versus single-piece titanium, narrow-diameter dental implants in the anterior maxilla: 5-year post-loading results of a randomized clinical trial.

The aim of this study was to evaluate esthetic parameters in the anterior maxillary region by comparing single-piece zirconia versus titanium narrow-diameter implants. Additionally, clinical, radiological and patient-reported outcome measures (PROMs) were analyzed. Thirty implants (tissue level implant) were placed in 30 patients in the maxillary esthetic sector. Depending on randomization, a zirconia (test) or titanium implant (control) was placed. Esthetic, clinical, and radiological parameters, including the implant crown esthetic index (ICAI), pink esthetic score (PES), probing pocket depth, bleeding on probing, plaque index, and marginal bone levels, were evaluated at 12, 36 and 60 months after loading. Sixty months after crown placement, no significant differences were found between groups. The ICAI values were 5.25 ± 4.21 and 4.50 ± 2.98 for the test and control groups, respectively. The corresponding PES values were 7.44 ± 1.93 and 7.43 ± 1.74 for the test and control groups, respectively. There were no significant intergroup differences for the rest of the parameters evaluated. It can be suggested that monotype zirconia implants may serve as a potential alternative to titanium implants in selected clinical scenarios. While the results demonstrated comparable esthetic, clinical, and radiological aspects for zirconia implants as compared to titanium implants after a 5-year follow-up period, further research with larger sample sizes and longer-term follow-up is recommended.

Advanced restorative management of focal microdontia: A brief review and case report.

Focal microdontia is a dental anomaly characterized by the presence of a single abnormally small anterior or posterior tooth. The objective of this article is to provide an updated review of the literature on the advanced restorative management of focal microdontia, and to document a clinical case where the reviewed advanced restorative approaches were applied to treat a young adult presenting with a non-syndromic asymmetrical focal microdontia.We conducted a preliminary examination of the existing literature on the advanced restorative management of focal microdontia. Additionally, we presented a minimally invasive approach to the treatment of an 18-year-old female patient with non-syndromic asymmetrical focal microdontia. The primary advantage of adhesive dentistry is that it can better preserve the structure of smaller teeth. A review of literature reveals a paucity of reports on localized microdontia in the maxillary anterior region of the mouth. However, novel minimally invasive restorative procedures satisfy patients' aesthetic and functional preferences. Well-executed additive diagnostic wax-ups and intraoral mock-ups can serve as a permanent restoration blueprint, providing predictable results for focal dental anomalies in the aesthetic zone. In conclusion, the use of minimally invasive dental approaches in young patients with focal microdontia can result in long-term satisfactory aesthetic outcomes.

Diagnosis and Management of a case of impacted central incisor associated with compound odontoma in a 4 years old girl

Odontomes are benign tumors developing from the epithelial and mesenchymal cells which are completely differentiated into ameloblasts and odontoblasts that forms enamel and dentin. They are of two types, complex and compound. Complex odontomes are typically seen in the mandibular posterior region where as compound odontomes have a preference towards the maxillary anterior region. They are rarely associated with deciduous dentition. This article presents a case of compound odontoma in a child below 4 years old who reported with a history of missing deciduous left central Incisor. Key words: Compound odontome, Deciduous Dentition, Odontome

Rehabilitation of aesthetic zone with narrow maxillary ridge by staged implant protocol

It can be difficult to achieve an aesthetically pleasing implant-supported restoration in the maxillary anterior region. With regard to the variety of factors that could affect the therapy, the treatment planning for an implant restoration is distinct. A number of elements, including those linked to the patient, careful planning of the course of treatment, implant and abutment selection, soft tissue contour, implant axis, occlusion, and other considerations, all contribute to the final clinical result. Implant supported restorations can have more prosthetic flexibility as a result of the option to select multi-unit abutments in oral implantology. Multi-unit abutments have advantages in that they provide good fit and performance together with predictable aesthetics, which significantly increases the efficacy of prostheses supported by implants. This case report describes the rehabilitation of a 42-year-old male patient with a partially edentulous arch in the maxillary anterior area using an implant-supported restoration and a multi-unit abutment.