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PURPOSE: The growing demand for implants has led to their implementation by general dental practitioners (GDPs) in clinical practice. The present study assessed referral patterns of GDPs for the surgical phase of implant dental treatment. MATERIALS AND METHODS: One hundred fifty GDPs were asked to fill out a structured questionnaire containing their demographic data and answer six questions characterising their referral patterns for implant dentistry. RESULTS: Forty-one (41%) percent performed the surgical phase, and 87% provided implant restoration. Gender was the only influencing factor for the surgical phase, as 51.4% of male GDPs and 6.5% of female GDPs performed implant surgery themselves. Experience and practice set-up did not influence the referring decision. Fifty-four percent of the practitioners referred 0 to 5 patients per month, and the chosen specialists were: 80% oral and maxillofacial surgeon, 11% periodontist, and 9% selected a specialist depending on the individual case. The major reasons influencing the referral pattern were the complexity of the surgical procedure, followed by systemic medical compromise of the patient. CONCLUSIONS: Most implant surgeries in Israel are still performed by specialists.

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OBJECTIVE: The aim of this study was to simulate reusing an opened package of bone substitute (BS) under typical clinical conditions, by analyzing bacterial growth in samples of resealed packages of alloplast and xenograft BS following different time periods up to a week. MATERIALS AND METHODS: The experiment was performed in 2 stages: dry stage and wet stage. In the dry stage, BS samples were exposed to air for 15 minutes and then were sealed again in their original package. After several "aging" periods [no aging (t0), 24 hours (t1), and 1 week (t7)], BS samples were plated onto brain heart infusion agar and were incubated at 37 °C for 24 hours under aerobic conditions. Bacterial colonies were enumerated and colony forming units per 1 mL was calculated. In the wet stage, the experiment was repeated but BSs were left to age in a brain heart infusion broth to simulate a more supporting humid environment to encourage bacterial growth. RESULTS: In the dry stage of the experiment, no bacterial growth was detected in both xenograft and alloplast samples (colony forming units/mL=0), in any of the time points (t0, t1, t7). In the wet stage, average bacterial growth was 0 for both groups in t0. In t1: 1.14 × 10 4 ±4.16 × 10 3 for the xenograft and 7.73 × 10 5 ± 9.99 × 10 5 for the alloplast. In t7: 1.64 × 10 9 ±1.82 × 10 8 in the xenograft compared with 8.86 × 10 8 ±4.00 × 10 8 for the alloplast. Analysis of variance with repeated measures showed a significant difference in comparison of the 2 BSs for each time group (t1 and t7) ( P <0.005). CONCLUSION: Under dry conditions, in a resealed package, there was no bacterial growth for up to 1 week for both BSs. Once the BSs are introduced to a humid environment, which supports bacterial growth, the xenograft BS allowed more rapid bacterial growth, compared with the alloplastic BS.

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PURPOSE: To know whether there is a correlation between maxillary advancement and the nasolabial angle change allows to preoperatively predict the precise affect a planned maxillary advancement will have over the nasolabial angle. The aim of this study was to determine the relationship between the maxillary advancement and the nasolabial angle. METHODS: The study is a retrospective analysis of 32 patients (12 males and 20 females, mean age 21 ±â€Š3.4 years) who underwent a maxillary advancement. Lateral cephalometric radiographs were taken preoperatively and postoperatively. The lateral cephalograms were traced. Measurements were evaluated statistically using paired sample t-test and Pearson's correlation test. RESULTS: The mean maxillary advancement was 4.81 ±â€Š3.01 mm with a mean vertical change of -0.28 ±â€Š2.80 mm. The nasolabial angle decreased by a mean of 3.78 ±â€Š9.64° with statistical significance of P = 0.03 using a paired sample t-test, however using Pearson's correlation test, no direct correlation between maxillary advancement and the nasolabial angle was found. Furthermore, the study contains a review of the literature from the last 25 years, which shows that in most studies there was no correlation and in some patients even opposite results. CONCLUSION: Maxillary advancement might influence the nasolabial angle; however, preoperatively predicting the influence a maxillary advancement will have over the nasolabial angle is difficult, and further studies need to be conducted.

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OBJECTIVE: New oral anticoagulants, or "direct oral anticoagulants" (DOACs), have been used worldwide in recent years. An evidence-based enigma regarding dental patients using DOACs still exists. METHOD AND MATERIALS: This was a 4-year, cross-sectional study on individuals receiving DOAC therapy, treated in a single maxillofacial center. A bleeding event was the outcome parameter. Potential contributing risk factors were evaluated. RESULTS: Of a total of 111 patients, 72 underwent a total of 305 oral procedures in 115 sessions. The overall frequency of bleeding events was 6.1% per session. One "major" (0.9%) and six "minor" (5.2%) events were recorded. The management was simple, local hemostasis. Statistically significant association was found between bleeding events and (1) history of spontaneous hemorrhage and (2) surgical procedures involving soft tissue manipulation. Withdrawal of DOAC therapy was not associated with decreased postoperative bleeding events. CONCLUSION: The risk of bleeding in dental patients using DOACs is low with no major consequences. The data support not stopping DOACs prior to dental treatment, regardless of the complexity or the extent of the procedure. Dosage adaptation is recommended in patients with a history of spontaneous hemorrhage.

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PURPOSE: Different lesions in the fibro-osseous group share microscopic features; thus, establishing a definitive diagnosis based on microscopic features alone can be a challenge. There is a need for additional microscopic tools to aid in differentiating these lesions. This study compared parameters related to vascularity among 3 lesions in the fibro-osseous group: fibrous dysplasia (FD), central ossifying fibroma (COF), and cemento-osseous dysplasia (COD). MATERIALS AND METHODS: This study was a cross-sectional analysis of biopsied lesions retrieved from 3 medical centers over a 14-year period. The primary predictor variables were the vascularity parameters (number, perimeter, and area). The outcome variables were diagnoses of FD, COF, and COD. Diagnosis was based on clinical, microscopic, and radiologic correlations. From each histopathologic slide, 5 representative fields were captured with a computerized digital camera. The number of blood vessels was counted, and the surface area and vascular perimeter were measured by tracing the perimeter of each vessel. Data were statistically analyzed using analysis of variance with logarithmic transformation and a Tukey adjustment. RESULTS: Sixty-six cases were included in the study (26 in FD group, 26 in COF group, and 14 in COD group). The mean number of vessels showed only a tendency to be larger in the FD group compared with the COF and COD groups (5.4 ± 2.6, 3.7 ± 2.3, and 3.6 ± 1.7, respectively), but the results did not reach the threshold for significance. The mean vascular perimeter was 1,385.8 ± 859.2 pixels in the FD group and 742.6 ± 661.8 in COF group after logarithmic transformation (P = .012). The perimeter in the COD group was smaller (941.1 ± 502) compared with that in the FD group, but the difference did not reach the threshold for significance. The mean area was 25,061 ± 24,875.6 in the FD group and 11,773.8 ± 21,734.4 in the COF group after logarithmic transformation (P = .004). The perimeter in the COD group was smaller (13,011.1 ± 8,338.3) compared with the FD group, but the difference did not reach the threshold for significance. CONCLUSION: The vascular content of the FD group was markedly higher than of the COF group. These vascular changes can aid in differentiating these lesions microscopically.

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PURPOSE: To evaluate the efficiency of decompression in treating odontogenic cystic lesions of the jaws in children. MATERIALS AND METHODS: All consecutive odontogenic cysts occurring in children and treated by decompression from 1994 to 2009 at 1 maxillofacial center were included in the present study. Clinical data included age, gender, jaw, histopathologic diagnosis, and decompression time. Radiologic data from panoramic radiographs before and after decompression included tooth involvement, locularity, location, involvement of adjacent vital anatomic structures, and cyst area. RESULTS: Thirty-two odontogenic cystic lesions from 26 children (14 boys [53.8%] and 12 girls [46.2%]) treated with decompression were included. The average age at the time of presentation was 11.6 ± 3.3 years (range, 7 to 18 yr). The mandible was involved in 13 cases (40.6%) and the maxilla in 19 (59.4%). All cysts were unilocular at presentation. Twenty-seven cysts (84.4%) showed tooth involvement. The diagnoses consisted of dentigerous cysts (20 [62.5%]), keratocysts (9 [28.1%]), and radicular cysts (3 [9.4%]). The mean decompression period was 7.45 ± 2.6 months (2 to 14 months). The mean standard lesion area index changed from 12.7 ± 0.9 mm(2) (3.6 to 44 mm(2)) before compression to 2.3 ± 4.3 mm(2) (0 to 22.3 mm(2)) after decompression. The mean percentage of reduction (POR) was 82 ± 16% (49 to 100%). The POR was ranked as good in 22 lesions (69%), moderate in 9 lesions (28%), and poor in 1 lesion (3%). Surgery was performed for 15 lesions (47%). CONCLUSION: Decompression results in good regeneration potential of the bone in the developing craniofacial skeleton of children. Children might benefit from a less invasive surgical protocol.

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OBJECTIVES: To investigate the clinical characteristics and pre- biopsy provisional diagnoses of benign oral mucosal tumors. MATERIAL AND METHODS:A 10- year retrospective analysis of all benign tumors of the oral mucosa, from a university- affiliated oral and maxillofacial surgery department.RESULTS:146 benign tumors were included. The mean age was 49.6 years, with an approximately equal gender distribution. The most prevalent tumor types were lipomatous tumors (27.4%), vascular (23.3%), and salivary gland tumors (16.5%). Tongue, labial and buccal mucosa were the most frequently involved sites. The vast majority (98.6%) presented as non-ulcerated masses. Only 2 (1.4%) presented as ulcerated masses. The clinical provisional diagnosis correctly classified lesions as non-malignant in 93.3%. In only 9 (6.7%) suspicion of malignancy was included in the provisional diagnosis. However, benignneoplasia was unsuspected in 42.1% of tumors. These cases were clinically classified as reactive. CONCLUSION: Benign tumors were most likely to be clinically correctly classified as non-malignant, but even in the setting of experienced oral surgeons, neoplasia was unsuspected in more than 40% of cases. This data strongly supports the need to biopsy every oral mucosal mass, since inaccurate clinical evaluation of the lesion's biological nature was a frequent event

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Objective was to describe the effect of bioactive glass putty with and without topical simvastatin on new bone formation in critical-sized defects of rat calvaria. A calvarial bone defect was created in 20 male Wistar rats and filled with bioactive glass alone (n = 10) or combined with simvastatin (n = 10). After 4 weeks, the defects were histomorphometrically evaluated for volume fraction (Vv) of woven bone, vessel density, bioglass quantity, and inflammation. Compared to the bioglass-only group, rats treated with simvastatin had greater Vv of blood vessels (3.3% ± 0.7 vs 1.6% ± 0.1, P = .0002) and new bone (2.3% ± 0.2 vs 1.8% ± 2.5, P = .003). The Vv of the bioglass remnants in the bioglass-only group was higher than in the group treated with simvastatin (2.4% ± 0.08 vs 1.7% ± 0.3, P < .0004). Chronic inflammation was noted in 1 rat from each group. Topical simvastatin seems to improve the pro-angiogenic and pro-osteogenic properties of bioglass putty in rat calvaria critical-size defects without significant inflammation.

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BACKGROUND: Gingiva that is prone to inflammation may serve as a pre-metastatic niche for the attraction of circulating malignant cells. The aim of this study is to analyze cases of metastatic lesions to the gingiva compared with cases metastasizing to other oral mucosal sites. The pathogenesis of gingival metastases is discussed, with emphasis on the role of inflammation. METHODS: The English-language literature between 1916 and 2011 was searched for cases of metastatic lesions to the oral mucosa; only cases metastasizing in the oral mucosa, gingiva, and periodontium were included. RESULTS: Two hundred seven cases were included. The gingiva was the most common site (60.4%), followed by tongue and tonsil. The most common primary sites were lung (24.2%), kidney (13.5%), skin (10.6%), and breast (8.7%). In 27%, the oral lesion was the first sign of a malignant disease. In most cases, the lesion appeared as an exophytic mass (96%) diagnosed clinically as a reactive gingival lesion. The presence of teeth was significantly associated with the development of gingival metastases: in 108 of 125 gingival metastases, the lesion was found adjacent to teeth (P <0.001; odds ratio = 8.2). The average life expectancy after diagnosis of the metastasis was 3.7 months. CONCLUSIONS: The gingiva is the most common site for metastases to oral soft tissues, with strong association with the presence of teeth. This finding may be related to the role of inflammation in the attraction of metastatic cells to chronically inflamed gingiva.

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OBJECTIVES: To investigate the clinical characteristics and pre- biopsy provisional diagnoses of benign oral mucosal tumors. MATERIAL AND METHODS: A 10- year retrospective analysis of all benign tumors of the oral mucosa, from a university- affiliated oral and maxillofacial surgery department. RESULTS: 146 benign tumors were included. The mean age was 49.6 years, with an approximately equal gender distribution. The most prevalent tumor types were lipomatous tumors (27.4%), vascular (23.3%), and salivary gland tumors (16.5%). Tongue, labial and buccal mucosa were the most frequently involved sites. The vast majority (98.6%) presented as non-ulcerated masses. Only 2 (1.4%) presented as ulcerated masses. The clinical provisional diagnosis correctly classified lesions as non-malignant in 93.3%. In only 9 (6.7%) suspicion of malignancy was included in the provisional diagnosis. However, benignneoplasia was unsuspected in 42.1% of tumors. These cases were clinically classified as reactive. CONCLUSION: Benign tumors were most likely to be clinically correctly classified as non-malignant, but even in the setting of experienced oral surgeons, neoplasia was unsuspected in more than 40% of cases. This data strongly supports the need to biopsy every oral mucosal mass, since inaccurate clinical evaluation of the lesion's biological nature was a frequent event.

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PURPOSE: To evaluate the clinical appearance and rate of ulceration of oral mucosal malignancies, and to investigate the accuracy of clinical provisional diagnoses. METHODS: A 10-year retrospective analysis, which included diagnostic biopsies of malignant tumors of the oral mucosa. The clinical provisional diagnoses were compared with final diagnoses. RESULTS: Two hundred and twenty-seven oral mucosal malignant tumors were included. Squamous cell carcinoma and its variants accounted for the majority (78%) of all malignant tumors. The most common clinical presentations were non-ulcerated (59.7%) and ulcerated masses (20.4%). Only 11.9% presented as indurate ulcers. The highest ulceration rate of all malignancies was recorded for SCC, with only about half of SCC and its variants ulcerated at the time of biopsy. 31.1% of all malignancies were not clinically suspected to be malignant and did not even include a request to rule out malignancy. There was a better agreement between the clinical provisional diagnoses and microscopic diagnoses in the SCC group than in other types of malignancy (P < 0.001). CONCLUSION: Within this study sample, non-ulcerated masses rather than indurate ulcers are the most common clinical appearance of oral mucosal malignancies, and even for SCC, that showed the highest ulceration rate at presentation, half were non-ulcerated. Approximately, one-third of oral mucosal malignancies were not suspected to be malignant prior to biopsy. Thus, the level of suspicion currently reserved for mucosal ulcers and ulcerated masses should also be applied to non-ulcerated oral mucosal masses.

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To compare the spectrum of pathologies in ulcerated versus non-ulcerated exophytic oral mucosal lesions and explore the significance of surface ulceration as an indication of malignancy. Retrospective analysis of exophytic lesions of the oral mucosa, 2009-2011. 713 biopsies of exophytic lesions of oral mucosa were included, of which 9.4% were ulcerated. Significant differences were found between ulcerated and non-ulcerated lesions. Of the ulcerated lesions 67.2% were reactive, 31.3% malignant and 1.5% benign, compared to 86, 8.4 and 5.6% respectively in non-ulcerated lesions (p < 0.0001). Malignancies were most prevalent in ulcerated lesions, in patients over 50. Malignancies presented the highest ulceration rate (36.8%, p < 0.001), compared to reactive (7.5%) and benign neoplasia (1.8%), however, the majority of oral mucosal malignancies (63.2%) presented as non-ulcerated masses. Squamous cell carcinoma presented the highest ulceration rate among malignancies, but even these were only ulcerated in 50% of cases. Non-epithelial malignancies were non-ulcerated in all cases. One-third of all malignancies were not suspected as such clinically, however, there was a better agreement between the clinical and microscopic diagnosis of malignancy in ulcerated lesions. Although the statistical likelihood of ulcerated masses to represent malignancy was higher than non-ulcerated lesions, especially in patients over 50, the majority of malignancies presented as non-ulcerated masses. Thus, all exophytic lesions should be submitted for microscopic analysis, and the status of ulceration should not be regarded neither as a factor in the decision to biopsy, nor a reliable indicator for malignancy.

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INTRODUCTION: Our objectives were to evaluate and quantify upper lip soft-tissue changes in the vertical dimensions both at rest and at maximum smile, and to examine the correlation between upper labial vestibular attachment height and maxillary gingival exposure on smiling. METHODS: Seventy-two volunteers (36 men, 36 women) aged 20 to 40 (mean, 30.49 years) were recruited for this study. For each subject, 9 measurements of upper lip position and maxillary incisor crown height at rest and in maximum smile were recorded. RESULTS: A statistically significant sexual dimorphism was apparent in most of the measured variables. Relaxed external upper lip length was 3.1 mm shorter in the women than in the men. The mean maxillary central incisor display at rest was 1.78 mm greater in the women than in the men. A high smile line was 2.5 times more prevalent in the women. The upper lip was shortened by 30% in subjects with a high smile line compared with 23% in subjects with a low smile line. CONCLUSIONS: The following findings were observed in subjects with a high smile pattern: (1) short upper lip length, (2) low smiling/resting upper lip length ratio, (3) inferior attachment of the upper labial vestibule, and (4) prominent upper lip vermilion.

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BACKGROUND: Neurovascular hamartoma (NVH), in particular in the oral cavity, is rarely described in the literature. The low number of cases may reflect a genuine rarity of the lesion, or it may be due to its being unrecognized and/or under-reported. OBJECTIVES: To investigate clinical and microscopic features of oral NVH and to define microscopic diagnostic criteria with emphasis on the differential diagnosis. METHODS: Archival cases diagnosed as oral NVH between 1999 and 2011 were retrieved; clinical and demographic data were collected, and a paired morphometric analysis was conducted, with each case of NVH a case of fibrous hyperplasia (FH) from the same oral location. The nerve bundle and blood vessel density were quantified in five microscopic fields at ×100 magnification. RESULTS: The study group included 25 oral NVH, 11 men and 14 women, aged 6-76 years, (mean 44). The majority occurred in the tongue (54%), followed by the buccal mucosa and lower lip (17% each), clinically presenting as asymptomatic 0.25-2.5 cm exophytic masses. Microscopic characteristics included poorly circumscribed masses of closely packed nerve bundles and blood vessels in a loose matrix, containing minimal or no inflammation. The mean nerve bundle density was significantly higher in NVH (4.28 ± 1.26) in comparison with FH (0.27 ± 0.27), (P < 0.00001), and mean vessel density was significantly lower (5.98 ± 1.4 vs. 7.8 ± 1.9, respectively), (P < 0.0003). CONCLUSION: Oral NVH may not be as rare as previously considered. Morphometric analysis demonstrated that NVH presents a separate distinct entity.

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OBJECTIVE: The aim of this study was to evaluate the effectiveness of decompression as the initial treatment for odontogenic cysts. STUDY DESIGN: Pre- and postdecompression panoramic radiographs of 57 patients treated for 73 odontogenic cysts were reviewed for reduction parameters. Findings were evaluated against time of decompression and clinical and histopathologic data. RESULTS: Decompression reduced lesion area by a mean of 79.3%. The reaction was good in 60% of cysts, moderate in 29%, and poor in 11%. Mean decompression time was 9.2 ± 5.2 months; it was 7.6 months in patients ≤18 years old and 10.2 months in older patients (P < .0001). Mean rate of reduction was 0.14 in cysts <10 cm(2) and 0.10 in cysts >20 cm(2) (P = .0884); by age, values were 0.14 in patients ≤18 years old and 0.09 in older patients (P < .05). CONCLUSIONS: Decompression is effective in reducing odontogenic cysts. A shorter decompression period is needed for young patients. For aggressive lesions, secondary definitive surgery is recommended.

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This study was conducted to establish the efficiency of microcomputerized tomography (micro-CT) in detection of trabecular bone remodeling of onlay grafts in a rodent calvaria model, and to compare bone remodeling after onlay grafts with beta-tricalcium phosphate (TCP) or coral calcium carbonate. Ten rats received calvarial onlay blocks-5 with TCP and 5 with coral calcium carbonate. The grafts were fixed with a titanium miniplate screw and were covered with a collagen resorbable membrane. Three months after surgery, the calvaria were segmented, and a serial 3-dimensional micro-CT scan of the calvarium and grafted bone block at 16-micrometer resolution was performed. Image analysis software was used to calculate the percentage of newly formed bone from the total block size. Newly formed bone was present adjacent to the calvarium and screw in all specimens. The mean area of newly formed bone of the total block size ranged from 34.67%-38.34% in the TCP blocks, and from 32.41%-34.72% in the coral blocks. In the TCP blocks, bone remodeling was found to be slightly higher than in the coral blocks. Micro-CT appears to be a precise, reproducible, specimen-nondestructive method of analysis of bone formation in onlay block grafts to rat calvaria.

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OBJECTIVES: The aim was to evaluate the effectiveness of the long-term administration of intranasal calcitonin spray for the treatment of central giant cell granuloma (CGCG) in a retrospective case study. STUDY DESIGN: The medical files of 5 patients (4 male, 1 female; ages 8-66 years) with CGCG of the jaws treated with calcitonin nasal spray 200 U/spray once or twice daily were reviewed for lesion-related parameters, outcome, and adverse effects of therapy. RESULTS: Three lesions were located in the mandibular body and ramus region and 2 in the anterior maxilla. Mean lesion size on radiography was 3.2 x 2.3 cm. The duration of calcitonin treatment was 9-60 months (mean 28 months). All the lesions considerably decreased in size with a high degree of calcification. There were no recurrences. CONCLUSIONS: Calcitonin nasal spray appears to be safe and effective for the treatment of CGCG and might be considered an alternative to surgery. Further controlled studies are needed to corroborate these findings.

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OBJECTIVES: The purpose of this case series was to describe late complications of maxillary sinus augmentation procedures, including paranasal sinusitis and oroantral fistula, and to discuss the definitive surgical methods of treatment. STUDY DESIGN: The case series included 13 patients hospitalized for a failed lateral-approach maxillary sinus augmentation, performed by a dental practitioner, with or without simultaneous implant placement. Data on patient gender and age, presenting signs and symptoms, radiographic appearance, method of repair, and follow-up were recorded. RESULTS: There were 7 female and 6 male patients aged 53-74 years. Twenty-six of the total 34 implants inserted failed, of which 7 were displaced into the sinus. All patients had maxillary sinusitis, and 2 also had an inflammation of other paranasal sinuses. Ten patients presented with an oroantral fistula. Review of the files of the referring practitioner revealed the preoperative presence of chronic maxillary sinusitis in 4 patients and an odontogenic cyst in 1. Caldwell-Luc operation served as the definitive surgical treatment. All fistulas were successfully closed by a palatal rotation advancement flap (8 patients) or a buccal flap (2 patients). CONCLUSIONS: Thorough clinical and radiographic evaluation is necessary before sinus procedures to minimize complications. Total elimination of sinusitis and other pathologic conditions is recommended before maxillary sinus augmentation and implant surgery.

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Carcinoma cuniculatum is a rare variant of carcinoma usually involving the foot. Only 13 cases have been described in the oral cavity, none of which was in the English-language literature. We describe a 56-year-old man who presented with a soft exophytic mass in the maxillary gingiva, alveolar bone destruction, and loosening of the teeth. Histopathologic study revealed thin papillary projections covered by a thick keratin layer in the superficial areas and multiple, branching keratin-filled crypts surrounded by well-differentiated squamous epithelium with only mild cytologic atypia but frequent mitosis. Immunohistochemistry results of p53 and polymerase chain reaction analyses for human papillomavirus 6, 11, 16, and 18 DNA were negative. The diagnosis was carcinoma cuniculatum of the jaw. The literature on this unusual oral pathosis is reviewed and the diagnostic challenge described. We suggest that carcinoma cuniculatum may sometimes be misdiagnosed as squamous cell carcinoma or verrucous carcinoma and, therefore, might be more prevalent than the small number of published cases implies.

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