JOS - European Journal of Oral Surgery

JOS European journal of oral surgery

Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

1 ISSUE 3 VOL.

December 2010

ISSN 2037-7525

CASA EDITRICE ARIESDUE

ITALIA PRESS EDIZIONI

European journal of oral surgery Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale www.ejos.eu

European journal of oral surgery

Editor-in-chief

Publisher

Prof. Franco Santoro (Italy)

ARIESDUE SRL

ITALIA PRESS EDIZIONI

Via Airoldi, 11 22060 Carimate (CO) +39 (0)31.79.21.35 +39 (0)31.79.07.43 www.ariesdue.it info@ariesdue.it

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Editorial Director Prof. Carlo Maiorana (Italy)

Associate Editor

ISSN: 2037-7525

Prof. Piero Balleri (Italy) Prof. Pascal Valentini (France)

Editorial Board Dr. Giovanni Battista Grossi (Italy) Prof. Alan Herford (USA) Prof. Fouad Khoury (Germany) Prof. Jaime A. Gil (Spain) Prof. Massimo Simion (Italy) Prof. Anton Sculean (Switzerland) Prof. Tiziano Testori (Italy) Prof. Leonardo Trombelli (Italy) Dr. Istvan Urban (Hungary)

DIRECTOR Dino Sergio Porro EDITORIAL STAFF Angela Battaglia: a.battaglia@ariesdue.it Cristina Calchera: farma@ariesdue.it Simona Marelli: doctoros@ariesdue.it MARKETING & ADVERTISING Barbara Bono: b.bono@ariesdue.it Paola Cappelletti: p.cappelletti@ariesdue.it Franco De Fazio: f.defazio@ariesdue.it WEB & GRAPHIC DESIGN Michele Moscatelli: grafica@ariesdue.it Simone Porro: simone@ariesdue.it Cover image courtesy of Alessio Sabbadini

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European journal of oral surgery

Issue 3 Volume 1 December 2010

page 74

A one-year case report of implant placement in combination with sinus membrane elevation without biomaterials

page 79

Diode laser vaporization on unresponsive oral lichen planus: case followed for two years

page 85

Immediate adjacent implants in the aesthetic area: a case report

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JOS VOL.1 N.3 2010

European journal of oral surgery Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

European journal of oral surgery

Editor-in-chief

Prof. Franco Santoro SISCOO President

Editorial Dear colleagues, the third issue of JOS is now going to be released and we are proud of the feedback we got from those of you who showed their appreciation for the clinical level of the previous issues.

Last september the first SISCOO congress took place in Milano and the speakers covered some of the hottest topics in osseointegration, ranging from the soft tissue management to the approach to patients affected by bisphosphonates-related jaw osteonecrosis, from piezosurgery to the current trends in endodontic surgery. I want to take this opportunity to thank all the sponsors who decided to support the initiative and to become SISCOO partners.

The population of specialists in oral surgery is increasing every year and we are making an effort to make our Society more and more attractive to all the dentists who are interested in oral and periodontal surgery and implantology.

We are now working at the 2011 scientific program, which provides for two courses entrusted to worldwide renown speakers, in spring and fall time as well as to the editorial plan for JOS 2011. In order to make SISCOO growing we do need your contribution and support to advertise the scientific community about this new Society focused on oral surgery and we will appreciate your suggestions to make SISCOO bigger and stronger.

Next february the General Assembly will meet to elect the new Board and I hope that all the members will join us to discuss the future trends of the Society.

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Case report

A one-year case report of implant placement in combination with sinus membrane elevation without biomaterials Piero Balleri MD, DDS Mario Veltri DDS, PhD

Department of Oral Surgery, University of Siena, Italy

Aim:

Membrane elevation in combination with implant placement without biomaterials is a rather new technique for sinus lifting. The procedure is described with the case of a patient with pneumatised maxillary sinus and requesting single molar replacement. A one-year after loading clinical and radiographic follow-up is also reported.

Methods: A patient with a mean residual bone height of 4 mm was scheduled for sinus lifting. After opening a replaceable bone window, the membrane was dissected from the sinus walls. An implant was placed in the residual crest and it kept the membrane lifted upwards. After window repositioning the flap was sutured. A six-month healing period was allowed. The patient was re-examined after 24 months of loading.

Results: The implant was stable during the follow-up period. New bone formed around the lifted membrane after one year of follow-up.

Conclusions: Within the limitation of this case report, implant placement in combination with sinus membrane elevation seems to be a reliable technique for implant placement in pneumatised sinus when a single molar is missing.

No extra costs for biomaterial or morbidity for bone harvesting were necessary.

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Key words: Sinus membrane Minimal intervention Bone reformation.

Case report

Introduction Posterior edentulous areas of the upper jaws may have not enough bone for adequate implant stability. When this severe atrophy is due to the pneumatisation of the maxillary sinuses at the expenses of the alveolar crest, grafting of the sinus floor is generally performed, several techniques and grafting materials have been used for this purpose. As a general rule, grafting techniques should be as simple, less invasive, complication free and with the shortest healing time as possible (1). The rather novel sinus augmentation technique presented by Lundgren and co-workers (2, 3, 4) seems to satisfy the abovementioned requirements. When the sinus membrane is carefully dissected and maintained lifted by implants placed in the residual bone volume, spontaneous bone regeneration results around the implants. Without any grafting material, the new bone formation is promoted by the coagulum in the isolated area created around the implants. Animal studies have shown histological evidence of osseointegration around implants placed in combination with this technique (5). In addition, the health of the sinus mucosa has been shown not to be compromised after the lifting and implant placement procedure (6). This technique has already undergone clinical investigations from a few different centres with similarly good results (2, 3, 6, 7, 8, 9, 10). However further clinical data are desirable to document the effectiveness and predictability of the sinus membrane elevation technique in combination with placement of dental implants without grafting material.

The author had presented elsewhere a case where membrane lifting in combination with implant placement was successfully used to rehabilitate an edentulous atrophic posterior maxilla (9). It would therefore be interesting to assess the outcome of implants placed in combination with the above-mentioned technique to replace missing single molars. Implant replacement of maxillary single molars is in fact a treatment

associated with somewhat lower success rates probably due to the lack of splinting, soft bone conditions and great occlusal loading to withstand (10, 11).

The application of the technique is here described in a patient with pneumatised sinus and requesting a single molar replacement. A one-year of loading clinical and radiographic follow-up is presented.

Case report A 28 years old male patient seeking implant replacement for a lost maxillary first molar presented to the clinic. After the explanation of the treatment planning, he signed the informed written consent.

Preoperative panoramic radiograph and tomograms showed healthy sinus conditions and atrophy of the residual bone crest that was unsuitable for conventional implant

sinus membrane from the sinus floor. The membrane was then lifted upwards, so that a separate area for the implants was created (Fig. 6). In the residual alveolar crest, implant position was marked with a round bur and then 2, 2.5 and 3.2 mm diameter twist drills were used to prepare the sites aiming at high primary stability. The residual bone height, measured with a depth gauge (Depth Gauge Fixture, Astra Tech, MÜlndal, Sweden), was 4 mm. These intra-operatory data were then used to determine the height of the membrane lift achieved, i.e. the implant protrusion inside the sinus, as well as used as a baseline to calculate bone formation around the implants at the end of the followup. The patient received a 13 mm implant (ø 4mm, Osseospeed, Astra Tech, MÜlndal, Sweden) that protruded for 9 mm inside the sinus and with its apical portion, like a tent pole, lifted the membrane (Fig. 7). After implant placement,

FIG. 1

Preoperative x-ray shows insufficient bone volume for conventional implant placement.

placement (Fig. 1).

A mucoperiostal flap was raised to access the lateral wall of the sinus (Fig. 2). A bone window was then opened into the sinus using a piezoelectric handpiece (Surgybone, Silfradent, Cesena, Italy) (Fig. 3, 4). Whenever possible angled osteotomies were attempted so that the bone window had bevelled margins to facilitate its repositioning at the end of the procedure (Fig. 5). After removal of the bone window, small elevators were used to carefully dissect the

FIG. 2

Flap elevation and access to the lateral sinus wall.

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Balleri P. and Veltri M:

FIG. 3

FIG. 4

FIG. 5

Creation of a bone window in the lateral sinus wall using a piezoelectric handpiece.

Creation of a bone window in the lateral sinus wall using a piezoelectric handpiece.

Exposed sinus membrane after removal of the window. Note bevelled osteotomy bone margins to aid window repositioning at the end of the procedure.

FIG. 6

Dissected membrane. The implant will maintain the space created by keeping the membrane raised as a tent pole. Note the space that will be filled by coagulum.

FIG. 7

The placed implant and the space created between the sinus floor and the membrane filled with blood.

FIG. 8

The surgical glue used for stabilizing the bone window comes in a convenient sterile blister.

FIG. 9

Replaced window stabilised with surgical glue.

FIG. 10

FIG. 11

The implant three months after placement.

The implant after one year of loading.

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the bevelled margins of the bone window aided its repositioning in place on the sinus wall. Few drops of cyanacrilate-based surgical glue (Glubran2, Gem, Lucca, Italy) helped to achieve its firm stabilization (Fig. 8, 9). The flap was then sutured (Vicryl 3-0; Ethicon Inc, Somerville, NJ). The patient was dismissed with a prescription of antibiotics (Rocefin, Roche, Milan, Italy) and analgesics (Toradol, Recordati, Milan, Italy). He was also instructed not to blow his nose. After two weeks the patient was reviewed and sutures removed.

The wound healing was uneventful.

The overall procedure was well tolerated by the patient, who reported only little postoperative swelling and minor discomfort.

A six-month healing period was allowed before performing abutment surgery. The patient received a cemented single crown. Radiographic examinations (Fig. 10, 11) were made after three months of healing and after one year of loading, when patient follow up and clinical examinations were performed.

The intraoral periapical x-rays were taken with the aid of a film holder. At the one-year follow-up it was also recorded the absence of pain, discomfort or infection associated with the implant. The sinus bone regeneration after one year of loading, calculated from the baseline value measured at surgery, was 7 mm (mean bone regeneration obtained at the mesial and distal implant aspects).

Case report

Discussion Implant placement in combination with sinus membrane elevation technique without additional biomaterials has been recently presented as an effective alternative when bone is insufficient for implant support in the posterior maxilla (2, 3, 4). Actually, it has been recently proven that the Schneiderian membrane contains osteoprogenitor cells and is associated with a genuine ostogenic potential that might sustain bone formation in the absence of any ostoconductive material (12). The technique seems particularly appealing because it is relatively simple, little invasive, has low complication risks and requires a relatively short healing time.

Here it is reported the one-year outcome of an implant that was placed according to the abovementioned surgical technique. No complication occurred and a satisfactory stability resulted after the one-year loading period. These data are in accordance with the outcomes already reported in the available clinical literature concerning the technique (2, 3, 6-9).

Another interesting finding comes from the radiographical analysis. A mean of 7 mm of bone regeneration around the implant threads was obtained. In agreement with this finding, Thor and co-workers (7) reported similar regeneration when using TiO Blast Astra Tech implants in combination with sinus membrane elevation as done in this study. In fact, they obtained 6,5 mm of regenerated bone with a greater bone gain at most resorbed sites (2 to 5,5 mm of residual crestal bone). It is also interesting to note that the bone gain around the implant (7 mm) was lower than the mean lifting height obtained after surgery (9 mm) with the implant apex that was left uncovered by the regenerated bone. The reason for the incomplete ossification of the coagulum space seems to be that implants do not provide a lifting action sufficient to completely resist the intrasinus air pressure. As a result, a partial collapse of the membrane and a consequent decrease of the

amount of regenerated bone are unavoidable. The instability of the newly formed bone after elevation of the sinus membrane was already described in a rabbit model (13).

The pressure caused by respiration was thought to be the cause of resorption of the new-formed bone during the first six weeks after surgery. After six weeks the shrinking process stopped and after ten a new cortical border reformed under the elevated membrane (13). Similar results were described in other animal studies where new bone formation occurred up to the midthird portion of the implants while the membrane alone was covering the apical portion (5, 14). On the other hand it is sometimes a normal finding that a root protrudes into the maxillary sinus (15) and consequently it could be possible that the same situation is recreated around a dental implant placed with this technique.

It seems that more studies will be necessary to clarify what is the amount of bone required around an implant placed in a grafted sinus to obtain its long-term success.

With regard to the evaluation of bone regeneration, it has also to be noted that intraoral radiography is not able to provide comprehensive data on bone regeneration, nevertheless tomography scans were not performed for ethical reasons.

In any case, the new bone formation here obtained was enough to guarantee stability to the implant during the first year of loading. This is particularly interesting because implant substitution of missing maxillary single molars is a demanding procedure from the functional point of view that in the literature shows somewhat lower success compared to restoration supported by multiple implants (10, 11). The relative simplicity of this surgical technique should be regarded as positive when it comes to managing the challenge posed by the substitution of a missing maxillary molar in presence of a pneumatised sinus.

A final aspect to consider is the surgical management of the mucosal membrane. Dissecting the membrane is a delicate phase of the technique; it has been shown experimentally that when accomplished successfully there are no

variations in the physiology of the sinus ostium and mucosa (12). Unfortunately very thin, easy to tear membranes are sometimes found; as a consequence lacerations have been described in the previous literature (2, 7). Possible strategies in these cases might be suturing of the membrane (2, 7), periostal grafts (7), use of surgical glues (16) or biomaterials, however the best approach for perforation repair has still to be established. In the present case no perforation occurred, however it has been nicely suggested that, with the investigated surgical technique, tearing of the membrane seems not to be catastrophic as long as an isolated compartment around the implants can be created, for instance by suturing the membrane (16). If the repair is not accomplished, bone regeneration will be most likely minimal (16). In fact, it has been observed in animal studies (12, 17) that when implants perforate the membrane and protrude inside the sinus, the membrane adheres to a more cervical portion of the implant while sinus health and osseointegration in the residual bone are not jeopardized. Therefore it could be speculated that the present technique is somewhat safer also in cases of poorly managed perforations.

One last technical-related remark is about the use of a surgical glue to stabilise the bone window once replaced at the end of the procedure (8). Its use is probably unnecessary from a strictly regenerative point of view, as previous publications that relied only on the effect of the colagulum for stabilizing the window, showed similar results (2, 3, 7). However, the glue, being no harmful, seems helpful in firmly and rapidly stabilizing the bony window after its replacement, therefore guaranteeing its immobility during flap repositioning and suturing. This could be an advantage especially when the stability of the window once back in place is not excellent because the osteotomies are not neatly angled and therefore its margins are little bevelled.

One limitation to the application of the technique is finding adequate primary stability for the implants in the residual bone. A carefully

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Balleri P. and Veltri M: adapted surgical technique with use of thinner drills than the implant diameter has therefore been recommended in previous reports on this technique (3, 7). By following this recommendation it was feasible to successfully apply the membrane elevation technique also in cases where preoperative bone volumes were much less than in the case here presented (7).

In conclusion, this case confirms that placement of dental implants in combination with membrane elevation could be beneficial when a sinus lifting is required. A satisfactory outcome can be obtained without extra costs for biomaterial or morbidity for autologous bone harvesting. Also the new bone formation occurs contemporary to osseointegration therefore keeping the overall treatment time short.

All in all, the technique appears worthy of further investigations about its long term outcomes, such assessment is presently underway.

References 1. Esposito M, Grusovin MG, Kwan S, Worthington HV, Coulthard P. Interventions for replacing missing teeth: bone augmentation techniques for dental implant treatment.

Cochrane Database of Systematic Reviews 2008 16: CD003607.

2. Lundgren S, Andersson S, Sennerby L. Spontaneous bone formation in the maxillary sinus after removal of a cyst: coincidental or expected reaction? Clin Implant Dent Rel Res 2003; 5: 78-81.

3. Lundgren S, Andersson S, Gualini F, Sennerby L. Bone reformation with sinus membrane elevation: a new surgical technique for maxillary sinus floor augmentation. Clin Implant Dent Rel Res 2004; 6: 165-73.

4. Lundgren S, Cricchio G, Palma VC, Salata LA, Sennerby L. Sinus membrane elevation and simultaneous insertion of dental implants: a new surgical technique in maxillary sinus floor augmentation.

Periodontol 2000 2008; 47: 193-

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205.

5. Palma VC, Magro-Filho O, de Oliveria JA, Lundgren S, Salata LA, Sennerby L. Bone reformation and implant integration following maxillary sinus membrane elevation: an experimental study in primates. Clin Implant Dent Rel Res 2006; 8: 1124.

6. Sul SH, Choi BH, Li J, Jeong SM, Xuan F. Histologic changes in the maxillary sinus membrane after sinus membrane elevation and the simultaneous insertion of dental implants without the use of grafting materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: e1-5.

7. Thor A, Sennerby L, Hirsch JM, Rasmusson L. Bone formation at the maxillary sinus floor following simultaneous elevation of the mucosal lining and implant install ation without graft material: An evaluation of 20 patients treated with 44 Astra Tech Implants. J Oral Maxillofac Surg 2007; 65: 64-72.

8. Hatano N, Sennerby L, Lundgren S. Maxillary sinus augmentation using sinus membrane elevation and peripheral venous blood for implantsupported rehabilitation of the atrophic posterior maxilla: case series. Clin Implant Dent Rel Res 2007; 9: 150–155.

9. Sani E, Veltri M, Cagidiaco MC, Balleri P, Ferrari M. Sinus membrane elevation in combination with placement of blasted implants: A 3year case report of sinus augmentation without grafting material. Int J Oral Maxillofac Surg 2008; 37: 966-9.

10. Becker W, Becker BE, Alsuwyed A, Al-Mubarak S. Long-term evaluation of 282 implants in maxillary and mandibular molar positions: a prospective study. J Periodontol.

1999 Aug;70(8):896-901.

11. Kim YK, Kim SG, Yun PY, Hwang JW, Son MK. Prognosis of single molar implants: a retrospective study. Int J Periodontics Restorative Dent. 2010 Aug;30(4):401-7.

12. Sul SH, Choi BH, Li J, Jeong SM, Xuan F. Effects of sinus membrane

elevation on bone formation around implants placed in the maxillary sinus cavity: an experimental study.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 684-7.

13. 14. Xu H, Shimizu Y, Ooya K. Histomorphometric study of the stability of newly formed bone after elevation of the floor of the maxillary sinus. Br J Oral Maxillofac Surg 2005; 43: 493-499.

14. Haas R, Haidvogl D, Donath K, Watzek G. Freeze-dried homogeneous and heterogeneous bone for sinus augmentation in sheep. Clin Oral Impl Res 2002; 13: 396–404.

15. Sharan A, Madjar D. Correlation between maxillary sinus floor topography and related root position of posterior teeth using panoramic and cross-sectional computed tomography imaging. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.

2006 Sep;102(3):375-81 16. Thor A. TiOblast and OsseoSpeed implants in sinus lift surgery. Appl Osseointegration Res 2008; 7: 1725.

17. Jung JH, Choi BH, Zhu SJ, Lee SH, Huh JY, You TM, Lee HJ, Li J. The effects of exposing dental implants to the maxillary sinus cavity on sinus complications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102: 602-5.

Case report

Diode laser vaporization on unresponsive oral lichen planus: case followed for two years Massimiliano De Biase Gianpaolo Bombeccari Francesco Pallotti* Francesco Spadari

Department of Reconstructive and Diagnostic Surgical Sciences, IRCCS Hospital Ca’ Granda Foundation, Unit of Oral Pathology and Medicine University of Milan, Milan, Italy *Unit of Anatomical Pathology, IRCCS Hospital Ca’ Granda Foundation, University of Milan, Milan, Italy

Aim:

Oral Lichen planus (OLP) is a rather common chronic inflammatory mucocutaneous disease. Current trends classify OLP into 3 major clinical presentations: reticular/hyperkeratotic, erosive/erythematous, and ulcerative forms. The examination of histological features of the lesions is necessary to confirm the clinical OLP diagnosis.

Case report: In January 2009, a female patient displayed an asymptomatic plaque-like OLP form, with a small erosive area in the right buccal mucosa. The treatment with topical clobetasol propionate was not effective. The lesion evidenced a close relationship with the dental alloy of the restoration bridge, and the patient was patch test positive to palladium. After incisional biopsy we decided for excision of the lesion, under local anaesthesia, with 808 nm diode-laser set at 2 Watt in continuous wave (CW) in focalized modality. For complete excision of the plaque, one session of laser surgical therapy was required. After one year and 8 month, the follow-up controls showed no relapse.

Conclusion: Laser-therapy can be contemplated in palliative treatment of some OLP forms, especially in the plaque-like variant which is unresponsive to topical application of clobetasol propionate.

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Key words: Oral lichen planus Oral lichenoid lesions Diode laser Wound healing Oral surgery

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De Biase M. et al.

Introduction Oral Lichen Planus (OLP) is a chronic mucocutaneous disease of unknown causes. It is a relatively common clinical condition with an estimated prevalence in the general population ranging from 0.2% to 4% and the female-to-male ratio is about 2:1 (1). Patients with OLP frequently have concomitant diseases in one or more extra-oral sites. Approximately, 15% of OLP patients develop cutaneous lesions (2). OLP is a disease of middle age, since children and young people are rarely affected by it, although this disorder may develop at any age (3). As it is common to observe under manifold pathological conditions, the severity of the mucocutaneous lesions is commonly parallel to the patient level of stress (1).

It is generally considered to be an immunologically mediated process which microscopically resembles a hypersensitivity reaction. It is characterized by an intense T-cell infiltrate (CD4 and especially CD8 cells) localized to the epithelium-connective tissue interface. Other immune-regulating cells (macrophages, factor XIII a-positive dendrocytes, Langerhans cells) are seen in increased numbers in OLP tissues. The pathogenetic processes seems to develop in several steps: an initiating factor/event, focal release of regulatory cytokines, upregulation of vascular adhesion molecules (known as ELAM-1, ICAM-1, and VCAM-1), recruitment and retention of T cells and cytotoxicity of basal keratinocytes mediated by the T cells. Some of the cytokines believed to be responsible for the up-regulated adhesion molecules are tumor necrosis factor (TNF-a), interleukin-1 and interferon-a (3).

OLP is characterized by a chronic remitting and relapsing course with mild tendency at spontaneous remission and the diagnosis is based on a combination of characteristic clinical signs,

JOS VOL.1 N.3 2010

medical history and histopathological findings (1,2).

Patients with OLP have a variety of clinical presentations in one or more extra oral sites and OLP is frequently associated with systemic diseases such as hypertension, diabetes mellitus, systemic lupus erythematous and psychogenic factors (3). Hepatitis C Virus (HCV) infection has also been associated with the development of OLP (4). Concomitant cutaneous involvement occurs in 15% of cases, while involvement of the scalp, nails, esophagus and eyes occurs much less frequently (5).

OLP can be categorized into several clinical variants. Current trends classify (Eisen, 2002) OLP into 3 major clinical presentations: reti cular/hyperkeratotic (white-OLP), erosive-erythematous, and ulcerative forms (red-OLP).(5) The hyperkeratotic form with reticular pattern, characterized

by Wickham’s striae, is the most common form and is often asymptomatic. Typically the Wickham’s striae are bilateral with spread white lesions.

The erosive-erythematous form causes a continuous local discomfort with pain symptomatology, which is exacerbated with the assumption of food or drinks.

The ulcerative form is always painful and presents as shallow ulcerations that have a yellow fibrin clot on the surface (sometimes referred to as a pseudomembrane). Often, mixed clinical forms with combinations of reticular-hyperkeratotic, erosiveerythematous, and ulcerative lesions occur at different sites, or at different times so as the disease evolves and resolves (2, 3).

Other conditions may, however, present similar histopathological findings as the one of OLP. We can include local lichenoid reactions, oral lesions of systemic lupus erythematosus, hyperkeratosis with oral leukoplakia, erythro-leukoplakia and proliferative verrucous leukoplakia (6). The possibility of malignant transformation has been raised. At present, OLP is categorized as a potentially precancerous disorder (7).

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Corticosteroids are considered the most effective agents in the treatment of OLP, and topical corticosteroids have been preferred to systemic ones, except for refractory cases and systemic conditions (8).

Topical corticosteroids, when applied for short duration, are safe, but the prolonged use can produce side effects such as secondary candidiasis and, although rarely, atrophy and smarting sensation of the oral mucosae (9).

The aim of the present work is to report a case of a plaque-like OLP of the cheek mucosa, treated with a 808 nm Diode Laser (Doctor Smile ®D5, Lambda Scientifica, Italy).

Materials and Methods In April 2005, a 64 year-old woman was referred to our unit of Pathology and Medicine of Dental University Institute, IRCCS Hospital - Cà Granda Foundation of Milan.

The oral examination evidenced reticular lesions present as white lines and papules, characterized

by Wickham's striae on the buccal mucosae, and a papular form on the dorsum of the tongue. Her medical history was no-contributory. She had never used any tobacco nor alcohol and there was no history of local trauma. The patient did not report any pharmacological therapy, except for an occasional use of anti-inflammatory drugs for skeletal, articular and muscle pains. The initial treatment consisted of topical applications of clobetasol propionate with significant reduction of the oral lesions and local symptomatology.

After fifteen days of pharmacological treatment with local steroids, the papular lesions had regressed and the oral mucosa appeared completely normalized and restored. Insofar, the patient has clinically been followed at semestral controls and has never manifested partic-

Case report

FIG. 1

Clinical evidence of the plaque-like OLP lesion on the right buccal mucosa, in the area near the metal restoration.

FIG. 2

Microscopic particular of hyper-parakeratosis and hypertrophic granular layer OLP-associated. Signs of colliquative degeneration of the basal layer. Original magnification 40X, Hemathoxylin&Eosin stain.

FIG. 3

Presence of well-defined band-like zone of cellular infiltration (mainly lymphocytes), confined to the superficial part of the connective tissue.

Original magnification 10X, Hemathoxylin&Eosin stain.

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ularly suspicious oral lesions.

At the time of the clinical inspection in January 2009, the patient showed an oral lesion on the right buccal mucosa, compatible with plaque-like OLP. In the lesional area, an ulcerative and erosive lesion was observed (Fig. 1). Moreover, further oral examination revealed an atrophy of both the oral mucosae and dorsum of the tongue, secondary to chronic erythematous and atrophic oral candidiasis.

No cutaneous signs of OLP were present at time of the clinical examination.

The lesion was localized in close opposition to the dental metal restoration. The patient showed patch testing positivity to palladium (palladium chloride 2% in petrolatum), but she was not able to clear up if such metal was present in the dental alloy of her prosthetic bridge.

The treatment with topical applications of clobetasol propionate was not successful. Subsequently, an incisional biopsy was performed on her right buccal mucosa. The surgically removed specimen was fixed in 10% buffered formalin. The sections were stained with Haematoxylin and Eosin.

The histological examination revealed hyper-parakeratosis with a band-like lymphocytic T-cell inflammatory infiltrate present in the papillary lamina propria and with the absence of malignant changes and signs of degeneration due to liquefaction in basal cell layers (Fig. 2, 3).

After the histological examination, due to the fact that the patient was not prone to remove the restoration any time soon, the excision of the lesions, was performed under local anaesthesia, by the 808 nm diode-laser set at 2 Watt in continuous wave (CW) in focalized modality.

In order to get the complete excision of the lesion, one session of laser surgical therapy was required. The fiber used for the treatment was 300 m in diameter.

Post-surgical observation of the wound healing was performed one and two weeks later (Fig. 4,

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De Biase M. et al.

FIG. 4

Lesional area after the diode laser vaporization.

5, 6). Follow-up visits showed no relapse after one year and eight months (Fig. 7).

Discussion

FIG. 5

The same area one week after the surgical laser treatment.

FIG. 6

The wound healing at postsurgical examination on the second week.

FIG. 7

Clinical objectivity of the lesion: until the last follow up no evidence of relapse was detected.

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The primary advantages of the 808 nm diode laser treatments include prompt hemostasis, wound sterilization and the healing process is usually faster and less painful compared to conventional surgery techniques (10).

This kind of minimally-invasive surgery reduces relapses and improves post-surgical compliance in the healing process, thus also improving patient’s comfort in the post-surgical period (11). However, laser therapies do not involve healing (i.e. do not contribute to the healing) the clinical status in the patient affected by OLP. In fact, the basal cell damage mechanism appears to be related to a cellmediate immune process involving Langherans cells, T lymphocytes (T8) and macrophages.

It is hypothesized that Langherans and the keratinocytes cells could get in contact with an antigen, possibly of microbiologic (supposedly HCV), pharmacologic, or allogenic origin (2).

Several authors consider the contact allergy to dental amalgam as a potential cause of OLP (12), whereas others claim the existence of two separate diseases: oral lichenoid lesions (OLL) and OLP (13). The clinical manifestations and histopathological changes of lichenoid lesions and those for OLP can be similar.

Oral lichenoid contact lesions (OLCL) as a result of allergic contact stomatitis (delayed T-cell-immune mediated hypersensitivity) are seen in direct topographic relationship with dental restorative materials, most commonly amalgam, or other metallic agents (14).

The released mercury (and other metallic elements of the dental restoration) is reported as being taken up by oral soft tissues and, in some patients, causing local toxicity or/and allergic ef-

Case report fects such as oral lichenoid reactions (OLLs). Since OLLs are considered to be premalignant in the same way as OLP, a long standing status of the lesions gravity and the permanence of the putative etiologic factor could worsen the morbidity of this condition (15).

It is important to consider the possibility of the surgical treatment in hyper-keratotic lesions with atrophic areas with or without dysplastic changes or in local complications of OLP (1618).

Our surgical approach was justified because of the patient’s refusal to change the prosthetic material. In fact, the removal and replacement of the dental metal restoration is a costly and time-consuming procedure and not always of immediate realization.

However, although the case described has shown satisfactory results, we can highlight that laser therapy does not interfere with any ameliorative effect in the etio-pathogenetic course of OLP. The majority of authors report that laser therapy accelerates the process of the tissue repair, but further studies are suggested to determine the best parameters to be used (19).

Some authors have preliminarily tested the effect of diode laser irradiations on unresponsive OLP patients, supporting a step forward for the enhanced management of this quite common condition.(20) The case here reported suggest that the diode laser-therapy can represent a possible therapeutic preventive option in the treatment of OLP-plaque-like variant, which is unresponsive to corticosteroid therapy although such outcome reflects a palliative meaning.

In theory this holds true when the particular situations, as those related to the present OLP case, restrict the field of the therapeutic action even further.

Additional researches associated with a wider cases spectrum about the clinical application of the diode laser in the OLP environment are needed, in order to

define the predictivity of the therapeutic benefit.

To this aim, we are going to collect prospective data of future OLP cases in order to find more evidence and thus sustain the reliability of our preliminary findings.

References

8. The Cochrane Database of Systematic Review Chan ES, Thornhill M, Zakrzewska J: Intervention for treating oral lichen planus. The Cochrane Library 2005, Vol. 1 9. Lodi G, Tarozzi M, Sardella A et al: Miconazole as adjuvant therapy for oral lichen planus: a double-blind randomized controlled clinical trial.

Br J Dermatol 2007;156:1336-41

2. Scully C, Beyli M, Ferreiro MC, Ficarra G, Gill Y, Griffiths M, et al.

Update on oral lichen planus: etiopathogenesis and management. Crit Rev Oral Biol Med 1998;9(1):86-122.

10. Capodiferro S, Maiorano E, Loiudice AM, Scarpelli F, Favia G. Oral laser surgical pathology: a preliminary study on the clinical advantages of diode laser and on the histopathological features of specimens evaluated by conventional and confocal laser scanning microscopy. Minerva Stomatol. 2008 Jan-Feb;57(12):1-6, 6-7.

3. Eisen D, Carrozzo M, Bagan Sebastian J-V, Thongprasom K. Mucosal disease series Number V: Oral lichen planus: clinical features and management. Oral Disease 2005;11:338-349

11. Romanos G, Nentwig GH. Diode laser (980 nm) in oral and maxillofacial surgical procedures: clinical observations based on clinical applications. J Clin Laser Med Surg. 1999 Oct;17(5):193-7.

4. Nagao Y, Sata M, Noguchi S, Seno’o T, Kinoshita M, Kameyama T, et al. Detection of hepatitis C virus RNA in oral lichen planus and oral cancer tissues. J Oral Pathol Med 2000;29:259–266

12. Laijendacher R, Dekker K,S, Burger M. P, Mulder H.P.G, Van Joost T, Neumann H.A M. Oral lichen planus and allergy to dental amalgam restoration.

Arch Dermatol. 2004; 140:1434-1438

5. Eisen D. The clinical features, malignant potential, and systemic association of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;2:207-214

13. van der Meij EH, Schepman KP, van der Waal I. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96(2):16471.

1. Axéll T, Rundquist L. Oral lichen planus - a demographic study.

Community Dent Oral Epidemiol 1987;15(1):52-6.

6. Lodi G, Scully C, Carrozzo M, Griffiths M, Sugerman PB, Thonprasom K. Current controversies in oral lichen planus: report of an international meeting: Part 2. Clinical management and malignant transformation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100(2):16478 7. van der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management.

Oral Oncol 2009;45(4-5):317-23.

14. Laine J, Konttinen Y.T, Belaiev N, Happonen R-P. Immunocompetent cells in amalgam-associated oral lichenoid contact lesions. J Oral Pathol Med 1999,28(3):117-121 15. van der Meij EH, Mast H, van der Waal I. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective five-year follow-up study of 192 patients. Oral Oncol 2007;43(8):742-8.

16. Horch HH, Gerlach KL, Schaefer

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HE. CO2 laser surgery of oral premalignant lesions. Int J Oral Maxillofac Surg 1986;15:19-24 17. Vedtofte P, Holmstrup P, HjortingHansen E, Pindborg JJ. Surgical treatment of premalignant lesions of the oral mucosa. Int J Oral Maxillofac Surg 1987;16:656-664 18. KoK TC, Ong ST. The effects of CO2 laser on oral lichen planus and oral lichenoid lesions. Annal Dent Univ Malaya 2001;8:35-42 19. Da Silva JP, Da Silva MA, Almeida AP, Lombardi Junior I, Matos AP. Laser therapy in the tissue repair process: a literature review.

Photomed Laser Surg. 2010 Feb;28(1):17-21.

20. Cafaro A, Albanese G, Arduino PG, Mario C, Massolini G, Mozzati M, Broccoletti R. Effect of low-level laser irradiation on unresponsive oral lichen planus: early preliminary results in 13 patients.

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Case report

Immediate adjacent implants in the aesthetic area: a case report Sergio Cremonesi* Francesco Bett** Marco Benigni** Carlo Maiorana***

University of Milan, School of Dentistry Dental Clinic Ospedale Maggiore IRCCS CĂ Granda Milan Director: Prof. Franco Santoro *Specialist in Oral Surgery **Department of Implantology ***Professor and Chairman, Oral Surgery and Implantology

Background: The success of implant therapy in the anterior maxilla is determined not only by the achievement of osseointegration, but also by the presence of sound and stable peri-implant tissues. The achievement of predictable peri-implant esthetics requires proper preservation of bone and soft tissues around the failing teeth, proper 3-D implant placement and proper understanding of the prosthetic management. Nowadays it is possible to perform immediate implants and immediate prostheses to improve esthetics and to simplify the treatment.

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Key words: Immediate implant placement Flapless surgery Full ceramic restoration

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Introduction In the last few decades, implant supported restorations have become a valid option for the treatment of partial or total edentoulism, thanks to the improvement of both the materials used and the clinical procedures. Along with these improvements, the requests of the patients are changing: in the past, in most cases, edentulous ridges were restored after a long healing period, both before and after implant placement. Now patients tend to prefer the immediate restoration of a tooth that has to be extracted.

The simplification of the treatment plan, with the reduction of the number of operative steps, represents a real challenge for the clinician in terms of selection of the cases and surgical-prosthetical skills. Immediately restored post-extractive implants offer an important option for the treatment of patients with high aesthetic requests and expectations, especially when frontal sites are involved.

The long term success of this particular type of restoration depends on the respect of the biological width, the creation of a good transmucosal connection between the implant and the peri-implant tissues and the absence of inflammation of the peri-implant mucosa (1,2).

FIG. 2

Pre-operative clinical view. The central and lateral left incisors have to be extracted.

FIG. 1

Pre-operative radiograph.

FIG. 3

Clinical situation at the end of the extrusion.

FIG. 4a, 4b

Fresh alveolar sockets, buccal and occlusal views.

Materials and Methods A 50-years-old male patient presented with hopeless left upper incisors (Fig. 1, 2). Before extracting the teeth it was decided to apply an orthodontic extrusion force on the roots to lead to a more favorable outcome. Dental removal by extrusion involves applying traction to all regions of the periodontal ligament to stimulate marginal apposition of the crestal bone. The gingiva follows the vertical movement, and the amount of keratinized tissue is increased through eversion of the sulcular

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FIG. 5

Occlusal view of the sites 21 and 22 after the installation of the implants placed without flap elevation.

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FIG. 6

Temporary abutments screwed on implants.

FIG. 7

Immediate provisional restorations relined on the abutments and screwed on implants.

FIG. 9

Definitive zirconium abutments and alumina cores.

FIG. 8

Post-operative radiograph.

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epithelium, appearing first as immature unkeratinized tissue and then as keratinized tissue (3-6).

After a period of six months, when the position of the soft tissues was acceptable (Fig. 3) the extractions of teeth 21 and 22 were performed and two post-extractive implants inserted. Antibiotic prophylaxis was prescribed with Amoxicillin 2g per os 1 hour prior to the surgery; after a mouthwash with clorexidine 0,2% for 1 minute, local anesthesia was obtained by injecting Ecocain® with adrenaline 1:50000 (Moltenidental srl, Scandicci, Italy) (Fig. 4a, 4b). After having extracted the teeth, the alveolar bone was explored by means of a periodontal probe to assess its integrity and to establish the implant diameter.

The implants (Certain® Prevail®, BIOMET 3i Inc., Palm Beach Gardens, FL Usa) were inserted 3 mm apical to the free gingival margin with a proper 3-D placement (Fig. 5). Two individual screwed provisional crowns were relined with acrylic resin (Yates & Bird / Motloid, Chicago, IL USA) to the switched platform temporary abutments. After the resin polymerization the provisional crowns were removed and resin was added to fill the gap between the crowns and the abutments, and then the provisional was finished and its transmucosal part was shaped with a concave design, more pronounced in the buccal side than in the palate and in the interproximal ones (Fig. 6-8). The provisional was manually screwed, maintaining it stable with two fingers so to not transmit any force to the implants. Finally, the accessing holes to the screws were filled with Fermit-N® (Ivoclar-Vivadent AG, Schaan, Liechtenstein). The occlusion was checked and both the contacts in centric relation and in protrusive/lateral movements were removed. The patient kept the provisional for 12 months and then an impression, according to Hinds’ method was made (7). Two zirconium custom made abutments with a switched platform were manufactured and screwed to the implants at 30 Ncm of torque; two definitive alumina crowns were then cemented on them (Fig. 912).

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FIG. 10a, 10b

Buccal and occlusal view of the soft perimplant tissue.

FIG. 11a, 11b

Full-ceramic restorations cemented.

FIG. 12

Discussion Many parameters, such as the quantity of keratinized mucosa, the thickness and height of buccal bone, the 3-D position of the implant and the shape of transmucosal implant components can influence the soft tissue interface and mucosal recession (8). The literature reports that with immediate implants and temporary prosthesis it can be more simple to maintain papillae, but a stable long term buccal mucosa is not so predictable; on the contrary, a delayed implant insertion allows to have more control of the facial tissues, but less predictability on the presence of papillae (9-11).

Flapless surgery, both for extraction and implant insertion, showed some advantages such as treatment time reduction, tissue contour preservation and patient and dentist satisfaction.

In this case the final aesthetic outcome was very satisfactory, and in contrast with the existing data, the present sites showed buccal soft tissue stability and not recessions after two years followup. The good result obtained could be due: to the increase of the keratinized tissue before surgery, the atraumatic extraction of the compromised teeth, the correct surgical planning and the skilled intra-operative management (3-D implant position), the switched platform implant-abutment connection and the accurate prosthetic management.

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