clinical articles • management advice • practice profiles • technology reviews January/February 2014 – Vol 7 No 1
F I L L
PROMOTING EXCELLENCE IN IMPLANTOLOGY
T H E D E F E C T.
Dr. Cary A. Shapoff
A chemotherapy patient’s experience with dental implants Dr. Bryan R. Krey and Dr. Richard G. Dong
PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!
Verified osteoinductive allograft putty for dental implant regeneration Dr. John Lupovici
D E F E C T !
Tackling a challenging esthetic clinical situation
Drs. Peter Fairbairn and Sharon Stern
E N T I R E
DIO
Multi-disciplinary approach to the treatment of traumatic root fracture
T H E
Corporate profile
White Box covering the left side bleed should be removed.
Practice profile Dr. Louis Kaufman
Learn how to easily prevent particle migration using expandable NuOss® XC Socket and NuOss® XC Sinus. For details see page 49
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EDITORIAL ADVISORS Steve Barter BDS, MSurgDent RCS Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS, MsurgDent Philip Bennett BDS, LDS RCS, FICOI Stephen Byfield BDS, MFGDP, FICD Sanjay Chopra BDS Andrew Dawood BDS, MSc, MRD RCS Professor Nikolaos Donos DDS, MS, PhD Abid Faqir BDS, MFDS RCS, MSc (MedSci) Koray Feran BDS, MSC, LDS RCS, FDS RCS Philip Freiburger BDS, MFGDP (UK) Jeffrey Ganeles, DMD, FACD Mark Hamburger BDS, BChD Mark Haswell BDS, MSc Gareth Jenkins BDS, FDS RCS, MScD Stephen Jones BDS, MSc, MGDS RCS, MRD RCS Gregori M. Kurtzman, DDS Jonathan Lack DDS, CertPerio, FCDS Samuel Lee, DDS David Little DDS Andrew Moore BDS, Dip Imp Dent RCS Ara Nazarian DDS Ken Nicholson BDS, MSc Michael R. Norton BDS, FDS RCS(ed) Rob Oretti BDS, MGDS RCS Christopher Orr BDS, BSc Fazeela Khan-Osborne BDS, LDS RCS, BSc, MSc Jay B. Reznick DMD, MD Nigel Saynor BDS Malcolm Schaller BDS Ashok Sethi BDS, DGDP, MGDS RCS, DUI Harry Shiers BDS, MSc, MGDS, MFDS Harris Sidelsky BDS, LDS RCS, MSc Paul Tipton BDS, MSc, DGDP(UK) Clive Waterman BDS, MDc, DGDP (UK) Peter Young BDS, PhD Brian T. Young DDS, MS CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon
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New technologies in the advancement of implant dentistry
W
hen I think about advancements in implant dentistry that have most influenced my practice, I think about three things: 3D imaging, sinus grafting techniques, and guided bone regeneration (GBR) procedures. When I opened my practice 11 years ago, I was trying to decide if I should implement digital imaging or continue with film. Today, I have a three-dimensional image of my patient’s maxilla and mandible before I’ve even introduced myself. It has provided us with the ability to accurately know the position of nerves, sinuses, and that sneaky osseous defect that can be lingering buccal to our osteotomy. Because of this information, flap designs have become minimally invasive and far less painful for our patients. Case acceptance has increased, providing patients a more thorough understanding of their treatment. 3D imaging has made the next advancement, sinus grafting, so predictable that we now even can see the exact thickness of the wall we need to drill through to access the sinus. Sinus grafting itself hasn’t changed. It is still a surgical procedure aiming to increase the amount of bone in the posterior maxilla by sacrificing the volume of the maxillary sinus. Thus, increasing our ability to place dental implants using fixed restorations on more patients. Although the outcome is the same, the methods have changed drastically. The Piezosurgery® unit allows us to cut bone without harming soft tissue. We can now predictably free up the Schneiderian membrane. There are drill kits akin to those used in neurosurgery, developed to allow surgeons to cut through the skull without harming the underlying dura mater. This same technology is now in place with the direct sinus procedure. Similar drills are used in order to avoid perforating the membrane of the sinus. When evaluating bone grafting techniques, the criteria must be predictability and ease of use. I find it fascinating that cow bone, which has been popular for ages, is now mixed within a collagen matrix to allow for precise placement, minimal migration, and enhanced bone growth at the site. The same Piezo unit spoken about with sinus grafting can be used for minimal heating of bone for a sagittal split with ridge-splitting techniques. This technique, when used in the right situation, can result in some of the most predictable gain in bone volume. The highly porous collagen structure allows for quicker turnover to bone via a highly formulated matrix. You can actually put bone where you want it; it stays, and it grows. There are now bone grafts used that have signals to form bone — bone morphogenic protein (BMP) — calling in stem cells to allow for quicker, more predictable bone formation. My practice has always been focused on patient comfort, and these advancements in 3D imaging have allowed for the most minimally invasive flap procedures, the most predictable bone placement, and in turn, significantly decreased pain and down time for my patients. Ryan Taylor, DDS, MS Dr. Taylor established his practice in Periodontics and Implant Dentistry in Sarasota, Florida, in 2004. He is an active member in the American Academy of Periodontology, American Academy of Implant Dentistry, the Academy of Osseointegration, and the Academy of Oral Implantology. He is also a member of the American Dental Association, Florida Dental Association, West Coast District Dental Association, and Sarasota County Dental Association.
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Volume 7 Number 1
Implant practice 1
INTRODUCTION
January/February 2014 - Volume 7 Number 1
TABLE OF CONTENTS
Case study Tackling a challenging esthetic
Practice profile
6
Dr. Louis Kaufman: Continuing a legacy
clinical situation Dr. Cary A. Shapoff illustrates a case replacing two adjacent maxillary central incisors ........................... 14
This clinician is driven by inspiration, a great team, and desire for knowledge.
Patient insight A chemotherapy patient’s experience with dental implants Dr. Bryan R. Krey and retired engineer Dr. Richard G. Dong join forces to facilitate implant placement during cancer treatment ............. 18
ON THE COVER Cover photo courtesy of Dr. John Lupovici. Article begins on page 42.
Corporate profile
9
DIO Corporation Promoting happiness and healthy lifestyles
2 Implant practice
Volume 7 Number 1
TABLE OF CONTENTS
38 Continuing education Multi-disciplinary approach to the treatment of traumatic root fracture: a case study Drs. Peter Fairbairn and Sharon Stern present a multi-disciplinary approach to tackling a tricky trauma case.....25 Management of biological and biomechanical implant complications Drs. Yung-Ting Hsu and HomLay Wang summarize and reveal management protocols for implant complications ...............................32
4 Implant practice
Advanced technologies
Technology
Product profile
Advanced technologies and materials to efficiently deliver full
NuOss速 XC bone grafting composite ..................................49
mouth reconstructions Dr. Ara Nazarian suggests a treatment solution that results in more control
On the horizon
and fewer appointments ...............38 Verified osteoinductive allograft putty for dental implant regeneration: preliminary findings of three clinical applications Dr. John Lupovici illustrates clinical cases using RegenerOss速 Allograft Putty to regenerate three distinct osseous defects ...........................42
I want my teeth yesterday! Dr. Justin Moody discusses a timesaving technology in a fast-paced world.............................................50
Materials & equipment .....................54 Diary .....................................56
Volume 7 Number 1
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PRACTICE PROFILE
Dr. Louis Kaufman Continuing a legacy What can you tell us about your background? I was born into a dental family. I graduated from the University of Illinois College of Dentistry, and in 1995, joined my father Richard’s well-established 50-year-old general dentistry practice treating thirdand fourth-generation patients. Besides my clinical experience, I have a diverse business background. I earned an MBA from the Computer Science Executive Management Program at DePaul University and a BA in Marketing and Economics from Kendall College in Evanston, Illinois. Prior to attending dental school, I worked in management at Pillsbury Corporation as a specialist in point-of-service site development and restaurant management for 5 years. The skill set that I developed in corporate management has helped me grow my Hyde Park (Chicago) private practice into a multimillion dollar business focused on comprehensive oral healthcare and cosmetic smile design. I serve on the advisory board of numerous dental manufacturers, consult on product development, and am honored to educate clinicians around the globe at approximately 20 continuing education programs annually. I also have published numerous articles focused on restorative and cosmetic dentistry.
Is your practice implants?
limited
to
restoring and treatment planning implants, and recently completed my training in the surgical placement of implants.
What is the most satisfying aspect of your practice? The greatest satisfaction is giving patients back the ability to function and re-create their smile.
Professionally, what are you most proud of? I am proud of how as a profession we stand together on so many fronts. We have dentists who lobby and legislate for those on the front lines providing care to patients. There is a “we” mentality versus an “I” mentality. I couldn’t imagine a better career. Coming from corporate America years ago, to being a true entrepreneur with guidance and backing all around is incredible.
Who has inspired you? I believe inspiration comes from within or the desire to learn and do more. I am lucky my father was a practicing dentist for more than 60
No.
years. He always stayed up
Why did you decide to focus on implantology?
to date on techniques and
I have been restoring implants since graduating dental school.
procedures. I was fortunate
How long have you been practicing, and what systems do you use?
The dental community has
Biomet 3i™, Noble Biocare®, BioHorizons®, Astra Tech Implant System™, and Straumann®.
to have a strong role model. many amazing specialists and general dentists whom I learn from by reading and reviewing journals.
What do you think is unique about your practice? Without a doubt, it’s location. If you have never been to Hyde Park (a neighborhood in Chicago), then it’s worth the trip. It is a microcosm of the world. So many nationalities and economic strata exist. Another unique aspect is that we have been a part of the community for 60-plus years. We provide care to fifth-generation patients.
What has been your biggest challenge? The biggest challenge right now is space. I am in an old building, and our suites are not designed for sit-down dentistry. I ask myself how my dad did it for so long. At the present time, I am 2½ years out for my lease. I am getting quotes on gutting the existing space or moving to a different floor so we can continue to operate until it’s time to move. Having stayed on top of technology, I am finding we are running out of space.
you
What would you have become if you had not become a dentist?
I have taken numerous courses on
Great question. I would have wanted to become a thoracic surgeon but did not
What training undertaken?
6 Implant practice
have
Volume 7 Number 1
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PRACTICE PROFILE
Dr. Kaufman’s dog, Max
Dr. Kaufman’s team Dr. Kaufman with his children, Rachel and Jacob
want to be finishing up in my forties. I already changed careers to go into either medicine or dentistry. After my research of both, I decided on the dental career path because at age 27 I would not have finished a medical-surgical path until around 40 years old.
What is the future of implants and dentistry? The future of implants in dentistry is continually growing. We have so many dentists who are not restoring or placing implants. My goal this year was to take an implant surgical course to place implants, and I will only do the straightforward cases. Everything else goes to the oral surgeon or periodontist. I strongly believe that the use of surgical guides will become the standard of care in the placement of the implant.
What are your top tips for maintaining a successful practice? The key ingredient is to be engaged and to surround myself with a great team of people. We have to continually motivate, educate, and appreciate our team members. I am a big believer in educating my team. I try to teach something new to as many people as possible. I try to learn something new from somebody every day. The other key is to make sure you give your
8 Implant practice
patients the time they deserve. Become interested in them as people. There are so many pearls. The bottom line is that we are in a “people business,” and we have to have a team that works great with the public. Also, don’t be afraid to fire a team member that just won’t perform to the levels that the business demands.
What advice would you give to budding implantologists? Take lots of continuing-education courses. Get educated on the restorative side and the surgical side of implants. Treatment planning from the functional restorative side is key for long-term success.
What are your hobbies, and what do you do in your spare time? I like to spend my spare time with my teenage kids. It’s not a lot of time, but I take what I can get. I like to read fiction and enjoy going to the movies. I recently rescued a dog, and we take a lot of walks. I go to the gym regularly. Our profession is physically and mentally demanding, so I have become a big believer in eating right and being on a fitness program. I also like taking my bike out for rides. The rest of my time is spent preparing for upcoming lectures that I am presenting. IP
Top Ten Favorites 1. Planmeca ProMax® 3D — the coolest piece of technology. I am constantly learning with this technology. 2. The technology called NuCalm™. Everybody should have it. 3. Chocolate Chip Banana Blizzard from Dairy Queen. 4. Must have music playing in the office. I am old school rock-androll with some of the new. 5. I like to try new restaurants. 6. Deep-fried Oreos with vanilla ice cream. If I go to Las Vegas, I go to Lava to have this. So much for nutrition. 7. I like new clothes and should not go into Nordstrom. 8. Taking my daughter clothes shopping. I get time to talk to her. 9. I love the game of basketball. Going to see the Chicago Bulls play is one of my greatest sources of entertainment. I understand the game but could never play it well. 10. I like pretending I have a bad cold/cough at the movie theater so nobody will sit in front of me, and I can put my feet up. :-)
Volume 7 Number 1
CORPORATE PROFILE
CORPORATE PROFILE
DIO Corporation Promoting happiness and healthy lifestyles
About the company We at DIO Corporation (Kosdaq:039840) are dedicated to promoting happiness and healthy lifestyles in over 70 countries around the world with investment in and development of state-of-the-art dental implant technologies and advanced digital dental solutions. To further enhance our efforts, the DIO Implant Academy was established to provide both practical and advanced dental education to our partner clinicians globally. DIO also organizes annual educational symposia that serves as a way for our partner clinicians to meet, exchange knowledge and collaborate with renowned scholars and practitioners in the dental implant field. DIO will lead the “Paradigm Shift in Dental Implants”
• So called “Premium” Implants → “Affordable, Value-Added” Implants • Traditional “Analog” Dentistry → “Digital Dental Solutions”
is in a strategic partnership with Dentsply International (NASDAQ: XRAY) by virtue of Dentsply being DIO’s largest shareholder. Dentsply is one of the largest global dental products companies in the world.
DIO has long term staying power. DIO
Volume 7 Number 1 Implant practice 1 9 Volume 7 Number
DIO Symposium at Las Vegas “Paradigm Shift in Implant Dentistry” will be held on May 10 - 11th, 2014 at the Mandalay Bay Resort and Casino. DIO Symposium Las Vegas 2014 will be an informative and educational event that will be a landmark event for our Company; and one that will not be forgotten.
PARADIGM SHIFTININIMPLANT IMPLANT DENTISTRY PRADIGM SHIFT DENTISTRY “Premium” Implants to “Affordable, Value Added” Implants Traditional “Analog” Dentistry to “Digital Dental Solutions”
We chose to organize our 2014 symposium in Las Vegas, which is an international destination for world-class entertainment, ultracool nightlife, renowned restaurants and luxury shopping venues. Furthermore, stunning hotels have raised the bar for service and entertainment. Amazing venues showcase world-class entertainers, whether they’re on the latest leg of a world tour or they’re must-see Las Vegas staples. The city is also home to some of the world’s best magicians, singers, impressionists, comedians and tribute acts.
10 Implant practice 1 Volume 7 Number
Volume 7 practice Number X 1 Implant
CORPORATE PROFILE
CORPORATE PROFILE
CORPORATE PROFILE DIO Implant Renowned dental implants in over 70 countries DIO Implant offers a full line up of implant designs and options to perfect your implant procedure under any situation with predictable and optimal results. UF, SM, Protem, Extrawide, FSN/FTN DIO holds best in class design, superior surfaces, state-of-the-art manufacturing, highest quality tools, drills and kits along with easy to learn protocols.
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UFUNIVERSAL FIXTURE 12 Implantpractice practice X Implant
Volume 7 Number 1
DIO Digital Solutions • DIO Digital Solutions “Trione” brand lineup is composed of the “tried and true” best products and technologies globally. • Includes the most advanced intra-oral scanners, CAD applications & software and precision milling technologies. • DIO has developed highly advanced implant-oriented integrated digital applications and solutions designed for leading dental clinics and laboratories. • DIO is leading the “Paradigm Shift” from Analog to Digital Dentistry IP
Milling (Trione G)
Milling (Trione Z)
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This information was provided by DIO.
Volume Implant Volume 77 Number Number 1 1 Implantpractice practice13X
CORPORATE PROFILE
DIO Digital Solutions
CASE STUDY
Tackling a challenging esthetic clinical situation Dr. Cary A. Shapoff illustrates a case replacing two adjacent maxillary central incisors
R
eplacing two adjacent maxillary central incisors is one of the most challenging esthetic clinical situations we face in providing dental implant therapeutics. The maxillary anterior region provides numerous esthetic, technical, and sequencing challenges. This article describes a surgical and restorative workflow for this clinical problem from treatment planning considerations to selection of a dental implant system that provides surgical and restorative advantages in order to enhance the esthetic outcome.
Figure 1
Figure 2
Case 1 A 53-year-old female presented for functional surgical crown-lengthening procedure around her maxillary central incisors (teeth Nos. 8 and 9) prior to replacement of new crowns. The patient reported mobility of the existing crowns and an unpleasant odor in her mouth. According to patient history, these crowns were recent replacements of prior longstanding unesthetic crowns. The patient had an unremarkable medical history and had previously sought dental and dental hygiene care on a regular basis. Both teeth Nos. 8-9 had prior endodontic therapy (Figure 1). At her initial examination, a complete dental and periodontal evaluation, including full-mouth radiographs, was completed with photographic documentation. Significant marginal inflammation was noted around teeth Nos. 8-9 associated with poor fit of the crown margins and with recurrent decay. The patient demonstrated normal to thick biotype with rolled, reddened margins around the central incisors associated with
Cary A. Shapoff, DDS, has practiced in Fairfield, Connecticut for over 36 years. He is in private practice as a periodontist, and is a Diplomate and past director of the American Board of Periodontology. He lectures both nationally and internationally on periodontal disease and its treatment, bone grafting procedures, and dental implant surgery. He has also written articles published in the Journal of Periodontology, Compendium, the International Journal of Periodontics and Restorative Dentistry, and The Dental Guide (Canada). He has been a consultant and lecturer for BioHorizons for 7 years. Dr. Shapoff can be contacted at: cas@shapoff.com.
14 Implant practice
Figure 3
Figure 4
a high smile line and a dental history of mouth breathing (Figure 2). All other regions of her mouth demonstrated marginal gingivitis associated with retained interproximal plaque. The existing shape of her central incisor crowns were square and short and disproportionate in shape and size to her other natural anterior teeth. The existing crowns were carefully removed, and the underlying tooth structure was inspected. It was noted that there was inadequate core portion of the crowns, with only the coronal aspect of an endodontic post and composite retaining the crowns. There had been no ferrule portion of the tooth preparations in the cervical region (Figure 3). The likely contributing factor to the mobility of the crowns was the excessive tooth preparation resulting in crown flexure and marginal leakage resulting in recurrent caries. At her request, she was referred to a prosthodontist for further restorative treatment. A composite-based diagnostic wax-up was completed to assist in
determining optimum tooth height and shape. Treatment plan options were developed after discussing surgical and restorative considerations with the patient. These included functional surgical crown lengthening and new crowns, orthodontic extrusion of the two central incisors, followed by functional crown lengthening and new crowns, or extraction of the teeth and replacement with two dental implants and crowns. Based on the missing core portion of her teeth and the extent of decay around the post spaces, it was determined that extraction of the teeth and replacement with dental implants was the treatment of choice. Based on the anatomy of the tooth sockets and dimensions of palatal bone, identified by three-dimensional imaging CBCT, it was further determined that immediate extraction and placement of dental implants with intra-socket bone grafting was possible. The patient preferred interim fixed provisionalization during the initial healing phase, rather than any of the removable provisional options discussed with her. The surgical phase consisted of Volume 7 Number 1
CASE STUDY
Figure 5
Figure 6
It’s amazing what a great image can do for your practice. The CS 9300 Select is ready to work hard for your practice.
Figure 7A
Figure 7B
extraction of teeth with a flapless approach followed by careful curettage of the intact socket walls. Utilizing a surgical guide based on the diagnostic wax-up, two dental implants were placed, engaging the palatal wall of the intact sockets (Figure 4). The implants selected were the BioHorizons® Tapered Internal with LaserLok® microchannels on the coronal collar portion (3.8 mm x 15 mm with 3.5 mm prosthetic platforms). Precise threedimensional positioning was established with the surgical guide. Following implant placement, the voids within the socket were bone grafted with a combination cortical and cancellous allograft (MinerOss®), and flared healing abutments were placed to support the soft tissues (Figure 5). The composite-based diagnostic wax-
This technologically-advanced system will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry. It will also show your patients how dedicated you are to their oral health. • O ne system with superior 3D scans with multiple fields of view, 2D panoramic imaging and optional one-shot cephalometric imaging • Dedicated 2D digital panoramic imaging with variable focal trough technology that produces high-quality images in 13 seconds • Intelligent Dose Management provides high-resolution 3D images and low dose as collimation limits exposure to area of interest • Five selectable fields of view ranging from 5cm x 5cm to 10cm x 10cm help you get the proper image size for each procedure To learn more about what a great image can do for your oral and maxillofacial surgery practice, visit carestreamdental.com/CS9300 or call 800.944.6365 today. © Carestream Health, Inc. 2013 10232 OM DI AD 0114
Volume 7 Number 1 Implant practice 15
CASE STUDY
Figure 8
Figure 9
Figure 10A
Figure 12A Figure 10B
Figure 11
up was then bonded to adjacent laterals as a fixed provisional. Three months after surgical placement of the implants, screw-retained provisional crowns were fabricated onto PEEK abutments and were modified to achieve ideal tooth shape and gingival architectural framework (Figure 6). Maintenance of the interproximal bone between the implants was achieved with use of the BioHorizons implants with Laser-Lok microchannels. Minor modifications to the interproximal and facial dimensions of the composite crowns were made over a period of 12 weeks (Figures 7A and 7B). Once ideal tooth and gingival size and shape were established, custom, opentray impressions were taken to capture the precise ideal subgingival form for final crown fabrication (Figures 8-9). Final crowns were then provisionally cemented and monitored for potential additional minor modifications (Figures 10A and 10B). The radiograph of the final crowns at 12 months demonstrates the maintenance of the crestal bone around each dental implant as well as maintenance of the interproximal bone between the implants (Figure 11).
the design of the failed crowns did not mimic the tapered shape of her adjacent natural teeth. Critical documentation of tooth shape and size and smile analysis is an essential element of proper treatment planning. Lack of adequate ferrule and lack of coronal tooth portion should have precluded placement of the failed permanent crowns.
Discussion Numerous lessons can be learned from a critical review of this case. 1. Evaluation of the failed crowns identified excessive tooth preparation and inadequate coronal portion of the tooth to provide predictable restoration with basic fixed partial dentures (crowns). In addition, 16 Implant practice
2. Dental implant treatment planning should include photographic documentation, diagnostic wax-up, evaluation of the gingival tissue biotype, position of the maxillary lip position relative to the gingival margin of the teeth, and shape and form of the intended implant restoration. 3. Surgical treatment planning should include three-dimensional imaging especially if a flapless approach is considered. Because of the thick gingival biotype and intact sockets of both teeth, immediate placement was considered. In other cases of high smile line, and thinner biotype, a delayed two-phased approach of grafting followed by implant placement would have been the treatment choice. A delayed two-phased approach would also be required if the remaining alveolar bone prevented adequate initial biomechanical stability at implant insertion. 4. Selection of the BioHorizons Tapered Internal implant was a key element of the success of maintaining interproximal bone between two implants. Use of the tapered 3.8 implant body allowed ideal positioning
Figure 12B Figure 13: Polarized light micrograph
Figure 14
in the palatal bone without encroachment on the facial bone dimension or elimination of the mesiodistal bone within the socket reducing initial stability. Intra-socket bone grafting with a calcified allograft minimized the horizontal dimension bone resorption often seen even with immediate implant placement. The use of the BioHorizons implants with the Laser-Lok microchannels was another key element in maintaining the ideal intra-implant bone level, which in turn supported the ideal height of the interproximal papilla. Numerous published articles have supported the concept of enhanced bone maintenance with the non-random Laser-Lok microchannels (Figures 12A and 12B). Additional animal and human clinical and histologic studies have demonstrated “functionally oriented� connective tissue attachment to the LaserLok surface along with inhibition of the epithelial downgrowth against the implant surface and Laser-Lok abutment surface (Figure 13).
Volume 7 Number 1
CASE STUDY
Figure 15
5. Maintaining support of the facial and interproximal tissue contours with use of the flared healing abutments assisted in recapturing the proper gingival contour around the provisional crowns. This could have been further improved by fabrication of “custom” healing abutments utilizing the BioHorizons 3inOne abutment and composite. This customized technique is used often in this practice but was not utilized in this case. 6. Fabrication and modification of the wellcontoured, screw-retained provisionals by the prosthodontist, Dr. Jeffrey O’Connell, (Bridgeport, Connecticut) was also another key element in achieving ideal tooth shape and gingival framework. In addition, the established subgingival contours were captured in the final impression technique utilizing the BioHorizons open-tray copings modified with resin. The excellent working relationship of the prosthodontist and his dental laboratory technician also needs to be mentioned in achieving naturallooking, all-ceramic crowns. This case was completed before the company release of CAD-CAM custom abutments with Laser-Lok microchannels (Figure 14). Use of these abutments would have further enhanced the attachment of soft tissue to the abutment surface resulting in protection of the underlying crestal bone. In summary, the patient was successfully restored with two singlecrown dental implant restorations following an interdisciplinary workflow from treatment planning through final restorations. The use of the BioHorizons Tapered Internal dental implant with Laser-Lok microchannels was an integral part of the success of this case. In similar cases where the gingival biotype is thinner, I would have considered using the platform switched BioHorizons Tapered Internal Plus implant in order to create a thicker dimension of marginal tissue around the abutments (Figure 15). IP
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PATIENT INSIGHT
A chemotherapy patient’s experience with dental implants Dr. Bryan R. Krey and retired engineer Dr. Richard G. Dong join forces to facilitate implant placement during cancer treatment Background Dental problems of cancer patients are often worsened when the patient undergoes chemotherapy. Dentists and other dental care professionals have seen this. Dental problems definitely worsened for Dr. Richard G. Dong, a retired engineer, during his 3½ years of treatment with the chemo-therapeutic drug Bacillus CalmetteGuerin (BCG), a live bacteria injection used to treat bladder cancer. The problems included persistent infections developing in two existing molar dental implants on teeth Nos. 19 and 30. Dr. Bryan R. Krey is the oral surgeon performing the dental implant procedures and has followed Dr. Dong’s problems and his inventive ways of handling them. This article describes the simple instruments and techniques Dr. Dong developed that saved one of the existing implants and, together with Dr. Krey’s help, extended the life of the other by an estimated 2 years. Conclusions reached by Dr. Dong and Dr. Krey are summarized at the end of the article regarding the handling and designing of implants for individuals on chemotherapy or who had chemotherapy, and who had experienced worsened
Richard G. Dong, PhD, was born and raised in Sacramento, California. He earned his BS and MS degrees in Mechanical Engineering at the University of California in Berkeley, California. He worked for 2 years at the Aerojet-General Corporation in Sacramento, California. He returned to the Berkeley campus and earned his PhD in Structural Mechanics. He then worked at the Lawrence Livermore National Laboratory in Livermore, California, as a research engineer and as one of the technical reviewers for the laboratory’s Nuclear Test Program. He retired in 1993. He lives in Danville, California, where he and his wife raised two children. Bryan R. Krey, DMD, was born and raised in Brentwood, California. He earned his dental degree at Oregon Health and Science University in Portland, Oregon, in 1993. He completed his Oral Surgery residency at Highland Hospital in Oakland, California, and later completed his board exams and is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He is in private practice with offices in Berkeley and Orinda, California. He lives in Lafayette, California, with his wife and four children.
18 Implant practice
Figure 1: Radiograph prior to placement of tooth No. 19 implant
Figure 2: Radiograph with tooth No. 19 and tooth No. 30 implants in place. Prior to restoration. Ideal bone levels
dental problems while on chemotherapy. Dr. Dong is a nonsmoker, with no diabetes or other systemic disorders. He exercises regularly and eats a healthy diet.
more able to fight the cancer, a secondary positive change was that his seasonal hay fever became much milder. Not everyone would react the same way to this particular chemotherapy, and therefore, not everyone is necessarily going to have the reactions mentioned. Everyone’s immune system is different. This is becoming increasingly clear in general cancer research. Immune systems in individuals could vary widely as revealed in current research using humanized mice. The immune systems of numerous individuals are grown in mice to study their reactions to various cancer-fighting drugs and various cocktails of the drugs. The reactions were found to vary widely among the immune systems. Ideally, the longer the chemotherapy Dr. Dong received could continue, the more his immune system would be altered to fight the cancer. However, it became apparent to him that the likely reason the standard duration is set at 3½ years is because that is probably what a typical patient could tolerate before the immunity reactions become more intolerable than the cancer. However, at the current level of alteration, Dr. Dong prefers to put up with current reactions than to have his immune system return to how it was, thus allowing the cancer an increased chance of recurring.
Effects of an altered immune system The chemotherapy was to train Dr. Dong’s immune system to fight the cancer. The following might or might not be medically established, but from an engineer’s point of view, this means the immune system will be altered; and therefore, various changes in immunity reactions will progressively show up as the alteration increases. This was confirmed by the fact that various forms of immunity reaction came forth one after the other over Dr. Dong’s 3½ years of treatment. This included arthritic autoimmunity reactions, weakened ability to fight off certain bacteria, such as those causing dental problems and those causing cellulitis. Dr. Dong’s last treatment resulted in a severe rash all over his body, as his immune system became sensitized to the drug. Thank goodness it was the last treatment; who knows what else might have arisen next. General tiredness, headache-nausea reactions to weather changes, and allergic reactions to certain foods also developed. The bladder became hyper from three rounds of surgeries and from the prolonged exposure to the chemotherapy drug. Hyper is defined here as constant urgency and frequency to urinate on an hourly basis. Therefore, this is also at least partly an immunity reaction. Besides the immune system becoming
Implant failure increases when the implant procedure is timed near or during chemotherapy Bone formation takes place slowly to fill in Volume 7 Number 1
PATIENT INSIGHT
Figure 3A: Restored tooth No. 30 implant with vertical bone loss
Figure 5: Radiograph showing loss of tooth No. 30 implant, restored tooth No. 19 implant, and recently placed tooth No. 18 implant. Tooth No. 18 implant features internal abutment connection and platform switching
the hole left from a tooth extraction. After 4 months, enough bone has usually formed to enable the implant post to be installed. But an X-ray would clearly indicate the bone has not yet reached normal density. Four months after that, the crown is usually installed. An X-ray would indicate the bone density is better but still not at normal level. From an engineer’s perspective, the bacteria could now begin accumulating at the crown-implant junction. The surface transitioning from the crown to the post would not be perfectly smooth, as could be seen on the implant removed from Dr. Dong’s molar tooth No. 30 site. The crown and post are minutely different in diameter and roundness such that a tiny ridge and a tiny shelf are formed there. Tiny gaps likely also exist at various locations where the crown mates with post. Such imperfections are deeply located and somewhat hidden since they are not easily reached during brushing and flossing. Bacteria could accumulate at these imperfections and then migrate to where the post meets the bone to initiate bone loss. Also, as pointed out by Dr. Dong’s regular dentist, the migration is intensified by the “pumping” action during food chewing. There must be reasons why bone loss occurs after the crown is installed, and the factors mentioned seemed logically to be why. If bone density were less than normal, 20 Implant practice
Figure 3B: Prior to tooth No. 19 implant being restored.
the initiation of bone loss would be easier, and continued bone loss would be faster. In addition, if the patient’s immune system’s ability to fight the bacteria were weakened by chemotherapy, the entire bone loss process would progress even faster. Under this condition, the pocket formed by bone loss could quickly grow to where the bacteria would have many corners and crevices in which to hide and colonize. Once colonization occurs, the bacteria would be more difficult to dislodge and eliminate, bone loss might be slowed with extraordinary care but not stopped, and the implant would eventually fail. Under normal circumstances, with the patient’s immune system well able to fight off the bacteria, bone loss could initiate but would stabilize and essentially stop. The implant would then be successful. An X-ray could show a small amount of bone loss, but that would be considered normal. Dr. Dong’s experience with implants appears to match the descriptions in the preceding paragraphs. Four of his molars at different times needed to be replaced with implants, and chemotherapy affected all four. The following are the timelines relative to the beginning or ending of chemotherapy. Molar 19 • Implant post was installed 1.25 years before chemotherapy began. • Crown was installed 0.88 years before chemotherapy began. • While chemotherapy affected this implant, the implant was saved by the procedure developed by Dr. Dong. Molar 30 • Implant post was installed 1.0 year before chemotherapy began. Crown was installed 0.63 years before
Figure 4: Restored tooth No. 30 implant. 2011. Severe bone loss.
chemotherapy began. • The implant failed due to effects of chemotherapy, in spite of Dr. Dong and Dr. Krey’s best efforts, and was removed 1.4 years after chemotherapy ended. Thus, the implant lasted 5.53 years after the crown was installed. • The implant procedure is currently being repeated. Implant post is not yet installed. Molar 18 • Molar 18 was extracted 1.06 years after chemotherapy ended and about 0.06 years after the chemotherapy drug completely left the body. • Implant post was installed 1.4 years after chemotherapy ended and about 0.4 years after the chemotherapy drug completely left the body. Crown is not yet installed. Molar 31 • Molar 31 was extracted 1.7 years after chemotherapy ended and about 0.7 years after the chemotherapy drug completely left the body. • Implant post is not yet installed. • The fact that molar 31 went bad quickly could indicate that Dr. Dong’s immune system remains altered and was thus unable to fight the bacteria adequately. His urologist treating the cancer and his primary care doctor indicated his immune system is likely to remain altered for the rest of this life, especially since chemotherapy was done at his somewhat advanced age of 70 years. Dr. Dong had quite a few dental problems even before he had cancer. According to his dentist, he keeps his teeth so clean; he should not have so many problems. Consequently, it must be in his genes. The need to replace molars Volume 7 Number 1
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PATIENT INSIGHT
19 and 30 with implants happened before chemotherapy began. However, infections and gum swelling, bleeding, pocket formation, and bone loss started happening soon after chemotherapy began. The molar 19 implant remains successful while the molar 30 implant failed. Molars 19 and 30 are at the same locations at opposite sides of the lower jaw. Therefore, their environments should be essentially identical. A notable difference is the molar 19 implant had 3 months more to increase bone density than the molar 30 implant had before chemotherapy began. The 3 additional months apparently enabled the bone density for the molar 19 implant to reach a high enough level to prevent the rate of bone loss from becoming unstable. Molar 18 experienced multiple problems while Dr. Dong was undergoing chemotherapy. The dentist and Dr. Dong did their best to save molar 18, but couldn’t. It seemed that once the bacteria gained a foothold, it is very difficult to stop the destruction when the immune system is unable to fight the bacteria well enough. An infection occurred at the periapical region of molar 31’s roots, and it led to the molar’s loss. Age-related gum recession exposed the bifurcation point between the roots and allowed bacteria to enter. An earlier root canal eventually resulted in root brittleness, and one root developed a crack that allowed the bacteria to migrate to the lower region of the roots. The entire process happened very quickly and could not be caught even with biannual hygienic cleaning and inspection by the dentist. The process apparently accelerated because the immune system was unable to fight off the bacteria well.
Stopping the 4-week cycling between infections and healing The gum surrounding molars 19 and 30 implants started getting infected, swollen, and bleeding shortly after chemotherapy began, and worsened as chemotherapy continued. Pockets started to form, and a bit of exudate could be expelled when pressure is applied to the pockets. The problem occurred at the buccal face side of the implants but not at the lingual side. For some reason, this is common. Perhaps the pressure and motions of the tongue kept the bacteria from gaining a foothold at that side of the implants. Dr. Dong tried handling the problem by brushing, flossing, and using an 22 Implant practice
interdental brush, but none worked. It became apparent that blood clots and other materials the bacteria could cling to or hide in must be removed, and that some method of flushing them out needed to be developed. Therefore, he made some instruments consisting of various shapes of plastic toothpicks, toothpick holders that hold toothpicks at 90º from the handle, an eyedropper, a length of flexible plastic tube 0.05 inches outer diameter, and a covered low container of Listerine®. Plastic toothpicks rather than wooden ones were used because plastic ones would not fray and lose their shape. The steps in the procedure Dr. Dong developed are as follows: Step 1: • He used the smooth, round blunt end of a toothpick holder to gently rub against the pockets to expel the exudate accumulated in the pockets. • The exudate would be a larger amount and a bigger concern when infection exists. If infection does not exist, the exudate would be a smaller amount and of minor concern. Step 2: • A blunt toothpick was used to scoop up the exudate. • The mouth was rinsed with plain water before performing the next step. Step 3: • The reason for omitting this step here will be explained later in the article. Step 4: • A more sharply pointed toothpick is used to slightly enlarge the front and rear openings of the pocket and to mechanically gently dislodge the bacteria from the surfaces of the pocket. The center edge of the pocket is usually still attached to the post, and this part of the pocket is not to be forced open. Otherwise injury would occur leading to infection. Step 4 is performed only if the openings of the pocket are large enough to allow the toothpick to easily enter, as was the case for the molar 30 implant. • If the openings of the pocket are very small, as is the case for the molar 19 implant, Step 4 is omitted, and Step 5 would still be effective. • The mouth is rinsed before going to Step 5.
Step 5: • The syringe made with an eyedropper with a length of 0.05-inch outer diameter flexible plastic tube fastened to it with a glue gun. This is used to squirt Listerine into the pocket to flush out the bacteria and any other materials. The tube is inserted into one of the two openings widened in Step 4, and that part of the pocket is flushed. This procedure is repeated with the other openings. Flushing is repeatedly alternated between the two openings until all the Listerine in the eyedropper is used up. • If the pocket was bleeding to begin with, Step 5 was performed three times to stop the bleeding. A blood clot must not be allowed to form in the pocket. Listerine apparently has an ingredient that helps stop the bleeding. • As explained, Step 4 is omitted for the molar 19 implant. Squirting the Listerine into the pocket through openings as they already exist without being further opened by Step 4 seems to work adequately for the molar 19 implant. • The mouth was rinsed, and the usual teeth brushing was then performed for the entire mouth. • A flexibility syringe made as explained works better and safer than using a standard rigid syringe. The plastic tube was held at the opening of the pocket with one hand, while the other hand squeezed the eyedropper. The flexibility of the plastic tube enabled the tube to be easily and safely held at the opening of the pocket. This is likely to be much more difficult to do using a standard rigid syringe. Step 3 is left blank in the above list for the following reason. The four steps listed would dislodge and flush out the bacteria and thus promote healing. However, as healing progresses, the gum would tighten against the post. Steps 4 and 5 would then become more difficult and less effective to perform. Consequently, the bacteria begins to re-establish in the pocket. This caused infection to start again. The infection and swelling would cause the openings of the pocket to enlarge. This then enables Steps 4 and 5 to be more easily and effectively performed. Healing would then be promoted again. The net result is we get 2 weeks of healing followed by 2 weeks of infection, swelling, and bleeding. This 4-week cycle continues to repeat with only the four steps listed above. Volume 7 Number 1
PATIENT INSIGHT Dr. Dong discovered that by adding a Step 3, the 4-week cycle would be stopped. In Step 3, he uses a toothpick, not quite as pointed as the one used in Step 4, to clean the gum line around the post where brushing and flossing would not reach. This would be where a tiny trough is formed over the length of the edge of the pocket that remains attached to the post. This is the length of the edge of the pocket that is not to be opened in Step 4. Apparently, this trough provides a lodging site for the bacteria. When the pocket could not be flushed out very well, these bacteria would migrate into the pocket and add to those not flushed out. The total would reach a level that would cause infection to start. Step 3 is as follows: Step 3: • Use a toothpick not quite as pointed as the one used in Step 4, and clean along the gum line at the face side and the tongue side of the implant. While cleaning the tongue side is probably not necessary, you might as well do it just in case. • The mouth is rinsed before performing Step 4. By adding Step 3, the 4-week cycle was stopped. Bone loss in the molar 19 implant was stabilized, and the implant was saved. Unfortunately, the addition of Step 3 was unsuccessful in saving the molar 30 implant. The pocket there had become so large and deep with so many corners and crevices in which bacteria could hide that while the 4-week cycle was stopped, enough bacteria remained in hiding to cause continued bone loss even without apparent infection. Dr. Krey tried cleaning out the pocket to minimize the places where bacteria could hide, but as he later explained, once the bacteria colonized within the pocket, they were very difficult to completely dislodge and flush out. In this case, “colonization” means the bacteria became established in some hard-toclean and flush locations in which to hide and breed. Nevertheless, by stopping the 4-week cycle and thus slowing the rate of bone loss, the molar 30 implant’s life span was extended by 2 years, by Dr. Dong’s estimate.
Best to repeat the procedure every 12 hours Based on Dr. Dong’s experience, the procedure described is best repeated 24 Implant practice
every 12 hours. This enables the openings of the pocket, in the case of the molar 30 implant, to remain reasonably open so that Steps 4 and 5 could be performed effectively. If more than 12 hours have passed, the openings would decrease to where Steps 4 and 5 could be more difficult or impossible to perform. Then infection could start again. If the procedure were performed more frequently than every 12 hours, injury and inflammation could occur leading to infection. Every step of the procedure must be done not too gently or too forcefully, even while squirting Listerine into the pocket. Enough force is needed to dislodge or flush out the bacteria, but too much force can cause injury followed by infection. The tissue inside the pockets is very tender and fragile since it is well protected and not toughened by exposure during brushing, flossing, and contact with foods.
Conclusions Based on the differences in the behaviors of the molars 19 and 30 implants, and how installing the crown on the post could initiate bone loss, Drs. Dong and Krey came up with two conclusions. If the patient is under chemotherapy or had chemotherapy in the past, and if dental problems significantly worsened while on chemotherapy, then Conclusion 1 would apply. Conclusion 1 Installing the crown onto the post should be delayed to allow more time for the bone density to reach a high enough level to prevent easy initiation of bone loss followed by a fast rate of bone loss. How much delay time is required to achieve this is not known at this time. However Dr. Dong’s experience indicates waiting 1.25 years after the post is installed would most likely achieve the desired result. But waiting 1.25 years is probably longer than really necessary. According to Dr. Dong’s experience, an increase of 0.25 years in doing the implant procedure before chemotherapy commenced was enough to make a significant difference. While this is not the same as waiting 0.25 years before installing the crown onto the post, it does confirm that allowing extra time for the bone density to increase before chemotherapy begins is beneficial. Therefore, instead of waiting 1.25 years to install the crown, we could try doubling or tripling the standard waiting time of 4 months after the post is installed before installing the crown and
see if that is enough to achieve the desired result. Dr. Dong plans to try this for the molars 18, 30, and 31 implants and could report on the results at a later time. The post installed at the molar 18 site has a new design to help hinder the migration of bacteria to where the post meets the bone. The new design has the same overall proportions as the preceding design except a location that is a short distance below the top has a smaller diameter. This forms a circumferential grove for the gum tissue to grow into. This makes the path more difficult for the bacteria to negotiate to reach where the post meets the bone. In Conclusion 2, Drs. Dong and Krey present another possible new design for the implant post following a different approach to preventing bacteria from migrating to where the post meets the bone. Conclusion 2 As stated earlier, tiny imperfections, such as a ridge, a shelf, and gaps, formed where the crown meets the post are possible sites for the bacteria to accumulate. These sites are not easy to reach during brushing and flossing. The bacteria could accumulate there and then migrate to where the post meets the bone to initiate bone loss. This chain of events could be avoided if the post and crown were reconfigured. The crown-post assembly has the shape of a wine glass with a very stout stem minus the base. The tiny imperfections would be located where the cup meets the stem. If the imperfections were relocated higher up onto the cup, then any bacteria accumulated there would be more exposed and more easily removed by brushing and flossing. This would eliminate the imperfections as sites where bacteria could accumulate, and from which to migrate to where the post meets the bone. The post would have a head similar to how a flat-head wooden screw has a head. The crown would be flatter to accommodate the head on the post. The appearance might not be desirable if the base of the implant is visible to others. The implant post design presented would benefit any dental implant recipient regardless of whether or not the recipient is going through chemotherapy or had worsened dental problems while on chemotherapy in the past. IP
Volume 7 Number 1
Drs. Peter Fairbairn and Sharon Stern present a multi-disciplinary approach to tackling a tricky trauma case
T
raumatic injuries to the anterior teeth can be a tragic experience for the patient and require thorough treatment planning, experience, and skill on behalf of the dentist. Advances in techniques used both in endodontics and implantology have allowed us to save more of the patient’s own teeth — and patients’ wishes to retain their own teeth, if possible, must be respected. In this case study, the use of membrane and autogenous-free bone regeneration with simultaneous implant placement (Fairbairn, 2011; Podaropolous, et al., 2009), as well as microscopeenhanced endodontics, helped achieve the result the patient desired.
Introduction Dental trauma often involves a team of dental practitioners: the general dentist along with one or more specialist dentists. Since trauma is not a common occurrence in general practice, management of traumatized teeth can be both demanding
Dr. Peter J.M. Fairbairn, BDS, is principal of the referralbased Scarsdale Dental Aesthetic and Implant Clinic in Kensington, London. He is visiting Professor in the Department of Periodontology and Implant Dentistry at the University of Detroit Mercy School of Dentistry in Michigan (United States). Dr. Fairbairn can be contacted at Peterdent66@aol.com. Dr. Sharon Stern graduated in 1999 as a general dentist from the University of the Witwatersrand (South Africa), before moving to London where she worked in private practice and the Acute Dental Care Department at Guys Hospital. In 2006 she completed the Certificate in Restorative Dentistry at Eastman Dental Institute. Dr. Stern completed her specialist training in endodontics at Guys Hospital in 2010 and was accepted on the GDC Specialist Register for Endodontics in 2010. Since qualifying as an endodontist, Dr. Stern works mainly in private practice and is involved on a part-time basis in the postgraduate clinical program in endodontology at Kings College London. She has also been the main author of a research article and co-author in a peerreviewed journal article. Dr. Stern can be reached by email at endodontics@hotmail.co.uk or on 020 7937 2160.
Educational aims and objectives The aim of this article is to present a multi-disciplinary case study that demonstrates how patients’ needs can sometimes be better met when clinicians work together. Expected outcomes Correctly answering the questions on page 31, worth 2 hours of CE, will demonstrate the reader can: • Recognize the recommended approach for dealing with root fracture. • See where implant therapy and endodontics can combine. • Identify some of the principles behind soft tissue grafting and healing.
and challenging, as it is accompanied by emotional factors on the patient’s part. Horizontal root fractures can be classified according to the location of the fracture line (apical third, middle third, and cervical third). Injury factors to the tooth, such as location of the fracture line, mobility of the coronal fragment, the degree of dislocation of the coronal fragment and diastasis between fragments (rupture of the pulp at the fracture site), stage of root development (immature or mature root), and age of the patient (growth of the alveolar process) have the greatest influence upon healing (Andreasen, et al., 2004; 2007). In the horizontally fractured tooth, necrosis of the pulp usually occurs in the coronal fragment, while the pulp of the apical fragment remains vital (Andreasen and Hjorting-Hansen 1967; Hitchcock, et al., 1985). This provides a basis for treatment of the horizontally root fractured teeth. In permanent teeth with horizontal fractures in the apical and middle thirds, root treatment of the coronal fragment only with gutta percha (with calcium hydroxide dressing in the interim) has been proved to be successful, whereas unfavorable outcomes have occurred when both fragments have been endodontically treated with gutta percha (Cvek, et al., 2004; 2008). The aim of this is to form a calcific
barrier at the apical end of the coronal root fragment, in the same way as treating a non-vital immature tooth (by apexification). Mineral trioxide aggregate (MTA), was developed in the 1990s as a root end filling material (Torabinejad, et al., 1993; 1995). Since then, it has been used extensively in all aspects of endodontic treatment. It is associated with favorable apical healing when used as an apexification material in immature teeth with open apices (Pace, et al., 2007; Simon, et al., 2007; Felippe, et al., 2006) because it encourages hard tissue formation (Pitt Ford, et al., 1996; Nair, et al., 2008; Accorinte Mde, et al., 2008), is biocompatible (Pitt Ford, et al., 1996; Nair, et al., 2008; Aeinechi, et al., 2002), provides a good seal (prevents microleakage) (Torabinejad, et al., 1993; Pitt Ford, et al., 1996; Lee, et al., 1993; Lawley, et al., 2004), and is nonresorbable (Torabinejad and Chivian, 1999). Consequently, MTA is the treatment of choice instead of gutta percha for root filling the coronal segment of teeth with horizontal root fractures. This case involves three teeth that were involved in trauma and the multidisciplinary approach used to treat them. After careful assessment, sometimes the only option is removal and replacement with a dental implant. Guided bone regeneration is generally needed in trauma cases where dental implants are to be placed due to bone damage during the trauma or as a result of post-traumatic infection. The co-
Volume 7 Number 1 Implant practice 25
CONTINUING EDUCATION
Multi-disciplinary approach to the treatment of traumatic root fracture: a case study
CONTINUING EDUCATION
Figure 1: Trauma area 13, 12, and 11
author has used only alloplast or synthetic particulate graft materials for the last 10 years using no autogenous (blocks, chips, or scrappings) for the last 9 of them. A delayed immediate placement protocol is the standard procedure where the tooth or root is removed carefully, so as to not damage the residual bone, and then left to heal for 3 weeks. This standard protocol — employed in more than 1,800 cases in the 10 years by the co-author — allows for soft tissue closure yet ensures the preservation of adjacent bone prior to the phase of modeling (Schropp, et al., 2003). Ridge preservation, rather rebuilding the profile of the modeled ridge, can be both more time efficient and less traumatic for the patient. Bone healing is further improved by not using a traditional (collagen-type) membrane that inhibits periosteal blood to the graft site, which accounts for 85% (or more) of the blood supply to the site. The stability and soft tissue cell occlusive properties needed for successful bone regeneration (Schenk 1995) are achieved by a CaSO4 (calcium sulfate) element in the graft material; hence, the graft is its own membrane.
Case The 25-year-old male patient was involved in a motor vehicle accident that resulted in trauma to his UR1, UR2, and UR3. Horizontal root fractures were evident in the mid to apical third of the UR2 and UR3 (Figure 1). All four teeth were splinted at his local hospital’s dental unit after the initial visit to the accident and emergency (A&E) and later treated by his general dental practitioner. The case was referred to the authors 3 months post-trauma with a swelling and pain associated with the UR2. Clinical examination revealed that the UR2 was 26 Implant practice
Figure 2A Figure 2B Figures 2A and 2B: Radiograph at 3 months post-trauma
grade 3 mobile; the UR1 and UR3 were firm. The UR3 had not responded to sensitivity tests (electric pulp testing and cold testing). Periapical radiographs of the associated teeth (Figure 2) showed that both the UR2 and UR3 had horizontal root fractures at the junction of the middle and apical third of the roots. The UR2 was root filled; the coronal fragment was laterally dislocated; the diastasis between the coronal and apical root fragments was over 2 mm; and a lateral radiolucent area was evident. The UR3 was not root filled, the diastasis was less than 1 mm, and lateral radiolucent area was evident. The UR1 was root treated but not ideally obturated; however, no apical radiolucencies were associated with these roots. The patient was determined to retain both the UR2 and UR3. Since the 13 was not mobile, the diastasis between the coronal and apical fragments was less than 1 mm and had no associated pockets, the prognosis for treating this tooth was good. However, the fact that the UR2 had grade 3 mobility, the only option for the lateral incisor was an extraction. This prospect suited the patient who had been initially referred for the placement of two implants, and the necessary treatment consent was completed. The initial treatment would be to secure the future of the canine, and endodontic treatment was arranged.
Endodontic treatment of the UR3 A decision was made to treat only the coronal fragment of the UR3 as the apical fragment was assumed to be vital (Andreasen and Hjorting-Hansen 1967; Hitchcock, et al., 1985). Rubber dam was secured over the tooth using a Q9 rubber dam clamp (Dentsply Ash instruments, UK). The access was established with a long tapered diamond bur. The pulp chamber
Figure 3: MTA placed
was then fully accessed and refined using a BUC-1 ultrasonic tip under the copious water spray. One canal was identified with the aid of an operating microscope (Global G3, Global Surgical Corporation) using a DG16 explorer probe (Dentsply Ash instruments). The working length of the root canal of the coronal fragment was determined using an apex locator (Raypex® 5; VDW). A working length radiograph was taken to verify the apex locator readings . The canals were instrumented to working length with hand K-Flexofiles® (Dentsply Maillefer) to an ISO size 70 using the balanced force technique. The UR3 was root filled to the level of the root fracture with a minimum of 4 mm of mineral trioxide aggregate (MTA) (Angelus) using the Messing Root Canal Gun (Miltex) to deliver the MTA (Figure 3). An activated, stainless steel ultrasonic tip was used to apply ultrasonic energy to a number 2/3 Machtou condenser (Dentsply Maillefer), which was used to pack, flow, and settle the MTA. The rest of the root canal was backfilled with gutta percha, and the access cavity was restored with composite (Filtek™ Supreme XT Universal Composite, 3M ESPE). A postoperative radiograph of the completed root canal treatment was taken (Figure 4). There is slight extrusion of the MTA beyond the fracture line; however, since MTA is biocompatible, the prognosis of the treatment is still good.
Implant placement at UR2 The surgical phase was then initiated with the removal of the fractured lateral incisor. A plastic partial denture was made as a temporary rather than the preferred resinbonded bridge due to cost factors and the patient’s desire not to involve adjacent teeth. The root tip was removed using a Volume 7 Number 1
Figure 5A Figures 5A and 5B: Use of periotome to remove the root tip
Figure 5B
Figure 6: Defect shown by probe
Figure 7: Partial denture fitted
Figure 8: Three weeks later showing soft tissue healing
Figure 9: But also showing hard tissue loss
Figure 10A Figure 10B Figures 10A and 10B: Implant (DIO 3.8 mm x 12 mm) placed palatally, with site-specific flap retaining papillae
Periotome (Figures 5A and 5B), taking care not to damage the buccal plate any further. Probing the socket showed the resultant buccal bone defect (Figure 6) and the thin biotype of the gingiva. The partial denture was then fitted (Figure 7), and the site was then allowed to heal for 3 weeks. After the period of soft tissue healing, we generally have good enough soft tissue closure (Figures 8 and 9), but the effects of hard tissue modeling can already be seen due to the extent of the infected site bone loss. A site-specific flap is then raised not to affect the papillae of the adjacent teeth. The concept of employing the membrane in the graft (Fairbairn 2011; Podaropolous, et al., 2009) allows this flap
to be smaller, reducing patient trauma, as well as allowing the all-important blood supply from the periosteum unimpeded access to the site. The periosteum in a bone damage site also plays a role in the induction of stromal cell derived factors (Fairbairn 2011), which results in an increased presence of mesenchymal cells important for healing (Zhao, et al., 2012). Thus, the author feels the use of traditional collagen-type membranes may be a hindrance rather than a help to the body’s healing (Gutta, et al., 2009). The site was then vigorously curetted to ensure the removal of any granulation tissue. The bacteriostatic nature of CaSO4 enabled the co-author to dispense with
the need for the use of chlorhexidine, even though its effect on fibroblasts is debatable. A DIO 3.8 mm by 12 mm implant (DIO Implant Corporation) was placed slightly palatally in the socket (Figures 10-11) to the desired torque of 35 Nm. The author always places the implant at the time of grafting — even in extreme bone loss cases — due to the inherent regenerative capabilities of the titanium implant (Brunette 2001), as well as its mechanical stabilization of the particulate graft. The implant can thus be considered the most important of graft materials — as well as aiding the bone regeneration, it will be needed to attach the abutment and crown in the near future.
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Figure 4: Completed root canal
CONTINUING EDUCATION The Osstell reading (Bornstein, et al., ND) was then taken using a type 49 peg, which here was 38 ISQ, a low reading. Always make sure to correctly seat the peg as shown (Figure 12) to prevent incorrect readings. The particulate graft (Vital, Biocomposites) was prepared according to the manufacturer’s instructions and packed into the site and allowed to “set” using gauze to restrict the blood ingression into the site for a 3-minute period (Figure 13). This ability to set and hence become more stable has been shown to lead to more successful graft site with improved bone regeneration (Schenk 1995). The site was then closed carefully and sutured using 5.0 Vicryl™ sutures (Ethicon, Inc. [Figure 14]). The CaSO4 element of the material will supply a soft tissue cell occlusive barrier for the first 3 weeks (patient dependent) while being vascularly porous to ensure angiogenesis. This vascular porosity increases as the CaSO4 element
Figure 11: Adjacent bone prior to modeling, need to graft
bio-absorbs, providing elements for the bone regeneration process in the structure of the BTcP (99% pure beta tricalcium phosphate) element of the material (Smeets, et al., 2009). It is also noted that most particulate graft materials (Vital in particular) exhibit a negative iso-electric charge in an aqueous solution, which attracts host bone morphogenetic proteins (BMPs) such as osteoponin and osteocalcin in greater numbers to the site (Hunt and Cooper 2012). These then attract the host’s negatively charged mesenchymal cells (osteoblasts) and therefore up-regulating the host healing response. Hence, the author has not used any autogenous bone in the last 9 years as he feels introducing dead bone to the site delays the healing process due to the initial osteoclastic phase. Not using autogenous bone results in reduced patient morbidity and hence a greater acceptance of the surgical
Figure 12: Osstell smart peg (type 47) fitted to DIO implant
procedures. After 12 weeks, a flap was then raised to show new bone formation, with some remnant graft material on the surface (Figure 15). A round bur (Meisinger) was used to access the implant head completely (Figure 16), which is important to seat the Osstell peg perfectly and prevent false readings. The full bio-absorption of the graft material is important in returning the site to true human host bone. Numerous research papers by the co-author (Leventis, et al., 2012) and others have shown that by 10 weeks up to 85% of the graft material may have already bio-absorbed to facilitate improved bone regeneration in line with the host healing process (Figure 17). The flap was also used to move the attached, keratinized gingival tissue buccally (a small rollover type flap) when the healing cap (SANH 4224) was fitted and the denture re-fitted for another week (Figure 18). The further improvement in the profile
Figure 13A Figures 13A and 13B: The Set Vital graft, control bleeding
Figure 13B
Figure 14: Sutured carefully with 5.0 Vicryl
Figure 15: Flap raised at 3 months to show new bone and some remnant graft material (less than 15%)
Figure 16: Round bur used to remove excess bone
Figure 17: Core sample showing small graft remnants at 3 months, H and E stain (Dr. Mangham)
Figure 18: Fitting healing cap and denture
Figure 19: Soft tissue healed after 1 week
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Volume 7 Number 1
Figure 21: Six months loaded showing retention of profile
Figure 22: Six months loaded with further improved bone levels
can be seen in Figure 19. The correct abutment (SACN 4835T) was selected to move the crown margin to a level 1 mm below the gingival margin despite the deeper placement of the implant (Figure 20). This was used to optimize the platform switching benefits of this indexed tapered abutment system and improve the soft tissue seal above the implant. An IPS e.max® crown (Ivoclar Vivadent) was made and cemented with Premier® Implant Cement (Premier Products Co.) The excess was removed during the “gel” phase to ensure no residual cement was left sub-gingivally. The patient was happy with the outcome and was asked attend every 6 months to enable long-term assessment of this more complicated case.
associated with the UR3 shows bone remodeling (Figure 23). It can take up to 4 years for healing to occur fully (Torabinejad and Chivian 1999). The patient has been symptom free, the UR3 is not mobile, no pockets over 3 mm are evident, and there are no swellings or sinus tracts present. The overall prognosis for the UR3 is good.
treatment only after pulp necrosis, not as a prophylactic intervention. Trauma cases should be carefully monitored clinically, radiographically, and with sensitivity tests (thermal, electric pulp testing). The treating practitioner should treat each case individually as no trauma case is the same. In this case pulpal necrosis developed, and endodontic treatment of the coronal fragment only was indicated, as root fractured teeth often possess a vital apical fragment even when the coronal fragment is necrotic (Andreasen and Hjorting-Hansen 1967; Hitchcock, et al., 1985; Cvek, et al., 2004). In the study by Cvek, et al., (2004), gutta percha was used to fill the root canal, and the authors found that overfilled root canal filling material between the fragments did not lead to healing. In this case healing was evident even though the root canal was overfilled; this could be because MTA was used instead of gutta percha. Radiological evaluation of root fractures is usually based on multiple periapical radiographs and occlusal views; however, with cone beam CT (the patient declined this), it is possible to examine the root in three dimensions, and this may aid in further assessment of the prognosis of the injured tooth.
Review At the first review appointment, an improved buccal profile and gingival health was observed (Figure 21) with stippling and no bleeding on probing despite the excess cement of a recently re-cemented veneer on the UR1. Radiographically, the bone density appeared to have improved in the cervical area (Figure 22), possibly as a result of functional remodeling and the final “turning over” of the remnant graft material, which can take up to 9 months depending on patient physiology. This full bio-absorption of the graft material is important to return the host bone back to a healthy state without the presence of foreign hydroxyapatite (HA), which may impede the natural osteoclastic and osteoblastic cycle of natural bone. Once loaded, there appears to be little change in the profile in line with Wolff’s Law, in that function is essential to retain bone. Twelve months after the UR3 was root treated, the lateral radiolucent area
Discussion At 1 year following loading, patient recall showed further bone regeneration in the UR2 area due to further functional remodelling (Figure 23). The co-author feels the need for the use of a particulate graft material in the repair of bone defects — not only to provide a scaffold for the bone regeneration but also for the upregulation of the host response, with their use as shown in recent research that tested 38,000 genes (Zhao, et al., 2012). The patient’s oral hygiene was not ideal due to a reluctance to floss, but again no bleeding on probing was observed, and the patient had no adverse symptoms from the treatment. Healthy papillae were retained (Figure 24), although the need for improved OH was again stressed. The prognosis of root fractured teeth depends on the extent of the fracture line, the pulp tissue status, mobility of the coronal fragment, and dislocation of fragments (Andreasen, et al., 2004). Survival is poorest for root fractures located at the gingival third of the root (Welbury, et al., 2002). The UR3 was horizontally fractured at the junction of the middle and apical third of the roots. It was not mobile, and the coronal fragments did not appear dislocated; hence, the prognosis for treatment was good. The International Association of Dental Traumatology (IADT) guidelines (Flores, et al., 2007) recommend endodontic
Conclusion The result achieved for the patient has exceeded his expectations, with the use of newer materials and techniques having reduced both the treatment time scale as well as patient morbidity. These synthetic bone regeneration materials also negate the need for a material specific consent procedure, and their ability to “turnover” to host bone is often a vital factor in the patient consenting to the entire treatment plan as no remnant donor material (human or bovine) is present
Volume 7 Number 1 Implant practice 29
CONTINUING EDUCATION
Figure 20: Abutment fitted — note new bone level
CONTINUING EDUCATION
Figure 23: Radiograph at 1 year loaded — further bone improvement even in sites adjacent the canine
Figure 24A
in years to come. Material and technique advances in endondontics have also allowed us to
treat fractured roots, providing the correct protocols are initially followed. Accordingly, the patient’s desire for
References Accorinte Mde L, Holland R, Reis A, Bortoluzzi MC, Murata SS, Dezan E Jr, Souza V, Alessandro LD. Evaluation of mineral trioxide aggregate and calcium hydroxide cement as pulp-capping agents in human teeth. J Endod. 2008;34:1-6. Aeinechi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate and calcium hydroxide as pulp capping agents in human teeth: A preliminary report. Int Endod J. 2002;36:225-31. Andreasen FM, Andreasen JO, Cvek M. Root fractures. In: Andreasen Jo, Andreasen FM, Andersson L(eds.):Textbook and color atlas of traumatic injuries to the teeth. Munksgaard, Kopenhagen. Wiley-Blackwell, 2007:337-371. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 intra-alveolar root-fractures: 1. Effect of pre-injury and injury factors such as sex, age, stage of root development, fracture type, location of fracture and severity of dislocation. Dental Traumatol. 2004;20:192-202. Andreasen JO, Hjorting-Hansen E.Intraalveolar root fractures, radiographic and histology study of 50 cases. J Oral Surg. 1967;25:414-26.
Figures 24A and 24B: After 1 year of loading — needs more oral hygiene care
Pitt Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc. 1996; 127: 1491-4.
Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al.,. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol. 2007;23:66-71.
Podaropolous L, Vies A et al.,. Bone regeneration using Beta Tri-Calcium Phosphate in a Calcium Sulfate matrix, Journal of Oral Implantology 35(1):28-36.
Gutta R, Baker R, et al.,. Barrier membranes used for ridge augmentation: is there an optimal pore size? J Oral Maxillofac Surg. 2009;67(6):1218-25. Hitchcock R, Ellis E, Cox CF. Intentional vital root resection: a 52 week histopathologic study in Macaca Mulatta. J Oral Surg., Oral Med., Oral Path. 1985;60: 2-14. Hunt JA, Cooper JJ (2012). The significance of zeta potential in osteogenesis. society for biomaterials , 31st meeting for biomaterials , Pittsburgh, PA 2006. 2012;592. Lawley GR, Schindler WG, Walker WA, Kolodrubetz D. Evaluation of ultrasonically placed MTA and fracture resistance with intracanal composite resin in a model of apexification. J Endod. 2004;30:167-172. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations.0 1993;19:541-4.
Brunette TM (2001). Titanium in Medicine. Springer 649-673.
Nair PN, Duncan HF, Pitt Ford TR, Luder HU. Histological, ultrastructural and quantitative investigations on the response of healthy human pulps to experimental capping with mineral trioxide aggregate: a randomized controlled trial. Int Endod J. 2008;41:128-150.
Cvek M, Tsilingaridis G, Andreasen JO. Survival of 534 incisors after intra-alveolar root fracture in patients aged 7-17 years. Dental Traumatol. 2008;24:379-87.
a cost-effective, low-pain, and ethical solution have been met. IP
Felippe WT, Felippe MC, Rocha MJ. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. Int Endod J. 2006;39:2-9.
Bornstein M, Hart C, Buser D et al.,. Early loading of nonsubmerged Titanium Implants with a chemically modified, sandblasted and acid-etched surface ; 6 month results of a prospective case series study in the posterior mandible, focusing on peri-implant crestal bone changes and Implant stability Quotient (ISQ) values. Clin Implant Dent Relat Res. 2009;11(4):338-47.
Cvek M, Mejare I, Andreasen JO. Conservative treatment of teeth fractured in the middle or apical part of the root. Dent Traumatol. 2004;20:261-269.
Figure 24B
Leventis M, Fairbairn P, Vasiliadis O et al.,. Socket Grafting using Beta Tri-Calcium Phosphate in a Calcium Sulfate matrix. EAO Poster, Copenhagen. 2012: 525.
Pace R, Giuliani V, Pin Prato L, Baccetti T, Pagavino G. Apical plug technique using mineral trioxide aggregate: results from a case series. Int Endod J. 2007; 40:478484.
Schenk RK. Bone regeneration: biologic basis. In: Buser D, Dahlin K, and Schenk RK, eds. Guided Bone regeneration in Implant Dentistry. London, UK: Quintessence; 1995:49-100. Schropp L, Wenzel A, et al.,. Bone Healing and soft tissue changes following a single tooth extraction: A Clinical and radiographic 12 month study. Int J Periodontics Restorative Dent. 2003;23(4):313-23. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one visit apexification treatment: a prospective study. Int Endod J. 2007;40:186-197. Smeets R, Kolk A, et al., A new biphasic osteoinductive calcium composite material with a negative zeta potential for bone augmentation. Head & Face Medicine. 2009;13(5):13. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod. 1999;25:197-205. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod. 1995;21:349-353. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a rootend filling material. J Endod. 1995; 19:591-595. Welbury RR, Kinirons MJ , Day P, Humphreys K, Gregg TA. Outcomes for root-fractured permanent incisors: a retrospective study. Pediatr Dent. 2002;24: 98-102. Zhao J, Watanabe T et al.,. Transcriptome analysis of BTcP implanted in a dog mandible bone. Elsevier. 2012;864-877.
Fairbairn P. Membrane-free guided bone regeneration. EDI Journal. 2011;7(3):74-80.
30 Implant practice
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Multi-disciplinary approach to the treatment of traumatic root fracture: a case study 1. In the horizontally fractured tooth, ______ usually occurs in the coronal fragment, while the pulp of the apical fragment remains vital. a. necrosis of the pulp b. calcium deficiency c. residual bone d. an access cavity 2. ______was developed in the 1990s as a root end filling material. a. Gutta percha b. Mineral trioxide aggregate (MTA) c. CaSO4 (calcium sulfate) d. Chlorhexidine 3. It (MTA) is associated with favorable apical healing when used as an apexification material in immature teeth with open apices because it ______, and is nonresorbable. a. encourages hard tissue formation b. is biocompatible c. provides a good seal (prevents microleakage) d. all of the above 4. Guided bone regeneration is generally needed in trauma cases where dental implants are to be placed due to _____. a. mature root resorption b. bone damage during the trauma
c. as a result of post-traumatic infection d. both b and c
c. chlorhexidine d. titanium
5. A delayed immediate placement protocol is the standard procedure where the tooth or root is removed carefully, so as to not damage the residual bone, and then left to heal for ___ week(s). a. 1 b. 2 c. 3 d. 4
8. It is also noted that most particulate graft materials (Vital in particular) exhibit a _____ isoelectric charge in an aqueous solution, which attracts host bone morphogenetic proteins (BMPs) such as osteoponin and osteocalcin in greater numbers to the site. a. negative b. positive c. neutral d. stable
6. Bone healing is further improved by not using a traditional (collagen-type) membrane that inhibits periosteal blood to the graft site, which accounts for ____ (or more) of the blood supply to the site. a. 50% b. 65% c. 85% d. 92% 7. The stability and soft tissue cell occlusive properties needed for successful bone regeneration are achieved by a ____element in the graft material; hence, the graft is its own membrane. a. MTA b. CaSO4
9. Once loaded, there appears to be little change in the profile in line with ____, in that function is essential to retain bone. a. Wolff’s Law b. Lambert-Beer’s law c. Fresnel’s law d. Bouger’s law 10. Trauma cases should be carefully monitored _____. a. clinically b. radiographically c. with sensitivity tests (thermal, electric pulp testing) d. all of the above
Volume 7 Number 1 Implant practice 31
CE CREDITS
IMPLANT PRACTICE CE
CONTINUING EDUCATION
Management of biological and biomechanical implant complications Drs. Yung-Ting Hsu and Hom-Lay Wang summarize and reveal management protocols for implant complications
T
here is no doubt that the advent of dental implants is a revolution in modern dentistry. In addition to fixed and removable prostheses supported by natural teeth, patients are now offered implants for replacement of their missing teeth. Without sacrificing tooth structure, implants resemble natural teeth in both function and esthetics. Thus, more and more implants have been placed in the past decades. Like the occurrence of periodontal disease or caries on natural teeth, however, the presence of peri-implant complications has been rising in recent years.
What are implant complications? From the authors’ point of view, implant complications can be categorized into three major types: biological, biomechanical, and esthetic implant complications. Similarly to periodontal disease, biological implant complications (ie, peri-implant diseases) present the inflammatory reactions on peri-implant tissues, including peri-implant mucositis, peri-implantitis, and implant loss. The primary etiologic factors of biological implant complications are bacterial pathogens and impaired host immune response. Besides these, multiple
Yung-Ting Hsu, DDS, MSD, finished the residency program in graduate periodontics at University of Michigan (Ann Arbor, Michigan, USA) in 2013. Hom-Lay Wang, DDS, MSD, PhD, is Collegiate Professor of Periodontics, Professor and Director of Graduate Periodontics at the University of Michigan. Dr. Wang has published more than 22 book chapters/ invited reviews and more than 300 scientific articles. He serves as a chair of the Website Educational Committee for the Academy of Osseointegration, is a diplomate and a former co-chair and director of the American Board of Periodontology, and a fellow of American College of Dentists. He serves as an associate editor for JOMI, is a founding editorial board member for Clinical Advances in Periodontics, and an editorial board member on many other publications. The authors do not have any financial interests, either directly or indirectly, in the products or information listed in the paper.
32 Implant practice
Educational aims and objectives The aim of this article is to present a clear explanation of and suggested treatment approaches for implant complications. Expected outcomes Correctly answering the questions on page 36, worth 2 hours of CE, will demonstrate the reader can: • Recognize the difference between biological and biomechanical complications. • See how they present clinically. • Realize the current consensus on treatment protocols.
factors have been linked with the presence of biological implant complications, such as a history of periodontal disease, inadequate oral hygiene, and so on. Residual cement and smoking have also been reported as the risk factors (Mombelli and Decaillet 2011; 2013). On the other hand, mechanical overload is considered as the main cause of biomechanical implant complications (Misch, et al., 2005). Unlike natural teeth, dental implants contact supporting bone directly instead of the periodontal ligament (PDL). Without the cushion provided by the PDL, occlusal overstressing on dental implants tends to concentrate on crestal bone regions or implant prosthetic components and thereby causes biomechanical complications. Furthermore, other factors may also contribute to the occurrence of biomechanical overload, including inappropriate implant position, poor implant or prosthetic designs, and parafunction (Fu, et al., 2012; Hsu, et al., 2012). Even though the implant survival rate is high in general, the presence of implant complications is not rare. Previous studies reported the incidence of peri-mucositis was approximately 50% (Roos-Jansaker, et al., 2006; Rinke, et al., 2011). It is believed that this number was underestimated due to the reversibility of peri-mucositis (2013). For the complications caused by occlusal overload, Goodacre and co-workers reported several complications occurring in 1%-22% of implant-supported fixed prostheses (Goodacre, et al., 2003).
As for the occurrence of marginal bone loss, however, it varied from the definition/ criteria used in different studies. Depending on the criteria, the prevalence of marginal bone loss ranged from 16.0%-36.6% (Roos-Jansaker, et al., 2006; Koldsland, et al., 2010). In fact, these data are suggesting that it is about time to face the challenges of peri-implant complications and learn how to properly manage them to better serve our professional, as well as the patients whom we are treating.
How to manage biological and biomechanical implant complications? People say, “An ounce of prevention is worth a pound of cure.” To decrease the incidence of implant complications, it is important to have a comprehensive treatment plan and sound clinical performance both surgically and prosthetically. Regular implant maintenance is also essential after active therapy. Indeed, most of the implant biological complications are found during supportive therapy. The earlier the complication is diagnosed, the easier the clinician can fix the problem. The following section aims to suggest a flow chart about management of implant complications, which is summarized in Figure 1.
Examination During implant maintenance, a thorough examination is the first step to prevent the existing peri-implant complications getting Volume 7 Number 1
Examinations
Biomechanical complications
Diagnosis
• Fracture or loosening of implant/ prosthesis components • Marginal bone loss • Implant fracture
Biological complications • Tissue reactions: Peri-implant mucositis or peri-implantitis • Loss of osseointegration
Management Remove etiological factors and control contributing factors, including occlusal equilibration
For fracture or loosening of implant/prosthesis components • Retighten or replace the component • Occlusal bite splint delivery
For tissue reaction and/or marginal bone loss • Non-surgical therapy • Surgical therapy • Regenerative surgery • Resective surgery plus implantoplasty • Adjunctive therapy: laser, antibiotics • Occlusal bite splint delivery
For severe marginal bone loss (> 1/2 implant length), loss of osseointegration or implant • Implant removal
Regular maintenance Figure 1: Management of biological and mechanical implant complications
worse. The clinician can identify these complications by patients’ complaints, clinical examination, and radiographic assessment. Clinically, probing around implants with light force (0.25 N) using conventional probes is allowed and helpful to detect periimplant diseases in the early stage (Etter, et al., 2002; Heitz-Mayfield, et al., 2013). Probing depth and bleeding on probing (BOP), as well as gingival color alteration, may indicate the changes of peri-implant health and the severity of disease. Checking occlusion and the integrity of prosthetic components is also helpful in recognizing possible biomechanical implant complications. Nevertheless, implant mobility is not considered as an effective indicator because it could only detect the differences in the late stage (2013). Besides, the changes to hard tissue can be investigated by using radiographic aids. Conventional radiographic examina-
tions, such as periapical films and vertical bitewings, are necessary for baseline and annual assessment. They can help discover the crestal bone level changes, or the presence of pathologic lesions. In spite of scattering effects, cone beam computed tomography (CBCT) scan may also provide the information for fenestration or dehiscence through its three-dimensional images. In some persistent cases of biological complications, clinicians and patients may benefit from microbiological analysis to select antibiotics adjunctive therapy.
Diagnosis After examination, accurate diagnosis is the next step that guides us toward the direction of treatment strategies. According to the recent American Academy of Periodontology (AAP) statement, peri-mucositis has been defined as an inflammatory reaction limited on soft tissue around implants, whereas peri-
implantitis infects both soft tissue and supporting bone (2013). The signs of peri-implant disease include BOP, gingival redness, and possible suppuration (Lang and Berglundh 2011). Biomechanical implant complications comprise the fracture or loosening of implant prosthetic components, early implant loss, and fracture of the implant body. Moreover, they share the same characteristics: progressive marginal bone loss, which may lead to implant loss in the late stage. For those implants without a radiographic baseline, peri-implantitis may be diagnosed if the marginal bone loss is ≥ 2 mm following biological bone remodeling (Sanz, et al., 2012). It should be kept in mind that the signs of both biological and biomechanical implant complications may be combined in the same lesions due to the presence of multiple etiologic factors.
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• Clinical examinations (probing, BOP, exudate, occlusion, mobility ... etc ) • Radiographic examination if needed (peri-apical films, vertical bitewing, and CBCT scan) • Microbiological analysis
CONTINUING EDUCATION
Figure 2: The presence of peri-implant complications on the LL5 implant-supported crown with cryonic periimplant mucosa as well as the presence of BOP and exudate
Figure 3: The presence of peri-implant complications with marginal bone loss
Figure 4: After flap reflection, an infrabony defect on buccal aspect of the implant was noticed
Figure 5: Regenerative therapy was performed using allograft and collagen membrane
Figure 6: Postoperative outcome at 3 months after surgery. Significant bone fill of the infrabony defect was noticed
Figure 7: Postoperative outcome at 6 months after surgery. The postoperative crestal bone level remains stable
Management
or repaired. Besides, occlusal bite splint is highly recommended for patients suffering from parafunction (Hsu, et al., 2012). Treatment strategies vary in the management of marginal bone loss, depending on the morphology and severity of bony destruction. For minor bony destruction (i.e., vertical bone loss ≤ 2 mm), non-surgical therapy, including adjunctive therapies, is recommended. Instead, surgical therapy is more effective in the treatment of bony destruction > 2 mm where that is still less than half of implant fixture length. Similarly to periodontal defects, regenerative surgery should only be considered for 2- or 3-wall intrabony defects. Meanwhile, osseous resective surgery and implantoplasty are suggested for those defects presenting suprabony or non-regenerative destruction (Okayasu and Wang 2011; Muthukuru, et al., 2012; Renvert, et al., 2012). If occlusal overload contributes to the marginal bone loss, occlusal splint should be considered after correction of occlusal problems (change/modification of implant prosthesis or selective occlusal adjustment).
In addition to conventional methods, various adjunctive therapies have been suggested in the treatment of periimplantitis to decontaminate the implant surface, such as chemical, mechanical, and laser treatments and photodynamic therapy (PDT). A recent meta-analysis suggested that the use of local antibiotic delivery brought minor but significant improvement in the treatment of periimplantitis (Muthukuru, et al., 2012). On other hand, the adjunctive benefits of systemic antibiotics have not been investigated (Renvert, et al., 2012). Laser therapy has also been used for the decontamination of the implant surface. Nevertheless, the efficacy has not been confirmed in either non-surgical or surgical treatments (Meyle 2012; Renvert, et al., 2012). Implant removal should also be kept in mind as an option in the treatment of severe implant complications. For example, those implants with loss of osseointegration should be removed as soon as possible to prevent further inflammation and tissue loss. In implants with severe bony destruction — of more than 1/2 of implant length — or placed in inappropriate positions, removing
Removal of etiologic factors and control of contributing factors are essential to stop disease progression. In other words, eliminating biofilms and related risk factors are the primary goal when treating biological implant complications. In addition to adequate home/ professional care and controlled systemic disease, smoking cessation should be discussed with patients prior to implant therapy. For peri-implant mucositis, it is believed that non-surgical therapy using mechanical debridement is capable of controlling the inflammation and reducing probing pocket depth (Porras, et al., 2002; Trejo, et al 2006). Non-surgical therapy also includes laser treatment and chemical antimicrobial agents (Heitz-Mayfield, et al., 2013). As for the management of biomechanical implant complications, finding and removing the source of overstress are essential (Kim, et al., 2013). Occlusal equilibration should be done prior to retightening the loosening prosthesis/abutment screw. The fracture prosthetic components should be replaced 34 Implant practice
Volume 7 Number 1
the implant is a good option instead of saving implants with uncontrolled infection (Okayasu and Wang 2011; Aljateeli, et al., 2012). In around 1% of cases presenting biomechanical implant complications, implant removal is the only option to treat implant body fracture (Hsu, et al., 2012).
prosthetic components, clinicians need to consider the occlusal bite splint therapy as a proactive precaution. Nevertheless, implant removal should always be an option when the destruction is too severe to be repaired. With the increasing need for implant placement, the occurrence of peri-implant complications is becoming a worldwide challenge. As implantologists in a new era, clinicians should have the knowledge of implant therapy, as well as associated peri-implant complications. More research is needed to further investigate peri-implant complications and their management. With the changing of these treatment approaches, it should be borne in mind that “a disease known is half-cured.” IP This paper was partially supported by the University of Michigan Periodontal Graduate Student Research Fund.
Case report This 50-year-old female, who is a former smoker, presented for implant maintenance. The implants were placed on the LL5 and LL6 about 6 months ago. She reported the tenderness of periimplant mucosa starting from a couple of weeks after the implant-supported crown delivery. In addition to localized gingival redness (Figure 2), the probing depth was 7 mm on buccal and distobuccal aspects of the LL5 implant with BOP and exudate discharge. Periapical film also showed marginal bone loss (Figure 3). Fortunately, there was no premature contact or signs of overloading when checking occlusion. This lesion was thus diagnosed as a biological implant complication. To treat a peri-implant defect with >2 mm vertical bone loss, surgical therapy was planned. Due to the defect morphology (Figure 4), regenerative surgery was performed using allograft (enCore® mineralized allograft, Osteogenics Biomedical) and a collagen membrane (Pericardium, Zimmer Dental Inc.) (Figure 5). Significant regeneration was found at 3 months and 6 months post-operatively (Figures 6 and 7). After 6 months healing, the peri-implant mucosa returned to healthy status without BOP or exudate (Figure 8).
Conclusion In conclusion, treatment strategies of periimplant complications should be chosen based upon each individual case scenario.
References Clem DS, Cochran DL, Froum SJ, McAllister BS, Renvert S, Rosen PS, Wang H-L. American Academy of Perioodntology Report. Peri-implant mucositis and peri-implantitis: a current understanding of their diagnoses and clinical implications. J Periodontol. 2013;84(4): 436-443. Aljateeli M, Fu JH, et al. Managing peri-implant bone loss: current understanding. Clin Implant Dent Relat Res. 2012;14(Suppl 1):e109-118. Etter TH, Hakanson I, et al. Healing after standardized clinical probing of the perlimplant soft tissue seal: a histomorphometric study in dogs. Clin Oral Implants Res. 2002;13(6):571-580. Fu JH, Hsu YT, et al.. Identifying occlusal overload and how to deal with it to avoid marginal bone loss around implants. Eur J Oral Implantol. 2012;5(Suppl): S91-S103. Goodacre CJ, Bernal G, et al. Clinical complications with implants and implant prostheses. J Prosthet Dent. 2003;90(2):121-132. Heitz-Mayfield LJ, Needleman I, et al. Consensus Statements and Clinical Recommendations for Prevention and Management of Biologic and Technical Implant Complications. Int J Oral Maxillofac Implants. 2013 Aug 15. Hsu YT, Fu JH, et al. Biomechanical implant treatment complications: a systematic review of clinical studies of implants with at least 1 year of functional loading. Int J Oral Maxillofac Implants. 2012; 27(4):894-904.
Meyle J. Mechanical, chemical and laser treatments of the implant surface in the presence of marginal bone loss around implants. Eur J Oral Implantol. 2012;5 (Suppl): S71-S81. Misch CE, Suzuki JB, et al. A positive correlation between occlusal trauma and peri-implant bone loss: literature support. Implant Dent. 2005;14(2):108-116. Mombelli A and Decaillet F (2011). The characteristics of biofilms in peri-implant disease. J Clin Periodontol 38 (Suppl 11):203-213. Muthukuru MA, Zainvi A, et al. Non-surgical therapy for the management of peri-implantitis: a systematic review. Clin Oral Implants Res. 2012;23 (Suppl 6):7783. Okayasu K and Wang HL. Decision tree for the management of peri-implant diseases. Implant Dent. 2011;20(4):256-261. Porras R, Anderson GB, et al. Clinical response to 2 different therapeutic regimens to treat peri-implant mucositis. J Periodontol. 2002;73(10):1118-1125. Renvert S, Polyzois I, et al. (2012). Surgical therapy for the control of peri-implantitis. Clin Oral Implants Res. 2012;23(Suppl 6):84-94. Rinke S, Ohl S, et al. Prevalence of peri-implant disease in partially edentulous patients: a practicebased cross-sectional study. Clin Oral Implants Res. 2011;22(8):826-833.
Kim Y, Oh TJ, et al. Occlusal considerations in implant therapy: clinical guidelines with biomechanical rationale. Clin Oral Implants Res. 2005;16(1):26-35.
Roos-Jansaker AM, Lindahl C, et al. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. J Clin Periodontol. 2006; 33(4):290-295.
Koldsland OC, Scheie AA, et al. Prevalence of periimplantitis related to severity of the disease with different degrees of bone loss. J Periodontol. 2010; 81(2): 231-238.
Trejo PM, Bonaventura G, et al. Effect of mechanical and antiseptic therapy on peri-implant mucositis: an experimental study in monkeys. Clin Oral Implants Res. 2006;17(3): 294-304.
Lang NP and Berglundh T. Peri-implant diseases: where are we now? Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol. 2011;38(Suppl 11):178-181.
Volume 7 Number 1 Implant practice 35
CONTINUING EDUCATION
Figure 8: Postoperative outcome at 6 months after surgery. Peri-implant mucosa returned to healthy status without BOP or exudate
Comprehensive examinations together with accurate diagnoses are essential for the successful management of implant complications. In spite of the complexity of the treatments, the prime objective of the treatment is to eliminate/control the etiologic factors and the contributing factors. Depending on the severity of diseases, various approaches are available to manage biological implant complications, including non-surgical mechanical/chemical debridement, regenerative surgery, and resective surgery with or without implantoplasty. Adjunctive therapies, such as antibiotics and laser, may be helpful in certain cases. Meanwhile, occlusal equilibration should be achieved when treating biomechanical implant complications. Following repair or replacement of implant/
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Management of biological and biomechanical implant complications 1. Similarly to periodontal disease, biological implant complications (ie, periimplant diseases) present the inflammatory reactions on peri-implant tissues, including _______. a. peri-implant mucositis b. peri-implantitis c. implant loss d. all of the above 2. The primary etiologic factors of biological implant complications is(are) _____. a. bacterial pathogens b. impaired host immune response c. biomechanical overload d. both a and b 3. Unlike natural teeth, dental implants contact supporting bone _____instead of the periodontal ligament (PDL). a. directly b. indirectly c. incidentally d. inadequately 4. Without the cushion provided by the PDL, occlusal overstressing on dental implants tends to concentrate on crestal
36 Implant practice
bone regions or implant prosthetic components and thereby causes ____. a. pathogenic reactions b. biomechanical complications c. residual cement d. peri-implantitis 5. Even though the implant survival rate is high in general, the presence of implant complications is not rare. Previous studies reported the incidence of peri-mucositis was approximately ____. a. 25% b. 35% c. 50% d. 75% 6. During implant maintenance, _____is the first step to prevent the existing periimplant complications from getting worse. a. a thorough examination b. frequent radiographs c. fenestration d. premedication 7. ______ is also helpful in recognizing possible biomechanical implant complications.
a. Tomograms b. Checking occlusion c. Checking integrity of prosthetic components d. Both b and c 8. The signs of peri-implant disease include _____. a. BOP (bleeding on probing) b. gingival redness c. possible suppuration d. all of the above 9. Occlusal equilibration should be done _____retightening the loosening prosthesis/abutment screw. a. after b. prior to c. during d. instead of 10. In around ___ of cases presenting biomechanical implant complications, implant removal is the only option to treat implant body fracture. a. 1% b. 5% c. 10% d. 15%
Volume 7 Number 1
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MDI
Mini Dental Implants
TECHNOLOGY
Advanced technologies and materials to efficiently deliver full mouth reconstructions Dr. Ara Nazarian suggests a treatment solution that results in more control and fewer appointments
H
aving the ability to take a patient from point A-Z in a fewer amount of appointments within your practice allows you to position yourself as a provider who can fulfill your patient’s surgical and restorative needs. With the proper training, a dental provider may provide extraction, grafting, and implant placement within one appointment at one location. Not only does this allow you to reduce the amount of visits for the patient, but this type of service also helps stay within the patient’s budget. Most importantly, this enables the dental provider full control of the surgical and prosthetic outcome. Depending on the patient’s desires, the clinical conditions of the oral environment present, and the skills of the provider, a dentist may choose to extract teeth, level bone, and graft with simultaneous dental implant placement. A patient in his mid-60s presented to the office with discomfort due to multiple rampant caries and generalized advanced periodontal disease (Figures 1 and 2). Having already visited multiple providers for a consultation, he was very frustrated with the treatment options offered due to varying treatment plans that were segmented by different disciplines. Since many of these options did not complement the other, the patient decided to come to us for full treatment (A-Z) after being referred to us by one of our patients who had already undergone a Total Dental Solutions Reconstruction™. Before the surgical appointment, a CBCT scan was taken to accurately treatment plan this case to make certain
Ara Nazarian, DDS, DICOI, maintains a private practice in Troy, Michigan, with an emphasis on comprehensive and restorative care. He is a Diplomate in the International Congress of Oral Implantologists (ICOI). His articles have been published in many of today’s popular dental publications. Dr. Nazarian is the director of the Reconstructive Dentistry Institute. He has conducted lectures and hands-on workshops on esthetic materials and dental implants throughout the United States, Europe, New Zealand, and Australia. Dr. Nazarian is also the creator of the DemoDent patient education model system. He can be reached at (248) 457-0500 or at the website www.aranazariandds.com
38 Implant practice
Figure 1: Retracted preoperative view
Figure 2: Preoperative panorex
Figure 3: Maxillary virtual treatment plan
Figure 4: Mandibular virtual treatment plan
that no complications would arise from doing all the procedures (extract, graft, and implant placement) in the Total Dental Solutions Reconstruction protocol. SimPlant® software (Materialise Dental, Glen Burnie, Maryland) was used through 3D Diagnostix virtual assistance to precisely plan the placement of six Engage™ (OCO Biomedical) dental implants in the maxillary arch, as well as seven Engage dental implants in the mandibular arch, using CTbased surgical pilot guides (Figure 3 and 4). The final treatment plan desired was fixed bridges on implants in the upper and lower arches. Engage dental implants were selected (Figure 5) because I have personally experienced their high implant stability at placement, which is a critical success factor during the early healing process of osseointegration with these types of cases. With the combination of their patented Bull Nose Auger™ tip and Mini Cortic-O Thread™, the Engage (OCO Biomedical) implant system offers practitioners a bone level implant with high initial stability
for selective loading options. In fact, the Engage (OCO Biomedical) implant body creates a tapping pattern when threaded for an enhanced mechanical lock in the bone. Other dental implant systems with aggressive threading may include but are not limited to NobelActive (Nobel Biocare®), Seven (MIS), ETIII (Hiossen), I5 (AB Dental USA), and AnyRidge® (Megagen). In order to be effective and more proficient during these Total Dental Solutions Reconstruction procedures, I will utilize IV sedation. Not only does it make the appointment easier for me, but also patients prefer to get everything done in one visit. Since they are sedated, a mouth prop is needed to keep their mouth open. Because of this, I will routinely extract teeth in quadrants starting from the upper left to the upper right and then down to the lower right and lower left. This allows great time savings as it is easier to keep the patient’s mouth open and be able to proceed around the arches safely. Once the teeth are extracted, I will reflect the tissue in order to get the bone Volume 7 Number 1
One? Or two stage? Immediate? Early? Or delayed loading? Resonance Frequency Analysis as a technique to measure implant stability and osseointegration is fast becoming a global diagnostic standard. With more than 500 articles published in scientific journals it is a proven scientific method as a guide to predictable surgical and restorative protocols. Manage implants at risk - You’ll find Osstell ISQ especially valuable for achieving more predictable outcomes when treating higher risk patients and implants at risk for failure due to poor integration. Osstell gives you an early warning, as a decreased ISQ value, if osseointegration isn’t progressing as expected. It can help you avoid costs of an implant failure or redoing a crown due to premature loading. Osstell can also assist you in being more confident about treating
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patients with risk factors, more predictably. Reduce treatment time - If the initial mechanical stability is high enough a one-stage approach is often used together with immediate- or early loading. By measuring again before the final restoration, and comparing that value to the baseline value taken at placement, the decision whether to proceed or not is made quick and easy. With Osstell as a part of your quality assurance system it’s also easier to explain treatment planning and healing time to your patients and colleagues. Now Osstell brings you and your patient new certainty.
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TECHNOLOGY
Figure 5: Engage™ dental implant
Figure 6: Aseptico surgical motor
Figure 7: Using pilot guide
Figure 8: Osstell® ISQ unit
Figure 9: Goodfit Instant Custom C&B Tray
Figure 10: Full arch impression
Figure 11: Retracted postoperative view
Figure 12: Postoperative panorex
level surgical guides seated and fixed with their respective retention pins. Using these pilot surgical guides provided by 3D Diagnostix, the sites for the implants were begun with a 1.95 mm pilot drill utilizing the Mont Blanc surgical handpiece and Aseptico surgical motor (AEU 7000) at a speed of 1200 rpm with copious amounts of sterile saline (Figures 6 and 7). Paralleling pins were placed in the sites of the osteotomies to confirm the accuracy of the surgical guide, and X-rays were taken to check the angulations of the pins within the maxilla and the mandible. Once the osteotomies were complete, an implant finger driver was used to place the Engage dental implants until increased torque was necessary. The ratchet wrench was then connected to the adapter, and the implants torqued to final depths reaching a torque level of about 50-60 Ncm. Adequate implant fixation was further verified using an Osstell® implant stability quotient (ISQ) implant stability meter (Osstell), which uses resonance frequency analysis as a method of measurement (Figure 8). Several studies have been conducted based on resonance frequency analysis (RFA) measurements and the ISQ scale. They provide valid indications that the acceptable stability range lies above 55 ISQ. Extended healing caps were handtightened to the implants. A postoperative radiograph was made of the implants and the healing caps to ensure complete seating. The immediate dentures were soft relined with a silicone-based soft denture relining material Ufi Gel SC (VOCO 40 Implant practice
America). Some of the advantages I have personally experienced with this material are that it is biocompatible, tasteless, and odorless. By using the extended healing caps with the soft reline, the immediate dentures were much more retentive. The soft tissue and implants were evaluated clinically after 1 week. The patient stated he had very little postoperative discomfort or swelling. Within 10 days, the patient returned to the dental office. The soft tissue around the extended healing caps healed very nicely with a healthy pink color. Using impression posts, full arch impressions were taken using Instant Custom C&B Trays (Goodfit). These custom trays can be adapted and fitted in minutes, eliminating the need for models, light cure materials, monomers, and extra laboratory time in custom impression tray fabrication because they are made of a material, polymethyl methacrylate (PMMA), that becomes adjustable when heated (Figure 9) and maintains its shape while cooling. Once molded for the patient, full arch impressions were taken using a polyvinylsiloxane impression material (Take 1® Advanced, Kerr®) (Figure 10). Bite relations, as well as instructions for size, shape, and color for full arch provisionals, were forwarded to the dental laboratory. With only a 5-day turnaround, the custom abutments and provisionals were forwarded to the dental office and inserted. The patient was very pleased with the esthetics and function of these provisional restorations. He was instructed about their care and use in
eating, speaking, and biting. Approximately 4 months after the initial placement of the dental implants, the patient returned for the definitive porcelain fused to metal restoration impressions. The provisional restorations were removed using the Pneumatic Crown and Bridge Remover (DentCorp). Any temporary cement was removed and the abutments inspected. If there was any settling or recession of the gingival tissue, the abutments were modified using a carbide bur with copious amounts of water so as not to overheat the abutments. This way, the margins could be brought right at or slightly below the free gingival marginal area. A full arch impression was taken in a similar fashion for the abutments and the provisionals. In addition, the relations between maxillary and mandibular arches were captured. Within 3 weeks, the porcelain fused to metal restorations were inserted and a panorex taken (Figures 11 and 12). More and more patients are presenting to dental practices requiring this type of reconstruction. By providing multiple services in a shorter number of visits with the use of CBCT and other technologies, you, the dental provider, will find more patients who will accept treatment. In doing so, you are not only helping your patients get to proper form and function, but also helping them achieve a Total Dental Solutions Reconstruction in a fewer amount of appointments. IP
Volume 7 Number 1
G N I H T T E S N E O B B E H T NEXT TO
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Visit TrabecularMetal.zimmerdental.com to view a special bone ingrowth animation and request a Trabecular Metal Technology demo. www.zimmerdental.com ©2013 Zimmer Dental Inc. All rights reserved. * Data on file with Zimmer Dental. Please check with a Zimmer Dental representative for availability and additional information.
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TECHNOLOGY
Verified osteoinductive allograft putty for dental implant regeneration: preliminary findings of three clinical applications Dr. John Lupovici illustrates clinical cases using RegenerOssŽ Allograft Putty to regenerate three distinct osseous defects Introduction Many events may lead to the loss of native oral bone. These include trauma, developmental anomalies, pathological processes (acute and chronic), and tooth loss.1-3 When alveolar bone resorption occurs, the residual hard tissue may be insufficient to support dental implants. Alternatively, implants may be placed, but the dearth of bone may lead to improper positioning, compromising the definitive restoration. Improperly positioned implants are associated with biomechanical concerns (screw loosening, fractures of the screw, implant, implant collar, prosthesis, or porcelain)4-6 as well as poor screw-access positioning and unnatural emergence profiles. A variety of bone-augmentation strategies have been developed to avoid such problems and enable dentists to accurately recreate natural dental function and esthetics. Onlay, inlay, and veneer grafts,7-9 sinus augmentation,10-12 ridge splitting and expansion,13,14 guided bone regeneration,15-19 nerve lateralization,20 and distraction osteogenesis21 all have a documented record of success when used to treat horizontally and vertically atrophic ridges, extraction sockets, implantassociated defects, and other anatomical deficiencies. Most of these techniques require the use of bone-grafting materials. Autografts, allografts, xenografts, and alloplasts all have been documented to be successful, used either alone or in combination. Among them, autogenous bone has long been considered the gold standard. Depending upon the donor site and the manner in which it is harvested, autogenous bone has proven to be osteoconductive, osteoinductive, and nonantigenic — all
John Lupovici, DDS, is a Diplomate of the American Board of Periodontology and a faculty member at the New York University College of Dentistry Department of Periodontics.
42 Implant practice
Figure 1: Initial occlusal view of the extraction socket of the mandibular first molar
Figure 2: Post-extraction alveolus filled with osteoinductive graft material
Figure 3: Occlusal view of the regenerated site 3 months after extraction and grafting
Figure 4: The implant was placed in the newly regenerated bone adjacent to the biopsy core harvest site.
properties of an ideal grafting material. However, the use of autogenous bone also has been associated with a number of disadvantages, including patient morbidity, parasthesia, anesthesia, and neurosensory changes to the proximal teeth and tissue, edema, ptosis, incision dehiscence, and infection.8,22-25 Implants placed in autogenous block grafts have been associated with lower survival rates,26 and significant resorption has been reported.7,27-30 Allograft bone, commercially available in a variety of sizes, shapes, and processing techniques, is an alternative to autogenous material. Successful results from using allografts have been reported in the periodontal and implant-regenerative literature for more than three decades.31 Moreover, using this material enables patients to avoid having a second surgical site. The question of whether freeze-dried
bone allograft (FDBA) or demineralized freeze-dried bone allograft (DFDBA) is superior for regeneration has generated some controversy. Successes with both have been documented in case reports, and when used primarily in intraosseous defects, significant clinical differences between the two materials have not been found.19,32-34 However, DFDBA historically has been considered to be a better choice in challenging regenerative sites because of the demineralization process. Urist has described35 how this process bathes the allograft in an acidic solution, thereby exposing the bone-morphogenetic proteins, which theoretically render it osteoinductive. When used in dental applications in combination with a barrier membrane, clinical results of DFDBA grafts in both humans and animals have varied significantly,36-39 and the osteoinductivity of the DFDBA has come into question. The variaVolume 7 Number 1
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TECHNOLOGY
tion in clinical results has been linked to a number of potential factors, including sterilization techniques,40-41 particle size,42 and donor age.43 The processing techniques of individual bone banks also may affect the inductive capacity of the bone.44,45 RegenerOssŽ Allograft Putty (Biomet 3i, Palm Beach Gardens, Florida) is an allograft material that was used for a long time in orthopedics before recently being adapted for oral and maxillofacial grafting applications. It presents in putty form, consisting of osteoinductive DFDBA (40% by weight) suspended in lecithin, an organic phosphatidylcholine. The DFDBA in RegenerOss Allograft receives routine screening for HIV, hepatitis, and other infectious agents. Furthermore, the Saos cell-proliferation test is used to verify the osteoinductivity of every sample. Results of this assay have demonstrated a correlation coefficient of 0.850 (p < 0.0005) with implantation of demineralized bone into athymic rat muscle.46 Although one aspect of the processing technique for removing lipids from demineralized bone has been found to inhibit osteoinduction significantly, adding purified lecithin to the DFDBA appears to restore the osteoinductive activity and enhance biological activity above that of a standard demineralized bone preparation.47 Naturally present in cell membranes, tissues, and organs, lecithin is believed to play an active role in the biologic calcification that occurs during osteogenesis.48 Clinical benefits of the lecithin carrier include the fact that, as a lipid, it is hydrophobic, offering high resistance to irrigation, blood, and saliva. It provides remarkable ease of handling and excellent graft containment after being exuded into the defect site. When incubated at 37°C, the putty maintains a solid state and remains intact at the graft site for 7 to 14 days, after which it is absorbed by the body with no foreign-body reaction. Autogenous or other additional bone-grafting material easily can be combined with it, should that option be desired. Other commercially available allograft putties use glycerol as a binding agent, and hence, may pose concerns over toxicity. The following clinical cases illustrate the use of RegenerOss Allograft Putty to regenerate three distinct osseous defects.
44 Implant practice
Figure 5: Three-month histology of newly formed bone, in association with residual graft material. A large degree of trabeculation is evident. Original magnification x10
Figure 6: Six-month histology sample displaying new bone and vasculature, with a reduction in medullary space. Original magnification x10
Figure 7: High-power magnification of 6-month sample displaying blood vessel. Original magnification x40
Case Presentations Case No. 1 This 47-year-old, systemically healthy female patient presented with a periodontally
hopeless mandibular right first molar. Following administration of local anesthesia (Lidocaine with epinephrine 1:100,000), the molar was sectioned, and the mesial and Volume 7 Number 1
TECHNOLOGY
Figure 8: A buccal dehiscence defect exposed four threads on the facial aspect of the mesial implant
Figure 9: Osteoinductive allograft putty was applied to cover the residual threads
Figure 10: A biologic membrane was adapted over the graft material
Figure 11: Intraoperative view of the newly regenerated bone 5 months after grafting
Figure 12: A full-thickness mucoperiosteal flap was reflected, and the maxillary right central incisor and left lateral incisor were extracted, revealing the narrow dimensions of the ridge
Figure 13: The facial view of the defect revealed vertical alveolar loss in conjunction with the horizontal defect seen in Figure 12
distal roots were atraumatically elevated from the alveolus (Figure 1). Care was taken to avoid traumatizing the alveolus. All granulation tissue was carefully curetted from the socket, which then was filled with the inductive allograft putty (Figure 2). A 2-mm thick slice of a collagen wound dressing material was placed over the graft to better contain the putty. The tissues were sutured, and no attempt was made to achieve primary closure. The patient received antibiotic therapy consisting of Amoxicillin 250 mg 3 times a day for 1 week. The regenerated area remained unloaded throughout the healing process. The patient returned for postoperative evaluation at 1, 3, 6, and 12 weeks postoperative. Soft-tissue healing was uneventful. Three months after the extraction and augmentation, the patient presented for implant placement. Intraoral examination revealed successful maintenance of the alveolar ridge width. Following administration of anesthesia, a fullthickness flap was reflected, and the preservation of the hard tissue was confirmed (Figure 3). A 3 mm trephine histology core was harvested on the mesial aspect of the graft site. This specimen was immediately fixed in 10% neutral buffered formalin for later histological preparation and examination. The osteotomy created by harvesting
the trephine core was enlarged, and the bone quality was noted to be Type 2-3, according to the Lekholm and Zarb scale. A parallel-walled implant was placed (Figure 4), and primary stability was verified. The tissues were then sutured, and primary closure was achieved. Three months after implant placement, osseointegration was verified radiographically. A full-thickness flap was reflected to enable placement of a healing abutment. To accommodate this, removal of a 1 x 2 mm wedge of augmented bone from the distal aspect of the previously regenerated socket was found to be necessary. The harvested bone was immediately stored in 10% neutral buffered formalin for later histologic examination.
months revealed newly formed bone and minimal residual graft material. The residual graft particles that were present were in close contact with bone or connective tissue. The new lamellar bone appeared vital with osteocytes in the lacunae (Figure 5). The histology sample obtained at 6 months displayed further new bone and vasculature with a reduced presence of residual graft material as well as medulary space. No histologic signs of inflammation were present in any of the sample slices (Figures 6 and 7).
Histological examination
processing
and
Both samples were dehydrated in increasing grades of ethanol and subsequently infiltrated with resin. After being embedded in methylmethacrylic resin, the samples were polymerized and sectioned vertically using a cutting-grinding unit. The 250-Âľm thick units obtained were further reduced by microgrinding and polishing to a final thickness of about 20-30 Âľm. The sections were stained with hematoxylin and eosin, and examined under a light microscope equipped with an image system. The histologic section obtained at 3
Case No. 2 The patient was a 54-year-old male who presented for full-mouth rehabilitation with fixed, implant-retained restorations. His medical history was unremarkable. The antibiotic regime described above was administered. A crestal incision of one edentulous mandibular segment was made, and reflection of a full-thickness gingival flap revealed the horizontal dimension of the residual alveolar ridge to be approximately 4-5 mm. Two implants were placed according to the manufacturerâ&#x20AC;&#x2122;s protocol, and primary stability was achieved for both. However, a buccal dehiscence defect exposed four threads on the facial aspect of the mesial implant (Figure 8). RegenerOss Allograft Putty was applied to the dehiscence to cover the
Volume 7 Number 1 Implant practice 45
TECHNOLOGY
Figure 14: RegenerOss Allograft Putty was adapted to the ridge before being covered with a resorbable collagen membrane
exposed threads completely (Figure 9), and a biologic membrane was trimmed to fit the contours of the graft site and placed in position (Figure 10). Passive primary closure was obtained by means of periosteal releasing incisions. Primary closure was maintained throughout the healing period. Five months after implant placement, a radiograph indicated successful osteointegration. One month later, re-entry for healing abutment connection revealed that the previously exposed threads were completely encased in newly regenerated bone (Figure 11). Case No. 3 The 44-year-old male patient presented with a failing three-unit anterior maxillary bridge that had been fabricated 15 years earlier. Examination revealed that the right central incisor structure was inadequate to support a replacement restoration. The left central incisor site, a long-standing pontic, was an atrophic knife-edge ridge. The left lateral incisor presented with severe periodontal involvement, vertical loss of attachment, and mesial-buccal loss of all facial plate to the apex. After the patient began antibiotic treatment, a papillary-preserving releasing incision was made on the mesial of the right lateral incisor, extending to the left cuspid. A full-thickness flap was reflected, and the right central incisor and left lateral incisor were extracted, revealing a loss of horizontal and vertical bone (Figures 12 and 13). RegenerOss Allograft Putty was adapted to the ridge (Figure 14), and a resorbable cross-linked collagen membrane was placed on top of the putty. Periosteal releasing incisions were made to attain passive primary closure. 46 Implant practice
Figure 15: Re-entry after 6 months demonstrated excellent bone regeneration and an increase in both the vertical and horizontal ridge dimensions
After 6 months of healing, papillarypreserving incisions were made, and a full-thickness flap was reflected, revealing notable regeneration of the alveolar crest (Figure 15). Two implant osteotomies were created in the two lateral incisor sites, and a 2 x 8 mm trephine core was harvested from a point midway between them for histological examination, and immediately stored in 10% neutral buffered formalin for histologic examination. The regenerated bone was judged to be Type 2-3. Two implants were placed in the lateral incisor positions, and primary stability was achieved. The implants healed unremarkably. Histologic preparation was executed in the same manner as described above. Microscopic examination of the histologic section revealed vital bone cells in conjunction with notable woven bone (Figure 16). The amount of residual graft particles noted in this sample was minimal and concentrated in the middle sections.
Discussion The outcome of osseous regeneration attempts has been shown to depend substantially on the defect morphology and the graft material used. In this case series, the same allograft putty was utilized in three different types of defects. When lesions are intraosseous, such as an extraction socket, proper containment of the graft material within the alveolar housing is limited only by the area of ingress to the bone, such as the socket entrance. Graft containment thus may be achieved in one of several ways. One technique utilizes a biocompatible collagen wound-dressing material over the graft material.49 This protects the graft from displacement, while at the same time
Figure 16: Histology revealed vital bone cells in conjunction with notable woven bone
inducing blood-clot formation via platelet aggregation and wound stabilization. The collagen material also functions chemotactically to attract fibroblasts and promote wound coverage.50 If a membrane or collagen sponge is not used to contain the allograft within the defect, the surgeon should attempt to achieve primary closure to prevent displacement of the graft material. The author believes this is particularly important when using RegenerOss Allograft Putty as a grafting material, because the tactile feeling and taste of the lecithin carrier tends to prompt increased patient tongue habits that potentially could displace the material. When the graft material must be applied outside the skeletal envelope, space maintaining becomes a concern. The lecithin carrier of the RegenerOss product has some space-maintaining properties, as the successful results seen in Case Nos. 2 and 3 attest. However, in the opinion of the author, combining the putty with an osteoconductive graft material is apt to yield even more predictably superior clinical results. It should be noted that in the two cases reported here in which the regenerated bone was later entered surgically, the bone was judged to be Type 2 or 3, despite displaying excellent histologic results. The explanation for this may lie in the nature of the demineralized allograft material. Even though no statistical difference in percentages of new bone formed has been found between sites grafted with DFDBA and FDBA, significantly less residual bone has been documented at DFDBAgrafted sites. If the mineralized material takes longer to resorb, sites regenerated with it might appear to be harder while, in fact, being no more successful than sites grafted with demineralized material. Volume 7 Number 1
TECHNOLOGY Conclusion The results obtained in the cases presented in this short-term preliminary report indicate that DFDBA combined with a lecithin carrier can be used to successfully augment a variety of deficient alveolar sites.
Although the regenerated bone in two of the three cases was Type 2-3, histological findings confirmed the development of well-vascularized bone marrow and newly formed bone. The verification of the osteoinductivity of this allograft putty
References 1. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extractions: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23:313-323. 2. Simon BI, Von Hagen S, Deasy MJ, Faldu M, Resnansky D. Changes in alveolar bone height and width following ridge augmentation using bone graft and membranes. J Periodontol. 2000;71:1774-1791. 3. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of buccal wall of extraction sockets of teeth with prominent roots. Int. J Periodontics Restorative Dent. 2006;26:19-29. 4. Rangert B, Jemt T, Jorneus L. Forces and moments on Branemark implants. Int J Oral Maxillofac Implants. 1989;3:241-247. 5. Patterson EA, Burguete RL, Thoi MH, Johns RB. Distribution of load in an oral prosthesis system: an in vitro study. Int J Oral Maxillofac Implants. 1995;5:552560.
18. Tolman D. Reconstructive procedures with endosseous implants in grafted bone: a review of the literature. Int J Oral Maxillofac Implants. 1995;10:275294. 19. Block MS, Degen M. Horizontal ridge augmentation using human mineralized particulate bone: preliminary results. J Oral Maxillofac Surg. 2004;62:67-72,Suppl 2. 20. Jensen J, Reiche-Fischel O, Sindet-Pederson S. Nerve transposition and implant placement in the atrophic posterior mandibular alveolar ridge. J Oral Maxillofac Surg. 1994;52:662-668. 21. Urbani G, Lombardo G, Santi E, Consolo U. Distraction osteogenesis to achieve mandibular vertical bone regeneration: a case report. Int J Periodontics Restorative Dent. 1999;19:321-331. 22. Pikos MA. Block autografts for localized ridge augmentation: part II. The posterior mandible. Implant Dent. 2000;9:67-75. 23. Schwartz-Arad D, Levin L, Sigal L. Surgical success of intraoral autogenous block onlay grafting for alveolar ridge augmentation. Implant Dent. 2005;14:131-138.
6. Khraisat A, Abu-Hammad O, Dar-Odeh N, Al-Kayed AM. Abutment screw loosening and bending resistance of external hexagon implant system after lateral cyclic loading. Clin Implant Dent Relat Res. 2004;3:157-164.
24. Raghoebar GM, Louwerse C, Kalk WW, Vissink A. Morbidity of chin bone harvesting. Clin Oral Implants Res. 2001;12(5):503-507.
7. Proussaefs P, Lozada J. The use of intraorally harvested autogenous block grafts for vertical alveolar ridge augmentation: a human study. Int J Periodontics Restorative Dent. 2005;25:351-363.
25. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complications. Clin Implant Dent Relat Res. 2003;5(3):154-160.
8. Misch C. Comparison of intraoral donor sites for onlay grafting prior to implant placement. Int J Oral Maxillofac Implants. 1997;12:767-776.
26. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? [published erratum appears in: Int J Oral Maxillofac Implants. 2008;23(1):56]. Int J Oral Maxillofac Implants. 2007;22(Suppl):49-70.
9. Pikos MA. Block autografts for localized ridge augmentation: part I. The posterior maxilla. Implant Dent. 1999;8:279-285. 10. Boyne P, James R. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg. 1980;38:613-616. 11. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30:207-229. 12. Lazzara RJ. The sinus elevation procedure in endosseous implant therapy. Curr Opin Periodontol. 1996;3:178-183. 13. Duncan J, Westwood R. Ridge widening for the thin maxilla: a clinical report. Int J Oral Maxillofac Implants. 1997;12:224-227. 14. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent. 1994;14(5):451-459. 15. Mellonig JT, Nevins M. Guided bone regeneration of bone defects associated with implants: an evidencebased outcome assessment. Int J Periodontics Restorative Dent. 1995;15(2):168-185. 16. Zitzmann N, Naef R, Schärer P. Resorbable versus nonresorbable membranes in combination with Bio-Oss for guided bone regeneration [published erratum appears in: Int J Oral Maxillofac Implants. 1998;13(4):576]. Int J Oral Maxillofac Implants. 1997;12(6):844-852. 17. Dahlin C, Lekholm U, Becker W, et al. Treatment of fenestration and dehiscence bone defects around oral implants using the guided tissue regeneration technique: A prospective multicenter study. Int J Oral Maxillofac Implants. 1995;10:312-318.
48 Implant practice
27. Misch CM, Misch CE, Resnik RR, Ismail YH. Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: a preliminary procedural report. Int J Oral Maxillofac Implants. 1992;7(3):360-366. 28. Raghoebar GM, Batenburg RH, Vissink A, Reintsema H. Augmentation of localized defects of the anterior maxillary ridge with autogenous bone before insertion of implants. J Oral Maxillofac Surg. 1996;4(10):1180-1186. 29. Widmark G, Andersson B, Ivanoff CH. Mandibular bone graft in the anterior maxilla for single-tooth implants. Presentation of surgical method. Int J Oral Maxillofac Surg. 1997;26(2):106-109. 30. McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol. 2007;78(3):377-396. 31. Libin BM, Ward HL, Fishman L. Decalcified, lyophilized bone allografts for use in human periodontal defects. J Periodontal. 1975;46(1):51-56. 32. Piattelli A, Scarano A, Corigliano M, Piattelli M. Comparison of bone regeneration with the use of mineralized and demineralized freeze-dried allografts: a histological and histochemical study in man. Biomaterials. 1996;17(11):1127-1131. 33. Francis J, Brunsvold M, Prewett A, Mellonig J. Clinical evaluation of an allogeneic bone matrix in the treatment of periodontal osseous defects. J Periodontol. 1995;66:1074-1079. 34. Minichetti JC, D’Amore JC, Hong AY, Cleveland DB. Human histologic analysis of mineralized bone
may increase its reliability as a boneaugmentation material. However, future controlled clinical trials are recommended to confirm this. IP
allograft (Puros) placement before implant surgery. J Oral Implantol. 2004;30:74-82. 35. Urist MR, Mikulski A, Boyd SD. A chemosterilized antigen-extracted autodigested alloimplant for bone banks. Arch Surg. 1975;110:416. 36. Becker W, Schenk R, Higuchi K, Lekholm U, Becker BE. Variation in bone regeneration adjacent to implants augmented with barrier membranes alone or with demineralized freeze-dried bone or autologous grafts: a study in dogs. Int J Oral Maxillofac Implants. 1995;10:143-154. 37. Smukler H, Landi L, Setayesh R. Histomorphometric evaluation of extraction sockets and deficient alveolar ridges treated with allograft and barrier membrane: a pilot study. Int J Oral Maxillofac Implants. 1999;14:407416. 38. Parashis A, Andronikaki-Faldami A, Tsiklakis K. Comparison of 2 regenerative procedures – guided tissue regeneration and demineralized freeze-dried bone allograft – in the treatment of intrabony defects: A clinical and radiographic study. J Periodontol. 1998;69:751-758. 39. Lian JB, Gundberg CM. Osteocalcin. Biochemical consideration and clinical applications. Clin Orthop Res. 1998;226:267-291. 40. Aspenberg P, Lindqvist S. Ethene oxide and bone induction. Controversy remains. Acta Orthop Scan. 1998;69:173-176. 41. Tshamala M, Cox E, De Cock H, Goddeeris BM, Matheeuws D. Antigenicity of cortical bone allograft in dogs and effect of ethylene oxide-sterilization. Vet Immunol Immunopathol. 1999;69:47-59. 42. Shapoff CA, Bowers GM, Levy B, Mellonig JT, Yukna RA. The effect of particle size on the osteogenic activity of composite grafts of allogeneic freeze-dried bone and autogenous marrow. J Periodontol. 1980;51:625-630. 43. Schwartz Z, Somers A, Mellonig JT, et al. Ability of commercial demineralized freeze-dried bone allograft to induce new bone formation is dependant on donor age but not gender. J Periodontol. 1998;69:470-478. 44. Schwartz Z, Mellonig JT, Carnes DL Jr. Ability of commercial demineralized freeze-dried bone allograft to induce new bone formation. J Periodontol. 1996;67:918926. 45. Zhang M, Powers RM, Wolfinbarger L. Effect of demineralization process on the osteoinductivity of demineralized bone matrix. J Periodontol. 1997;68:10851092. 46. Adkisson HD, Strauss-Schoenberger J, Gillis M, Wilkins R, Jackson M, Hruska KA. Rapid quantitative bioassay of osteoinduction. J Orthop Res. 2000;18:503511. 47. Han B, Tang B, Nimni ME. Combined effects of phosphatidylcholine and demineralized bone matrix on bone induction. Connect Tissue Res. 2003;44:160-166. 48. Wuthier RE. Effect of phospholipids on the transformation of amorphous calcium phosphate to hydroxapatite in vitro. Calcif Tissue Res. 1975;19(3):197210. 49. Wang H-L, Tsao YP. Histologic evaluation of socket augmentation with mineralized human allograft. Int J Periodontics Restorative Dent. 2008;28:231-237. 50. Gross J. Ridge preservation using HTR synthetic bone following tooth extraction. Gen Dent. 1995;43:364367.
Volume 7 Number 1
PRODUCT PROFILE
NuOss® XC bone grafting composite
N
uOss® XC Self Expanding bone grafting composite is a unique patent-pending bone grafting composite comprised of 80% mineralized porous anorganic bovine bone, and 20% type I bovine collagen that allows for the successful implantation of a bone grafting material with increased control and less concern for subsequent complications. In its expanded form, the composite material provides optimal spacing for the bone grafting particulate, which allows for improved vascular access into the graft. The material is pre-formed into shapes and volumes commonly used for the filling of extraction sockets to enhance preservation of the alveolar ridge and in sinus lift procedures. Unlike traditional particulate materials, NuOss XC can be placed without hydration, in a compressed format, allowing for expansion upon contact with blood or saline. The composite nature of the material allows for precise placement of the graft, with minimal concern of particle migration. Efficiency of graft placement into the sinus cavity or extraction socket may be enhanced as well. NuOss XC requires no special handling and can be stored at room temperature. The unique composite nature of this material allows for minimal graft preparation time and graft delivery. As well, the complete binding of the particles within the collagen framework increases confidence in minimal risk of particle migration and subsequent infections. The unique self-expanding nature of the material may allow for a less invasive procedure to be utilized while still allowing an adequate amount of grafting material to be placed.
NuOss XC is the latest development in natural bone substitutes. • NuOss XC supports bone growth in periodontal and oral maxillofacial defects. • NuOss XC is a composite grafting material comprised of mineralized deproteinated bovine granules and purified type I bovine collagen. When placed into a bleeding site, the material expands to a predetermined size and shape. • NuOss XC is available in both socket and sinus forms. • NuOss XC is easy to place, prevents particle migration, and saves time.
Features and Benefits:
NuOss® XC Socket
• Expanding composite material allows for placement in a compressed form with self-expansion to fill the entire defect upon hydration. • Simple implantation technique. • Composite nature of the material enhances graft stability and minimizes particulate migration. • Optimizes spacing between particulate to allow for bone ingrowth. Expansion time: Immediately upon contact with blood source or by hydration with sterile saline after implantation. IP To learn more about NuOss® XC and other bone grafting solutions offered by ACE Surgical, visit their web site at www.acesurgical.com.
NuOss® XC Sinus
This information was provided by Ace Surgical Supply.
Volume 7 Number 1 Implant practice 49
ON THE HORIZON
I want my teeth yesterday! Dr. Justin Moody discusses a time saving technology in a fast paced world
I
n the ever-changing world of implant dentistry, we are finding ourselves in a battle with our patients over the amount of time needed to provide their care. With national ad campaigns discussing teeth in an hour and teeth in a day, we often find ourselves backed into a corner in respect to time and credibility. When our patients ask questions regarding TV or print advertisements, they are really trying to find out if we do those procedures. We usually try to answer them in an educated manner based on proper clinical techniques and evidence-based dentistry; however, patients perceive anything contrary to the advertisement as an excuse. We must strive to be proactive with our own treatment plans particularly in the field of immediately loaded dental implants. I recently mentored a live surgery at the Rocky Mountain Dental Institute where this was indeed the case. The doctor treatment planned an immediately loaded lower denture case using BioHorizons’ TeethXpress™ protocol. The problem was not with the procedure but in the expectation of the final product. The immediately converted denture is not the definitive restoration but merely a transitional appliance on the way to the final prosthesis. The ultimate final prosthesis is based on many variables such as a screw-retained denture, a locator-retained denture or any number of full fixed appliances. These choices come with different price tags as well as different treatment time frames. This case was treatment planned for six dental implants using Tx STUDIO™ and
Dr. Justin Moody is a Diplomate with the American Board of Oral Implantology and with the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, Adjunct Professor at the University of Nebraska Medical College, and Founder and Director of the Rocky Mountain Dental Institute. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at justin@rockymountaindentalinstitute.com or at drjustinmoody.com.
50 Implant practice
Figure 1: Duplicated denture used as surgical guide
Figure 2: Placement of the multiunit abutment
Figure 3: Titanium pickup copings
Figure 4: Lower denture conversion
Figure 5: Final i-CAT pano
a CBCT from the i-CAT® FLX (Imaging Sciences International) machine. A duplicate denture was fabricated to use as a surgical guide for implant placement and positioning and six BioHorizons’ LaserLok Tapered dental implants were placed, and the anterior four implants were used to convert the denture chairside following the TeethXpress protocol. The simplicity and quality of the BioHorizons’ multiunit abutment makes these kinds of cases very predictable. The doctor’s plan is for
4 months of integration prior to fabrication of the final restoration, which is treatment planned for a screw-retained full fixed prosthesis. This resulted in a wonderful treatment for the patient and an even better experience for the dentist. By avoiding the excuses and being proactive with patient education, we can win this battle. I will part with a quote from one of my mentors, Dr. John Kois, “Dentists should not be viewed as the hitman, but rather as the healer.” IP Volume 7 Number 1
AUTHOR GUIDELINES
Implant Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Implant Practice US is designed to be read by specialists in Periodontics, Oral Surgery, and Prosthodontics.
Submitting articles Implant Practice US requires original, unpublished article submissions on implant topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Implant Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 52 Implant practice
Pictures/images
Disclosure of financial interest
Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).
Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.
Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.
References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year;vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF
(Multiple) Doe JF, Roe JP
Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.
Manuscript Review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.
Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkaz.com
Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.
Checklist for article submissions: 3 A copy of the manuscript and figures/ captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com
Volume 7 Number 1
More than a supplier.
A partner for life.
800/448 8168 www.straumann.us
MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Implant planning with Anatomage Full resolution –— no compromise Anatomage can utilize full-resolution DICOM data very easily for both 3D volume renderings and 2D cross sections. When placing implants, a fraction of a millimeter can make the different between success and failure, and Anatomage gives you ability to plan with the highest level of accuracy for clinical success and patient safety. Fast planning Anatomage offers the fastest workflow for implant planning — so fast, it can be done chairside in front of the patient for the most exciting patient presentations. After opening the DICOM data directly from the CBCT machine, implants can be placed immediately, with no waiting for file conversions, no model making, no issues with noise having to be cut out, and no confusing navigation or software interfaces.
BIOMET 3i™ T3® Tapered Implant System The BIOMET 3i™ T3® Tapered Implant System has been engineered to provide: * The primary stability necessary for early esthetic provisional restoration and/or tissue sculpting. * A refined surface design to enhance osseointegration, with no increased risk of peri-implantitis and compared to hybrid implants. * The system strength for long-term esthetic function. * An implant/abutment geometry and related connection features designed to preserve bone at and around the implant to provide support for the development and maintenance of soft tissue. * Highly accurate connection well-positioned to meet current and future digital restorative needs. For more information, visit: biomet3i.com.
Osteocel® allograft cellular bone matrix product retaining MSCs and osteoprogenitors
Restoration-based implant planning Anatomage supports both crown-down and implant-up treatment planning methods by combining other types of clinical data with the CT scan, such as a laser scan of the stone models or an intraoral scan of the dentition. Virtual wax-ups can be incorporated as well. Furthermore, these advanced options are exclusively tied in with our surgical guide service to complete the circle of virtual planning to clinical treatment.
The proprietary processing technology that produces Osteocel results in a viable bone matrix product that preserves the native MSCs and osteoprogenitors found in marrow-rich bone. It was the first product available to have the desired beneficial properties of autograft — osteoconduction, osteoinduction, and osteogenesis — and that allows surgeons to provide their patients with a complete solution without the added risk and cost of a secondary procedure.
No conversion Anatomage has completely done away with the file conversion step of implant planning by allowing you to start with your own DICOM file and place implants immediately.
For more information, visit Ace Surgical at www.acesurgical.com.
Visual simulations Anatomage software has multiple simulation creation tools as options for the most cutting-edge case presentation potential. Guided surgery With Anatomage’s very own surgical guide, your virtual treatment plan can become a real device that can be used to accomplish your treatment exactly as planned. For more information, visit Anatomage at www.anatomage.com.
Innovative Imprint™ 4 VPS Impression Material WIth innovative advancements in material sciences, Imprint 4 VPS Impression Material cuts intraoral setting time nearly in half of its predecessor, Imprint 3 VPS Impression Material, and other leading competitive VPS dental impression materials. You can noticeably reduce chair time and stress for patients — without reducing the precision of your impression result. Imprint 4 material offers the fastest intraoral stewing time among leading VPS fastsetting impression materials. For more information, visit 3M ESPE at: http://solutions.3m.com/wps/portal/3M/en_US/3M-ESPE-NA/ dental-professionals/
54 Implant practice
Volume 7 Number 1
Announcing DEXIS Mac
DEXIS, an industry leader and the manufacturer of the highly awarded DEXIS® Digital X-ray system, is now in the process of completing its development for the Mac platform and will soon be expanding its Imaging Suite of products to natively support Apple® hardware and the OS X operating system 10.8.0 and above. DEXIS Mac™ is an innovative dental imaging solution that offers dentists a unified experience across Mac and iOS products. Once released, the native OS X software will provide clinicians with a highly efficient digital imaging workflow and seamless integration with Mac-based practice management programs Viive™ and MacPractice®. This DEXIS software product will provide an intuitive user interface and advanced functionality that Mac users expect — combined with tried-and-true DEXIS image management and enhancement tools, as well as a tight integration with the award-winning DEXIS go® app for patient communication, and the just released DEXIS photo™ app for extra-oral image acquisition. For more information, visit: www.dexis.com.
ASA DENTAL ASA Dental, manufacturer of dental instruments, proudly announces the launch of AsaFresh, a new line of mint-scented saliva ejectors. With its cool mint scent, AsaFresh provides a pleasant feeling of mouth freshness and helps patients relax throughout the duration of the visit. AsaFresh is patented by Asa Dental.
New coating, Ti Golden®, improves esthetics and biological interface BTI Biotechnology Institute’s R&D Department has developed a new and efficient solution: The Ti Golden® coating that converts titanium into a material with a number of advantages.
For more information, visit: www.asadental.com/index.asp.
Golden finish: The golden color of these prosthetic attachments with the Ti Golden® layer achieves a better esthetic, which is highly significant in transmitting greater warmth to the gingival tissues.
S-4000 Quantum Light
At gingival level: Improved union between the hemidesmosones and the new surface, improving the biological seal.
Standard Features of the S-4000 Quantum Light include: • Variable Light Intensity from 650 f.c. to 2800 f.c. @ 24”. • Motion sensor on/off. • Flex Arm provides 53” of horizontal reach and 27” of vertical adjustment. • Optics feature four LED lights rated for 50,000 hours. • Color temperature is 5500-6500 degrees K. • Light field is 2.75” x 7” @ focal length of 24”. • Light head has 3 axis adjustability. • Handle is removable and autoclavable.
Improves the antimicrobial properties: The bacterial colonization decreases, therefore minimizing the risk of peri-implantitis. See more at: http://bti-biotechnologyinstitute.com/us/latestnews/product-news/new-proscetic-components-tigoldentiblack/#sthash.pCvMxLq8.dpuf. For more information, visit: bti-biotechnologyinstitute.com/us.
For more information, visit: www.boydindustries.com.
Volume 7 Number 1 Implant practice 55
DIARY
lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll CE Aesthetics Through Innovation Clinical Expertise Evening Seminars January 21, 2014 – Montreal, Canada January 22, 2014 – Toronto, Canada January 28, 2014 – Bethesda, MD January 29, 2014 – Los Angeles, CA February 6, 2014 – San Francisco, CA www.iird.com/education.html
Graft-less Solutions in Implant Dentistry implanteducation.net
Free Webinars Are Diode Lasers Worth the Investment? Todd Snyder, DDS www.amdlasers.com
Navigating Today’s Clinical Challenges Pam Hughes, RDH, MS February 1, 2014 Las Vegas, NV sdm.unlv.edu/ce
The AMD LASERS’ Picasso is THE soft tissue hand-piece and is an essential part of dental practice for the dentist and the hygienist Dr. Edward Lynch www.amdlasers.com
Risk Management Strategies to Reduce Dental Liability Dr. Michael Regan February 15, 2014 Las Vegas, NV sdm.unlv.edu/ce
The role of the diode laser in restorative cosmetic dentistry Dr. Glenn van As www.amdlasers.com
The Role of the Implant Treatment Coordinator: From Office Infrastructure to Referral and Patient Management February 7, 2014 Palm Beach Gardens, FL 1-800-717-4143 inside.3iimplant.com/global_pro_ed/pdf/ MKT833%20020714%20Collins%20 ITC%20Flyer.pdf Implantology Course 1- Hands-on Dental Implant Placement Training CE and Bone Grafting Seminars January 31 - February 1, 2014 March 7 - 8, 2014 Burbank, CA 1-888-393-6355 implantologyseminars.com
Webinars Diagnosis and Treatment Planning in the Esthetic Zone - Part I implanteducation.net Diagnosis and Treatment Planning in the Esthetic Zone - Part II implanteducation.net
56 Implant practice
An introduction to diode lasers: Top 10 procedures you can do with your diode laser Dr. Glenn van As www.amdlasers.com An open panel discussion on laser dentistry Dr. Fay Goldstep and Dr. George Freedman www.amdlasers.com
Events Comprehensive Implant Residency Program 6 (CIRP) Dr. Michael McCracken January 23-25, 2014 Birmingham, AL www.biohorizons.com Hybridge Education Seminar: Level Training January 23-25, 2014 Rochester, NY www.biohorizons.com Georgia Academy of Cosmetic Dentistry Dr. John C. Kois January 24, 2014 Atlanta, GA www.biohorizons.com
The 39th Annual USC International Periodontal and Implant Symposium January 24, 2014 Los Angeles, CA www.biohorizons.com Michigan Periodontal Association 2014 Annual Meeting Dr. Marc Nevins January 25, 2014 Novi, MI www.biohorizons.com Washington State Society of Oral and Maxillofacial Surgeons (WSSOMS) January 28, 2014 Bellevue, WA www.biohorizons.com Rocky Mountain Dental Institute: Grafting - Hard and Soft Tissue as well as Sinus Dr. Lewis Cummings January 30, 2014 Denver, CO www.biohorizons.com Southwest Dental Conference 87th Annual Meeting January 30 - February 1, 2014 Dallas, TX www.biohorizons.com Yankee Dental Congress January 30 - February 1, 2014 Boston, MA www.biohorizons.com Pikos Implant Institute: Extraction Site Management Dr. Mike Pikos January 31 - February 1, 2014 Trinity, FL /www.biohorizons.com CDS Midwinter Meeting McCormick Place West Building February 20 - 22, 2014 Chicago, IL www.bicon.com/index.htm
Volume 7 Number 1
A Legacy of Innovation New
Legacy™4 Implant All-in-1 Packaging includes implant, fixturemount, abutment, transfer, cover screw & healing collar — $225 SBM, $250 HA surface
Torque- safety feature prevents damage to implant interface
Square top detaches with impression for
Concave transgingival profile
metal to metal transfer accuracy
matched with healing collar to shape soft tissue for improved esthetics
Two-Piece fixture-mount (patent pending) with
preparable abutment Quadruple-lead micro-threads Progressively deeper buttress threads
A Legacy of Innovation from Dr. Gerald Niznick
Legacy 4 – the culmination of 30 years of evolution Introducing a revolutionary 2-piece fixture-mount/abutment that provides the accuracy of an open-tray transfer with the simplicity of a closed-tray transfer.
Square top detaches with the impression, providing a snap attachment for abutment/analog.
Three long cutting grooves
The abutment portion of the fixture-mount snaps onto the transferred top for the accuracy of a metal-to-metal connection
Angled Multiple-Unit Plastic GPS™ Laboratory Straight Straight 15° Angled Gold/ Zirconia/Ti Temporary w/Cap & Transfer Ball GPS™ Abutment Snap-On Contoured Contoured Plastic Abutment Abutment Attachment Attachment Attachment Straight Angled Our price
$85
$100
$100
$100
$120
$120
$40
$112
$100
$120
$100
$120
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