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JOS European journal of oral surgery

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


June 2010

ISSN 2037-7525




Trovato il gap! – sfidiamo i dogmi del passato Qual è il modo migliore per avere risultati riabilitativi eccezionali e che durino nel tempo per i vostri pazienti? Lo standard per il successo dei trattamenti implantari, dal 1986, non riflette le possibilità raggiungibili oggi. Non c’è ragione per la quale il paziente e il medico debbano accettare una perdita di osso marginale fino a 1.5 mm, basandosi

su uno standard di 20 anni fa. Numerosi studi provano che, con il sistema implantare Astra Tech, la riduzione media del livello di osso marginale è di solamente 0.3 mm dopo cinque anni. È ora di colmare la lacuna.

Mantenimento dell’osso marginale con Astra Tech Implant System™ 1 year

2 years

3 years

5 years

Mean marginal bone level change (mm)

0 - 0.2 - 0.3 - 0.4 - 0.6 - 0.8 -1.0

Astra Tech Implant System™ level*

-1.2 -1.4 -1.5

Standard norm**


Time period (yrs)


Livelli Astra Tech Implant System™ basati su dati ottenuti da oltre 40 pubblicazioni scientifiche supportate da dati radiografici; Aprile 2008 ** Standard da: Albrektsson T., et al., Int J Oral Maxillofac Implants 1986;1(1):11-25 Albrektsson T. and Zarb G.A., Int J Prosthodont 1993;6(2):95-105 Roos J., et al., Int J Oral Maxillofac Implants 1997;12(4):504-514

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

European journal of oral surgery



Prof. Franco Santoro (Italy)



Via Airoldi, 11 22060 Carimate (CO)  +39 (0)  +39 (0)

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Associate Editor

ISSN: 2037-7525

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

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

DIRECTOR Dino Sergio Porro EDITORIAL STAFF Angela Battaglia: Cristina Calchera: Simona Marelli: MARKETING & ADVERTISING Barbara Bono: Paola Cappelletti: Franco De Fazio: WEB & GRAPHIC DESIGN Michele Moscatelli: Simone Porro: Cover image courtesy of Mirko Marcon


JOS VOL.1 N.1 2010





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European journal of oral surgery

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Current trends in sinus lift procedures

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JOS VOL.1 N.1 2010

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

European journal of oral surgery



Prof. Franco Santoro SISCOO President

Dear colleagues, it is my privilege to present you the first issue of eJOS, the European Journal of Oral Surgery, official organ of the Italian Society of Specialists in Oral Surgery (SISCOO). After founding in 2009 SISCOO, whose aim was to collect the specialists in Oral Surgery and all the dentists who are daily practicing this discipline, we felt the necessity to build up a highly clinical journal to support the practioner in his job. The journal structure, in english language and in the online fashion, is similar to that of other well renowned international journals and its release every four months allows to face the most interesting clinical aspects in the fields of oral surgery, periodontology and implantology, thanks to monographs and case reports. The International Board of Referees, whose job is to strictly evaluate the content of the contributions, is highly qualified and guarantees the top level of the journal. Thanks to the subscription to JOS, all of you will be able to be updated on the scientific events created or supported by SISCOO every year. Moreover, for the first year the contents of the website will be free for all registered users. My personal aknowledgments to the publishers Ariesdue and Italiapress that complied with my project and took care of its realization. I deeply hope that you will appreciate this new scientific initiative and will attend the first SISCOO National Congress taking place in Milano, September, 24th, 2010.


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Current trends in sinus lift procedures Mario Beretta DDS, PhD

University of Milan Ospedale Maggiore IRCCS Ca’ Granda Dental Clinic, Director Prof Franco Santoro Dept of Implantology, Head Prof Carlo Maiorana and Giovanni Battista Grossi


Loss of maxillary molar teeth leads to rapid bone loss in the maxillary sinus floor and increases the size of the maxillary sinus. Maxillary sinus floor elevation is one of the most common preprosthetic procedures to solve this problem. The placement and integration of endosseous implants in such patients requires augmentation of the maxillary sinus floor. Two technique procedures, the classic lateral antrostomy and the crestal approach, will be analized in this article. The anatomical variability, the indications and limits will be discussed taking care of pathological conditions such as the presence of mucosal cyst and the possible complications related to the surgical procedure. Analizing the most recent literature, the discussion will be focused also to the different biomaterials available as grafts in the subantral cavity.

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Key words: Sinus lift, graft materials, mucosal cyst, perforation, resorbable membrane


Introduction Loss of maxillary molar teeth leads to rapid bone loss in the maxillary sinus floor and increases the size of the maxillary sinus. Bone loss can extend to the alveolar process, leaving only a thin wall of bone between the maxillary sinus and the oral cavity. The placement and integration of endosseous implants in such patients requires augmentation of the maxillary sinus floor. Maxillary sinus floor elevation is one of the most common preprosthetic procedures to solve this problem. In this article two techniques, the classic lateral antrostomy and the crestal approach, will be analyzed. Lateral antrostomy allows for a greater amount of bone augmentation to the atrophic maxilla but requires a larger surgical access. The crestal approach is minimally invasive but permits only a limited amount of augmentation. Maxillary sinus floor elevation was initially described by Tatum in 1976 and subsequently published by Boyne in 1980 (1, 2). The procedure is one of the most common preprosthetic surgeries performed in the

FIG. 1

Intraoperative view of the anastomosis between alveolar posterior artery and infraorbital artery

FIG. 2

Lateral antrostomy without damaging the artery.

implant dentistry today. Since its first description, several articles (3) have been published in this field regarding different grafting materials, modifications to the classic technique, and comparisons between different surgical approaches. Sinus anatomy The maxillary sinus is a pyramid-shaped cavity with its base adjacent to the nasal wall and apex pointing to the zygoma. The size of the sinus is insignificant until the eruption of permanent dentition. The average dimensions of the adult sinus are 2.5 to 3.5 cm wide, 3.6 to 4.5 cm tall, and 3.8 to 4.5 cm deep (4). It has an estimated volume of approximately 12 to 15 cm3 (5). Anteriorly, it extends to the canine and premolar area. The sinus floor usually has its lowest point near the first molar region. The size of the sinus is normally increased with age and if the area is edentulous. The extent of pneumatization varies from person to person and from side to side (5). Nonetheless, this process often leaves the bone lateral and occlusal alveolus paper-thin in the posterior maxilla. The maxillary sinus bone cavity is lined with the sinus membrane, also known as the Schneiderian membrane, which consists of ciliated epithelium like the rest of the respiratory tract. It is continuous with, and connects to, the nasal epithelium through the ostium in the middle meatus. The membrane has a thickness of approximately 0.8 mm. Antral mucosa is thinner and less vascular than nasal mucosa. The blood supply to the maxillary sinus is primarily derived from the posterior superior alveolar artery and the infraorbital artery, both being branches of the maxillary artery. There are significant anastomoses between these 2 arteries in the lateral antral wall. Testori reported the diameter of these anastomoses as remarkable risk factor for possible hemorrhage during the corticotomy for the lateral approach (6) (Fig. 1, 2). The greater palatine artery also supplies the lower portion of the sinus (7). However, because the blood supplies to the maxillary sinus are from terminal branches of peripheral vessels, significant hemorrhage during sinus lift procedures is rare. Nerve supply to the sinus is derived from the superior alveolar branch of the maxillary division of the trigeminal nerve. X-rays examination Radiographic evaluation should include orthopantomogram and coronal and axial computerized tomographic scans (CT) in all clinical cases. The standard orthopantogram carried out during the preoperative assessment reports general informations regarding maxillary sinus anatomy, vertical dimension of the sinus floor, and a first evaluation of any pathological findings. CT scan is recommended to evaluate sinus anatomy and dimension, the bone height above the sinus floor, residual bone width and the possible presence of intrasinusal bony septa. Moreover pathological conditions as well as chronic sinusitis, nasal septum deviation and ostium stenosis, Schneiderian membrane thickening and sinus cysts can be detected (Fig. 3-6).


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Beretta M.

Surgical approach Nowdays, two main approaches to the maxillary sinus floor elevation procedure can be found in the literature. The first approach, lateral antrostomy, is the classic and the more commonly performed technique originally described by Tatum and more recently by Kent and Block (8). More recently, Summers proposed a new approach: the crestal approach, using osteotomes (9). Lateral antrostomy An antibiotic therapy, specifically 1.5 g amoxicillin+clavulanic acid for 1 week, starting 1 hour before the procedure, is mandatory. After the anestetic injection, before the surgical procedure, all patients receive a local injection of corticosteroid to reduce postoperative swelling and edema (10). Lateral antrostomy is performed by a crestal incision on the alveolar ridge and two vertical release incisions mesially and distally from the area to be grafted. Sometimes, this incision is made slightly palatal to the crest to preserve a wider band of keratinized attached gingiva for a more solid wound closure and to avoid wound dehiscence. A fullthickness flap is then raised to allow access to the lateral antral wall. Once the flap has been raised to a desired level, antrostomy is performed with a round bur to create a bone window on the lateral buttress of the maxilla. The literature reports the possibility of ultrasonic surgery to obtain the lateral approach to the sinus, reducing the risk of membrane perforation during the drilling phase (11). The height of this trapdoor should not exceed the width of the sinus (it can be measured in the computerized tomogram) to allow for a final horizontal position of the new floor. A curette is inserted at the level of the lower border to begin separating the sinus membrane from adjacent bone. The sinus membrane is then gently lifted from the bone floor by means of antral curettes and elevators. It is important to free up the sinus membrane in all directions (anteriorly, posteriorly, and medially) before attempting to intrude the trapdoor medially. A space is created after the sinus membrane has been elevated by the intruded trapdoor. This space is then grafted with different materials to provide bone regeneration needed for implant placement (1,2,8). The different materials available for the sinus grafting procedure will be analized later on. The posterior part of the cavity has to be grafted first, followed by the anterior portion and finally the central area. Care should be taken not to obstruct the middle nasal meatus to allow free sinus drainage and not to overfill the recipient site, because it could cause membrane necrosis. The mucoperiosteal flap is then replaced and sutured with single and multiple horizontal mattress sutures. An analgesic compound of acetaminophen and codeine can be prescribed for pain. Topically, 0.20% rinses with chlorhexidine mouthwash are recommended starting with the day after the procedure (Fig. 7-20).

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FIG. 3

Panorac with 2 pneumatized maxillary sinus.

FIG. 4-5-6

View of sinus anatomy.


FIG. 7

Preoperative panorac: maxillary sinus pneumatization in area 1.5-1.7 can be appreciated.

FIG. 11-12

Full thickness flap and osteotomy.

FIG. 13

Sinus membrane mobilization.

FIG. 14

Graft material in the medial portionof the subantral cavity and implant placement.

FIG. 8-9-10

Intraoral view with a surgical stent.


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Beretta M.

FIG. 17

Collagene resorbable membrane placement.

FIG. 15-16

Sinus grafting procedure.

Implants can be placed either simultaneously with the graft (1-stage lateral antrostomy) or after a delayed period of up to 8 months to allow for graft maturation (2-stages lateral antrostomy). The initial bone thickness at the alveolar ridge seems to be a reliable indicator in deciding between these 2 methods. If the bone thickness is 4 mm or less, initial implant stability would be jeopardized. Therefore, a 2-stage lateral antrostomy should be carried out. The reverse holds true for a 1-stage procedure. A 1-stage procedure is less time-consuming for both the clinician and the patient (12,13). However, it is more technique-sensitive and its success relies heavily on the amount of residual bone (Fig. 21-36). Crestal approach Every time the residual ridge’s height is 6-7 mm, the surgeon can decide for using short implants or elevating the sinus floor for 2-3 mm with the Summer’s osteotome technique. The procedure, wrongly named “minor sinus elevation”, is a blind procedure and should be considered with care. In the 1994 Summers proposed a modified surgical approach to the sinus lift using a crestal access made by burs and osteotomes (14-16). This technique begins with a crestal incision. A full-thickness flap is raised to expose the alveolar ridge. An osteotome of the smallest size is then tapped into place by a mallet or drill into the bone. Preoperative bone height underneath the sinus is measured to determine the desired depth for osteotome extension. The goal is to insert the instruments in order to gently elevate sinus floor and subsequently the Schneiderian membrane.

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FIG. 18-19

Final implant rehabilitation.

FIG. 20

Postoperative control panorac.

FIG. 21

Preoperative panorac: sinus pneumatization in area 2.4-2.7 and a intrasinusal septum can be appreciated


FIG. 27

Two different bony windows performed to isolate the intrasinusal septa.

FIG. 22-23

Preoperative CT view

FIG. 28

Intraoperative view: the large septa can be appreciated.

FIG. 29

Collagene resorbable membrane placed to close the small perforation avoiding the intrasinusal graft intrusion.

FIG. 24-25

Intraoral preoperative view.

FIG. 26

Full thikness flap: a small perforation in the Schneiderian membrane can be noticed.

FIG. 30

Subantral cavity grafting procedure.


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Beretta M.

FIG. 31

FIG. 34

Collagene resorbable membrane placed to protect the graft material

Implant sites praparation.

FIG. 32-33

FIG. 35

Clinical view after 8 months healing.

The newly formed bone: some granules of biomaterial are still present.

Osteotomes of increasing sizes are introduced sequentially to expand the alveolus. With each insertion of a larger osteotome, bone is compressed, pushed laterally and apically. Summers stated that the very nature of this technique improves bone density of the posterior maxilla where type IV bone is normally found. Once the largest osteotome has expanded the implant site, a prepared bone mix is added to the osteotomy as grafting material. Summers suggested a 25% autogenous bone with 75% hydroxyapatite mix; however, a variety of graft materials have also been used. The final stage of sinus floor elevation is completed by reinserting the largest osteotome to the implant site with the graft material in place. This causes the added bone mix to exert pressure onto the sinus membrane and to elevate it. Additional grafting material can subsequently be added and tapped in to achieve the desired amount of elevation. Once this height is gained, the implant fixture is inserted. The implant fixture should be slightly larger in diameter than the osteotomy site created by the largest osteotome. It becomes the final osteotome, “tenting� the elevated maxillary sinus membrane (1618) (Fig. 37). The main advantage of the crestal osteotome technique is that it is a less invasive procedure. It improves the density of the maxillary bone, which allows greater initial stability of implants. It also has the potential for

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FIG. 36

Postoperative control panorac.

FIG. 37

The use of an osteotome to perform transcrestal sinus lift according with Summers.

Monograph the use of less autogenous grafting material. Summers suggested the crestal incision to be extended distally to the tuberosity area where autogenous bone can be harvested. The disadvantage of the crestal approach is that the initial implant stability is unproven if the residual bone height is less than 6 mm. The chances of achieving high enough elevation with the osteotome technique is limited. With this approach, there could also be a higher chance of misaligning the long axis of the osteotome during the sequential osteotomy (19, 20). Another technique with crestal access is the balloon sinuslift, that has been proposed in the literature (1922). This is a particular surgical approach in which saline solution and an elastic catheter, is used to swell an elastic balloon throught the drill and osteotom preparation and to obtain the sinus membrane lifting (21, 22). Aside from its higher costs this technique presents high risk of membrane perforation and intrasinusal graft material intrusion due to its blind approach. The disadvantages of all these transcrestal technique are its limited indications (possibility to obtain maximum 2-3 mm of sinus floor elevation) and the absence of direct visual control of the membrane during the lifting procedure (23).

diagnosis and treatment planning (26, 27). The incidence of antral septa varies between 16% and 58% according to the literature (6,25-27). Antral septa divide the caudal part of the sinus into multiple compartments, known as recesses, and dividing the sinus into smaller accessory sinuses. During sinus surgery, septa represent a risk factor for membrane perforation and laceration because they can complicate both the inversion of the bone trap door and the mobilization of the sinus membrane. For these reason a modification of the conventional procedure is required when septa are present. Boyne (3) proposed cutting the septa with a narrow chisel and removing them with a hemostat, so the bone graft can be placed over the entire antral floor. The buccal bony wall can be divided into anterior and posterior parts with respect to the septa and then, after membrane mobilization mesially and distally, the septa can be removed before the lifting procedure (Fig. 38, 39, 40). In other anatomic conditions, after the membrane mobilization trought the two trap doors, the septa can be left into the sinus performing two different augmentation procedure in two separate subantral cavity (Fig. 41, 42, 43).

Anatomical and pathological variations Septa The presence of anatomic variations within hte maxillary sinus, such as septa, has been reported to increase the risk of sinus membrane perforation during the sinus elevation procedure (4, 24). These anatomic conditions were first described by Underwood in 1910 and the etiology has been discussed in the literature. Neivert (25) proposed that the septa were derived from the fingerlike projections produced by the embryologic outpouching of the ethmoid infundibulum, where the contiguous wall did not resorb. Krennmair (26) classified the septa into primary and secondary, with the primary arising from the development of the maxilla, whereas the secondary septa were supposed to arise from the irregular pneumatization of the sinus floor following tooth loss. Etiologically, antral septa constitute partly congential and partly acquired malformations. Congenital septa, also referred to as “primary septa� can devolope in all maxillary sinuses during the growth of the middle part of the face. Vinter (27) observed that atrophy of the maxillary alveolar process proceeded irregularly in different regions, leaving bone crests on the maxillary sinus floor, also known as secondary septa. From the radiological point of view, the literature (27) reported that panoramic radiography can lead to a false diagnosis regarding the positive or negative identifications of a septa in 21.3% of cases. Several authors have suggested that CT images can be useful in

FIG. 38-39-40

CT and panorac view of underwood septa.


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Beretta M. the alveolar ridge for implant rehabilitation (28). The literature reported two different values of antral cyst prevalence depending on the type of radiological examinations: between 1.4% and 9.6% in case of panoracs and 12.4 in case of CT scan (29). Sinus augmentation is associated with several complications, with postoperative sinusitis and bone graft infection as the most serious. The development of sinusitis following sinus augmentation can be directly related to drainage disturbances, mainly as a result of septal deviation and allergy, combined with oversized inferior and middle turbinates. The presence of anantral pseudocyst reduces the size of the maxillary antrum. Therefore, it can be speculated that lifting the maxillary mucosal lining in this case would further reduce the sinus size and postoperative edema of the Schneiderian membrane. The ostium opening may be blocked causing stasis of fluids, which when contaminated, could lead to sinusitis. Nevertheless, because of the high position of the ostium relative to the sinus floor, especially in a large antrum, the reported prevalence of sinusitis following sinus augmentation in the absence of any pathology is about 3% to 20% of the cases reported in the literature (30-34). Differential diagnosis of an antral pseudocyst from other sinus lesions is crucial for treatment planning. As the maxillary sinuses may become involved with several types of diseases, including chronic rhinosinusitis, benign and malignant neoplasms, or even dental disorders, appropriate diagnosis is mandatory prior to any intervention (35). In particular radiological evaluation (Panorex and CT scan) and ENT examination with endoscopic approach are necessary to determine the benign or malignant nature of the lesion (36). The risk of ostium stenosis is highly augmented in case of sinus lift procedure in presence of an antral cyst which can lead to the iatrogenic closure of the nasal meatus during the surgical procedure (37, 38). The perviety of the sinonasal ostium is fundamental to guarantee the possibility for the sinus to drain the fisiological mucus tanks to the mucociliar flux reducing the risk of sinusitits. In particular, the sinus lift procedure leads to a major quantity of mucus to be drained, due to the surgical insult or in case of migration of the grafting material in the antral cavity if the schneiderian membrane is perforated (32). Some authors suggest a surgical-endoscopic approach to remove the intrasinusal lesion, in order to perform sinus lift procedure and implant insertion (38) (Fig. 44, 45, 46).

FIG. 41

Preoperative panorac: a patient with multiple agenesis with an Underwood septa in the maxillary sinus before the grafting procedure.

FIG. 42

Postoperative control panorac: sinus lift.

FIG. 43

Postoperative final panorac: sinus lift and implant placement.

Sinus cysts and mucocele The mucocele is a pseudocystic formation with a secretive epithelial layer filled with a dense liquid, aseptic and slimy mucous. Some Authors stated that the presence of an antral cyst would be a contraindication for the predictability of the sinus lift procedure in these particular patients. Other studies assess that pseudocysts do not affect the possibility to perform a sinus grafting procedure (6). The presence of cyst-like opacity in the maxillary sinus is commonly asymptomatic and diagnosed on routine radiographic examination taken for other reasons, such as dental rehabilitation, impacted teeth, or to assess

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Intraoperative complications Perforation of the Schneiderian membrane is the major intraoperative complication, which is reported up to 44% of surgeries and up to 52% in case of presence of intrasinusal septa (6) (Fig. 47, 48, 49). The surgical procedures proposed are represented by the suture of the Schneiderian membrane (not recommended by the authors owing to the high risk to enlarge the perforation and because it represents a very challenging procedure), and the most reported into the literature which consists in the use of a resorbable membrane to close the hole into the sinusal membrane


FIG. 47

Intraoperative view: a large perforation in the sinusal membrane can be noticed.

FIG. 48

Collagene resorbable membrane placed to close the laceration.

FIG. 49

Subantral cavity grafting procedure after resorbable membrane placement.

FIG. 44-45-46

CT and panorac view of a mucocele in the right sinus.

avoiding the intrusion of grafting materials into the sinus cavity.

Graft materials Although autografts are the gold standard, allografts can be used as bone grafting material thank to its osteoconductive properties and, in some limited conditions, osteoinductive properties (39, 40). Allogeneic bone is a graft that is taken from a member of the same species as the host but is genetically dissimilar.

The grafts can be obtained as fresh, frozen, freeze-dried, mineralized, and demineralized, and each preparation may be purchased as cortical chips, cortical granules, cortical wedges, or cancellous powder (39-41). The properties of the allograft are directly related to the steps taken in processing the material. The rate of disease transmission has almost halted. The risk of contracting HIV is estimated to be 1 in 1.6 million, as compared with the risk of 1 in 450,000 in blood transfusions. Strct background checks are performed on the donor and his or her family before being accepted into the program (39). Once the grafts are harvested, they are processed through


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Beretta M. different methods, including physical de´bridement, ultrasonic washing, treatment with ethylene oxide, antibiotic washing, and gamma irradiation for spore elimination. With this additional processing, however, the graft’s biologic and mechanical properties are weakened. The goal of these steps is to remove antigenic components and reduce host immune response while retaining the biologic characteristic of the graft. Fresh or frozen allografts possess the highest osteoinductive and osteoconductive potential, but they are rarely used because of increased risk of host immune response and disease transmission. Compared with freeze-dried allografts, fresh or frozen allografts seem to induce much stronger immune response, which is the primary reason why processed grafts are suggested by some authors (39, 43). Freeze-dried, or lyophilized, grafts are the least immunogenic, but they possess inferior osteoinductive properties, mechanical properties, and strength compared with fresh or frozen (44). Host immune response and infection are reduced by eliminating the cellular phase of the allograft. Although freeze drying kills all cells, the chemical integrity of the graft remains intact. Processing freeze-dried demineralized bone involves placing the graft in antibiotic wash twice at 4°C for 1 hour. Then the material is stored at 70° C to dry up to 5% of water. Another favorable finding is that HIV has not been transmitted in freezedried bone (45). Although the graft undergoes lyophilization, microfractures form along the collagen fibers. These cracks result in a decrease in the mechanical properties of the graft (44). When DFDBA was compared with autologous bone in maxillary sinus augmentations, DFDBA showed 29% new bone formation compared with 40% with autologous bone (34). It was also noted that the DFDBA particles located near pre-existing bone were surrounded by new bone, but the particles located near the center of the graft showed no signs of remineralization or new bone formation. DFDBA does not necessarily remove all minerals from the graft. Demineralized bone matrix (DBM) is an option as an allograft material for defect repair (39, 44). It is produced through decalcification of cortical bone. Because of the processing method, it is found to be more osteoinductive than standard mineralized allograft while retaining most of the bone growth factors after removal of the mineral phase. The advantage to using DBM is its ability to be modelled to fill the desired area with graft material. One disadvantage of this material is the technical challenge associated with its low viscosity (41). Recently, excipients have been added to the DBM. Once the DBM and the excipient are combined, the mixture begins to harden at the surgical site, which allows for better handling and adaptability. The mineral content of the allograft directly affects how additional proteins/factors can be used at the grafting site. Mineralized bone matrix has no osteoinductive properties, and BMPs are encased by the bone minerals (44). Decreasing mineral content in the graft, the osteoinductive property is elevated by making growth factors more available to stimulate mesenchymal cells. Unfortunately, reduction of mineral content decreases mechanical strength of the graft.

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Synthetic materials Synthetic grafting materials have been shown to possess two of the four characteristics of an ideal graft: osteoconduction and osteointegration (45-47). The ideal synthetic graft material should be biocompatible, support new bone growth and undergo remodeling. Other features include similar toughness, modulus of elasticity, and compressive strength compared with host cortical or cancellous bone. Many synthetic materials are available, including bioactive glasses, glass ionomers, aluminum oxide, calcium sulfate, calcium phosphates, a- and b-tricalcium phosphate (TCP), and synthetic hydroxyapatite (48-51). The bioactive glasses are nonporous and consist of silicon dioxide (SiO2), calcium oxide (CaO), phosphorus pentoxide (P2O5), and sodium oxide (Na2O). Solubility is directly related to the proportion of sodium oxide found in the formulation (48). By altering the concentrations of sodium oxide, silicon dioxide, and calcium oxide, glasses with different properties are produced. These materials exhibit significantly greater strength compared with calcium phosphates. A positive feature with the use of these substitutes includes the formation of a strong bond between the glass and the host bone, which is accomplished through hydroxyapatite crystals. The most important disadvantage with the use of this product is that it does not resorb (49, 50). Synthetic substitutes create a new avenue for clinicians to explore as adjuncts in surgical procedures. These materials may not necessarily be used solely for reconstructive procedures, but when used in the correct situations in combination with autologous, allograft, or other synthetic materials, the results have the potential for more desirable results. Xenograft Xenografts are derived from a genetically different species than the host. One of the most used xenografts is bovine bone. Deproteinized bovine bone mineral, is normally treated by having all of its organic material removed. This treatment leaves a crystal structure that practically matches human cancellous bone in structure. The particle size of this material is 0.25 to 1 mm. Pores with these dimensions have been shown to promote osteogenesis (12, 13). This has 75% of its volume contained in its porous scaffold. This structure greatly increases the surface area and results in a material that is good for osteoconduction. This large surface area increases angiogenesis and enhances new bone growth (22). In a study that compared anorganic bovine bone to autologous bone in maxillary sinus augmentation procedures, this material resulted in 39% new bone formation compared with 40% with autologous bone after 6 months (13). These results showed the effectiveness of this substitute material by almost matching the amount of new bone formation as seen with autologous bone. Although the results of new bone generation were nearly similar at 6 months, 31% of the grafted anorganic bovine bone was still present at the graft site as compared with only 18% with autologous bone (14). Substitute materials can be also obtained

Monograph from other species such as horse or porcine models but few reports in the literature are available. The future of bone graft substitutes will continue to expand with increasing technologic advances, which allow us to better understand bone healing, the role that factors such as BMP, transforming growth factor, plateletderived growth factor, and others play in this process, and how to better induce these processes when desired. The site of reconstruction, size of the defect to repair, objectives of the surgery, examination of the patient, expectations of the patient, and knowledge of graft materials are all factors that must be considered before surgery. There are many options in graft materials from which to choose, all with advantages and disadvantages (453). The surgical procedures, such as the well known Boyne and James technique and autogenous bone or bone substitutes, have been used for a long time to fill up the subantral cavity. At present, the reports of long term prospective and retrospective studies confirm that bone substitutes are able to regenerate new bone without harvesting autogenous bone and the implant survival rate in augmented sinuses with biomaterials is remakably higher than the obtained using autogenous bone chips (3). In the Cawood and Howell class VI only autogenous bone is recommended, since the severe atrophy needs all the power of an osteoproliferative material. This means that at least 80% of the sinus elevation procedures can be performed using biomaterials alone. All bone substitutes currently used in sinus elevation procedures, either xenogenic or alloplasts, offer osteoconductive properties only. The decision should be taken after considering the human hydroxilapatite structure: the more the granule of a biomaterials is similar to human hydroxilapatite crystal, the greater the osteoconductive effect (54, 55). Another parameter to be taken into consideration is the biomaterial’s resorption time. A too quickly resorbable material does not allow the osteoblats and the new vessels to promote a woven bone formation (56). A too slowly resorbable material, delaying its total substitution with newly formed bone, inhibit the bone to implant contact which is essential for osseointegration. A 6 to 10 months resorption time can be reasonably considered as ideal. In our experience, anorganic bovine bone has been giving excellent results in over 15 years of sinus elevation surgeries, giving a new bone quality close to a class 2 native bone (52, 55-58) and a very good osteoconductive property as from many histomorphometric studies (57). Nevertheless, we have been using other bone substitutes as beta tricalcium phospate, calcium solphate, DFDBA, whose clinical efficacy has been demonstrated in some studies, even though with a lower consideration in terms of bone quality and implant survival rate (3).

References 1. Tatum OH. Maxillary and sinus implant reconstruction. Dent Clin North Am. 1986;30:207–229. 2. Boyne P, James RA. Grafting of the maxillary sinus floor with

autogenous marrow and bone. J Oral Maxillofac Surg. 1980;17:113–116 3. Del Fabbro M, Testori T, Francetti L, Taschieri S, Weinstein R. Systematic review of survival rates for immediately loaded dental implants. Int J Periodontics Restorative Dent 2006;26:249–264. 4. Van den Bergh JPA, ten Bruggenkate CM, et al. Anatomical aspects of sinus floor elevations. Clinical Oral Implants Resources. 2000;11:256–265. 5. Chanavaz M. Maxillary sinus: anatomy, physiology, surgery and bone grafting related to implantology. Eleven years of surgical experience (1979–1990). Journal of Oral Implantology. 1990;16:199–209. 6. Testori T., Weinstein R., Wallace S. La chirurgia del seno mascellare. Edizioni Acme, Milano 2005; 37 7. Solar P, Geyerhofer U, et al. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clinical Oral Implants Research. 1999;10:34–44. 8. Block MS, Kent JN. Sinus augmentation for dental implants: the use of autogenous bone. J Oral Maxillofac Surg.1997;55:1281–1286. 9. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compend Contin Educ Dent.1994;15:152–162. 10. Grossi GB, Maiorana C, Garramone RA, Borgonovo A, Beretta Farronato MD, Santoro F. Effect of submucosal injection of dexamethasone on postoperative disconfort after third molar surgery: a prospective study. International Journal of Oral Maxillofacial Surgery. 2007 Nov; 65 (11):2218-26. 11.Vercellotti T, Pollack AS.A new bone surgery device: sinus grafting and periodontal surgery. Compend Contin Educ Dent 2006 May; 27(5):319-25 12. Valentini P, Abensur D, Wenz B et Al. Sinus grafting with porous bone mineral ( Bio-Oss): a study on 15 patients. Int J Period Rest Dent 2000; 20:245-52 13. Valentini P, Abensur D. Maxillary sinus grafting with anorganic bovine bone: a clinical report of long-term results Int J Oral Maxillofac Impl 2003;18:556-60 14.Pjetursson BE, Rast C, Brägger U, Schmidlin K, Zwahlen M, Lang NP Maxillary sinus floor elevation using the (transalveolar) osteotome technique with or without grafting material. Part I: Implant survival and patients’ perception. Clin Oral Implants Res. 2009 Jul;20(7):667-76. Epub 2009 May 26. 15. Davarpanah M., Martinez H., Tecucianu J. F., Hage G., Lazzara R. The modified osteotome technique. Int J Periodontics Restorative Dent. 2001 Dec; 21(6):599- 607. 16. Summers RB. Sinus floor elevation with osteotomes. Journal of Esthetic Dentistry 1998;10:164–171. 17. Diserens V, Mericske E, Schäppi P, Mericske-Stern Transcrestal sinus floor elevation: report of a case series. Int J Periodontics Restorative Dent. 2006 Apr;26(2):151-9. 18. Zitzmann NU, Scharer P. Sinus elevation procedures in the resorbed posterior maxilla: Comparison of the crestal and lateral approaches. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85:8–17. 19. Troedhan AC, Kurrek A, Wainwright M, Jank S Hydrodynamic ultrasonic sinus floor elevation--an experimental study in sheep. J Oral Maxillofac Surg. 2010 May;68(5):1125-30. 20. Hu X, Lin Y, Metzmacher AR, Zhang Y. Sinus membrane lift using a water balloon followed by bone grafting and implant placement: a 28-case report. Int J Prosthodont. 2009 MayJun;22(3):243-7. 21. Muronoi M, Xu H, Shimizu Y, Ooya K. Simplified procedure for augmentation of the sinus floor using a haemostatic nasal balloon. Br J Oral Maxillofac Surg. 2003 Apr;41(2):120-1. 22. Soltan M, Smiler DG. Antral membrane balloon elevation. J Oral Implantol. 2005;31(2):85-90.


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Beretta M. 23. Stelzle F, Benner KU. Evaluation of different methods of indirect sinus floor elevation for elevation heights of 10 mm: an experimental ex vivo study. Clin Implant Dent Relat Res. 2009 Aug 3. jaw. A multi center prospective study. Clinical Oral Implants Research 15: 278–284. 24. Underwood AS. An inquiry into the anatomy and pathology of the maxillary sinus J Anat Physiol 1910; 44:354-369. 25. Neivert H. Surgical anatomy of the maxillary sinus. Laryngoscope 1930; 40:1-4. 26. Krennmair G., Ulm GW, Lugmayr H, Solar P. The incidence, location and height of maxillary sinus septa in the edentulous and dentate maxilla. J. Oral Maxillofac Surg 1999; 57:667-671. 27. Velasquez-Plata D, Hovey LR, Peach CC, Alder ME. Maxillary sinus septa: a 3-dimensional computerized tomographic scan analysis. Int. J Oral Maxillafac implants 2002; 17:854-860 28. Mardinger O, Manor I, Mijiritsky E, Hirshberg A. Maxillary sinus augmentation in the presence of antral pseudocyst: a clinical approach Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Feb;103(2):180-4. 29. MacDonald-Jankowski DS. Mucosal antral cysts observed within a London inner-city population. Clin Radiol 1994;49:195-8. 30. Bhattacharyyan N. Do maxillary sinus retention cysts reflect obstructive sinus phenomena? Arch Otolaryngal Head Neck Surg 2000;126:1369-71. 31. Wiltfang J, Schultze-Mosgau S, Merten HA, Kessler P, Ludwig A, Engelke W. Endoscopic and ultrasonographic evaluation of the maxillary sinus after combined sinus floor augmentation and implant insertion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:288-91. 32. Timmenga NM, Raghoebar GM, Boering G, Van Weissenbruch R. Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral Maxillofac Surg 1997;55:936-9. 33. Garg AK, Mugnolo GM, Sasken H. Maxillary antral mucocele and its relevance for maxillary sinus augmentation grafting: a case report. Int J Oral Maxillofac Implants 2000;15:287-90 34. Beaumont C, Zafiropoulos GG, Rohmann K, Tatakis DN. Prevalence of maxillary sinus disease and sbnormalities in patients scheduled for sinus lift procedures. J Periodontol 2005;76:461-7. 35. Gilbert JG. Antroscopy in maxillary sinus disease associated with nasal polyposis. J Laryngol Otol 1989;103:861-863. 36. Earwaker J. Anatomic variants in sinonasal CT. Radiographics 1993;13:381-415 37. Bachert C, Ganzer U. Experimental studies on the relationship between maxillary sinus ventilation and various obstructions of the moise and the nasopharynx. Rhinology 1989;27:37-43. 38. Stammberger H, Posawetz W. Functional endoscopic sinus surgery. Concept, indications and results of the Messerklinger technique. Eur Arch Otorhinilaryngol 1990;247:63-76. 39. Strong DM, Friedlanender GE, Tomford WW, et al. Immunologic responses in human recipients of osseous and osteochondral allografts. Clin Orthop 1996; 326:107–14. 40.Khan SN, Cammisa FP Jr, Sandhy HS, et al. The biology of bone grafting. J Am Acad Orthop Surg 2005;13(1):77–86. 41.Ehrler DM, Vaccaro AR. The use of allograft bone in lumbar spine surgery. Clin Orthop 2000;371: 38–45. 42. Cornell CN. Osteoconductive materials and their role as

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substitutes for autogenous bone grafts. Orthop Clin North Am 1999;30:591–8. 43. Scarano A, Degidi M, Iezzi G, et al. Maxillary sinus augmentation with different biomaterials: a comparative histologic and histomorphometric study in man. Implant Dent 2006;15(2):197–207. 44. Moghadam HG, Sa´ndor GKB, Holmes HHI, et al. Histomorphometric evaluation of bone regeneration using allogeneic and alloplastic bone substitutes. J Oral Maxillofac Surg 2004;62:202–13 45. Glowacki J, Altobelli D, Mulliken JB. The fate of mineralized and demineralized osseous implants in cranial defects. Calcif Tissue Int 1981;33:71–6. 46. Cho BC, Chung HY, Lee DG, et al. The effect of chitosan bead encapsulating calcium sulfate as an injectable bone substitute on consolidation in the mandibular distraction osteogenesis of a dog model. J Oral Maxillofac Surg 2005;63:1753–64. 47. Klinge B, Alberius P, Isaksson S, et al. Osseous response to implanted natural bone mineral and synthetic hydroxyapatite ceramic in the repair of experimental skull bone defects. J Oral Maxillofac Surg 1992;50:241–9. 48. Kokubo T. Design of bioactive bone substitutes based on biomineralization process. Materials Science and Engineering C 2005;25:97–104 49. Moore WR, Graves SE, Bain GI. Synthetic bone graft substitutes. ANZ J Surg 2001;71:354–61. 50. Constantino PD, Freidman CD. Synthetic bone graft substitutes. Otolaryngol Clin North Am 1994; 27:1037–73. 51. Habal MB, Reddi AH. Bone grafts and bone substitutes. Philadelphia: W.B. Saunders Company 1992, p. 243–4, 247. 52. Maiorana C , Sigurtà D, Mirandola A et Al Bone resorption around implants placed in grafted sinuses: a clinic and radiologic follow-up after up to four years Int J Oral maxillofac Impl 2005;2:261-65 53. Geurs NC, Wang JC, Schulman LB et Al Retrospective readiographic analysis of sinus graft and implant placement procedures from the Academy of Ossoeintegration Consensus Conference on sinus graft Int J Period rest dent 2001;21: 517-24 54. Haas R, Mailath G, Dortbudak O et Al.Bovine hydroxiyapatite for maxillary sinus augmentation: analysis of interfacial bond sterngth of dental implants using pull-out tests Clin Oral Impl Res 1998; 17: 151-75 55. Maiorana C, Redemagni M, Rabagliati M et Al. Treatment of maxillary ridge resorption by sinus augmentation with iliac cancellous bone, anorganic bovine bone and implants: a clinical and histologic report Int J Oral Maxillofac Impl 2000;15:873-78 56. Wallace SS, Froum SJ, Cho Sc et Al. Sinus augmentation utilizing anorganic bovne bone ( Bio-Oss) with absorbable and non absorbable membranes placed over the lateral window: histomorphometric and clinical analyses Int J Period Rest dent 2005;25:551-59 57. Hallman M, Sennersbt L, lungren S. A clinical and histologic evaluation of implant integration in the posterior maxilla after sinus floor augmentation with autogenous bone, bovine hydrxyapatite , or a 20:80 mixture. Int J Oral Maxillofac Impl 2002;17:635-43 58. Santoro F, Maiorana C. Advanced osseointegration; RC Books, Milano, 2005:117-124.

Case report

Eruption of an Impacted Second Premolar Associated with a Follicular Cyst after Marsupialization: a Case Report Giovanni Battista Grossi DMD, DDS, MD Adriano Giussani DDS Ramon Boninsegna DDS Rocco Alberto Garramone DDS, MD Andrea Enrico Borgonovo DMD, MD

University of Milan Ospedale Maggiore IRCCS Ca’ Granda Department of Surgical, Reconstructive and Diagnostical Sciences, Director Prof Fanco Santoro


Follicular cyst is one of the most common types of odontogenic lesions and is associated with the crown of an unerupted or developing tooth. Enucleation of the cyst and the associated tooth is the usual treatment; the decompression of the lesion, as a subsequent marsupialization, could preserve the tooth involved. The authors report a case of dentigerous cyst involving an impacted permanent mandibular second premolar which was recovered through the marsupialization of the lesion and without any orthodontic treatment.


Key words: Follicular cyst, impacted tooth, marsupialization, decompression.

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Grossi G.B. et al.


Case report

Three months after the decompression of the follicular cyst, the impacted premolar reached half-way to the ideal position.

Follicular cysts are the second most frequent type of odontogenic cysts and the most common developmental cysts of the jaws (1). They approximately represent the 20% of all cysts of the jaws and in the 75% of the cases they are located in the mandible (1). Follicular cysts are associated with the crown of an unerupted or developing tooth: the teeth mainly associated to the dentigerous cysts are the mandibular third molars and premolars (2) and the maxillary canines, which can be more frequently impacted. Anyway, any tooth can be involved; in rare cases the dentigerous cysts could involve also primary teeth (3, 4). During the latency period, follicular cysts are usually asymptomatic and grow slowly. They could be diagnosed through a routine dental radiograph as a well-defined radiolucent lesion of alveolar bone, embracing the crown of an unerupted tooth (5). If the follicular cysts are not recognized at an early stage, they could enlarge causing tooth displacement, erosion of the cortical bone, bone expansion, facial asymmetries and even pathologic fractures (6). Dentigerous cysts, moreover, inhibit the eruption of the involved permanent tooth (7). Removal of the whole cyst with the impacted tooth is the common treatment to prevent recurrence of the cyst. Marsupialization is another advisable treatment to preserve the cyst-associated tooth and promote its eruption (8). This report describes the case of a follicular cyst associated with an impacted second premolar in the lower jaw of a 10-year-old female. The lesion was marsupialized under local anesthesia and followed monthly, while the second premolar gradually erupted up to reach the alveolar mucosa. This report shows that marsupialization can allow the eruption of impacted tooth associated with dentigerous cysts in the lower jaw.

A 11-years-old female was referred to the Department of Oral Surgery of Dental Clinic I.R.C.C.S., Milan- because her parents complained of a swelling overlying the left cheek. Extraoral examination revealed mild soft tissue swelling in the masseter region; intraoral examination showed an hard mass at the base of the vestibule. Inferior alveolar nerve was not functionally injured. Radiographic examination showed a radiolucent area from the mandibular left first molar tooth to the mandibular left first premolar, and an impacted second premolar located at the bottom of the cyst (Fig. 1). A diagnostic suspect of odontogenic cyst arose. Because of an extensive boneinvolvement, it was required a Computed Tomography which revealed a huge extension of the lesion associated to erosion of the vestibular cortical bone, being the lingual cortical bone partially preserved (Fig. 2). Due to the age of the patient and the possibility of a natural eruption, a marsupialization of the lesion was decided. The mandibular deciduous second molar was extracted during the surgery. After a mucoperiosteal flap had been elevated, an ostectomy on the crestal bone was performed, then the cyst membrane was fenestrated and subsequently sutured to the mucosa of the oral cavity. Then, a gauze iodoform pack was positioned into the marsupialized cyst cavity. The packing was replaced every other day up to a complete riepithelization. Histological examination confirmed the diagnosis of follicular cyst. The patient periodically underwent radiographic examinations and it was observed that the impacted premolar slowly moved toward the alveolar crest: after 2 months, the tooth was

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FIG. 1

Panoramic radiograph showing the large follicular cyst and displaced premolar.

FIG. 2

Computed Tomography revealed an extensive bony involvement.

FIG. 3

Two months later, the tooth began to erupt slowly.

FIG. 4

Case report

FIG. 5

FIG. 8

Intraoral view after three months.

Fourteen months after marsupialization, the eruption of cyst-associated tooth was done. FIG. 7

Intraoral view after ten months.

FIG. 6

Ten months after marsupialization, tooth reached the alveolar mucosa.

erupting slowly (Fig. 3). After 3 months, eruption was still in progress (Fig. 4, 5). After 10 months, the tooth reached the alveolar mucosa (Fig. 6, 7) and after 14 months the premolar was completely erupted without any orthodontic traction (Fig. 8, 9).

Discussion Follicular cysts are associated with the crown of an unerupted or developing tooth (1). Like other cysts, they show no symtomps until swelling becomes noticeable; moreover, in the lower jaw, an inferior alveolar nerve paresthesia or a neurosensory disturbance are rare symptoms. Considering the etiopathogenesis of follicular cysts, regarding Benn and Altini (9), the cyst of this case report had an inflammatory origin due to a periapical inflammation caused by the nonvital deciduous tooth, which involved the follicle of the unerupted permanent successor.

Histologically, the wall of the cyst was composed of a thin layer of connective tissue, lined by stratified squamous epithelium. The epithelium included a variable number of plasma cells. In the adjacent connective tissue there was the presence of islands of inactived odontogenetic epithelium (Fig. 10). As a consequence of inflammation, epithelial cells are fragmented and become osmotically active particles involving an increase of the osmotic pressure in the cyst, which expands itself independently (10). Generally, follicular cysts are enucleated at the same time with the extraction of the associated impacted tooth. This treatment is chosen for small and medium cysts and involving non-strategic impacted tooth, such as third molars. Large cysts involving a serious loss of bone are often treated by marsupialization: the reduction of intracystic pressure stimulates shrinkage of the cyst promoting bone filling, taking it away from


FIG. 9

Intraoral view fourteen months after marsupialization. The eruption of cystassociated tooth was done.

FIG. 10

Histological image of the wall of the dentigerous cyst.

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Grossi G.B. et al. noble structures such as the inferior alveolar nerve and reducing the possibility of a pathologic fracture. This treatment, moreover, preserve the involved tooth in the cyst. In this case report, because of the young age of the patient, the bone around the entire cyst presents a high rate of regenerative potential (11). Marsupialization can be useful in helping the eruption of a deeply impacted cyst-associated tooth. Without treatment, the cyst inhibits the eruption of the impacted tooth and can also move it to an unusual position in the jaw (12): in a study by Hyomoto et al. (13) the natural eruption of an impacted tooth in the dentigerous cyst after marsupialization was 72.4%. There is a close relationship between the possibility of a natural eruption of a cyst-associated tooth and the level of dental root formation (14). Generally, a permanent tooth breaks through the alveolar bone and erupts when two-thirds of root formation is completed. The impacted tooth without complete root formation with an open apex has a considerable eruption potential (15, 16). Cyst size and the dental space between the adjacent teeth could compromise the results of eruption. Dental space is important for the position of the erupting tooth in the dentition: in some cases an adjunctive orthodontic therapy could be required (17, 18). Moreover, orthodontic traction of impacted tooth with matured root is often necessary after marsupialization of a large cyst (19). However, in our case, the tooth erupted with only marsupialization without orthodontic traction. Marsupialization requires a cooperative patient who will follow up regularly, not only because of the high rate of medications, but also in order to evaluate a possible recurrence, due to the pathological tissue left in situ (20, 21).

References 1. Weber AL. Imaging of the cysts and odontogenic tumors of the jaw. Definition and classification. Radiol Clin North Am 1993; 31;1:101-20 2. Tachibana T, Shimizu M, Shioda S, et

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al: Clinical observation on the cysts of the jaws in childhood, especially on the follicular cysts. Jpn J Oral Maxillofac Surg 1980; 26:337 3. O’Neil DW, Mosby EL, Lowe JW. Bilateral mandibular dentigerous cysts in a five-year-old child: report of a case. ASDC J Dent Child 1989; 56:382 4. Miller CS, Bean LR. Pericoronal radiolucencies with and without radiopacities. Dental Clin North Am 1994; 38:51-61 5. Lucas RB. Dentigerous cyst. In: Pathology of tumours of the oral tissue. 4th ed. London: Churchill Livingstone 1984; 366-9 6. Han MH, Chang KH, Lee CH, Na DG, Yeon KM, Han MC. Cystic expansile masses of the maxilla: differential diagnosis with CT and MR. AJNR 1995; 16:333-8 7. Golden AL, Foote J, Lally E, et al: Dentigerous cyst of the maxillary sinus causing elevation of the orbital floor. Oral Surg 1981; 52:133 8. Thoma KH. Oral surgery II. 5th ed. St Louis: Mosby 1969 9. Benn A, Altini M. Dentigerous cysts of inflammatory origin. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 81:203-9 10. Toller PA: The osmolality of fluids from cysts of the jaws. Br Dent J 1970; 129:275 11. Takagi S, Koyama S. Guided Eruption of an Impacted Second Premolar Associated with a Dentigerous Cyst in the Maxillary Sinus of a 6-Year-old Child. J Oral Maxillofac Surg 1998; 56:237-9 12. Alling CC, Helfrick JF, Alling RD. Impacted maxillary teeth. In: Impacted teeth. Philadelphia: W. B. Saunders 1993; 247-69 13. Hyomoto M, Kawakami M, Inoue M, et al: Clinical conditions for eruption of maxillary canines and mandibular premolars associated with dentigerous cysts. Am J Orthod Dentfacial Orthop 2004; 124:515 14. Miyawaki S, Hyomoto M, Tsubauchi J, et al: Eruption speed and rate of angulation change of a cyst-associated mandibular second premolar aftermarsupialization of a dentigerous cyst. Am J Orthod Dentofac Orthop 1999; 116:578 15. Marks SC Jr, Schroeder HE. Tooth eruption: theories and facts. Anat Rec 1996; 245:374-93 16. Demerjian A, Levesque GY. Sexual differences in dental development and prediction of emergence. J Dent Res 1980; 59:1110-22 17. Clauser C, Zuccati G, Barone R, Villano A. Simplified surgicalorthodontic treatment of a dentigerous cyst. J Clin Orthod 1994; 28:103-6 18. Jena AK, Duggal R, Roychoudhury A, et al: Orthodontic assisted tooth eruption in a dentigerous cyst: A case report. J Clin Pediatr Dent 2004; 29:33


19. Tominaga K, Kikuta T, Fukuda J, Uemura S, Yasumitsu C, Yamada N. Marsupialization for dentigerous cysts in children: especially behaviors of the involved teeth. Jpn J Oral Maxillofac Surg 1988; 34:133-8 20. Peterson LJ, Ellis EIII, Hupp JR, et al: Contemporary Oral and Maxillofacial Surgery (ed 3). St Louis, MO, Mosby 1998; 540 21. Omnell KA, Rohlin M. Case challenge: chronic maxillary inflammation. J Contemp Dent Pract 2000; 15:100-5

Case report

Non-carious cervical lesion combined with recession: restorative-periodontal procedure. A case report Carlo Ghezzi* Gregory Brambilla** Giacomo Santoro*** University of Milan Ospedale Maggiore IRCCS Ca’ Granda Dental Clinic, Director Prof Franco Santoro *Department of Periodontology, Head Prof Massimo Simion ***Department of Implantology Head Prof Carlo Maiorana and Giovanni Battista Grossi **Private practice, Milan (Italy)


The cervical region of teeth can often be affected by non-carious lesions (NCCLs) in combination with soft tissue recession. This article reports a case of a cervical abrasion with soft tissue recession. After a careful preparation and motivation of the patient a periodontal restorative prosthetic treatment was plannned, which aimed at the biological restoration of the teeth, the correction of the imperfection, and the elimination of dentinal sensitivity that had led the patient to undergo the treatment. In particular, the use of conservative techniques combined with muco-gingival surgery to treat NCCLs with gingival recessions can now ensure the achievement of high aesthetic results as well as a satisfying functional anatomy achievement of the area.


Key words: Cement-enamel junction; gingival recession surgery; surgical flap; tooth abrasion.

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Santoro G.


FIG. 1

Preoperative examination: NCCL combined with recession at tooth 2.3.

FIG. 2

Intraoral sight: the inadequate crowns at teeth 2.2 and 2.4 were removed; CEJ has disappeared from teeth 2.3 with NCCL and an accentuated horizontal component of the defect can be seen.

The cervical region of teeth can often be affected by non-carious lesions (NCCLs) in combination with soft tissue recession. Gingival recession is defined as an apical migration of the soft tissue margin from the cementenamel junction (CEJ), mainly caused by plaque or an incorrect brushing technique. Even if the correlation between tissue recession and cervical lesions has not been demonstrated in literature, it is easy to infer that, as the accumulation of plaque in the presence of cervical lesions is easier, it causes tissues inflammation. The high possibility of negative evolution of these lesions recommends their treatment to obtain a correct profile and integrity of the tooth and its supporting structures, relevant characteristics to perform correct oral hygiene techniques. This article reports a case of a cervical abrasion with soft tissue recession. The patient was treated with a restorative procedure, plus mucogingival surgery and prosthetic rehabilitation of the adjacent teeth in order to optimize the final aesthetic and functional result.

Materials and methods

FIG. 3

Additional intraoral view highlighting the horizontal deficit at 2.3.

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A 55 years patient came to our observation in good general health and without systemic risk factors. After a careful periodontal evaluation, a diagnosis of periodontal disease led to a custom program of plaque control, together with brushing technique correction. The re-evaluation of the patient one month after confirmed the treatment success, by measuring plaque and bleeding indices. Clinical examination showed aesthetic compromission due to two inadequate crowns at teeth 2.2 and 2.4 and a cervical lesion connected to the gingival


recession at tooth 2.3 (Fig. 1). The NCCL was most likely the result of traumatic brushing manoeuvres associated with inflammation. Occlusal anomalies, that might suggest the presence of occlusal factors (abfraction), were not recognized. Tooth 2.3, where aesthetics had to be improved, needed a soft tissue coronal reposition, to alleviate the irritating sensibility reported by the patient, to harmonize the adjacent tissues and to allow proper home oral hygiene to be performed. At teeth 2.2 and 2.4 the aim was to obtain a correct prosthetic rehabilitation through the creation of new crowns. The recession at 2.3 belonged to class I of Miller classification with a sufficient amount of keratinized tissue. The first phase of the treatment was the removal of the inadequate crowns at 2.2 and 2.4 (Fig. 2), which were replaced by an acrylic provisional prosthesis. Tooth 2.3, with a high enameldentinal cleft was also treated (Fig. 3). The issue in cases of cleft that has led to a CEJ’s loss is twofold. In the restorative treatment, the clinician can not know where to create a correct emerging profile, while in periodontology the only parameter that can guide us to the prediction of new gingival margin healing position goes lost. It is necessary to assume, however, the position of the lost CEJ and this is done through the analysis of the gingival margins of the adjacent teeth and through the assessment of the contralateral tooth (1-23).Therefore, after calculating the "relative" length of the clinical crown, a restoration more apical than the relative CEJ (rCEJ) of about 1.5 mm was performed, to avoid the problem in case of partial root coverage or of an error in the placement of the rCEJ. The restoration was performed at first under local anesthesia and by means of a dental dam, placing the apical margin of the restoration, performed with a diamond burs, in a supragingival position. This made the isolation with dam possible as well as

Case report layering techniques, finishing and polishing techniques and to avoid soft tissue’s damage during the reconstruction. The cavity preparation was smoothed by performing odontoplasty with diamond disks in the coronal portion of the lesion (Fig. 4). Then the composite restoration was done, preceded by sandblasting, etching and application of the adhesive in the cavity preparation previously made. The nano-filled composite drawing up was performed with dedicated micro-spatulas (Fig. 56). Periodontal surgery was performed after 2 weeks, in order to avoit overly trauma to the area. Soft tissues surgery, under local anesthesia, consisted of a coronally repositioned flap (4) to obtain the required root coverage. This phase provided for surgical vestibular incisions (Fig. 7), an initial half thickness detachment followed by a full-thickness and half thickness flap. After papilla de-epithelialization, the flap was coronally repositioned and then stabilized with individual sutures, and a suspended suture (CV7Gore Ž Flagstaff, AZ, USA) in the coronal part of the tooth (Fig. 8). After surgery amoxicillin clavulanate (Augmentin) 2 g per day for six days and Mesulid fast 2 g/day for 3 days were administered. The patient was advised not to brush and not to move the dental floss in the area during the first 2 months. He was also recommended to rinse with chlorhexidine 0.2% twice a day for the first 20 days and 0.12% thereafter. The sutures were removed 10 days later. The treated area underwent prophylaxis every week for 2 months. The patient was then placed on a recall program every three months. Two months later, when gingival tissues stability was achived, the compatibility between the marginal periodontium and the composite reconstruction could be checked, and treatment was concluded with final ceramic crowns at 2.2 and 2.4 (Fig. 9). Careful preparation and

motivation of the patient made possible a periodontic-restorativeprosthetic treatment plan aimed at the biological restoration of the teeth, the correction of the imperfection, and the elimination of dentinal sensitivity that had led the patient to undergo the treatment. The records after six months show biocompatibility between the marginal tissue and the underlying composite reconstruction (Fig. 10).

FIG. 4

The margins of the cavity preparation.

Discussion Black was the first author who studied the non-carious cervical lesions in 1908. In a recent study, some authors underlined that the amount and the severity of non-carious cervical lesions increase with age (5-6). The increase of patients’ age leads the clinician to frequently deal with this type of lesions. The successful treatment of these lesions is not necessarily related to the recognition and to the elimination of all possible factors that had caused the lesion (6-7). Several studies were performed to assess the correct position of the gingival margin and to provide data to use as benchmarks in the frontal rehabilitation of the aesthetic areas (1-2-3). Some studies compared, with similar results, root coverage performed on teeth with recession, both combined with cervical lesions limited to the root of the tooth both without related cervical lesions (8). The evaluation of a complete root coverage could, however, be considered difficult because cervical lesions often may extend beyond the CEJ, involving not only the areas belonging to the root, but also those of the crown. The incisal edge of cervical lesions is in fact often mistaken for the CEJ, although it is not always correlated with it (9). For this reason, the true height of a gingival recession can not be measured very precisely and often its extension is less than the extension of the non-carious


FIG. 5

Front view of the composite reconstruction.

FIG. 6

Finish-line of the composite reconstruction.

FIG. 7

Vestibular incisions.

JOS VOL.1 N.1 2010

Santoro G.

FIG. 8

Detail of the suture.

FIG. 9

Postoperative view after 6 months.

FIG. 10

Front view after 6 months.

cervical lesion. Many factors, including the thickness of the flap, the tension of the flap, the height of adjacent papillae and post-surgical position of the gingival margin (10-14) can influence the final level of root coverage. Even after a flawless surgical procedure, in most cases the coverage of the coronal part of NCCLs is not possible, giving to the patient the impression of failure (9). Moreover, exposed tissues are liable to a continuous dental hypersensitivity. For this reason, in order to correct non carious cervical lesions associated with gingival recession, many authors reported the effectiveness of mucogingival surgery combined with resin cervical restorations, both with case reports (15-17) and randomized clinical trials comparing qualitatively root coverage performed exclusively with muco-gingival surgery technique and root coverage performed with muco-gingival surgery technique combined with resin restorations (4-18-19). At first, the use of composite resin restorations in direct contact with the gingival margin was criticized (20). It was subsequently shown that the use of composite resins beneath soft tissues does not seem to lead to health problems at the surrounding periodontal tissues (21-25). This change is likely the result of time innovation that has characterized the techniques and tools used during the restoration’s layering, finishing and polishing. After six months, the health of the treated area is also confirmed by the absence of bleeding on probing, and by a correct probing depth.

Conclusion The treatment of NCCLs requires patient motivation and education, the initial assessment of the biological patient value and a multidisciplinary approach. In this way it is today possible to obtain results without being aggressive, thus preserving as much tissue as possible and postpone more aggressive

JOS VOL.1 N.1 2010


operations. In particular, the use of conservative techniques combined with muco-gingival surgery to treat NCCLs related to gingival recessions can now ensure the achievement of high aesthetic results combined with an adequate functional anatomy of the area involved. The possibility of postponing the conservative treatment is to be assessed from case to case depending on the position and on the depth of the cleft.

References 1. Carolina M.L. Mattos, Ronaldo B. Santana. Quantitative evaluation of the spatial displacement of the gingival Zenith in the maxillary anterior dentition. J Periodontol 2008; 79: 1880-1885. 2. Charruel, Perez, Foti, Camps, Monnet-Corti. Gingival contour assessment: clinical parameters useful for esthetic diagnosis and treatment. J Periodontol 2008; 79: 795-801. 3. Chu, Tan, Stappert, Tarnow. Zenith positions and levels of the maxillary anterior dentition. ESTHETE Restor Dent J 2009; 21: 113-121. 4. Santamaria, M. P, Suaid, F. F., Nociti, F. H. Jr., Casati, M. Z. Shallum, A. W. Shallum & E. A. (2008) Coronally Positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession Associated with Non-carious cervical lesions. A rando-mized controlled clinical trial. Journal of Periodontology 79 621-628. 5. Borcic, Anic, Urek, Ferreri. The noncarious cervical lesions of prevalence in permanent dentition. J Oral Rehabil 2004; 31: 117-23. 6. Wood, Jawad, Paisley, Brunton. Noncarious cervical tooth surface loss: A literature review. Journal of Dentistry 2008, 36: 759-766. 7. Litonjua LA, Andreana S, Bush PJ, Tobias TS, Cohen RE. Noncarious and abfractions cervical lesions: a reevaluation. Am Dent Assoc 2003; Aug; 134 (7): 845-50. 8. M Goldstein, Nasatzky And Goultschin J, Boyan BD, Schwartz Z. Coverage of previously carious roots is as Predictable procedures as coverage of intact roots. J Periodontol 2002; Dec, 73: 1419-26. 9. Zucchelli, G., Testori, T. & De Sanctis, M. (2006) Clinical and anatomical factors limit-ing treatment outcomes of gingival recession: a new method to predetermine the line of root coverage. Journal of Periodontology

Case report 77, 714-721. 10. Pini Prato, Pagliaro, Baldi, Nieri, Saletta, Cairo, Cortellini. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: a randomized controlled clinical study. J Periodontol 2000; 71: 188-201. 11. Pini Prato, Baldi, Nieri, Franseschi, Cortellini, Clauser, Rotundo, Muzzi. Coronally Advanced Flap: The PostSurgical Position of the Gingival Margin Is an Important Factor for Achieving Complete Root Coverage. J Periodontol 2005; 76: 713-722. 12. Saletta, Pini Prato, Pagliaro, Baldi, Mauri, Nieri. Coronally advanced flap procedures: is th Interdental papilla a prognostic factor for root coverage?. J Periodontol 2001, 72:760-766. 13. Baldi, Pini Prato, Pagliaro, Nieri, Saletta, Muzzi, Cortellini. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to Achieve root coverage? A 19-case series. J periodontal 1999; 70: 1077-1084. 14. Hwang Wang. Flap thickness as a predictor of root coverage: a Systematic Review. J Periodontal 2006; 77: 1625-1634.

21. Dragoo, M. R. (1997) Resin-ionomer and hybrid-ionomer cements: part II, human clin-ical and histologic wound healing responses in specific periodontal lesions. International Journal of Periodontics and Restorative Den-tistry 17, 75-87. 22. Dragoo MR. Resin-ionomer and hybrid-ionomer cements: Part I. Comparison of three materials for the treatment of subgingival root lesions. Int J Periodontics Restorative Dent Dec 1996, 16 (6): 594-601. 23. Alkan, Keskiner, Yuzbasioglu. Tissue Grafting Mr Resin ionomer in Localized Gingival Recession. J Periodontol 2006, 77: 1446-1451. 24. Santos, Lucchesi, Knife, Amaral, Feres, Mendes Duarte. Effects of Glass ionomer and subgingival Microfilled Composite Restorations on Periodontal Tissue and subgingival biofilm: A 6-Month Evaluation. J Periodontol 2007; 78:1522-1528. 25. Martins, Woods, No'brega, Nagata, Garcia, Fucini. Periodontal Tissue Response to Coverage of Root Cavities Restored With Resin Materials: A Histomorphometric Study in Dogs. J Periodontol 2007; 78:1075-1082.

15. Allegri, Landi, Zucchelli. The restoration of the cervical protocols and operational relationships with the periodontium. The Modern Dentist 2009; 11: 41-68. 16. Santamaria, M. P., Suaid, F. F., Nociti, F. H. Jr., Casati, M. Z. Shallum, A. W. Shallum & E. A. (2007) and glass ionomer Periodontal surgery restoration in the treatment of gingival recession-sion Associated with a non-carious cervical lesions. Report of three cases. Journal of Periodontology 78, 1146-1153. 17. Allegri, Landi, Zucchelli. Non-carious cervical lesions Associated with multiple gingival recessions in the maxillary arch. A restorativeperiodontal esthetic effort for success. A 12 month case report. ESTHETE Eur J Dent 2010; 5: 1027. 18. Lucchesi, J. A. Santos, V. R., Amaral, C. M., Peruzzo, D. C. & Duarte, P M. (2007) Cor-onally Positioned Flap for Treatment of restored root surfaces: a 6-month clinical evaluation. Journal of Periodontology 78, 615623. 19. Santamaria MP, Ambrosio GMB, MZ Casati, FH Nior Nociti Ju, AW and Shallum Shallum EA. Connective tissue graft plus resin-modified glass ionomer restoration For the treatment of gingival recession Associated with Non-carious cervical lesions: a randomized-controlled clinical trial. J Clin Periodontol 2009; 36: 791798. 20. Larato DC. To Influence of composite resin restoration on the gingiva. J Prosthet Dent. 1972 Oct; 28 (4): 402-4.


JOS VOL.1 N.1 2010

JOS - European Journal of Oral Surgery  

European Journal of Oral Surgery

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