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Bio-Oss® produced more favorable results than allogenic materials for the preservation of extraction sockets prior to dental implantation1 The long-term osteoconductive scaffold, Bio-Oss® induced more new bone deposition than allografts and exhibited increased osteoblastic activity. Rapid resorption of the allografts resulted in more fibrous connective tissue and less new bone than Bio-Oss®.

*

30

10 0

* 23.6% 17.2% 12.0%

Bio-Oss® Rocky Mtn

Puros®

% residual graft

% new bone

40

20

50

*

40

*

30 20

* 25.4%

10 0

50

*

Bio-Oss®

12.0%

13.7%

Rocky Mtn

Puros®

% fibrous tissue

50

*

40 30

* * 45.9%

46.3%

Rocky Mtn

Puros®

34.1%

20 10 0

Bio-Oss®

Histograms showing the percentages of (left) new bone, (middle), residual graft particles, and (right) fibrous connective tissue in the biopsy specimens. *Significant difference (P < .05) T = 4.5 months; n = 20

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References: 1Lee DW, Pi SH, Lee SK, Kim EC. Comparative Histomorphometric Analysis of Extraction Sockets Healing Implanted with Bovine Xenografts, Irradiated Cancellous Allografts, and Solvent-Dehydrated Allografts in Humans. Int J Oral Maxillofac Implants 2009; 24: 609-615. Bio-Oss® is a registered trademarks of Ed. Geistlich Söhne Ag Fur Chemische Industrie and is marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. Puros® is a registered trademark of Zimmer, Inc. ©2009 Luitpold Pharmaceuticals, Inc. OHD239 Iss. 9/2009


Volume 1, No. 7

o ctober 2009

The Journal of Implant & Advanced Clinical Dentistry

Bisphosphonate Related Osteonecrosis of the Jaw

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The Journal of Implant & Advanced Clinical Dentistry Volume 1, No. 7 â&#x20AC;˘ o ctober 2009

Table of Contents

13 Case of the Month

Treatment Planning and Execution of Minimally Invasive Dentistry Michael Apa

21 JIACD Continuing Education

Successful Management of a Severe Case of Bisphosphonate Related Osteonecrosis of the Jaw in a Multiple Myeloma Patient

Cesar Luchetti, Sebastian Yantorno, Julian Barrales, Juan Napal, Jorge Milone, Alicia Kitrilakis

31 The Bio-Derm Ridge Plumping Technique for Pontic Site Development Nicholas Toscano, Dan Holtzclaw

The Journal of Implant & Advanced Clinical Dentistry

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The Journal of Implant & Advanced Clinical Dentistry Volume 1, No. 7 â&#x20AC;˘ o ctober 2009

Table of Contents

49 Minimally Invasive Antral

Membrane Balloon Elevation to Treat Previous Sinus Augmentation Failure: A Case Report Ziv Mazor, Efraim Kfir

59 Comparison of Stress Patterns In and Around Orthodontic Micro-implants: A Finite Element Study S. Sakthish, Sridevi Padmanabhan, Arun Chithranjan

71 Dental 3D Imaging Centers Usage and Findings: Part II Anatomical Features of the Lingual Artery

Alan A. Winter, Kouresh Yousefzadeh, Alan S. Pollack, Michael I. Stein, Frank J. Murphy, Christos Angelopoulos

77 Cultivating Your Online

Dental Reputation with Blogs Shannon Mackey

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The Journal of Implant & Advanced Clinical Dentistry Volume 1, No. 7 • o ctober 2009

Publisher SpecOps Media, LLC Design Jimmydog Design Group www.jimmydog.com Production Manager Stephanie Belcher 336-201-7475 Copy Editor JIACD staff Digital Conversion NxtBook Media Internet Management InfoSwell Media Subscription Information: Annual rates as follows: Non-qualified individual: $99(USD) Institutional: $99(USD). For more information regarding subscriptions, contact info@jiacd.com or 1-888-923-0002. Advertising Policy: All advertisements appearing in the Journal of Implant and Advanced Clinical Dentistry (JIACD) must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. The publication of an advertisement in JIACD does not constitute an endorsement by the publisher. Additionally, the publisher does not guarantee or warrant any claims made by JIACD advertisers. For advertising information, please contact: info@JIACD.com or 1-888-923-0002 Manuscript Submission: JIACD publishing guidelines can be found at http://www.jiacd.com/author-guidelines or by calling 1-888-923-0002.

Copyright © 2009 by SpecOps Media, LLC. All rights reserved under United States and International Copyright Conventions. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying or any other information retrieval system, without prior written permission from the publisher. Disclaimer: Reading an article in JIACD does not qualify the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its staff, and parent company SpecOps Media, LLC (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACDSOM. JIACD-SOM disclaims any responsibility or liability for such material and does not guarantee, warrant, nor endorse any product, procedure, or technique discussed in JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its affiliated websites, or affiliated communications. Conflicts of Interest: Authors submitting articles to JIACD must declare, in writing, any potential conflicts of interest, monetary or otherwise, that may exist with the article. Failure to submit a conflict of interest declaration will result in suspension of manuscript peer review. Erratum: Please notify JIACD of article discrepancies or errors by contacting editors@JIACD.com JIACD (ISSN 1947-5284) is published on a monthly basis by SpecOps Media, LLC, Saint James, New York, USA.

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The Journal of Implant & Advanced Clinical Dentistry

Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS

Founder, Co-Editor in Chief Nicholas Toscano, DDS, MS

Board A Minimally Invasive and SystematicEditorial Approach Advisory to Sinus Grafting Tara Aghaloo, DDS, MD Faizan Alawi, DDS Michael Apa, DDS Alan M. Atlas, DMD Charles Babbush, DMD, MS Thomas Balshi, DDS Barry Bartee, DDS, MD Lorin Berland, DDS Peter Bertrand, DDS Michael Block, DMD Chris Bonacci, DDS, MD Hugo Bonilla, DDS, MS Gary F. Bouloux, MD, DDS Ronald Brown, DDS, MS Bobby Butler, DDS Donald Callan, DDS Nicholas Caplanis, DMD, MS Daniele Cardaropoli, DDS Giuseppe Cardaropoli DDS, PhD John Cavallaro, DDS Stepehn Chu, DMD, MSD David Clark, DDS Charles Cobb, DDS, PhD Spyridon Condos, DDS Sally Cram, DDS Tomell DeBose, DDS Massimo Del Fabbro, PhD Douglas Deporter, DDS, PhD Alex Ehrlich, DDS, MS Nicolas Elian, DDS Paul Fugazzotto, DDS Scott Ganz, DMD Arun K. Garg, DMD David Guichet, DDS Kenneth Hamlett, DDS Istvan Hargitai, DDS, MS Michael Herndon, DDS Robert Horowitz, DDS Michael Huber, DDS

Richard Hughes, DDS Debby Hwang, DMD Mian Iqbal, DMD, MS Tassos Irinakis, DDS, MSc James Jacobs, DMD Ziad N. Jalbout, DDS John Johnson, DDS, MS Sascha Jovanovic, DDS, MS John Kois, DMD, MSD Jack T Krauser, DMD Gregori Kurtzman, DDS Burton Langer, DMD Aldo Leopardi, DDS, MS Shannon Mackey Miles Madison, DDS Carlo Maiorana, MD, DDS Jay Malmquist, DMD Louis Mandel, DDS Michael Martin, DDS, PhD Ziv Mazor, DMD Dale Miles, DDS, MS Robert Miller, DDS John Minichetti, DMD Uwe Mohr, MDT Jaimee Morgan, DDS Dwight Moss, DMD, MS Peter K. Moy, DMD Mel Mupparapu, DMD Ross Nash, DDS Gregory Naylor, DDS Marcel Noujeim, DDS, MS Sammy Noumbissi, DDS, MS Arthur Novaes, DDS, MS Andrew M. Orchin, DDS Charles Orth, DDS Jacinthe Paquette, DDS Adriano Piattelli, MD, DDS Stan Presley, DDS

George Priest, DMD Giulio Rasperini, DDS Michele Ravenel, DMD, MS Terry Rees, DDS Laurence Rifkin, DDS Georgios E. Romanos, DDS, PhD Paul Rosen, DMD, MS Joel Rosenlicht, DMD Larry Rosenthal, DDS Steven Roser, DMD, MD Salvatore Ruggiero, DMD, MD Anthony Sclar, DMD Frank Setzer, DDS Maurizio Silvestri, DDS, MD Dennis Smiler, DDS, MScD Dong-Seok Sohn, DDS, PhD Muna Soltan, DDS Michael Sonick, DMD Ahmad Soolari, DMD Christian Stappert, DDS, PhD Neil L. Starr, DDS Eric Stoopler, DMD Scott Synnott, DMD Haim Tal, DMD, PhD Gregory Tarantola, DDS Dennis Tarnow, DDS Geza Terezhalmy, DDS, MA Tiziano Testori, MD, DDS Michael Tischler, DDS Michael Toffler, DDS Tolga Tozum, DDS, PhD Leonardo Trombelli, DDS, PhD Ilser Turkyilmaz, DDS, PhD Dean Vafiadis, DDS Hom-Lay Wang, DDS, PhD Benjamin O. Watkins, III, DDS Alan Winter, DDS Glenn Wolfinger, DDS Richard K. Yoon, DDS

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Editorial Commentary

A Great Meeting in Boston

N

ick and I just attended the 95th Annual Meeting of the American Academy of Periodontology (AAP) in Boston and what a great trip it was. We arrived in Boston a few nights before the meeting started that is when the fun began. The trip started off with a bang when my iPhone was stolen at a restaurant downtown. I always had a fear about this happening, so I never kept any highly confidential information on the phone (thank goodness!). Within a few minutes of the phone disappearing, I sent a text message offering $100 for the safe return of the phone, but alas, no response. I promptly reported the phone as being stolen, suspended all services to that particular phone, and changed all of my account passwords just to be safe. That was a wonderful first night of the trip! The next day, Nick and I attended a marketing course offered by Dr. Paul Fugazzotto. Dr. Fugazzotto’s course was outstanding and I highly recommend it for anyone in private practice. He was a gracious host and the information presented was as good as gold! The food and wine were pretty good as well! After attending Paul’s course, we went back to the hotel to meet and greet everyone as they began to arrive for the meeting. It was nice seeing some old friends and even better making new ones. With the night one theatrics of my stolen phone behind us, we had a drink in the hotel lobby prior to heading out for dinner. Upon finishing my drink, I asked for my bill and was somewhat surprised to see that I had been charged nearly $200. Hmm, I have had some good cocktails in my day, but I can’t remember one ever costing $200. I chatted with the waitress for a bit about

my bill and, of course, she had mixed my tab with the group that was sitting next to me. The waitress apologized and had the charges reversed…or so I thought. The $200 drink showed up on my statement the next morning and it took me a few days to clear up that situation. What fun! Aside from my phone being stolen and my $200 drink, which was subsequently changed to the correct price of $20 (still a bit pricey for a single drink if you ask me), the actual meeting was outstanding. The AAP put together a great meeting with some top notch lecture topics. Growth factors and the treatment/prevention of implant complications seemed to be one of the major focuses of this meeting. As always, the corporate forums provided some outstanding clinical lectures and a number of rooms were standing room only…until the convention officials kicked people out of the room for violating the fire code! When the rooms are packed to overflowing, that is always a great sign. In addition to providing some informative lectures, the corporate entities had some great deals in the exhibition hall. Next year’s AAP meeting is in the beautiful state of Hawaii. Having lived in Hawaii for three years in the past, I am excited to go back! If next year’s meeting is as good as this year’s meeting, it will be a great one. I will be sure to register as soon as I get a new phone. ●

Dan Holtzclaw, DDS, MS Founder, Co-Editor-In-Chief

Nick Toscano, DDS, MS Founder, Co-Editor-In-Chief

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Kurtzman


Case of the Month Treatment Planning and Execution of Minimally Invasive Dentistry

Kurtzman

Michael Apa, DDS1

AbstrAct

cAse report

Conservation of tooth structure is essential in any patient. Multi-disciplinary treatment planning has allowed this to be a reality in contemporary dentistry. The case presented in this article involves an 18 year old college bound female who was unhappy with her smile. Treatment planning that involved a combination of periodontics, orthodontics, and restorative dentistry allowed the patient to be treated in a manner where she was happy with her smile from the time of initial treatment until delivery of her final restorations

Figures 1-3 show the patient at initial presentation with congenitally developed peg laterals, canted midline, and a flared anterior segment due to a thumb-sucking habit. In order to treat this case conservatively, orthodontia was required. However, to satisfy the patientĂ­s goals of improving her smile immediately, something had to be done aesthetically prior to her leaving for college. As such, the four anterior teeth were minimally prepared for veneers, rolling in the teeth slightly. Final plans were to finish this case with InvisalignÂŽ (Santa Clara, California, USA) and bring the upper anterior segment into the proper arch form.

KeY WorDs: Orthodontics, periodontics, restorative dentistry, composite restorations, veneers 1. Private practice limited to prosthodontics, New York, NY USA

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Apa

In order to understand how much tooth structure truly needed to be removed, a mock-up of the future position of the teeth was made and then depth cut through an accurate set of provisionals. This allowed for planning of the proper amount of tooth structure removal. For this case, anesthesia was not administered in order to make sure to tooth preparation remained in enamel. Topical anesthetic was applied to the gingival tissue for minor plasty on the zeniths of teeth 7, 8, and 10. Figure 4 shows rolling in the centrals and minor adjustments that were made to the gingiva with a diode laser. Now that the ìarch formî was correct, the provisionals were fabricated. This process is similar to what a laboratory does for an additive/reductive wax-up, yet allows the clinician to utilize facial landmarks to be accurate (figures 5-7). Prior to depth cutting, an alginate impression was taken for a stent to make final provisionals. At this point, the provisional restorations are depth cut (figure 8) according to desired porcelain thickness, keeping in mind initial color and desired color. Minimal tooth structure removal was needed in this case due to the light stump shade. Final margins and preparation were performed, followed by smoothing of all line angles (figure 9). At this point, an alginate impression was filled with Luxatemp® (Zenith Dental, Englewood, New Jersey, USA) and checked to see if there was enough room for ceramic (figures 10,11). Final impressions were taken, along with a bite registration, stump shade photos, and a counter impression. The provisionals were bonded in place and final shaping was done along with the approval of the patient (figure 12). Four individual veneers were bonded to teeth 7-10, the bite was adjusted, and the patient was sent to the orthodonist to be fitted for Invis-

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October 2009

align® treatment. The patient now left for college with a very aesthetic result, minimal tooth structure removal, and clear orthodontics to finish off bringing the anterior segment into the arch (figures 13-15). She went through 8 months of orthodontic therapy and returned to the office where the occlusion and aesthetics were checked. A lingual wire was bonded behind the upper anterior teeth for retention (figure 16) and the case was completed (figures 17-21). The spaces distal to the laterals were closed, which confirmed that the anterior teeth were now in proper position. The final color was chosen to be a half shade lighter than the original teeth to give the patient a ìbleachedî yet natural aesthetic utilizing the chameleon effect of the arch.

conclusion Being conservative will always allow for enhanced bonding strength, less micro leakage, and longer lasting restorations. Also, using the underlying tooth for color will always result in a much more natural appearing restoration, which should be the goal for both the aesthetic clinician and patient. By treatment planning in a multi-disciplinary approach, goals of minimally invasive dentistry can be achieved with outstanding transitional and final aesthetic results. ● Disclosure The author reports no conflicts of interest with anything mentioned in this article. correspondence Dr. Michael Apa 30 East 76th Street, Suite 5B New York, NY 10021


Apa

● Figures 1-3 The Journal of Implant & Advanced Clinical Dentistry

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Apa

● Figures 4-7 16 •

Vol. 1, No. 7

October 2009


Apa

● Figures 8-12 The Journal of Implant & Advanced Clinical Dentistry

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Apa

● Figures 13-16 18 •

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October 2009


Kurtzman Apa

● Figures 17-21 The Journal of Implant & Advanced Clinical Dentistry

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JIACD Continuing Education Successful Management of a Severe Case of Bisphosphonate Related Osteonecrosis of the Jaw in a Multiple Myeloma Patient

Luchetti et al

Cesar Luchetti, DDS, MS1 • Sebastian Yantorno, MD2 • Julian Barrales, MD3 Juan Napal, MD4 • Jorge Milone, MD, PhD5 • Alicia Kitrilakis, DDS, PhD6 Abstract Background: Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious oral complication of bisphosphonate treatment involving the exposure of necrotic maxillary or mandibular bone. BRONJ is associated with pain, paresthesia, and oral dysfunction generating an impairment of the quality of life. Treatment of this complication remains difficult and the most useful action is prevention. Case Report: This is a case report of a multiple

myeloma patient whose first signs of BRONJ began in 2002 with the development of an aggressive bilateral osteonecrosis of the mandible. Successful management of this case is described with 17 months of follow up monitoring. Conclusions: This case supports the concept that BRONJ may be successfully treated. The approach described to treat this case, especially regarding sequestrum management, could minimize the surgical corrections after the sequestrum is removed.

KEY WORDS: Bisphosphonate necrosis, osteonecrosis, multiple myeloma 1. Associate Professor, Department of Implant Dentistry. National University of La Plata. (Universidad Nacional de La Plata). La Plata, Buenos Aires, Argentina. 2. Specialist in Haematology and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 3. Specialist in Infectology. La Plata, Buenos Aires, Argentina 4. Specialist in Internal Medicine and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 5. Specialist in Internal Medicine and Specialist in Haematology. Head of Oncohaematology and Transplants and Director of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 6. Head Professor, Department of Implant Dentistry and Department of Prosthodontics - National University of La Plata. (Universidad Nacional de La Plata) La Plata, Buenos Aires, Argentina This article provides 2 hours of continuing education credit. Please click here for details and additional information.

The Journal of Implant & Advanced Clinical Dentistry

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JIACD Continuing Education

Learning Objectives After reading this article, the reader should be able to: 1. Discuss Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ)and its causes. 2. Understand how to diagnosis and manage BRONJ 3. Understand the surgical and pharmocological management of BRONJ

INTRODUCTION Bisphosphonates, a class of drugs that inhibit bone resorption, were widely developed over the last four decades starting with the work of Herbert Fleish, who published the first report in 1968.1 To date, the main use of the drug was for the prevention and treatment of osteoporosis and other bone metabolism diseases, based on their ability to decrease bone turnover trough the inhibition of osteoclast differentiation and a decrease in its activity and survival rate.2 Recently, bisphosphonate use was extended to treat oncological diseases which present bone affectation such multiple myeloma and bone metastasis, in order to lower the skeletal effects. First studies are dated at the beginning of the nineties,3 being today a very important component of the therapeutic approach in these conditions.4 However, by the end of 2003, a new and a challenging entity developed as a complication in patients treated with bisphosphonates was described mainly associated with Pamidronate and Zoledronic Acid.5,6 Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a serious oral complication of bisphosphonate treatment involving the exposure of necrotic maxillary or mandibular

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Figure 1: Non-healing sockets after extractions in December 2002.

bone, occurring in 1.8 to 12.8 % of the cases with intravenous bisphosphonates administration.7

CASE DESCRIPTION A 48 year old white, male patient was referred to the Department of Implant Dentistry at the National University of La Plata. (Universidad Nacional de La Plata) in La Plata, Buenos Aires, Argentina in December 2005. The patient was undergoing treatment for multiple myeloma. The patient was diagnosed with multiple myeloma, IgG monoclonal band in proteinogram, in June 1996. Upon diagnosis of multiple myeloma, the patient was initially treated with four cycles of the “VAD protocol” (vincristine, adriamycin and dexamethasone) and autologous bone marrow transplantation in May 1997. Maintenance was accomplished with interferon until 2000, and later thalidomide until 2002. Concomitant treatments with bisphosphonates were pamidronate from September 2001 to December 2001 and zoledronic acid from January 2002 to December 2005. The patient experienced a relapse in 2006 and bortezomib was used for 8 cycles. The patient has since experi-


JIACD Continuing Education

Figure 2: Control radiograph in March 2003 showed no improvements.

Figure 3: In September 2003, patient lost teeth 18, 20, and 29.

Figure 4: Patient lost an additional tooth, number 31 in March 2004 and boy sequestrums began to form.

Figure 5: Control x-ray in December 2004 showed the limits of the affected bone.

Figure 6: First contact with the patient in December 2005. Extensive bilateral bone exposure is noted.

Figure 7: Radiograph showing the status of the affected bone in December 2005. The Journal of Implant & Advanced Clinical Dentistry

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JIACD Continuing Education

Figure 8: Clinical situation in September 2006, without changes.

Figure 10: Computer tomography scan showing the extension of the lesions.

enced complete remission following this treatment. In 2002, the patient had some routine dental extractions which never fully healed and resulted in chronically exposed bone. Suspecting myeloma dissemination to the mandible, the oral surgeon at that time took a biopsy sample. The condition now known as BRONJ was not yet known at that time (figure 1). A few months later, the condition became increasingly aggrivated, with the consequent loss of more teeth and a progressive affectation to the bone (figures 2-5).

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Figure 9: Radiograph taken in November 2006 showing a progression of the affected bone.

The patient was first seen in our department in December 2005 and presented with significant bilateral bone exposure in the mandible (figures 6,7). According to the recommendations at the time, our approach was to try to maintain the exposed bone as clean as possible to prevent further infection. Our treatment consisted of long term antibiotics (Amoxicillin plus clavulanic acid, 1 gr, twice a day and metronidazole 500 mg twice a day), local rinses with clorhexidine 0.12 % 3 times a day, and rinses with 3% hydrogen peroxide once a day. After nine months of this conservative treatment, the patient showed no improvement. Additionally, the exposed bone in the right side of the mandible began to form a sequestrum and loosen (figures 8-10). At this time, the patient asked for a solution to his problem. We explained the risks and our approach based in the management of previous smaller cases. Following our discussions of the risk and benefits of treatment, the patient agreed to proceed. As such, our treatment protocol for this patient was modified as follows. We started to manipulate the bony sequestrum by gently trying to loosen it three times a


JIACD Continuing Education

Figure 11: Clinical situation after removing the sequestrum on the right side in December 2006.

Figure 12: Sequestrum removed.

Figure 13: Histology showing necrotic bone, with empty lacunaes and associated infected tissue. (H&E stain, magnification x 100)

Figure 14: Gram staining demonstrated Gram (+) bacillus. (magnification x 100)

week. During each visit, we carefully irrigated and cleansed the area apical to the sequestrum. To accomplish such, we used 5cc of clorhexidine 0.12% followed by 5cc of 3% hydrogen peroxide. Detritus were eliminated by means of a hand brush and finally, an additional two irrigations with clorhexidine and hydrogen peroxide were performed. After a couple of weeks the sequestrum was loose enough to attempt removal. We successfully removed the sequestrum with rongeurs and used rotary instruments to eliminate

remaining bony spicules to get a smooth bone surface and facilitate healing (figures 11,12). The sequestrum was submitted for histologic examination which revealed necrotic bone with empty lacunaes and associated infected tissue. With gram staining, Gram (+) bacillus were identified (figures 13,14). Fifteen days following surgery, the soft tissue healing looked acceptable and at one month, complete healing of the surgical site was observed (figure 15). Having achieved this, we decided

The Journal of Implant & Advanced Clinical Dentistry

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JIACD Continuing Education

Figure 15: Clinical situation one month after sequestrum removal.

Figure 16: Removal of the first part of the left sequestrum in February 2007.

Figure 18: Radiograph in July 2007.

to proceed in the same fashion on the left side. Bone sequestrum on the left side presented as two parts, first from the buccal and a few months later from the lingual (figures 16,17). After two months, the tissues at the surgical sites were stable. Radiographic examination did not reveal formation of additional bone sequestrum. We also performed a Serum C-terminal telopeptide (CTX) test according to the Marx protocol8 and got a result of 130 pg/ml, compatible with a moderate risk (figure 18). We then fabricated and delivered a maxillary dental prosthesis to give the patient the possibility to return to normal function, both masticatory and aesthetics wise, after several years (figures 19-21). Seventeen months later, the previously affected tissues continue to appear stable (figure 22).

DISCUSSION

Figure 17: Clinical situation after removal of the remaining part of the left sequestrum.

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Bisphosphonate s associated osteonecrosis of the jaw was first described in late 2003 and early 2004.5,6 At this time, surgery was almost totally contraindicated in theses cases because of the probability of aggravating the condition. The usual recommendation was, and still applies, to main-


JIACD Continuing Education

Figure 19: Removable prosthesis.

tain the exposed bone JIACD infectionContinuing free and to have in mind that the patient can live with some bone Education exposure without further problems.9,10 However, as we demonstrated in this case, the infection of the bone can worsen, no matter how great the effort to provide minimally invasive palliative treatment. Our thought is that once the lesion affects the cortical plate and the medullary bone becomes exposed, adequate cleansing of the area seems to be more difficult and the infection control requires extreme care, both home and professional. Clorhexidine is the antiseptic of choice cited in most articles.9,10 We also like to use 3% hydrogen peroxide based on our experience in managing abscess lesions in soft tissues which are usually present in the limits of the exposed bone. Also, 3% hydrogen peroxide can help in cases where the exposed bone presents a rough surface in which anaerobic bacteria could grow. Microbiological identification is important adjunct to aid infection management. Cultures must be made to search for aerobic and anaerobic bacteria, and also for fungus. Fungus can be present as a result of many situations, with the most common being systemic immunity impairment

Figure 20: Removable prosthesis.

Figure 21: Removable prosthesis.

Figure 22: Clinical situation in December 2008, showing stability of the soft tissues.

The Journal of Implant & Advanced Clinical Dentistry

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JIACD Continuing Education

and the previous use of long term antibiotics. More recently, surgical approaches have been described in order to achieve soft tissue healing in certain cases. Common features of these approaches are: 1) conservative resection of the necrotic bone with attempts at obtaining a smooth surface; 2) use of platelet derived growth factors; 3) tension free primary wound closue.11,12 We have used these approaches, especially with the use of platelet derived growth factor (PDGF), both for prevention in tooth extractions in compromised patients and for treatment of BRONJ. In cases where a bony sequestrum is present, it may be beneficial to loosen them in steps rather than remove them in a single attempt. With proper homecare involving the patient irrigating below the sequestrum, this conservative approach may lead to initial healing of the overlying soft tissue, which could minimize surgical corrections upon removal of the sequestrum. The serum C-terminal telopeptide (CTX) test8 is currently recommended as a way to measure the risks of development and progression of BRONJ. When used together with imaging, clinical examination, and other complementary studies, CTX testing may prove to be a valuable adjunct in the decision process for treating patients at risk for or currently affected by BRONJ. The patient treated in this case report had moderate CTX levels and proceeded to heal without complication. Whether this healing was a result of the CTX values or the treatment rendered cannot be determined at this time.

CONCLUSIONS The latest literature, and also this case, supports the concept that BRONJ may be successfully treated in the short term. The approach

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described to treat this case, especially regarding sequestrum management, could minimize necessary surgical corrections upon removal of the sequestrum. However, the resolution of this particular case does not ensure that every case can be resolved in the same way or with the same results, but shows us that there is a real possibility to treat this pathology with success. Each case must be evaluated individually and primary approaches must always be conservative and focused on prevention. Additional studies on the development, diagnosis, prevention, and management of BRONJ are warranted. ● Disclosure The authors report no conflicts of interest with anything mentioned in this article. Acknowledgements The author (Luchetti) would like to thank Dr. Cesar Migliorati, who was kind enough to share his opinion with him in Buenos Aires regarding this particular case. The authors would also like to thank Dr. Gregori Kurtzman, Dr. Len Tolstunov, and Dr. Douglas Martin for their assistance in the preparation of this manuscript. References 1. Fleisch H, Russell R, Bisaz S, Casey P, Muhlbauer R. The influence of pyrophosphates analogues (diphosphonates) on the precipitation and dissolution of calcium phosphate in vivo and in vitro. Calcif Tissue Res 1968; 2(suppl.): 10-10a. 2. Fleisch H. Bisphosphonates: Mechanisms of action and clinical use. En: Bilezikian et al Principles of Bone Biology, Ed. Academic Press, 1996: 10371052. 3. Merlini G, Parrinello G, Piccinini L, Crema F, Fiorentini ML, et al. Long-term effects of parenteral dichloromethylene bisphosphonate (CL2MBP) on bone disease of myeloma patients treated with chemotherapy. Hematol Oncol 1990; 8(1):23-30. 4. Body J. Bisphosphonates for malignancy-related bone disease: current status, future developments. Support Care Cancer 2006; 14(5):408-418. 5. Marx R. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61(9):1115-1117. 6. Ruggiero S, Mehrotra B, Rosenberg T, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004; 62(5):527-534. 7. Mehrotra B, Ruggiero S. Bisphosphonate complications including osteonecrosis of the jaw. Hematology Am Soc Hematol Educ Program 2006:356-360. 8. Marx R, Cillo J, Ulloa J. Oral bisphosphonate-induced osteonecrosis: Risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 2007; 65(12):2397-2410. 9. Marx R, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: Risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005; 63(11):1567-1575. 10. Migliorati C, Casiglia J, Epstein J, Jacobsen P, Siegel M, Woo S. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005; 136(12):1658-1668. 11. Kademani D, Koka S, Lacy M, Rajkumar S. Primary surgical therapy for osteonecrosis of the jaw secondary to bisphosphonate therapy. Mayo Clin Proc 2006; 81(8):1100-1103. 12. Adornato M, Morcos I, Rozanski J. The treatment of bisphosphonateassociated osteonecrosis of the jaws with bone resection and autologous platelet-derived growth factors. J Am Dent Assoc 2007; 138(7):971-977.


JIACD Continuing Education Luchetti et al

Continuing Education JIACD Quiz #3 1. Bisphosphonates are a class of drugs that inhibit bone resorption. a. True b. False 2. The main use of Bisphosphonates was for the prevention and treatment of osteoporosis and other bone metabolism diseases, based on their ability to increase bone turnover trough the activation of osteoclast differentiation and a decrease in its activity and survival rate. a. True b. False 3. What percentage of BRONJ cases are associated with intravenous bisphosphonate administration? a. 2 - 10% b. 1.8 - 12.8% c. 12.8 - 20.3% d. 0.001 - 0.002% 4. What is the antiseptic of choice cited for treatment? a. Saline b. Listerine c. Clorhexidine 5. Cultures must be made to search for aerobic bacteria, anaerobic bacteria, and fungus. a. True b. False

6. Bisphosphonate use was extended to treat oncological diseases in order to lower the skeletal effects. a. True b. False 7. The VAD Protocol includes the use of Vincristine, Adriamycin and Dexamethasone. a. True b. False 8. BRONJ was first described in what year? a. 2000 b. 1998 c. 2003 d. 2009 9. BRONJ must be evaluated individually and primary approaches must always be conservative and focused on prevention. a. True b. False 10. In cases where a bony sequestrum is present, it may be beneficial to loosen them in steps rather than removing in a single attempt. a. True b. False

CliCk here to take the quiz

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Does your bone grafting material measure up? Improvements in clinical and radiographic parameters in the GEM 21S® pivotal trial compare favorably with or exceed, documented outcomes for other regenerative therapies in studies examining defects with similar baseline characteristics.1,2,3,4 Radiographic Linear Bone Growth (LBG)

Radiographic Percent Bone Fill (BF%)

3.0 Mean LBG (mm)

57 40

20

4.0 3.7

2.6 2.0

1.0

1.1*

CAL Gain (mm)

60

Mean % BF

Clinical Attachment Level (CAL) Gain

3.0 2.7* 2.0

14* 0

GEM 21S®

0

Enamel Matrix Derivative (EMD)

GEM 21S®

Enamel Matrix Derivative (EMD)

0

GEM 21S®

Enamel Matrix Derivative (EMD)

*EMD results at 8 months, GEM 21S® results at 6 months

To learn more, please visit us online at www.osteohealth.com or call 1-800-874-2334 View prescribing information: www.osteohealth.com/documents/52.pdf

IMPORTANT SAFETY INFORMATION GEM 21S® Growth-factor Enhanced Matrix is intended for use by clinicians familiar with periodontal surgical grafting techniques. It should not be used in the presence of untreated acute infections or malignant neoplasm(s) at the surgical site, where intra-operative soft tissue coverage is not possible, where bone grafting is not advisable or in patients with a known hypersensitivity to one of its components. It must not be injected systemically. The safety and effectiveness of GEM 21S® has not been established in other non-periodontal bony locations, in patients less than 18 years old, in pregnant or nursing women, in patients with frequent/excessive tobacco use (e.g. smoking more than one pack per day) and in patients with Class III furcations or with teeth exhibiting mobility greater than Grade II. In a 180 patient clinical trial, there were no serious adverse events related to GEM 21S®; adverse events that occurred were considered normal sequelae following any periodontal surgical procedure (swelling, pain). For full prescribing information, go to www.osteohealth.com or call 1-800-874-2334 and a copy will be sent to you. References: 1. Nevins M, Giannobile WV, McGuire MK, Mellonig JT, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE. Platelet Derived Growth Factor (rhPDGF-BB) Stimulates Bone Fill and Rate of Attachment Level Gain. Results of a Large Multicenter Randomized Controlled Trial. J Periodontol 2005; 76: 2205-2215. 2. Heijl L, Heden G, Svardstrom G, Ostgren. Enamel matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997; 24: 705-714. 3. Zetterstrom O, Andersson C, Driksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontol defects. J Clin Periodontol 1997; 24: 697-704. 4. See full prescribing infromation for more detail. Emdogain® is a registered trademark of BioVentures BV Corporation. ©COPYRIGHT Osteohealth Company 2008. All rights reserved. OHD235e Rev. 9/2009.


The Bio-Derm Ridge Plumping Technique for Pontic Site Development

Toscano et al

Nicholas Toscano, DDS, MS1 • Dan Holtzclaw, DDS, MS2 Abstract Background: Seibert Class III apicocoronal and buccolingual alveolar ridge defects with associated gingival mucosal atrophy and absence of interdental papillae are common in edentulous areas within the anterior esthetic zone of the maxilla. Normal emergence profiles, critical to achieving esthetic restorations, require restoration of normal hard and soft tissue morphology, including re-establishment of adjacent interdental papillae.

Results: In all cases normal crestal hard and soft tissue architecture was restored, including re-establishment of interdental papillae, through simultaneous bone and soft tissue grafting without resorting to secondary autogenous graft harvesting procedures. Definitive non-implant supported fixed restorations with cleansable and esthetic ovate pontics and normal emergence profiles were achieved in each case.

Methods: In this 30 patient consecutive case series, significant Seibert Class III defects were simultaneously grafted with a slowly resorbing xenograft (Bio-Oss®) and an acellular dermal matrix allograft (Puros Dermis®) in order to effect both functional and esthetic improvements in the anterior maxilla without requiring secondary harvesting procedures. Fixed interim restorations with ovate pontics served as guides for the development of critically important interdental papillae.

Conclusions: Thirty consecutive patients with significant Seibert Class III alveolar ridge defects were successfully treated with simultaneous bone (Bio-Oss® particulate) and soft tissue grafting (Puros® Dermis Allograft) procedures. By avoiding autogenous hard and soft tissue grafts, the Bio-Derm Ridge Plumping Technique eliminated the need for additional invasive harvesting surgeries while allowing for the completion of both bone and soft tissue augmentation procedures in a single surgical visit.

KEY WORDS: Mucogingival surgery, bone graft, pontic, prosthetics 1. Private Practice, Washington DC, USA 2. Private Practice, Austin, TX, USA

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IntRODuCtIOn In the esthetic zone of the maxilla a proper emergence profile, predicated on healthy normal marginal gingival tissues with intact interdental papillae, is critical to achieving esthetically pleasing traditional fixed and implant supported restorations. Adequate soft tissue morphology, however, is dependent upon a stable, adequate volume of underlying bone capable of serving as a viable, biologic foundation for overlying soft tissues. Without the harmony afforded by a proper balance of underlying bone and overlying soft tissue, esthetic restorations are not possible, especially in the anterior maxilla. Frequently, however, alveolar bone loss disturbs that critical balance, resulting in marginal tissue distortion, recession and loss of esthetically crucial interdental papillae. Bone loss is common in the esthetic zone and can result from multiple precipitating events, the most common following tooth extraction. Multiple studies have documented predictable 3 mm to 4 mm of buccolingual and apicocoronal ridge resorption within 6 months after removal of maxillary anterior teeth. If left untreated up to 50% buccolingual bone loss will occur after one year post tooth removal in the critical esthetic zone.1-3 Buccal marginal bundle bone loss following disruption of intact PDL fibers after tooth removal and prominent, thin buccal bone subject to critical blood supply loss following extraction, are frequent causes of post-extraction bone loss within the maxillary esthetic zone.3-4 In addition, advanced periodontal disease, trauma, periapical infection and developmental defects commonly lead to bone loss and ridge deformities in areas critical to esthetic restorations. As a consequence of such frequently encountered bone loss, negative soft tissue morphologic changes

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often occur, including reduction or loss of keratinized marginal gingiva and disappearance of interdental papillae, both essential for esthetic dental reconstruction in the esthetic zone of the maxilla. Seibert, in an attempt to develop rational therapeutic approaches to alveolar ridge deformities, classified three major types of ridge deformities.5 Class I is a buccolingual loss of tissue with a normal apicocoronal dimension. Class II is an apicocoronal loss of tissue with normal buccolingual ridge width. Class III is a combination of buccolingual and apicocoronal loss of tissue resulting in loss of both normal height and width and is the most difficult class to successfully treat. Correctly classifying the type of ridge deformity as a guide to effective surgical and restorative treatment will help optimize the final restorative result. Numerous procedures, including distraction osteogenesis, bone splitting, guided bone regeneration and autogenous onlay bone grafting provide surgeons with a wide range of alternative approaches to managing the bony component of alveolar ridge deformity.6-11 Autogenous bone grafts have been considered the “gold standard” for bone regenerative procedures.12-13 Autogenous bone harvesting, however, is both invasive and technically demanding. Moreover, autogenous grafted bone resorption up to 40-50% has been demonstrated when autogenous grafts are used for treating horizontal and vertical alveolar ridge defects.14 Distraction osteogenesis, while an alternative approach to vertical ridge augmentation, is technically demanding and often difficult for patients unable to tolerate intra-oral distraction devices.14-15 While suitable for Seibert Class II defects, distraction osteogenesis cannot treat the horizontal components of Seib-


Toscano et al

ert Class I and III alveolar ridge deformities. Guided bone regeneration (GBR) is used for bony ridge augmentation with or without osseointegrated implant placement.16-17 GBR, with a barrier membrane in combination with bone grafts or bone graft substitutes, offers predictability in providing bone augmentation simultaneously in both horizontal and vertical directions, and is therefore appropriate for treating all three deformities within Seibertâ&#x20AC;&#x2122;s classification.18-20 Allografts, alloplasts and xenografts have all been used in GBR procedures to correct alveolar ridge defects prior to restorative treatment. Although critical to restorative success in the esthetic zone of the maxilla, regeneration of normal bony ridge architecture must also be associated with restoration of normal soft tissue anatomy, including recreation of missing interdental papillae. Insufficient volume of gingival soft tissue as well as poorly configured soft tissue architecture will mandate modifications in the design of fixed or removable prostheses to compensate for the deformity. Often such modifications result in overly large, ridge-lap pontics that fail to promote normal function, esthetics and ready cleansibility.21 Current surgical methods to correct soft tissue ridge deficiencies rely primarily on autogenous soft tissue grafts or allograft acellular dermal matrices, either alone or in conjunction with bone regenerative procedures. A variety of autogenous soft tissue graft types are available for correction of ridge deficiencies. Small to moderate Class I defects can be treated with the roll technique, utilizing a deepithelialized palatal connective tissue pedicle flap inserted within a properly prepared buccal pouch.22 Likewise, subepithelial connective tissue grafts are widely used for correction of primarily Seibert

Class I defects, although they can be used to correct mild vertical height deficiencies as well. Connective tissue grafts provide good to excellent color match with adjacent gingival tissues, often resulting in increased amounts of keratinized tissue at the graft site.23-26 Free gingival fullthickness onlay grafts are used to correct Seibert Class I, II and III ridge deficiencies, but often pose esthetic problems with adjacent tissue.27 Although widely used, soft tissue autografts require an additional invasive surgical procedure to harvest the graft material, increasing the potential for increased surgical morbidity. A finite amount of available autogenous tissue also limits the amount of soft tissue grafting that can be done at any one point in time. Furthermore, autograft shrinkage often demands further soft tissue grafting, requiring additional harvesting procedures, each with the potential for increased postoperative pain, hemorrhage, or infection.25 In an attempt to avoid some of the problems unique to soft tissue autografts, including the need for a second surgical procedure, clinicians have turned to acellular dermal matrix allografts as an alternative to autogenous soft tissue grafts. Originally developed for the treatment of fullthickness burn wounds, acellular dermal matrix is an allograft obtained from human skin.28-29 Processed so that the epidermal layer and all dermal cells are removed, the result is a graft matrix with normal type I collagen bundling architecture and an intact basement membrane. Removal of all cells eliminates the possibility of viral survival and transmission as well as the components necessary for graft rejection. Rather than healing by granulation, acellular dermal matrix grafts serve as conductive matrices, allowing cellular migration and neovascularization from the surrounding

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Figure 1: Midline crestal and releasing incisions made prior to flap reflection.

host bed to repopulate and replace the graft site. Although originally designed as an alternative treatment for burn wounds, acellular dermal matrices have been used extensively in dentistry as alternatives to autogenous soft tissue grafts. Dental use has included management of gingival recession,30-37 increasing the zone of keratinized tissue around teeth and implants,38-40 and preserving and/or increasing gingival thickness in edentulous areas.41-47 The purpose of this thirty patient consecutive case series was to investigate the efficacy of simultaneously grafting significant anterior maxillary Seibert Class III alveolar ridge defects with a slowly resorbing xenograft particulate (Bio-Oss®, Osteohealth Company, Shirley, NY) combined with an overlying acellular dermal matrix allograft (Puros® Dermis Allograft, Zimmer Dental Inc.) in order to restore both normal osseous and soft tissue contours, including restoration of interdental papillae, in patients requiring traditional fixed prosthetic restorations.

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Figure 2: Full-thickness mucoperiosteal flaps allowed complete access to all areas of the Seibert Class III defect.

MAtERIAlS AnD MEthODS Study Population Thirty consecutive patients with significant apicocoronal and buccolingual alveolar hard and soft tissue ridge deformities (Seibert Class III) were included in this reported case series. The patient population included 12 females and 18 males between 19 to 58 years of age. Detailed past medical and dental histories were obtained for each patient. All patients were treated by the authors as part of their clinical practice. Clinical Evaluation Following a detailed clinical examination, panoramic and full-mouth periapical radiographs were obtained for each patient. All patients presented with edentulous areas within the maxillary esthetic zone that had been previously restored with traditional, non-implant supported fixed restorations. Entrance into the study required Seibert Class III deficiencies, including loss of interdental papillae.


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Figure 3: Bio-Oss® particulate graft material was carefully placed over the exposed buccal and palatal cortices as well as the alveolar crest to allow bone regeneration to occur in all areas of the ridge defect.

Figure 4: After being trimmed and saturated with sterile saline, Puros® Dermis was positioned over the Bio-Oss® graft in order to act as both a GBR barrier membrane and conductive matrix for gingival soft tissue regeneration.

Overview of the Surgical Procedure Prior to surgery, all patients received oral hygiene instructions as well as full mouth scaling and curettage. Detailed informed consents were obtained, indicating understanding of the nature of the proposed surgical treatment. Using a #15 scalpel, midline crestal incisions were made at each edentulous site. Mesial and distal vertical release incisions allowed wide exposure of the maxillary buccal cortex (figure 1). Full-thickness buccal and palatal mucoperiosteal flaps were reflected, exposing the entire extent of the alveolar ridge deformity (figure 2). Following thorough wetting with sterile saline, small particle size Bio-Oss® particulate graft material was carefully placed over the exposed buccal cortex as well as the over the alveolar crest and palatal cortex to allow bone regeneration to occur in all areas of the ridge defect (figure 3). Puros® Dermis Allograft was then trimmed to size, saturated with saline, and placed over the Bio-Oss® graft in order

to act as a conductive matrix for gingival soft tissue regeneration to occur simultaneously with underlying new bone formation (figure 4). Importantly, the Puros® Dermis was placed facing the periosteal surface of the mucoperiosteal flap. The soft tissue flaps were then repositioned and closed without tension via multiple interrupted 5.0 ePTFE sutures (figure 5). A carefully prepared interim fixed restoration with ovate shaped pontics was then placed onto previously prepared abutment teeth (figure 6). In addition to satisfying both functional and esthetic requirements, the interim restoration was used as a guide during soft tissue maturation for creation of a more natural soft tissue profile, including the formation of interdental papillae. Pleasing emergence profiles were thus created by guiding the morphology of the soft tissues with the interim restoration during soft tissue regeneration.

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Figure 5: Soft tissue flaps were closed without tension via multiple interrupted 5.0 Gore-Tex sutures.

Figure 6: An interim restoration with ovate shaped pontics served as a guide during soft tissue maturation for the development of interdental papillae.

Figure 7: Seibert Class III defect demonstrates significant apicocoronal bone loss.

Figure 8: An occlusal view demonstrates severe buccopalatal narrowing in the esthetic zone of the maxilla.

REvIEW Of REPRESEntAtIvE CASES The following illustrate several representative cases that demonstrate both specific surgical and prosthetic procedures as well as obtained results when correcting difficult to treat hard and soft tissue defects within the esthetic zone of the maxilla with Bio-Oss® particulate graft and Puros® Dermis Allograft.

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Case #1 The patient, a 37 year old male presented with a Seibert Class III anterior maxillary edentulous defect of 15 years duration (figures 7, 8). The patient’s current prosthodontist constructed a new interim fixed restoration to replace a previously made and now clinically deficient fixed bridge. In order to compensate for significant apicocoronal and buccolingual bone loss as well as for loss of interdental papillae, overly large


Toscano et al

Figure 9: Ridge lap pontics attempt to compensate for ridge deficiency of case 1.

Figure 10: Additional view of ridge lap pontics from case 1.

Figures 11: Flap reflection revealed significant buccopalatal bone loss as well as the remnants of a residual cyst.

Figure 12: Additional view of defect from case 1.

ridge-lap pontics were placed in the edentulous area (figures 9, 10). At augmentation surgery, well-released full thickness buccal and palatal flaps revealed severe alveolar ridge narrowing as well as a small residual cyst in the right lateral incisor region. When removed, the residual cyst resulted in an additional anatomic defect within the anterior maxillary ridge (figures 11, 12). In order to restore the anatomic integrity of the bony ridge to its normal dimensions, small par-

Figure 13: Small particle size Bio-OssÂŽ was carefully grafted to cover all areas of the anterior maxillary defect site.

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Figure 14: A double layer of Dermis allograft was placed over the Bio-Oss® graft.

Figure 15: Additional view of layered grafting technique.

conductive matrix for overlying soft tissue regeneration (figures 14, 15). The mucoperiosteal flaps were then closed primarily via multiple 5.0 ePTFE sutures. A new fixed interim restoration with ovate shaped pontics, no longer over-sized, was temporarily cemented into place (figure 16). During the ensuing healing period the interim restoration was revised as needed in order to act as a guide during soft tissue maturation for the development of critically important interdental papillae (figures 17, 18). Figure 16: A new fixed interim restoration with ovate shaped pontics, no longer over-sized, was temporarily cemented into place.

ticle size, slowly resorbing Bio-Oss® particulate graft material was carefully placed along both the entire exposed buccal cortex and alveolar ridge crest. Slight over-contouring with Bio-Oss® was required in order to assure restoration of normal apicocoronal and buccolingual dimensions once healing was complete (figure 13). A double layer of Puros® Dermis allograft was then placed over the Bio-Oss® graft, serving as both a Guided Bone Regenerative barrier membrane and as a

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Case #2 The second case is a 52 year old male with severe maxillary ridge atrophy in the maxillary central incisor area secondary to long standing tooth loss in this region (figure 19). In an attempt to compensate for both apicocoronal and bucco-palatal bone loss, the patient presented with oversized ridge lap pontics of both maxillary central incisors (figures 20-22). In addition to the patient’s Seibert’s Class III ridge defect, the patient also presented with a deep anterior overbite secondary to supreruption of the mandibular incisors,


Toscano et al

Figure 17: Case 1 interim restoration used for soft tissue guidance.

loss of interdental papillae within the edentulous space, periodontally compromised maxillary lateral incisor teeth, and multiple stained teeth throughout both arches (figure 21). Following reflection of full-thickness buccal and palatal mucoperiosteal flaps, both maxillary lateral incisors were removed, exposing large fenestrated and dehiscence bony defects of the buccal cortex, further exaggerating the alveolar ridge deformity (figure 23). As in Case #1, small particle size, Bio-Oss® particulate graft material was carefully placed along both the entire exposed buccal cortex and alveolar ridge crest (figure 24). Puros® Dermis allograft was then placed over the Bio-Oss® graft and the flaps closed primarily with multiple interrupted ePTFE sutures (figures 25, 26). An interim restoration with ovate shaped pontics was temporarily cemented into place (figure 27). Over the next 4 months the interim restoration served as a guide for the formation of esthetically important interdental papillae (figure 28). In planning for the definitive restorative result, care was taken to address each of the

Figure 18: Additional view of interim restoration with ovate pontics guiding soft tissue healing.

Figure 19: Severe apicocoronal and bucco-palatal maxillary ridge atrophy seen in case 2.

patient’s dental problems, including correction of occlusal plane discrepancies with its deep overbite and supraeruption of the mandibular incisors. The cast metallic framework for the final maxillary restoration dramatically illustrates the increase in ridge width as well as creation of interdental papillae obtained by correcting the patient’s severe Seibert’s Class III defect with simultaneous bone and soft tissue grafting (figure 29). No longer are ridge lap pontics required. Rather proper placement of the fixed

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Figure 20: Oversized ridge lap pontics attempt to compensate for ridge deficiency of case 2.

Figure 21: Note deep overbite associated with pre-op restorations of case 2.

Figure 22: Occlusal view demonstrates severe ridge deficiency of case 2.

Figure 23: Removal of peridontally compromised lateral incisors exposed significant fenestrated and dehiscence defects of the buccal cortex.

restoration relative to normal anatomic emergence profiles of all four maxillary incisor teeth is now possible, satisfying the stringent esthetic requirements within the esthetic zone of the maxilla. Improvement in both function and esthetics is dramatically evident in the final definitive restorations following correction of the patient’s occlusal plane discrepancies (figures 30, 31).

Case #3 Case #3 dramatically illustrates the potential of simultaneous grafting with Bio-Oss® particulate plus Puros® Dermis Allograft in the correction of a severe dental Class III occlusal discrepancy. The patient, a 24 year old male lost both maxillary central incisors secondary to trauma nine years prior to presenting for definitive restorative treatment. Trauma induced bone loss resulted

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Toscano et al

Figure 24: Small particle size Bio-Oss® particulate graft material was placed along the exposed buccal cortex and alveolar ridge crest.

Figure 25: Dermis allograft was placed over the BioOss® graft, serving as a conductive matrix for soft tissue regeneration.

Figure 26: Using 5.0 ePTFE sutures the mucoperiosteal flaps were closed without tension.

Figure 27: An interim restoration with ovate shaped pontics was temporarily cemented into place.

in a severe Seibert Class III defect, resulting in a dental Class III occlusal relationship (figures 32, 33). In order to compensate for the trauma induced functional and esthetic deformity, the patient wore a removable appliance with an exaggerated bucco-palatal flange (figures 34, 35). Figures 1 through 6 describe the step-by-step corrective surgical procedures used in this case, including placement of an interim restoration that

served as a guide for the development of interdental papillae. An occlusal view of the fixed interim restoration demonstrates the elimination of the abnormal “emergence profile” seen in the patient’s removable appliance (figure 36). The traumatically induced Class III occlusal relationship has been eliminated through simultaneous bone and soft tissue grafting, allowing proper positioning of the fixed restoration. Overly contoured, ridge lap

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Figure 28: Using the interim restoration as a guide, interdental papillae have been formed in order to allow for excellent esthetics and proper emergence profiles of the definitive fixed restoration.

Figure 29: The cast metallic framework for the final maxillary restoration demonstrates the increase in ridge width as well as creation of interdental papillae obtained by correcting the patient’s Seibert’s Class III defect with simultaneous bone and soft tissue grafting.

Figure 30: Improvement in both function and esthetics is evident following Bio-Derm ridge plumping and delivery of final restorations.

Figure 31: Note improved soft/hard tissue relationship compared to figure 20.

pontics are unnecessary once the patient’s normal anatomy was restored. Instead, esthetic and readily cleansable ovate shaped pontics become the replacement restoration of choice (figure 37). The final definitive fixed restoration demonstrates dramatic functional and esthetic improvements once the patient’s hard and soft tissue ridge

deficiencies were corrected through simultaneous hard and soft tissue grafting (figures 38-40).

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DISCuSSIOn Proper crestal gingival anatomy, including intact interdental papillae, are absolute prerequisites for natural appearing emergence profiles of


Toscano et al

Figure 32: Case 3 pre-op profile.

Figure 33: Pre-op Siebert III ridge deficiency of case 3.

Figure 34: Exaggerated bucco-palatal flange of patient’s old removable appliance.

Figure 35: Note exaggerated flaring of incisors with patient’s old removable appliance.

Figure 36: An occlusal view of the fixed interim restoration demonstrates the elimination of the abnormal “emergence profile” seen in the patient’s removable appliance.

Figure 37: Correcting the patient’s anterior ridge deformity allowed fabrication of readily cleansable, esthetic ovate shaped pontics. The Journal of Implant & Advanced Clinical Dentistry

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Figure 38: Case 3 final restorations.

Figures 38-40: By eliminating the Class III dental malocclusion through correction of the anterior maxillary alveolar defect, dramatic functional and esthetic improvements were possible in the final definitive fixed restoration.

traditional fixed or implant supported restorations in the esthetic zone of the maxilla. Without normal soft tissue morphology, truly esthetic restorations cannot be achieved regardless of additional clinical effort. Adequate soft tissue architecture, however, is dependent upon a foundation of anatomically stable and healthy alveolar bone.48 In the critical esthetic zone, however, marginal buccal alveolar bundle bone, combined

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Figure 39: Note improvement of soft/hard tissue relationship after Bio-Derm augmentation.

with thin buccal cortical bone, lead to significant bone resorption following tooth removal.3-4 Gingival recession, distortion, and loss of interdental papillae are the inevitable sequelae of bone loss in the anterior maxilla. Seibert Class I, II, and III defects are therefore commonly encountered in the esthetic zone and must be adequately treated if esthetic fixed restorations are to be achieved. A variety of clinical approaches have been used to restore normal soft tissue architecture.22-29 Frequently, when non-implant supported fixed restorations are contemplated, autogenous or allograft soft tissue augmentation procedures are used without regard to the underlying bony morphology. While sometimes effective, multiple soft tissue grafting surgeries are often required before an adequate gingival profile can be achieved.25 At times the results from soft tissue grafting alone are inadequate to sustain long-term stable results, especially when attempting to reconstruct interdental papillae in the presence of significant underlying apicocoronal and bucco-palatal bone loss. A more predictable approach to achieving esthetic and stable soft tissue marginal tissues


Toscano et al

in the anterior maxilla may be to correct both the hard and soft tissue deficiencies present in most ridge defects. In the current 30 patient case series, simultaneous grafting of both the underlying bone and the overlying soft tissue defects without the need of invasive harvesting procedures appeared to result in the natural emergence profiles critical to esthetic fixed restorations. Critically important to restoring normal 3-dimensional ridge anatomy, especially when faced with significant buccal and crestal bone loss, is to consider the grafting requirements needed for long term stability of the augmented ridge. In order to maintain stable bone volume and architecture in the anterior maxilla, a slowly resorbing graft material with a low substitution rate is needed that can act as a long-term scaffold for continuing bone formation.49-50 In addition, the graft material should be highly osteoconductive, with a highly porous particle structure and a large inner surface area, both essential prerequisites for effective bone graft substitutes.51 The bony ridge defects treated in this case series were difficult to treat Seibert Class III deformities with significant apicocoronal and buccopalatal bone loss. Successful resolution of these defects required effective bone regeneration with sustained, stable 3-dimensional bony architecture over time. Bio-Oss® bone mineral combines a complex, interconnected pore system conducive for effective vascular and osteoblastic cellular ingrowth with slow particle resorption, characteristics ideal for ongoing bone regeneration and long term morphologic ridge stability.52-54 BioOss® was therefore chosen as the graft material of choice since it is likely to provide the necessary bony support over time required by regenerated gingival soft tissues, including interdental papillae.

Effective bone regeneration, while vitally important to esthetic success of dental restorations within the esthetic zone, must also be associated with adequate overlying soft tissue thickness and architecture in order for true restorative success to be achieved. In each case within this 30 patient case series, apicocoronal and bucco-palatal bone loss was also associated with gingival mucosal atrophy and absence of interdental papillae. Regeneration of normal crestal gingival thickness and restoration of interdental papillae were crucial elements required for successful definitive dental restoration in this critically esthetic area. As noted earlier, most attempts at soft tissue regeneration rely primarily on autogenous grafts, especially subepithelial connective tissue grafts from the palate.22-27 Although effective, such grafts require a second invasive surgery and impose a limit to the amount of grafting available at any one time. In addition, the potential for post-operative complications and morbidity are always present.25 Therefore, in the current series an allogenic acellular dermal matrix was chosen as an alternative to autogenous grafts. Puros® Dermis allograft served three purposes: 1) To serve as a resorbable barrier membrane, preventing unwanted fibroblastic cellular migration into the Bio-Oss® grafted site during the active Guided Bone Regenerative period; 2) To increase overall gingival thickness; and 3) To provide sufficient soft tissue depth for the formation of interdental papillae. Although generally placed directly onto a periosteal bed as a subsequent procedure following successful bone regeneration, in this particular series the acellular dermal matrix was placed immediately over the Bio-Oss® graft, simultaneously accomplishing both bone grafting and soft tissue augmentation in a single

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surgical visit. Vascular ingrowth from all areas of the surrounding host bed, including the overlying periosteum, appeared adequate for successful bone and soft tissue regeneration to occur. While hard and soft tissue grafting were critically necessary procedures, proper development of interdental papillae through careful fabrication and continued appropriate revision of the fixed interim restoration cannot be overstated. Meticulous use of properly shaped ovate pontics adjacent to regenerating gingival soft tissues allowed for the development of interdental papillae and natural appearing emergence profiles, elements crucial to final restorative success.

COnCluSIOn Thirty consecutive patients with significant Seibert Class III alveolar ridge defects were successfully treated with simultaneous bone (Bio-Oss® particulate) and soft tissue grafting (Puros® Dermis Allograft) procedures. The authors have coined this procedure the “Bio-Derm Ridge Plumping Technique for Pontic Site Development.” By avoiding autogenous hard and soft tissue grafts, the Bio-Derm Ridge Plumping Technique eliminates the need for additional invasive harvesting surgeries while at the same time allowing for the completion of both bone and soft tissue augmentation procedures in a single surgical visit. ● Correspondence: Nicholas Toscano, DDS, MS Diplomate American Board of Periodontology Practice Limited to Periodontics and Implant Surgery 1140 19th Street, NW Suite 310 Washington, DC 20036 navygumdoc@aol.com

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Disclosure The authors report no conflicts of interest with anything mentioned in this article. Acknowledgements Special thanks to Dr. Stuart Kay (Huntington, NY) for his help with the organization and production of this manuscript. References 1. Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M, Kenney EB, Dimitrijevic B, Nedic M. Preservation of alveolar bone in extraction sockets using bioasorbable membranes. J Periodontol 1998 Sep;69(9):1044-49. 2. Schropp L, Kostopoulos L, Wenzel A. Bone Healing and Soft Tissue Contour Changes Following Single-Tooth Extraction: A Clinical and Radiographic 12-month Prospective Study. Int J Periodontics Restorative Dent 2003 Aug;23(4):313-323. 3. Nevins M, Camelo C, DePaoli S, Friedland B, Schenk RK, Parma-Benfenati S, Simion S, Tinti C, Wagenberg B. A Study of the Fate of the Buccal Wall of Extraction Sockets of Teeth with Prominent Roots. Int J Periodontics Restorative Dent 2006;26:19-29. 4. Araujo M, Linder E, Wennstrom J, Lindhe J The Influence of Bio-Oss Collagen on Healing of an Extraction Socket: An Experimental Study in the Dog. Int J Periodontics Restorative Dent 2008;28:123-135. 5. Seibert JS, Reconstruction of Deformed, Partially Edentulous Ridges, Using Full Thickness Onlay Grafts. Part I. Technique and Wound Healing. Compend Cont Educ Dent 1983;4:437-453. 6. Simion, M., Trisi, P. & Piattelli, A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. International Journal of Periodontics and Restorative Dentistry 1994;14: 496-511. 7. Nyman S. Bone regeneration using the priniciple of guided tissue regeneration. J Clin Periodontol 1991(18);494-498. 8. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent. 1994 Oct;14(5):451-459. 10. Froum SJ, Rosenberg ES, Elian N, Tarnow D, Cho SC. Distraction osteogenesis for ridge augmentation: prevention and treatment of complications: thirty case reports. Int J Periodontics Restorative Dent. 2008 Aug;28(4):337-345. 11. McAllister BS, Haghighat K. Bone augmentation techniques: J Periodontol 2007;78:377-396. 12. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007;78:18-21. 13. Cushing M. Autogenous red marrow grafts: potential for induction osteogenesis. J Periodontol 1969;40:492-497. 14. Sottostanti JS, Bierly JA. The storage of marrow and its relation to periodontal grafting procedures. J Periodontol 1975;46:162-170. 15. Wang JH, Waite DE, Steinhauser E. Ridge augmentation: An evaluation and follow-up report. J Oral Surg 1976;34:600-612. 16. Jensen OT, Laster Z. Preventing complications arising in alveolar distraction osteogenesis. J Oral maxillofac Surg. 2002;60(10):1217-8. 17. Becker W, Becker BE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case reports. Int. J Periodontics Restorative Dent. 1990;10(5):376-391. 18. Nyman S, Lang NP, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration: A report of two cases. Int J Oral Maxillofac Implants 1990;5(1):9-14. 19. Simion, M., Trisi, P. & Piattelli, A.Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994; 14: 496-511.


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20. Nevins M, Mellonig J.T. Enhancement of the damaged edentulous ridge to receive dental implants: A combination of allograft and the Gore-Tex membrane. Int J Periodontics Restorative Dent 1992(12) 97-111.

41. Schulman J. Clinical evaluation of an acellular dermal allograft for increasing the zone of attached gingival. Practical Periodontics Aesthet Dent 1996;8:201208.

21. Nyman S. Bone regeneration using the priniciple of guided tissue regeneration. J Clin Periodontol 1991(18);494-498.

42. Luczyszyn SM, Papalexiou V, Novaes AB, Grisi MF, Louza SL, Taba M. Acellular Dermal Matrix and Hydroxyapatite in Prevention of Ridge Deformities after Tooth Extraction. Implant Dent 2005;14:176-184.

22. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199. 23. Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992;12:415-425. 24. Langer B, Calagna LJ. The subepithelial connective tissue graft. J Prosthet Dent 1980;42:363-367. 25. Langer B, Calagna LJ. The Subepithelial Connective Tissue Graft. A New Approach to the Enhancement of Anterior Cosmetics. Int J Periodont Restorative Dent 1982;9(2):23-33. 26. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199. 27. Orth C. A Modification of the Connective Tissue Graft Procedure for the Treatment of Type II and Type III Ridge Deformities. Int J Periodont Rest Dent 1996;16:267-277. 28. Seibert JS. Reconstruction of deformed, partially edentulous ridges using full thickness onlay grafts. Part 1. Technique and wound healing. Compendium Continuing Educ Dent 1983;4:437-451. 29. Wainwright DJ. Use of an acellular allograft dermal matrix (Alloderm) in the management of full-thickness burns. Burns 1995;21:243-248. 30. Lattari V, Jones LM, Varcelotti JR, Latenser BA, Sherman HF, Barrette RR. The use of a permanent dermal allograft in full-thickness burns of the hand and foot: a report of three cases. J Burn Care Rehabil 1997;18:147-155. 31. Richardson CR, Maynard JG. Acellular Dermal Graft: A Human Histologic Case Report. Int J Periodontics Restorative Dent 2002;22:21-29. 32. Cummings LC, Kaldahl WB, Allen EP. Histologic Evaluation of Autogenous Connective Tissue and Acellular Dermal Matrix Grafts in Humans. J Periodontol 2005;76:178-186. 33. Santos A, Goumenos G, Pascual A. Management of Gingival Recession by the Use of an Acellular Dermal Graft Material. J Periodontol 2005;76:1982-1990. 34. Hirsch A, Goldstein M, Goultschin J, Boyan BD, Schwartz Z. A 2-Year FollowUp of Root Coverage Using Subpedicle Acellular Dermal Matrix Allografts and Subepithelial Connective Tissue Autografts. J Periodontol 2005;76:1323-1328. 35. Mehlbauer MJ, Greenwell H. Complete Root Coverage at Multiple Sites Using an Acellular Dermal Matrix Allograft. Compendium 2005;26:727-733. 36. Harris RJ. A Short-Term and Long-Term Comparison of Root Coverage With an Acellular Dermal Matrix and a Subepithelial Graft. J Periodontol 2004;75:734743.

43. Fowler EB, Breault LG, Rebitski G. Ridge Preservation Utilizing an Acellular Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: part I. A Report of 2 Cases. J Periodontol 2000;71:1353-1359. 44. Fowler EB, Breault LG, Rebitiski G. Ridge Preservation Utilizing an Acellular Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: Part II. Immediate Endosseous Implant Placement. J Periodontol 2000;71:1360-1364. 45. Batista EL, Batista FC, Novaes AB. Management of Soft Tissue Ridge Deformities With Acellular Dermal Matrix. Clinical Approach and Outcome After 6 Months of Treatment. J Periodontol 2001;72:265-273. 46. Fowler EB, Breault LG. Ridge Augmentation with a Folded Acellular Dermal Matrix Allograft: A Case Report. J Contemp Dent Pract 2001;(2)3:31-40. 47. Breault LG, Lee SY, Mitchell NE. Fixed Prosthetics with a Connective Tissue and Alloplastic Bone Graft Ridge Aumentation: A Case Report. J Contemp Dent Pract 2004 November;(5)4:111-122. 48. Scarano A, Barros RM, Iezzi G, Piattelli A, Novaes AB. Acellular Dermal Matrix Graft for Gingival Augmentation: A Preliminary Clinical, Histologic, and Ultrastructural Evaluation. J Periodontol 2009;80:253-259. 49. Grunder, U, Gracis S, et al. Influence of the 3-D Bone-to-Implant Relationship on Esthetics. Int J Periodontics Restorative Dent 2005; 25:113-119. 50. Elian N, Ehrlich B, et al. Advanced Concepts in Implant Dentistry: Creating the “Aesthetic Site Foundation”. Dent Clin N Am 2007;51:547-563. 51. Traini T, Valentini P, et al. A Histologic and Histomorphometric Evaluation of Anorganic Bovine Bone Retrieved 9 Years After a Sinus Augmentation Procedure. J Periodontol 2007; 78:955-961. 52. Lee Yong-Moo, Shin Seung-Yun, et al. Bone Reaction to Bovine Hydroxyapatite for Maxillary Sinus Floor Augmentation: Histologic Results in Humans. Int J Periodontics Restorative Dent 2006; 26:471-481. 53. Orsini G, Traini T, Scarano A, Degidi M et al. Maxillary sinus augmentation with Bio-Oss particles: a light, scanning and transmission electron microscopy study in man. J Biomed Mater Res.B: Appl Biomater 2005;74(1):448-457. 54. Piattelli M, Favero GA, Scarano A, et al. Bone reactions to anorganic bovine bone (Bio-Oss) used in sinus augmentation procedures: a histologic long-term report of 20 cases in humans. Int J Oral Maxillofac Implants 1999;14:835-840. 55. Sartori S, Silvestri M, Forni F, et al. Ten-year follow-up in a maxillary sinus augmentation using anorganic bovine bone (Bio-Oss). A case report with histomorphometric evaluation. Clin Oral Implants Res 2003;14:369-372.

37. Haim T, Moses O, Zohar R, Meir H, Nemcovsky C. Root Coverage of Advanced Gingival Recession: A Comparative Study Between Acellular Dermal Matrix Allograft and Subepithelial Connective Tissue Grafts. J Periodontol 2002;73:1405-1411. 38. Woodyard JG, Greenwell H, Hill M, Drisko C, Iasella JM, Scheetz J. The Clinical Effect of Acellular Dermal Matrix on Gingival Thickness and Root Coverage Compared to Coronally Positioned Flap Alone. J Periodontol 2004;75:44-56. 39. Harris RJ. Root coverage with a connective tissue with a partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodonotol 1998;69:1305-1311. 40. Cortes, ADQ, Maraatins AG, Nociti FH, Sallum AW, Casati MZ, Sallum EA. Coronally Positioned Flap With or Without Acellular Dermal Matrix Graft in the Treatment of Class I Gingival Recessions: A Randomized Controlled Clinical Study. J Periodontol 2004;75:1137-1144.

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Minimally Invasive Antral Membrane Balloon Elevation to Treat Previous Sinus Augmentation Failure: A Case Report

Mazor et al

Ziv Mazor, DMD1 • Efraim Kfir, DMD2 Abstract Background: Successful implant placement in the atrophic posterior maxilla is often complicated by the quality and volume of available bone. Sinus floor elevation is advocated in these cases in order to gain sufficient bone around the implants. Sinus elevation can be done either by an open lateral window approach or by a closed osteotome approach depending on the available bone height. This case report demonstrates the feasibility and safety of minimally- invasive antral membrane balloon elevation (MIAMBE), followed by bone augmentation and implant fixation in a patient who had previous sinus augmentation failure done by a lateral approach. Methods: A 55 year old male patient was referred for a second posterior maxillary bone augmentation. After undergoing pre-procedural assessment and signing an informed consent, the patient underwent alveolar crest exposure and osteotomy (3 mm diameter), followed MIAMBE. PRF (platelet rich fibrin) and xenograft bone substitute were injected into the sinus under the antral membrane and implant placement was performed.

Results: The procedure went smoothly with no complications. Postsurgical healing was uneventful. Six months following the surgical procedure, periapical radiographs were performed and prosthetic rehabilitation was initiated. Conclusion: MIAMBE can be applied to patients in need of posterior maxilla bone augmentation. Absence of patient morbidity and satisfactory bone augmentation with this minimally invasive procedure suggests that MIAMBE should be considered as an alternative to the currently employed methods of maxillary bone augmentation.

KEY WORDS: Sinus lift, antral membrane, maxillary sinus, dental implants 1. Private practice limited to Periodontics and Implant Dentistry, Ra’anana Israel 2. Private practice, Petach Tikva Israel

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IntRODuCtIOn Successful implant placement in the atrophic posterior maxilla is often complicated by the quality and volume of available bone. Types 3 and 4 bone tend to predominate in the posterior maxilla making this region typically the least dense bone in the oral cavity.1 Postextraction resorption patterns, use of a removable prosthesis, physical trauma, periodontal disease, and pneumatization of the maxillary sinus can significantly reduce or eliminate the height and width of the residual alveolar ridge. In the atrophic posterior maxilla, longer and wider implants are needed to enhance long-term survival. As such, this area often requires bone augmentation beneath the sinus to increase the vertical height of bone. The subantral augmentation, or “sinus lift” procedure, was first reported by Tatum and has evolved over the last 25 years. A lateral window (modified Caldwell-Luc) approach to the maxillary sinus is used, and has shown such favorable results that the posterior maxilla is often considered one of the most predicable regions for grafting prior to or simultaneously with implant placement.2-7 The basic technique involves creation of a hinged window in the lateral wall of the maxilla.8 When completed, the window is gently pressed inward and upward into the sinus cavity, which lifts the Schneiderian membrane and serves as a new sinus floor. The void between the elevated tissues and the original sinus floor is filled with bone graft material. Implants may be simultaneously placed, or the graft may be allowed to heal prior to implant placement.9-12 The lateral maxillary window offers average implant survival of 91.8% (ranging from 61.7-100%).17 This method involves

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potential complications (membrane tear, bleeding, infection and sinus obstruction), swelling and discomfort, relative contra-indications (sinus convolution septum or narrow sinus and previous sinus surgery). The lateral maxillary window technique also requires considerable surgical skill, specialized equipment, and time. The osteotome technique as introduced by Summers,13 also called bone added osteotome sinus floor elevation (BAOSFE), is an alternative approach for sinus elevation in cases where a small amount of bone height is missing.14 BAOSFE can be complicated by membrane perforation and tearing,15 which can be somewhat reduced with expert technique and dedicated instrumentation.16 The minimally-invasive antral membrane balloon elevation (MIAMBE) technique is a modification of the BAOSFE method in which antral membrane elevation is executed through the osteotomy site (of 3.5 mm) using a dedicated balloon. Former reports have demonstrated the use of this technique as an alternative to conventional procedures. This manuscript describes a case of using this treatment modality and its advantages in a case previously treated with an open approach that failed.

MAtERIAlS AnD MEthODS Patient: A 55 year old male (noncontributory medical history) with a history of previous failed open sinus augmentation was referred for treatment. Materials: (a) MIAMBE balloon harboring device (MIAMBE, Netanya, Israel) – This is a stainless steel tube that connects on its proximal end to


Mazor et al

Figure 1: Balloon harboring device with Holtem stoppers.

Figure 2: Silicone balloon during inflation.

Figure 3a: Presurgical panoramic radiograph.

Figure 4: Full thickness mucoperiostal flap reflection with two small vertical incisions.

the dedicated inflation syringe, and on its distal portion has a screw-in mechanism, which secures the device into the osteotomy site (figure 1). The single use balloon is concealed in the distal end until it is inflated (figure 2). (b) Dedicated “MIAMBE kit” including bone graft injector, osteotome, screw-tap and a suction syringe device (MIAMBE) (c) Coronary angioplasty (Merit Medical, Galway, with diluted contrast Figure 3b: Presurgical CBCT scan showing ridge height and previous sinus window.

inflation syringe Ireland) – filled material (Ultrav-

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Figure 5a: Drilling with piezosurgery diamond tip 1 mm short of the sinus floor.

Figure 5b: Periapical radiograph with osteotome verifying position of sinus floor.

Figure 6a: PRF is inserted to the osteotomy site.

Figure 6b: The sinus floor is upfractured using MIAMBE osteotome.

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Figure 7: The metal sleeve of the balloon-harboring device is inserted into the osteotomy 1 mm beyond the sinus floor (depth control by Teflon stopper). October 2009


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Figure 8a: Initial balloon inflation pressure (2 atm).

Figure 8b: Once the balloon emerges from the metal sleeve apical to the sinus membrane, the pressure drops to 0.5 atm.

Figure 9: The balloon inflation and membrane elevation are evaluated by a periapical X-ray.

Figure 10: Membrane integrity is assessed by direct visualization during inspiration.

ist 300 by Schering AG, Berlin, Germany)

Clinical protocol: Pre-procedural panoramic radiographs and computed tomography (CT) scans (figures 3a, 3b) were used to assess the following: mucosa thickness and pathology, bone height and thickness, sinus structure, and major blood vessels. The patient received an oral explanation regard-

(d) PRF autologous platelet rich fibrin - obtained by centrifugation of 10 ml divided into 4 test tubes and spun for 10 minutes at 2700 RPM. (e) Xenograft bone graft (Endobone, Biomet 3I)

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Figure 11a: Bone graft material consisted of Xenograft (Endobone Biomet 3I) and PRF.

Figure 11b: Bone syringe filled with the grafting material.

Figure 12a: Osteotomy and sinus filled with grafting material.

Figure 12b: Periapical radiograph showing bone fill of the sinus.

ing the procedure and signed an informed consent. A pre-procedural non-steroidal antiinflammatory agent and AUGMENTIN (clavulanate potassium) 875 mg twice daily were initiated 24 hours prior to the procedure. Local anesthesia (infiltration of posterior, middle superior alveolar and greater palatine nerves) was performed

using 2% Lidocaine. 40ml of the patient’s blood was drawn by venous puncture and processed to obtain platelet rich fibrin (PRF). Under local anesthesia, a horizontal full thickness flap with palatal bias followed by 2 small vertical incisions to expose the alveolar crest were performed (figure 4). Drilling was performed with

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Figure 13a: Implant fixture delivery.

Figure 13b: Implant fixtures delivered to full depth.

Piezosurgical tips in the center of the alveolar crest to a point 1-2 mm short of the sinus floor. The depth of this initial drilling preparation was predetermined according to measurements obtained from the CT scan and periapical x-rays (figures 5a, 5b). The osteotomy was enlarged from 2.0mm to 2.9 mm with the MIAMBE Osteotome. Bone graft material and PRF were inserted into the osteotomy followed by upfracturing of the sinus floor with osteotomes limited by Teflon stoppers (figures 6a, 6b). After removing the osteotome, Schneiderian membrane integrity was assessed by Valsalva maneuver. The metal sleeve of the balloon-harboring device was inserted into the osteotomy 1 mm beyond the sinus floor with overextension prevention by a Teflon stopper (figure 7). The balloon was slowly inflated to two standard atmospheres (atm). With this technique, once the balloon emerges from the metal sleeve apical to the sinus membrane, the pressure drops to 0.5 atm. Subsequently, the balloon is inflated

with progressively higher volumes of contrast fluid (figures 8a, 8b). The balloon inflation and membrane elevation are evaluated by sequential periapical radiographs. Once the desired elevation (usually >10 mm) is obtained, the balloon should be left inflated for five minutes to reduce sinus membrane elasticity (figure 9). After five minutes, the balloon is deflated and removed and membrane integrity is assessed by: 1) Valsalva maneuver; 2) Respiratory movement of blood within the osteotomy; 3) Direct visualization into osteotomy (figure 10). After confirming Schneiderian membrane integrity, the bone substitute (Endobon, Biomet 3i) is injected through the osteotomy filling the space created beneath the Antral membrane (figures 11a, 11b, 12a, 12b). After addition of the bone graft, dental implant fixtures (Nanotite Certain, Biomet 3i) were delivered in the standard fashion (figures 13a, 13b). The flap was then primarily closed and periapical radiographs verified Implant and graft placement (figure 14a).

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Figure 14a: Periapical radiograph immediately post-op.

Figure 14b: Periapical radiograph 5 months post-op.

Results: Initial healing following surgery was uneventful. Six months following the surgical procedure, periapical radiographs were performed (figure 14b) and prosthetic rehabilitation was initiated.

augmentation, requires considerable skills, and may frequently result in membrane tear.21

Discussion: This case report supports the notion18,19 that MIAMBE, a minimally invasive single sitting procedure of maxillary bone augmentation and implant placement can be executed even in a case where previous conventional sinus augmentation has failed. The “osteotome technique” is truly minimally invasive, but not recommended if the residual ridge height is ≤ 4mm.20 The osteotome technique, even when selectively applied and endoscopically controlled, yields modest antral membrane elevation and bone

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COnCluSIOn MIAMBE appears to be a safe and effective way to perform antral membrane elevation and posterior maxillary bone augmentation. The procedure is minimally invasive, produces mild patient discomfort, and delivers satisfactory augmentation results. ● Correspondence: Ziv Mazor, DMD 142 Ahuza st Ra’anana Israel 43300 Tel: 972-97400336,Fax: 972-97602839 Email: drmazor@netvision.net.i


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Disclosure The authors report no conflicts of interest with anything mentioned in this article. References 1. Truhlar RS, Orenstein IH, Morris HF, Ochi S. Distribution of bone quality in patients receiving endosseous dental implants. J Oral Maxillofac 1987; 55(Suppl 5): 38-45. 2. Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986; 30: 207-229. 3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980; 38: 613-616. 4. Misch CE. Maxillary sinus augmentation for endosteal implants: Organized alternative treatment plans. Int J Oral Implantol 1987; 4: 49-58. 5. Block MS, Kent JN, Kallukaran FU, Thunthy K, Weinberg R. Bone maintenance 5 to 10 years after sinus grafting. J Oral Maxillofac Surg 1998; 56: 706-714. 6. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants: A systematic review. Ann Periodontol 2003; 8(1): 328-343. 7. Peleg M, Garg AK, Mazor Z. Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of 2132 implants placed into 731 human sinus grafts. Int J Oral Maxillofac Implants 2006; 21(1): 94-102. 8. Friberg B, Nilson H, Olsson M, Palmquist C. MkII: The self-tapping Branemark implant: 5-year results of a prospective 3-center study. Clin Oral Impl Res 1997; 8: 279-285. 9. roum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho SC. Sinus floor elevation using anorganic bovine bone matrix (OstoGraf/N) with and without autogenous bone: A clinical, histologic, radiographic, and histomorphometric analysisâ&#x20AC;&#x201D;Part 2 of an ongoing study. Int J Periodont Rest Dent 1998; 18: 529-543. 10. Peleg M, Chaushu G, Mazor Z, Ardekian L, Bakoon M. Radiological findings of the post-sinus lift maxillary sinus: A computerized tomography follow-up. J Periodontol 1999; 70: 1564-1573. 11. Smiler DG. The sinus lift graft: Basic technique and variations. Pract Periodontics Aesthet Dent 1997; 9: 885-893. 12. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol 1998; 69: 1397-1403.

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13. Summers RB. Sinus floor elevation with osteotomes. J Esthet Dent 1998; 10: 164-171. 14. Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: a preliminary prospective study. Int J Oral Maxilofac Implants 2002; 17: 557-566. 15. Berengo M, Sivolella S, Majzoub Z, Cordioli G. Endoscopic evaluation of the bone-added osteotome sinus floor elevation procedure. Int J Oral Maxillofac Surg 2004; 33: 189-194. 16. Toffler M. Staged sinus augmentation using a crestal core elevation procedure and modified osteotomes to minimize membrane perforation. Pract Proced Aesthet Dent 2002; 14: 767-774. 17. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003; 8: 328-343. 18. Kfir E, Kfir V, Mijiritsky E, Rafaeloff R, Kaluski E. Minimally invasive antral membrane balloon elevation followed by maxillary bone augmentation and implant fixation. J Oral Implantol 2006; 32(1): 26-33. 19. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol 2007; 78(10): 2032-2035. 20. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH,Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999; 14(6): 853-858. 21. Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontol 2003; 74(11): 1682-1691.

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Comparison of Stress Patterns In and Around Orthodontic Micro-implants: A Finite Element Study

Sakthish et al

S. Sakthish, MDS1 • Sridevi Padmanabhan, MDS2 • Arun Chithranjan, MDS3 Abstract Background: Conservation of anchorage has always been a priority for efficient orthodontics. For this reason, temporary anchorage devices such as micro-implants have become popular. While orthodontic miro-implants have been successfully used to withstand orthodontic force, their efficiency in withstanding heavier forces such as orthopaedic force has not been tested. Methods: Using finite element analysis mode of evaluation, this study aimed to compare: i) the stress patterns in the surrounding bone and micro implant when placed at angulations of 30o, 60o, 90o; ii) Effect of orthodontic and orthopaedic forces on surrounding bone and micro-implants when tested on osseointegrated and non–osseointegrated implant models. Results: Micro-implant 30o angulation produced better stress distribution on the surrounding bone and micro-implant compared to

60o and 90o angulations. All three angulations brought about stresses within the physiological limits in bone. Stress produced in the surrounding bone was within physiological limits in both osseointegrated and non-osseointegrated micro-implant models with 200g of orthodontic force application. With orthopaedic force (400g) application, however, the stress produced in the surrounding bone in osseointegrated microimplant models (205.14g) was within physiological limits whereas the stress in surrounding bone in non-osseointegrated micro-implant models (530.42g) exceeded physiological limits. Conclusions: Both perpendicular and diagonal placements of implants are acceptable and produce tolerable stress patterns. Both osseointegrated and non-osseointegrated implants are acceptable for orthodontic force. However, osseointegration of micro-implants is indicated for successful loading of orthopaedic forces.

KEY WORDS: bone, osseointegration, orthodontic anchorage, microimplants, dental implants, temporary anchorage device 1. Former PG student, Sri Ramachandra Dental College 2. Professor, Dept. of Orthodontics, Sri Ramachandra Dental College 3. Prof and HOD, Dept. of Orthodontics, Sri Ramachandra Dental College

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Sakthish et al

INTRODUCTION Anchorage control is fundamental to successful orthodontic treatment and has been addressed in a variety of ways including: 1) increasing the number of teeth in the anchorage unit; 2) altering the angulation of anchor teeth; 3) using extraoral and intraoral anchorage devices. Intraoral anchorage devices may not provide absolute anchorage control, whereas extraoral appliances are dependent on patient compliance. The advent of osseointegrated implants by the pioneer studies of Branemark1 changed the scenario. The standard dental implants made of titanium have been used and have proved effective for anchorage purposes,2,3 however they have draw backs such as bulk, osseointegration wait time, and added cost. For these reasons, temporary anchorage devices (TAD’s) such as micro/mini dental implants have become popular for enhancing orthodontic anchorage. These devices reinforce anchorage by either supporting the reactive unit or by eliminating the need for the reactive unit altogether.4 Two types of microimplant placement have been recommended: 1) diagonal placement; 2) perpendicular placement.5 Micro-implants are placed diagonally to the long axis of the tooth in order to avoid injury to the roots, but there are no studies to prove which micro implant angulation brings about optimal stress in the surrounding bone. TAD’s can be fixed to the bone mechanically by cortical stabilization (or) biochemically by osseointegration.4,6 Most TAD’s are retained by primary stability where the maximum applicable load is proportional to the surface area of the bone contact to the implant. With osseointegrated implants, on the other hand, the maximum load is proportional to the quan-

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tity of osseointegration. The efficiency of microimplants has been evaluated in various studies and the general consensus is that even with immediate orthodontic loading, micro-implants are able to withstand forces of 200-300g.7,8 While osseointegrated implants have been used as anchors for orthopaedic devices, these studies used conventional osseointegrated Branemark implants which were loaded with orthopaedic forces up to 5N.9,10 However, there is no reported literature in the efficiency of TAD’s used as anchors to apply orthopaedic force. Recently, orthodontic micro-implants capable of osseointegration have also been introduced.11 Finite element analysis (FEM) is a modern tool for numerical stress analysis, which has the advantage of being applicable to solids of irregular geometry that contain heterogeneous material properties. Finite element analysis provides the orthodontist with quantitative data that can extend the understanding of physiologic reactions that occur within the dentoalveolar complex. Such numerical techniques may yield an improved understanding of the reactions and interactions of individual tissues.12 Concerning dental implants, finite element analysis has proven to be a precise and applicable tool for evaluating stress patterns in surrounding bone.14 Hence, FEM analysis was selected in this study to assess the stress patterns in the surrounding bone and micro implant models. Using FEM, This study sought to determine which micro-implant angulation achieves optimal stress in the surrounding bone. Additionally, stress in the surrounding bone was evaluated when osseointegrated and nonosseointegrated micro-implants are used for orthodontic or orthopaedic anchorage purposes.


Sakthish et al

MATERIAlS AND METhODS The objectives of this study were as follows: 1) To compare stress patterns in the surrounding bone and micro-implant when placed at angulations of 30o, 60o and 90o; 2) To compare the stress patterns affected by orthodontic and orthopaedic force on the microimplant and surrounding bone in both osseointegrated and non-osseointegrated models. To achieve such, this study was carried out in two parts. In the first part of the study a finite element model of the maxillary arch with all of the teeth except the first premolars was constructed. A model of a non-osseointegrated micro-implant was traced and placed in the alveolar bone distal to the roots of the second premolar at three different angulations (30o, 60o, 90o) to the long axis of the teeth. An orthodontic force of 200g was applied in the direction simulating anterior retraction and the stress patterns in the surrounding bone and micro implant models were studied. In the second part of the study, micro-implants with and without osseointegration were modelled. An orthodontic force of 200g was applied from the head of the micro implant in a direction simulating maxillary anterior retraction and an orthopaedic force of 400g was also applied from the head of the implant simulating the force from the protraction face mask in both the models. The stress patterns in the micro implant models and surrounding bone were studied. Geometric modelling of the maxilla and the maxillary dentition was accomplished in a number of steps. First, a computerized tomogram (CT) scan of a patient maxilla and the dentition was acquired with images taken at 1mm intervals. Next, the scanned images were viewed

Figure 1: Finite element model of maxilla with orthodontic micro-implant.

with the dental software EZDICOM (SourceForge, Incorporated, Mountain View, California, USA). These images were then copied to AUTOCADÂŽ(Autodesk, Incorporated, San Rafael, California, USA) and traced. This procedure was done for each slice. The traces were arranged in a complete set to make a single unit using the modelling software PRO/ENGINEER (Parametric Technology Corporation, Needham, Massachusetts, USA). The maxilla, maxillary dentition, and alveolar bone were modelled geometrically. The first premolars were removed for our study purpose. The region of maxillary first molar, second premolar, alveolar bone and the micro implants were taken for this study. The assembly of single unit was transferred to the finite element analysis software ANSYS (ANSYS, Incorporated, Cononsburg, Pennsylvania, USA) to create elements and nodes for the teeth, alveolar bone, periodontal ligament, and the micro implant. The geometric model was converted to finite element model by connecting the elements with the nodes in all the directions (Figure 1).

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Figure 2: Simulation of non-osseointegrated microimplant model.

Figure 3: Simulation of osseointegrated micro-implant model.

A micro implant similar to Absoanchor No.1312-07 (Dentos India Pvt. Ltd), taper type with a length of 7mm and diameter of 1.3 mm at the base and 1.2 mm at apex was modelled which was then traced to create a geometric and finite element model. Simulation of micro implant model without osseointegration was simulated as only the upper part of threads of micro-implant surface in contact with the surrounding bone (Figure 2). Simulation of the micro-implant model with osseointegration was

simulated as the entire surface of the threads of micro-implant getting fused with the surrounding bone (Figure 3). Geometric modelling of the micro-implant was accomplished by placing the traced micro implants distal to the roots of the second premolar at 30o, 60o, 90o angulations to the long axis of the tooth, with the head oriented towards the crown (Figure 4). A line passing through the long axis of the second premolar was traced in ANSYS that was used as a reference plane for placing the

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the non-osseointegrated micro-implant the number of elements was 212,266 and 36,777 nodes. The material properties (Table 1) were assigned to the various structures such as the implant, alveolar bone, tooth, and periodontal ligament in the finite element model.15 Boundary conditions of the maxillary model were restrained at the superior border of the maxilla in order to avoid any movement against the loads imposed on the dentoalveolar structure. Concerning application of force, 200g of force was applied on the models simulating non-osseointegrated and osseointegrated micro-implants placed at 30o, 60o and 90o angulations to the long axis of the tooth. For orthopaedic force, 400g of force was applied on the models (Figures 5a,5b). Figure 4: Model of the maxillary arch with micro-implants at angulations of 30o, 60o, and 90o.

micro implant in various angulations. Finite element modelling of micro implant was accomplished by converting the geometric model into a finite element model by connecting the elements with the nodes in all the directions. The finite element model of the osseointegrated micro-implant had 237,833 elements and 40,197 nodes. For

RESUlTS Part I In the peri-implant region, maximum compressive stresses were observed in the mesial side of implant neck and minimum compressive stresses were observed in the distal side of implant apex. Maximum tensile stresses were observed in the distal side of the implant neck and minimum tensile stresses were observed in the mesial side of the implant apex. This was a common observation

Table 1: Material Properties Materials

Young’s Modulus

Poisson’s Ratio

Titanium

1.10E + 05

3.0E – 01

Alveolar Bone

1.37E + 03

3.0E – 01

Periodontal Ligament

6.67E – 01

4.5E – 01

Tooth

1.96E + 04

3.0E – 01

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Sakthish et al

Figure 5a: Orthodontic force finite element model.

Figure 5b: Orthopaedic force finite element model.

for all three angulations of implants (Table 2). Of the three angulations, the least amount of stress was observed in the implant in the bone and peri-implant region when the implant was placed at 300 (Table 3).

pattern of stress distribution was also observed in the nonâ&#x20AC;&#x201C;osseointegrated micro-implant, but the osseointegrated micro-implant showed a more even stress distribution in the periimplant region although stresses were more on the mesial side in the direction of the force application (Table 4). The osseointegrated model showed less stress in the microimplant and in the surrounding bone as compared to the non-osseointegrated model (Table 5). On orthopaedic force application, the stress patterns were similar to that of orthodontic force application but with higher stress values due to increased force magnitudes. The mag-

Part II On orthodontic force application, the osseointegrated implant model showed the maximum and minimum compressive stresses on the mesial sides of the implant neck and apex respectively. Maximum and minimum tensile stresses were observed in the distal sides of the implant neck and apex respectively. This

Table 2: Compressive and tensile stresses in the peri-implant region of non-osseointegrated micro implant at various angulations. Various Angulations

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Compressive Stress Neck Apex

Tensile Stress Neck Apex

30O

-281.69g

-0.01128g

209.25g

5.36g

60O

-285.35g

-0.02016g

215.26g

4.19g

90O

-289.28g

0.02093g

223.57g

2.91g

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Table 3: Stresses on the surrounding bone and non osseointegrated micro implant at various angulation placement. Various Angulation Placement

Stress in Surrounding Bone

Stress in Micro Implant

30o

255.21g

4420g

60o

267.21g

4515.21g

90o

276.12g

4595.22g

Table 4: Compressive and tensile stresses in the peri-implant region of the micro implant with and without osseointegration on orthopedic force application. Micro-Implant Model

Compressive Stress Neck Apex

Tensile Stress Neck Apex

Osseointegrated

-102.59g

-0.02276g

97.47g

2.56g

Non-Osseointegrated

-281.69g

-0.01128g

209.25g

5.36g

Table 5: Stresses on the surrounding bone and the micro implant model with and without osseointegration on orthopedic force application. Micro Implant at 30o (Orthodontic force â&#x20AC;&#x201C; 200g)

Stress in Surrounding Bone

Stress in Micro Implant

Osseointegrated

100.56g

4395g

Non-Osseointegrated

255.21g

4420g

nitude of compressive and tensile stresses in the peri-implant region were found to be less in the osseointegrated implant model as compared to non-osseointegrated implant model (Table 6). Similarly the osseointegrated model also showed less stress in the microimplant and in the surrounding bone (Table 7)

DISCUSSION Temporary anchorage devices like screws and plates have become popular because they have the advantages of smaller size and the capability for immediate loading. Additionally, they are relatively inexpensive, increase patient comfort, and are easy to place and remove.

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Table 6: Comprehensive and temsile stresses in the peri-implant region of the micro-implant with and without osseointegration on orthopaedic force application. Micro-Implant Model

Compressive Stress Neck Apex

Tensile Stress Neck Apex

Osseointegrated

-214.78g

-0.02357g

193.48g

2.90g

Non-Osseointegrated

-578.25g

-0.04531g

491.36g

7.28g

Table 7: Stresses on the surrounding bone and the micro-implant model with and without osseointegration on orthopaedic force application. Micro Implant at 30o (Orthodontic force – 400g)

Stress in Surrounding Bone

Stress in Micro Implant

Osseointegrated

205.14g

8618g

Non-Osseointegrated

530.42g

8856g

FEM has been used extensively in the prediction of biomechanical performance of dental implant systems.14,16 These studies have evaluated osseointegrated implants in response to occlusal forces which may be axial, non–axial, or oblique occlusal. However, there are not many FEM studies evaluating the performance of orthodontic micro implants. In contrast to dental implants, these microimplants are generally non-osseointegrated and are subjected to forces in a non-axial direction. The magnitude of force is also significantly less than those placed on dental implants. Immediate loading of these micro/mini implants is recommended if the force applied is less then two Newtons.7,8 The long-term clinical performance of a dental implant is dependent upon the preservation of good quality of bone in the peri-implant region which,

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in turn, is dependent on the appropriate level of bone remodelling that occurs in response to the stress in the surrounding bone and implant.12 The stress in the surrounding bone should be within range of physiologic homeostasis. The range of acceptable compressive stress needed for healthy maintenance of bone appears to be between 1.4 to 5 Mpa (140 to 500g).14,17 Stresses exceeding this range have been reported to cause bone resorption and fatigue failure of the implant. Bone is a porous material with complex, nonhomogenous anisotropic microstructure. Cortical bone has the highest load bearing capacity due to its dense nature when compared to porous trabecular bone.18 In cortical bone, stress dissipation is restricted to the immediate area of bone surrounding the implant where as in trabecular bone,


Sakthish et al

Figure 6a: Stress patterns in surrounding bone at 30ยบ angulation.

Figure 6c: Stress patterns in surrounding bone at 90ยบ angulation.

a fairly broader distant stress distribution occurs. One must keep this in mind when planning placement of micro-implants for orthodontic purposes as the nature of bone varies in different areas of maxilla and mandible.19 For orthodontic retraction of the anterior segment, micro-implants are typically placed between the premolar and molar. Accordingly, in this study, D4 bone (posterior maxilla) was simulated for studying stress patterns. Micro-implants aid retention by mechanical means rather than osseointegration. While both

Figure 6b: Stress patterns in surrounding bone at 60ยบ angulation.

perpendicular loading and diagonal loading have been advocated for orthodontic implants, there is no literature documenting which angulation produces optimal stress in the bone. The first part of the study evaluated stress patterns in relation to various angulation placements and found that 30o angulation placement of non-osseointegrated micro-implant model produced the less amount of stress in the peri-implant region when compared to 60o and 90o angulation placement. It was also found that the stresses in the surrounding bone (Figures 6a-c) and non-osseointegrated microimplant were comparatively less at 30o angulation when compared to 60o and 90o. However, the difference among all of these stress patterns was not statistically significant and all three angulation placements brought about stress levels within physiological limits. Maximum compressive stresses were observed in the mesial side of neck of implant towards the direction of force application and maximum tensile stresses were observed in the distal side of neck in the direction opposite of force application. This was true for all three angulation placements with minor variations in magnitude.

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Figure 7a: Stress patterns in the osseointegrated microimplant with orthodontic force application.

Figure 7b: Stress patterns in the non-osseointegrated micro-implant with orthodontic force application.

The second part of study demonstrates that with orthodontic force application, the stresses produced in the peri-implant region, surrounding bone, and micro-implant were less in the osseointegrated model than in the non-osseointegrated model. Both models demonstrate maximum compressive stresses at the implant neck in the direction of force application while maximum tensile stress was observed at the implant neck in the direction opposite of force application. While the stress patterns appeared more evenly distributed around the implant neck of the osseointegrated model as compared to the non-osseointegrated model (Figures 7a,7b), the stresses in both models were found to be within the physiological limits. With orthopedic force application, the stresses in the peri-implant region in the non-osseointegrated micro-implant models were found to exceed physiological limits in contrast to the osseointegrated implant model. Like the orthodontic force model, stresses for the orthopaedic force model also appeared more evenly distributed around the osseointegrated microimplant than in the nonosseointegrated micro-implant (Figures 8a,8b).

With both the orthodontic and orthopaedic force models demonstrating reduced stress patterns in the osseointegrated micro-implants versus non-osseointegrated micro-implants, contact patterns between the implants and bone must be considered. In the osseointegrated model, the entire surface of the micro-implant interfaces with the surrounding bone and distributes force over a greater surface area. This does not occur in the non-osseointegrated model. Skalak et al20 noted that the close apposition of bone to the implant surface means that under loading, the interface moves as a unit without any relative motion, which is essential for transmission of stresses. Our study model appears to support this assessment.

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CONClUSION From this study, it was found that: 1) Placement of non-osseointegrated micro-implants at a 30o angulation model produced better stress distribution on the surrounding bone and micro-implant compared to 60o and 90o angulation placements. All three angulation placements brought about stresses within physiological limits of bone with minimal


Sakthish et al

Figure 8a: Stress patterns in the osseointegrated microimplant with orthopaedic force application.

variations in the stress values. Thus, both perpendicular and diagonal placements of implants are acceptable. 2) It was found that with 200g of orthodontic force application, stress produced in the surrounding bone was within physiological limits in both osseointegrated and non-osseointegrated micro-implant models. However, with 400g of orthopaedic force application, the stress produced in the surrounding bone in the osseointegrated micro-implant model (205.14g) was within physiological limits whereas the stress generated in the non-osseointegrated micro-implant model (530.42g) exceeded physiological limits. Hence osseointegration of micro-implants is recommended for successful loading of orthopaedic force. â&#x2014;? Correspondence: Dr. Sridevi Padmanabhan Professor, Dept. of Orthodontics Sri Ramachandra Dental College Porur,1, Ramachandra Nagar, Chennai-600116 Ph: 044-28156665;9600077428 e-mail: sridevipadu@gmail.com

Figure 8b: Stress patterns in the non-osseointegrated micro-implant with orthopaedic force application. Disclosure The authors report no conflicts of interest with anything mentioned in this article. References 1. Branemark P. Osseointegration and its experimental background. J Prosthet Dent 1983; 50(3):399-410. 2. Mazzocchi AR, Bernini S. Osseointegrated implants for maximum orthodontic anchorage. J Clin Orthod 1998; 7(7):412-415. 3. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous implant utilized as anchorage to protract molar and close an atrophic extraction site. Angle Orthod 1990; 60(2):135-152. 4. Mah J, Bergstrand F. Temporary anchorage devices: A status report. J Clin Orthod 2005; 39(3):132-136. 5. Kyung H, Park H, Bae S, Sung J, Kim I. Development of orthodontic micro implants for intra oral anchorage. J Clin Orthod 2003; 37(6):321-328. 6. Cope JB. Temporary anchorage devices in orthodontics: A paradigm shift. Seminars in Orthodontics 2005; 11(1):3-9. 7. Bae S, Park H, kyung H, Kwon O, Sung J. Clinical application of micro implant anchorage. J Clin Orthod 2002; 36(5):298â&#x20AC;&#x201C;302. 8. Miyawaki S, koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod 2003; 124(4):373-378. 9. De Pauw GAM, Dermaut L, De Bruyn H, Johansson C. Stability of implants as anchorage for orthopedic traction. Angle Orthod 1999; 69(5):401-407. 10. Singer SL, Henry PJ, Rosenberg I. Osseointegrated implants as an adjunct to face mask: A case report. Angle Orthod 2000; 70:253-260. 11. Chung K, Kim S, Kook Y. The C-Orthodontic microimplants. J Clin Orthod 2004; 38(9):478-486. 12. Geng J, Tan KBC, Liu G. Application of finite element analysis in implant dentistry: A review of the literature. J Prosthet Dent 2001; 85(6):585-598. 13. Tanne K, Sakuda M, Burstone CJ. Three dimensional finite element analysis for stress in the periodontal tissues by orthodontic forces. Am J Orthod 1987; 92:499-505. 14. Holmgren EP, Seckinger RJ, Kilgren LM, Mante F. Evaluating parameter of osseointegrated dental implant using finite element analysis: A two dimensional comparative study examining the effects of implants diameter, implant shape and load direction. J Oral Implantology 1998; 24(2):80-88. 15. Vasquez M, Calao E, Becerra, Ossa J, Enriquez C, Fresneda C. Initial stress differences between sliding and sectional mechanics with an endosseous implant as anchorage: A 3-D FEM analysis. Angle Orthod 2001; 71:247-255. 16. Rieger MR, Mayberrt M, Brose MO. Finite element analysis of six endosseous implants. J Prosthet Dent 1990; 63:671-676. 17. Bozkaya D, Muftu S, Muftu A. Evaluation of load transfer characteristics of five different implants in compact bone at different load levels by finite element analysis. J Prosthet Dent 2004; 92(6):523-530. 18. Martin RB, Burr DB, Sharkey NA. Skeletal tissue mechanics. 1st edition New York; 1998:127-178. 19. Lin JC, Liou EW. A new bone screw for orthodontic anchorage. J Clin Orthod 2003; 37(12):676-681. 20. Skalak R.Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent 1983; 49:843-848.

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Winter et al

Dental 3D Imaging Centers - Usage and Findings: Part II – Anatomical Features of the Lingual Artery

Alan A. Winter, DDS1 • Kouresh Yousefzadeh, DDS2 • Alan S. Pollack, DDS3 Michael I. Stein, DMD4 • Frank J. Murphy, DDS5 Christos Angelopoulos, DDS6 Abstract Background: This is part 2 of a 5 part study evaluating data obtained from dental referral usage of radiological labs for three dimensional (3D) anatomical scans. The purpose of this portion of the study was to gather detailed data on the lingual artery and discuss its potential impact on dental implant delivery.

having vessels inserting in the premolar areas. 87.2% had either one or two lingual arteries with the superior most vessel inserting through the middle of the lingual plate in 88.5% of the patients. Over 91% of the vessels inserted above the genial tubercle and 80.3% of the vessels were less than 1mm in diameter.

Methods: Data from 500 consecutive patients sent to i-dontics dental radiological centers from 9 centers locations in 3 states were evaluated. This study evaluated the presence, location, length, and diameter of the insertion of the lingual artery into the mandible.

Conclusions: Implant placement in the mandibular anterior region is most often a benign procedure. However, clinicians should bear in mind the potential risk of piercing the lingual plate and injuring the lingual artery. This review of 296 CBCT scans demonstrates the value of 3D CBCT scans in identifying the presence, location, length, and diameter of the insertion of the lingual artery into the mandible.

Results: Of the 500 scans in this study, 296 were of the mandible. 98% of the patients had identifiable lingual arteries, with the remainder

KEY WORDS: Cone beam computed tomography, lingual artery, mandible, dental implants 1. Assistant Clinical Professor, Department of Periodontics and Implant Dentistry, New York University College of Dentistry 2. Private practice, New York, USA 3. Private practice, New York, USA 4. Private practice, New York, USA 5. Private practice, New York, USA 6. Director Maxillofacial Dental Radiology and Associate Professor of Clinical Dentistry, Columbia School of Dental Medicine

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Winter et al

IntRODuCtIOn The recent advent of cone beam computed tomography (CBCT) technology has vastly increased the diagnostic options for dental treatment. While this technology is continually improving in terms of quality, equipment size, and cost, most dental offices do not own CBCT scanners at this time. Accordingly, many practices currently refer patients to freestanding dental radiological labs for three dimensional (3D) anatomical scans. The purpose of this series of studies was to determine how and for what reason dentists currently utilize dental 3D imaging centers. Part one of this study series evaluated demographic data and the reasons why patients were referred for 3D evaluation. The purpose of this current study was to gather detailed data on the lingual artery and discuss its potential impact on dental implant delivery. Specifically, the following parameters of the lingual artery were evaluated: the radiographic presence or absence of the lingual artery, the location of its insertion into the mandible, how many branches of the lingual artery were present, and what was the diameter of the most superior branch of the lingual artery.

MAtERIAlS AnD MEthODS CBCT scans of the dental arches from 500 consecutive patients taken in 9 centers located in 3 states were uploaded to the main processing center of a single dental radiological practice (i-dontics, LLC., New York, NY) which is limited to taking and processing 3D CT images for the dental community. Scans were taken on either i-CAT scanners (8 centers) or on a (1) NewTom 3G scanner. All studies were converted to SimPlant™ (Materialise, Glen Burnie, MD). When not specified,

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the data was converted to SimPlant™ version 10. The current study evaluated data concerning the lingual artery including: the radiographic presence or absence of the lingual artery, the location of its insertion into the mandible, how many branches of the lingual artery were present, and what was the diameter of the most superior branch of the lingual artery.

RESultS CT scans from 500 consecutive patients requiring cone beam scans were included in this study. Of these scans, 296 were of the mandible. 98% (290/296) had observable insertions of the lingual artery into the mandible. The following observations were noted: number of lingual arteries: 1. 40.2% (119/296) had one lingual artery 2. 47% (139/296) had 2 lingual arteries 3. 10.7% (31/296) had 3 lingual arteries 4. 0.34% (1/296) had four lingual arteries Average length of the lingual artery: 1. Average length of lingual artery inserted into the alveolar bone = 9.6mm location of insertion of lingual artery relative to mandibular height: 1. Insertion in crestal 1/3 of madible = 3.44% (10/296) 2. Insertion in middle 1/3 of madible = 88.5% (262/296) 3. Insertion in apical 1/3 of madible = 59.45% (176/296) * Cumulative percentages exceed 100% due to some patients having multiple branches of the lingual artery.


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location of insertion of lingual artery relative to the genial tubercle: 1. Insertion coronal to genial tubercle = 91.55% (271/296) 2. Insertion below genial tubecle = 57.43% (170/296) 3. Insertion equal to genial tubercle = 12.76% (37/296) * Cumulative percentages exceed 100% due to some patients having multiple branches of the lingual artery. Diameter of lingual artery: 1. Less than 1mm diameter = 80.3% (233/296) 2. Greater than 1mm in diameter = 19.7% (57/296)

DISCuSSIOn Schick et al scanned 32 patients scheduled for mandibular implants to determine if CT scans could depict the presence, diameter, position, direction and frequency of vessels. In their study, lingual vascular canals were demonstrated in all patients. Most lingual canals were located in the midline and the mean diameter of the lingual canals was 0.7mm. Similar studies in 3 cadavers confirmed these findings, concluding that the occurrence, position and size of the lingual vessels could be depicted on CT scans. As more patients seek implant placement in order to avoid or stabilize mandibular dentures, it is important for clinicians to understand the limitations of two-dimensional (2D) imaging, especially when it comes to identifying the presence, location, and diameter of the lingual artery in respect to its insertion into the mandible. The importance of this was demonstrated when Niamtu described a case of a 1

Figure 1: Lingual artery distribution.

near-fatal airway obstruction which resulted from sublingual bleeding following implant placement.2 An additional case was described by Isaacson3 in which sublingual hematoma likely resulted from dental implant perforation of the lingual cortex and violation of one of the branches of the sublingual or facial arteries. A review of the literature revealed that these occurrences could be life-threatening.4-15 The current article and those just mentioned demonstrate the value of 3D imaging in preparation for anterior mandibular implant placement. Figure 2 is a panoramic view of a mandibular anterior edentulous site where dental implants were to be considered for insertion. In the 2D image, there is no sense of either the width of available bone or where the lingual artery inserts into the mandible. Figure 3 is a transaxial view through the #25 site. It reveals a narrow, spinous crest of bone that contains very little cancellous bone. Midway down the lingual plate, the lingual artery can be observed inserting into the mandible. This artery is not very wide but may be of concern

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Figure 2: 2D Panoramic view does not reveal osseous width or location of mandibular insertion of the lingual artery.

should it be violated during implant placement. This information was not clinically evident nor was it indicated on conventional 2D imaging. Figure 4 is an example (no implant is planned in this case) of a wide-diameter lingual artery that puts the patient in jeopardy should it be severed during implant surgery. This is an example of how a critical anatomic structure may not be observed through conventional 2D imaging but is readily apparent in transaxial (cross-sectional) views from medical and dental CT scanners. While cases of atrophy compromise any edentulous area that is adjacent or proximal to key anatomic structures, the mandibular anterior region is particularly vulnerable to potential risk relative to the width and insertion of the lingual artery. Seemingly innocuous perforations can lead to large hematomas or life threatening arterial bleeds.

COnCluSIOn Implant placement in the mandibular anterior region is most often a benign procedure. However, clinicians should bear in mind

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the potential risk of piercing the lingual plate and injuring the lingual artery. This review of 296 CBCT scans demonstrates the value of 3D CBCT scans in identifying the presence, location, length, and diameter of the insertion of the lingual artery into the mandible. ● Correspondence: Dr. Alan Winter a.winter@i-dontics.com

Disclosure Support for this study was generously given by NobelBiocare, Mahwah, NJ and Imaging Sciences Inc., Hatfield, PA. References 1. Schick S, Zauza K, Watzek G. Lingual Vascular Canals of the Mandible: Evaluation with Dental CT. Radiology 2001; 220(1):186-189. 2. Niamtu, J. Near-fatal airway obstruction after routine implant placement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92(6): 597-600. 3. Isaacson, T. Sublingual hematoma formation during immediate placement of mandibular endosseous implants. J Am Dent Assoc 2004; 135: 168-172. 4. Goldstein B. Acute dissecting hematoma: A complication of oral and maxillofacial surgery. J Oral Surg 1981; 39(1): 40-43. 5. Mordenfield A, Andersson L, Bergstrom B. Hemorrhage in the floor of mouth during implant placement in the edentulous mandible: A case report. Int J Oral Maxillofac Implants 1997; 12: 558–561.


Winter et al

Figure 3: Transaxial (cross-sectional) view demonstrates the value of 3D imaging by exposing the narrow width of the crestal bone and the location where the lingual artery inserts into the mandible.

6. ten Bruggenkate CM, Krekeler G, Kraaijenhagen HA, Foitzik C, Oosterbeek HS. Hemorrhage of the floor of the mouth resulting from lingual perforation during implant placement: A clinical report. Int J Oral Maxillofac Implants 1993; 8: 329–334. 7. Mason ME, Triplett RG, Alfonso WF. Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 1990; 48: 201–204. 8. Givol N, Chaushu G, Halamish-Shani T, Taicher S. Emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region. J Periodontol 2000; 71:1893–1895. 9. Burke R, Masch G. Lingual artery hemorrhage. Oral Surg Oral Med Oral Pathol 1986; 62: 258–261.

Figure 4: An example of a wide lingual artery viewed in cross-section than cannot be seen in 2D images.

11. Laboda G. Life-threatening hemorrhage after placement of an endosseous implant: Report of case. J Am Dent Assoc 1990; 121: 599–600. 12. Darriba MA, Mendonca-Caridad JJ. Profuse bleeding and life-threatening airway obstruction after placement of mandibular dental implants. J Oral Maxillofac Surg 1997; 55: 1328–1330. 13. Panula K, Oikarinen K. Severe hemorrhage after implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87(1): 2. 14. Mardinger O, Manor Y, Mijiritsky E, Hirshberg A. Lingual perimandibular vessels associated with life-threatening bleeding: An anatomic study. Int J Oral Maxillofac Implants 2007; 22(1): 127-131. 15. Kattan B, Snyder H. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991; 9: 421-424.

10. Krenkel C, Holzner K. Lingual bone perforation as causal factor in a threatening hemorrhage of the mouth floor due to a single tooth implant in the canine region. Quintessence 1986; 37: 1003–1008.

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Cultivating Your Online Dental Reputation with Blogs

Mackey

Shannon Mackey1 IntroductIon Let’s face it: to a clinical dentist whose expertise lies primarily inside the human mouth, success on the Web can be a daunting, elusive goal. For that matter, Web success can be a daunting objective for even the most seasoned, savvy online marketers. Why? Consider the following: ● the internet is a vast, growing repository of information and communication — as of March 31st, 2009, the U.S Census Bureau and Nielsen Online estimated that there were 1.6 billion users of the World Wide Web. That is 24% of the world’s population! ● the technology powering the Web is constantly changing — as companies vie for financial success by creating innovative experiences for us to enjoy, new technologies in support of those experiences continue to reshape the way we utilize the Web. ● the Web is an untamed, evolving organism — although governed by a fundamental architecture, many people across the world use the Internet but no one entity controls it. When properly utilized, the internet is offers the opportunity to showcase your practice in nearly any reflection of your identity that you desire. To achieve such, you must think in creative and ingenious ways. This article is the first in a

series of “how to” online marketing thoughts born out of my personal experience as Co-Owner and Customer Relations Director for Roadside Multimedia, one of the nation’s leading professional dental website providers. The specific focus of this article is how to utilize “blogs” to effectively communicate to your customer and referral base.

the Blog: An IndIspensABle Asset Your website is one of the most indispensible assets of your dental practice. In many cases, a customer’s first impression of your practice will come from your website. When a patient is referred to your practice, whether it be from another dentist, or better yet by another patient, they will often research your background by visiting your website. When they visit your site, what message is the patient receiving? First and foremost, you must realize that your website does not exist primarily to make money. Sound contradictory? While it is true that the ultimate goal of your website is to indirectly raise revenue via the recruitment of new patients, revenue generation should always be a result of your online reputation and the message that you convey to your patients. Online recruitment of new patients requires persuasive and authentic communication. One effective method to achieve such communication with prospective patients is via blogging. As

1. Owner & Customer Relations Director Roadside Multimedia, Marysville, WA

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recently as 2006, “web-logs” (as they were first termed) were viewed as nothing more than a curious quasi-voyeuristic method of online journalism, a brief online phenomenon, or narcissistic personal hobby. Make no mistake, blogging is much more than a passing fad. It is here to stay and will continue to grow with time. Accordingly, taking advantage of blogging to enhance our online reputation demands our attention. The exploding popularity of blogs represents a major shift in how consumers prefer to research and buy goods and services. No longer are there invisible lines of protocol between seller and buyer. The internet has allowed consumers to become much more educated about the goods and services they intend to purchase. As such, many consumers no longer passively listen to salespersons, or their treatment provider for that matter. With their newfound knowledge, consumers and patients often actively engage in discussions regarding their potential purchase or healthcare plan. In early online sales models, the product was the focus; now, the experience is the focus. While eventual purchase of a good or service is always the ultimate goal, the quality of the sales experience plays a much larger role in the overall success of the product. For example, how many times have you seen poor quality dentistry on a patient that raves about how they have or had a great dentist? Even though the dentistry was of poor quality, the patient was happy because of the way they were treated. The overall success for this patient was largely fashioned by factors external to the actual dental restoration. On the other hand, patients that receive quality care sometimes are dissatisfied with their dentist due to factors completely unrelated to the actual dental restoration. Truly, the overall success of dental treatment can

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no longer be related to the restorative or surgical care alone; the entire treatment experience is what determines success or failure in the patient’s mind. Blogging affords practitioners the opportunity to convey messages to prospective and current patients in a format that is comfortable and non-threatening. Patients can access this information from the familiarity and safety of their home and have adequate time to process this information without feeling pressured. This sincerity makes the blog significantly more trustworthy than your average website marketing lingo or hollow-sounding sales-speak. This concept is not new, but the medium is. You are already doing this every day in your office. When a patient arrives at your office, the sales process begins. When the patient parks their car in your parking lot, the aesthetic exterior of your building affects the patient’s perception of your practice. When a patient enters your waiting area, the cleanliness of the building, the friendliness of the staff, and a cornucopia of other factors affect the patient’s psyche. Your website is no different. Your website is often the very first impression that a patient. Anything you can do to enhance the patient’s experience on your website will ultimately benefit your patient attraction and retention goals. Something blogs also do very well, which is central to any effective marketing effort, is to gently open the door and establish a dialogue between you and a new prospect. Once that basic rapport has developed and the door is open, the opportunity to sell increases dramatically. Trust and confidence are the keys. Once you have gained the patient’s trust and confidence, the door will open. Blogs can help you accomplish as much. Basic steps can you take to cultivate your online reputation via blogging include:


Mackey

● Establish a blog through your website company or at www.blogger.com ● Send an email to your existing patients to announce the blog. ● Avoid canned commerciaism or a “sales-like” tone. ● Speak your mind on a variety of dental topics, both the esoteric and the mundane. ● Answer commonly asked dental questions. This may end up saving you time by eliminating repetitive questions. ● Express your personality through your writings. Patients may develop a bond with you by simply identifying with the manner in which you write. ● Think from the patient’s perspective. What information do they seek? ● Communicate practice news and updates. Announce your awards, speaking engagements, and publications. ● Establish a sense of community. Show your involvement with local people, businesses, volunteer efforts, and social/sports activities. ● Use hyperlinks to integrate your blog with your dental website. Correctly designed, properly maintained and routinely updated, a blog can become a traffic-generating powerhouse. It is capable of establishing your personality, improving your visibility, building a sense of community, maintaining an open dialogue between you and your patients, and keeping them fully informed. Blogging remains an effective tool for use in conjunction with a myriad of other online innovations such as search-engine optimization and webcasts to strengthen your overall marketing strategy and enable a dental experience that fully satisfy your patient’s expectations. Blogging doesn’t have to be a time consuming activity for the practicing dentist. Ask your

hygienist, treatment coordinator, dental assistants and other office staff to begin writing blog entries. It is recommended that you preview each blog prior to publication on your website. Depending on typing speed, it shouldn’t take any longer than 15-20 minutes for your team members to write a few paragraphs. As your team begins to craft a unique online narrative of their lives at your practice, give your patients every opportunity to have their voices heard. Be the gentle, knowledgeable, respectful expert you are. You might want to conduct an online promotion aimed exclusively at your blog community. You might ask other local dentists to participate in your blog to enrich the conversation and expand the site’s scope and influence. The possibilities are endless.

conclusIon As more traditional advertising and marketing vehicles continue to lose market share to their digital counterparts, consider utilization of blogs for your website. It should be an essential aspect of your marketing plan. Does it take some time to write? Yes. Is it new and a little unnatural? Of course. Will it complement your online marketing plan? Most definitely. Simply put, if you blog on a regular basis, it’s going to spell success for your dental practice. ● correspondence: Shannon Mackey Owner & Customer Relations Director Roadside Multimedia shannon@roadsidemultimedia.com (425) 530-1848 Direct Line (801) 996-0758 Fax

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