Volume 3, No. 1
D ecember/January 2011
The Journal of Implant & Advanced Clinical Dentistry
Sinus Perforation
Treatment &
Classifications
Dr. Paul Fuggazzotto
on the Role of Guided
Tissue Regneration in
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1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I.
Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543.
2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth
factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5.
3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF;
Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract).
4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF;
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The Journal of Implant & Advanced Clinical Dentistry
Volume 3, No. 1 • D ecember/January 2011
Table of Contents
19 S inus Perforation:
Treatment and Classifications
Leon Chen, Jennifer Cha,
Hsin-Chen Chen, Hong Liang Lin
33 T he Role of Guided Tissue
Regenerative Therapy in
Today’s Clinical Practice
Paul A. Fugazzotto
49 O utcomes of Implant Treatment
in Patients with Aggressive
Periodontitis and Multiple
Maxillary External Root
Resorption: Review and
Five Year Follow-up
Francisco Mesa, Pablo Galindo-Moreno,
Ricardo Muñoz, Luis A. Perez,
Hom-Lay Wang
The Journal of Implant & Advanced Clinical Dentistry
• 5
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1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010.
2. Implant strength & fatigue testing done in accordance with ISO standard 14801.
3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC.
Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288.
4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim.
SPMP10109 REV D SEP 2010
International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008.
The Journal of Implant & Advanced Clinical Dentistry
Volume 3, No. 1 • D ecember/January 2011
Table of Contents
59 G uided Bone Regeneration
Using a Rapidly Formed
Absorbable Polymer Barrier:
A Case Series Report
Paul S. Rosen, Mark A. Reynolds
75 Immediate Loading of
Dental Implants with
Provisional Restorations
and Soft Tissue Manipulation for
Achieving Optimal Esthetics:
A Case Report
Sudhindra Kulkarni, Srinath Thakur,
Sampath Kumar
83 O ral Bisphosphonate and
Dental Implants:
A Review and Update
Manpreet S Walia, Saryu Arora,
Bhawana Singal
The Journal of Implant & Advanced Clinical Dentistry
• 7
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References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich
Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010
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The Journal of Implant & Advanced Clinical Dentistry
Volume 3, No. 1 • January/D ecember 2011
Publisher
SpecOps Media, LLC
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The Journal of Implant & Advanced Clinical Dentistry
• 11
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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
Editorial Advisory Board
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
David Garber, DMD
Arun K. Garg, DMD
Ronald Goldstein, DDS
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
Edward Lowe, DMD
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
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
Charles Orth, DDS
Jacinthe Paquette, DDS
Adriano Piattelli, MD, 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
Henry Salama, DMD
Maurice Salama, DMD
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
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
Emil Verban, DDS
Hom-Lay Wang, DDS, PhD
Benjamin O. Watkins, III, DDS
Alan Winter, DDS
Glenn Wolfinger, DDS
Richard K. Yoon, DDS
The Journal of Implant & Advanced Clinical Dentistry
• 13
ΣS Speed
3
Strength Stability
Accelerated Osseointegration
Advancing the science of dental implant treatment
The aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most
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Letters to the Editors
JIACD has been a great addition for
dentists to learn about the latest in
techniques and interdisciplinary care.
The thing that has impressed me the most
about this journal is that the information
is online, easy to access, and the quality
of the photos and case presentations is
amazing.
Dr. Paul Rosen, Philadelphia,
Pennsylvania, USA
I really appreciate JIACD because it’s a
fundamental tool for both practitioner and
researcher in the field of Periodontology and
dental implant continuing education. What I
prefer most is the reliability, the friendly use, and
the extremely high quality of the images and the
interesting topics. Clinicians and scientists can
find clear clinical suggestions and solutions to
new and old problems for daily practice.
Dr. Giulio Rasperini, Italy
JIACD is a very informative and educational
online journal. Each issue educates with cutting
edge clinical technology. The best advantages
of JIACD are unlimited openness to clinicians
all over the world. I highly recommend dental
clinicians to become subscribers of JIACD.
Dr. Dong-Seok Sohn, Republic of Korea
The internet is now the medium of choice
for the timely distribution and collection of
knowledge. The editors and reviewers of
JIACD understand the concept of “timely”. The
JIACD review process is thorough but streamlined
and a camaraderie building experience with your
peers. Additionally, you can receive feedback
from readers in over 80 countries in as quickly as
3 to 6 months following submission. TRY IT!
Dr. Tom Wilcko, Erie, Pennsylvania, USA
JIACD brings to all aspects of dentistry some
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The articles are timely, relate to all aspects of
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AND reading the current research performed
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has needed for a long time to help us all move
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state-of-the-art care to our patients.
Dr. Robert Horowitz, Scarsdale, New York, USA
My complements on what you have
accomplished with this online publication.
Content has been superb. What a service
to implantology.
Dr. Gary Henkel, Horsham, Pennsylvania, USA
After reading several informative, well written
articles by highly respected educators and
clinicians I was inspired to submit my own article
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and painless and the reviewers made some very
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submission. I intend to continue writing for the
journal as I am anxious to be a part of this superb
online educational process.
Dr. Michael Toffler, New York, New York, USA
The Journal of Implant & Advanced Clinical Dentistry
• 15
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Chen et al
Sinus Perforation: Treatment and Classifications
Leon Chen, DMS, MS1 • Jennifer Cha, DMS, MS2
Hsin-Chen Chen, MD3 • Hong Liang Lin, MD4
Abstract
Background: Tooth loss in the posterior area
of the maxilla will result in the atrophying of
bone along the alveolar ridge over time. This
can make implant placement in the sinus area
impossible without first re-establishing sufficient bone height. The traditional answer
to this problem is the lateral window sinus lift.
Methods: In this article, we present a system of classifications and reparations of the
sinus membrane perforations while performing
sinus augmentation from the crestal approach.
The classification consists of 5 classes of
varying perforation severity, each with corresponding management techniques. We will
also introduce two medical terms, sinus cavity space (SCS), and sinus membrane space
(SMS).
It is very important to distinguish
between these two spaces in this article as
they both occupy the same sinus area and are
distinguished by the existence of a perforation.
Conclusions: This article presents a new identification method and treatment planning guide
for sinus membrane perforations. We have
attempted to account for all sizes and types of
sinus membrane perforations and to create a
method for treatment that is both simple to perform and will minimize further complications.
KEY WORDS: Maxillary sinus, bone graft, sinus augmentation, complication, repair
1. CEO and Co-Founder of the Dental Implant Institute, Las Vegas, Nevada
2. President and Co-Founder of the Dental Implant Institute, Las Vegas, Nevada
3. Private Practice limited to otolaryngology, Chang-Hwa City, Taiwan
4. Private Practice limited to otolaryngology, Yonghe City, Taiwan
The Journal of Implant & Advanced Clinical Dentistry
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Chen et al
Introduction
The advent of crestal approached based sinus
lift methods have produced methods to perform
a sinus lift procedure with fewer complications,
less trauma, and a shorter healing time than the
traditional lateral window.1-10 There are currently
only two principle techniques of penetrating the
crestal bone in order to reach the sinus membrane. The first involves cracking the bone, better
known as the osteotome technique.6 The second
includes drilling through the bone, which is known
as hydraulic sinus condensing technique.2 Once
through the bone, there are many modifications
that have been developed for actually dissecting
the sinus membrane in order to create sinus membrane space (SMS). These methods use a variety
of tools and materials such as: bone,2 sinus elevators,11 balloon,14 collagen,4 sinus condensers,2 and
sinus curettes.5 Two important terms are introduced in this paper. The aforementioned SMS
refers to the space between the sinus membrane
and its underlying bone. This space can only be
created by elevating the Schneiderian membrane
away from the underlying bone. The sinus cavity space (SCS) is that space which can only be
reached by perforating the Schneiderian membrane. Under normal circumstances, this space
is fully surrounded by intact sinus membrane.
Sinus membrane perforation is a potential obstacle that must be avoided or managed
while performing any type of sinus augmentation procedure, whether through crestal or lateral access. Few papers have been published
on lateral sinus membrane perforation and their
corresponding repair techniques.4,8 These techniques have been tested and clinically proven
successful. This report, however, will show a
method of classifying and repairing sinus mem-
20 •
Vol. 3, No. 1
•
December/January 2011
brane perforations from a crestal approach.
Whether preexisting, or created during the
procedure itself, a sinus perforation can cause
short and long term complications5,8,9 and
should be dealt with immediately. By classifying the perforations we provide a simple set of
rules to follow when performing these procedures. These procedures allow the clinician to
quickly identify and execute the proper technique
necessary to promote the healing of the sinus
membrane and the overall health of the patient.
Classification of sinus
membrane perforations
The classification of membrane perforations
will be made primarily by size and degree of
separation of the soft and hard tissues. Perforations will be separated into 5 classes, each
with their own severity and course of action.
Class 1 Perforation – Utilize Grafting
Material
A class 1 perforation is less than 2mm in diameter. A membrane perforation into the SCS
of less than 2mm is not typically cause for concern8,9 and will not usually require any special
treatment. Simply continue the bone graft and
implant placement exercising extreme care not
to enlarge the perforation. The act of elevating
the sinus membrane will naturally cause the perforated membrane to fold over itself, causing the
membrane to close and heal. The perforation
should heal on its own with no repercussions.
Class 2 Perforation – Sinus Membrane
Folding Technique
If the membrane perforation is larger than 2mm
but less than 5mm, you may consider per-
Chen et al
Figure 1a: Dissecting sinus membrane away from
underlying bone in a Class 2 membrane perforation.
Figure 1b: Condensing bone into the SMS after the sinus
membrane has folded itself close in a Class 2 membrane
perforation.
Figure 1c: Multiple clinical photographs depicting closure of a Class 2 membrane perforation utilizing the Sinus Membrane
Folding Technique.
forming the Sinus Membrane Folding Technique.
This technique can be immediately
performed when the space is discovered and
the clinician will not need to postpone the
bone grafting or placement of implants. This
type of perforation is most commonly created during a traumatic extraction or while lift-
ing the sinus membrane and can be seen
more in patients with a very thin mucosa.10
Gently dissect approximately 5 to 10 mm
of membrane from around the edges of the
bone. Once this has been accomplished, fold
the membrane in on itself while gently elevating the membrane. After folding the mem-
The Journal of Implant & Advanced Clinical Dentistry
• 21
Chen et al
Figure 2a: Primarily healed Class 3 membrane perforation
prior to grafting. Note that a soft tissue plug closes the
oro-antral communication.
Figure 2b: Split thickness incision allowing the
granulation tissue plug to remain fused to the sinus
membrane.
Figure 2c: Bone condensation into the SMS utilizing
the granulation tissue plug to close the Class 3 sinus
membrane perforation.
Figure 2d: Dental implant delivery into repaired/grafted
Class 3 sinus membrane perforation.
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Chen et al
Table 1: Definition of SCS and SMS
Sinus Cavity Space
(SCS)
Sinus Membrane
Space (SMS)
Can only be reached
through a perforation
in the sinus membrane
Must remain
a cavity
Cannot exist in an
Can be
area where a
filled in
sinus membrane
perforation exists
brane and gently elevating, place your bone
grafting material inside the SMS. Using bone
grafting material to compact the membrane
will adequately seal the perforation, allowing
you to continue normally with the implant procedure. Demonstration of Class 2 sinus perforation and repair is shown in figures 1a-1c.
Class 3 Perforation – Delayed Membrane
Sandwich Technique
A class 3 perforation will consist of a complete
tear (greater than 5mm) of the sinus membrane
occurring during a surgical procedure causing the SCS to be fully exposed. In a class
3 situation, you will not be able to locate the
SMS. The patient will not be eligible for a sinus
lift procedure until the gingival tissue is fully
formed. As the membrane is already perforated
beyond repair, you should not sequential drill
the osteotomy. Instead, utilize the final drill size
to efficiently complete the osteotomy through
to the SCS. While apparently counter-intuitive,
this will create a uniform osteotomy, which will
allow for predictable healing results and a safer
re-entry into the SMS once the osteotomy has
healed. Close the site and allow it to heal for
Naturally occuring
from birth
Created by dissecting
the sinus membrane from the bone
a minimum of 3 weeks. This will allow gingival
tissue to grow in the area of the perforation
and granulation tissue to form in the osteotomy.
Once this tissue has fully healed, you can
then reopen the site and make a split thickness incision in order to create a flap with
the gingival tissue and expose both the osteotomy and the granulation tissue plug. Over
the course of 3 weeks the sinus membrane
or gingival connective tissue will have had a
chance to repair and attach to the granulation tissue. The newly formed granulated plug
will have fully compartmentalized the SCS and
SMS. Using a condenser, elevate the sinus
membrane/gingival connective tissue gently
using bone graft material (in effect, this “sandwiches” the bone between the connective tissue.) You are now able to place an implant in
the SMS. Demonstration of Class 3 sinus perforation and repair is shown in figures 2a-2d.
Class 4 Perforation - Split Thickness Sinus
“Membrane Sandwich” Technique
While class 1, 2, and 3, perforations are typically encountered and repaired during the surgical procedure, class 4 and 5 perforations
The Journal of Implant & Advanced Clinical Dentistry
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Chen et al
Figure 3a: Intra-surgical photograph of Class 4 sinus
membrane perforation prior to treatment.
Figure 3b: Intra-surgical photograph of Class 4 sinus
membrane perforation after treatment.
Figure 3c: Radiograph of Class 4 sinus membrane
perforation prior to treatment.
Figure 3d: Radiograph of Class 4 sinus membrane
perforation after treatment.
will be encountered after the perforation has
occurred and typically has attempted to heal.
These perforations are usually created during
extraction complications, or multiple failed sinus
lift attempts. A class 4 perforation will show
bony antra-oral communication, with only the
soft tissue intact. This type of perforation will
require the “Membrane Sandwich Technique”.
This technique is identical to the “Delayed
Membrane Sandwich Technique” with one difference. Instead of making a final osteotomy
and waiting for it to heal, we are using the site
as it has naturally healed. This is basically the
delayed technique without the delay, and again
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Chen et al
Table 2: Perforation Size, Classification, and Repair Technique
Class 1
Perforation
Class 2
Perforation
Class 3
Perforation
Class 4
Perforation
< 2mm
2 - 5mm
Complete
Bony oro-antral
Size
tear
communication,
soft tissue intact
Repair
Technique
Continue
with bone
grafting
Sinus
membrane
folding
technique
is only suitable in those cases where the patient
has had a perforated sinus membrane present long enough for tissue to grow into the
tooth socket or osteotomy. Make a split thickness incision, and create a gingival connective
tissue flap, exposing the healed tissue inside.
Use a condenser; elevate the gingival connective tissue flap. Use the connective tissue flap
as if it were the sinus membrane itself. Gently
“sandwich” bone grafting material between the
two gingival connective tissue flaps to create
a new SMS. Demonstration of Class 3 sinus
perforation and repair is shown in figures 3a-3d.
Class 5 Perforation - Invagination Technique
A class 5 perforation usually results from
severe extraction complications or multiple
perforations resulting from repeated attempts
to perform a sinus lift when both the bone
and the gingival tissue fail to heal properly.
This perforation is classified by the fact that
Delayed
membrane
sandwich
technique
Split thickness
sinus membrane
sandwich
technique
C lass 5
Perforation
Complete
communication.
Soft and hard
tissues are
separated
Invagination
technique
there is complete antra-oral communication
ranging in size from a pinhole, to several centimeters in diameter. In every class 5 perforation, the gingival tissue will have grown into
the opening which will prevent the bone or
sinus from naturally closing the wound. In
order to repair this type of a perforation we
need to use the “Invagination Technique.”
Start by making an incision in the gingival
tissue about 2 mm around the opening. Gently remove the gingival tissue from the bone,
and elevate the sinus membrane within the
cavity. Due to the antra-oral communication,
the sinus membrane will now have extra tissue attached to it in the form of gingival tissue that will have flapped from the bone. It is
important to be very gentle while working with
this gingival tissue. Fold the gingival connective
tissue together and secure with a resorbable
suture on the extra gingival tissue. By suturing the gingival tissue together, the SCS and
The Journal of Implant & Advanced Clinical Dentistry
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Chen et al
Figure 4a: Class 5 sinus membrane perforation.
Figure 4b: Split thickness dissection of gingival tissue
surrounding Class 5 sinus membrane perforation.
Note that the gingival tissue remains attached to
the Schneiderian membrane at the perimeter of the
perforation.
Figure 4c: Initial elevation of sinus membrane/gingival
tissue in the Class 5 sinus membrane perforation repair.
Figure 4d: Once the sinus membrane/gingival tissues
have been fully elevated away from the underlying bone,
the gingival tissue ring surrounding the perimeter of the
Class 5 sinus membrane perforation is sutured together to
separate the SMS from the SCS.
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Chen et al
Figure 4e: Continued elevation of the repaired sinus
membrane creates a larger SMS.
Figure 4f: Initial bone condensation into the SMS
following repair of the Class 5 sinus membrane perforation.
SMS will separate into two separate spaces.
Compact the new SMS with bone grafting
material and vertically translate the existing
gingival tissue over the site for primary closure.17 After allowing this area to heal for 3
months, the site will be ideal for implant placement. Demonstration of Class 5 sinus perforation and repair is shown in figures 4a-4o.
Discussion
Figure 4g: A buccal flap is advanced to close the crestal
access to the repaired/grafted Class 5 sinus membrane
perforation.
In order to successfully treat a patient, it is
important to be prepared to handle any situation that may arise. The sinus membrane
can create many variables in the placement of
implants in the maxillary posterior. While membrane perforations are rarer and much easier
to repair from a crestal approach than a lateral approach,3,6 they are still a reality. Membrane perforations can also be created during
The Journal of Implant & Advanced Clinical Dentistry
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Chen et al
Figure 4h: Intra-surgical photograph of Class 5 sinus
membrane perforation.
Figure 4i: Demonstration of split thickness incision
around perimeter of Class 5 sinus membrane perforation
(corresponds to figure 4b).
Figure 4j: Intra-surgical photograph of initial elevation
of sinus membrane/gingival tissue in the Class 5 sinus
membrane perforation repair (corresponds to figure 4c).
Figure 4k: Intra-surgical photograph showing the gingival
tissue ring surrounding the perimeter of the Class 5 sinus
membrane perforation being sutured together to separate
the SMS from the SCS (corresponds to figure 4d).
extraction or implant placement. Therefore, the
membrane could have been perforated months
or even years before it is discovered. Knowing how to handle perforations of any size and
type will increase your overall success rate
and give you more confidence to perform and
repair sinus lift procedures in patients regardless of membrane health or bone height.
28 •
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Chen et al
Figure 4m: Intra-surgical photograph of buccal flap
being advanced to close the crestal access to the
repaired/grafted Class 5 sinus membrane perforation
(corresponds to figure 4g).
Figure 4l: Intra-surgical photograph of initial bone
condensation into the SMS following repair of the Class 5
sinus membrane perforation (corresponds to figure 4f).
Figure 4n: Pre-surgical CBCT of Class 5 sinus membrane
perforation prior to repair.
Figure 4o: Post-surgical CBCT of Class 5 sinus membrane
perforation after repair.
The Journal of Implant & Advanced Clinical Dentistry
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Chen et al
One thing to note with the Invagination
Technique is that the gingival epithelium, that
at one time was in the oral cavity, will fold
in and become part of the membrane facing
the SCS. The gingival connective tissue will
then be in the SMS. This will make sure that
the sinus cavity is completely covered with
epithelial tissue, while the non-epithelial connective tissue will be facing the graft material.
While more research and long term followup studies need to be performed, the goal
of these techniques is that clinicians using
this guide will be able to repair any sinus
membrane perforation that they encounter.
Conclusions
This article presents a new identification
method and treatment planning guide for sinus
membrane perforations. We have attempted to
account for all sizes and types of sinus membrane perforation, and to create a method
for treatment that is both simple to perform
and will minimize further complications. ●
Correspondence:
Dr. Chen
Dental Implant Institute
6170 W Desert Inn Rd.
Las Vegas, Nevada, USA 89146
Phone: (702) 220-5000
Fax: (702) 247-4014
E-mail: drchen@diilv.com
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Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1: F
errigno N, Laureti M, Fanali S. Dental implant placement in conjunction with
osteotom sinus floor elevation: a 12-year life-table analysis from a prospective
study on 588 ITI implants. Clin Oral Implants Res 2006; 17(2):194-205.
2: C
hen, Leon, & Cha, Jennifer. An 8-Year Retrospective Study: 1,100 Patients
Receiving 1,557 Implants using the Minimally Invasive Hydraulic Sinus
Condensing Technique. Innovations in Periodontics 2005; 76(3):482-491.
3: H
ernández-Alfaro F, Torradeflot MM, Marti C. Prevalence and management of
Schneidarian membrane perforations during sinus-lift procedures. Clin Oral
Implants Res 2008; 19(1): 91-98.
4: P
ikos MA. Maxillary sinus membrane repair: update on technique for large and
complete perforations. Implant Dent 2008; 17(1):24-31.
5: M
isch CE. The maxillary sinus lift and sinus graft surgery. In: Misch CE, ed.
Contemporary Implant Dentistry. Chicago, IL:Mosby;1999:469-495.
6: S
ummers, RB. The osteotome technique: part 3. Less invasive methods of
elevating the sinus floor. Compendium Cont Educat Dent 1994. 15(6):698708.
hanavaz, M. Maxillary sinus: anatomy, physiology, surgery, and bone grafting
7: C
related to implantology - eleven years of surgical experience (1979-1990). J
Oral Implantology 1990; 16(3):199-209.
8: F
ugazzotto P, Vlassis J. A Simplified Classification and Repair System for Sinus
Membrane Perforations. Innovations in Periodontics 2003; 73(10): 15341542.
imetti M, Romognoli R, Ricci G, Massei G. Maxillary sinus elevation: the
9: A
effect of macrolacerations and microlacerations of the sinus membrane as
determined by endoscopy. Int J Periodontics and Rest Dent 2001; 21(6):581589.
10: N
kenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The
endoscopically controlled osteotome sinus floor elevation: a preliminary
prospective study. Int J Oral Maxillofac Implants 2002; 17(4):557-566.
atum, O.H. Jr., Maxillary and sinus implant reconstruction, Dental Clinics of
11: T
North America 1986; 30:207-229.
12: W
ood RM, Moore DL. Grafting of the maxillary sinus floor with intraorally
harvested autogenous bone prior to implant placement. Int J Oral Maxillofac
Implants 1988; 3: 209-214.
13: Z
inner I, Small S. Sinus lift graft: using the maxillary sinuses to support
implants. J Am Dent Assoc 1996; 127:51-57.
14: S
oltan, Muna, Smiler, Dennis G. Antral Membrane Balloon Elevation. J Oral
Implantology 2005; 31(2):85-90.
15: W
allace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian
membrane perforation rate during sinus elevation using piezosurgery: clinical
results of 100 consecutive cases. Int J Periodontics Rest Dent 2007;
27(5):413-419.
atum OH, Maxillary sinus grafting for endosseous implants. Presented at the
16: T
annual meeting of the Alabama Implant Study Group. Birmingham Alabama,
April 1977.
17: Chen L, Cha J, Chih-Hsiang H. A Three-Point-Translation Technique for Root
Coverage With 4 Year Follow-up. Dentistry Today 2002; 21(10):112-115.
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The Role of Guided Tissue Regenerative
Therapy in Today’s Clinical Practice
Fugazzotto
Paul A. Fugazzotto, DDS1
Abstract
G
uided tissue regeneration (GTR) was
introduced into clinical practice in the
United States in the mid-1980’s, and
quickly became an important component of the
clinical periodontists’ therapeutic armamentarium.
GTR is conceptually based upon the selective repopulation of a previously diseased root
surfaces by specific cell types. GTR utilizes an
occlusive membrane, which is placed to create space for regeneration and to prevent ingrowth of cells from the overlying epithelium
or the connective tissue corium. While the
cells in the marrow spaces of the supporting
osseous structures facing the defect and root
surface could theoretically repopulate the diseased root surface, the relatively slow migra-
tory capacity of these cells renders such a
consideration moot. As a result of appropriate
membrane selection and placement, the pluri
potential mesenchymal cells in the perivascular
tissues of the periodontal ligament migrate over
the previously diseased root surface, effecting
regeneration of damaged periodontal attachment apparatus. Such regeneration is characterized by the formation of new cementum
and Sharpey fiber insertion into the cementum.
When utilized appropriately, GTR therapy
yields highly predictable therapeutic results,
when treating both periodontally involved furcations and infrabony defects. The aim of this
article is to provide a timely update on the role
of GTR therapy in today’s clinical practice.
KEY WORDS: Guided tissue regeneration, bone graft, periodontal disease, review
1. Private practice limited to periodontics and dental implants, Milton, Massachusetts, USA
The Journal of Implant & Advanced Clinical Dentistry
• 33
Fugazzotto
BACKGROUND
Based upon the pioneering work of Nyman, Gottlow, Karring, and Lindhe1-4 guided tissue regeneration (GTR) was introduced into clinical practice
in the United States in the mid-1980’s, and quickly
became an important component of the clinical periodontists’ therapeutic armamentarium.
GTR is conceptually based upon the selective repopulation of a previously diseased root
surfaces by specific cell types. GTR utilizes an
occlusive membrane, which is placed to create
space for regeneration and to prevent in-growth
of cells from the overlying epithelium or the connective tissue corium. While the cells in the marrow spaces of the supporting osseous structures
facing the defect and root surface could theoretically repopulate the diseased root surface, the
relatively slow migratory capacity of these cells
renders such a consideration moot. As a result
of appropriate membrane selection and placement, the pluri potential mesenchymal cells in the
perivascular tissues of the periodontal ligament
migrate over the previously diseased root surface, effecting regeneration of damaged periodontal attachment apparatus. Such regeneration is
characterized by the formation of new cementum
and Sharpey fiber insertion into the cementum.
Numerous animal studies have demonstrated
histologic reattachment to previously diseased
root surfaces following the use of an occlusive
membrane to effect regeneration.1,2 Clinical studies have consistently demonstrated the attainment of superior results following treatment of
Class II furcation involvements and/or infrabony
defects with GTR, as opposed to the use of
non-surgical or open flap debridement therapies. While root resective techniques have demonstrated a high level of efficacy in the treatment
34 •
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December/January 2011
of Class II and III furcation involvements, and
long term stability,5 such a treatment approach is
dependent on strict diagnostic and case selection criteria, is technically demanding, and entails
a significantly greater expense to the patient
than the aforementioned regenerative efforts.
GTR therapy was initially viewed as a “magic
bullet” which would allow the clinician to easily attain reattachment and closure of periodontally involved furcations and eliminate infrabony
defects, in all clinical situations. Such expectations were unreasonable. Unfortunately, as GTR
therapy “failed” repeatedly, the same clinicians
who were proponents of its indiscriminate use
condemned GTR treatment as a short term solution at best, and often as an outright failure of
therapy. Such an assessment was not accurate.
Utilized appropriately, GTR therapy yields highly
predictable therapeutic results, when treating both
periodontally involved furcations and infrabony
defects. The vast majority of failures when
employing GTR therapy may be directly attributed
to inappropriate diagnosis, poor case selection,
errors in technical execution, or all of the above.
FAILURES IN DIAGNOSIS
Unfortunately, no standardized classification system exists for considering periodontally involved
furcations.
Any diagnostic system employed
must be easy to utilize, reproducible, and provide
information which is directly applicable to treatment selection. When considering mandibular
furcation involvements, the following furcation
classification system has proven highly useful:
Horizontal Furcation Involvements
Class I: Entrance into the furcation extends less
than half of the horizontal dimension of the tooth.
Fugazzotto
Class II: Entrance into the furcation
extends greater than half of the horizontal dimension of the tooth, but less than
the full horizontal dimension of the tooth.
Class III:
Entrance into the furcation
extends along the complete horizontal dimension of the tooth, connecting both the buccal and the lingual furcation entrances.
Vertical Furcation Involvements
A: Loss of attachment apparatus
less than 25% of the vertical
ponent of the furcation of the
along
comtooth.
treated, maxillary molars present unique diagnostic and therapeutic challenges when considering guided tissue regenerative therapies.
A Class II buccal furcation involvement which
does not extend either mesially or distally into the
internal aspects of the mesial and distal furcations
of the tooth being considered, may be treated
more predictably with regenerative therapy than a
Class II buccal furcation involvement which does
extend into the mesial and/or distal furcations
of the tooth internally, for reasons which will discussed below. As such, the following degrees
of furcation involvement must also be considered
when assessing a maxillary molar for GTR therapy:
B:
Loss
of
attachment
apparatus along more than 25% of the vertical component but less than 50% of the
vertical component of the furcation of the tooth.
i: The
cation
roots
zontal
C: Loss of attachment apparatus along
more than 50% of the vertical component of the furcation of the tooth.
ii: Entrance into the furcation between the other
two roots extends greater than 25% the horizontal dimension of the tooth, but less than the full
horizontal dimension of the tooth, in this area.
The vertical component of furcation involvement has significant ramifications in the treatment
of Class II furcations. However, this vertical component plays no role in the treatment of Class I furcations, unless the vertical furcation involvement
extends to such a degree as to render attainment
of appropriate osseous morphologies impossible,
or reaches the apices of the tooth in question. In
such situations, molar extraction must be effected.
Additional Considerations for Maxillary
Furcation Involvements
Due to the presence of three roots, and thus
additional potential furcation involvements to be
horizontal dimension of the internal furinvolvement between the other two
extends less than 25% of the horidimension of the tooth in this area.
iii: Entrance into the furcation between the
other two roots extends along the complete
horizontal dimension of the tooth in this area.
Any extension of the vertical dimension of the furcation involvement between
the two other roots of greater than 25%
is problematic, as will be discussed.
Cemento Enamel Projections
Cemento enamel projections or enamel pearls
in the furcation area prevent the establishment
of true attachment to the root surface, as con-
The Journal of Implant & Advanced Clinical Dentistry
• 35
Fugazzotto
nective tissue will not insert into enamel. These
cemento enamel projections thus represent a
potential “funnel” for bacteria into the entrance
of the furcation, as the only barrier to such penetration is an overlying junctional epithelial
adhesion.
Junctional epithelial adhesion has
demonstrated significantly greater vulnerability to
detachment in the presence of plaque than connective tissue attachment.
Cemento enamel
projections should be classified as follows:
A: Previously called a Class I cemento
enamel projection (CEP), this CEP extends
less than half the distance from the “normal” CEP to the entrance to the furcation.
B:
This
CEP,
formally
classified
as
Class II, extends greater than half the distance
from
the
“normal”
position
of
the CEJ to the furcation entrance, but
does not reach the furcation entrance.
C:
This
CEP,
formally
classified
as
Class III, extends from the “normal” CEJ
area to the entrance of the furcation.
Class A cemento enamel projections are of no
clinical significance in development of treatment
algorithms. Class B cemento enamel projections are only of clinical significance if the patient
presents with a root trunk short enough to result
in the Class B cemento enamel projection being
within 1mm of the furcation entrance. Such proximity does not allow enough vertical dimensions
for development of adequate connective tissue
attachment coronal to the furcation entrance.
Class C CEPs must always be eliminated, as
they represent a potential furcation involvement.
36 •
Vol. 3, No. 1
•
December/January 2011
Root Morphology
In order to employ GTR therapy effectively, it
is imperative that periodontal ligament pluri
potential mesenchymal cells (PMC) be available for migration and differentiation over the
previously diseased root surface.
As such,
if a tooth presents with a Class II furcation
involvement, fusion of the roots apical to the
furcation involvement, and no bone vertically
between the furcation defect and the point of
root fusion, it is unreasonable to expect GTR
therapy to be successful. The paucity of available PMCs for use is an absolute contraindication to employing a GTR therapeutic approach.
Interproximal Bone Levels
The presence of interproximal bone at a level
coronal to that of the furcation entrance is of
paramount importance when considering GTR
therapy. Once again, the clinician must realistically assess the reservoir of available PMCs
for use, and the expected behavior of these
cells. GTR therapy must occur within strictly
proscribed temporal limits. A nonresorbable
membrane must be removed approximately six
weeks post-operatively due to the overlying tissue response. Resorbable membranes employed
during GTR therapy lose their structural integrity and effectiveness approximately six weeks
after insertion. It is unreasonable to believe that
appropriate cell migration will occur in the allotted
time to effect root surface repopulation if these
cells are a significant distance from the site to be
treated, and if the cells must be expected to perform aerial acrobatics to access the treated area.
Tooth Mobility
An effort must be made to determine whether the
Fugazzotto
Figure 1: A patient presents with a deep infrabony defect
between the maxillary cuspid and lateral incisor.
Figure 2: Following utilization of DFDBA and a covering
Guidor membrane, significant regeneration is noted eight
months post-operative. Probing depths are less than 3mm.
encountered mobility is increasing or increased.
Increasing mobility is a sign of an unstable situation and may be a result of primary or secondary
occlusal trauma. Such mobility must be appropriately addressed, whether it be through occlusal
equilibration, reconstructive therapy, splinting,
tooth extraction, or a combination of the above.
Increased mobility is not pathologic. Rather, such
mobility may be noted due to loss of periodontal support, or other factors. If no surgical intervention is anticipated and teeth demonstrate an
increased, but not an increasing, mobility, these
teeth need not undergo other types of therapy.
If GTR therapy is to be contemplated around
a tooth demonstrating increasing mobility, the
etiologic agents responsible for this increasing
mobility must be determined, and the problems
appropriately managed, prior to initiation of surgical intervention. When GTR therapy is planned
for a tooth which demonstrates increased mobility, the tooth should be splinted to adjacent teeth,
through either extra coronal or intra coronal means
depending upon the overall treatment plan, prior
to initiation of surgical treatment. There is no
doubt that periodontal regenerative therapy demonstrates a significantly higher degree of success
The Journal of Implant & Advanced Clinical Dentistry
• 37
Fugazzotto
when performed around stable teeth, as compared to their mobile counterparts. The endodontic, restorative, periodontal and occlusal state of
the tooth to be treated must also be considered.
In addition, the importance of the tooth to the overall treatment plan must be assessed presurgically.
As has been discussed in detail elsewhere,6
all surgical therapy must be grounded in comprehensive diagnosis and development of a
definitive interdisciplinary treatment plan. No
surgical intervention should be undertaken
unless these prerequisites have been met. The
steps involved in performing such diagnosis
and treatment planning have been well elucidated elsewhere and will not be discussed here.
As the understanding of the prerequisites
for performance of successful GTR therapy
have evolved, the diagnostic criteria employed
have likewise advanced.
These criteria are
grounded in the basic tenants of GTR therapy:
●T
horough debridement of the previously
diseased root surface.
● Exclusion of undesirable cell populations
from the root surface to be treated through
the use of an occlusive membrane.
● Provision of adequate space between the
occlusive membrane and the root surface to
allow ingress of the desired regenerative cells.
DEBRIDEMENT
The difficulties faced when attempting to debride
a periodontally involved furcation have been
well established. Attempts at “maintenance” of
involved furcations center around debridement of
a closed or surgical nature, or tunneling to provide
38 •
Vol. 3, No. 1
•
December/January 2011
access for professional and patient plaque control efforts. Such therapies are merely a means
by which to slow down progression of the disease process in periodontally involved furcations.
The literature underscores the inadequacy of
therapies aimed at “maintenance” of periodontal
health in periodontally involved furcations, without elimination of the aforementioned furcation
involvement. Becker et al.7 in a longitudinal study
of patients who refused active periodontal therapy but remained under continued maintenance
care, tooth loss for non furcated teeth of 7.2% in
the maxilla and 11.7% in the maxilla. Maxillary furcated teeth were lost at a rate of 11.6%. Mandibular furcated teeth were lost at a rate of 9.4%.
Goldman et al.8 assessed tooth loss in 211
patients treated in a private periodontal practice through root planing, curettage, and open
flap debridement, and maintained for fifteen
to thirty years on a consistent recall schedule.
Furcation involvements were not eliminated. The overall rate of tooth loss was 13.4%.
Maxillary and mandibular teeth with furcation involvements were lost at a rate of 30.7%
and 24.2% respectively, a significantly higher
incidence of loss than non-furcated teeth.
McFall9 reporting upon tooth loss in one
hundred treated patients with periodontal disease, maintained for fifteen years or longer
following active therapy, demonstrated loss
of maxillary and mandibular teeth with furcation involvements at rates of 22.3% and
14.7%, respectively.
Similar findings have
been consistently reported in the literature.10-12
A study by Fleisher et al.13 underscores the
difficulty in performing appropriate debridement of a periodontally involved furcation. Fifty
molars were treated through closed curet-
Fugazzotto
Figure 3: A patient presents with a severe infrabony defect
on the mesial aspect of the maxillary left central incisor,
and a Class II+ mobility of the tooth.
Figure 4: Following extra coronal splinting, placement of
DFDBA, and utilization of a covering Guidor membrane
sutured around the tooth being treated, marked bone
regeneration is noted six months after treatment. No
probing depths are present in excess of 3mm.
tage or open flap debridement.
The teeth
were extracted and stained to assess the efficacy of intrafurcal root debridement. 32% of
the tooth surfaces facing the involved furcations stained positive for plaque and/or calculus.
In order to maximize long-term prognosis,
the furcation must be eliminated, thus providing
the patient with a milieu amenable to appropriate plaque control efforts. Prior to contemplating
GTR therapy in a periodontally involved furcation, it is crucial that the root surfaces are thor-
oughly debrided. A challenge becomes effecting
such debridement in these areas. Following flap
reflection and defect debridement with curettes
and ultrasonic instruments, higher magnification is highly advantageous to ensure that the
root surfaces have been planed as thoroughly
as possible. A super fine diamond bur is then
utilized on all root surfaces against which regenerative therapy will be performed. When treating mandibular molars, a small diamond shaped
bur is utilized on the internal aspect of the mesial
The Journal of Implant & Advanced Clinical Dentistry
• 39
Fugazzotto
root, due to the fluted nature of this root. The
root surfaces are next treated with EDTA, to
remove bacterial remnants and effect decalcification of the outer aspect of the root surface.
The ability or inability to debride a given
root surface is an absolute indication or contraindication to the performance of GTR therapy in the area. When faced with a maxillary
molar which demonstrates a Class II buccal
furcation involvement which extends internally
between the other roots of the tooth in question to a degree of ii or iii, effective root debridement is not predictable, and GTR is not indicated.
When GTR therapy was first introduced as
clinical modality, it was touted as the ideal therapy to be performed when the clinician encountered a Class II furcation involvement or a two
or three wall infrabony defect. Diagnostic criteria were rapidly modified to state that maxillary and mandibular buccal Class II furcation
involvements could be more predictably treated
with GTR therapy than mesial or distal maxillary Class II furcation involvements. The reasons
cited for this fact were both the greater availability of surrounding periodontal ligament cells
when treating buccal furcation involvements
than their mesial and distal counterparts, and the
ability to more easily debride the region. However, such diagnostic criteria proved inadequate.
All Class II maxillary buccal furcation involvements are not equal with regard to predictability
following GTR therapy. As already mentioned,
if the furcation involvement in question extends
internally between the other two roots of the tooth,
appropriate debridement cannot be affected.
Therefore, all other components being equal, a
maxillary Class II i furcation involvement is more
amenable to GTR therapy than a maxillary Class
40 •
Vol. 3, No. 1
•
December/January 2011
II ii or a maxillary Class II iii furcation involvement.
Treatment of Class III maxillary and mandibular furcation involvements is highly predictable.
Regenerative therapy always fails in such areas.
INFRABONY DEFECTS
Defect Morphology
Infrabony defects may be classified as one wall,
two wall, three wall, or a combination of the
above as previously described in the literature.
This classification system is well established and
widely utilized. The greater the number of osseous walls surrounding the periodontal infrabony
defect to be treated, the more predictable regenerative therapy will be. This fact has been attributed to a number of considerations, including the
greater percentage of PMCs which surround the
defect and are available to contribute to healing; the ability to better place particulate graft
materials into a contained defect and have them
remain where desired to help effect clot stabilization and prevent clot shrinkage; and the role the
greater number of osseous walls plays in helping to prevent soft tissue collapse into the defect.
Debridement
The most daunting challenge a clinician faces
when treating deep infrabony defects is thorough
debridement of both the root surface and the
base of the defect. Such debridement is accomplished through the use of hand and ultrasonic
instrumentation, followed by utilization of a thin
super fine diamond to ensure debridement of the
most apical extent of the previously diseased root
surface, in the narrowest and otherwise inaccessible aspect of the infrabony defect. Once again,
the root is treated with EDTA to remove bacterial
remnants and effect decalcification of the outer
Fugazzotto
Figure 5: A significant osseous defect is present between
the maxillary right first molar and second bicuspid.
A Class I mesial furcation involvement is present on the
maxillary first molar.
Figure 6: Following elimination of the furcation through
odontoplasty, placement of DFDBA, and utilization of a
covering Guidor membrane sutured around the maxillary
right first molar, bone regeneration has been effected. The
area probes less than 3mm clinically.
aspect of the root surface. All other considerations which have been previously discussed,
including interproximal bone height, mobility,
etc apply when contemplating GTR therapy in
the treatment of periodontal infrabony defects.
lium.
Flap Design
Specific flap designs must be employed to help
attain soft tissue coverage of both the defect and
regenerative materials which have been placed.
Such flap closure must be tension free, so as
to maintain soft tissue coverage over the area.
Initial Incision
Either a subsulcular buccal incision is
employed which extends at least one tooth
mesial and distal of the tooth to be crown
lengthened. A 15 blade is angled in such
a manner as to remove the sulcular epithe-
The incision is carried to osseous crest.
Releasing Incisions
Mesial and distal releasing incisions are placed
in such a manner as to ensure that the most
mesial incision is placed on the distal aspect of
the interproximal papilla, and the most distal incision is placed on the mesial aspect of the interproximal papilla. The scalpel blade is angled so
as to create a beveled incision which will blend
into the body of the papilla. A common technical error is to place the most mesial releasing
incision on the mesial aspect of the papilla and/
or the most distal releasing incision on the distal aspect of the interproximal papilla. In such a
situation, the vertical releasing incision must be
beveled into thinner buccal radicular soft tissues,
rather than the thicker interproximal papilla. The
net result will be more post operative scarring
The Journal of Implant & Advanced Clinical Dentistry
• 41
Fugazzotto
and greater evidence of the incision upon healing.
Vertical releasing incisions must be of adequate
extension to allow repositioning of the buccal
mucoperiosteal flap at the desired level following
osseous resective therapy, as will be discussed.
The buccal flap is now reflected in a full thickness manner beyond both the mucogingival
junction and the level the defect to be treated.
Reflection of the most apical few millimeters of
the buccal mucoperiosteal flap is carried out in
a split thickness manner, utilizing a 15 blade.
Even if a distal wedge procedure is to be
performed, the aforementioned releasing incisions are placed on the mesial and distal
aspects of the buccal and palatal flaps. Such
an approach allows positioning of the buccal
flap independent of the final soft tissue position of the buccal distal wedge flap, as well as
providing greater access and visualization for
management of the disto buccal and disto palatal line angles of the terminal tooth in the arch.
The palatal flap is thinned, utilizing a tissue
forceps or a 1-2 pickup, to its most apical extent.
This “internal wedge” of tissue is scored at its
base with a 15 blade or Goldman-Fox 7 gingivectomy knife. The separated internal wedge of soft
tissue is removed. If concomitant mucogingival
therapy is required on the buccal aspects of the
teeth being treated, the internal distal wedge tissue will be employed as a connective tissue graft
beneath a buccal flap. The purpose of thinning
the palatal flap is to ensure an even thickness of
palatal tissues upon suturing. Such thinning of the
palatal flap helps ensure that a soft tissue “ledge”
will not be created on the palatal aspects of the
treated teeth. If a soft tissue “ledge” did result
following therapy, subsequent healing would lead
to a more coronal final position of the palatal soft
42 •
Vol. 3, No. 1
•
December/January 2011
tissue margin, a greater extent of palatal soft tissue repocketing, and a compromised outcome
to the crown lengthening surgery. Soft tissues
do not heal at sharp angles. Failure to manage
soft tissue morphologies during surgery has significant, undesirable post healing ramifications.
If flap mobility is not adequate to ensure passive primary closure over the membranes which
have been placed, the vertical release incisions
and flap reflection are extended until passivity
is attained. This coverage of the membrane by
soft tissues significantly enhances the final treatment outcome. Following defect debridement, if
the infrabony defect to be treated is not actively
bleeding, decortication of the defect walls should
be accomplished, utilizing a Piezo surgical tip
or a #2 round carbide bur. Such decortication
helps maximize the influx of blood and pluri potential mesenchymal cells into the area, and significantly contributes to the final therapeutic result.
Membrane Selection
An appropriate
onstrate
the
membrane
following
should demcharacteristics:
● Configurations which can be well adapted to
the defect to be treated.
● Ease of clinical manipulation.
● The ability to be trimmed and reshaped
without shredding.
● Sufficient body and memory to maintain the
established morphology during placement
and suturing.
● The ability to be easily sutured around the
tooth in question.
● The presence of a thicker occlusive portion which will be placed against the tooth,
coronal to the defect to be treated.
Fugazzotto
Figure 7: Flap reflection and defect debridement reveal a
severe two wall osseous defect on the distal aspect of the
mandibular left first molar.
Figure 8: The defect and diseased root surface have
been thoroughly debrided, DFDBA has been placed, and
a Guidor membrane has been trimmed appropriately and
sutured around the first molar. The mucoperiosteal flaps
will now be sutured in such a manner as to provide passive
soft tissue coverage of the regenerative materials which
have been placed.
● The ability to maintain structural integrity
for six to eight weeks, thus affording pluri
potential cells the time necessary to repopulate the previously diseased root surface.
● A predictable time table of loss of occlusive ability, and further degradation.
● A degradation process which does not
cause inflammation at the healing site.
A membrane composed of a blend of polylactic acid and citric acid ester, in a design of
multi perforated layers (Guidor) is currently
the only product available which fulfills all
of these requirements. The aforementioned
matrix design helps stabilize the wound site
and effects early integration with the gingival connective tissues.
The presence of
a thicker occlusal collar effectively prohibits epithelial downgrowth into the healing
site. The literature has conclusively demonstrated the ability to effect regeneration and
reattachment to a previously diseased root
surface through appropriate use of Guidor
membranes.14-19 In addition, the time of degradation and the chemical pathways found during degradation are well established and well
suited to the clinical problems to be treated.
A variety of membranes have been introduced which tout simplicity due to their “ease
of handling” and the fact that “no suturing of
the membrane around the tooth is necessary.”
While such claims abound, no evidence based
data is available to substantiate them. One of
the basic tenants of GTR therapy is utilization
of an occlusive membrane to ensure selected
repopulation of the previously diseased site.
Such cell occlusion can only be guaranteed
The Journal of Implant & Advanced Clinical Dentistry
• 43
Fugazzotto
through tight adaptation and suturing of the
occlusive membrane to the tooth surface. To
expect a membrane which has been placed
without suturing to remain exactly where the
clinician desires throughout the course of healing, and to thus perform the occlusal function
so vital to successful GTR results, is misguided
at best. The additional advantage offered by
the Guidor membrane is the fact that the suture,
made of similar material, is an integral part of the
membrane, greatly aiding the suturing process.
Odontoplasty in
Furcation Areas
Class I furcation involvements can always be
eliminated through odontoplasty. However, if
the Class I furcation involvement has a vertical
component which extends to such an extent
that positive osseous architecture may not be
developed, the problems in this region cannot be resolved through ondontoplasty. Such
developments are rare when treating Class I
furcation involvements. The roof of the furcation is recontoured to eliminate the cul-de-sac
which traps plaque, and the newly established
tooth contours are carried onto the radicular surfaces of the tooth to create a continuous, smooth morphology conducive to patient
plaque control efforts. Osseous resection with
apically positioned flaps is performed at the
same time, in the conventional manner. The
result of treatment is elimination of both deeper
pocket depths (defined as > 3mm) and Class I
furcation involvements. Coincident to odontoplasty is the elimination of any cemento enamel
projections which are encountered, enhancing the formation of an appropriate attachment
apparatus to protect the furcal entrance. Such
44 •
Vol. 3, No. 1
•
December/January 2011
odontoplasty is highly predictable and may be
carried out without a prosthetic commitment.
Unfortunately, Class II furcation involvements cannot be eliminated through odontoplasty, as such tooth recontouring would
result in a tooth morphology which was deeply
“notched” and not conducive to plaque control efforts. When treating a Class II furcation involvement, ondontoplasty is performed
to the horizontal depth which would be appropriate for elimination of a Class I horizontal furcation involvement.
The appropriate
Guidor membrane is then trimmed, positioned
and sutured over the area. Passive soft tissue coverage of the membrane is attained,
and the mucoperiosteal flaps are sutured.
Utilization of odontoplasty in conjunction
with GTR therapy significantly enhances treatment outcomes by lessening the horizontal
dimension of the furcation involvement, and
thus the distance which PMCs must travel from
the interradicular bone to the outer aspect of
the furcation involvement. Because GTR therapy has severe temporal restrictions of six to
eight weeks, with regard to either removal of
a nonresorbable membrane or degradation on
a resorbable membrane, reduction of the horizontal component of the furcation by 50% or
more positively affects treatment outcomes.
Particulate Graft
Materials
The size and morphology of the defect which is
being treated will help determine whether or not
particulate graft materials are placed beneath
the membrane prior to membrane suturing.
Prior to the advent of predictable implant reconstructive therapy, GTR therapy was performed
Fugazzotto
around teeth which exhibited large one and two
walled defects, resulting in a lower predictability of therapy than desired. In these situations,
significant amounts of particulate graft material
were placed beneath the membrane, to help
stabilize the forming blood clot, and to add support to the membrane. Such treatment is no longer warranted. When faced with such a severely
compromised tooth, extraction and concomitant
regenerative therapy, in anticipation of eventual implant placement and restoration, is indicated. Nevertheless, particulate graft materials
are still placed in situations where combination
osseous defects are encountered, which demonstrate one or two wall bony components. The
purposes of these graft materials are to better
stabilize the initial blood clot and thus enhance
healing, and to help ensure that adequate
space remains beneath the covering membrane
for ingress of the desired regenerative cells.
Definitions of Success
The goal of GTR therapy in furcation areas
is the elimination of furcation involvements.
As such, successful GTR therapy results in
no horizontal probing depths into the furcation. “Resolution” of a furcation defect to
such an extent that a residual horizontal probing of 2-3mm remains, is unsuccessful therapy. Such a residual furcation involvement will
continue to break down periodontally. Should
this treatment result be encountered, second
stage ondontoplasty must be carried out to
eliminate the residual furcation involvement.
Vertical probing depths in access of 3mm
at the entrance to a furcation previously
treated with GTR therapy are also unacceptable. The literature has established the fact
that deeper probing depths beyond 3-4mm
are more difficult to maintain, and more
prone to subsequent periodontal breakdown.
Successful periodontal therapy, whether
it be resective or regenerative in nature,
or a combination of both, yields a post
therapeutic result of no horizontal furcation involvement and no probing depths
in excess of 3mm, assuming patient compliance both with the selected course of
therapy and post operative plaque control.
Conclusions
Guided tissue regeneration therapy is highly
predictable, assuming appropriate diagnosis and rigorous case selection are carried
out. While many teeth which were previously
treated through GTR therapy in an attempt at
maintenance are now extracted and replaced
with implant supported prosthetics, GTR
therapy should still play a significant role
as a component of the conscientious clinician’s therapeutic armamentarium.
Failure
to utilize this treatment modality will result
in the loss of teeth which otherwise could
be saved in a highly predictable, and less
financially taxing, manner for the patient. ●
Correspondence:
Dr. Paul A. Fugazzotto
25 High Street
Milton, MA 02186
United States of America
617-696-7257
progressiveperio@aol.com
The Journal of Implant & Advanced Clinical Dentistry
• 45
Fugazzotto
Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
The Journal of Implant & Advanced Clinical Dentistry
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References
1. N
yman S, Gottlow J, Karring T, et al: The regenerative potential of the
periodontal ligament. An experimental study in the monkey. J Clin Periodontol
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ottlow J, Nyman S, Karring T, et al: New attachment formation as the result of
controlled tissue regeneration. J Clin Periodontol 1984; 11:494-503.
3. N
yman S, Lindhe J, Karring T, et al: New attachment following surgical
treatment of human periodontal disease. J Clin Periodontol 1982; 9:290-296.
4. G
ottlow J, Nyman S, Lindhe J, et al: New attachment formation in the human
periodontium by guided tissue regeneration. Case reports. J Clin Periodontol
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5. F
ugazzotto P.A. A comparison of the success of root resected molars and
molar position implants in function in a private practice: Results up to 15-plus
years. J Periodont 2001; 72:1113-1123
ugazzotto PA. Implant and Regenerative Therapy in Dentistry: A Guide to
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Decision Making. Iowa: Wiley-Blackwell, 2009.
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ecker W, Becker BE, Berg L, et al: New attachment after treatment with root
isolation procedures. Report for treated Class III and Class II furcations and
vertical osseous defects. Int J Periodontics Restorative Dent 1998; 8:8-23.
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maintained for 15 years or longer. A retrospective study. J Periodontol 1986;
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cFall WT: Tooth loss in 100 treated patients with periodontal disease – a
long-term study. J Periodontol 1982; 53: 539-549.
10. Wood WR, Greco GW, McFall WT Jr: Tooth loss in patients with moderate
periodontitis after treatment and long-term maintenance. J Periodontol 1989;
516-520.
11. Hirschfeld L, Wasserman B: A long-term study of tooth loss in 600 treated
periodontal patients. J Periodontol 1978; 49: 225-237.
12. Wang HL, Burgett FG, Shyr Y, et al: The influence of molar furcation
involvement and mobility of future clinical periodontal attachment loss. J
Periodontol 1994; 65: 25-29.
13. Fleicher HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD. Scaling and root
planning efficacy in multi-rooted teeth. J Periodontol 1989:60: 402-409.
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14. Falk H, laurel L, Ravald N, Teiwik A, Persson R. Guided tissue regeneration
of 203 consecutively treated intrabony defects using a bioabsorbable matrix
barrier: Clinical and radiographic findings. J Periodontol 1997; 68: 571-581.
15. Hugoson A, Ravald N, Fornell J, Johard G, Teiwik A, Gottlow J. Treatment
of class II furcation involvements in humans with bioresorbable and
nonresorbable guided tissue regeneration barriers. A randomized multi-center
study. J Periodontol 1995; 66: 624-634.
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barrier for guided tissue regeneration. J Swed Dent Assoc 1994; 86: 741756.
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ottlow J, Laurell L, Teiwik A, Genon P. Guided tissue regeneration using a
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18. Gottlow J, Laurell L, Lundgren D, MAthisen T, Nyman S, Rylander H,
Bogentoft C. Periodontal tissue response to a new bioresorbable guided
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1993; 64: 1157-1165.
Mesa et al
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S i m p l e
Outcomes of Implant Treatment in Patients
with Aggressive Periodontitis and Multiple
Maxillary External Root Resorption: Review
and Five Year Follow-up
Mesa et al
Francisco Mesa1 • Pablo Galindo-Moreno2 • Ricardo Muñoz1
Luis A. Perez3 • Hom-Lay Wang4
Abstract
Background: Generalized external root resorption (ERR), only the upper jaw, on permanent
teeth is a rare finding. The treatment of multiple ERR depends on the symptoms, extent,
and severity of the root resorption. Implant
placement in patients with a history of multiple ERR has not been previously documented, and its predictability remains unknown.
Results: We present two cases of multiple ERR in the maxilla with aggressive periodontitis that were successfully treated with
five implants (from
three different commercial systems) placed in sites of previous
external root resorption, showing a 100% successful outcome at 5 years. The role of periodontal disease in multiple ERR was also reviewed.
Conclusions: Our cases are the first in all the
literature indicating that implant therapy may be
a useful approach in patients with this disease.
Nevertheless, well-controlled prospective longitudinal studies are required to establish the
effects of resorption on implant osseointegration.
KEY WORDS: Dental implants, root resorption, aggressive periodontitis
1. Department of Periodontics, School of Dentistry, University of Granada, Spain
2. Department of Oral Surgery, School of Dentistry, University of Granada, Spain
3. Private Practice, Periodontics and Dental Implants, Flint, Michigan, USA
4. Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA
The Journal of Implant & Advanced Clinical Dentistry
• 49
Mesa et al
Figure 1A: Severe ERR of upper right 2nd molar and 2nd
premolar.
INTRODUCTION
Root resorption (RR) can occur internally at the
pulp chamber and/or root canal or externally at
the cervical or apical portion of the root surface.1
Injury and stimulation have been related to play
a role on its occurrence.2,3 Multiple RR on permanent teeth is a rare event.4 External RR (ERR)
is a remodeling process with multiple different etiologies. One of the most common etiologies is damage to or pressure of the periodontal
ligament (PDL), which may induce a chemotactic
effect on cytokines. This in turn stimulates the
reaction of inflammatory-related multinucleated
cells such as osteoclasts and odontoclasts. An
increase in the activity of these cells may lead
to resorption of cementum and dentin.1 The
tooth structure occasionally becomes part of
the osseous system that is undergoing remodeling, causing ankylosis of the root.1,5 Various factors can trigger this response,1,6,7,8.9 categorized
as physiologic, systemic, local or idiopathic.
50 •
Vol. 3, No. 1
•
December/January 2011
Figure 1B: Generalized moderate-to-severe bone loss and
ERR on all maxillary teeth except for the upper left 2nd molar.
Bakland’s etiologic classification for root
resorption4 is one of the most frequently cited.
Etiologies associated with RR include infection,
trauma, avulsion, luxation, orthodontic tooth movement, excessive occlusal forces, and a variety of
systemic conditions such as hyperparathyroidism,
Paget’s disease, and Papillon Lefevre syndrome.
Periodontitis may expose root cementum to the
periodontal pocket and inflamed PDL, which could
produce transient cementum resorption.4,10,11
Crespo et al. and Rodriguez-Pato showed apical
cementum resorption in periodontal disease that
involved teeth with no history of orthodontic movement or external trauma.11,12 However, it remains
controversial whether inflammation per se is an
etiologic factor for multiple ERR at the apical level.
The presence of multiple ERR has been
reported by several authors.13-16, 39-54 Multiple
ERR in permanent teeth without periodontal
involvement was first described by Balanger &
Coke.13 Since then, only a few isolated case
Mesa et al
Figure 1C: Panoramic radiograph at 2 year follow-up.
Figure 1D: Panoramic radiograph at 5 year follow-up.
reports have been published,14-20 including
patients with multiple resorption in combination with periodontitis. With this background,
the purpose of this study was to examine the
etiologic factors that may contribute to ERR
and determine the correct periodontal management of these conditions, reporting the treatment
of two ERR patients, including the placement
of dental implants, and the outcome at 5 years.
history of orthodontic treatment, occlusal interferences, or facial trauma. Radiographic examination revealed generalized moderate-to-severe
bone loss and generalized ERR on all maxillary
teeth except for the upper left 2nd molar (Figs.
1A, 1B). Hematological and biochemical findings were in normal ranges, and there was no
medical or family history of interest. The patient
was diagnosed with generalized aggressive periodontitis23 in combination with multiple ERR.
The upper right 2nd molar, upper right and
left central incisors, and lower left central incisor were extracted. The hygienic phase consisted of behavioral modification (smoking
cessation counseling and OH instructions) and
full-mouth scaling and root planing. The surgical phase involved osseous surgery on the mandibular quadrants. After a three-month interval,
dental implants were placed on upper right 1st
molar, upper right central incisor, upper left central incisor, and lower left central incisor. The
CASE REPORTS
CASE A
A 37 year-old Caucasian male was referred for
evaluation. He was a smoker of 40 cigarettes per
day with the following: poor oral hygiene (OH),
presence of supra- and sub-gingival calculus,
generalized (100%) gingival bleeding on probing
(BOP),21 grade 3 mobility22 and suppuration of
upper right 2nd molar, upper right and left central
incisors, and lower left central incisor, with probing depths ranging from 4 to 7mm. He had no
The Journal of Implant & Advanced Clinical Dentistry
• 51
Mesa et al
patient has quit smoking and is undergoing a
3x/yr supportive periodontal treatment regimen.
Panoramic radiography at 2 and 5 year follow-up visits (Figs. 1C, 1D) revealed no progression of the resorptions but showed minimal
attachment levels for upper right 1st premolar, upper right lateral incisor, and upper left
canine.
There were no signs/symptoms of
active periodontal disease (pain, BOP, mobility
and increasing attachment loss) or progression
of root resorptions during the 5 year follow-up
period. However, grade 1 mobility22 of the upper
right lateral incisor was detected at 5 years.
CASE B
A 36-yr-old Caucasian male presented with avulsion of the upper right central incisor after minor
facial trauma (Fig. 2A). He was a smoker of 20
cigarettes per day with the following: poor OH;
presence of generalized supra- and sub-gingival
calculus; BOP (100%) 21; grade 0 mobility22
and localized suppuration in lower left canine,
lower left lateral incisor, lower right canine, and
lower right 1st and 2nd premolars, with probing pocket depths ranging from 3 to 5mm. He
had no history of orthodontic treatment or
occlusal interferences. Several faulty restorations were observed. Radiographic evaluation
revealed generalized mild-to-moderate bone loss
and severe ERR in all maxillary teeth except for
the upper right 2nd molar. There was no medical or family history of interest. The patient was
diagnosed with avulsion of upper right central incisor and generalized aggressive periodontitis23 in combination with multiple ERR.
Clinical evaluation of the avulsed tooth (upper
right central incisor) showed complete resorption
of the root (Fig. 2A). An immediate implant was
52 •
Vol. 3, No. 1
•
December/January 2011
Figure 2A: Severe ERR with avulsion of upper right central
incisor.
placed at the initial appointment, using the avulsed
crown as a temporary restoration (Fig. 2B) until
restoration with a metal-porcelain crown at 3
months. The hygienic phase consisted of behavioral modification (smoking cessation counseling
and oral hygiene instruction) and full mouth scaling and root planing. To manage his periodontal
condition, the patient quit smoking, his faulty restorations were replaced, and he is undergoing a
3x/year supportive periodontal treatment regimen.
At the 5 year follow-up, a panoramic
radiograph revealed no progression of the
resorptions, with implant osseointegration
and no residual bone loss (Fig. 2C). Probing depths were reduced to ≤ 3mm, except
for a depth of 5mm at the upper left 2nd premolar, and there were no signs or symptoms of active periodontal disease (i.e., pain,
BOP, mobility, or increased attachment loss).
Mesa et al
Figure2B: Immediate implant. The avulsed crown was used
as a temporary restoration.
DISCUSSION
The literature was reviewed by searching the
Web of Knowledge, PubMed, and Scopus databases, using “root resorption” and “multiple”
or “permanent teeth” as key words, with postorthodontic root resorption as the only exclusion
criterion. Although ERR associated with orthodontic pressure due to biological and mechanical factors is frequently observed in isolated
teeth,24 it is uncommon in a generalized form,4
especially in non-orthodontic cases. Therefore,
we had to rule out various local and systemic factors before inflammation could be established
as the main cause in our cases of multiple RR.
Both of our patients presented with generalized aggressive periodontitis,23 showing inflammation of the periodontium. This is a common
cause of multiple external root resorption, which is
induced by localized inflammatory reaction. Several pathogenic mechanisms have been proposed
for the induction of root resorption by periodontal inflammation.25-27 Thus, an acidic environment
Figure2C: Panoramic radiograph at 5 year follow-up.
produced by a decrease in the pH value may
enhance osteoclastic activity, and hydroxyapatite
becomes more soluble when pH reaches 3 and
4.5,25 favoring resorption. Numerous systemic
factors such as parathormone (PTH), 1, 25-dihydroxyvitamin D3 (Vitamin D), and calcitonin, have
also been found to regulate osteoclastic activity. Cytokines, such as interleukins (specifically
IL-1, IL-6, and IL-11), prostaglandin E2, and tumor
necrosis factor (TNF)-α are local factors that have
been shown to stimulate osteoclastic activity by
affecting the balance of RANKL (Receptor Activator for Nuclear Factor κ B Ligand) and osteoprotegerin.27 All of these factors are influenced
by the inflammatory cells present in periodontitis
(macrophages, neutrophils, and lymphocytes).
Odontoclasts
have
been
related
to
deciduous tooth and internal root resorptions, while cementoclasts have been associated
with
external
tooth
resorption.28
In published reports of ERR in periodontally
involved teeth with no history of orthodontic treat-
The Journal of Implant & Advanced Clinical Dentistry
• 53
Mesa et al
ment and/or trauma, the resorption ranged from
41% to 98% and increased proportionally with
the severity of periodontitis.11,12,29 The apical third
was the predominant site for resorption, involving
cementum and dentin. It has been hypothesized
that the cellular cementum on the apical third
may be more easily resorbed due to its organic
components and less mineralized structure.30
More recently, peripheral sensory neural
systems have also been associated with the
development of acute and chronic inflammatory processes through the local release of neuropeptides.31 In vitro and in vivo studies showed
that the neuropeptide substance P (SP) stimulates the production of cytokines such as IL-1β,
IL-6, and TNF-α in human dental pulp fibroblasts.31,32 This may play an important role in root
resorption in the presence of orthodontic movement. In addition, the loss of PDL fibers diminishes the capacity of the tooth to sustain vertical
and lateral occlusal loads, potentially triggering
PDL inflammation and tooth mobility. It is well
documented that moderate-to-severe attachment loss may produce pathologic tooth migration,33 which may also be responsible for the root
resorption noted in the setting of periodontitis.
The radiography studies in the present
patients revealed apico-coronal resorption with
progressive shortening of the root length, affecting all maxillary teeth to some degree. Once
the periodontal disease was treated and controlled, RR was no longer observed, supporting our diagnoses of inflammatory-related ERR.
To our best knowledge, asymmetric ERR
involving only maxillary teeth has not been previously reported. Multiple ERR may be more
common in the maxilla because of its greater
blood supply and lesser bone density in com-
54 •
Vol. 3, No. 1
•
December/January 2011
parison to the mandible, which may facilitate
the rapid spread of the inflammatory process.
Smoking can also have a local effect on the
periodontium; it weakens the immune response
and reduces the gingival blood flow, number of circulating cells, and oxygen levels,
thereby affecting the attachment, proliferation, and chemotaxis of periodontal cells.34-36
The treatment of multiple ERR depends on
the symptoms, extent, and severity of the root
resorption. Implant placement in patients with
a history of multiple ERR has not been previously documented, and its predictability remains
unknown.37, 38 The present report shows that a
stable outcome can be achieved at 5 yrs after
implantation in sites of tooth loss due to ERR.
CONCLUSIONS
Five implants (from 3 three different commercial systems) placed in sites of previous ERR
show a 100% successful outcome at 5 yrs,
indicating that implant therapy may be a useful
approach in patients with this disease. Nevertheless, well-controlled prospective longitudinal
studies are required to establish the effects of
resorption on implant osseointegration. ●
Correspondence:
Dr. Francisco Mesa
Facultad de Odontología. Univ. De Granada
Campus de Cartuja S/N 18071, Granada,
Spain
Tel +34 958240654
Fax +34 958240908
E-mail: fmesa@ugr.es
Mesa et al
Disclosure
The authors do not have any financial interests,
either directly or indirectly, in the products listed in
the study.
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52. Iwamatsu-Kobayashi Y, Satoh-Kuriwada S,
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The Journal of Implant & Advanced Clinical Dentistry
• 55
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Guided Bone Regeneration Using a Rapidly
Formed Absorbable Polymer Barrier:
A Case Series Report
Rosen et al
Paul S. Rosen, DMD, MS1 • Mark A. Reynolds, DDS, PhD2
Abstract
Background: Guided bone regeneration (GBR)
using a nonabsorbable barrier has provided
clinicians with the ability to place implants in
sites that are compromised by insufficient bone
including those where teeth have been immediately extracted. GBR efforts originally involved
a barrier of expanded polytetrafluoroethylene
(ePTFE) used alone or in conjunction with a
bone replacement graft. Today, resorbable barriers have gained much favor with this treatment.
Methods: This report presents a case series
of 17 patients with 32 osseous defects who
were consecutively treated with guided bone
regeneration (GBR). An absorbable polymer
barrier of poly(DL-lactide) was used in conjunction with a composite graft of freeze-dried bone
allograft (FDBA)/ demineralized freeze-dried bone
allograft (DFDBA) mixed in a ratio of 1:1. Two
techniques of barrier formation were assessed;
one where the barrier is formed in situ and the
other where the barrier is rapidly formed at chairside prior to its placement. Second stage surgeries were performed at 6 months (range 3.5
to 8.5 months) post-placement. Biopsy material from 7 sites was obtained while exposing
the implant for healing abutment connection.
Results: An overall success rate of 93.8% was
achieved. Histologic evaluations revealed the
formation of viable bone, frequently in close
amalgamation with residual graft particles.
Conclusion: These results suggest that a
poly(DL-lactide) polymer can be used as a
physical barrier with a composite bone replacement graft to achieve successful GBR results.
The compilation of case information is ongoing to determine whether similar results will
be found in a larger number of patients.
KEY WORDS: Bone graft, dental implants, barriers, guided bone regeneration, GBR
1. Clinical Associate Professor, Department of Periodontics, Baltimore College of Dental Surgery University of Maryland,
Baltimore, MD
2. Professor, Chairman and Postgraduate Director, Department of Periodontics, Baltimore College of Dental Surgery,
University of Maryland, Baltimore, MD
The Journal of Implant & Advanced Clinical Dentistry
• 59
Rosen et al
Introduction
Guided Bone Regeneration (GBR) has
expanded the placement of dental implants to
sites that were not a part of the original implant
protocol.
GBR has expanded the predictable treatment options for clinicians to meet
patients’ aesthetic and masticatory needs.
The principles of GBR date back close to
50 years.2-4 Early experimental studies5-8, clinical studies9-15 and case reports16-42 demonstrated successful outcomes for GBR at a wide
variety of osseous defects thereby facilitating
implant placements. The original GBR reports
discussed the successful use of expanded
po|ytetrafluroethylene (e-PTFE) (GoreTex®, W.L.
Gore), a non-absorbable barrier, either alone915,18-20,23,26,29,34,37-40
or in combination with a bone
replacement graft21,22,24,25,27,30-33,37,41 Subsequent
evidence suggests that an absorbable barrier of
polylactic acid/polyglycolic acid (PLA/PGA) used
over autogenous bone can be as effective as the
same treatment with e-PTFE, the gold standard,
for dehiscence/fenestrations around implants.43
An absorbable barrier has been developed
where a polymer of poly(DL-lactide) is dissolved
in a carrier of N-methyl-2-pyrrolidone (NMP)
(ATRISORB®, Tolmar Inc., Fort Collins, Colorado), which upon contact with water or other
aqueous solution, forms a barrier of firm consistency. Originally, a partially set barrier was
formed at chairside that could be trimmed to the
dimensions of a periodontal defect.44,45 Once
placed, the polymer completely solidified in
situ forming an absorbable barrier for GTR.46
A regenerative technique for periodontal
defects has been described where this poly(DLlactide) polymer was flowed in situ to form a
custom fitting barrier directly over composite
60 •
Vol. 3, No. 1
•
December/January 2011
Figure 1A: Placement of a 4 mm wide implant into
maxillary right canine area leaves a dehiscence defect in
the coronal 1/3 of the implant due to optimal prosthetic
positioning.
bone replacement graft, resulting in successful
clinical outcomes.47,48 Since the polymer does
not significantly degrade until 5-6 months,46
the same benefits of clot stability, space maintenance, and tissue exclusion might also be
gained in GBR procedures with implants.
The purpose of this case series report is
to present consecutive clinical experiences
with a poly(DL-lactide) polymer (ATRISORB®)
used either in an in situ technique or an extraoral (rapid polymerization) technique with a
composite bone replacement graft for GBR
around implants. Implant sites requiring ostectomy for exposure of the fixture permitted histologic evaluation of the new bone formation.
Materials & Methods
Seventeen consecutively treated patients (12
male and 5 female) with an average age of 51.4
(range 32-81) years had a total of 32 acid-etched
implant fixtures (Osseotite®, Biomet/3i, Palm
Rosen et al
Figure 1B: Composite osseous graft of DFDBA/FDBA in a
ratio of 1:1 is placed over the implant.
Figure 1C: A rapidly formed barrier has been made at
chairside and is placed over the composite graft, implant
and defect.
Figure 1D: Re-entry at 4.5 months shows the barrier is still
present.
Figure 1E: Dense connective tissue and hard bone tissue
revealed after removal of the barrier.
Beach Gardens, FL) (Restore®, Noble Biocare,
Yorba Linda, CA) inserted in combination with a
GBR procedure. The implant surgeries were conducted utilizing standard protocols of the respective implant systems, notwithstanding the GBR
procedure. All implant placements were done in
the absence of pre-tapping the site. Photographs
were taken throughout the implant and GBR procedures and clinical measurements were made
of the osseous defects treated. All measurements were done from the most coronal aspect
of the implant collar to the base of the defect.
With the exception of one 3-wall lesion which
required no graft, all defects received a com-
The Journal of Implant & Advanced Clinical Dentistry
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Rosen et al
Figure 2A: Teeth 5 and 6 were extracted in this 59-year
old female due to vertical root fracture with immediate
implant placements. The implant at site 6 is 5 mm wide
and has a narrow 3-wall defect at its palatal aspect and a
combined dehiscence-3 wall defect at its facial aspect.
Figure 2B: DFDBA/FDBA composite osseous graft is placed
at both implants.
Figure 2C: The poly(DL-lactide) polymer barrier has been
applied using an in situ technique. Sterile water from
the handpiece has initiated its formation which can be
detected by opacification of the surface.
Figure 2C: Stage II surgery at 5.5 months reveals hard
tissue formation.
posite graft of demineralized freeze-dried bone
allograft (DFDBA) (particle size 250-710 micrometers) mixed with freeze-dried bone allograft
(FDBA) (particle size 250-710 micrometers) in
a 1:1 ratio. Both graft materials were obtained
from a tissue bank that has demonstrated inductivity for its DFDBA material (LifeNet Health, Virginia Beach, VA).49.50 The graft was re-hydrated
62 •
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Rosen et al
Figure 2E: Removal of the newly formed bone was
necessary for abutment connection.
Figure 2F: Photomicrograph at 10X power reveals
amalgamation of new bone with residual graft particles.
with sterile saline prior to its placement around
the implants and the defect was filled incrementally using light pressure. An in situ (FreeFlow™)
method of barrier placement was used for the first
14 implants. The polymer was expressed from
the dose pack through an 18 gauge, 1-inch long
cannula. The barrier was formed by applying sterile saline from the implant handpiece and its formation was determined by surface opacification
being visible. Any portion of the composite graft
not covered with the initial application received
additional polymer to fill any voids or gaps. The
next 17 implant sites received a rapidly formed
chairside application of the barrier. Five-ten drops
of polymer were placed from the dose pack into
a sterile glass dappen dish. Sterile saline was
added in a ratio of two drops for every five drops
of polymer. A 7A wax spatula (Hu-Friedy, Chicago, IL) introduced the saline throughout the
polymer and rapid mixing was performed for 8-10
seconds in order to drive of the NMP. Care was
taken to press the forming barrier against the
sides of the dampen dish to begin barrier formation. Corn suture pliers (Hu-Friedy, Chicago, IL)
were used to remove the polymer barrier from
the dappen dish to trim it to an appropriate size
with suture scissors. If necessary, the barrier was
handled with gloves to facilitate trimming. The barrier was then placed at the graft site with 2-3mm
overlapping the adjacent osseous structure. If
additional barrier was needed, the same process
was repeated with the new piece overlapping the
prior barrier with the two coalescing together.
The endpoint of flap management was passive primary closure, which was achieved by using
releasing incisions that extended well beyond the
mucogingival junction and into the buccal turn
of the vestibule. Partial thickness dissection in
the apical portion of the facial flaps allowed the
flaps to be passively drawn together. A mono-
The Journal of Implant & Advanced Clinical Dentistry
• 63
Rosen et al
filament suture was used of either an absorbable, Monocryl (Ethicon, Sommerville, NJ), or a
non-absorbable material, e-PTEE (W.L. Gore &
Associates, Flagstaff, AZ), for flap adaptation.
The antibiotic regimen was 2g of amoxicillin
at the time of implant surgery followed by 500mg
3 times per day for 10 days. The regimen was followed by doxycycline 100mg taking 2 capsules
on the first day and then 1 capsule per day for
13 days. Two patients were allergic to amoxicillin and were placed on the doxycycline regimen
64 •
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•
December/January 2011
for a total of 21 days. Patients were instructed
to use a 0.12% chlorhexidine rinse 2 times per
day for the first 30 days or during the entire
healing period if the barrier became exposed.
Flaps were reflected at the second stage surgery to place healing abutments at which time
the success or failure of the GBR procedure
was assessed. Clinical photographs were used
to determine results of treatment. Complete success, partial success, and failure were based on
the definitions offered by Mellonig & Triplett.30
Rosen et al
Complete success was defined as coverage of
all threads or exposed implant surfaces with bone
or with bone and dense, firm connective tissue.
Partial success was deemed as incomplete
coverage of most threads or exposed implant
surfaces with a maximum of two threads or
2mm of implant surface left uncovered by bone
or by bone and dense, firm connective tissue.
Failure was defined as no coverage by bone
or by bone and dense, firm connective tissue
beyond two threads or 2mm of implant surface.
Results
The osseous defects treated included 19 dehiscence/fenestration defects, 10 extraction sites
and 3 thin buccal alveolar housings. Representative clinical cases and outcomes are illustrated in Figures 1-3. Second stage surgeries
and evaluations were performed between 3.5
and 8.5 months (6.0 months average). Table l
summarizes the outcomes of the GBR procedure by defect type. Extraction sites and thin
buccal alveolar housings responded favorably
The Journal of Implant & Advanced Clinical Dentistry
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Rosen et al
to both techniques with complete success at
100% and 90%, respectively. Dehiscence/fenestration defects had a complete success rate
of 78.9% with an overall success rate of 94.7%.
Table ll summarizes outcomes by technique. Both the in situ and rapidly formed
chairside techniques had an overall success rate of 93.8%. The in situ method
had a 73.3% complete success rate which
appeared related to its reduced performance
for dehiscence/fenestration defects (Table lll).
66 • Vol. 3, No. 1 •
December/January 2011
A summary of the outcome data for each
technique, categorizing by defect type (Tables
lll & lV), suggests that both methods were
effective for extraction sites and thin buccal bone. The in situ method (Table lll) was
not as successful at treating dehiscence/
fenestration defects with complete and partial success totaling only 88.9%. The rapidly
formed chairside method, however, was successful in achieving a positive regenerative
result for all three types of defects except for
Rosen et al
one extraction site where the barrier became
prematurely exposed, leading to 4 threads
exposed at the second stage surgery (Table lV).
Premature loss of the barrier occurred at
three implant sites approximately 4 weeks following clinical exposure. One of these sites
resulted in a regenerative failure, as discussed
previously, though the implant was integrated.
Premature loss of the barrier at 2 implant sites
was observed 3 weeks post-placement secondary to physical forces during mastication.
Fragmentation of the barrier resulted in its premature loss. The barriers were otherwise well
tolerated by the tissue with no sites demonstrating untoward granulation reactions or infection.
The histologic evaluation of biopsy specimens revealed the presence of viable bone and
residual grab particles. Islands of viable bone
were frequently observed in close amalgamation
with graft particles. Notably absent in all specimens was evidence of an inflammatory reaction.
The Journal of Implant & Advanced Clinical Dentistry
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Rosen et al
Discussion
The clinical outcomes of this case series are
consistent with the results of studies9,13,43 and
case reports21,22,26,33 describing the application of nonabsorbable and absorbable barriers
in GBR therapy. Nevertheless, comparisons
across studies remain difficult because of
differences in the variety of bone defects
treated, temporal sequencing of implant and
GBR surgeries and surgical outcome measures. Given the concern for the preservation of aesthetics, the Mellonig & Triplett30
outcome criteria was chosen to evaluate the
GBR results. Removal of any dense connective tissue present might have compromised any newly regenerated bone, which
could have impacted on the soft tissue height.
GBR therapy using the in situ and rapidly
formed chairside techniques for barrier formation was highly effective for extraction sites
and thin buccal bone defects. In contrast, the
in situ method demonstrated a lowered overall
success rate of 88.9% for dehiscence/fenestration defects with complete success at only
55.6% in these cases to date. The reason for
the lower success rate may be related to sample size and/or the inability to control the flow
of the polymer over large areas, especially in
the posterior maxilla. Unseen voids and gaps in
the in situ formed barrier could permit epithelial and/or connective tissue down-growth and
loss of graft material, thereby diminishing the
regenerative outcome. Barrier formation using
the rapidly formed chairside technique reduces
the likelihood of developing gaps or voids.
A bone replacement graft was used in combination with the polymer barrier, in part, to
avoid barrier deformation prior to its final for-
68 •
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•
December/January 2011
mation. Consistent with this possibility, an
absorbable barrier of PLA/PGA was previously associated with reduced regenerative
outcomes, compared to e-PTFE due to collapse of the barrier.51 In these case reports
the GBR procedure incorporated a composite graft of DFDBA/FDBA in a 1:1 ratio, which
previously has been shown to support successful regenerative outcomes.21 The concept
of mixing these two graft materials capitalizes
on combining the potential osteoinductive/
osteoconductive capabilities of DFDBA49,50
with the osteocondudive and spacemaking advantages of FDBA.21 Allograft materials
used in this case series were obtained from
the same tissue bank, which routinely verifies
the osteoconductive potential of its processed
DFDBA in the athymic mouse model.49,50
Histologic evaluation of the new bone
formation was possible at 7 sites, where
ostectomy had been required to expose the
implant for placement of the healing abutment. In all histologic specimens, viable bone
was observed in the absence of an inflammatory infiltrate. New bone formation was frequently in close amalgamation with residual
graft particles. These histologic findings are
consistent with previous reports following the
use of DFDBA in regenerative therapy.52,53
There are a number of advantages to a liquid
polymer barrier. Previous reports demonstrated
the clinical benefits of the poly(DL-lactide) barrier, which can be formed in a chairside kit44,45
or in situ47,48 for GTR procedures. This case
series documents and confirms the successful
application of the poly(DL-lactide) barrier with
bone replacement grafts in GBR procedures
involving dental implants.55 This dual capacity
Rosen et al
for GBR and GTR use simplifies the clinician’s
inventory of barriers since the material can be
flowed or trimmed to a variety of clinical situations. The barrier can be rapidly formed (8-10
second) avoiding the cumbersome 4-5 minute
wait that was part of the original chairside kit
instructions. The in situ method may further prevent bacterial contamination of the barrier since
it is not handled which may add to its intrinsic
antimicrobial property.54 The polymer system
permits repairs or modification of the barrier if
it is inaccurately cut or trimmed since additional
material can be added to the existing barrier
with the two coalescing. The barrier’s final consistency is hard and rigid adding to its space
maintenance capabilities.
It takes approximately 5-6 months for significant degradation of
the barrier to begin and since it is completely
absorbed by twelve months, there is less concern that remaining barrier could affect the site.
There are also some limitations to this barrier. The final consistency of the material is
hard and firm making it susceptible to fracture
and premature loss in the presence of untoward occlusal forces. Although this occurred
in one patient at two implant sites, the clinical
outcome was still favorable. In the presence
of large defects, premature loss of the barrier
might substantially compromise the regenerative outcome. A second concern is that exposure of the poly(DL-lactide) barrier may also
lead to premature loss. Early exposure of the
barrier occurred at two patients’ implant sites
at 7 days after placement. While the barrier
remained intact at both for approximately 4-5
weeks, one of the sites had a failed regenerative
outcome. Exposure of nonabsorbable barriers,
which remain intact, permit bacterial coloniza-
tion and potentially affect the final regenerative
outcome.56 The regenerative consequences of
barrier exposure and loss are related to the maturational stage of the wound healing process.
The results of this consecutive case series
suggest that a poly9DL-lactide) polymer can
be used as a physical barrier with a composite bone replacement graft to achieve
successful GBR results with implants. The
compilation of case information is ongoing to determine whether similar results will
be found in a larger series of patients. ●
Correspondence:
Paul S. Rosen, DMD, MS
907 Floral Vale Boulevard
Yardley, PA 1906
Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
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Immediate Loading of Dental Implants with
Provisional Restorations and Soft Tissue
Manipulation for Achieving Optimal Esthetics:
A Case Report
Sudhindra Kulkarni1 • Srinath Thakur1 • Sampath Kumar2
Abstract
T
he restoration of anterior maxilla in an
esthetically acceptable way is probably the
most challenging of all clinical scenarios.
Ideal implant positioning as well as proper soft
tissue management is the key to achieve optimal esthetic result. Immediate loading of dental
implants is now an accepted clinical reality and
provides the clinician with an option to rehabilitate the anterior maxilla with immediate provisional
restorations thus enhancing patients’ comfort.
The following case report is of a patient who was
treated with immediate provisional restorations
and soft tissue contouring was carried out to
achieve harmonious hard and soft tissue esthetics.
KEY WORDS: Dental implants, Immediate load, Provisionalization, Esthetics
1. Faculty, Department of Periodontics and Implantology, SDM College of Dental Sciences and Hospital,
Dharwad, Karnataka, India
2. Faculty, Department of Prosthodontics and Implantology, SDM College of Dental Sciences and Hospital,
Dharwad, Karnataka, India
The Journal of Implant & Advanced Clinical Dentistry
• 75
Kulkarni et al
Figure: 1: Pre-Operative intraoral photograph.
Introduction
In the current scenario of implant practice, our
patients desire immediate and esthetically pleasing results. At the time when the concept of
osseointegration and the basic principles for
implantology were being laid down by Branemark,1 the main goal of therapy was to provide
fixed and more stable replacements; esthetics
and immediate replacement were not considered.
To overcome the 2nd stage surgery and
avoid resulting trauma for the patient along with
reduced surgery time for the surgeon, a non submerged approach or also known as one-stage
implant placement was carried out and reported
successful osseointegration.2,3 This approach
further lead to development of immediate loading of the implants either at the time of implant
placement or within a short period of time. Tarnow et al. reported a success rate of 96% over a
period of 5 years for implants immediately loaded
with fixed prosthesis in 10 completely edentulous cases.4 A recent review by Jokstad and Carr
reported that over a 1-10 year period there is no
significant difference between immediate and
76 •
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•
December/January 2011
Figure 2: Pre-operative radiograph.
conventional delayed loading of the implants.5
The increased esthetic demands of the patient
make it important to not only have the implants
placed in an ideal location and loaded immediately, but also achieve soft tissue contours that
result in a natural appearing emergence profiles.
This is more critical in those patients who display gingival margins of the maxillary anterior
teeth during facial expression. Achieving proper
emergence profiles is not only esthetic but also
promotes optimal plaque control and gingival
health.6,7 Many techniques have been suggested
in the literature for soft tissue management.9-12
The following report is of a case where
implants were loaded immediately with temporary
restorations which were later replaced with provisional restorations to achieve harmonious soft tissue contours and esthetically pleasing outcomes.
Case Report
A 56 year old female patient reported to the
Department of Oral Implantology, SDM College of Dental Sciences and Hospital, Dharwad,
Karnataka, India with a chief complaint of miss-
Kulkarni et al
Figure 3: Implant placed in the maxillary anterior.
Figure 4: Immediate provisional restorations.
ing teeth in the maxillary anterior area and the
right maxillary/mandibular posterior areas of the
jaw. Three years prior, the teeth were extracted
due to endodontic complications and a removable partial denture was fabricated that replaced
her anterior teeth. She desired a replacement
which was fixed and also esthetically pleasing.
Clinical and Radiographic examination (figures 1 and 2) revealed multiple missing teeth.
Teeth numbers 7, 11, 14, and 32 were endodontically treated, #11 had an acrylic temporary crown, #’s 5 and 6 had connected crowns
which supported cantilever prosthesis for tooth
#4. The gingiva appeared healthy on all the
remaining teeth, though #29 displayed some
amount of bone loss and gingival recession.
The patient was informed about the treatment plan which involved post and core restoration on #7 and placement of one implant
per missing teeth in both the arches. The maxillary anterior implants were to be loaded with
immediate
provisional
restorations;
where
as the posterior implants would be left submerged. All the implants would receive the
final restorations after a period of six months.
Treatment
A prefabricated post was inserted into the
tooth #7 and core build-up was done. The
acrylic crown on was removed and an acrylic
prosthesis extending from #’s 7-11 was fabricated on the cast which would then be used as
a guide during the surgery and later modified
to act as an immediate temporary restoration.
It was decided to place the posterior implants
first followed by the anterior implants. A full thickness mucoperiosteal flap was elevated in the maxillary posterior area. Sequential drilling was carried
out and two implants of 3.5 mm and 5.0mm diameter of 12mm and 9mm in length were placed in
the #’s 2 and 3 areas respectively (Maestro, Biohorizons Dental Implants, Birmingham, AL, USA).
A 4.0mm diameter and 12mm in length
implant was placed at site #8 and 3.5x12mm
implants were placed at sites 9 and 10. It was
noted that the implant in site #9 was not in a
favorable position, so it was decided to cover it
with a cover screw and leave it submerged (fig-
The Journal of Implant & Advanced Clinical Dentistry
• 77
Kulkarni et al
Figure 5: Soft Tissue contouring.
Figure 6: Final set of provisional restorations.
Figure 7: Final restorations.
Figure 8: Radiograph of the final restorations.
ure 3.). The abutments were kept on the implants
at sites #8 and 10 and the flaps were approximated and closed with 3-0 resorbable sutures.
In the areas of teeth 30/31, it was noted that
the mesio-distal space was inadequate for placement of two conventional implants. To create the
space it was suggested to the patient to extract
third molar in the quadrant which would then help
in creating the necessary space, but the patient
refused to have the tooth removed. A 3.0x12mm
single stage implant (Biohorizons, Maximus Dental Implant, Birmingham, AL, USA) was placed at
site #30 and a conventional 3.5x12mm implant
was placed at site #31. All implants had good
primary stability. The flaps were then approximated and closed with 3-0 resorbable sutures.
The acrylic temporary was modified and
relined at the conclusion of the surgery so as
to fit the natural as well as the implant abutments extending and was cemented with
luting cement (IRM, Dentsply) (figure 4).
Post-operatively, the patient was prescribed
amoxicillin 500mg tid and ibuprofen 400mg.
Home care instructions were given and 10 days
78 •
Vol. 3, No. 1
•
December/January 2011
Kulkarni et al
Figure 9: Two year post-operative photo (Frontal view).
Figure 10: Two year post operative radiograph (maxilla).
Figure 11: Two year post operative radiograph
(mandible).
later the sutures were removed. The patient was
recalled after 90 days after the implant placement and evaluated. It was noticed that the soft
tissues had healed well around the implants, but
the soft tissue contours were not pleasing. The
temporary acrylic restorations were removed,
gingival contouring was accomplished around
the implants as well as the adjacent natural
teeth to improve soft tissue contours and emergence profiles (figure 5). Impressions were then
made and heat polymerized acrylic provisional
restorations were fabricated to match with the
newly created soft tissue contours. (figure 6)
Three months later the patient reported
for her final restorations. Second stage procedures were carried out to uncover the
implants in the posterior maxilla and mandible. Fifteen days later the final impressions
were made and final restorations were fabricated and cemented (figures 7,8). The patient
expressed satisfaction with the new final restorations. At the two year follow-up period we
could note stable hard and soft tissue margins and the screw access hole completely
The Journal of Implant & Advanced Clinical Dentistry
• 79
Kulkarni et al
covered by the soft tissue (figures 9-11).
Discussion
The advantages of one stage and immediate loading of the implants with temporary restorations in the maxillary anterior
area cannot be overstated. In the current
case only the implants in the maxillary anterior were immediately loaded with temporary restorations primarily for esthetic
reasons. The implants in the posterior areas
of the jaws were submerged to be exposed
6 months later for conventional loading.
Immediate loading of implants aids in splinting the implants together which enhances load
distribution over a wide area. While replacing the anterior teeth, immediate temporization offers the benefits of enhanced function
and stability during the healing period. The
patients need not wear a removable prosthesis, which in turn has a strong psychological impact and increases the acceptance of
implant treatment.5 With success rates of
95 - 100% survival over 3-5 years13-16 which
is similar to conventionally loaded implants
and better bone-implant contact for immediate loaded implants,17,18 immediate loading may be well suited for the anterior maxilla.
Even though there is ample support in the
literature for immediate loading of implants
even in the posterior areas, in the current case
we decided to load the posterior implants in a
conventional way after a period of 6 months.
The demand for esthetics around any form
of restorations is paramount, whether it is
around natural teeth or around implants. A
proper emergence profile should be considered in 3 dimensions to avoid the develop-
80 •
Vol. 3, No. 1
•
December/January 2011
ment of a “ball on a stick” restoration.19 Bain
and Weisgold20 state that most healing abutments and transfer copings are round and do
not simulate the normal cross section of anterior teeth, resulting in an unnatural sulcular form
around implant abutments. The provisional
restoration must therefore flow from a round
shape into a crown shape to develop a naturallooking replacement. In this case the immediate
temporary restorations that were placed on the
day of the surgery were not aiding in creating
the desired soft tissue contours. After a period
of initial healing, the gingival tissues around
the implants and the adjacent natural teeth
were contoured and we replaced the immediate temporary restorations with heat polymerized acrylic resin provisional restorations that
adapted to newly created form. This method
planed the provisional restoration emergence
profile so that the developed shape may also
be repeated for the definitive prosthesis.19
This approach of immediate loading followed
by soft tissue contouring for the anterior restorations and a conventional approach for the
posterior implant restorations aided in achieving optimal esthetics as desired by the patient.
Over a period of 1 year follow-up, the
bone levels were maintained and none of the
implants were lost. Misch and Degidi reported
a bone loss of approximately 0.07mm from
final prosthesis delivery to 1 year radiographic
evaluation.16 They also reported mean cumulative bone gain after 1 year or more around
some of those implants in their study and attributed it to the implant design, which permitted
a bone turnover rate less than 5m/d which corresponds to the rate of lamellar bone remodeling and a success rate of 100% over 5 years.21
Kulkarni et al
Conclusion
Immediate
loading
of
implants
along
with
soft
tissue
contouring
supported
by heat polymerized provisional restorations helps in creating optimal emergence
profiles which can be later maintained
around the final restorations over 1 year. ●
Correspondence:
Dr Sudhindra Kulkarni
Faculty, Department of Periodontics and
Implantology
SDM College of Dental Sciences and Hospital
Dharwad, Karnataka, India
drsudhindrak@gmail.com
Ph: +91-836-2468142
Fax: +91-836-2467676
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
References
1. B
ranemark PI, Hansson BO, Adell R.Osseointegrated implants in the treatment
of the edentulous jaws. Experience from a ten year period. Scand J plast
Reconsttr Surg Suppl 1977;16: 1-132.
2. G
otfredsson K, Hjorting-Hansen E. Histologic and histomorphometric
evaluation of submerged and non submerged titanium implants. In. Laney WR,
Tolman DE, eds. Oral Orthopedic and maxillofacial reconstruction. Chicago:
Quintessence,1990:31-40.
3. B
user D, Weber HP, Bragger U et al. Tissue integration of one stage ITI implants :
3 year results of longitudinal study with hollow cylinder and hollow screw
implants. Int J Oral Maxillofac Implants 1991;6:405-412.
4. T
arnow D, Emitiag S, Classi A. immediate loading of threaded implants at stage
one surgery in edentulous arches. Ten consecutive case reports with 1-5 year
data. Int J Oral Maxillofac implants 1997;12:319-324.
5. J okstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed
or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants.
2007;22 Suppl:19-48.
6. N
aele D, Chee WW. Development of implant soft tissue emergence profile: a
technique. J Prosthet Dent 1994; 72:364-367.
7. K
hourg K, Happe A. Soft tissue management in oral implantology: A review
of surgical techniques for shaping an esthetic and functional peri-implant soft
tissue structure. Quintessence Int 2000;31: 483-499.
8. S
alama H, Rose LF, Salama M, Betts NJ. Immediate loading of bilaterally splinted
titanium root form implants in fixed Prosthodontics- techniques reexamined: two
case reports. Int J Periodontics Restorative Dent. 1995;15:344-361.
9. L
anger B. Spontaneous insitu gingival augmentation. Int J Periodontics
Restorative Dent 1994;14:524-535.
10. Evian CL, Al-Maseeh J, Symeonides E. Soft tissue augmentation for implant
dentistry. Compend Educ Dent 2003;24:195-198.
11. Sclar AG. Vascularized interposition periosteal connective tissue (VIP-CT)
flap. Sclar AG, ed. Soft tissue and esthetic considerations in Implant therapy.
Chicago: Quintessence. 2003:163-168.
12. El-Salam, El-Askary A. Use of a titanium papillary insert for the construction of
the inter-implant papillae. Implant Dent 2000; 9:358-362.
13. Jaffin RA, Kumar A, Berman CL. Immediate loading of implants in partially
and fully edentulous jaws: a series of 27 case reports. J Periodontol.
2000;71(5):833-838.
14. De Bruyn H, Van de Velde T, Collaert B. Immediate functional loading of TiOblast
dental implants in full-arch edentulous mandibles: a 3-year prospective study.
Clin Oral Implants Res. 2008;19:717-723.
15. Glauser R, Zembic A, Ruhstaller P, Windisch S. Five-year results of implants with
an oxidized surface placed predominantly in soft quality bone and subjected
to immediate occlusal loading.J Prosthet Dent. 2007; 97(6 Suppl):S59-68.
16. Misch CE, Degidi M. Five year prospective study of immediate/ early loading
of fixed prostheses in completely edentulous jaws with a bone quality-based
implant system. Clin Impl Dent Rel Res 2003;5:17-28.
17. P
iatelli A Corigliano M,Scarano, Quaranta M. Bone reactions to early occlusal
loading of two stage titanium plasma sprayed implants. A pilot Study in
monkeys. Int J Periodont Restorative Dent. 1997;17:162-169.
18. Piatelli A, Corigliano M,Scarano, Costigola G, Paolantonio M. Immediate
loading of titanium plasma sprayed implants. An histologic analysis in monkeys.
J Periodontol.1998; 69: 321-327.
19. Macintosh DCT, Sutherland M. Method for developing an optimal emergence
profile using heat-polymerized provisional restorations for single-tooth implantsupported restorations. J Prosthet Dent 2004; 91:289-292.
20. Bain CA, Weisgold AS. Customized emergence profile in the implant crown- a
new technique. Compend Contin Educ Dent 1997; 18:41-45.
21. Misch CE, Qu AL, Bidez MW. Mechanical properties of trabecular bone in
the human mandible. Implications for dental implant treatment planning and
surgical placement. J Oral Maxillofac Surg 1999;57:700-706.
The Journal of Implant & Advanced Clinical Dentistry
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October 2008
Review | Oral Implications of Cancer Cheomotherapy
Walia et al
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24
The Journal of Implant & Advanced Clinical Dentistry
JIACD
Oral Bisphosphonates and Dental Implants:
A Review and Update
Walia et al
Manpreet S Walia, MDS1 • Saryu Arora, MDS2 • Bhawana Singal, MDS3
Abstract
T
his review was made to establish the convenience of Dental Implant treatment in
patients receiving bisphosphonates. Clinicians must be aware of the potential risk of
Osteonecrosis in patients treated with bisphosphonates via the oral or intravenous route.
Bisphosphonates related osteonecrosis of the
jaw (BRONJ) is a well documented devastating
side effect of long term bisphosphonates (BP)
use. There is scarce information in the literature
on BRONJ associated with dental implants (DIs).
It would be of interest to design studies to evaluate the risk factors among dental implant patients
receiving treatment with bisphosphonates.
KEY WORDS: Bisphosphonates, Osteonecrosis, Dental Implants
1. Professor & Head Dept.of Prosthodontics, H.S.Judge Institute of Dental Sciences and Hospital Chandigarh
2. Senior Lecturer Dept. of Prosthodontics, Shri Sukhmani Dental College and Hospital, Derabassi, Punjab
3. Senior Lecturer Dept. of Conservative Dentistry and Endodontics, Shri Sukhmani Dental College and Hospital,
Derabassi, Punjab
The Journal of Implant & Advanced Clinical Dentistry
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Walia et al
INTRODUCTION
Bisphosphonates (BPs) are drugs for inhibiting
bone resorption, widely used for the treatment
of osteoporosis, multiple myeloma and skeletal
complications of bone metastases.1 The two
main categories of BPs are the non-nitrogen
and nitrogen-containing BPs. Bisphosphonates
can be administered orally or intravenously.
Oral Bisphosphonates are also called nitrogen containing BPs. Their most common side
effects are oral erosions, gastric ulcer, esophagitis and esophageal stenosis. The adverse
effects of intravenous bisphosphonates are
similar, but also include phlebitis, transient
febricula, chills, and pseudoinfluenza syndrome.2
Bisphosphonate-related osteonecrosis of the
jaws (BRONJ) is a well-documented devastating
side effect of long-term use of BPs.3 Osteonecrosis (ON) presents as an exposure of alveolar bone either spontaneously or secondary to
invasive oral surgical procedures. Radiologically, ON can manifest as normal bone, while
the histological findings can correspond to
bone necrosis with bacterial colonization. This
article discusses the association of BRONJ and
dental implants with its clinical presentation.
ACTIONS OF
BISPHOSPHONATES
Bisphosphonates are powerful inhibitors of osteoclastic activity. They are analogues of inorganic
pyrophosphates with low intestinal absorption, are
excreted through the kidneys without metabolic
alteration, and have a high affinity for hydroxyapatite crystals. Because they are incorporated into
the skeleton without being degraded, they are
remarkably persistent drugs; the estimated halflife for alendronate is up to 12 years. Alendro-
84 •
Vol. 3, No. 1
•
December/January 2011
nate, risedronate, pamidronate, zoledronic acid,
andibandronate, which are called aminobisphosphonates, have much higher potency because
they contain nitrogen in a side chain (Table 1). The
non-aminobisphosphonates are metabolized by
osteoclasts to inactive nonhydrolyzable adenosine triphosphate analogues that are directly cytotoxic to the cell and induce apoptosis. The newer
aminobisphosphonates have two actions: induction of another adenosine triphosphate analogue
that induces apoptosis, and inhibition of farnesyl
diphosphonate synthase, which is part of the mevalonate pathway of cholesterol synthesis. Such
inhibition results in dysregulation of intracellular
transport, cytoskeletal organization, and cell proliferation, leading to inhibition of osteoclast function. In addition, aminobisphosphonates reduce
recruitment of osteoclasts and induce osteoblasts
to produce an osteoclast-inhibiting factor. Aminobisphosphonates exert several antitumor effects,
including induction of tumor cell apoptosis, inhibition of tumor cell adhesion to the extracellular
matrix, and inhibition of tumor invasion. Bisphosphonates also have antiangiogenesis properties
and can activate T cells. The use of bisphosphonates in patients with multiple myeloma and metastatic cancer to the bones, such as breast, prostate,
lung, and renal cell carcinomas, has resulted in a
statistically significant reduction in skeletal complications, including pathologic fractures, spinal
cord compression, hypercalcemia of malignant
disease, and the need for subsequent radiotherapy or surgery to bone. Intravenous bisphosphonates have improved bioavailability and do not
produce gastrointestinal side effects, resulting
in better patient adherence. They have become
standard therapy in the management of patients
with multiple myeloma and metastatic cancer.4
Walia et al
Table 1: Bisphosphonate Formulations
Generic
Name
Brand
Name
Etidronate
Didronel
Disodium
Manufacturer
and Location
Dosage
Forms
Procter & Gamble
200-and
Pharmaceuticals
400-mg tablets
Cincinnati, OH
Clodronate
Bonefos
Schering AG,
Disodium
(Canada)
Berlin, Germany
Tiludronate
Skelid
Disodium
400-and 800-mg
tablets:
60mg/mt. ampule*
Sanofi-Synthelabo
200-mg tablet
Inc., New York, NY
Alendronate
Fosamax
Merck & Co. Inc.
Sodium
Whitehorse
Station, NJ
NitrogenContaining
No
No
No: Sulfer Moiety
5-, 10-, 35-, 40-,
and 70-mg tablets;
70mg/75kL oral
solution
Yes
Merck & Co. Inc
Whitehorse
Station, NJ
70-mg and 2800-U
cholecalciferol
tablet
Yes
Pamidronate
Aredia
Disodium
Novartis
Pharmaceuticals
East Hanover, NJ
30-, 60-, and
90-mg vials*
Yes
Risedronate
Actonel
Sodium
Procter & Gamble
Pharmaceuticals
Cincinnati, OH
35- and 500-mg
Calcium tablet
Yes
Procter & Gamble
Pharmaceuticals
Cincinnati, OH
5-, 30- and
35-mg tablet
Yes
Zoledronic
Zometa
Acid
Novartis
Pharmaceuticals
East Hanover, NJ
4-mg vial*
Yes
Ibandronate
Boniva
Sodium
Roche
Laboratories, Inc.
Nutley, NJ
2.5-mg tablet
150-mg tablet
3mg/3mL*
Yes
Alendronate
Fosamax
Sodium plus
Plus D
Vitamin D
Risedronate
Actonel
Sodium
with Calcium
plus Calcium
FDA = Food and Drug Administration
*Drug is administered intravenously
The Journal of Implant & Advanced Clinical Dentistry
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Walia et al
RISK FACTORS
Various systemic and local factors could influence
the incidences of BRONJ. There is a greater
occurrence of BRONJ with more potent BP’s
and if they are taken for extended periods of time.
Local risk factors which increase the incidence of
BRONJ include dental extractions, implant placement, surgical procedures including osteotomy,
and anatomical structures such as tori. Systemic risk factors which increase the incidence
of BRONJ include: increasing age, diabetes mellitus, steroid use, cancer therapy, and smoking.
ASSOCIATION OF BRONJ
WITH DENTAL IMPLANTS
As the aging population grows, the number of
patients with osteoporosis and skeletal disorder increases, thus the number of patients taking
BP’s for the treatment is also on the rise. Numerous reports of the occurrence of BRONJ suggest
that the dental extractions are the main triggering
event for its development.5-7 However, there are
few reports on BRONJ associated with the placement of dental implants (DIs) or failure of DIs associated with BP therapy. Fugazzotto et al8 placed
169 DIs in 61 patients, Grant et al9 placed 468
DIs in 115 patients, Bell and Bell10 placed 101
DIs in 42 patients, and Jeffcoat11 placed 102
DIs in 25 patients. None of these researchers
found any cases of BRONJ associated with the
DIs. Moreover, some studies have demonstrated
a positive effect of oral BPs on the osseointegration of DIs and treatment of periodontitis.12-14
One of the most important issues concerning
BRONJ is the timing of the development of BRONJ
in reference to the placement of the DIs. BRONJ
that developed less than 6 months from the time of
DI placement was classified as surgically related,
86 •
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•
December/January 2011
and BRONJ that developed atleast after 6 months
was classified as spontaneous. According to
study done by Lazarovici et al 22.2% cases were
surgically related and 77.8% developed spontaneously and occurred as a late complication.3
The other issue is the route of administration
of drugs. Incidence of BPs associated ON of
the jaw is estimated to the range of 0.8-12% for
patients receiving intravenous formulations.15 16
For patients taking oral medication, the incidence
is estimated to be 0.7 per 1,000,000 persons per
year of exposure.17 Patient’s taking oral BPs manifest less bone exposure and mild symptoms compared to patients with intravenous BP’s, since with
oral bisphosphonates it took longer to develop BP
induced osteonecrosis because of a slower accumulation rate in bone. Intravenous BP administration is regarded as an absolute contraindication
to the placement of DIs. However, controversy
arises in the cases of treatment with the oral BPs.
Madrid and Sanz reviewed 1 prospective
and 3 retrospective studies and reported that
there was no BRONJ after implant placement in
217 patients who took oral BPs for less than 5
years.18 According to Jeffcoat et al, there was a
100% success rate with no clinical evidence of
infection, pain, or necrosis in the patients who
received oral bisphosphonates for 1-3 years.11
Grant et al placed 468 implants in 115
patients those were receiving oral biphosphonate therapy. There was no evidence
of
bisphosphonate-associated
osteonecrosis of the jaw in any of the patients.9
DISCUSSION
The demand of DIs has increased enormously in
recent years. A large percentage of the population requiring treatment with DIs is elderly per-
Walia et al
sons over 65 years of age in which osteoporosis
is very common. This increased demand for the
placement of DIs in osteoporotic patients treated
with BPs makes necessary for dental professionals to improve their knowledge of this disease, its
treatment, and the effects of BPs upon DI surgery.
The placement of DIs induces a series of metabolic changes around the implants that should
lead to the formation of bone intrinsically bound
to the implant surface. If the bone surrounding
the DI presents a medium to high concentration of
BP’s, the turnover and remodeling processes will
be hindered or prevented, with the risk of necrosis of the surrounding bone. If dental implants are
to be placed, the physician should be contacted
who has prescribed the oral BP’s prior to surgery,
to suggest an alternate dosing, a drug holiday
or an alternative to bisphosphonates therapy.19
The American Dental Association expert panel
recommends that patients taking oral bisphosphonates be informed about benefits and risks
relating to possible implant failure and osteonecrosis of the jaw for patients taking oral BPs. They
further recommend that nonsurgical or less invasive treatment alternatives be used when possible
but they did not prohibit the placement of dental
implants in patient receiving oral BPs treatment.
When treatment plan involves the medullary
bone and/or periosteum in multiple sextants,
treatment of one sextant or tooth at a time should
be done and a 2 month disease free follow-up
before other sextant to be treated.17,19 Although
the patients may be at increased risk when
extensive implant placement or guided bone
regeneration is necessary but the additional
research is necessary to guide the additional
diagnostic testing, management or treatment
modifications for patients taking oral BPs.
CONCLUSION
Current evidence suggests the avoidance of
dental implant procedure in patients that have
been receiving intravenous BPs. In the case
of administration via the oral route caution is
required avoiding these procedures or indicating them only when absolutely necessary. ●
Correspondence:
Dr. Manpreet S Walia
H.No. 477, Sector 6, Panchkula
Phone: 09876644433
Email: drmanpreetwalia@gmail.com
References:
1. S
edghizadeh PP, Stanley K, Caligiuri M, Hofkes S, Lowry B, Shuler CF. Oral
bisphosphonate use and the prevalence ofosteonecrosis of the jaw: An
institutional Oral bisphosphonate use and the prevalence of inquiry. J Am Dent
Assoc 2009; 140: 61-6.
2. P
onte-Fernández N, Estefanía-Fresco R, Aguirre-Urizar JM. Bisphosphonates an
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2006 Aug 1; 11(6):E396-400.
3. L
azarovici TS, Yahalom R, Taicher S, Schwartz-Arad D, Peleg O, Yarom N.
Bisphosphonate-Related Osteonecrosis of the Jaw Associated With Dental
Implants. J Oral Maxillofac Surg 2010; 68:790-6.
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oo SB, Hellstein JW, Kalmar JR. Systemic Review: Bisphosphonates and
osteonecrosis of the jaws. Ann Intern Med 2006;144: 753-61.
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igliorati CA, Casiglia J, Epstein J, et al: Managing the care of patients with
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avrokokki T, Cheng A, Stein B, et al: Nature and frequency of bisphosphonateassociated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg 2007;
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8. F
ugazzotto PA, Lightfoot WS, Jaffin R, et al: Implant placement with or
without simultaneous tooth extraction in patients taking oral bisphosphonates:
Postoperative healing, early followup, and the incidence of complications in two
private practices. J Periodontol 2007; 8:1664.
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patients taking oral bisphosphonates: A review of 115 cases. J Oral Maxillofac
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10. Bell BM, Bell RE: Oral bisphosphonates and dental implants: A retrospective
study. J Oral Maxillofac Surg 2008; 66:1022.
11. Jeffcoat MK: Safety of oral bisphosphonates: Controlled studies on alveolar
bone. Int J Oral Maxillofac Implants 2006; 21:349.
12. Anonymous: Alendronate may enhance implant osseointegration, study finds. J
Am Dent Assoc 2008; 139:679.
13. Giro G, Sakakura CE, Gonçalves D, et al: Effect of 17betaestradiol and
alendronate on the removal torque of osseointegrated titanium implants in
ovariectomized rats. J Periodontol 2007; 78:1316.
14. Stadelmann VA, Gauthier O, Terrier A, Bouler JM, Pioletti DP. Implants
delivering bisphosphonate locally increase periprosthetic bone density in an
osteoporotic sheep model. a pilot study. European Cells and Materials 2008;
16: 10-6.
15. Bamias A, Kastritis E, Bamia C, Moulopoulos LA, Melakopoulos I, Bozas G et
al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates:
Incidence and risk factors. J Clin Oncol. 2005 Dec 1; 23(34):8580-7.
16. Zavras AI, Zhu S: Bisphosphonates are associated with increased risk for jaw
surgery in medical claims data; Is it osteonecrosis? J Oral Maxillofac Surg
2006; 64:917.
17. A
merican Dental Association Council on Scientific Affairs: Dental
management of patients receiving oral bisphosphonate therapy: Expert panel
recommendations. J Am Dent Assoc 2006; 137: 1144.
18. Madrid C, Sanz M. What impact do systemically administrated bisphosphonates
have on oral implant therapy? A systematic review. Clin Oral Implants Res
2009;20 Suppl 4:87-95.
19. Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws,
The Journal of Implant & Advanced Clinical Dentistry
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