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Bio-Oss® produced more favorable results than allogenic materials for the preservation of

extraction sockets prior to dental implantation1

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

Optimal Site Preservation%

new

bone

50

40

30

20

10

0Rocky Mtn Puros®

23.6% 17.2%

12.0%

*

*

*

50

40

30

20

10

0

23.6% 17.2%

12.0%

*

*

*

50

40

30

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10

0

25.4%

12.0% 13.7%

*

*

*

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40

30

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* *

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The Journal of Implant & Advanced Clinical Dentistry

Volume 1, No. 7 october 2009

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 1, No. 7 • october 2009

Table of Contents

13 Case of the Month Treatment Planning and Execution of Minimally Invasive Dentistry Michael Apa

21 JIACD Continuing Education Successful Management of a Severe Case of Bisphosphonate Related Osteonecrosis of the Jaw in a Multiple Myeloma Patient Cesar Luchetti, Sebastian Yantorno, Julian Barrales, Juan Napal, Jorge Milone, Alicia Kitrilakis

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

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Table of Contents

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

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

71 Dental 3D Imaging Centers Usage and Findings: Part II Anatomical Features of the Lingual Artery Alan A. Winter, Kouresh Yousefzadeh, Alan S. Pollack, Michael I. Stein, Frank J. Murphy, Christos Angelopoulos

77 Cultivating Your Online Dental Reputation with Blogs Shannon Mackey



PublisherSpecOps Media, LLC

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Disclaimer: Reading an article in JIACD does not qualify the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its staff, and parent company SpecOps Media, LLC (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.

Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-SOM. JIACD-SOM disclaims any responsibility or liability for such material and does not guarantee, warrant, nor endorse any product, procedure, or technique discussed in JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its affiliated websites, or affiliated communications.

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JIACD (ISSN 1947-5284) is published on a monthly basis by SpecOps Media, LLC, Saint James, New York, USA.


A Minimally Invasive and Systematic Approach to Sinus Grafting

Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSDonald Callan, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSScott Ganz, DMDArun K. Garg, DMDDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MSMichael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDS

Richard Hughes, DDSDebby Hwang, DMDMian Iqbal, DMD, MSTassos Irinakis, DDS, MScJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSShannon MackeyMiles Madison, DDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTJaimee Morgan, DDSDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSArthur Novaes, DDS, MSAndrew M. Orchin, DDSCharles Orth, DDSJacinthe Paquette, DDSAdriano Piattelli, MD, DDSStan Presley, DDS

George Priest, DMDGiulio Rasperini, DDSMichele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDChristian Stappert, DDS, PhDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSMichael Toffler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS



Nick and I just attended the 95th Annual Meeting of the American Academy of Periodontology (AAP)

in Boston and what a great trip it was. We arrived in Boston a few nights before the meeting started that is when the fun began.

The trip started off with a bang when my iPhone was stolen at a restaurant downtown. I always had a fear about this happening, so I never kept any highly confidential information on the phone (thank goodness!). Within a few minutes of the phone disappearing, I sent a text message offering $100 for the safe return of the phone, but alas, no response. I promptly reported the phone as being stolen, suspended all services to that particular phone, and changed all of my account passwords just to be safe. That was a wonderful first night of the trip!

The next day, Nick and I attended a marketing course offered by Dr. Paul Fugazzotto. Dr. Fugazzotto’s course was outstanding and I highly recommend it for anyone in private practice. He was a gracious host and the information presented was as good as gold! The food and wine were pretty good as well!

After attending Paul’s course, we went back to the hotel to meet and greet everyone as they began to arrive for the meeting. It was nice seeing some old friends and even better making new ones. With the night one theatrics of my stolen phone behind us, we had a drink in the hotel lobby prior to heading out for dinner. Upon finishing my drink, I asked for my bill and was somewhat surprised to see that I had been charged nearly $200. Hmm, I have had some good cocktails in my day, but I can’t remember one ever costing $200. I chatted with the waitress for a bit about

my bill and, of course, she had mixed my tab with the group that was sitting next to me. The waitress apologized and had the charges reversed…or so I thought. The $200 drink showed up on my statement the next morning and it took me a few days to clear up that situation. What fun!

Aside from my phone being stolen and my $200 drink, which was subsequently changed to the correct price of $20 (still a bit pricey for a single drink if you ask me), the actual meeting was outstanding. The AAP put together a great meeting with some top notch lecture topics. Growth factors and the treatment/prevention of implant complications seemed to be one of the major focuses of this meeting.

As always, the corporate forums provided some outstanding clinical lectures and a number of rooms were standing room only…until the convention officials kicked people out of the room for violating the fire code! When the rooms are packed to overflowing, that is always a great sign. In addition to providing some informative lectures, the corporate entities had some great deals in the exhibition hall.

Next year’s AAP meeting is in the beautiful state of Hawaii. Having lived in Hawaii for three years in the past, I am excited to go back! If next year’s meeting is as good as this year’s meeting, it will be a great one. I will be sure to register as soon as I get a new phone. ●

Dan Holtzclaw, DDS, MSFounder, Co-Editor-In-Chief

Nick Toscano, DDS, MSFounder, Co-Editor-In-Chief

A Great Meeting in Boston

Editorial Commentary

Kurtzman

Kurtzman

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

cAse reportFigures 1-3 show the patient at initial presentation with congenitally developed peg laterals, canted midline, and a flared anterior segment due to a thumb-sucking habit. In order to treat this case conservatively, orthodontia was required. How-ever, to satisfy the patientís goals of improving her smile immediately, something had to be done aesthetically prior to her leaving for college. As such, the four anterior teeth were minimally pre-pared for veneers, rolling in the teeth slightly. Final plans were to finish this case with Invisalign®

(Santa Clara, California, USA) and bring the upper anterior segment into the proper arch form.

Case of the MonthTreatment Planning

and Execution of Minimally Invasive Dentistry

Michael Apa, DDS1

1. Private practice limited to prosthodontics, New York, NY USA

KeY WorDs: Orthodontics, periodontics, restorative dentistry, composite restorations, veneers


14 • Vol. 1, No. 7 • October 2009

Apa

In order to understand how much tooth struc-ture truly needed to be removed, a mock-up of the future position of the teeth was made and then depth cut through an accurate set of provisionals. This allowed for planning of the proper amount of tooth structure removal. For this case, anesthe-sia was not administered in order to make sure to tooth preparation remained in enamel. Topical anesthetic was applied to the gingival tissue for minor plasty on the zeniths of teeth 7, 8, and 10.

Figure 4 shows rolling in the centrals and minor adjustments that were made to the gingiva with a diode laser. Now that the ìarch formî was correct, the provisionals were fabricated. This process is similar to what a laboratory does for an additive/reductive wax-up, yet allows the cli-nician to utilize facial landmarks to be accurate (figures 5-7). Prior to depth cutting, an alginate impression was taken for a stent to make final provisionals. At this point, the provisional res-torations are depth cut (figure 8) according to desired porcelain thickness, keeping in mind ini-tial color and desired color. Minimal tooth struc-ture removal was needed in this case due to the light stump shade. Final margins and prepara-tion were performed, followed by smoothing of all line angles (figure 9). At this point, an alginate impression was filled with Luxatemp® (Zenith Den-tal, Englewood, New Jersey, USA) and checked to see if there was enough room for ceramic (figures 10,11). Final impressions were taken, along with a bite registration, stump shade pho-tos, and a counter impression. The provisionals were bonded in place and final shaping was done along with the approval of the patient (figure 12).

Four individual veneers were bonded to teeth 7-10, the bite was adjusted, and the patient was sent to the orthodonist to be fitted for Invis-

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

conclusionBeing conservative will always allow for enhanced bonding strength, less micro leakage, and lon-ger lasting restorations. Also, using the under-lying tooth for color will always result in a much more natural appearing restoration, which should be the goal for both the aesthetic clini-cian and patient. By treatment planning in a multi-disciplinary approach, goals of minimally invasive dentistry can be achieved with outstand-ing transitional and final aesthetic results. ●

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

correspondenceDr. Michael Apa30 East 76th Street, Suite 5BNew York, NY 10021


Apa

● Figures 1-3

16 • Vol. 1, No. 7 • October 2009

Apa

● Figures 4-7


Apa

● Figures 8-12

18 • Vol. 1, No. 7 • October 2009

Apa

● Figures 13-16

KurtzmanKurtzmanApa

● Figures 17-21


Luchetti et al

Background: Bisphosphonate-related osteone-crosis of the jaw (BRONJ) is a serious oral complication of bisphosphonate treatment involving the exposure of necrotic maxillary or mandibular bone. BRONJ is associated with pain, paresthesia, and oral dysfunction gen-erating an impairment of the quality of life. Treatment of this complication remains diffi-cult and the most useful action is prevention.

Case Report: This is a case report of a multiple

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

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

Cesar Luchetti, DDS, MS1 • Sebastian Yantorno, MD2 • Julian Barrales, MD3

Juan Napal, MD4 • Jorge Milone, MD, PhD5 • Alicia Kitrilakis, DDS, PhD6

1. Associate Professor, Department of Implant Dentistry. National University of La Plata. (Universidad Nacional de La Plata). La Plata, Buenos Aires, Argentina.

2. Specialist in Haematology and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina.

3. Specialist in Infectology. La Plata, Buenos Aires, Argentina

4. Specialist in Internal Medicine and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina.

5. Specialist in Internal Medicine and Specialist in Haematology. Head of Oncohaematology and Transplants and Director of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina.

6. Head Professor, Department of Implant Dentistry and Department of Prosthodontics - National University of La Plata. (Universidad Nacional de La Plata) La Plata, Buenos Aires, Argentina

Abstract

KEY WORDS: Bisphosphonate necrosis, osteonecrosis, multiple myeloma


This article provides 2 hours of continuing education credit. Please click here for details and additional information.

22 • Vol. 1, No. 7 • October 2009

JIACD Continuing Education

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

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

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

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

After reading this article, the reader should be able to:1. Discuss Bisphosphonate Related Osteone-

crosis of the Jaw (BRONJ)and its causes.2. Understand how to diagnosis and manage

BRONJ3. Understand the surgical and

pharmocological management of BRONJ

Learning Objectives



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

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

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

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

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

Figure 7: Radiograph showing the status of the affected bone in December 2005.

24 • Vol. 1, No. 7 • October 2009


enced complete remission following this treatment.In 2002, the patient had some routine den-

tal extractions which never fully healed and resulted in chronically exposed bone. Suspect-ing myeloma dissemination to the mandible, the oral surgeon at that time took a biopsy sample. The condition now known as BRONJ was not yet known at that time (figure 1). A few months later, the condition became increasingly aggrivated, with the consequent loss of more teeth and a progressive affectation to the bone (figures 2-5).

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

We started to manipulate the bony seques-trum by gently trying to loosen it three times a

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

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

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



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

remaining bony spicules to get a smooth bone surface and facilitate healing (figures 11,12).

The sequestrum was submitted for histo-logic examination which revealed necrotic bone with empty lacunaes and associated infected tissue. With gram staining, Gram (+) bacil-lus were identified (figures 13,14). Fifteen days following surgery, the soft tissue heal-ing looked acceptable and at one month, com-plete healing of the surgical site was observed (figure 15). Having achieved this, we decided

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

Figure 12: Sequestrum removed.

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

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

26 • Vol. 1, No. 7 • October 2009


to proceed in the same fashion on the left side. Bone sequestrum on the left side presented

as two parts, first from the buccal and a few months later from the lingual (figures 16,17). After two months, the tissues at the surgical sites were stable. Radiographic examination did not reveal formation of additional bone seques-trum. We also performed a Serum C-terminal telopeptide (CTX) test according to the Marx pro-tocol8 and got a result of 130 pg/ml, compatible with a moderate risk (figure 18). We then fabri-cated and delivered a maxillary dental prosthe-sis to give the patient the possibility to return to normal function, both masticatory and aesthetics wise, after several years (figures 19-21). Sev-enteen months later, the previously affected tis-sues continue to appear stable (figure 22).

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

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

Figure 15: Clinical situation one month after sequestrum removal.

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

Figure 18: Radiograph in July 2007.



Figure 19: Removable prosthesis. Figure 20: Removable prosthesis.

Figure 21: Removable prosthesis.

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

tain the exposed bone infection free and to have in mind that the patient can live with some bone exposure without further problems.9,10 However, as we demonstrated in this case, the infection of the bone can worsen, no matter how great the effort to provide minimally invasive palliative treatment.

Our thought is that once the lesion affects the cortical plate and the medullary bone becomes exposed, adequate cleansing of the area seems to be more difficult and the infection control requires extreme care, both home and professional. Clor-hexidine is the antiseptic of choice cited in most articles.9,10 We also like to use 3% hydrogen peroxide based on our experience in managing abscess lesions in soft tissues which are usually present in the limits of the exposed bone. Also, 3% hydrogen peroxide can help in cases where the exposed bone presents a rough surface in which anaerobic bacteria could grow. Micro-biological identification is important adjunct to aid infection management. Cultures must be made to search for aerobic and anaerobic bac-teria, and also for fungus. Fungus can be pres-ent as a result of many situations, with the most common being systemic immunity impairment

JIACD Continuing

Education

28 • Vol. 1, No. 7 • October 2009


and the previous use of long term antibiotics. More recently, surgical approaches have

been described in order to achieve soft tissue healing in certain cases. Common features of these approaches are: 1) conservative resec-tion of the necrotic bone with attempts at obtain-ing a smooth surface; 2) use of platelet derived growth factors; 3) tension free primary wound closue.11,12 We have used these approaches, especially with the use of platelet derived growth factor (PDGF), both for prevention in tooth extrac-tions in compromised patients and for treatment of BRONJ. In cases where a bony sequestrum is present, it may be beneficial to loosen them in steps rather than remove them in a single attempt. With proper homecare involving the patient irri-gating below the sequestrum, this conservative approach may lead to initial healing of the over-lying soft tissue, which could minimize surgi-cal corrections upon removal of the sequestrum.

The serum C-terminal telopeptide (CTX) test8

is currently recommended as a way to mea-sure the risks of development and progression of BRONJ. When used together with imaging, clinical examination, and other complementary studies, CTX testing may prove to be a valu-able adjunct in the decision process for treat-ing patients at risk for or currently affected by BRONJ. The patient treated in this case report had moderate CTX levels and proceeded to heal without complication. Whether this heal-ing was a result of the CTX values or the treat-ment rendered cannot be determined at this time.

CONCLUSIONSThe latest literature, and also this case, sup-ports the concept that BRONJ may be success-fully treated in the short term. The approach

described to treat this case, especially regard-ing sequestrum management, could minimize necessary surgical corrections upon removal of the sequestrum. However, the resolution of this particular case does not ensure that every case can be resolved in the same way or with the same results, but shows us that there is a real possibility to treat this pathology with success. Each case must be evaluated individually and primary approaches must always be conserva-tive and focused on prevention. Additional stud-ies on the development, diagnosis, prevention, and management of BRONJ are warranted. ●

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.AcknowledgementsThe author (Luchetti) would like to thank Dr. Cesar Migliorati, who was kind enough to share his opinion with him in Buenos Aires regarding this particular case. The authors would also like to thank Dr. Gregori Kurtzman, Dr. Len Tolstunov, and Dr. Douglas Martin for their assistance in the preparation of this manuscript. References1. Fleisch H, Russell R, Bisaz S, Casey P, Muhlbauer R. The influence of

pyrophosphates analogues (diphosphonates) on the precipitation and dissolution of calcium phosphate in vivo and in vitro. Calcif Tissue Res 1968; 2(suppl.): 10-10a.

2. Fleisch H. Bisphosphonates: Mechanisms of action and clinical use. En: Bilezikian et al Principles of Bone Biology, Ed. Academic Press, 1996: 1037-1052.

3. Merlini G, Parrinello G, Piccinini L, Crema F, Fiorentini ML, et al. Long-term effects of parenteral dichloromethylene bisphosphonate (CL2MBP) on bone disease of myeloma patients treated with chemotherapy. Hematol Oncol 1990; 8(1):23-30.

4. Body J. Bisphosphonates for malignancy-related bone disease: current status, future developments. Support Care Cancer 2006; 14(5):408-418.

5. Marx R. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; 61(9):1115-1117.

6. Ruggiero S, Mehrotra B, Rosenberg T, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004; 62(5):527-534.

7. Mehrotra B, Ruggiero S. Bisphosphonate complications including osteonecrosis of the jaw. Hematology Am Soc Hematol Educ Program 2006:356-360.

8. Marx R, Cillo J, Ulloa J. Oral bisphosphonate-induced osteonecrosis: Risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 2007; 65(12):2397-2410.

9. Marx R, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: Risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005; 63(11):1567-1575.

10. Migliorati C, Casiglia J, Epstein J, Jacobsen P, Siegel M, Woo S. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005; 136(12):1658-1668.

11. Kademani D, Koka S, Lacy M, Rajkumar S. Primary surgical therapy for osteonecrosis of the jaw secondary to bisphosphonate therapy. Mayo Clin Proc 2006; 81(8):1100-1103.

12. Adornato M, Morcos I, Rozanski J. The treatment of bisphosphonate-associated osteonecrosis of the jaws with bone resection and autologous platelet-derived growth factors. J Am Dent Assoc 2007; 138(7):971-977.


Luchetti et al Luchetti et al

1. Bisphosphonates are a class of drugs that inhibit bone resorption.

a. True b. False

2. The main use of Bisphosphonates was for the prevention and treatment of osteoporosis and other bone metabolism diseases, based on their ability to increase bone turnover trough the activation of osteoclast differentiation and a decrease in its activity and survival rate.

a. True b. False

3. What percentage of BRONJ cases are associated with intravenous bisphosphonate administration?

a. 2 - 10% b. 1.8 - 12.8% c. 12.8 - 20.3% d. 0.001 - 0.002%

4. What is the antiseptic of choice cited for treatment?

a. Saline b. Listerine c. Clorhexidine

5. Cultures must be made to search for aerobic bacteria, anaerobic bacteria, and fungus.

a. True b. False

6. Bisphosphonate use was extended to treat oncological diseases in order to lower the skeletal effects.

a. True b. False

7. The VAD Protocol includes the use of Vincristine, Adriamycin and Dexamethasone. a. True b. False

8. BRONJ was first described in what year? a. 2000 b. 1998 c. 2003 d. 2009

9. BRONJ must be evaluated individually and primary approaches must always be conservative and focused on prevention.

a. True b. False

10. In cases where a bony sequestrum is present, it may be beneficial to loosen them in steps rather than removing in a single attempt.

a. True b. False

Continuing Education JIACD Quiz #3

CliCk here to take the quiz


Toscano et al

References: 1. Nevins M, Giannobile WV, McGuire MK, Mellonig JT, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE. Platelet Derived Growth Factor (rhPDGF-BB) Stimulates Bone Fill and Rate of Attachment Level Gain. Results of a Large Multicenter Randomized Controlled Trial. J Periodontol 2005; 76: 2205-2215. 2. Heijl L, Heden G, Svardstrom G, Ostgren. Enamel matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997; 24: 705-714. 3. Zetterstrom O, Andersson C, Driksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontol defects. J Clin Periodontol 1997; 24: 697-704. 4. See full prescribing infromation for more detail. Emdogain® is a registered trademark of BioVentures BV Corporation. ©COPYRIGHT Osteohealth Company 2008. All rights reserved. OHD235e Rev. 9/2009.

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

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

Mean

LBG

(mm)

3.0

2.0

1.0

0GEM 21S® Enamel Matrix

Derivative (EMD)

2.6

1.1*

Radiographic Linear Bone Growth (LBG)

Mean

% B

F

60

40

20

0 GEM 21S®

Enamel MatrixDerivative (EMD)

57

14*

Radiographic Percent Bone Fill (BF%)

CAL G

ain (m

m)

4.0

3.0

2.0

0GEM 21S® Enamel Matrix

Derivative (EMD)

3.7

2.7*

Clinical Attachment Level (CAL) Gain

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

IMPORTANT SAFETY INFORMATIONGEM 21S® Growth-factor Enhanced Matrix is intended for use by clinicians familiar with periodontal surgical grafting techniques. It should not be used in the presence of untreated acute infections or malignant neoplasm(s) at the surgical site, where intra-operative soft tissue coverage is not possible, where bone grafting is not advis-able or in patients with a known hypersensitivity to one of its components. It must not be injected systemically. The safety and effectiveness of GEM 21S® has not been established in other non-periodontal bony locations, in patients less than 18 years old, in pregnant or nursing women, in patients with frequent/excessive tobacco use (e.g. smoking more than one pack per day) and in patients with Class III furcations or with teeth exhibiting mobility greater than Grade II. In a 180 patient clinical trial, there were no serious adverse events related to GEM 21S®; adverse events that occurred were considered normal sequelae following any periodontal surgical procedure (swell-ing, pain). For full prescribing information, go to www.osteohealth.com or call 1-800-874-2334 and a copy will be sent to you.

Toscano et al

Background: Seibert Class III apicocoronal and buccolingual alveolar ridge defects with associ-ated gingival mucosal atrophy and absence of interdental papillae are common in edentulous areas within the anterior esthetic zone of the max-illa. Normal emergence profiles, critical to achiev-ing esthetic restorations, require restoration of normal hard and soft tissue morphology, including re-establishment of adjacent interdental papillae.

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

Results: In all cases normal crestal hard and soft tissue architecture was restored, including re-establishment of interdental papillae, through simultaneous bone and soft tissue grafting with-out resorting to secondary autogenous graft harvesting procedures. Definitive non-implant supported fixed restorations with cleansable and esthetic ovate pontics and normal emer-gence profiles were achieved in each case.

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

The Bio-Derm Ridge Plumping Technique for Pontic Site Development

Nicholas Toscano, DDS, MS1 • Dan Holtzclaw, DDS, MS2

1. Private Practice, Washington DC, USA

2. Private Practice, Austin, TX, USA

Abstract

KEY WORDS: Mucogingival surgery, bone graft, pontic, prosthetics


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IntRODuCtIOnIn the esthetic zone of the maxilla a proper emer-gence profile, predicated on healthy normal marginal gingival tissues with intact interdental papillae, is critical to achieving esthetically pleas-ing traditional fixed and implant supported res-torations. Adequate soft tissue morphology, however, is dependent upon a stable, adequate volume of underlying bone capable of serving as a viable, biologic foundation for overlying soft tis-sues. Without the harmony afforded by a proper balance of underlying bone and overlying soft tis-sue, esthetic restorations are not possible, espe-cially in the anterior maxilla. Frequently, however, alveolar bone loss disturbs that critical balance, resulting in marginal tissue distortion, recession and loss of esthetically crucial interdental papil-lae. Bone loss is common in the esthetic zone and can result from multiple precipitating events, the most common following tooth extraction. Mul-tiple studies have documented predictable 3 mm to 4 mm of buccolingual and apicocoronal ridge resorption within 6 months after removal of max-illary anterior teeth. If left untreated up to 50% buccolingual bone loss will occur after one year post tooth removal in the critical esthetic zone.1-3

Buccal marginal bundle bone loss follow-ing disruption of intact PDL fibers after tooth removal and prominent, thin buccal bone subject to critical blood supply loss following extraction, are frequent causes of post-extraction bone loss within the maxillary esthetic zone.3-4 In addition, advanced periodontal disease, trauma, periapical infection and developmental defects commonly lead to bone loss and ridge deformities in areas critical to esthetic restorations. As a conse-quence of such frequently encountered bone loss, negative soft tissue morphologic changes

often occur, including reduction or loss of kerati-nized marginal gingiva and disappearance of inter-dental papillae, both essential for esthetic dental reconstruction in the esthetic zone of the maxilla.

Seibert, in an attempt to develop rational ther-apeutic approaches to alveolar ridge deformities, classified three major types of ridge deformities.5

Class I is a buccolingual loss of tissue with a nor-mal apicocoronal dimension. Class II is an apico-coronal loss of tissue with normal buccolingual ridge width. Class III is a combination of bucco-lingual and apicocoronal loss of tissue resulting in loss of both normal height and width and is the most difficult class to successfully treat. Cor-rectly classifying the type of ridge deformity as a guide to effective surgical and restorative treat-ment will help optimize the final restorative result.

Numerous procedures, including distrac-tion osteogenesis, bone splitting, guided bone regeneration and autogenous onlay bone graft-ing provide surgeons with a wide range of alternative approaches to managing the bony component of alveolar ridge deformity.6-11 Autog-enous bone grafts have been considered the “gold standard” for bone regenerative proce-dures.12-13 Autogenous bone harvesting, how-ever, is both invasive and technically demanding. Moreover, autogenous grafted bone resorp-tion up to 40-50% has been demonstrated when autogenous grafts are used for treating horizontal and vertical alveolar ridge defects.14

Distraction osteogenesis, while an alter-native approach to vertical ridge augmen-tation, is technically demanding and often difficult for patients unable to tolerate intra-oral distraction devices.14-15 While suitable for Seib-ert Class II defects, distraction osteogenesis cannot treat the horizontal components of Seib-


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ert Class I and III alveolar ridge deformities.Guided bone regeneration (GBR) is used

for bony ridge augmentation with or without osseointegrated implant placement.16-17 GBR, with a barrier membrane in combination with bone grafts or bone graft substitutes, offers predict-ability in providing bone augmentation simultane-ously in both horizontal and vertical directions, and is therefore appropriate for treating all three deformities within Seibert’s classification.18-20

Allografts, alloplasts and xenografts have all been used in GBR procedures to correct alveo-lar ridge defects prior to restorative treatment.

Although critical to restorative success in the esthetic zone of the maxilla, regeneration of nor-mal bony ridge architecture must also be asso-ciated with restoration of normal soft tissue anatomy, including recreation of missing inter-dental papillae. Insufficient volume of gingival soft tissue as well as poorly configured soft tis-sue architecture will mandate modifications in the design of fixed or removable prostheses to com-pensate for the deformity. Often such modifica-tions result in overly large, ridge-lap pontics that fail to promote normal function, esthetics and ready cleansibility.21 Current surgical methods to correct soft tissue ridge deficiencies rely primar-ily on autogenous soft tissue grafts or allograft acellular dermal matrices, either alone or in con-junction with bone regenerative procedures.

A variety of autogenous soft tissue graft types are available for correction of ridge deficiencies. Small to moderate Class I defects can be treated with the roll technique, utilizing a deepithelialized palatal connective tissue pedicle flap inserted within a properly prepared buccal pouch.22 Like-wise, subepithelial connective tissue grafts are widely used for correction of primarily Seibert

Class I defects, although they can be used to correct mild vertical height deficiencies as well. Connective tissue grafts provide good to excel-lent color match with adjacent gingival tissues, often resulting in increased amounts of kerati-nized tissue at the graft site.23-26 Free gingival full-thickness onlay grafts are used to correct Seibert Class I, II and III ridge deficiencies, but often pose esthetic problems with adjacent tissue.27

Although widely used, soft tissue autografts require an additional invasive surgical proce-dure to harvest the graft material, increasing the potential for increased surgical morbidity. A finite amount of available autogenous tissue also limits the amount of soft tissue grafting that can be done at any one point in time. Furthermore, autograft shrinkage often demands further soft tissue grafting, requiring additional harvesting procedures, each with the potential for increased postoperative pain, hemorrhage, or infection.25

In an attempt to avoid some of the problems unique to soft tissue autografts, including the need for a second surgical procedure, clinicians have turned to acellular dermal matrix allografts as an alternative to autogenous soft tissue grafts. Originally developed for the treatment of full-thickness burn wounds, acellular dermal matrix is an allograft obtained from human skin.28-29 Pro-cessed so that the epidermal layer and all der-mal cells are removed, the result is a graft matrix with normal type I collagen bundling architecture and an intact basement membrane. Removal of all cells eliminates the possibility of viral survival and transmission as well as the components nec-essary for graft rejection. Rather than healing by granulation, acellular dermal matrix grafts serve as conductive matrices, allowing cellular migra-tion and neovascularization from the surrounding

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host bed to repopulate and replace the graft site. Although originally designed as an alterna-

tive treatment for burn wounds, acellular der-mal matrices have been used extensively in dentistry as alternatives to autogenous soft tis-sue grafts. Dental use has included manage-ment of gingival recession,30-37 increasing the zone of keratinized tissue around teeth and implants,38-40 and preserving and/or increas-ing gingival thickness in edentulous areas.41-47

The purpose of this thirty patient consecu-tive case series was to investigate the efficacy of simultaneously grafting significant anterior maxillary Seibert Class III alveolar ridge defects with a slowly resorbing xenograft particulate (Bio-Oss®, Osteohealth Company, Shirley, NY) combined with an overlying acellular dermal matrix allograft (Puros® Dermis Allograft, Zim-mer Dental Inc.) in order to restore both nor-mal osseous and soft tissue contours, including restoration of interdental papillae, in patients requiring traditional fixed prosthetic restorations.

MAtERIAlS AnD MEthODSStudy PopulationThirty consecutive patients with significant api-cocoronal and buccolingual alveolar hard and soft tissue ridge deformities (Seibert Class III) were included in this reported case series. The patient population included 12 females and 18 males between 19 to 58 years of age. Detailed past medical and dental histories were obtained for each patient. All patients were treated by the authors as part of their clinical practice.

Clinical EvaluationFollowing a detailed clinical examination, pan-oramic and full-mouth periapical radiographs were obtained for each patient. All patients presented with edentulous areas within the maxillary esthetic zone that had been previ-ously restored with traditional, non-implant supported fixed restorations. Entrance into the study required Seibert Class III deficien-cies, including loss of interdental papillae.

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

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


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Overview of the Surgical ProcedurePrior to surgery, all patients received oral hygiene instructions as well as full mouth scal-ing and curettage. Detailed informed consents were obtained, indicating understanding of the nature of the proposed surgical treatment.

Using a #15 scalpel, midline crestal inci-sions were made at each edentulous site. Mesial and distal vertical release incisions allowed wide exposure of the maxillary buccal cortex (figure 1). Full-thickness buccal and palatal mucoperiosteal flaps were reflected, exposing the entire extent of the alveolar ridge deformity (figure 2). Following thorough wetting with ster-ile saline, small particle size Bio-Oss® particu-late graft material was carefully placed over the exposed buccal cortex as well as the over the alveolar crest and palatal cortex to allow bone regeneration to occur in all areas of the ridge defect (figure 3). Puros® Dermis Allograft was then trimmed to size, saturated with saline, and placed over the Bio-Oss® graft in order

to act as a conductive matrix for gingival soft tissue regeneration to occur simultaneously with underlying new bone formation (figure 4). Importantly, the Puros® Dermis was placed fac-ing the periosteal surface of the mucoperiosteal flap. The soft tissue flaps were then reposi-tioned and closed without tension via mul-tiple interrupted 5.0 ePTFE sutures (figure 5).

A carefully prepared interim fixed restora-tion with ovate shaped pontics was then placed onto previously prepared abutment teeth (fig-ure 6). In addition to satisfying both func-tional and esthetic requirements, the interim restoration was used as a guide during soft tissue maturation for creation of a more natu-ral soft tissue profile, including the formation of interdental papillae. Pleasing emergence profiles were thus created by guiding the mor-phology of the soft tissues with the interim restoration during soft tissue regeneration.

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

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

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REvIEW Of REPRESEntAtIvE CASES

The following illustrate several representa-tive cases that demonstrate both specific sur-gical and prosthetic procedures as well as obtained results when correcting difficult to treat hard and soft tissue defects within the esthetic zone of the maxilla with Bio-Oss® par-ticulate graft and Puros® Dermis Allograft.

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

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

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

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

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


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ridge-lap pontics were placed in the edentulous area (figures 9, 10). At augmentation surgery, well-released full thickness buccal and palatal flaps revealed severe alveolar ridge narrowing as well as a small residual cyst in the right lat-eral incisor region. When removed, the residual cyst resulted in an additional anatomic defect within the anterior maxillary ridge (figures 11, 12).

In order to restore the anatomic integrity of the bony ridge to its normal dimensions, small par-

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

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

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

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

Figure 12: Additional view of defect from case 1.

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

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

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

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

Figure 16: A new fixed interim restoration with ovate shaped pontics, no longer over-sized, was temporarily cemented into place.

Figure 15: Additional view of layered grafting technique.


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loss of interdental papillae within the edentu-lous space, periodontally compromised maxil-lary lateral incisor teeth, and multiple stained teeth throughout both arches (figure 21).

Following reflection of full-thickness buccal and palatal mucoperiosteal flaps, both maxillary lateral incisors were removed, exposing large fenestrated and dehiscence bony defects of the buccal cortex, further exaggerating the alveo-lar ridge deformity (figure 23). As in Case #1, small particle size, Bio-Oss® particulate graft material was carefully placed along both the entire exposed buccal cortex and alveolar ridge crest (figure 24). Puros® Dermis allograft was then placed over the Bio-Oss® graft and the flaps closed primarily with multiple interrupted ePTFE sutures (figures 25, 26). An interim restoration with ovate shaped pontics was temporarily cemented into place (figure 27). Over the next 4 months the interim restoration served as a guide for the formation of estheti-cally important interdental papillae (figure 28).

In planning for the definitive restorative result, care was taken to address each of the

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

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

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

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

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

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

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

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

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

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


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

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

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

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

in a severe Seibert Class III defect, resulting in a dental Class III occlusal relationship (figures 32, 33). In order to compensate for the trauma induced functional and esthetic deformity, the patient wore a removable appliance with an exag-gerated bucco-palatal flange (figures 34, 35).

Figures 1 through 6 describe the step-by-step corrective surgical procedures used in this case, including placement of an interim restoration that

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

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pontics are unnecessary once the patient’s nor-mal anatomy was restored. Instead, esthetic and readily cleansable ovate shaped pontics become the replacement restoration of choice (figure 37). The final definitive fixed restoration demonstrates dramatic functional and esthetic improvements once the patient’s hard and soft tissue ridge

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

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

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

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

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

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


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Figure 32: Case 3 pre-op profile.

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

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

Figure 37: Correcting the patient’s anterior ridge deformity allowed fabrication of readily cleansable, esthetic ovate shaped pontics.

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

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

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traditional fixed or implant supported restora-tions in the esthetic zone of the maxilla. With-out normal soft tissue morphology, truly esthetic restorations cannot be achieved regardless of additional clinical effort. Adequate soft tissue architecture, however, is dependent upon a foun-dation of anatomically stable and healthy alveo-lar bone.48 In the critical esthetic zone, however, marginal buccal alveolar bundle bone, combined

with thin buccal cortical bone, lead to significant bone resorption following tooth removal.3-4 Gin-gival recession, distortion, and loss of interdental papillae are the inevitable sequelae of bone loss in the anterior maxilla. Seibert Class I, II, and III defects are therefore commonly encountered in the esthetic zone and must be adequately treated if esthetic fixed restorations are to be achieved.

A variety of clinical approaches have been used to restore normal soft tissue architecture.22-29

Frequently, when non-implant supported fixed restorations are contemplated, autogenous or allograft soft tissue augmentation procedures are used without regard to the underlying bony mor-phology. While sometimes effective, multiple soft tissue grafting surgeries are often required before an adequate gingival profile can be achieved.25 At times the results from soft tissue grafting alone are inadequate to sustain long-term stable results, especially when attempting to reconstruct inter-dental papillae in the presence of significant under-lying apicocoronal and bucco-palatal bone loss.

A more predictable approach to achieving esthetic and stable soft tissue marginal tissues

Figure 38: Case 3 final restorations.

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

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


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in the anterior maxilla may be to correct both the hard and soft tissue deficiencies present in most ridge defects. In the current 30 patient case series, simultaneous grafting of both the under-lying bone and the overlying soft tissue defects without the need of invasive harvesting proce-dures appeared to result in the natural emergence profiles critical to esthetic fixed restorations.

Critically important to restoring normal 3-dimensional ridge anatomy, especially when faced with significant buccal and crestal bone loss, is to consider the grafting requirements needed for long term stability of the augmented ridge. In order to maintain stable bone volume and architecture in the anterior maxilla, a slowly resorbing graft material with a low substitution rate is needed that can act as a long-term scaf-fold for continuing bone formation.49-50 In addition, the graft material should be highly osteoconduc-tive, with a highly porous particle structure and a large inner surface area, both essential pre-requisites for effective bone graft substitutes.51

The bony ridge defects treated in this case series were difficult to treat Seibert Class III defor-mities with significant apicocoronal and bucco-palatal bone loss. Successful resolution of these defects required effective bone regeneration with sustained, stable 3-dimensional bony architec-ture over time. Bio-Oss® bone mineral combines a complex, interconnected pore system condu-cive for effective vascular and osteoblastic cellular ingrowth with slow particle resorption, charac-teristics ideal for ongoing bone regeneration and long term morphologic ridge stability.52-54 Bio-Oss® was therefore chosen as the graft material of choice since it is likely to provide the necessary bony support over time required by regenerated gingival soft tissues, including interdental papillae.

Effective bone regeneration, while vitally impor-tant to esthetic success of dental restorations within the esthetic zone, must also be associ-ated with adequate overlying soft tissue thickness and architecture in order for true restorative suc-cess to be achieved. In each case within this 30 patient case series, apicocoronal and bucco-pal-atal bone loss was also associated with gingival mucosal atrophy and absence of interdental papil-lae. Regeneration of normal crestal gingival thick-ness and restoration of interdental papillae were crucial elements required for successful definitive dental restoration in this critically esthetic area.

As noted earlier, most attempts at soft tis-sue regeneration rely primarily on autogenous grafts, especially subepithelial connective tis-sue grafts from the palate.22-27 Although effec-tive, such grafts require a second invasive surgery and impose a limit to the amount of grafting avail-able at any one time. In addition, the potential for post-operative complications and morbidity are always present.25 Therefore, in the current series an allogenic acellular dermal matrix was chosen as an alternative to autogenous grafts.

Puros® Dermis allograft served three pur-poses: 1) To serve as a resorbable barrier mem-brane, preventing unwanted fibroblastic cellular migration into the Bio-Oss® grafted site during the active Guided Bone Regenerative period; 2) To increase overall gingival thickness; and 3) To pro-vide sufficient soft tissue depth for the formation of interdental papillae. Although generally placed directly onto a periosteal bed as a subsequent procedure following successful bone regenera-tion, in this particular series the acellular dermal matrix was placed immediately over the Bio-Oss®

graft, simultaneously accomplishing both bone grafting and soft tissue augmentation in a single

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surgical visit. Vascular ingrowth from all areas of the surrounding host bed, including the overly-ing periosteum, appeared adequate for success-ful bone and soft tissue regeneration to occur.

While hard and soft tissue grafting were critically necessary procedures, proper devel-opment of interdental papillae through careful fabrication and continued appropriate revision of the fixed interim restoration cannot be over-stated. Meticulous use of properly shaped ovate pontics adjacent to regenerating gingival soft tis-sues allowed for the development of interdental papillae and natural appearing emergence pro-files, elements crucial to final restorative success.

COnCluSIOnThirty consecutive patients with significant Seibert Class III alveolar ridge defects were successfully treated with simultaneous bone (Bio-Oss® par-ticulate) and soft tissue grafting (Puros® Dermis Allograft) procedures. The authors have coined this procedure the “Bio-Derm Ridge Plump-ing Technique for Pontic Site Development.” By avoiding autogenous hard and soft tissue grafts, the Bio-Derm Ridge Plumping Technique elimi-nates the need for additional invasive harvest-ing surgeries while at the same time allowing for the completion of both bone and soft tissue aug-mentation procedures in a single surgical visit. ●

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

AcknowledgementsSpecial thanks to Dr. Stuart Kay (Huntington, NY) for his help with the organization and production of this manuscript.

References1. Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M, Kenney EB,

Dimitrijevic B, Nedic M. Preservation of alveolar bone in extraction sockets using bioasorbable membranes. J Periodontol 1998 Sep;69(9):1044-49.

2. Schropp L, Kostopoulos L, Wenzel A. Bone Healing and Soft Tissue Contour Changes Following Single-Tooth Extraction: A Clinical and Radiographic 12-month Prospective Study. Int J Periodontics Restorative Dent 2003 Aug;23(4):313-323.

3. Nevins M, Camelo C, DePaoli S, Friedland B, Schenk RK, Parma-Benfenati S, Simion S, Tinti C, Wagenberg B. A Study of the Fate of the Buccal Wall of Extraction Sockets of Teeth with Prominent Roots. Int J Periodontics Restorative Dent 2006;26:19-29.

4. Araujo M, Linder E, Wennstrom J, Lindhe J The Influence of Bio-Oss Collagen on Healing of an Extraction Socket: An Experimental Study in the Dog. Int J Periodontics Restorative Dent 2008;28:123-135.

5. Seibert JS, Reconstruction of Deformed, Partially Edentulous Ridges, Using Full Thickness Onlay Grafts. Part I. Technique and Wound Healing. Compend Cont Educ Dent 1983;4:437-453.

6. Simion, M., Trisi, P. & Piattelli, A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. International Journal of Periodontics and Restorative Dentistry 1994;14: 496-511.

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

8. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent. 1994 Oct;14(5):451-459.

10. Froum SJ, Rosenberg ES, Elian N, Tarnow D, Cho SC. Distraction osteogenesis for ridge augmentation: prevention and treatment of complications: thirty case reports. Int J Periodontics Restorative Dent. 2008 Aug;28(4):337-345.

11. McAllister BS, Haghighat K. Bone augmentation techniques: J Periodontol 2007;78:377-396.

12. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007;78:18-21.

13. Cushing M. Autogenous red marrow grafts: potential for induction osteogenesis. J Periodontol 1969;40:492-497.

14. Sottostanti JS, Bierly JA. The storage of marrow and its relation to periodontal grafting procedures. J Periodontol 1975;46:162-170.

15. Wang JH, Waite DE, Steinhauser E. Ridge augmentation: An evaluation and follow-up report. J Oral Surg 1976;34:600-612.

16. Jensen OT, Laster Z. Preventing complications arising in alveolar distraction osteogenesis. J Oral maxillofac Surg. 2002;60(10):1217-8.

17. Becker W, Becker BE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case reports. Int. J Periodontics Restorative Dent. 1990;10(5):376-391.

18. Nyman S, Lang NP, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration: A report of two cases. Int J Oral Maxillofac Implants 1990;5(1):9-14.

19. Simion, M., Trisi, P. & Piattelli, A.Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994; 14: 496-511.

Correspondence:Nicholas Toscano, DDS, MSDiplomate American Board of Periodontology Practice Limited to Periodontics and Implant Surgery1140 19th Street, NW Suite 310 Washington, DC 20036 [email protected]


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

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

22. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199.

23. Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992;12:415-425.

24. Langer B, Calagna LJ. The subepithelial connective tissue graft. J Prosthet Dent 1980;42:363-367.

25. Langer B, Calagna LJ. The Subepithelial Connective Tissue Graft. A New Approach to the Enhancement of Anterior Cosmetics. Int J Periodont Restorative Dent 1982;9(2):23-33.

26. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199.

27. Orth C. A Modification of the Connective Tissue Graft Procedure for the Treatment of Type II and Type III Ridge Deformities. Int J Periodont Rest Dent 1996;16:267-277.

28. Seibert JS. Reconstruction of deformed, partially edentulous ridges using full thickness onlay grafts. Part 1. Technique and wound healing. Compendium Continuing Educ Dent 1983;4:437-451.

29. Wainwright DJ. Use of an acellular allograft dermal matrix (Alloderm) in the management of full-thickness burns. Burns 1995;21:243-248.

30. Lattari V, Jones LM, Varcelotti JR, Latenser BA, Sherman HF, Barrette RR. The use of a permanent dermal allograft in full-thickness burns of the hand and foot: a report of three cases. J Burn Care Rehabil 1997;18:147-155.

31. Richardson CR, Maynard JG. Acellular Dermal Graft: A Human Histologic Case Report. Int J Periodontics Restorative Dent 2002;22:21-29.

32. Cummings LC, Kaldahl WB, Allen EP. Histologic Evaluation of Autogenous Connective Tissue and Acellular Dermal Matrix Grafts in Humans. J Periodontol 2005;76:178-186.

33. Santos A, Goumenos G, Pascual A. Management of Gingival Recession by the Use of an Acellular Dermal Graft Material. J Periodontol 2005;76:1982-1990.

34. Hirsch A, Goldstein M, Goultschin J, Boyan BD, Schwartz Z. A 2-Year Follow-Up of Root Coverage Using Subpedicle Acellular Dermal Matrix Allografts and Subepithelial Connective Tissue Autografts. J Periodontol 2005;76:1323-1328.

35. Mehlbauer MJ, Greenwell H. Complete Root Coverage at Multiple Sites Using an Acellular Dermal Matrix Allograft. Compendium 2005;26:727-733.

36. Harris RJ. A Short-Term and Long-Term Comparison of Root Coverage With an Acellular Dermal Matrix and a Subepithelial Graft. J Periodontol 2004;75:734-743.

37. Haim T, Moses O, Zohar R, Meir H, Nemcovsky C. Root Coverage of Advanced Gingival Recession: A Comparative Study Between Acellular Dermal Matrix Allograft and Subepithelial Connective Tissue Grafts. J Periodontol 2002;73:1405-1411.

38. Woodyard JG, Greenwell H, Hill M, Drisko C, Iasella JM, Scheetz J. The Clinical Effect of Acellular Dermal Matrix on Gingival Thickness and Root Coverage Compared to Coronally Positioned Flap Alone. J Periodontol 2004;75:44-56.

39. Harris RJ. Root coverage with a connective tissue with a partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodonotol 1998;69:1305-1311.

40. Cortes, ADQ, Maraatins AG, Nociti FH, Sallum AW, Casati MZ, Sallum EA. Coronally Positioned Flap With or Without Acellular Dermal Matrix Graft in the Treatment of Class I Gingival Recessions: A Randomized Controlled Clinical Study. J Periodontol 2004;75:1137-1144.

41. Schulman J. Clinical evaluation of an acellular dermal allograft for increasing the zone of attached gingival. Practical Periodontics Aesthet Dent 1996;8:201-208.

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

43. Fowler EB, Breault LG, Rebitski G. Ridge Preservation Utilizing an Acellular Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: part I. A Report of 2 Cases. J Periodontol 2000;71:1353-1359.

44. Fowler EB, Breault LG, Rebitiski G. Ridge Preservation Utilizing an Acellular Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: Part II. Immediate Endosseous Implant Placement. J Periodontol 2000;71:1360-1364.

45. Batista EL, Batista FC, Novaes AB. Management of Soft Tissue Ridge Deformities With Acellular Dermal Matrix. Clinical Approach and Outcome After 6 Months of Treatment. J Periodontol 2001;72:265-273.

46. Fowler EB, Breault LG. Ridge Augmentation with a Folded Acellular Dermal Matrix Allograft: A Case Report. J Contemp Dent Pract 2001;(2)3:31-40.

47. Breault LG, Lee SY, Mitchell NE. Fixed Prosthetics with a Connective Tissue and Alloplastic Bone Graft Ridge Aumentation: A Case Report. J Contemp Dent Pract 2004 November;(5)4:111-122.

48. Scarano A, Barros RM, Iezzi G, Piattelli A, Novaes AB. Acellular Dermal Matrix Graft for Gingival Augmentation: A Preliminary Clinical, Histologic, and Ultrastructural Evaluation. J Periodontol 2009;80:253-259.

49. Grunder, U, Gracis S, et al. Influence of the 3-D Bone-to-Implant Relationship on Esthetics. Int J Periodontics Restorative Dent 2005; 25:113-119.

50. Elian N, Ehrlich B, et al. Advanced Concepts in Implant Dentistry: Creating the “Aesthetic Site Foundation”. Dent Clin N Am 2007;51:547-563.

51. Traini T, Valentini P, et al. A Histologic and Histomorphometric Evaluation of Anorganic Bovine Bone Retrieved 9 Years After a Sinus Augmentation Procedure. J Periodontol 2007; 78:955-961.

52. Lee Yong-Moo, Shin Seung-Yun, et al. Bone Reaction to Bovine Hydroxyapatite for Maxillary Sinus Floor Augmentation: Histologic Results in Humans. Int J Periodontics Restorative Dent 2006; 26:471-481.

53. Orsini G, Traini T, Scarano A, Degidi M et al. Maxillary sinus augmentation with Bio-Oss particles: a light, scanning and transmission electron microscopy study in man. J Biomed Mater Res.B: Appl Biomater 2005;74(1):448-457.

54. Piattelli M, Favero GA, Scarano A, et al. Bone reactions to anorganic bovine bone (Bio-Oss) used in sinus augmentation procedures: a histologic long-term report of 20 cases in humans. Int J Oral Maxillofac Implants 1999;14:835-840.

55. Sartori S, Silvestri M, Forni F, et al. Ten-year follow-up in a maxillary sinus augmentation using anorganic bovine bone (Bio-Oss). A case report with histomorphometric evaluation. Clin Oral Implants Res 2003;14:369-372.

Mazor et al

Mazor et al

Background: Successful implant placement in the atrophic posterior maxilla is often complicated by the quality and volume of available bone. Sinus floor elevation is advocated in these cases in order to gain sufficient bone around the implants. Sinus elevation can be done either by an open lateral win-dow approach or by a closed osteotome approach depending on the available bone height. This case report demonstrates the feasibility and safety of minimally- invasive antral membrane balloon eleva-tion (MIAMBE), followed by bone augmentation and implant fixation in a patient who had previous sinus augmentation failure done by a lateral approach.

Methods: A 55 year old male patient was referred for a second posterior maxillary bone augmenta-tion. After undergoing pre-procedural assess-ment and signing an informed consent, the patient underwent alveolar crest exposure and osteot-omy (3 mm diameter), followed MIAMBE. PRF (platelet rich fibrin) and xenograft bone substi-tute were injected into the sinus under the antral membrane and implant placement was performed.

Results: The procedure went smoothly with no complications. Postsurgical healing was uneventful. Six months following the surgical procedure, periapical radiographs were per-formed and prosthetic rehabilitation was initiated.

Conclusion: MIAMBE can be applied to patients in need of posterior maxilla bone augmentation. Absence of patient morbidity and satisfactory bone augmentation with this minimally invasive procedure suggests that MIAMBE should be considered as an alternative to the currently employed methods of maxillary bone augmentation.

Minimally Invasive Antral Membrane Balloon Elevation to Treat Previous Sinus

Augmentation Failure: A Case Report

Ziv Mazor, DMD1 • Efraim Kfir, DMD2

1. Private practice limited to Periodontics and Implant Dentistry, Ra’anana Israel

2. Private practice, Petach Tikva Israel

Abstract

KEY WORDS: Sinus lift, antral membrane, maxillary sinus, dental implants


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IntRODuCtIOnSuccessful implant placement in the atrophic posterior maxilla is often complicated by the quality and volume of available bone. Types 3 and 4 bone tend to predominate in the pos-terior maxilla making this region typically the least dense bone in the oral cavity.1 Postex-traction resorption patterns, use of a remov-able prosthesis, physical trauma, periodontal disease, and pneumatization of the maxil-lary sinus can significantly reduce or eliminate the height and width of the residual alveolar ridge. In the atrophic posterior maxilla, lon-ger and wider implants are needed to enhance long-term survival. As such, this area often requires bone augmentation beneath the sinus to increase the vertical height of bone.

The subantral augmentation, or “sinus lift” procedure, was first reported by Tatum and has evolved over the last 25 years. A lateral win-dow (modified Caldwell-Luc) approach to the maxillary sinus is used, and has shown such favorable results that the posterior maxilla is often considered one of the most predicable regions for grafting prior to or simultaneously with implant placement.2-7 The basic technique involves creation of a hinged window in the lat-eral wall of the maxilla.8 When completed, the window is gently pressed inward and upward into the sinus cavity, which lifts the Schneide-rian membrane and serves as a new sinus floor. The void between the elevated tissues and the original sinus floor is filled with bone graft mate-rial. Implants may be simultaneously placed, or the graft may be allowed to heal prior to implant placement.9-12 The lateral maxillary window offers average implant survival of 91.8% (rang-ing from 61.7-100%).17 This method involves

potential complications (membrane tear, bleed-ing, infection and sinus obstruction), swell-ing and discomfort, relative contra-indications (sinus convolution septum or narrow sinus and previous sinus surgery). The lateral maxillary window technique also requires considerable surgical skill, specialized equipment, and time.

The osteotome technique as introduced by Summers,13 also called bone added osteotome sinus floor elevation (BAOSFE), is an alternative approach for sinus eleva-tion in cases where a small amount of bone height is missing.14 BAOSFE can be compli-cated by membrane perforation and tearing,15

which can be somewhat reduced with expert technique and dedicated instrumentation.16

The minimally-invasive antral membrane bal-loon elevation (MIAMBE) technique is a modi-fication of the BAOSFE method in which antral membrane elevation is executed through the osteotomy site (of 3.5 mm) using a dedicated balloon. Former reports have demonstrated the use of this technique as an alternative to conventional procedures. This manuscript describes a case of using this treatment modal-ity and its advantages in a case previously treated with an open approach that failed.

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


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the dedicated inflation syringe, and on its dis-tal portion has a screw-in mechanism, which secures the device into the osteotomy site (fig-ure 1). The single use balloon is concealed in the distal end until it is inflated (figure 2). (b) Dedicated “MIAMBE kit” including bone graft injector, osteotome, screw-tap and a suction syringe device (MIAMBE)

(c) Coronary angioplasty inflation syringe (Merit Medical, Galway, Ireland) – filled with diluted contrast material (Ultrav-

Figure 1: Balloon harboring device with Holtem stoppers.

Figure 2: Silicone balloon during inflation.

Figure 3a: Presurgical panoramic radiograph.

Figure 3b: Presurgical CBCT scan showing ridge height and previous sinus window.

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

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

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

Figure 6a: PRF is inserted to the osteotomy site. Figure 6b: The sinus floor is upfractured using MIAMBE osteotome.

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


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ist 300 by Schering AG, Berlin, Germany)

(d) PRF autologous platelet rich fibrin - obtained by centrifugation of 10 ml divided into 4 test tubes and spun for 10 minutes at 2700 RPM.

(e) Xenograft bone graft (Endobone, Biomet 3I)

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

Figure 8a: Initial balloon inflation pressure (2 atm). Figure 8b: Once the balloon emerges from the metal sleeve apical to the sinus membrane, the pressure drops to 0.5 atm.

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

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

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ing the procedure and signed an informed consent. A pre-procedural non-steroidal anti-inflammatory agent and AUGMENTIN (clavulan-ate potassium) 875 mg twice daily were initiated 24 hours prior to the procedure. Local anesthe-sia (infiltration of posterior, middle superior alve-olar and greater palatine nerves) was performed

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

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

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

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

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


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Figure 13a: Implant fixture delivery. Figure 13b: Implant fixtures delivered to full depth.

Piezosurgical tips in the center of the alveolar crest to a point 1-2 mm short of the sinus floor. The depth of this initial drilling preparation was predetermined according to measurements obtained from the CT scan and periapical x-rays (figures 5a, 5b). The osteotomy was enlarged from 2.0mm to 2.9 mm with the MIAMBE Osteotome. Bone graft material and PRF were inserted into the osteotomy followed by upfrac-turing of the sinus floor with osteotomes limited by Teflon stoppers (figures 6a, 6b). After remov-ing the osteotome, Schneiderian membrane integrity was assessed by Valsalva maneuver.

The metal sleeve of the balloon-harboring device was inserted into the osteotomy 1 mm beyond the sinus floor with overextension pre-vention by a Teflon stopper (figure 7). The balloon was slowly inflated to two standard atmospheres (atm). With this technique, once the balloon emerges from the metal sleeve api-cal to the sinus membrane, the pressure drops to 0.5 atm. Subsequently, the balloon is inflated

with progressively higher volumes of contrast fluid (figures 8a, 8b). The balloon inflation and membrane elevation are evaluated by sequen-tial periapical radiographs. Once the desired elevation (usually >10 mm) is obtained, the balloon should be left inflated for five minutes to reduce sinus membrane elasticity (figure 9). After five minutes, the balloon is deflated and removed and membrane integrity is assessed by: 1) Valsalva maneuver; 2) Respiratory movement of blood within the osteotomy; 3) Direct visualization into osteotomy (figure 10).

After confirming Schneiderian membrane integrity, the bone substitute (Endobon, Biomet 3i) is injected through the osteotomy filling the space created beneath the Antral membrane (figures 11a, 11b, 12a, 12b). After addition of the bone graft, dental implant fixtures (Nanotite Certain, Biomet 3i) were delivered in the stan-dard fashion (figures 13a, 13b). The flap was then primarily closed and periapical radiographs verified Implant and graft placement (figure 14a).

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

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

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

COnCluSIOnMIAMBE appears to be a safe and effec-tive way to perform antral membrane elevation and posterior maxillary bone aug-mentation. The procedure is minimally inva-sive, produces mild patient discomfort, and delivers satisfactory augmentation results. ●

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

Correspondence:

Ziv Mazor, DMD

142 Ahuza st Ra’anana Israel 43300

Tel: 972-97400336,Fax: 972-97602839

Email: [email protected]


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DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

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in patients receiving endosseous dental implants. J Oral Maxillofac 1987; 55(Suppl 5): 38-45.

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3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980; 38: 613-616.

4. Misch CE. Maxillary sinus augmentation for endosteal implants: Organized alternative treatment plans. Int J Oral Implantol 1987; 4: 49-58.

5. Block MS, Kent JN, Kallukaran FU, Thunthy K, Weinberg R. Bone maintenance 5 to 10 years after sinus grafting. J Oral Maxillofac Surg 1998; 56: 706-714.

6. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants: A systematic review. Ann Periodontol 2003; 8(1): 328-343.

7. Peleg M, Garg AK, Mazor Z. Predictability of simultaneous implant placement in the severely atrophic posterior maxilla: A 9-year longitudinal experience study of 2132 implants placed into 731 human sinus grafts. Int J Oral Maxillofac Implants 2006; 21(1): 94-102.

8. Friberg B, Nilson H, Olsson M, Palmquist C. MkII: The self-tapping Branemark implant: 5-year results of a prospective 3-center study. Clin Oral Impl Res 1997; 8: 279-285.

9. roum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho SC. Sinus floor elevation using anorganic bovine bone matrix (OstoGraf/N) with and without autogenous bone: A clinical, histologic, radiographic, and histomorphometric analysis—Part 2 of an ongoing study. Int J Periodont Rest Dent 1998; 18: 529-543.

10. Peleg M, Chaushu G, Mazor Z, Ardekian L, Bakoon M. Radiological findings of the post-sinus lift maxillary sinus: A computerized tomography follow-up. J Periodontol 1999; 70: 1564-1573.

11. Smiler DG. The sinus lift graft: Basic technique and variations. Pract Periodontics Aesthet Dent 1997; 9: 885-893.

12. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontol 1998; 69: 1397-1403.

13. Summers RB. Sinus floor elevation with osteotomes. J Esthet Dent 1998; 10: 164-171.

14. Nkenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: a preliminary prospective study. Int J Oral Maxilofac Implants 2002; 17: 557-566.

15. Berengo M, Sivolella S, Majzoub Z, Cordioli G. Endoscopic evaluation of the bone-added osteotome sinus floor elevation procedure. Int J Oral Maxillofac Surg 2004; 33: 189-194.

16. Toffler M. Staged sinus augmentation using a crestal core elevation procedure and modified osteotomes to minimize membrane perforation. Pract Proced Aesthet Dent 2002; 14: 767-774.

17. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003; 8: 328-343.

18. Kfir E, Kfir V, Mijiritsky E, Rafaeloff R, Kaluski E. Minimally invasive antral membrane balloon elevation followed by maxillary bone augmentation and implant fixation. J Oral Implantol 2006; 32(1): 26-33.

19. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive antral membrane balloon elevation: report of 36 procedures. J Periodontol 2007; 78(10): 2032-2035.

20. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH,Fugazzotto PA. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999; 14(6): 853-858.

21. Fugazzotto PA. Augmentation of the posterior maxilla: a proposed hierarchy of treatment selection. J Periodontol 2003; 74(11): 1682-1691.

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Sakthish et al

Background: Conservation of anchorage has always been a priority for efficient orthodontics. For this reason, temporary anchorage devices such as micro-implants have become popular. While orthodontic miro-implants have been suc-cessfully used to withstand orthodontic force, their efficiency in withstanding heavier forces such as orthopaedic force has not been tested.

Methods: Using finite element analysis mode of evaluation, this study aimed to compare: i) the stress patterns in the surrounding bone and micro implant when placed at angula-tions of 30o, 60o, 90o; ii) Effect of orthodontic and orthopaedic forces on surrounding bone and micro-implants when tested on osseointe-grated and non–osseointegrated implant models.

Results: Micro-implant 30o angulation pro-duced better stress distribution on the sur-rounding bone and micro-implant compared to

60o and 90o angulations. All three angulations brought about stresses within the physiologi-cal limits in bone. Stress produced in the sur-rounding bone was within physiological limits in both osseointegrated and non-osseointegrated micro-implant models with 200g of orthodontic force application. With orthopaedic force (400g) application, however, the stress produced in the surrounding bone in osseointegrated micro-implant models (205.14g) was within physi-ological limits whereas the stress in surrounding bone in non-osseointegrated micro-implant mod-els (530.42g) exceeded physiological limits.

Conclusions: Both perpendicular and diagonal placements of implants are acceptable and pro-duce tolerable stress patterns. Both osseointe-grated and non-osseointegrated implants are acceptable for orthodontic force. However, osseointegration of micro-implants is indicated for successful loading of orthopaedic forces.

Comparison of Stress Patterns In and Around Orthodontic Micro-implants:

A Finite Element Study

S. Sakthish, MDS1 • Sridevi Padmanabhan, MDS2 • Arun Chithranjan, MDS3

1. Former PG student, Sri Ramachandra Dental College

2. Professor, Dept. of Orthodontics, Sri Ramachandra Dental College

3. Prof and HOD, Dept. of Orthodontics, Sri Ramachandra Dental College

Abstract

KEY WORDS: bone, osseointegration, orthodontic anchorage, microimplants, dental implants, temporary anchorage device


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INTRODUCTIONAnchorage control is fundamental to successful orthodontic treatment and has been addressed in a variety of ways including: 1) increasing the number of teeth in the anchorage unit; 2) altering the angulation of anchor teeth; 3) using extraoral and intraoral anchorage devices. Intraoral anchorage devices may not provide absolute anchorage control, whereas extraoral appli-ances are dependent on patient compliance.

The advent of osseointegrated implants by the pioneer studies of Branemark1 changed the scenario. The standard dental implants made of titanium have been used and have proved effec-tive for anchorage purposes,2,3 however they have draw backs such as bulk, osseointegration wait time, and added cost. For these reasons, temporary anchorage devices (TAD’s) such as micro/mini dental implants have become popu-lar for enhancing orthodontic anchorage. These devices reinforce anchorage by either supporting the reactive unit or by eliminating the need for the reactive unit altogether.4 Two types of micro-implant placement have been recommended: 1) diagonal placement; 2) perpendicular place-ment.5 Micro-implants are placed diagonally to the long axis of the tooth in order to avoid injury to the roots, but there are no studies to prove which micro implant angulation brings about optimal stress in the surrounding bone.

TAD’s can be fixed to the bone mechani-cally by cortical stabilization (or) biochemically by osseointegration.4,6 Most TAD’s are retained by primary stability where the maximum appli-cable load is proportional to the surface area of the bone contact to the implant. With osseointegrated implants, on the other hand, the maximum load is proportional to the quan-

tity of osseointegration. The efficiency of micro-implants has been evaluated in various studies and the general consensus is that even with immediate orthodontic loading, micro-implants are able to withstand forces of 200-300g.7,8

While osseointegrated implants have been used as anchors for orthopaedic devices, these studies used conventional osseointegrated Branemark implants which were loaded with orthopaedic forces up to 5N.9,10 However, there is no reported literature in the efficiency of TAD’s used as anchors to apply orthopaedic force. Recently, orthodontic micro-implants capable of osseointegration have also been introduced.11

Finite element analysis (FEM) is a modern tool for numerical stress analysis, which has the advantage of being applicable to solids of irreg-ular geometry that contain heterogeneous mate-rial properties. Finite element analysis provides the orthodontist with quantitative data that can extend the understanding of physiologic reac-tions that occur within the dentoalveolar com-plex. Such numerical techniques may yield an improved understanding of the reactions and interactions of individual tissues.12 Concern-ing dental implants, finite element analysis has proven to be a precise and applicable tool for evaluating stress patterns in surrounding bone.14 Hence, FEM analysis was selected in this study to assess the stress patterns in the surrounding bone and micro implant models.

Using FEM, This study sought to deter-mine which micro-implant angulation achieves optimal stress in the surrounding bone. Addi-tionally, stress in the surrounding bone was evaluated when osseointegrated and non-osseointegrated micro-implants are used for orthodontic or orthopaedic anchorage purposes.


Sakthish et al

MATERIAlS AND METhODSThe objectives of this study were as follows: 1) To compare stress patterns in the surround-ing bone and micro-implant when placed at angulations of 30o, 60o and 90o; 2) To com-pare the stress patterns affected by orthodon-tic and orthopaedic force on the microimplant and surrounding bone in both osseointegrated and non-osseointegrated models. To achieve such, this study was carried out in two parts.

In the first part of the study a finite element model of the maxillary arch with all of the teeth except the first premolars was constructed. A model of a non-osseointegrated micro-implant was traced and placed in the alveolar bone distal to the roots of the second premolar at three different angulations (30o, 60o, 90o) to the long axis of the teeth. An orthodontic force of 200g was applied in the direction simulat-ing anterior retraction and the stress patterns in the surrounding bone and micro implant models were studied. In the second part of the study, micro-implants with and without osseointegration were modelled. An orthodon-tic force of 200g was applied from the head of the micro implant in a direction simulating maxillary anterior retraction and an orthopae-dic force of 400g was also applied from the head of the implant simulating the force from the protraction face mask in both the mod-els. The stress patterns in the micro implant models and surrounding bone were studied.

Geometric modelling of the maxilla and the maxillary dentition was accomplished in a num-ber of steps. First, a computerized tomogram (CT) scan of a patient maxilla and the dentition was acquired with images taken at 1mm inter-vals. Next, the scanned images were viewed

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

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

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

simulated as the entire surface of the threads of micro-implant getting fused with the sur-rounding bone (Figure 3). Geometric model-ling of the micro-implant was accomplished by placing the traced micro implants distal to the roots of the second premolar at 30o, 60o, 90o

angulations to the long axis of the tooth, with the head oriented towards the crown (Figure 4). A line passing through the long axis of the second premolar was traced in ANSYS that was used as a reference plane for placing the

Figure 2: Simulation of non-osseointegrated micro-implant model.

Figure 3: Simulation of osseointegrated micro-implant model.


Sakthish et al

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

the non-osseointegrated micro-implant the num-ber of elements was 212,266 and 36,777 nodes.

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

RESUlTSPart IIn the peri-implant region, maximum compres-sive stresses were observed in the mesial side of implant neck and minimum compressive stresses were observed in the distal side of implant apex. Maximum tensile stresses were observed in the distal side of the implant neck and minimum ten-sile stresses were observed in the mesial side of the implant apex. This was a common observation

Figure 4: Model of the maxillary arch with micro-implants at angulations of 30o, 60o, and 90o.

Table 1: Material Properties

Materials Young’s Modulus Poisson’s Ratio

Titanium 1.10E + 05 3.0E – 01

Alveolar Bone 1.37E + 03 3.0E – 01

Periodontal Ligament 6.67E – 01 4.5E – 01

Tooth 1.96E + 04 3.0E – 01

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

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

pattern of stress distribution was also observed in the non–osseointegrated micro-implant, but the osseointegrated micro-implant showed a more even stress distribution in the peri-implant region although stresses were more on the mesial side in the direction of the force application (Table 4). The osseointegrated model showed less stress in the microimplant and in the surrounding bone as compared to the non-osseointegrated model (Table 5).

On orthopaedic force application, the stress patterns were similar to that of orthodontic force application but with higher stress values due to increased force magnitudes. The mag-

Figure 5a: Orthodontic force finite element model. Figure 5b: Orthopaedic force finite element model.

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

Various Compressive Stress Tensile Stress Angulations Neck Apex Neck Apex

30O -281.69g -0.01128g 209.25g 5.36g

60O -285.35g -0.02016g 215.26g 4.19g

90O -289.28g 0.02093g 223.57g 2.91g


Sakthish et al

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

Various Angulation Placement Stress in Surrounding Bone Stress in Micro Implant

30o 255.21g 4420g

60o 267.21g 4515.21g

90o 276.12g 4595.22g

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

Micro-Implant Compressive Stress Tensile Stress Model Neck Apex Neck Apex

Osseointegrated -102.59g -0.02276g 97.47g 2.56g

Non-Osseointegrated -281.69g -0.01128g 209.25g 5.36g

Table 5: Stresses on the surrounding bone and the micro implant model with and without osseointegration on orthopedic force application.

Micro Implant at 30o Stress in Stress in (Orthodontic force – 200g) Surrounding Bone Micro Implant

Osseointegrated 100.56g 4395g

Non-Osseointegrated 255.21g 4420g

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

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

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

Micro-Implant Compressive Stress Tensile Stress Model Neck Apex Neck Apex

Osseointegrated -214.78g -0.02357g 193.48g 2.90g

Non-Osseointegrated -578.25g -0.04531g 491.36g 7.28g

Table 7: Stresses on the surrounding bone and the micro-implant model with and without osseointegration on orthopaedic force application.

Micro Implant at 30o Stress in Stress in (Orthodontic force – 400g) Surrounding Bone Micro Implant

Osseointegrated 205.14g 8618g

Non-Osseointegrated 530.42g 8856g

FEM has been used extensively in the pre-diction of biomechanical performance of dental implant systems.14,16 These studies have evaluated osseointegrated implants in response to occlusal forces which may be axial, non–axial, or oblique occlusal. However, there are not many FEM stud-ies evaluating the performance of orthodontic micro implants. In contrast to dental implants, these microimplants are generally non-osseointegrated and are subjected to forces in a non-axial direction. The magnitude of force is also significantly less than those placed on dental implants. Immediate load-ing of these micro/mini implants is recommended if the force applied is less then two Newtons.7,8

The long-term clinical performance of a dental implant is dependent upon the preservation of good quality of bone in the peri-implant region which,

in turn, is dependent on the appropriate level of bone remodelling that occurs in response to the stress in the surrounding bone and implant.12 The stress in the surrounding bone should be within range of physiologic homeostasis. The range of acceptable compressive stress needed for healthy maintenance of bone appears to be between 1.4 to 5 Mpa (140 to 500g).14,17 Stresses exceed-ing this range have been reported to cause bone resorption and fatigue failure of the implant.

Bone is a porous material with complex, non-homogenous anisotropic microstructure. Cortical bone has the highest load bearing capacity due to its dense nature when compared to porous trabe-cular bone.18 In cortical bone, stress dissipation is restricted to the immediate area of bone sur-rounding the implant where as in trabecular bone,


Sakthish et al

a fairly broader distant stress distribution occurs. One must keep this in mind when planning place-ment of micro-implants for orthodontic purposes as the nature of bone varies in different areas of maxilla and mandible.19 For orthodontic retrac-tion of the anterior segment, micro-implants are typically placed between the premolar and molar. Accordingly, in this study, D4 bone (posterior max-illa) was simulated for studying stress patterns.

Micro-implants aid retention by mechanical means rather than osseointegration. While both

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

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

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

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

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The second part of study demonstrates that with orthodontic force application, the stresses produced in the peri-implant region, surround-ing bone, and micro-implant were less in the osseointegrated model than in the non-osseointe-grated model. Both models demonstrate maximum compressive stresses at the implant neck in the direction of force application while maximum ten-sile stress was observed at the implant neck in the direction opposite of force application. While the stress patterns appeared more evenly distributed around the implant neck of the osseointegrated model as compared to the non-osseointegrated model (Figures 7a,7b), the stresses in both mod-els were found to be within the physiological limits.

With orthopedic force application, the stresses in the peri-implant region in the non-osseointe-grated micro-implant models were found to exceed physiological limits in contrast to the osseointe-grated implant model. Like the orthodontic force model, stresses for the orthopaedic force model also appeared more evenly distributed around the osseointegrated microimplant than in the non-osseointegrated micro-implant (Figures 8a,8b).

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

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

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

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


Sakthish et al

variations in the stress values. Thus, both per-pendicular and diagonal placements of implants are acceptable. 2) It was found that with 200g of orthodontic force application, stress produced in the surrounding bone was within physiological limits in both osseointegrated and non-osseointe-grated micro-implant models. However, with 400g of orthopaedic force application, the stress pro-duced in the surrounding bone in the osseointe-grated micro-implant model (205.14g) was within physiological limits whereas the stress generated in the non-osseointegrated micro-implant model (530.42g) exceeded physiological limits. Hence osseointegration of micro-implants is recommended for successful loading of orthopaedic force. ●

Figure 8a: Stress patterns in the osseointegrated micro-implant with orthopaedic force application.

Figure 8b: Stress patterns in the non-osseointegrated micro-implant with orthopaedic force application.

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.References1. Branemark P. Osseointegration and its experimental background. J Prosthet

Dent 1983; 50(3):399-410.2. Mazzocchi AR, Bernini S. Osseointegrated implants for maximum orthodontic

anchorage. J Clin Orthod 1998; 7(7):412-415.3. Roberts WE, Marshall KJ, Mozsary PG. Rigid endosseous implant utilized as

anchorage to protract molar and close an atrophic extraction site. Angle Orthod 1990; 60(2):135-152.

4. Mah J, Bergstrand F. Temporary anchorage devices: A status report. J Clin Orthod 2005; 39(3):132-136.

5. Kyung H, Park H, Bae S, Sung J, Kim I. Development of orthodontic micro implants for intra oral anchorage. J Clin Orthod 2003; 37(6):321-328.

6. Cope JB. Temporary anchorage devices in orthodontics: A paradigm shift. Seminars in Orthodontics 2005; 11(1):3-9.

7. Bae S, Park H, kyung H, Kwon O, Sung J. Clinical application of micro implant anchorage. J Clin Orthod 2002; 36(5):298–302.

8. Miyawaki S, koyama I, Inoue M, Mishima K, Sugahara T, Takano-Yamamoto T. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am J Orthod 2003; 124(4):373-378.

9. De Pauw GAM, Dermaut L, De Bruyn H, Johansson C. Stability of implants as anchorage for orthopedic traction. Angle Orthod 1999; 69(5):401-407.

10. Singer SL, Henry PJ, Rosenberg I. Osseointegrated implants as an adjunct to face mask: A case report. Angle Orthod 2000; 70:253-260.

11. Chung K, Kim S, Kook Y. The C-Orthodontic microimplants. J Clin Orthod 2004; 38(9):478-486.

12. Geng J, Tan KBC, Liu G. Application of finite element analysis in implant dentistry: A review of the literature. J Prosthet Dent 2001; 85(6):585-598.

13. Tanne K, Sakuda M, Burstone CJ. Three dimensional finite element analysis for stress in the periodontal tissues by orthodontic forces. Am J Orthod 1987; 92:499-505.

14. Holmgren EP, Seckinger RJ, Kilgren LM, Mante F. Evaluating parameter of osseointegrated dental implant using finite element analysis: A two dimensional comparative study examining the effects of implants diameter, implant shape and load direction. J Oral Implantology 1998; 24(2):80-88.

15. Vasquez M, Calao E, Becerra, Ossa J, Enriquez C, Fresneda C. Initial stress differences between sliding and sectional mechanics with an endosseous implant as anchorage: A 3-D FEM analysis. Angle Orthod 2001; 71:247-255.

16. Rieger MR, Mayberrt M, Brose MO. Finite element analysis of six endosseous implants. J Prosthet Dent 1990; 63:671-676.

17. Bozkaya D, Muftu S, Muftu A. Evaluation of load transfer characteristics of five different implants in compact bone at different load levels by finite element analysis. J Prosthet Dent 2004; 92(6):523-530.

18. Martin RB, Burr DB, Sharkey NA. Skeletal tissue mechanics. 1st edition New York; 1998:127-178.

19. Lin JC, Liou EW. A new bone screw for orthodontic anchorage. J Clin Orthod 2003; 37(12):676-681.

20. Skalak R.Biomechanical considerations in osseointegrated prostheses. J Prosthet Dent 1983; 49:843-848.

Correspondence:Dr. Sridevi PadmanabhanProfessor, Dept. of OrthodonticsSri Ramachandra Dental CollegePorur,1, Ramachandra Nagar, Chennai-600116Ph: 044-28156665;9600077428e-mail: [email protected]

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Winter et al

Background: This is part 2 of a 5 part study evaluating data obtained from dental refer-ral usage of radiological labs for three dimen-sional (3D) anatomical scans. The purpose of this portion of the study was to gather detailed data on the lingual artery and discuss its potential impact on dental implant delivery.

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

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

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

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

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

Alan A. Winter, DDS1 • Kouresh Yousefzadeh, DDS2 • Alan S. Pollack, DDS3 Michael I. Stein, DMD4 • Frank J. Murphy, DDS5

Christos Angelopoulos, DDS6

1. Assistant Clinical Professor, Department of Periodontics and Implant Dentistry, New York University College of Dentistry

2. Private practice, New York, USA




6. Director Maxillofacial Dental Radiology and Associate Professor of Clinical Dentistry, Columbia School of Dental Medicine

Abstract

KEY WORDS: Cone beam computed tomography, lingual artery, mandible, dental implants


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IntRODuCtIOnThe recent advent of cone beam computed tomography (CBCT) technology has vastly increased the diagnostic options for dental treatment. While this technology is continu-ally improving in terms of quality, equipment size, and cost, most dental offices do not own CBCT scanners at this time. Accord-ingly, many practices currently refer patients to freestanding dental radiological labs for three dimensional (3D) anatomical scans. The purpose of this series of studies was to determine how and for what reason dentists currently utilize dental 3D imaging centers.

Part one of this study series evaluated demo-graphic data and the reasons why patients were referred for 3D evaluation. The purpose of this current study was to gather detailed data on the lingual artery and discuss its potential impact on dental implant delivery. Specifically, the follow-ing parameters of the lingual artery were evalu-ated: the radiographic presence or absence of the lingual artery, the location of its insertion into the mandible, how many branches of the lingual artery were present, and what was the diameter of the most superior branch of the lingual artery.

MAtERIAlS AnD MEthODSCBCT scans of the dental arches from 500 con-secutive patients taken in 9 centers located in 3 states were uploaded to the main processing cen-ter of a single dental radiological practice (i-don-tics, LLC., New York, NY) which is limited to taking and processing 3D CT images for the dental com-munity. Scans were taken on either i-CAT scan-ners (8 centers) or on a (1) NewTom 3G scanner. All studies were converted to SimPlant™ (Mate-rialise, Glen Burnie, MD). When not specified,

the data was converted to SimPlant™ version 10. The current study evaluated data con-

cerning the lingual artery including: the radio-graphic presence or absence of the lingual artery, the location of its insertion into the man-dible, how many branches of the lingual artery were present, and what was the diameter of the most superior branch of the lingual artery.

RESultSCT scans from 500 consecutive patients requiring cone beam scans were included in this study. Of these scans, 296 were of the mandible. 98% (290/296) had observable insertions of the lingual artery into the man-dible. The following observations were noted:

number of lingual arteries:1. 40.2% (119/296) had one lingual artery2. 47% (139/296) had 2 lingual arteries3. 10.7% (31/296) had 3 lingual arteries4. 0.34% (1/296) had four lingual arteries

Average length of the lingual artery:1. Average length of lingual artery inserted

into the alveolar bone = 9.6mm

location of insertion of lingual artery relative to mandibular height:1. Insertion in crestal 1/3 of madible = 3.44%

(10/296)2. Insertion in middle 1/3 of madible = 88.5%

(262/296)3. Insertion in apical 1/3 of madible = 59.45%

(176/296)* Cumulative percentages exceed 100% due to some patients having multiple branches of the lingual artery.


Winter et al

location of insertion of lingual artery relative to the genial tubercle:1. Insertion coronal to genial tubercle =

91.55% (271/296)2. Insertion below genial tubecle =

57.43% (170/296)3. Insertion equal to genial tubercle =

12.76% (37/296)* Cumulative percentages exceed 100% due to some patients having multiple branches of the lingual artery.

Diameter of lingual artery:1. Less than 1mm diameter = 80.3% (233/296)2. Greater than 1mm in diameter =

19.7% (57/296)

DISCuSSIOnSchick et al1 scanned 32 patients scheduled for mandibular implants to determine if CT scans could depict the presence, diameter, position, direction and frequency of vessels. In their study, lingual vascular canals were demon-strated in all patients. Most lingual canals were located in the midline and the mean diameter of the lingual canals was 0.7mm. Similar studies in 3 cadavers confirmed these findings, conclud-ing that the occurrence, position and size of the lingual vessels could be depicted on CT scans.

As more patients seek implant placement in order to avoid or stabilize mandibular den-tures, it is important for clinicians to under-stand the limitations of two-dimensional (2D) imaging, especially when it comes to identify-ing the presence, location, and diameter of the lingual artery in respect to its insertion into the mandible. The importance of this was dem-onstrated when Niamtu described a case of a

near-fatal airway obstruction which resulted from sublingual bleeding following implant placement.2 An additional case was described by Isaacson3 in which sublingual hematoma likely resulted from dental implant perforation of the lingual cortex and violation of one of the branches of the sublingual or facial arter-ies. A review of the literature revealed that these occurrences could be life-threatening.4-15

The current article and those just men-tioned demonstrate the value of 3D imaging in preparation for anterior mandibular implant placement. Figure 2 is a panoramic view of a mandibular anterior edentulous site where den-tal implants were to be considered for inser-tion. In the 2D image, there is no sense of either the width of available bone or where the lingual artery inserts into the mandible. Figure 3 is a transaxial view through the #25 site. It reveals a narrow, spinous crest of bone that contains very little cancellous bone. Midway down the lingual plate, the lingual artery can be observed inserting into the mandible. This artery is not very wide but may be of concern

Figure 1: Lingual artery distribution.

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Winter et al

should it be violated during implant placement. This information was not clinically evident nor was it indicated on conventional 2D imaging. Figure 4 is an example (no implant is planned in this case) of a wide-diameter lingual artery that puts the patient in jeopardy should it be sev-ered during implant surgery. This is an example of how a critical anatomic structure may not be observed through conventional 2D imaging but is readily apparent in transaxial (cross-sectional) views from medical and dental CT scanners.

While cases of atrophy compromise any edentulous area that is adjacent or proximal to key anatomic structures, the mandibular anterior region is particularly vul-nerable to potential risk relative to the width and insertion of the lingual artery. Seem-ingly innocuous perforations can lead to large hematomas or life threatening arterial bleeds.

COnCluSIOn

Implant placement in the mandibular ante-rior region is most often a benign proce-dure. However, clinicians should bear in mind

the potential risk of piercing the lingual plate and injuring the lingual artery. This review of 296 CBCT scans demonstrates the value of 3D CBCT scans in identifying the presence, location, length, and diameter of the inser-tion of the lingual artery into the mandible. ●

Disclosure Support for this study was generously given by NobelBiocare, Mahwah, NJ and Imaging Sciences Inc., Hatfield, PA.

References1. Schick S, Zauza K, Watzek G. Lingual Vascular Canals of the Mandible:

Evaluation with Dental CT. Radiology 2001; 220(1):186-189.

2. Niamtu, J. Near-fatal airway obstruction after routine implant placement. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 92(6): 597-600.

3. Isaacson, T. Sublingual hematoma formation during immediate placement of mandibular endosseous implants. J Am Dent Assoc 2004; 135: 168-172.

4. Goldstein B. Acute dissecting hematoma: A complication of oral and maxillofacial surgery. J Oral Surg 1981; 39(1): 40-43.

5. Mordenfield A, Andersson L, Bergstrom B. Hemorrhage in the floor of mouth during implant placement in the edentulous mandible: A case report. Int J Oral Maxillofac Implants 1997; 12: 558–561.

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

Correspondence:Dr. Alan [email protected]


Winter et al

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

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

6. ten Bruggenkate CM, Krekeler G, Kraaijenhagen HA, Foitzik C, Oosterbeek HS. Hemorrhage of the floor of the mouth resulting from lingual perforation during implant placement: A clinical report. Int J Oral Maxillofac Implants 1993; 8: 329–334.

7. Mason ME, Triplett RG, Alfonso WF. Life-threatening hemorrhage from placement of a dental implant. J Oral Maxillofac Surg 1990; 48: 201–204.

8. Givol N, Chaushu G, Halamish-Shani T, Taicher S. Emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region. J Periodontol 2000; 71:1893–1895.

9. Burke R, Masch G. Lingual artery hemorrhage. Oral Surg Oral Med Oral Pathol 1986; 62: 258–261.

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

11. Laboda G. Life-threatening hemorrhage after placement of an endosseous implant: Report of case. J Am Dent Assoc 1990; 121: 599–600.

12. Darriba MA, Mendonca-Caridad JJ. Profuse bleeding and life-threatening airway obstruction after placement of mandibular dental implants. J Oral Maxillofac Surg 1997; 55: 1328–1330.

13. Panula K, Oikarinen K. Severe hemorrhage after implant surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 87(1): 2.

14. Mardinger O, Manor Y, Mijiritsky E, Hirshberg A. Lingual perimandibular vessels associated with life-threatening bleeding: An anatomic study. Int J Oral Maxillofac Implants 2007; 22(1): 127-131.

15. Kattan B, Snyder H. Lingual artery hematoma resulting in upper airway obstruction. J Emerg Med 1991; 9: 421-424.

Mackey

IntroductIonLet’s face it: to a clinical dentist whose exper-tise lies primarily inside the human mouth, suc-cess on the Web can be a daunting, elusive goal. For that matter, Web success can be a daunt-ing objective for even the most seasoned, savvy online marketers. Why? Consider the following:

● the internet is a vast, growing reposi-tory of information and communication — as of March 31st, 2009, the U.S Census Bureau and Nielsen Online estimated that there were 1.6 billion users of the World Wide Web. That is 24% of the world’s population!

● the technology powering the Web is constantly changing — as companies vie for financial success by creating innova-tive experiences for us to enjoy, new tech-nologies in support of those experiences continue to reshape the way we utilize the Web.

● the Web is an untamed, evolving organ-ism — although governed by a fundamental architecture, many people across the world use the Internet but no one entity controls it.

When properly utilized, the internet is offers the opportunity to showcase your practice in nearly any reflection of your identity that you desire. To achieve such, you must think in creative and ingenious ways. This article is the first in a

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

the Blog: An IndIspensABle Asset

Your website is one of the most indispensible assets of your dental practice. In many cases, a customer’s first impression of your practice will come from your website. When a patient is referred to your practice, whether it be from another dentist, or better yet by another patient, they will often research your background by visiting your website. When they visit your site, what message is the patient receiving?

First and foremost, you must realize that your website does not exist primarily to make money. Sound contradictory? While it is true that the ultimate goal of your website is to indi-rectly raise revenue via the recruitment of new patients, revenue generation should always be a result of your online reputation and the message that you convey to your patients.

Online recruitment of new patients requires persuasive and authentic communication. One effective method to achieve such communica-tion with prospective patients is via blogging. As

Cultivating Your Online Dental Reputation with Blogs

Shannon Mackey1

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


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recently as 2006, “web-logs” (as they were first termed) were viewed as nothing more than a curi-ous quasi-voyeuristic method of online journal-ism, a brief online phenomenon, or narcissistic personal hobby. Make no mistake, blogging is much more than a passing fad. It is here to stay and will continue to grow with time. Accord-ingly, taking advantage of blogging to enhance our online reputation demands our attention.

The exploding popularity of blogs represents a major shift in how consumers prefer to research and buy goods and services. No longer are there invisible lines of protocol between seller and buyer. The internet has allowed consumers to become much more educated about the goods and services they intend to purchase. As such, many consum-ers no longer passively listen to salespersons, or their treatment provider for that matter. With their newfound knowledge, consumers and patients often actively engage in discussions regard-ing their potential purchase or healthcare plan.

In early online sales models, the product was the focus; now, the experience is the focus. While eventual purchase of a good or service is always the ultimate goal, the quality of the sales experi-ence plays a much larger role in the overall suc-cess of the product. For example, how many times have you seen poor quality dentistry on a patient that raves about how they have or had a great dentist? Even though the dentistry was of poor quality, the patient was happy because of the way they were treated. The overall success for this patient was largely fashioned by factors external to the actual dental restoration. On the other hand, patients that receive quality care sometimes are dissatisfied with their dentist due to factors com-pletely unrelated to the actual dental restoration. Truly, the overall success of dental treatment can

no longer be related to the restorative or surgical care alone; the entire treatment experience is what determines success or failure in the patient’s mind.

Blogging affords practitioners the oppor-tunity to convey messages to prospective and current patients in a format that is comfort-able and non-threatening. Patients can access this information from the familiarity and safety of their home and have adequate time to pro-cess this information without feeling pressured. This sincerity makes the blog significantly more trustworthy than your average website mar-keting lingo or hollow-sounding sales-speak.

This concept is not new, but the medium is. You are already doing this every day in your office. When a patient arrives at your office, the sales process begins. When the patient parks their car in your parking lot, the aesthetic exterior of your building affects the patient’s perception of your practice. When a patient enters your waiting area, the cleanliness of the building, the friendliness of the staff, and a cornucopia of other factors affect the patient’s psyche. Your website is no different. Your website is often the very first impression that a patient. Anything you can do to enhance the patient’s experience on your website will ultimately benefit your patient attraction and retention goals.

Something blogs also do very well, which is central to any effective marketing effort, is to gently open the door and establish a dialogue between you and a new prospect. Once that basic rapport has developed and the door is open, the opportunity to sell increases dramatically. Trust and confidence are the keys. Once you have gained the patient’s trust and confidence, the door will open. Blogs can help you accom-plish as much. Basic steps can you take to cul-tivate your online reputation via blogging include:


Mackey Mackey

● Establish a blog through your website company or at www.blogger.com

● Send an email to your existing patients to announce the blog.

● Avoid canned commerciaism or a “sales-like” tone.

● Speak your mind on a variety of dental topics, both the esoteric and the mundane.

● Answer commonly asked dental questions. This may end up saving you time by eliminating repetitive questions.

● Express your personality through your writings. Patients may develop a bond with you by simply identifying with the manner in which you write.

● Think from the patient’s perspective. What information do they seek?

● Communicate practice news and updates. Announce your awards, speaking engagements, and publications.

● Establish a sense of community. Show your involvement with local people, businesses, volunteer efforts, and social/sports activities.

● Use hyperlinks to integrate your blog with your dental website.Correctly designed, properly maintained and

routinely updated, a blog can become a traffic-gen-erating powerhouse. It is capable of establishing your personality, improving your visibility, building a sense of community, maintaining an open dia-logue between you and your patients, and keeping them fully informed. Blogging remains an effective tool for use in conjunction with a myriad of other online innovations such as search-engine optimi-zation and webcasts to strengthen your overall marketing strategy and enable a dental experi-ence that fully satisfy your patient’s expectations.

Blogging doesn’t have to be a time consum-ing activity for the practicing dentist. Ask your

hygienist, treatment coordinator, dental assis-tants and other office staff to begin writing blog entries. It is recommended that you preview each blog prior to publication on your web-site. Depending on typing speed, it shouldn’t take any longer than 15-20 minutes for your team members to write a few paragraphs.

As your team begins to craft a unique online narrative of their lives at your practice, give your patients every opportunity to have their voices heard. Be the gentle, knowledgeable, respect-ful expert you are. You might want to conduct an online promotion aimed exclusively at your blog community. You might ask other local dentists to participate in your blog to enrich the conversation and expand the site’s scope and influence. The possibilities are endless.

conclusIonAs more traditional advertising and market-ing vehicles continue to lose market share to their digital counterparts, consider utilization of blogs for your website. It should be an essen-tial aspect of your marketing plan. Does it take some time to write? Yes. Is it new and a little unnatural? Of course. Will it complement your online marketing plan? Most definitely. Sim-ply put, if you blog on a regular basis, it’s going to spell success for your dental practice. ●

correspondence:Shannon Mackey Owner & Customer Relations DirectorRoadside Multimedia [email protected] (425) 530-1848 Direct Line (801) 996-0758 Fax

jiacd-oct-2008

Documents

new bone deposition

percentages of left

bone growth

new bone5040302010

new orleans

cancellous allografts

trademark of orapharma

rocky mtn puros