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The Journal of Implant & Advanced Clinical Dentistry

Volume 9, No. 3 April 2017

GBR of Peri-Implantitis Defect

Custom Made Auricular Prosthesis

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The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 3 • April 2017

Table of Contents

6 A Custom Made Implant Supported Auricular Prosthesis Designed by Rapid Prototyping for Compromised Bone Support: A Case Report M. Lovely, Dinesh Gopal, Vinod Kumar, K. Chandrasekharan Nair, Biji.Thomas

12 Guided Bone Regeneration in Peri-Implantitis Bone Defect After Free Gingival Graft: A Case Report Daisuke Ueno, Tsuneaki Watanabe, Takatoshi Nagano

2 • Vol. 9, No. 3 • April 2017

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

20 Computer Based Textural Evaluation of Concentrated Growth Factors (CGF) in Osseointegration of Oral Implants in Dental Panoramic Radiography Francesco Inchingolo, Panagiotis G. Georgakopoulos, Gianna Dipalma, Stavros Tsantis, Tiziano Batani, Ezio Cheno, Ioannis P. Georgakopoulos

30 Extraction and Immediate Placement of Dental Implants in Mandibular Anterior Site with Delayed Prosthetic Loading Protocol in a Chronic Generalized Periodontitis Patient: A Case Report Dhaval Pandya


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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, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn 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, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

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

Co-Editor in ChiefLeon Chen, DMD, MS, DICOI, DADIA


Lovely et al

Implant supported auricular prosthesis requires a minimum of 6mm bone depth in the tem-poral bone area behind external auditory

meatus. Extra oral implants are available from 4mm to 7mm length with 5 to 6mm diameter flange. When the bone height is compromised and when only few regions have favorable posi-tions which are not part of the slot area all the existing extra oral systems cannot be used. In cases with compromised bone condition, a cus-tom made implant is the best choice that can offer good prognosis. This article presents a unique

case report in which rapid prototyping was used to build up the thickness and bone dimension of the patient’s available bone depth to design a custom made single piece Titanium implant with superstructure attachment. The advantage of this new method was that it could copy the available bone depth with the help of CT analy-ses and design an implant as per the dimensions obtained through the rapid prototyped model. This new technique is economical and also offers the patient all the advantages and com-fort of an implant retained auricular prosthesis.

A Custom Made Implant Supported Auricular Prosthesis Designed by Rapid Prototyping for Compromised Bone Support: A Case Report

M. Lovely, BDS, MDS, DipNb, PhD1

Dinesh Gopal, BDS, MDS, MOSRCS , FDS RCS (Edin)2

Vinod Kumar, M.B.B.S, M.S (Gen. Surgery), DipNb. (Plastic Surgery)3

K. Chandrasekharan Nair, BDS, MDS4

Biji.Thomas.George M.B.B.S, M.S (Gen Surgery), DipNb, FRCS (Glascow)5

Abstract

KEY WORDS: Rapid prototyping, implant retained auricular prosthesis, custom made implant

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1. 1. Asst.Prof Ras Alkhaimah College of Dental Sciences, RAK, UAE

2. 2. Consultant Oral and Maxillofacial surgeon, Trivandrum

3. 3. Consultant, Department of Plastic Surgery, Anandapuri Hospital, Trivandrum

4. 4. Professor Emeritus, Vishnu Dental College, Bhimavaram, Andhra Pradesh

5. 5. Consultant General surgeon SK Hospital Trivandrum

Lovely et al


INTRODUCTIONThe commonest reasons for auricular defects are congenital malformation, tumors or accidents. If there is skin loss and scarring an autogenous reconstruction is difficult and hence the only next available option remains to be implant retained auricular prosthesis. Extraoral implant retained prosthesis have predictable results for maxillofa-cial rehabilitation.1,2 Amongst the implant retained auricular prosthesis, the commonest ones used are extra oral implants which can either be soli-tary or group implants. The most commonly used solitary implants are the Brånemark system, ITI system by Straumann, IMZ by Friadent and Ankylosis by Dentsply. The implant dimen-sion for extra oral solitary implants vary from 3 to 5mm length with a diameter of 5.5mm. The grouped implants are Epitec and Epiplat-ing systems which are subperiosteal implants fixed with bone screws of 4, 5.5 and 7mm. Epitec was found to be flexible and hence pres-ently not used but the epiplating system with a plate thickness of 2mm with 4 thread turns are more reliable than the Epitec grid system.

Implant-retained auricular prosthesis provide convenience, consistent retention, eliminaties the need for adhesives, maintain marginal integrity and longevity.3,4 These are two stage implants, later connected with a supra structure design like a metal bar or magnetic connection. Numer-ous attachments are available for the retention of implant-retained prosthesis. Implant-retained auricular prosthesis usually require a bar with clips or retentive elements in addition to the pros-thetic ear.5,6,7 This article describes a new tech-nique to make a custom made implant designed with the help of a rapid prototyped model.

The implant placement in mastoid region

is only predictable after a CT of the tempo-ral bone is made to evaluate the thickness of bone available for the type of implant that can be used. An axial CT enables to visualize the distance from mastoid region to external audi-tory canal. If bone height is good in mastoid region the implant survival rate is the highest when compared to all maxillofacial implants.8

The ideal location of the implant should be 20mm away from external acoustic meatus and with a space of 15mm between implants. 9 and 11 clock positions are ideal for right side as the implants and the bar will be underneath antihe-lix ridge. Two stage procedure can result in scar tissue formation hence a single stage procedure is preferred. Common type of super structure design is a metal bar as Dolder or Hader that is screwed onto the percutaneous posts which are parallel on which the prosthesis is clipped on.9,10

CASE REPORTA 30-year-old man, who lost his right ear due to burn injury, who had undergone multiple graft surgical procedures reported to the hos-pital with the chief complaint of wanting a per-manent replacement for his missing ear. Heavy scarring was observed with the missing right ear. Due to scar formation, autogenous pro-cedures for ear reconstruction could not be done. The patient was young and wanted an implant retained auricular prosthesis. The CT scan showed atrophied temporal bone with the exception of a few areas with favorable bone depth but those areas were not ide-ally located for a solitary implant. Hence after case history taking and treatment planning it was decided to do a custom made extra-oral implant to retain the auricular prosthesis.

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Treatment plan:To evaluate the areas of adequate bone depth a CT of axial coronal and sagittal cuts of tempo-ral bone up to mastoid process was taken. The data was saved and transferred in DICOM (Digi-tal Imaging and Communications in Medicine) format for rapid prototyping. A 3D model was obtained from the data of computerized tomog-raphy with the help of software Mimics, Materi-alise Inc (Figure. 1). The Proto typed model was made of Polymethyl methacrylate (PMMA) indi-cating the surface morphology of bone and the varying bone depths available for implant screws.

The exterior morphology of the bone was smooth with no depth or undercuts making it favor-able for a custom implant. Areas with adequate bone depth were marked in the PMMA model so that screw slots could be made in those areas for the custom implant (Figure 2). Patient’s skin thick-ness was evaluated in the preauricular region after local anesthesia using needle prick technique.

This was to help in designing the superstruc-ture height from the base of the custom made implant. The final design for the custom made implant was drawn on the model and the super-structure dimension was separately instructed to the lab via a lab authorization form which included the neck of the abutment superstruc-ture height and bar attachment design (Figure 3).

Wax Pattern Trial for the Implant to be Custom MadeThe replica of the custom made implant in wax was tried in the patient to evaluate if the height of the supra structure was adequate. The position of the bar superstructure was assessed to check if the distance of the implant was 20mm away from auditory canal and the single bar structure with two abutment support were 15mm apart. The superstructure and the base of the implant wax pattern were tentatively placed on skin in position to check if the bar will be underneath

Figure 1: Conversion of CT image for rapid prototyping. Figure 2: Rapid prototyped model.

Lovely et al


antihelix ridge. (Figure 4). The corrected pattern was later casted in Titanium alloy superstructure.

Clinical ProcedureMarks were made with surgical ink and an inci-sion line was made 7 mm behind the implant site down to the periosteum. The procedure was done under general anesthesia. The custom designed Titanium frame work with multiple screw slots and the superstructure bar design was slid into place within the temporal bone region as marked by areas of bone depth and multiple 1.5mm×4mm titanium screws were used to hold the custom made implant in place (Figure 5). Before tighten-ing the screw slot the implant position, superstruc-ture position and the dimension of the abutment neck height was rechecked. After confirming the position along the axis with the other ear position using various facial plane measurements, the mul-tiple screws were tightened and the single stage titanium implant with the bar superstructure was

fixed in place. After the placement of the single stage custom implant in ideal position, sutures were placed approximating the abutment super-structure. Every week patient was recalled to observe if any inflammation or skin pocket was seen. The implant was left for osseointegration for three months. On recall it was found tissues had healed well with no post operative complications. A repeat CT showed good osseointegration and adaptation of the custom made implant (Figure 6).

Prosthesis FabricationHair adjacent to the ear was coated with petro-leum jelly and cotton was placed in the ear canal. Impression of the superstructure design was made with polyvinyl siloxane impression material (Elite H-D, Type 1, Zhermack). The impression was boxed and poured in die stone. An ear pattern was created using the donor technique that matched closely to the patient’s ear in dimensions. The rest of the carving was perfected in the wax pattern

Figure 3: Superstructure design. Figure 4: Wax pattern try in.

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Figure 5: Custom made implant in position. Figure 6: Post-operative CT image.

of ear to exactly match the opposite ear in size and shape. The prepared wax pattern was then adapted to the stone cast. Three retention clips were positioned on the Ti bars, in a substruc-ture (Figure 7). The substructure along with the ear wax pattern was tried for accuracy of fit, orientation, and esthetics with the patient in the physiologic rest position. Wax pattern was placed into a flask and conventional procedures for wax elimination of the mold were followed.

After the complete removal of wax, the sili-con elastomer (A-RTV-30, Factor II) which was colored intrinsically (Intrinsic Coloring Kit Fac-tor II) was then bulk filled, and the material was processed according to the manufacturer’s directions. After processing, the prosthesis was removed from the mold; and extrinsic matching of the colour was completed. The final correc-tions were made, and the silicon prosthesis’s was then adapted to the defect area (Figure 8).

DISCUSSIONMaxillofacial defects can be restored by remov-able or fixed methods. Many patients with these defects have been rehabilitated suc-cessfully with maxillofacial implants.2 The suc-cess of implant retained prosthesis depended on careful treatment planning.2,3 Advance-ments in computer technology to produce 3 dimensional (3D) models by rapid prototyping technology (RP) perfects the final restoration.

Rapid Prototyping (RP) Advantages of CAD/CAM include elimi-nation of impression making, good posi-tive replica and ability to store the models in hard disks. In this case report rapid pro-typed model has been used for accuracy of bone depth to make a custom made implant.

Lovely et al


Figure 7: Auricular prosthesis (tissue side). Figure 8: Final auricular prosthesis in place.

CONCLUSIONThis case report highlights the significance of choices for patients with atrophied bone. A custom made implant enables the same com-fort osseointegration success as that of a soli-tary implant retained auricular prosthesis with good prognosis. Rapid prototyping helps to clearly assess the varying bone depth avail-able for screws making the procedure more precise. The recall appointments even after two years confirm high prognosis as there was no postoperative complications and the patient is still comfortably using it.11,12 l

Correspondence:Dr.Lovely M. BDS, MDS, DipNb, PhD.

College of Dental Sciences, AlQuasidat, PO.Box 12973, RAK, UAEPhone: +971508951751Mail: [email protected]

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

References1. Bulbulian AH. Facial Prosthesis. Springfield, IL: Charles C. Thomas; 1973.

2. Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St. Louis: Medico Dental Media Intl; 1996.

3. Tolman D, Desjardins R. Extraoral applications of osseointegrated implants. J Oral Maxillofac Surg. 1991;49:33–45.

4. Parel S, Tjellstrom A. The United States and Swedish experience with osseointegration and facial prostheses. Int J Oral Maxillofac Implants. 1991;6:75–79.

5. Schaaf NG, Kielich M. Implant-retained facial prostheses. In: McKinstry RE, editor.Fundamentals of facial prosthetics. Arlington: ABI Professional Publications; 1995. pp. 169–179.

6. Wolfaardt JF, Coss P. An impression and cast construction technique for implant-retained auricular prostheses. J Prosthet Dent. 1996;75:45–49.

7. Bergstrom K. Prosthetic techniques for orbital defects. Bone anchored applications. In: Williams E, editor. Nobelpharma international updates. 93.2. Vol. 2. Goteborg: Nobelpharma; 1993. pp. 5–8.

8. Wang RR, Andres CJ. Hemifacial microsomia and treatment options for auricular replacement: a review of the literature. J Prosthet Dent. 1999;82:197–204.

9. Wright RF, Wazen JJ, Asher ES, Evans JH. Multidisciplinary treatment for an implant retained auricular prosthesis rehabilitation. N Y State Dent J. 1999;65:26–31.

10. Rubenstein JE. Attachments used for implant-supported facial prostheses: a survey of United States, Canadian, and Swedish centers. J Prosthet Dent. 1995;73:262–266

11. Penkner K, Santler G, Mayer W, Pierer G, Lorenzoni M. Fabricating auricular prostheses using three-dimensional soft tissue models. J Prosthet Dent. 1999;82:482–484.

12. Petzold R, Zeilhofer HF, Kalender WA. Rapid protyping technology in medicine--basics and applications. Comput Med Imaging Graph. 1999;23:277–284.

Lovely et al

Ueno et al

Background: Peri-implantitis is among the most common pathological conditions encountered in the field of implant dentistry, where regenerative therapy, when possible to perform, is needed. One of the reasons why bone regeneration in peri-implan-titis defects is difficult: due to prosthetic reasons, submerged healing is often not possible to per-form. Another difficulty arises particularly in cases of insufficient attached keratinized mucosa (KM), where the mobility of alveolar mucosa can increase leakage of grafting materials from the treated defect.

Methods: In this case report, a free gingival graft (FGG) was performed on the alveolar mucosa around peri-implantitis region of a 61-year-old male patient. Six months later, Guided bone regeneration (GBR) was performed with a non-

submerged approach in peri-implantitis bone defect (#31, 32) and the adjacent missing tooth region with advanced bone resorption (#30). Results: After a healing period of 5 months, an implant was placed in position #30 with fur-ther bone augmentation. At 23 months after implant placement, the radiographic image showed improvement of radiopacity in the graft-ing area compared to the preoperative radiograph.

Conclusions: Since lack of KM and narrowing of the oral vestibule promote effluence of bone graft-ing material in primary healing period, GBR after acquisition of KM might be a potentially useful sur-gical technique for regenerative therapy with non-submerged procedure in peri-implantitis defect.

Guided Bone Regeneration in Peri-Implantitis Bone Defect After Free Gingival Graft:

A Case Report

Daisuke Ueno, DDS, PhD1 • Tsuneaki Watanabe, DMD2

Takatoshi Nagano, DDS, PhD3

1. Division of Implantology and Periodontology, Kanagawa Dental University, Yokohama, Japan

2. Unit of Oral and Maxillofacial Implantology, Tsurumi University Dental Hospital, Yokohama, Japan

3. Department of Periodontology, Tsurumi University, School of Dental Medicine, Yokohama, Japan

Abstract

KEY WORDS: Guide bone regeneration, dental implants, bone grafting, gingival grafting

12 • Vol. 9, No. 3 • April 2017

Ueno et al


INTRODUCTIONSurgical regenerative therapy of peri-implantitis appears to be more predictable than any type of non-surgical treatment approach.1-3 Previ-ously, intrabony peri-implantitis defect has been tried to treated by regenerative therapy with sev-eral bone substitutes.3,4 Several studies, the majority of which involving deproteinzed bovine bone mineral (DBBM), have reported the effi-cacy of bone substitutes with gain in vertical bone level in intrabony peri-implantitis defect.1,2,5-7

One of the reasons why bone regenera-tion in peri-implantitis defects is difficult: sub-merged healing is often not possible to perform owing to prosthetic reasons. Particularly, insuf-ficient attached keratinized mucosa (KM), where the mobility of alveolar mucosa prob-ably increases leakage of grafting materials. To improve predictability in such cases, this case report demonstrates a novel strategy of bone augmentation in peri-implantitis bone defects.

CLINICAL PRESENTATION A 61-year-old male patient was referred to D.U at Tsurumi University Dental Hospital in April 2013 for chronic pain in tooth #30 and implant sites (#31, 32). Diagnosis of Endo-Perio lesion was observed around tooth #30 (Figure 1). In addition, diagnoses of peri-implantitis was made; radiographic image showed 2.4 and 1.8 mm vertical bone loss found respectively in mesial and distal aspects of the implant #32. 3.6 and 1.8 mm vertical bone loss were found respectively in mesial and distal aspects of the implant #31. Since significant bone resorption was observed after extraction of #30, bone aug-mentation was required for implant placement in site #30 and the proximal peri-implantitis bone defects.

Six weeks after extraction (in May 2013), the

mucosa has healed. Due to lack of KM observed in the sites, Free gingival graft (FGG) harvested from the light palatal mucosa was performed on the buccal alveolar mucosa (Figures 2a-d). No complications occurred during healing period. Since FGG was able to reduce the mobility of peri-implant mucosa, regenerative treatment was performed in September 2013 (4 months later). After administration of local anesthesia, a inci-sion was performed from middle of alveolar crest of the site #30 to the interproximal aspects of the #29, 31. The incision was extended intrasulcu-larly, and vertical releasing incisions were made in the mesial aspect of tooth #29 and distal aspect of implant #32. Full-thickness flaps were elevated in the buccal and lingual aspects. The ridge was resorbed in vertical dimension (Figure 3A). Granu-lation tissue was separated from implant and bone surfaces using hand curettes, and removed in a lump. The machined surface of the implant was cleaned with saline soaked gauze. Then, the sur-

Figure 1: Pre-operative radiographic image of advanced periodontitis and peri-implantitis sites.

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face was irradiated by Er:YAG laser (Morita Evo Yag laser, Morita, Tokyo, Japan) at 10PPS and 30mJ (Figure 3B). Intra-marrow penetration of the recipient site was achieved with a small round bur. The peri-implantitis intrabony bone defect was filled autogenous bone particle which was harvested from the buccal cortical bone of site #30-32 by bone scraper. Then, the supracrestal area of peri-implantitis bone defect and adjacent missing tooth region were filled with the grafting materials [ratio of DBBM (Bio-Oss®, Geistlich,

Biomaterials, Wolhuser, Switzerland): autogenous bone particle = 80:20] (Figure 3C). Graft sites were covered with a collagen membrane (Figure 3D). Finally, after periosteal-releasing incisions, flaps were sutured with 4-0 nylon sutures with-out flap tension. After the operation, antibiotics (Cefdinir, a third-generation oral cephalosporin antibiotic) were prescribed as 100mg, 3 times per day, for 3 days. Healing proceeded with-out any complications after bone augmentation.

Implant body was inserted 6 months (March

Figure 2a: Pre-operatively a lack of keratinized mucosa was observed in sites #30, 31.

Figure 2b: A free gingival graft (FGG) was performed on buccal alveolar mucosa.

Figure 2c: 10 days after free gingival graft. Figure 2d: 21 days after free gingival graft.

Ueno et al


2014) after the grafting procedure. Significant augmentation of ridge height was achieved (Fig-ure 4). A 10-mm long, 4.1-mm diameter implant (Straumann® Standard plus Implant, Basel, Swit-zerland) was placed (30 Ncm) in site #30. Then, further bone augmentation using DBBM was performed on the buccal aspect of the implant (Figure 4C). The graft sites were covered with a collagen membrane (BioMend absorbable col-lagen membrane, Zimmer Dental, CA, USA) and the full thickness flaps were sutured without flap

tension. The post-surgical course was uneventful.At 4 months (September 2014) after implant

placement, the screw-retained temporary crown was replaced by a cement-retained metal-ceramic crown (Figures 5a,b). The radiographic image showed significant fill around implants #30, 31 and 32. The vertical bone level had not changed at 23 months after implant placement (Figure 6). Improvement of radiopacity in the grafting area was observed on the radiograph, where the ver-tical radiographic defect fill was 3.6 and 1.2mm

Figure 3a: Significant bone resorption was observed in site #30-32.

Figure 3b: Cleaning of implant surface with Er:YAG laser.

Figure 3c: Bone augmentation with DBBM in the bone defects.

Figure 3d: The grafted sites were covered by collagen membrane.

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respectively in mesial and distal aspects of the implant #31 compared to the preoperative radio-graph. In addition, 1.8 mm vertical defect fill was observed in the mesial aspect of implant #32.

DISCUSSIONIn this case, GBR demonstrated vertical radio-graphic defect fill in the peri-implantitis bone defect and the adjacent missing tooth region with advanced bone resorption. Previously,

several researches have reported the efficacy of regenerative treatment in peri-implantitis intrabony defects has been supported by sev-eral articles.1,2,5-7 Matarasso et al. reported the possibility of GBR using DBBM and collagen membrane in peri-implantitis defects where 93% of intrabony defect fill was achieved.5 Roc-cuzzo et al. also reported GBR with DBBM in crater-like defect after treatment of implant sur-face by a 24% EDTA gel and a 1% chlorhexi-dine gel.6 Average of bone defect fill was 1.9mm.

From a biological point of view, the result of a surgical regenerative treatment approach might also be influenced by the defect configuration of the peri-implantitis lesion. Schwarz et al. demon-strated that defects with buccal bony dehiscence show a poorer prognosis as regards defect fill compared with circumferential bony defects.8 Also regarding bone augmentation in missing teeth region, external bone augmentation remains more difficult than internal bone augmentation.9 Since the contact surface area between residual bone and graft material is small, particularly in cases which require more vertical bone regen-

Figure 4a: Occlusal view immediately after flap reflection. Figure 4b: Lateral view after flap reflection.

Figure 4c: Occlusal view after implant placement with addition bone augmentation.

Ueno et al


Figure 5a: Intraoral view immediately after fixation of final prosthesis.

Figure 5b: Radiographic view immediately after fixation of final prosthesis.

Figure 6: Radiographic image at 23 months after implant placement.

eration, this configuration limits the blood supply and cell supply from residual bone to graft mate-rial. In addition, external augmentation is suscep-tible to tissue pressure such as masticatory and tongue pressure, which may result in promot-ing bone resorption and morphological change. Therefore selection of bone grafting material with high osteoconductive and mechanical properties are important. Titanium reinforced non-resorb-able membrane is useful for prevention of exter-nal pressure on grafting material in vertical ridge augmentation.10 However, membrane exposure is a frequent phenomenon, which is in agree-ment with previous studies.11 Considering the lower risk of post-operative mucosal dehiscence, the use of resorbable membranes is superior.12

Bone formation in submerged procedures is probably more reliable compared to that of non-submerged procedures, because in the former there may be less bacterial contamination and less dislodgement of bone graft material. How-ever, owing to prosthetic reasons, submerged healing is often not possible to perform. Since lack of KM and narrowing of the oral vestibule

promote soft tissue mobility around implants dur-ing healing period, effluence of bone grafting material may be caused easily. Therefore, FGG prior to regenerative treatment in peri-implanti-tis defects seems to improve the biological seal around implants and resistance to soft tissue mobility around implants, as well as avoids more plaque accumulation and tissue inflammation.13

Surface decontamination is indispensable for bone regeneration and re-osseointegration. Er:YAG laser having a sharpened irradiation tip

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18 • Vol. 9, No. 3 • April 2017

is thought to be an ideal tool for decontamina-tion of implant surface in narrow cleaning spaces. Er:YAG laser has high absorption rate by water molecules with minimum temperature increase. It leads to sterilization of the implant surface with less carbonization.14 An In vitro study con-cluded that Er:YAG irradiation at pulse energies below 30 mJ/pulse and 30 Hz with water spray in near-contact mode causes no damage and can be effective for debriding microstructured surfaces.15 However, it is still unknown to what extent these contaminants have to be removed to achieve a successful treatment outcome.16

Nonetheless, in this case report, the clini-cal outcome was carried out successfully with a regular implant placed in an augmented region where peri-implantitis and severe bone resorp-tion had taken place. After 23 months, the result seems quite promising, yet further prospec-tive studies are needed to evaluate the use-fulness of this technique. In addition, defect with bone substitute are hard to evaluate for new bone formation on radiographs.3 Evidence for re-osseointegration onto previously con-taminated implant surface is nonexistent of naturally occurring human peri-implantitis. l

Correspondence:Dr. Daisuke UenoDivision of Implantology and Periodontology, Graduate School of Dentistry, Kanagawa Dental University Yokohama Clinic, Yokohama, Japan 3-31-6 Tsuruya-cho, Kanagawa-ku, Yokohama, JapanFax: +81 -45-313-0007 E-mail: [email protected]

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

References1. Schwarz F, Sahm N, Bieling K, Becker J. Surgical regenerative treatment of

peri-implantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane: a four-year clinical follow-up report. J Clin Periodontol. 2009;36:807-14.

2. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Surgical treatment of peri-implantitis using a bone substitute with or without a resorbable membrane: a prospective cohort study. J Clin Periodontol. 2007;34:625-32.

3. Mombelli A, Moëne R, Décaillet F. Surgical treatments of peri-implantitis. Eur J Oral Implantol. 2012;5 Suppl:S61-70.

4. Larsson L, Decker AM, Nibali L, Pilipchuk SP, Berglundh T, Giannobile WV. Regenerative Medicine for Periodontal and Peri-implant Diseases. J Dent Res. 2016;95:255-66.

5. Matarasso S, Iorio Siciliano V, Aglietta M, Andreuccetti G, Salvi GE. Clinical and radiographic outcomes of a combined resective and regenerative approach in the treatment of peri-implantitis: a prospective case series. Clin Oral Implants Res. 2014 ;25:761-7.

6. Roccuzzo M1, Bonino F, Bonino L, Dalmasso P. Surgical therapy of peri-implantitis lesions by means of a bovine-derived xenograft: comparative results of a prospective study on two different implant surfaces. J Clin Periodontol. 2011;38:738-45.

7. Romanos GE, Nentwig GH. Regenerative therapy of deep peri-implant infrabony defects after CO2 laser implant surface decontamination. Int J Periodontics Restorative Dent. 2008;28:245-55.

8. Schwarz F, Sahm N, Schwarz K, Becker J.　Impact of defect configuration on the clinical outcome following surgical regenerative therapy of peri-implantitis. J Clin Periodontol. 2010;37:449-55.

9. Pommer1 B, Zechner1 W, Watzek1 G and Palmer R. To Graft or Not to Graft? Evidence-Based Guide to Decision Making in Oral Bone Graft Surgery. In: Bone Grafting, ed by Alessandro Zorzi, In Tech Europe, Croatia, 2012, pp160-182.

10. Rakhmatia YD, Ayukawa Y, Furuhashi A, Koyano K. Current barrier membranes: titanium mesh and other membranes for guided bone regeneration in dental applications. J Prosthodont Res. 2013;57:3-14.

11. Roos-Jansåker AM1, Renvert S, Egelberg J. Treatment of peri-implant infections: a literature review. J Clin Periodontol. 2003;30:467-85.

12. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res. 1990;1: 22–32.

13. Ueno D, Nagano T, Watanabe T, Shirakawa S, Yashima A, Gomi K. Effect of keratinized mucosa width on the health status of periimplant and contralateral periodal tissue: a coress-sectional study. Implant Dentistry. 2016;25:1-6

14. Yoshino T, Aoki A, Oda S, Takasaki AA, Mizutani K, Sasaki KM, Kinoshita A, Watanabe H, Ishikawa I, Izumi Y. Long- term histologic analysis of bone tissue alteration and healing following Er:YAG laser irradiation compared to electrosur- gery. J Periodontol 2009;80:82–92.

15. Taniguchi Y, Aoki A, Mizutani K, Takeuchi Y, Ichinose S, Takasaki AA, Schwarz F, Izumi Y. Optimal Er:YAG laser irradiation parameters for debridement of microstructured fixture surfaces of titanium dental implants. Lasers Med Sci. 2013;28:1057-68.

16. Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol 2000 2002;28:177–189.

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Inchingolo et al

Background: Concentrated growth factors (CGF) have positive impact in the field of regen-erative medicine. The osseointegration proper-ties of CGF around loaded oral implants were evaluated in this study by means of computer-ized textural analysis in Panoramic Radiographs.

Materials and Methods: Nineteen patients are randomly assigned to two groups. Test group comprise patients that received CGF application within osteotomy site and around new implants. Control group comprise patients with no CGF employment. The region under textural evalua-tion was the area between the implants in contact with the bone area. A clinical sample of 38 Digi-tized Panoramic Radiographs was analyzed, 19 corresponding to immediate implant loading and 19 after an 8-month follow-up period. The con-tact area was derived by means of a complicated segmentation algorithm. From each acquired region from implant windings, 42 textural fea-

tures were extracted so as to capture the textural differentiation between radiographs that corre-spond to immediate and after 8 months loading. Results: All selected features achieved Area-Under-Curve (AUC) values within 0.77–0.81 range in the group with CGF employment and manage to capture the significant tem-poral textural differentiation that can be attrib-uted to CGF properties. The control group, exhibit poor AUC values within 0.51–0.68 range, which in turn shows low osseointegra-tion activity in the bone-to-implant contact area.

Conclusion: The positive results of CGF employment have significant clinical inter-est proving the increment of osteoregenera-tive potential of surrounding tissues after dental implanting. Quantified evidence derived from the present study can orient the daily surgi-cal procedure towards CGF employment.

Computer Based Textural Evaluation of Concentrated Growth Factors (CGF) in Osseointegration of Oral

Implants in Dental Panoramic Radiography

Francesco Inchingolo1,4

Panagiotis G. Georgakopoulos1,2,4 • Gianna Dipalma1,4

Stavros Tsantis3 • Tiziano Batani4 • Ezio Cheno1,4 Ioannis P. Georgakopoulos1,4

1. Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Italy2. University Alfonso X El Sabio, Dental School, Madrid – Spain

3. Technological Education Institution of Athens, Department of Biomedical Engineering, Athens - Greece4. World Academy of Growth Factors & Stem Cells in Dentistry

Abstract

KEY WORDS: Concentrated Growth Factors, Dental Implants, Texture Analysis, segmentation, Fuzzy C-means, Panoramic Radiography.

20 • Vol. 9, No. 3 • April 2017

Inchingolo et al


BACKGROUNDImplantology plays a crucial role in dentistry effec-tiveness throughout the last few decades. Given the fact that a number of restorative options for missing teeth treatment still exist, none have proven to be as functionally effective and robust as implants. It has been proven that in most cases, dental implants may be the only consis-tent and successive choice for the teeth and sup-porting structures functionality restoration. Dental implants in use today are made primarily from tita-nium or titanium alloy.1 Most studies have exhib-ited a five-year success rate of 95% for lower jaw implants and a 90% success rate for upper jaw implants. The lower success rate for upper jaw implants compared to the lower jaw is due to lower density in that region (especially the pos-terior section), constituting a successful implan-tation and osseointegration difficult to achieve.2

Dental implants are until know the best pos-sible solution towards successful missing teeth treatment. However, the surgical procedure is highly affected by the osseoregenerative proper-ties of the surrounding tissues. In cases of poor properties, the surgical implant placement pro-cedure has decreased probability of success. In addition, primary implant stability (high value of insertion torque) is considered of value for a suc-cessful procedure.2 Another limitation is the pos-sibility that dental implants may break or become infected (like natural teeth) and their crowns may become loose. The aforementioned limitations have been generated several procedures in order to aid implant and bone grafts healing. Strength-ening of the bone-to-implant contact area so as to accelerate the osseous healing has been the key factor towards a successful procedure. The Concentrated Growth Factors (CGF) may be

a valuable aid in the field of regenerative medi-cine, to speed up the process of regeneration. The main feature of the CGF resides in its con-sistency: it is an organic matrix rich in fibrin, able to “trap” platelets, leukocytes and growth factors.

Platelets comprise several growth factors, such as TGF-b1, VEGF and stem cells CD34+, that have been reported to enhance tissue regen-eration.3 CGF has also been reported to aid various healing situations such as filling of extrac-tion sockets4 and cavities after cystectomy,5 or in sinus lifting procedures.6-8 Moreover, it has the capacity to be employed solely or combined with autologous bone particles or biomaterials.9

Several studies that have evaluated the prop-erties of CGF by means of Scanning Electron Microscopy (SEM), have shown that the CGF presents a fibrin network formed by thin and thick fibrillar elements.10 Histo-morphological studies11 have allowed to see the fibrin network structure and the distribution of blood cells (leukocytes, erythrocytes and platelets) in the CGF. Finally, in vitro studies using different human cell lines, have shown that the addition of the CGF to the culture medium, stimulated cell proliferation.11

An experimental case control study, in terms of a computerized texture analysis, that evalu-ated CGF osseoregeneration properties around dental implants is carried out. The current study’s aim is to quantify any texture differentiation after CGF employment into the bone-to-implant con-tact region, between a 0 and 8 month follow up period and to evaluate any difference between test and control groups (with and without CGF employment) that can be attributed to the CGF properties. The follow up period selected for the purposes of this study has been considered ade-quate for CGF osseoregeneration properties eval-

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22 • Vol. 9, No. 3 • April 2017

uation by the expert dentist conducted this study. Texture analysis employed in panoramic radio-graphs has been made by means of first order, co-occurrence and run length textural features along with Receiver Operating Characteristic (ROC) curve analysis. To the best of our knowledge until now there has been no texture-based quantifica-tion studies that investigate bone density altera-tion around implants after CGF employment.

METHODSCLINICAL DATASET A clinical dataset of 19 patients was selected for the study that was randomly assigned to two groups (test group–10 patients, control group–9 patients). The test group received CGF applica-tion around new implants and within the surgi-cal site whereas in the control group the new implants were placed without CGF Employment. Ages within the clinical dataset ranged from 29 – 61 years. Inclusion criteria for participating in to the study were mainly the absence of diabetes, osteoporosis, cardiac and thoracic diseases, non-

smoking and non-cancerous patients. All patients participating in the current study had maxillary and mandibular tooth loss and had chosen the surgical implant solution. All requirements for participation in the study have been given and every patient had a consent form signed. A follow up clinical sample for both groups of 38 digitized panoramic radiographs has been acquired and analyzed, corresponding to the 19 patients imaged imme-diately after implant loading and 8 months later.

SURGICAL PROCEDURES & CGF PREPARATIONSurgical procedures towards surgical implant placement were performed under local anesthesia (Ubistesin forte – 1.7 ml). An approximate number of 2 to 6 implants were placed in each selected patient. The bone surface area was exposed by of type –H– Incision causing bone defects of approximately 3.60 mm. Specific Implants with 4 mm and 4.5 mm thickness, and 10 mm and 12 mm length and diameter dimensions were then placed (B&B Duravit EV Implants Italy) after been immersed in CGF-CD34+ matrix that was also placed within each osteotomy site before implant loading. CGF preparation involves ini-tially the patient’s blood centrifugation using eight sterile tubes (9 ml each) in a specific centrifuge device (Medifuge, Silfradent srl, St. Sofia, Italy) for approximately 13 minutes in constant speed. For optimum quality of CGF matrices the blood sam-ples were centrifuged immediately after the blood was drawn. Following centrifugation, in each ster-ile tube three layers can be seen from top to bot-tom: (a) the upper layer, which is the liquid phase of plasma named platelet poor plasma (PPP); (b) the middle layer, in which solid CGF lies with the following intermediate sublayers: the upper white

Left Figure 1a: Phases of CGF. Right Figure 1b: Tube for the creation of CGF.

Inchingolo et al


sublayer, the middle “buffy coat*” sublayer and the red sublayer which coincides with the lower layer, where red blood cells (RBC) are aggregated containing mainly erythrocytes; (Figures 1A,B). A large number of growth factors and stem cells CD34+ are aggregated in the middle sublayer (between the dense polymerized fibrin buffy coat and the upper 3-4 mm of red blood corpuscles mass of the bottom layer). This growth factors-rich segment is then separated from the rest of the red corpuscles using scissors (Figure 2A) in order to obtain the CGF-CD34+ matrix (Figure 2B).Povidine-iodine solution (Betadine) was at first employed extra-orally towards surgical site dis-infection. Infiltration was then performed using a 2% lidocaine solution containing a ratio of 1:100,000 epinephrine. A CGF-CD34+ matrix, derived from the aforementioned procedure, was then equally cut. The one half of the matrix after being mixed with Novocor alloplastic bone graft-ing material (Figure 2C) was inserted through the osteotomy site using the fibrin injector (B&B-Italy – Figure 2D). The other half of the CGF-CD34+ matrix was squeezed with the CGF-forceps (Silfradent, Italy – Figure 2E) deriving the Liq-uid Phase of the Concentrated Growth Factors (LPCGF) and collected in a sterilized container. Each implant was fully immersed into the LPCGF

Top left Figure 2a: Separation of the CGF matrix using scissors.Top right Figure 2b: The CGF-CD34+ matrix.Middle left Figure 2c: A mixture of highly concentrated growth factors, stem cells CD34+ and B&B Novocore bone grafting material.Middle right Figure 2d: Placement of the aforementioned mixture in the osteotomy site.

Bottom left Figure 2e: Process of LPCGF with CD34+ production utilizing the CGF-forceps.Bottom right Figure 2f: B&B Duravit EV Implant immersions into LPCGF, towards the creation of a bioactive membrane around it.

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24 • Vol. 9, No. 3 • April 2017

to form a “bioactive” membrane around it (Fig-ure 2e).12 Finally, all implants were then placed using a hand wrench and with insertion torque value between 20-25 N/cm2. Low insertion torque values are considered necessary due to the small bone heights at all implant sites.

For each patient from both groups two pan-oramic radiographs were acquired. The first one (Class I, 54 implants) was taken immediately after implant placement (baseline panoramic radio-graph) and the second one (Class II, 54 implants), eight months later leading to a total of 38 radio-graphs. All panoramic radiographs were taken by the same technician according to a standard-ized protocol for patient positioning and exposure parameter setting. To further ensure the reliabil-ity of the subsequent texture analysis results, an intensity based registration method that utilized the mean square error metric was employed so as to compensate any minor geometrical distortions between the two panoramic radiographs of each patient. As a result, all pair of radiographs had a one-to-one geometrical correlation. The pan-oramic x-ray equipment used within this study was the Orthophos C (Siemens co, AG Wittelsbacher-platz 2, 80333 Munich, Germany) with parameter settings selected at 66-69 kVp and 16 mA. The provided digitized images were in TIFF format.

Top left Figure 3a: Dental Implant.Top right Figure 3b: FCM clusters.Middle left Figure 3c: Implant outline derived from convex hull processing.Middle right Figure 3d: Areas of bone to implant contact.Bottom Figure 3e: Fitted ROIs (black color pointed with white arrows).

Inchingolo et al


BONE-TO-IMPLANT CONTACT REGION (ROIs) EXTRACTIONA complicated of bone to implant contact region detection algorithm was designed for the pur-posed of this study. This particular region is located both in between and adjacent to implant windings, and is suitable for textural evaluation for any bone regeneration procedure. At first, the dental implant (Figure 3A) is extracted from the surrounding tissue by means of the Fuzzy C-means (FCM) method13 (Figure 3B). After the dental implant boundary extraction, the con-vex-hull14 is computed so as to isolate the par-ticular Regions of Interest (ROIs – Figure 3C). The subtraction between the convex-hull contour

and the already detected implant contour pro-vides us with the ROIs from which the textural features will be computed (Figure 3D, E). Two ROI classes for both groups were created corre-sponding to the radiographs acquired immediately after the implant placement and 8 months later.

TEXTURE AND STATISTICAL ANALYSISFrom each ROI extracted from the previous seg-mentation procedure, first and second order tex-tural features derived from the gray-scale values histogram, co-occurrence and run-length matrices were computed in order to acquire any intensity alteration that is indicative of CGF osseoregen-erative properties. In each ROI a normaliza-

Figure 4: ROC analysis results for the CGF Group.

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26 • Vol. 9, No. 3 • April 2017

Table 1: Textural Features Employed in the Texture-Based Evaluation

of Bone Formation Properties of CGF

Textural Feature

Gray-Level Histogram Features

1 Mean value(m)2 Standard Deviation (std)3 Skewness (sk)4 Kurtosis (k)

Co-Occurrence Features (Mean & Range)5 Angular Second Moment (ASM)6 Contrast (CON)7 Inverse Different Moment (IDM)8 Entropy (ENT)9 Correlation (COR)10 Sum of Squares (SSQ)11 Sum Average (SAV)12 Sum Entropy (SENT)13 Sum Variance (SVAR)14 Difference Variance (DVAR)14 Different Entropy (DENT)16 Information Measure of Correlation (ICM1)17 Information Measure of Correlation (ICM2)

Run-Length Features (Mean & Range)18 Short Run Emphasis(SRE)19 Long Run Emphasis(LRE)20 Grey Level Non Uniformity (GLNU)21 Run Length Non Uniformity (RLNU)22 Run Percentage (RP)

Table 2: Subset of Features Selected by SRA Analysis

a/a Feature Name

1 Mean value(m)2 Angular Second Moment3 Inverse Different Moment4 Short Run Emphasis5 Grey Level Non Uniformity6 Run Length Non Uniformity

tion procedure has been made in order to avoid any pixels that belong to the dental implants that might create outliers. The normalization was employed within the μ±3σ interval where

μ was the mean value of the gray levels inside the ROI and σ the standard deviation. Any pixel values outside the range [μ–3σ, μ+3σ] were excluded from the feature extraction procedure. All textural features computed for the purposes of the current study are depicted in Table 1.

Minimum-redundancy-maximum-relevance (mRMR) feature selection15 was utilized in the initial dataset of 42 features to avoid any pos-sible feature redundancy leading to a reduced feature subset (Table 2). The proposed fea-ture selection algorithm employs mutual infor-mation and distance/similarity scores so as to rank a feature’s relevancy in a selected feature set compared to its redundancy with the other features. The reduced feature subset (Table 2) acquired from the feature selection procedure is then analyzed by means of ROC analysis.

The selected feature subset, captures valu-able information, as regards any alteration within the bone-to-implant region throughout the 8-month period that caused by the CGF employment. Statistical differentiation for the selected subset was exploited by means of

Inchingolo et al


Table 3: Subset of Textural Features Minimum-redundancy-Maximum-Revelance Analysis & ROC Analysis in the CGF & Control Groups

CGF Group Control Group

Textural Feature AUC AUC (Lower-Upper 95.0% (Lower-Upper 95.0% Confidence Limit) Confidence Limit)

Mean Value 0.82 0.66 (0,69 - 0,87) (0,55 - 0,69)

Angular Second Moment 0.84 0.61 (mean) (0,74 - 0,88) (0,58 - 0,66)

Inverse Different Moment 0.87 0.56 (mean) (0,78 - 0,93) (0,49 - 0,61)

Short Run Emphasis 0.83 0.51 (mean) (0,78 - 0,93) (0,44 - 0,62)

Grey Level Non Uniformity 0.89 0.55 (0,79 - 0,89) (0,49 - 0,60)

Run Length Non Uniformity 0.85 0.68 (0,79 - 0,89) (0,59 - 0,73)

ROC curve analysis. ROC analysis is con-sidered a powerful statistical tool so as to evaluate the discriminant attributes of each textural feature from the selected subset. Features with high values of Area Under the Curve (AUC) encode high separability prop-erties between the two classes. The binormal parametric method was chosen for the pur-poses of this study to acquire the AUV values and graphs. This particular method is consid-ered as computationally more affordable and robust in small sample size feature sets.16,17

ALGORITHM IMPLEMENTATIONRegistration, segmentation Feature extrac-tion and selection were all implemented in Matlab R2014b (MathWorks, 3 Apple Hill Drive Natick, Massachusetts 01760, USA). ROC analysis was made by means of NCSS, PASS and GESS software pack-age (NCSS, 329 North 1000 East, Kaysville, Utah84037, USA). The computer used for processing had a Quad-Core Intel proces-sor running at 4.2 GHz and 16 GB of RAM.

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28 • Vol. 9, No. 3 • April 2017

Figure 5: ROC analysis results for the Control Group.

RESULTS AND DISCUSSIONWith regard to Bone-to-Implant contact region detection accuracy, the results provided by the proposed segmentation algorithm were com-pared with manual segmentations by an experi-enced dentist in terms of overlap degree between the two sets. Very high correlation was found with little bias on inter-observer (r = 0.996 and p < 0.0001) variability showing that manual ROI segmentation is reliable and can be regarded as the gold standard. The segmentation compara-tive study results demonstrated a high segmenta-tion accuracy, corresponding to overlap=0.934 ± 0.010. The feature subset in the test with CGF

employment group exhibit AUC values greater than 0.82, yielding increased differentiation capa-bility between the two classes (0 and 8 month period) (Figure 4). The same feature subset in the control group with no CGF employment yields smaller AUC values ranging from 0.51 – 0.68 (Table 2). The latter results are indicative of the poor discrimination between the two classes which in turn can be attributed to low osseoin-tegration activity in the bone-to-implant regions compared with the CGF group (Figure 5). Com-puterized texture analysis performed within this study in the CGF group as regards the impact CGF has in the osseointegration procedure

Inchingolo et al

The Journal of Implant & Advanced Clinical Dentistry • XX

around dental implants has demonstrated a sig-nificant difference in the selected texture sub-set between the two groups (0 and 8 months). On the contrary, in the test group the same fea-ture subset has pinpointed the poor osseo-integration activity bilaterally dental implants.

The results derived from the current study are in total accordance with previous studies6-8 in which the positive impact of the CGF in vari-ous dental cases has been reported. The six fea-tures that comprise the selected subset: Mean Value, Angular Second Moment, Inverse Differ-ent Moment, Short Run Emphasis, Grey Level Non Uniformity and Run Length Non Uniformity manage to capture in terms of texture differen-tiation the increased bone remodeling around implants after the CGF employment. The charac-teristics of the aforementioned features imply an active bone-regeneration procedure within the implant windings be means of increased vari-ability and high gray-level values (Table 3). For the first time a fully automatic texture analysis aimed to evaluate the clinical impact of CGF employment in dental implantology has been conducted for the purposes of the study. Digi-

tised panoramic radiographs acquired from a divided clinical dataset (CGF and Control group) were utilised by means of several textural fea-tures so as to capture any statistical differentia-tion between immediate implant loading and after 8 month follow up period. This differentiation is investigated with ROC analysis which is con-sidered as powerful measure of differentiation.

CONCLUSIONThe positive results as regards CGF employ-ment are considered of a significant clinical interest proving the increment of osteoregenera-tive potential of surrounding tissues after den-tal implanting. The latter can orient the daily surgical procedure towards CGF employment. l

Correspondence:Dr. Stavros TsantisDepartment of Biomedical Engineering, Technological Education Institution of Athens, Athens, GreeceEmail: [email protected], [email protected].: +30 6977635864Fax: +30 2132028608

DisclosureThe authors declare that there is no conflict of interests regarding the publication of this article.

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4. Tadić A, Puskar T, Petronijević B. Applica-tion of fibrin rich blocks with concentrated growth factors in pre-implant augmentation procedures. Med Pregl. 2014; 67:177-80.

5. Mirković S, Djurdjević-Mirković T, Pugkar T. Application of concentrated growth fac-tors in reconstruction of bone defects after removal of large jaw cysts--the two cases report. Vojnosanit Pregl. 2015 72:368-71.

6. Kim JM, Sohn DS, Bae MS, Moon JW, Lee JH, Park IS. Flapless transcrestal sinus augmentation using hydrodynamic piezoelectric internal sinus elevation with autologous concentrated growth factors alone. Implant Dent 2014; 23: 168-174

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9. Gheno E, Palermo A, Buffoli B, Rodella LF. The effectiveness of the use of xenoge-neic bone blocks mixed with autologous Concentrated Growth Factors (CGF) in bone regeneration techniques: a case series. J Osseointegr 2014; 6: 37-42

10. Rodella LF, Favero G, Boninsegna R, Buf-foli B, Labanca M, Scarì G, Sacco L, Batani T, Rezzani R. Growth factors, CD34 positive cells, and fibrin network analysis in concentrated growth factors fraction. Microsc Res Tech. 2011; 74:772-7.

11. Borsani E., Bonazza V., Buffoli B, Cocchi M.A, Castrezzati S., Scarì G., Baldi F., Pandini S., Licenziati S., Parolini S., Rezzani R., Rodella L.F. Biological Characterization and In Vitro Effects of Human Concentrated Growth Factor Preparation: An Innovative Approach to Tissue Regeneration. Biol Med (Aligarh) 2015, 7:5.

12. Georgakopoulos ćG, Makris N, Almasri M, Tsantis S, Georgakopoulos IP (2016) “IPG” DET Minimal Invasive Sinus Implant Placement and Grafting without Sinus Floor Elevation – The Evolution of New Age Concepts. Dentistry 6: 375. 2016

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15. H.C., Long, F., and Ding, C., “Feature selec-tion based on mutual information: criteria of max-dependency, max-relevance, and min-redundancy,” IEEE Transactions on Pat-tern Analysis and Machine Intelligence, Vol. 27, No. 8, pp. 1226–1238, 2005

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Pandya

In last few decades, implant dentistry has emerged as a fully accepted discipline in dentistry. During this period of development,

its concepts, treatment modalities and material science have undergone tremendous changes. The key to successful restorative driven implant therapy is appropriate examination, diagnosis

and treatment planning to achieve optimal func-tional and esthetic results. Most importantly, patients must be at the heart of this process. The clinical approach described, demonstrates points of consideration, when replacing a man-dibular anterior segment with immediate dental implants and delayed prosthetic loading protocol.

Extraction and Immediate Placement of Dental Implants in Mandibular Anterior Site with Delayed Prosthetic Loading Protocol in a Chronic Generalized Periodontitis Patient: A Case Report

Dhaval Pandya, MDS1

1. Fellow International College Of Dentists (Section Vi India, Sri Lanka & Nepal), Diplomate International Congress Of Oral Implantologists

Abstract

KEY WORDS: Dental implants, case report, prosthetics, periodontitis

30 • Vol. 9, No. 3 • April 2017

Pandya


INTRODUCTIONImplant dentistry has experienced dramatic changes in past few decades.1 Newer implant designs, surface technologies allow for much faster osseointegration and modulation of bone reaction to the implant.2 Implant therapy in peri-

odontally compromised patients has been suggested to have a different outcome when compared with patients without periodonti-tis.3 Long term survival rates varies according to the surgical technique used (78% for 1 stage technique versus 94% for 2 stage technique.4

Figure 1: Pre-op clinical view. Figure 2: Pre-op OPG.

Figure 3: Cross section view of CBCT. Figure 4: Additional cross section view of CBCT.

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32 • Vol. 9, No. 3 • April 2017

CASE REPORTA 54 year old woman presented to a general dentist with complaints of bleeding and swol-len gums (Figure 1) in her mouth with loosen-ing of her lower anterior teeth as well as her lower posterior teeth since a few weeks. The general dentist requested her to be seen by a periodontist. A detailed dental history taken by the periodontist revealed oral prophylaxis done by the patient intermittently and upper molar extractions carried out few years back because of advanced mobility. Routine medical and drug history revealed nothing significant. A cone beam CT scan along with routine hae-matological investigations were requested from the patient to further co- relate the clinical find-ings. Evaluation of the cone beam CT (Figures 2, 3 and 4) revealed advanced bone loss with

Figure 5: Minimally invasive extractions with periotomes. Figure 6: Extracted teeth.

Figure 7: Paralleling pins placed. Figure 8: Implant placement.

Figure 9: Torque achieved with implants.

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Figure 11: Occlusal adjustment.Figure 10: Model with abutments.

Figure 13: Occlusal adjustment.Figure 12: Occlusal adjustment.

respect to the patients mandibular four incisors and mandibular left and right second and third molars. A decision was made to extract all the mentioned teeth based on the CBCT examina-tion co relating with the degree of mobility clini-cally. Furthermore in mandibular anterior socket sites were studied in detail on the CBCT to consider a possibility of placing two implants immediately to reduce the appointments for the patient. Immediate extraction implants with a tapered design and oxidised surface treat-ment (Nobel Biocare Replace select tapered Narrow platform) was decided to replace man-

dibular lateral incisors and further prosthetic implant supported bridge over the two implants.

The patient was pre medicated with amoxi-cillin and clavulanic acid 625mg (Cap Augmen-tin ) and Chlorhexidine gluconate mouthwash (Perioguard 0.12%). On the day of the pro-cedure, local infilteration anaesthesia was administered with lignocaine hydrochloride (Xylocaine) at the lower mandibular anterior site and atraumatic extraction of lower four inci-sors with periotomes was carried out (Figures 5 and 6) The extraction sockets were thor-oughly debrided to remove granulation tissue

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34 • Vol. 9, No. 3 • April 2017

Figure 14: Soft tissue after 4 months.Figure 13: Post-op OPG.

and bleeding created to start with osteotomies for the implant placements. Initial drilling was checked with the parallel pin positioning (Figure 7) to verify the 3 D positioning and two implants were placed in the lateral incisor sockets (Fig-ure 8) Implant – tooth distance, buccolingual axial drilling final prosthetic emergence was taken into consideration at the drilling stage itself to achieve optimum prosthetic outcomes. The implants showed a final torque which was less than 35 Ncms (Figure 9). Hence, a decision to do a delayed prosthetic load-ing was taken and the patient was informed of the same. The lower second and third molars were extracted and the remaining salvageable teeth were subjected to periodontal flap sur-gery. A post-op panoramic x-ray was advised to check for implant positions (Figure 14) Fol-low up of 3 weeks and four months (Figure 15) revealed a healthy soft tissue healing around the implants and a decision to proceed with the prosthetic phase was carried out with sup-porting intra oral radiographs which revealed complete osseointegration of the two implants. Closed tray implant level impressions were

carried out and laboratory poured the models. Straight profiled prosthetic abutments (Nobel snappy) were requested (Figure 10) by the lab technician and the subsequent coping try ins, shade selection, and final prosthetic try in were done to adjust the occlusion (Figures 11, 12 and 13) The final abutments were torqued according to the manufacturer’s instructions (15 Ncms) and they were sealed with a Teflon tape and the final prosthesis (porcelain fused to metal implant supported bridge) was cemented using a provisional implant cement (Tempbond).

CONCLUSIONThe above case report demonstrates the effi-cacy of minimally invasive extractions of peri-odontally compromised teeth, with Type I timing of implant placements according to Hammerle et al.5 The advantage of this over the staged approach is fewer appointments for the patient and the dental team. However, in periodon-tally affected sockets, if the primary stability is not adequately achieved like in this case less than 35Ncms, then a decision may be taken to defer the loading of the implants and not jeop-

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Correspondence:

Dr. Dhaval Pandya

Email: drdhavalpandya @yahoo.com

[email protected]

Contact no: +91-9930998282

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

References1. Immediate loading of dental implants: Theory and and clinical practice

Mithridade Davarpannah and Serge Szmukler Moncler Quintessence 2008.

2. 4D implant therapy: Esthetic considerations for soft tissue management Akiyashi Funato and Tomohiro Ishikawa Quintessence 2008.

3. Van der weijden GA, Van Bemmel KM, Renvert S. J Clin Periodontol 2005; 32: 506-511

4. Baelum V, Ellegaard B. J Periodontol 2004; 75:1404-12.

5. Hammerle CH, Chen ST, Wilson TG Jr. Int J Oral Maxillofac Implants 2004;19 (Suppl) 26-28.

6. Paolantonio M, Dolci M, Scarano A, et al. J Periodontol 2001;72: 1560-1571

7. Lazzara RJ. Int J Periodontics Restorative Dent 1989 ; 9:332-343.

8. Araujo MG, Lindhe J. J Clin Periodontol 2005 ;32: 212- 218.

9. Garber DA. J Am Dent Assoc 1995 ; 126:319-325.

10. Funato A, Salama MA, Ishiakawa T, Garber DA, Salama H. Int J Periodontics Restorative Dent 2007; 27: 313-323.

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ardise the osseointegration process. Proper case selection, technique used, material selec-tion, and a good laboratory support will result in optimum functional and esthetic results. l

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