Tạp chí cấy ghép Implant IPUS tháng 01+02/2014 Vol.7 No.1

Tạp chí cấy ghép Implant IPUS tháng 01+02/2014 Vol.7 No.1

FILL THE DEFECT

Learn how to easily prevent particle migration using expandable

XC Sinus

For details see page 49

White Box covering the left side bleed should be removed.

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of traumatic root fracture

Drs Peter Fairbairn and

Sharon Stern

A chemotherapy

patient’s experience

with dental implants

Dr Bryan R Krey and

Dr Richard G Dong

PLAN SCAN

PLACE

RESTORE

WHEN THE OSTEOTOMY MUST BE NARROW

-SO MUST YOUR IMPLANT CHOICE

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©2013 ZEST Anchors LLC All rights reserved ZEST and LOCATOR are registered trademarks of ZEST IP Holdings, LLC.

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Volume 7 Number 1 Implant practice 1

January/February 2014 - Volume 7 Number 1

EDITORIAL ADVISORS

Steve Barter BDS, MSurgDent RCS

Anthony Bendkowski BDS, LDS RCS, MFGDP, DipDSed, DPDS,

MsurgDent

Philip Bennett BDS, LDS RCS, FICOI

Stephen Byfield BDS, MFGDP, FICD

Sanjay Chopra BDS

Andrew Dawood BDS, MSc, MRD RCS

Professor Nikolaos Donos DDS, MS, PhD

Abid Faqir BDS, MFDS RCS, MSc (MedSci)

Koray Feran BDS, MSC, LDS RCS, FDS RCS

Philip Freiburger BDS, MFGDP (UK)

Jeffrey Ganeles, DMD, FACD

Paul Tipton BDS, MSc, DGDP(UK)

Clive Waterman BDS, MDc, DGDP (UK)

Peter Young BDS, PhD

Brian T Young DDS, MS

CE QUALITY ASSURANCE ADVISORY BOARD

Dr Alexandra Day BDS, VT

Julian English BA (Hons), editorial director FMC

Dr Paul Langmaid CBE, BDS, ex chief dental officer to the Government

for Wales

Dr Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private

Dentistry

Dr Chris Potts BDS, DGDP (UK), business advisor and ex-head of

Boots Dental, BUPA Dentalcover, Virgin

Dr Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St

referral implant surgeon

PUBLISHER | Lisa Moler

Email: lmoler@medmarkaz.com Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld

Email: mali@medmarkaz.com Tel: (727) 515-5118

ASSISTANT EDITOR | Elizabeth Romanek

Email: betty@medmarkaz.com Tel: (727) 560-0255

EDITORIAL ASSISTANT | Mandi Gross

Email: mandi@medmarkaz.com Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning

Email: michelle@medmarkaz.com Tel: (480) 621-8955

NATIONAL SALES/MARKETING MANAGER

Drew Thornley

Email: drew@medmarkaz.com Tel: (619) 459-9595

PRODUCTION MANAGER/CLIENT RELATIONS

Adrienne Good

Email: agood@medmarkaz.com Tel: (623) 340-4373

PRODUCTION ASST./SUBSCRIPTION COORD

© FMC 2013 All rights reserved

FMC is part of the specialist publishing group Springer Science+Business Media The publisher’s written consent must be

obtained before any part of this publication may be reproduced in

any form whatsoever, including photocopies and information retrieval

systems While every care has been taken in the preparation of this

magazine, the publisher cannot be held responsible for the accuracy

of the information printed herein, or in any consequence arising from

it The views expressed herein are those of the author(s) and not

necessarily the opinion of either Implant Practice or the publisher.

When I think about advancements in implant dentistry that have most influenced

my practice, I think about three things: 3D imaging, sinus grafting techniques, and guided bone regeneration (GBR) procedures When I opened my practice 11 years ago, I was trying to decide if I should implement digital imaging or continue with film

Today, I have a three-dimensional image of my patient’s maxilla and mandible before I’ve even introduced myself It has provided us with the ability to accurately know the position of nerves, sinuses, and that sneaky osseous defect that can be lingering buccal

to our osteotomy Because of this information, flap designs have become minimally invasive and far less painful for our patients Case acceptance has increased, providing patients a more thorough understanding of their treatment 3D imaging has made the next advancement, sinus grafting, so predictable that we now even can see the exact thickness of the wall we need to drill through to access the sinus

Sinus grafting itself hasn’t changed It is still a surgical procedure aiming to increase the amount of bone in the posterior maxilla by sacrificing the volume of the maxillary sinus Thus, increasing our ability to place dental implants using fixed restorations on more patients Although the outcome is the same, the methods have changed drastically The Piezosurgery® unit allows us to cut bone without harming soft tissue We can now predictably free up the Schneiderian membrane There are drill kits akin to those used

in neurosurgery, developed to allow surgeons to cut through the skull without harming the underlying dura mater This same technology is now in place with the direct sinus procedure Similar drills are used in order to avoid perforating the membrane of the sinus When evaluating bone grafting techniques, the criteria must be predictability and ease of use I find it fascinating that cow bone, which has been popular for ages, is now mixed within a collagen matrix to allow for precise placement, minimal migration, and enhanced bone growth at the site The same Piezo unit spoken about with sinus grafting can be used for minimal heating of bone for a sagittal split with ridge-splitting techniques This technique, when used in the right situation, can result in some of the most predictable gain in bone volume The highly porous collagen structure allows for quicker turnover to bone via a highly formulated matrix You can actually put bone where you want it; it stays, and it grows There are now bone grafts used that have signals to form bone — bone morphogenic protein (BMP) — calling in stem cells to allow for quicker, more predictable bone formation

My practice has always been focused on patient comfort, and these advancements

in 3D imaging have allowed for the most minimally invasive flap procedures, the most predictable bone placement, and in turn, significantly decreased pain and down time for

my patients

Ryan Taylor, DDS, MS

Dr Taylor established his practice in Periodontics and Implant Dentistry in Sarasota, Florida, in 2004 He is an active member in the American Academy

of Periodontology, American Academy of Implant Dentistry, the Academy

of Osseointegration, and the Academy of Oral Implantology He is also a member of the American Dental Association, Florida Dental Association, West Coast District Dental Association, and Sarasota County Dental Association

New technologies in the advancement of implant dentistry

TABLE OF CONTENTS

Dr Louis Kaufman: Continuing a legacy

This clinician is driven by inspiration, a great team, and desire for knowledge.

Patient insight

A chemotherapy patient’s experience with dental implants

Dr Bryan R Krey and retired engineer Dr Richard G Dong join forces to facilitate implant placement during cancer treatment 18

the treatment of traumatic root

fracture: a case study

Drs Peter Fairbairn and Sharon Stern

present a multi-disciplinary approach

to tackling a tricky trauma case 25

Management of biological

and biomechanical implant

complications

Drs Yung-Ting Hsu and

Hom-Lay Wang summarize and reveal

management protocols for implant

complications 32

Advanced technologies

38

Technology

Advanced technologies and materials to efficiently deliver full mouth reconstructions

Dr Ara Nazarian suggests a treatment solution that results in more control and fewer appointments 38

Verified osteoinductive allograft putty for dental implant

regeneration: preliminary findings

of three clinical applications

Dr John Lupovici illustrates clinical cases using RegenerOss® Allograft Putty to regenerate three distinct osseous defects 42

Product profile

NuOss® XC bone grafting composite .49

On the horizon

I want my teeth yesterday!

Dr Justin Moody discusses a saving technology in a fast-paced world 50

time-Materials &

equipment 54 Diary 56

Discover

Patient satisfaction meets clinical benefi ts

suprastructures for partial- and full-arch restorations The range

of standard and custom bars, bridges and hybrids allows for

fl exibility in supporting fi xed and removable dental prostheses

For more information, including a complete implant

compatibility list, visit www.dentsplyimplants.com.

What can you tell us about your

background?

I was born into a dental family I graduated

from the University of Illinois College of

Dentistry, and in 1995, joined my father

Richard’s well-established 50-year-old

general dentistry practice treating third-

and fourth-generation patients

Besides my clinical experience, I have

a diverse business background I earned an

MBA from the Computer Science Executive

Management Program at DePaul University

and a BA in Marketing and Economics

from Kendall College in Evanston, Illinois

Prior to attending dental school, I worked

in management at Pillsbury Corporation

as a specialist in point-of-service site

development and restaurant management

for 5 years The skill set that I developed

in corporate management has helped

me grow my Hyde Park (Chicago) private

practice into a multimillion dollar business

focused on comprehensive oral healthcare

and cosmetic smile design

I serve on the advisory board of

numerous dental manufacturers, consult

on product development, and am honored

to educate clinicians around the globe at

approximately 20 continuing education

programs annually I also have published

numerous articles focused on restorative

and cosmetic dentistry

Is your practice limited to

implants?

No

Why did you decide to focus on

implantology?

I have been restoring implants since

graduating dental school

How long have you been

practicing, and what systems do

you use?

Biomet 3i™, Noble Biocare®, BioHorizons®,

Astra Tech Implant System™, and

Straumann®

What training have you

undertaken?

I have taken numerous courses on

restoring and treatment planning implants, and recently completed my training in the surgical placement of implants

What is the most satisfying aspect

of your practice?

The greatest satisfaction is giving patients back the ability to function and re-create their smile

Professionally, what are you most proud of?

I am proud of how as a profession we stand together on so many fronts We have dentists who lobby and legislate for those on the front lines providing care to patients There is a “we” mentality versus

an “I” mentality I couldn’t imagine a better career Coming from corporate America years ago, to being a true entrepreneur with guidance and backing all around is incredible

What do you think is unique about your practice?

Without a doubt, it’s location If you have never been to Hyde Park (a neighborhood

in Chicago), then it’s worth the trip It

is a microcosm of the world So many nationalities and economic strata exist Another unique aspect is that we have been a part of the community for 60-plus years We provide care to fifth-generation patients

What has been your biggest challenge?

The biggest challenge right now is space

I am in an old building, and our suites are not designed for sit-down dentistry I ask myself how my dad did it for so long At the present time, I am 2½ years out for

my lease I am getting quotes on gutting the existing space or moving to a different floor so we can continue to operate until it’s time to move Having stayed on top

of technology, I am finding we are running out of space

What would you have become if you had not become a dentist?Great question I would have wanted to become a thoracic surgeon but did not

I believe inspiration comes from within or the desire to learn and do more I am lucky

my father was a practicing dentist for more than 60 years He always stayed up

to date on techniques and procedures I was fortunate

to have a strong role model

The dental community has many amazing specialists and general dentists whom

I learn from by reading and reviewing journals.

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8 Implant practice Volume 7 Number 1

PRACTICE PROFILE

want to be finishing up in my forties I

already changed careers to go into either

medicine or dentistry After my research of

both, I decided on the dental career path

because at age 27 I would not have finished

a medical-surgical path until around 40

years old

What is the future of implants and

dentistry?

The future of implants in dentistry is

continually growing We have so many

dentists who are not restoring or placing

implants My goal this year was to take an

implant surgical course to place implants,

and I will only do the straightforward cases

Everything else goes to the oral surgeon or

periodontist I strongly believe that the use

of surgical guides will become the standard

of care in the placement of the implant

What are your top tips for

main-taining a successful practice?

The key ingredient is to be engaged and

to surround myself with a great team of

people We have to continually motivate,

educate, and appreciate our team

members I am a big believer in educating

my team I try to teach something new to

as many people as possible I try to learn

something new from somebody every day

The other key is to make sure you give your

patients the time they deserve Become interested in them as people There are

so many pearls The bottom line is that we are in a “people business,” and we have

to have a team that works great with the public Also, don’t be afraid to fire a team member that just won’t perform to the levels that the business demands

What advice would you give to budding implantologists?

Take lots of continuing-education courses

Get educated on the restorative side and the surgical side of implants Treatment planning from the functional restorative side is key for long-term success

What are your hobbies, and what

do you do in your spare time?

I like to spend my spare time with my teenage kids It’s not a lot of time, but I take what I can get I like to read fiction and enjoy going to the movies I recently rescued a dog, and we take a lot of walks

I go to the gym regularly Our profession

is physically and mentally demanding, so I have become a big believer in eating right and being on a fitness program I also like taking my bike out for rides The rest of

my time is spent preparing for upcoming lectures that I am presenting

Dr Kaufman’s team

Dr Kaufman’s dog, Max

Dr Kaufman with his children, Rachel and Jacob

Top Ten Favorites

1 Planmeca ProMax® 3D — the coolest piece of technology I

am constantly learning with this technology

2 The technology called NuCalm™ Everybody should have it

3 Chocolate Chip Banana Blizzard from Dairy Queen

4 Must have music playing in the office I am old school rock-and-roll with some of the new

5 I like to try new restaurants

6 Deep-fried Oreos with vanilla ice cream If I go to Las Vegas, I go

to Lava to have this So much for nutrition

7 I like new clothes and should not

go into Nordstrom

8 Taking my daughter clothes shopping I get time to talk to her

9 I love the game of basketball Going to see the Chicago Bulls play is one of my greatest sources of entertainment I understand the game but could never play it well

10 I like pretending I have a bad cold/cough at the movie theater

so nobody will sit in front of me, and I can put my feet up :-)

IP

Volume 7 Number 1 Implant practice 9

Promoting happiness and healthy lifestyles

We at DIO Corporation (Kosdaq:039840) are

dedicated to promoting happiness and

healthy lifestyles in over 70 countries around

the world with investment in and

develop-ment of state-of-the-art dental implant

technologies and advanced digital dental

solutions

To further enhance our efforts, the DIO

Implant Academy was established to provide

both practical and advanced dental

educa-tion to our partner clinicians globally DIO

also organizes annual educational symposia

that serves as a way for our partner clinicians

to meet, exchange knowledge and

collabo-rate with renowned scholars and practitioners

in the dental implant field is in a strategic partnership with Dentsply

International (NASDAQ: XRAY) by virtue of Dentsply being DIO’s largest shareholder

Dentsply is one of the largest global dental products companies in the world

• So called “Premium” Implants → “Affordable, Value-Added” Implants

• Traditional “Analog” Dentistry → “Digital Dental Solutions”

DIO has long term staying power DIODIO will lead the “Paradigm Shift in Dental

Implants”

10 Implant practice Volume 7 Number 1

CORPORATE PROFILE

DIO Symposium at Las Vegas

“Paradigm Shift in Implant Dentistry” will

be held on May 10 - 11th, 2014 at the

Mandalay Bay Resort and Casino

DIO Symposium Las Vegas 2014 will be an

informative and educational event that will be a

landmark event for our Company; and one that

will not be forgotten

We chose to organize our 2014 symposium in Las Vegas, which is an international destination for world-class entertainment, ultracool

nightlife, renowned restaurants and luxury shopping venues Furthermore, stunning hotels have raised the bar for service and ment Amazing venues showcase world-class entertainers, whether they’re on the latest leg of a world tour or they’re must-see Las

entertain-Vegas staples The city is also home to some of the world’s best magicians, singers, impressionists, comedians and tribute acts

PRADIGM SHIFT IN IMPLANT DENTISTRY

“Premium” Implants to “Affordable, Value Added” ImplantsTraditional “Analog” Dentistry to “Digital Dental Solutions”

PARADIGM SHIFT IN IMPLANT DENTISTRY

12 Implant practice Volume 7 Number 1

CORPORATE PROFILE

DIO Implant offers a full line up of implant designs

and options to perfect your implant procedure under

any situation with predictable and optimal results

UF, SM, Protem, Extrawide, FSN/FTN

DIO holds best in class design, superior surfaces,

state-of-the-art manufacturing, highest quality tools,

drills and kits along with easy to learn protocols

CORPORATE PROFILE

DIO Implant

Renowned dental implants in over 70 countries

BEST IN CLASS MANUFACTURING

DIO Implant holds ISO 13485 certification

ISO 13485 is an International Organization for tion (ISO) standard that represents the requirements for a comprehensive quality management system for the design and manufacture of medical devices.

DIO Digital Solutions

This information was provided by DIO.

• DIO Digital Solutions “Trione” brand lineup is composed of the “tried and true”

best products and technologies globally

• Includes the most advanced intra-oral scanners, CAD applications & software and precision milling technologies

• DIO has developed highly advanced implant-oriented integrated digital applications and solutions designed for leading dental clinics and laboratories

• DIO is leading the “Paradigm Shift” from Analog to Digital Dentistry

DIO Digital Solutions

Trios Scan

Milling (Trione G)

Milling (Trione Z)

DIO CNC Milling 3Shape Design

DIO Implant offers a full line up of implant designs

and options to perfect your implant procedure under

any situation with predictable and optimal results

UF, SM, Protem, Extrawide, FSN/FTN

DIO holds best in class design, superior surfaces,

state-of-the-art manufacturing, highest quality tools,

drills and kits along with easy to learn protocols

CORPORATE PROFILE

DIO Implant

Renowned dental implants in over 70 countries

BEST IN CLASS MANUFACTURING

DIO Implant holds ISO 13485 certification

ISO 13485 is an International Organization for tion (ISO) standard that represents the requirements for a comprehensive quality management system for the design

Standardiza-and manufacture of medical devices.

DIO Digital Solutions

This information was provided by DIO.

• DIO Digital Solutions “Trione” brand lineup is composed of the “tried and true”

best products and technologies globally

• Includes the most advanced intra-oral scanners, CAD applications & software and precision milling technologies

• DIO has developed highly advanced implant-oriented integrated digital applications and solutions designed for leading dental clinics and laboratories

• DIO is leading the “Paradigm Shift” from Analog to Digital Dentistry

DIO Digital Solutions

Trios Scan

Milling (Trione G)

Milling (Trione Z)

DIO CNC Milling 3Shape Design

IP

Replacing two adjacent maxillary central

incisors is one of the most challenging

esthetic clinical situations we face in

providing dental implant therapeutics The

maxillary anterior region provides numerous

esthetic, technical, and sequencing

challenges This article describes a

surgical and restorative workflow for this

clinical problem from treatment planning

considerations to selection of a dental

implant system that provides surgical and

restorative advantages in order to enhance

the esthetic outcome

Case 1

A 53-year-old female presented for

functional surgical crown-lengthening

procedure around her maxillary central

incisors (teeth Nos 8 and 9) prior to

replacement of new crowns The patient

reported mobility of the existing crowns

and an unpleasant odor in her mouth

According to patient history, these crowns

were recent replacements of prior

long-standing unesthetic crowns The patient

had an unremarkable medical history and

had previously sought dental and dental

hygiene care on a regular basis Both teeth

Nos 8-9 had prior endodontic therapy

(Figure 1)

At her initial examination, a complete

dental and periodontal evaluation, including

full-mouth radiographs, was completed with

photographic documentation Significant

marginal inflammation was noted around

teeth Nos 8-9 associated with poor fit

of the crown margins and with recurrent

decay The patient demonstrated normal to

thick biotype with rolled, reddened margins

around the central incisors associated with

a high smile line and a dental history of mouth breathing (Figure 2)

All other regions of her mouth strated marginal gingivitis associated with retained interproximal plaque The existing shape of her central incisor crowns were square and short and disproportionate in shape and size to her other natural anterior teeth

demon-The existing crowns were carefully removed, and the underlying tooth structure was inspected It was noted that there was inadequate core portion of the crowns, with only the coronal aspect

of an endodontic post and composite retaining the crowns There had been no ferrule portion of the tooth preparations

in the cervical region (Figure 3) The likely contributing factor to the mobility

of the crowns was the excessive tooth preparation resulting in crown flexure and marginal leakage resulting in recurrent caries

At her request, she was referred to

a prosthodontist for further restorative treatment A composite-based diagnostic wax-up was completed to assist in

determining optimum tooth height and shape Treatment plan options were developed after discussing surgical and restorative considerations with the patient These included functional surgical crown lengthening and new crowns, orthodontic extrusion of the two central incisors, followed by functional crown lengthening and new crowns, or extraction of the teeth and replacement with two dental implants and crowns Based on the missing core portion of her teeth and the extent of decay around the post spaces, it was determined that extraction of the teeth and replacement with dental implants was the treatment

of choice Based on the anatomy of the tooth sockets and dimensions of palatal bone, identified by three-dimensional imaging CBCT, it was further determined that immediate extraction and placement

of dental implants with intra-socket bone grafting was possible

The patient preferred interim fixed provisionalization during the initial healing phase, rather than any of the removable provisional options discussed with her The surgical phase consisted of

Tackling a challenging esthetic clinical situation

CASE STUDY

Dr Cary A Shapoff illustrates a case replacing two adjacent maxillary central incisors

Figure 1

Cary A Shapoff, DDS, has practiced in

Fairfield, Connecticut for over 36 years

He is in private practice as a periodontist,

and is a Diplomate and past director of the

American Board of Periodontology He lectures both

nationally and internationally on periodontal disease

and its treatment, bone grafting procedures, and dental

implant surgery He has also written articles published

in the Journal of Periodontology, Compendium, the

International Journal of Periodontics and Restorative

Dentistry, and The Dental Guide (Canada) He has been

a consultant and lecturer for BioHorizons for 7 years.

Dr Shapoff can be contacted at: cas@shapoff.com.

Figure 2

CASE STUDY

extraction of teeth with a flapless approach

followed by careful curettage of the intact

socket walls Utilizing a surgical guide

based on the diagnostic wax-up, two

dental implants were placed, engaging the

palatal wall of the intact sockets (Figure 4)

The implants selected were the

BioHorizons® Tapered Internal with

Laser-Lok® microchannels on the coronal collar

portion (3.8 mm x 15 mm with 3.5 mm

prosthetic platforms) Precise

three-dimensional positioning was established

with the surgical guide Following implant

placement, the voids within the socket were

bone grafted with a combination cortical

and cancellous allograft (MinerOss®), and

flared healing abutments were placed to

support the soft tissues (Figure 5)

The composite-based diagnostic

wax-Figure 5

Figure 6

• One system with superior 3D scans with multiple fields

of view, 2D panoramic imaging and optional one-shot cephalometric imaging

• Dedicated 2D digital panoramic imaging with variable focal trough technology that produces high-quality images

in 13 seconds

• Intelligent Dose Management provides high-resolution 3D images and low dose as collimation limits exposure

to area of interest

• Five selectable fields of view ranging from 5cm x 5cm to 10cm x 10cm help you get the proper image size for each procedure

To learn more about what a great image can do for your oral and maxillofacial surgery practice, visit carestreamdental.com/CS9300 or call 800.944.6365 today.

© Carestream Health, Inc 2013

10232 OM DI AD 0114

The CS 9300 Select is ready to work hard for your practice.

This technologically-advanced system will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry It will also show your patients how dedicated you are to their oral health

It’s amazing what a great image can do for your practice.

Figure 7A Figure 7B

16 Implant practice Volume 7 Number 1

CASE STUDY

up was then bonded to adjacent laterals as

a fixed provisional

Three months after surgical placement

of the implants, screw-retained provisional

crowns were fabricated onto PEEK

abutments and were modified to achieve

ideal tooth shape and gingival architectural

framework (Figure 6) Maintenance of the

interproximal bone between the implants

was achieved with use of the BioHorizons

implants with Laser-Lok microchannels

Minor modifications to the interproximal

and facial dimensions of the composite

crowns were made over a period of 12

weeks (Figures 7A and 7B)

Once ideal tooth and gingival size and

shape were established, custom,

open-tray impressions were taken to capture

the precise ideal subgingival form for

final crown fabrication (Figures 8-9) Final

crowns were then provisionally cemented

and monitored for potential additional

minor modifications (Figures 10A and 10B)

The radiograph of the final crowns at 12

months demonstrates the maintenance

of the crestal bone around each dental

implant as well as maintenance of the

interproximal bone between the implants

(Figure 11)

Discussion

Numerous lessons can be learned from a

critical review of this case

1 Evaluation of the failed crowns

identified excessive tooth preparation and

inadequate coronal portion of the tooth to

provide predictable restoration with basic

fixed partial dentures (crowns) In addition,

the design of the failed crowns did not mimic the tapered shape of her adjacent natural teeth Critical documentation of tooth shape and size and smile analysis is

an essential element of proper treatment planning Lack of adequate ferrule and lack of coronal tooth portion should have precluded placement of the failed permanent crowns

2 Dental implant treatment planning should include photographic documentation, diagnostic wax-up, evaluation of the gingival tissue biotype, position of the maxillary lip position relative to the gingival margin of the teeth, and shape and form of the intended implant restoration

3 Surgical treatment planning should include three-dimensional imaging especially if a flapless approach is considered Because of the thick gingival biotype and intact sockets of both teeth, immediate placement was considered In other cases of high smile line, and thinner biotype, a delayed two-phased approach

of grafting followed by implant placement would have been the treatment choice A delayed two-phased approach would also

be required if the remaining alveolar bone prevented adequate initial biomechanical stability at implant insertion

4 Selection of the BioHorizons Tapered Internal implant was a key element of the success of maintaining interproximal bone between two implants Use of the tapered 3.8 implant body allowed ideal positioning

in the palatal bone without encroachment

on the facial bone dimension or elimination

of the mesiodistal bone within the socket reducing initial stability Intra-socket bone grafting with a calcified allograft minimized the horizontal dimension bone resorption often seen even with immediate implant placement The use of the BioHorizons implants with the Laser-Lok microchannels was another key element in maintaining the ideal intra-implant bone level, which

in turn supported the ideal height of the interproximal papilla Numerous published articles have supported the concept of enhanced bone maintenance with the non-random Laser-Lok microchannels (Figures 12A and 12B) Additional animal and human clinical and histologic studies have demonstrated “functionally oriented” connective tissue attachment to the Laser-Lok surface along with inhibition of the epithelial downgrowth against the implant surface and Laser-Lok abutment surface (Figure 13)

Figure 12A Figure 12B

Figure 13: Polarized light micrograph

Figure 14

Figure 15

5 Maintaining support of the facial and

interproximal tissue contours with use of

the flared healing abutments assisted in

recapturing the proper gingival contour

around the provisional crowns This could

have been further improved by fabrication

of “custom” healing abutments utilizing

the BioHorizons 3inOne abutment and

composite This customized technique

is used often in this practice but was not

utilized in this case

6 Fabrication and modification of the

well-contoured, screw-retained provisionals by

the prosthodontist, Dr Jeffrey O’Connell,

(Bridgeport, Connecticut) was also another

key element in achieving ideal tooth shape

and gingival framework In addition, the

established subgingival contours were

captured in the final impression technique

utilizing the BioHorizons open-tray copings

modified with resin The excellent working

relationship of the prosthodontist and his

dental laboratory technician also needs

to be mentioned in achieving

natural-looking, all-ceramic crowns This case was

completed before the company release

of CAD-CAM custom abutments with

Laser-Lok microchannels (Figure 14) Use

of these abutments would have further

enhanced the attachment of soft tissue to

the abutment surface resulting in protection

of the underlying crestal bone

In summary, the patient was

successfully restored with two

single-crown dental implant restorations following

an interdisciplinary workflow from treatment

planning through final restorations The use

of the BioHorizons Tapered Internal dental

implant with Laser-Lok microchannels

was an integral part of the success of this

case In similar cases where the gingival

biotype is thinner, I would have considered

using the platform switched BioHorizons

Tapered Internal Plus implant in order to

create a thicker dimension of marginal

tissue around the abutments (Figure 15)

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Dental problems of cancer patients

are often worsened when the patient

undergoes chemotherapy Dentists and

other dental care professionals have seen

this Dental problems definitely worsened

for Dr Richard G Dong, a retired engineer,

during his 3½ years of treatment with the

chemo-therapeutic drug Bacillus

Calmette-Guerin (BCG), a live bacteria injection used

to treat bladder cancer The problems

included persistent infections developing in

two existing molar dental implants on teeth

Nos 19 and 30 Dr Bryan R Krey is the

oral surgeon performing the dental implant

procedures and has followed Dr Dong’s

problems and his inventive ways of handling

them This article describes the simple

instruments and techniques Dr Dong

developed that saved one of the existing

implants and, together with Dr Krey’s

help, extended the life of the other by an

estimated 2 years Conclusions reached by

Dr Dong and Dr Krey are summarized at

the end of the article regarding the handling

and designing of implants for individuals on

chemotherapy or who had chemotherapy,

and who had experienced worsened

dental problems while on chemotherapy

Dr Dong is a nonsmoker, with no diabetes

or other systemic disorders He exercises regularly and eats a healthy diet

Effects of an altered immune system

The chemotherapy was to train Dr Dong’s immune system to fight the cancer The following might or might not be medically established, but from an engineer’s point

of view, this means the immune system will

be altered; and therefore, various changes

in immunity reactions will progressively show up as the alteration increases This was confirmed by the fact that various forms of immunity reaction came forth one after the other over Dr Dong’s 3½ years

of treatment This included arthritic immunity reactions, weakened ability to fight off certain bacteria, such as those causing dental problems and those caus-ing cellulitis Dr Dong’s last treatment resulted in a severe rash all over his body,

auto-as his immune system became sensitized

to the drug Thank goodness it was the last treatment; who knows what else might have arisen next General tiredness, headache-nausea reactions to weather changes, and allergic reactions to certain foods also developed The bladder became hyper from three rounds of surgeries and from the prolonged exposure to the chemotherapy drug Hyper is defined here

as constant urgency and frequency to urinate on an hourly basis Therefore, this

is also at least partly an immunity reaction

Besides the immune system becoming

more able to fight the cancer, a secondary positive change was that his seasonal hay fever became much milder

Not everyone would react the same way to this particular chemotherapy, and therefore, not everyone is necessarily going to have the reactions mentioned Everyone’s immune system is different This is becoming increasingly clear in general cancer research Immune systems

in individuals could vary widely as revealed

in current research using humanized mice The immune systems of numerous individuals are grown in mice to study their reactions to various cancer-fighting drugs and various cocktails of the drugs The reactions were found to vary widely among the immune systems

Ideally, the longer the chemotherapy

Dr Dong received could continue, the more his immune system would be altered

to fight the cancer However, it became apparent to him that the likely reason the standard duration is set at 3½ years is because that is probably what a typical patient could tolerate before the immunity reactions become more intolerable than the cancer However, at the current level

of alteration, Dr Dong prefers to put up with current reactions than to have his immune system return to how it was, thus allowing the cancer an increased chance of recurring

Implant failure increases when the implant procedure is timed near

or during chemotherapy Bone formation takes place slowly to fill in

A chemotherapy patient’s experience with dental

Richard G Dong, PhD, was born and raised in

Sacramento, California He earned his BS and MS

degrees in Mechanical Engineering at the University of

California in Berkeley, California He worked for 2 years

at the Aerojet-General Corporation in Sacramento,

California He returned to the Berkeley campus and

earned his PhD in Structural Mechanics He then

worked at the Lawrence Livermore National Laboratory

in Livermore, California, as a research engineer and

as one of the technical reviewers for the laboratory’s

Nuclear Test Program He retired in 1993 He lives in

Danville, California, where he and his wife raised two

children.

Bryan R Krey, DMD, was born and raised in Brentwood,

California He earned his dental degree at Oregon

Health and Science University in Portland, Oregon,

in 1993 He completed his Oral Surgery residency at

Highland Hospital in Oakland, California, and later

completed his board exams and is a Diplomate of the

American Board of Oral and Maxillofacial Surgery He is

in private practice with offices in Berkeley and Orinda,

California He lives in Lafayette, California, with his wife

and four children.

Figure 2: Radiograph with tooth No 19 and tooth No 30 implants in place Prior to restoration Ideal bone levels

20 Implant practice Volume 7 Number 1

PATIENT INSIGHT

the hole left from a tooth extraction After 4

months, enough bone has usually formed

to enable the implant post to be installed

But an X-ray would clearly indicate the

bone has not yet reached normal density

Four months after that, the crown is usually

installed An X-ray would indicate the bone

density is better but still not at normal

level From an engineer’s perspective, the

bacteria could now begin accumulating at

the crown-implant junction The surface

transitioning from the crown to the post

would not be perfectly smooth, as could

be seen on the implant removed from Dr

Dong’s molar tooth No 30 site The crown

and post are minutely different in diameter

and roundness such that a tiny ridge and a

tiny shelf are formed there Tiny gaps likely

also exist at various locations where the

crown mates with post Such imperfections

are deeply located and somewhat hidden

since they are not easily reached during

brushing and flossing Bacteria could

accumulate at these imperfections and

then migrate to where the post meets the

bone to initiate bone loss Also, as pointed

out by Dr Dong’s regular dentist, the

migration is intensified by the “pumping”

action during food chewing There must

be reasons why bone loss occurs after

the crown is installed, and the factors

mentioned seemed logically to be why

If bone density were less than normal,

the initiation of bone loss would be easier, and continued bone loss would be faster In addition, if the patient’s immune system’s ability to fight the bacteria were weakened by chemotherapy, the entire bone loss process would progress even faster Under this condition, the pocket formed by bone loss could quickly grow

to where the bacteria would have many corners and crevices in which to hide and colonize Once colonization occurs, the bacteria would be more difficult to dislodge and eliminate, bone loss might be slowed with extraordinary care but not stopped, and the implant would eventually fail

Under normal circumstances, with the patient’s immune system well able to fight off the bacteria, bone loss could initiate but would stabilize and essentially stop The implant would then be successful An X-ray could show a small amount of bone loss, but that would be considered normal

Dr Dong’s experience with implants appears to match the descriptions in the preceding paragraphs Four of his molars

at different times needed to be replaced with implants, and chemotherapy affected all four The following are the timelines relative to the beginning or ending of chemotherapy

Molar 30

• Implant post was installed 1.0 year before chemotherapy began Crown was installed 0.63 years before

• The implant procedure is currently being repeated Implant post is not yet installed

Molar 18

• Molar 18 was extracted 1.06 years after chemotherapy ended and about 0.06 years after the chemotherapy drug completely left the body

• Implant post was installed 1.4 years after chemotherapy ended and about 0.4 years after the chemotherapy drug completely left the body Crown is not yet installed

Molar 31

• Molar 31 was extracted 1.7 years after chemotherapy ended and about 0.7 years after the chemotherapy drug completely left the body

• Implant post is not yet installed

• The fact that molar 31 went bad quickly could indicate that Dr Dong’s immune system remains altered and was thus unable to fight the bacteria adequately His urologist treating the cancer and his primary care doctor indicated his immune system is likely to remain altered for the rest of this life, especially since chemotherapy was done at his somewhat advanced age of 70 years

Dr Dong had quite a few dental problems even before he had cancer According to his dentist, he keeps his teeth so clean; he should not have so many problems Consequently, it must be

in his genes The need to replace molars

Figure 5: Radiograph showing loss of tooth No 30

im-plant, restored tooth No 19 imim-plant, and recently placed

tooth No 18 implant Tooth No 18 implant features

internal abutment connection and platform switching

Figure 3A: Restored tooth No 30 implant with

vertical bone loss Figure 3B: Prior to tooth No 19 implant being restored

Figure 4: Restored tooth No 30 implant 2011 Severe bone loss

MEISINGER USA, L.L.C.

10200 E Easter Ave • Centennial • Colorado 80112 • USA

Phone: +1 (303) 268-5400 • Fax: +1 (303) 268-5407 • Toll free: + (866)634-7464

22 Implant practice Volume 7 Number 1

PATIENT INSIGHT

19 and 30 with implants happened before

chemotherapy began However, infections

and gum swelling, bleeding, pocket

formation, and bone loss started happening

soon after chemotherapy began

The molar 19 implant remains

successful while the molar 30 implant

failed Molars 19 and 30 are at the same

locations at opposite sides of the lower

jaw Therefore, their environments should

be essentially identical A notable difference

is the molar 19 implant had 3 months more

to increase bone density than the molar 30

implant had before chemotherapy began

The 3 additional months apparently enabled

the bone density for the molar 19 implant

to reach a high enough level to prevent the

rate of bone loss from becoming unstable

Molar 18 experienced multiple

problems while Dr Dong was undergoing

chemotherapy The dentist and Dr Dong

did their best to save molar 18, but

couldn’t It seemed that once the bacteria

gained a foothold, it is very difficult to stop

the destruction when the immune system

is unable to fight the bacteria well enough

An infection occurred at the periapical

region of molar 31’s roots, and it led to the

molar’s loss Age-related gum recession

exposed the bifurcation point between

the roots and allowed bacteria to enter

An earlier root canal eventually resulted in

root brittleness, and one root developed a

crack that allowed the bacteria to migrate

to the lower region of the roots The entire

process happened very quickly and could

not be caught even with biannual hygienic

cleaning and inspection by the dentist The

process apparently accelerated because

the immune system was unable to fight off

the bacteria well

Stopping the 4-week cycling

between infections and healing

The gum surrounding molars 19 and 30

implants started getting infected, swollen,

and bleeding shortly after chemotherapy

began, and worsened as chemotherapy

continued Pockets started to form, and

a bit of exudate could be expelled when

pressure is applied to the pockets The

problem occurred at the buccal face side

of the implants but not at the lingual side

For some reason, this is common Perhaps

the pressure and motions of the tongue

kept the bacteria from gaining a foothold at

that side of the implants

Dr Dong tried handling the problem

by brushing, flossing, and using an

interdental brush, but none worked It became apparent that blood clots and other materials the bacteria could cling to

or hide in must be removed, and that some method of flushing them out needed to

be developed Therefore, he made some instruments consisting of various shapes of plastic toothpicks, toothpick holders that hold toothpicks at 90º from the handle,

an eyedropper, a length of flexible plastic tube 0.05 inches outer diameter, and a covered low container of Listerine® Plastic toothpicks rather than wooden ones were used because plastic ones would not fray and lose their shape

The steps in the procedure Dr Dong developed are as follows:

Step 1:

• He used the smooth, round blunt end

of a toothpick holder to gently rub against the pockets to expel the exudate accumulated in the pockets

• The exudate would be a larger amount and a bigger concern when infection exists If infection does not exist, the exudate would be a smaller amount and

• The reason for omitting this step here will

be explained later in the article

Step 4:

• A more sharply pointed toothpick

is used to slightly enlarge the front and rear openings of the pocket and

to mechanically gently dislodge the bacteria from the surfaces of the pocket

The center edge of the pocket is usually still attached to the post, and this part

of the pocket is not to be forced open

Otherwise injury would occur leading to infection Step 4 is performed only if the openings of the pocket are large enough

to allow the toothpick to easily enter, as was the case for the molar 30 implant

• If the openings of the pocket are very small, as is the case for the molar 19 implant, Step 4 is omitted, and Step 5 would still be effective

• The mouth is rinsed before going to Step 5

Step 5:

• The syringe made with an eyedropper with a length of 0.05-inch outer diameter flexible plastic tube fastened to it with a glue gun This is used to squirt Listerine into the pocket to flush out the bacteria and any other materials The tube is inserted into one of the two openings widened in Step 4, and that part of the pocket is flushed This procedure

is repeated with the other openings Flushing is repeatedly alternated between the two openings until all the Listerine in the eyedropper is used up

• If the pocket was bleeding to begin with, Step 5 was performed three times to stop the bleeding A blood clot must not be allowed to form in the pocket Listerine apparently has an ingredient that helps stop the bleeding

• As explained, Step 4 is omitted for the molar 19 implant Squirting the Listerine into the pocket through openings as they already exist without being further opened by Step 4 seems to work adequately for the molar 19 implant

• The mouth was rinsed, and the usual teeth brushing was then performed for the entire mouth

• A flexibility syringe made as explained works better and safer than using a standard rigid syringe The plastic tube was held at the opening of the pocket with one hand, while the other hand squeezed the eyedropper The flexibility

of the plastic tube enabled the tube to

be easily and safely held at the opening

of the pocket This is likely to be much more difficult to do using a standard rigid syringe

Step 3 is left blank in the above list for the following reason The four steps listed would dislodge and flush out the bacteria and thus promote healing However, as healing progresses, the gum would tighten against the post Steps 4 and 5 would then become more difficult and less effective to perform Consequently, the bacteria begins

to re-establish in the pocket This caused infection to start again The infection and swelling would cause the openings of the pocket to enlarge This then enables Steps 4 and 5 to be more easily and effectively performed Healing would then

be promoted again The net result is we get 2 weeks of healing followed by 2 weeks

of infection, swelling, and bleeding This 4-week cycle continues to repeat with only the four steps listed above

24 Implant practice Volume 7 Number 1

PATIENT INSIGHT

Dr Dong discovered that by adding a

Step 3, the 4-week cycle would be stopped

In Step 3, he uses a toothpick, not quite

as pointed as the one used in Step 4, to

clean the gum line around the post where

brushing and flossing would not reach This

would be where a tiny trough is formed

over the length of the edge of the pocket

that remains attached to the post This is

the length of the edge of the pocket that

is not to be opened in Step 4 Apparently,

this trough provides a lodging site for the

bacteria When the pocket could not be

flushed out very well, these bacteria would

migrate into the pocket and add to those

not flushed out The total would reach a

level that would cause infection to start

Step 3 is as follows:

Step 3:

• Use a toothpick not quite as pointed

as the one used in Step 4, and clean

along the gum line at the face side and

the tongue side of the implant While

cleaning the tongue side is probably not

necessary, you might as well do it just

in case

• The mouth is rinsed before performing

Step 4

By adding Step 3, the 4-week cycle

was stopped Bone loss in the molar 19

implant was stabilized, and the implant was

saved

Unfortunately, the addition of Step 3

was unsuccessful in saving the molar 30

implant The pocket there had become

so large and deep with so many corners

and crevices in which bacteria could hide

that while the 4-week cycle was stopped,

enough bacteria remained in hiding to

cause continued bone loss even without

apparent infection Dr Krey tried cleaning

out the pocket to minimize the places

where bacteria could hide, but as he later

explained, once the bacteria colonized

within the pocket, they were very difficult to

completely dislodge and flush out In this

case, “colonization” means the bacteria

became established in some

hard-to-clean and flush locations in which to hide

and breed Nevertheless, by stopping the

4-week cycle and thus slowing the rate of

bone loss, the molar 30 implant’s life span

was extended by 2 years, by Dr Dong’s

estimate

Best to repeat the procedure

every 12 hours

Based on Dr Dong’s experience, the

procedure described is best repeated

every 12 hours This enables the openings

of the pocket, in the case of the molar 30 implant, to remain reasonably open so that Steps 4 and 5 could be performed effectively If more than 12 hours have passed, the openings would decrease to where Steps 4 and 5 could be more difficult

or impossible to perform Then infection could start again If the procedure were performed more frequently than every 12 hours, injury and inflammation could occur leading to infection

Every step of the procedure must be done not too gently or too forcefully, even while squirting Listerine into the pocket

Enough force is needed to dislodge or flush out the bacteria, but too much force can cause injury followed by infection The tissue inside the pockets is very tender and fragile since it is well protected and not toughened by exposure during brushing, flossing, and contact with foods

ConclusionsBased on the differences in the behaviors

of the molars 19 and 30 implants, and how installing the crown on the post could initiate bone loss, Drs Dong and Krey came up with two conclusions If the patient is under chemotherapy or had chemotherapy in the past, and if dental problems significantly worsened while on chemotherapy, then Conclusion 1 would apply

Conclusion 1

Installing the crown onto the post should

be delayed to allow more time for the bone density to reach a high enough level

to prevent easy initiation of bone loss followed by a fast rate of bone loss How much delay time is required to achieve this is not known at this time However

Dr Dong’s experience indicates waiting 1.25 years after the post is installed would most likely achieve the desired result But waiting 1.25 years is probably longer than really necessary According to Dr Dong’s experience, an increase of 0.25 years

in doing the implant procedure before chemotherapy commenced was enough to make a significant difference While this is not the same as waiting 0.25 years before installing the crown onto the post, it does confirm that allowing extra time for the bone density to increase before chemotherapy begins is beneficial Therefore, instead of waiting 1.25 years to install the crown, we could try doubling or tripling the standard waiting time of 4 months after the post is installed before installing the crown and

see if that is enough to achieve the desired result Dr Dong plans to try this for the molars 18, 30, and 31 implants and could report on the results at a later time

The post installed at the molar 18 site has a new design to help hinder the migration of bacteria to where the post meets the bone The new design has the same overall proportions as the preceding design except a location that is a short distance below the top has a smaller diameter This forms a circumferential grove for the gum tissue to grow into This makes the path more difficult for the bacteria to negotiate to reach where the post meets the bone In Conclusion 2, Drs Dong and Krey present another possible new design for the implant post following

a different approach to preventing bacteria from migrating to where the post meets the bone

Conclusion 2

As stated earlier, tiny imperfections, such

as a ridge, a shelf, and gaps, formed where the crown meets the post are possible sites for the bacteria to accumulate These sites are not easy to reach during brushing and flossing The bacteria could accumulate there and then migrate to where the post meets the bone to initiate bone loss This chain of events could be avoided if the post and crown were reconfigured The crown-post assembly has the shape of a wine glass with a very stout stem minus the base The tiny imperfections would

be located where the cup meets the stem If the imperfections were relocated higher up onto the cup, then any bacteria accumulated there would be more exposed and more easily removed by brushing and flossing This would eliminate the imperfections as sites where bacteria could accumulate, and from which to migrate to where the post meets the bone The post would have a head similar to how

a flat-head wooden screw has a head The crown would be flatter to accommodate the head on the post The appearance might not be desirable if the base of the implant is visible to others

The implant post design presented would benefit any dental implant recipient regardless of whether or not the recipient

is going through chemotherapy or had worsened dental problems while on chemotherapy in the past.IP

CONTINUING EDUCATION

Traumatic injuries to the anterior teeth

can be a tragic experience for the

patient and require thorough treatment

planning, experience, and skill on behalf of

the dentist

Advances in techniques used both

in endodontics and implantology have

allowed us to save more of the patient’s

own teeth — and patients’ wishes to

retain their own teeth, if possible, must be

respected

In this case study, the use of

membrane and autogenous-free bone

regeneration with simultaneous implant

placement (Fairbairn, 2011; Podaropolous,

et al., 2009), as well as

microscope-enhanced endodontics, helped achieve the

result the patient desired

Introduction

Dental trauma often involves a team of

dental practitioners: the general dentist

along with one or more specialist dentists

Since trauma is not a common occurrence

in general practice, management of

traumatized teeth can be both demanding

and challenging, as it is accompanied by emotional factors on the patient’s part

Horizontal root fractures can be classified according to the location of the fracture line (apical third, middle third, and cervical third) Injury factors to the tooth, such as location of the fracture line, mobility of the coronal fragment, the degree

of dislocation of the coronal fragment and diastasis between fragments (rupture

of the pulp at the fracture site), stage of root development (immature or mature root), and age of the patient (growth of the alveolar process) have the greatest influence upon healing (Andreasen, et al., 2004; 2007)

In the horizontally fractured tooth, necrosis of the pulp usually occurs in the coronal fragment, while the pulp of the apical fragment remains vital (Andreasen and Hjorting-Hansen 1967; Hitchcock,

et al., 1985) This provides a basis for treatment of the horizontally root fractured teeth

In permanent teeth with horizontal fractures in the apical and middle thirds, root treatment of the coronal fragment only with gutta percha (with calcium hydroxide dressing in the interim) has been proved

to be successful, whereas unfavorable outcomes have occurred when both fragments have been endodontically treated with gutta percha (Cvek, et al., 2004; 2008)

The aim of this is to form a calcific

barrier at the apical end of the coronal root fragment, in the same way as treating a non-vital immature tooth (by apexification)

Mineral trioxide aggregate (MTA), was developed in the 1990s as a root end filling material (Torabinejad, et al., 1993; 1995)

Since then, it has been used extensively

in all aspects of endodontic treatment It is associated with favorable apical healing when used as an apexification material in immature teeth with open apices (Pace, et al., 2007; Simon, et al., 2007; Felippe, et al., 2006) because it encourages hard tissue formation (Pitt Ford, et al., 1996; Nair, et al., 2008; Accorinte Mde, et al., 2008), is biocompatible (Pitt Ford, et al., 1996; Nair,

et al., 2008; Aeinechi, et al., 2002), provides

a good seal (prevents microleakage) (Torabinejad, et al., 1993; Pitt Ford, et al., 1996; Lee, et al., 1993; Lawley, et al., 2004), and is nonresorbable (Torabinejad and Chivian, 1999) Consequently, MTA

is the treatment of choice instead of gutta percha for root filling the coronal segment

of teeth with horizontal root fractures

This case involves three teeth that were involved in trauma and the multi-disciplinary approach used to treat them

After careful assessment, sometimes the only option is removal and replacement with

a dental implant Guided bone regeneration

is generally needed in trauma cases where dental implants are to be placed due to bone damage during the trauma or as a result of post-traumatic infection The co-

Multi-disciplinary approach to the treatment of

traumatic root fracture: a case study

Drs Peter Fairbairn and Sharon Stern present a multi-disciplinary approach to tackling a tricky trauma case

Dr Peter J.M Fairbairn, BDS, is principal of the

referral-based Scarsdale Dental Aesthetic and Implant Clinic

in Kensington, London He is visiting Professor in the

Department of Periodontology and Implant Dentistry at

the University of Detroit Mercy School of Dentistry in

Michigan (United States) Dr Fairbairn can be contacted

at Peterdent66@aol.com.

Dr Sharon Stern graduated in 1999 as a general dentist

from the University of the Witwatersrand (South Africa),

before moving to London where she worked in private

practice and the Acute Dental Care Department at

Guys Hospital In 2006 she completed the Certificate

in Restorative Dentistry at Eastman Dental Institute Dr

Stern completed her specialist training in endodontics

at Guys Hospital in 2010 and was accepted on the

GDC Specialist Register for Endodontics in 2010 Since

qualifying as an endodontist, Dr Stern works mainly in

private practice and is involved on a part-time basis in

the postgraduate clinical program in endodontology

at Kings College London She has also been the main

author of a research article and co-author in a

peer-reviewed journal article Dr Stern can be reached by

email at endodontics@hotmail.co.uk or on 020 7937

2160

Educational aims and objectives

The aim of this article is to present a multi-disciplinary case study that demonstrates how patients’ needs can sometimes be better met when clinicians work together

• See where implant therapy and endodontics can combine.

• Identify some of the principles behind soft tissue grafting and healing.

26 Implant practice Volume 7 Number 1

CONTINUING EDUCATION

author has used only alloplast or synthetic

particulate graft materials for the last 10

years using no autogenous (blocks, chips,

or scrappings) for the last 9 of them A

delayed immediate placement protocol is

the standard procedure where the tooth

or root is removed carefully, so as to not

damage the residual bone, and then left to

heal for 3 weeks

This standard protocol — employed

in more than 1,800 cases in the 10 years

by the co-author — allows for soft tissue

closure yet ensures the preservation

of adjacent bone prior to the phase of

modeling (Schropp, et al., 2003) Ridge

preservation, rather rebuilding the profile

of the modeled ridge, can be both more

time efficient and less traumatic for the

patient Bone healing is further improved

by not using a traditional (collagen-type)

membrane that inhibits periosteal blood

to the graft site, which accounts for 85%

(or more) of the blood supply to the site

The stability and soft tissue cell occlusive

properties needed for successful bone

regeneration (Schenk 1995) are achieved

by a CaSO4 (calcium sulfate) element in the

graft material; hence, the graft is its own

membrane

Case

The 25-year-old male patient was involved

in a motor vehicle accident that resulted

in trauma to his UR1, UR2, and UR3

Horizontal root fractures were evident in

the mid to apical third of the UR2 and UR3

(Figure 1) All four teeth were splinted at his

local hospital’s dental unit after the initial

visit to the accident and emergency (A&E)

and later treated by his general dental

practitioner

The case was referred to the authors

3 months post-trauma with a swelling and

pain associated with the UR2 Clinical

examination revealed that the UR2 was

grade 3 mobile; the UR1 and UR3 were firm The UR3 had not responded to sensitivity tests (electric pulp testing and cold testing) Periapical radiographs of the associated teeth (Figure 2) showed that both the UR2 and UR3 had horizontal root fractures at the junction of the middle and apical third of the roots

The UR2 was root filled; the coronal fragment was laterally dislocated; the diastasis between the coronal and apical root fragments was over 2 mm; and a lateral radiolucent area was evident The UR3 was not root filled, the diastasis was less than 1 mm, and lateral radiolucent area was evident The UR1 was root treated but not ideally obturated; however, no apical radiolucencies were associated with these roots

The patient was determined to retain both the UR2 and UR3 Since the 13 was not mobile, the diastasis between the coronal and apical fragments was less than

1 mm and had no associated pockets, the prognosis for treating this tooth was good

However, the fact that the UR2 had grade

3 mobility, the only option for the lateral incisor was an extraction This prospect suited the patient who had been initially referred for the placement of two implants, and the necessary treatment consent was completed The initial treatment would be

to secure the future of the canine, and endodontic treatment was arranged

Endodontic treatment of the UR3

A decision was made to treat only the coronal fragment of the UR3 as the apical fragment was assumed to be vital (Andreasen and Hjorting-Hansen 1967;

Hitchcock, et al., 1985) Rubber dam was secured over the tooth using a Q9 rubber dam clamp (Dentsply Ash instruments, UK)

The access was established with a long tapered diamond bur The pulp chamber

was then fully accessed and refined using

a BUC-1 ultrasonic tip under the copious water spray One canal was identified with the aid of an operating microscope (Global G3, Global Surgical Corporation) using

a DG16 explorer probe (Dentsply Ash instruments)

The working length of the root canal

of the coronal fragment was determined using an apex locator (Raypex® 5; VDW)

A working length radiograph was taken to verify the apex locator readings The canals were instrumented to working length with hand K-Flexofiles® (Dentsply Maillefer) to

an ISO size 70 using the balanced force technique

The UR3 was root filled to the level of the root fracture with a minimum of 4 mm of mineral trioxide aggregate (MTA) (Angelus) using the Messing Root Canal Gun (Miltex)

to deliver the MTA (Figure 3) An activated, stainless steel ultrasonic tip was used to apply ultrasonic energy to a number 2/3 Machtou condenser (Dentsply Maillefer), which was used to pack, flow, and settle the MTA The rest of the root canal was backfilled with gutta percha, and the access cavity was restored with composite (Filtek™ Supreme XT Universal Composite, 3M ESPE) A postoperative radiograph of the completed root canal treatment was taken (Figure 4) There is slight extrusion of the MTA beyond the fracture line; however, since MTA is biocompatible, the prognosis

of the treatment is still good

Implant placement at UR2The surgical phase was then initiated with the removal of the fractured lateral incisor

A plastic partial denture was made as a temporary rather than the preferred resin-bonded bridge due to cost factors and the patient’s desire not to involve adjacent teeth

The root tip was removed using a

Figure 2BFigure 1: Trauma area 13, 12, and 11 Figure 2A Figure 3: MTA placed

Figures 2A and 2B: Radiograph at 3 months post-trauma

CONTINUING EDUCATION

Periotome (Figures 5A and 5B), taking care

not to damage the buccal plate any further

Probing the socket showed the resultant

buccal bone defect (Figure 6) and the thin

biotype of the gingiva The partial denture

was then fitted (Figure 7), and the site was

then allowed to heal for 3 weeks

After the period of soft tissue healing,

we generally have good enough soft tissue

closure (Figures 8 and 9), but the effects of

hard tissue modeling can already be seen

due to the extent of the infected site bone

loss A site-specific flap is then raised not

to affect the papillae of the adjacent teeth

The concept of employing the

membrane in the graft (Fairbairn 2011;

Podaropolous, et al., 2009) allows this flap

to be smaller, reducing patient trauma, as well as allowing the all-important blood supply from the periosteum unimpeded access to the site The periosteum in a bone damage site also plays a role in the induction of stromal cell derived factors (Fairbairn 2011), which results in an increased presence of mesenchymal cells important for healing (Zhao, et al., 2012)

Thus, the author feels the use of traditional collagen-type membranes may be a hindrance rather than a help to the body’s healing (Gutta, et al., 2009)

The site was then vigorously curetted

to ensure the removal of any granulation tissue The bacteriostatic nature of CaSO4 enabled the co-author to dispense with

the need for the use of chlorhexidine, even though its effect on fibroblasts is debatable

A DIO 3.8 mm by 12 mm implant (DIO Implant Corporation) was placed slightly palatally in the socket (Figures 10-11) to the desired torque of 35 Nm The author always places the implant at the time of grafting — even in extreme bone loss cases — due

to the inherent regenerative capabilities of the titanium implant (Brunette 2001), as well as its mechanical stabilization of the particulate graft

The implant can thus be considered the most important of graft materials —

as well as aiding the bone regeneration, it will be needed to attach the abutment and crown in the near future

Figure 5BFigure 4: Completed root canal

Figures 5A and 5B: Use of periotome to remove the root tipFigure 5A

Figure 8: Three weeks later showing soft tissue healingFigure 6: Defect shown by probe Figure 7: Partial denture fitted

Figure 10BFigure 9: But also showing hard tissue loss

Figures 10A and 10B: Implant (DIO 3.8 mm x 12 mm) placed palatally, with site-specific flap retaining papillaeFigure 10A