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Tạp chí implant tháng 11 2009 nâng xoang hàm trên Một tạp chí chuyên ngành răng hàm mặt với chủ đề về implant nha khoa. Trong tạp chí có nhiều bài miêu tả về ghép xương và phẩu thuật trong cấy ghép nha khoa

The Journal of Implant & Advanced Clinical Dentistry

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elements The Complete Prosthetic Set ensures an accurate fit for the final restoration.

13 Case of the Month

Biologic Shaping

Daniel Melker

19 JIACD Continuing Education

Management of the Actively

Bleeding and Hypovolemic

Dental Patient

Dan Holtzclaw, Nicholas Toscano

Gingival Grafting Utilizing

Palatal Donor Tissue

M Thomas Wilcko, William M Wilcko

Augmentation: A Histologic

and Histomorphometric Human

Grafting Study Comparing Two

Anorganic Bovine Bone Minerals

Aron Gonshor, Yoon-Je Jang

59 Preservation of Buccal Bone

Plate after Immediate Implant

Usage and Findings:

Part III – Bifid Canals and

Other Deviations of the Inferior

Alveolar Nerve

Alan Alan A Winter, Kouresh Yousefzadeh,

Alan S Pollack, Michael I Stein, Frank J

Murphy, Christos Angelopoulos

Non-qualified individual: $99(USD) Institutional: $99(USD)

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Journal of Implant and Advanced Clinical Dentistry (JIACD)

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the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures JIACD, its staff, and parent company SpecOps Media, LLC (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.

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

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A Minimally Invasive and Systematic Approach to Sinus Grafting

Jack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDShannon MackeyMiles Madison, DDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMD

Dale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTJaimee Morgan, DDSDwight Moss, DMD, MSPeter K Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSArthur Novaes, DDS, MSAndrew M Orchin, DDSCharles Orth, DDSJacinthe Paquette, DDSAdriano Piattelli, MD, DDS

George Priest, DMDGiulio Rasperini, DDSMichele Ravenel, DMD, MSTerry Rees, DDS

Laurence Rifkin, DDSGeorgios E Romanos, DDS, PhDPaul Rosen, DMD, MS

Joel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDAnthony Sclar, DMD

Frank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDS

Michael Sonick, DMDAhmad Soolari, DMDChristian Stappert, DDS, PhDNeil L Starr, DDS

Eric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSMichael Toffler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDS

Hom-Lay Wang, DDS, PhDBenjamin O Watkins, III, DDSAlan Winter, DDS

Glenn Wolfinger, DDS

Editorial Advisory Board

Iam a big history buff and I am always amazed

at the progress of mankind When you think

about what we as a people have accomplished,

it literally boggles the mind As civilizations

developed in millennia past, the isolation of

different communities resulted in a great number

of technologies that were quite disparate from

one another The sheer distances between

these communities and the difficulties of travel

imposed by various natural and human elements

hampered the sharing and dissemination of these

technologies In ancient times, the main source

of communication between civilizations rested in

the hands of merchant traders As they traveled

to distant lands to exchange goods, these traders

also acquired knowledge; knowledge of different

cultures and customs, knowledge of different arts

and humanities, and most importantly, knowledge

of different technologies Upon their return

home, this knowledge was imparted to their

native peoples and incorporated or adapted to

fit their needs This process was difficult, often

dangerous, and could take many years to complete

Now let’s shift gears and think about how

all of this relates to our beloved profession of

dentistry As recently as just a few years ago,

the dissemination of knowledge in our community

was a painfully slow process Essentially, if a

new technique or product was to be discussed,

it was first published in a print journal As I have

mentioned in a previous editorial, the peer review

and publication process for such an article can take

up to 24 months While waiting for the articles to

be published, companies wishing to promote their

new product, or procedures using their products,

would do a few things to get out information faster

First, they would advertise Second, they would

continuing education seminars Third, they would sponsor presentations at large organizational meetings The company sponsored campaigns did an effective job of generating interest in the new technique or product, but it was not until the articles were actually published that they gained full acceptance Once the articles were published, hopefully, you subscribed to the journal publishing said articles If not, you could purchase the article for upwards of $30 or you were just simply out of luck

When the Journal of Implant and Advanced Clinical Dentistry (JIACD) was released in early

2009, this process changed for the better Firstly, JIACD is available to everyone at no charge Second, JIACD is freely accessible via the internet With the simple click of a button, the entire world has access to every article ever published in JIACD Third, because JIACD is an online publication with an enormous peer review board, articles may

be reviewed and published with extraordinary promptness I suspect that it is only a matter of time before other journals begin to follow our lead The time has come for dental information to be free and instantly accessible to all

Modern technology has made the world a much smaller place, mainly through vast improvements

in our ability to communicate with one another Compared to our ancestors, when you think about how easy it is for us to acquire knowledge in

We Have the Technology Let’s Use It!

When performing conventional crown

lengthening, the existing margins of an

old restoration or the cementoenamel

junction (CEJ) of a non-restored tooth are used

to determine necessary bone removal to

estab-lish adequate space for biologic width

Creat-ing proper space for biologic width ensures that

the new margin will not infringe upon the

peri-odontal complex and reduces the likelihood for

future inflammation One significant problem of

this procedure is that, at times, significant bone

must be removed This can weaken the

stabil-ity of the tooth or create a weakened and

vulner-able furcation area The more bone removed

in the furcation, the greater the likelihood of

future problems with maintenance It is critical

to preserve as much bone as possible to

sup-port the tooth, especially in the furcation area

Considering these and other important aspects of crown lengthening, the concept

of “Biologic Shaping” was established sons for Biologic Shaping include: 1) Replace

Rea-or supplement the current indications fRea-or cal crown lengthening; 2) Minimize ostectomy; 3) Facilitate supragingival or intrasulcular mar-gins to preserve biologic width; 4) Eliminate developmental grooves; 5) Eliminate previous subgingival restorative margins; 6) Reduce

clini-or eliminate furcation anatomy and thus tate margin placement; 7) Allow supragingi-val or intracrevicular impression techniques The following article presents a series of Bio-logic Shaping cases and the author discusses requirements for successful treatment gleaned over the past 33 years of his career in which he has used this technique on over 30,000 teeth

1 Private practice limited to periodontics, Clearwater, Florida, USA

KEY WORDS: Biologic shaping, biologic width, ostectomy, osteoplasty

Abstract

The clinical prerequisites and steps for

success with Biologic Shaping are as follows:

should be removed

should be placed where necessary to

add volume to the teeth The core helps

determine where the final margin placement

of the new restoration will be placed

with Durelon (3M™ ESPE™; St Paul,

Minnesota, USA) as the temporary

cement This cement is recommended for

its antimicrobial properties and ability to

help decrease sensitivity

of surgery to allow better access

well as 360 degrees of CEJ’s Reduce

or eliminate cervical enamel projections

Facilitate ideal restorative emergence

profile (Flat is better than fat contours)

Diamond burs are recommended for this

process

remove necessary bone where violation of

biologic width may still be anticipated

the surgical site, add sufficient connective

to protect bone from bacterial infiltration

The connective also protects underlying

periodontal tissues from impression

material and cementation irritation

oxylate should be used to help decrease post-surgical sensitivity The liquid is applied

to the root surface for 45-60 seconds and then lightly air dried Repeat 2-3 times

9 Cement provisional prosthesis with a

(Dentsply International; York, Pennsylvania, USA) or Durelon

Chlorhexidine twice daily (morning and evening) and brushing with Prevident at bedtime After meals the patient rinses with water or Listerine to remove any food particles

remade or relined leaving 1mm of space for continued Biologic Width growth in a coronal direction No margination of tooth surface at this time

at the gingival collar and impressions taken When endodontics is present the new margin may be placed within the sulcus

procedures

Correspondence

Dr Daniel Melker

28465 US HWY 19 NSuite 204

Clearwater, FL 33761Phone: (727) 725-0100

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Background: With an increasing number of

den-tists incorporating surgical procedures such as

implant dentistry into their daily practice, the ability

to manage hemorrhagic complications is

indispens-able The purpose of this article is to provide an

updated review on contemporary oral hemostatic

measures and offer literature based

recommen-dations on the perioperative management of the

actively bleeding and hypovolemic dental patient

Methods: The authors reviewed medical and

dental literature for reports of dental related

hemorrhagic complications, oral hemostatic

measures, and treatment of hypovolemia

Results: Dental literature reported life ing hemorrhagic complications with common sur-gical dental procedures ranging from endosseous implant placement to third molar extractions In most cases, actively bleeding and hypovolemic patients were managed with relatively simple local measures

threaten-Conclusions: Under most circumstances, and with proper management, the risk of uncontrolled hem-orrhage attributed to dental procedures is minimal Proper management in such scenarios involves adequate pre-operative patient assessment, profi-ciency with local hemostatic control measures, and familiarity with hypovolemic treatment protocols

Bleeding and Hypovolemic Dental Patient

Dan Holtzclaw, DDS, MS • Nicholas Toscano, DDS, MS

1 Private practice limited to Periodontics and Implant Dentistry, Austin, TX, USA

2 Private practice limited to Periodontics and Implant Dentistry, Washington DC, USA

Abstract

KEY WORDS: Hypovolemia, bleeding, hemostasis, emergency

This article provides 2 hours of continuing education credit

Please click here for details and additional information.

Though rare, life threatening hemorrhage has been

reported with common surgical dental procedures

ranging from endosseous implant placement to

third molar extractions.1-3 With an increasing

number of dentists now incorporating surgical

procedures into their daily practice, their risk of

encountering hemorrhagic complications is likely

physiologic responses to, and clinical management

of excessive hemorrhage may prove useful for

pro-viders in such situations Accordingly, the purpose

of this case report is to review hemorrhage

man-agement in the dental setting and to provide an

example of practical application of such principles

PRE-OPERATIVE

CONSIDERATIONS

With systemically healthy patients, the possibility

of uncontrolled hemorrhage resulting from a

den-tal procedure seems remote In fact, the risk of

moderate to severe bleeding induced by dental

While obvious conditions such as Hemophilia and

Von Willenbrand’s Disease may cause clinicians

to consider the possibility of hemorrhagic

com-plications, most providers commonly associate potential bleeding problems with patients taking antiplatelet and/or anticoagulation medications Improved understanding of cardiovascular physiology and advances in the management and treatment of cardiovascular disease have ren-dered oral anticoagulation therapy a mainstay of modern medicine It is estimated that more than

50 million Americans adhere to a low dose daily aspirin protocol and other anticoagulants such as warfarin sodium and clopidogrel bisulfate routinely rank among the top 50 medications prescribed

in the United States.10,11 As such, the likelihood

of encountering anticoagulated patients is cant Should clinicians be worried about uncon-trolled hemorrhage with these patients? Studies examining the hemorrhagic effects of antiplatelet anticoagulants on dental procedures have found negligible increases in intraoperative and postoper-

cascade anticoagulants have generally found

no increased risk of intraoperative or tive bleeding that could not be controlled with local measures when International Normal Ratio (INR) values were within therapeutic levels.15-18

postopera-In addition to pre-operative consideration of a patient’s medication profile, anticipated blood loss from the planned procedure must be considered Expectant blood loss from a restorative procedure such as a dental amalgam will be considerably dif-ferent from that of a surgical procedure such as dental implant placement, periodontal flap proce-dure, or impacted third molar extraction Studies evaluating blood loss from restorative procedures have reported minimal hemorrhagic complications, while those evaluating surgical operations such as flap-osseous procedures have found up to 592ml

After reading this article, the reader should be

able to:

hypovolemia

hemorrhaging

Learning Objectives

of blood loss from a single surgical site.19,20 Blood

loss from surgical procedures is also influenced

by the experience level of the provider

Surger-ies performed by less experienced providers

have been shown to take up to three times

lon-ger and may result in nearly twice as much blood

loss as those performed by more experienced

practitioners.20 In general, however, most

stud-ies have found that blood loss from dental

pro-cedures is under 200ml and may be even less if

the duration of the procedure does not exceed 2

hours.20-23 Considering that a pint of blood, the

amount generally taken during blood donation, is

473ml, the amount of blood lost during most

den-tal procedures is well within the limits of safety

HYPOVOLEMIA RECOGNITION

AND MANAGEMENT

Life threatening situations resulting from

exces-sive blood loss are often due to hypovolemic

exceed-ing 1000ml, or 1/5 of an adult’s average blood

volume, may precipitate hypovolemic shock and

Compensatory signs of hypovolemia include

tachy-cardia, hypotension, tachypnea, pallor,

diaphore-sis, anxiety, nausea, thirst, and light headedness

If left untreated, hemorrhagic shock may progress

to loss of consciousness, coma, or even death

When the source of bleeding is known,

pri-mary goals in the treatment of hemorrhagic shock

are to stop the source of hemorrhaging and

restore circulating blood volume The

“three-to-one” rule for the treatment of hemorrhagic shock

dictates the administration of 3ml of crystalloid

(Lactated Ringers solution or normal saline) for

hemorrhagic shock does not typically occur until

blood loss exceeds 1000ml, dental literature ommends fluid replacement when blood loss exceeds 500ml to account for postoperative hemorrhagic oozing (figure 1).27,28 A pragmatic approach to fluid resuscitation in outpatient dental settings is limited to cases with less than 1000ml

rec-of blood loss and the ability to control rhaging Cases exceeding these parameters should be referred to a higher echelon of care

hemor-HEMHORRAGE MANAGEMENT

With proper management, nearly all narios of excessive bleeding can be ade-

local measures (Figure 2, Table 1) such as:

Positive Pressure

Positive pressure aids hemostasis by ing occlusion of the site of injury and provid-ing mechanical aid to clot formation.29 Positive pressure to intraoral wounds is typically accom-plished by compressing moistened gauze on the site of hemorrhaging Suturing wound margins

promot-or severed vessels is another method in which compressive force may be applied to bleed-

Figure 1: Blood clot removed from patient with slow continuous hemorrhaging secondary to osseous periodontal surgery.

Table 1: Local Hemostatic aids

Product or Action Composition Action

Positive Pressure N/A Manual occulusive aid

to clot formation Vasoconstrictor 1:100,000 Epinephrine Activation of a adrenergic

receptors Gelfoam® Porcine derived gelatin sponge Occlusive matrix; activation

of intrinsic pathway Surgicel® Plant derived a-cellulose Occlusive matrix: activation

of intrinsic pathway, antibacterial properties CollaCote®, CollaPlug® Bovine derived collagen Occlusive matrix, activation CollaTape®, UltraFoam TM of intrinsic pathway UltraWrap TM

HemCon® Crustacean derived chitosan Positively charged

chitosan attracts negatively negatively charged red blood cells, antibacterial properties 4.8% Tranexamic Acid Tranexamic acid Binds to lysine receptor Mouth Rinse sites on plasmin and

plasminogen inhibiting fibrin binding and fibrinolysis Topical Thrombin Bovine derived thrombin Enhances conversion of

fibrinogen to fibrin Electrocautery N/A High frequency electric

current cauterizes tissue and induces blood coagulation

ing areas.30 In many cases, minor hemorrhaging

is often controlled with positive pressure alone

Vasoconstrictor

Dental anesthetics contain vasoconstrictor

pri-marily to increase their duration of action and

minimize the risk of local anesthetic toxicity.31

Epinephrine, the most commonly utilized

vaso-constrictor in dental local anesthetics, is a

cat-echolamine that facilitates vasoconstriction via

the activation of alpha adrenergic receptors

Alpha adrenergic activation by

sympathomim-ietic drugs such as epinephrine induces smooth

muscle contraction within blood vessels and

ultimately leads to short term vasoconstriction

Absorbable Gelatin Sponge

Gelfoam® (Pfizer, New York, NY) is a

resorb-able gelatin sponge of porcine origin that is

capable of absorbing up to 45 times it weight in

aids hemostasis by providing a simple occlusive matrix and through contact activation of the intrin-sic pathway.33 When used for oral applications, this material typically liquefies within 2-5 days

Oxidized Regenerated Cellulose

Oxidized regenerated cellulose based products such as Surgicel® (Ethicon Inc, Somerville, NJ) are derived from plant based alpha-cellulose and function hemostatically in a manner similar to

of oxidized regenerated cellulose is antibacterial activity Because this product has a relatively low

pH, a broad range of gram negative, gram tive, and antibiotic-resistant bacteria have proven

posi-to be locally susceptible posi-to oxidized regenerated

this product typically resorbs with 7-14 days

Absorbable Collagen Products

Absorbable collagen products such as lagen tape, collagen plugs, and collagen foam are derived from bovine deep flexor ten-dons and typically resorb completely within 14

(Traatek, Inc, Fort Lauderdale, FL.) have lar properties In addition to providing a simple occlusive matrix, these products promote hemo-stasis by virtue of their collagen content which activates the intrinsic coagulation cascade

simi-Chitosan Derived Products

(HemCon Medical Technologies Inc, Portland, OR.) are extremely effective at promoting hemo-stasis and have recently been used by United

Figure 2: Products commonly used to aid hemostasis

Clockwise from top: Gelatin sponge, Collagen plug,

Collagen tape, Oxidized regenerated cellulose, Chitosan

derived.

States military medical personnel for treatment

of battlefield injuries Chitosan is a naturally

occurring polysaccharide that is commercially

produced via the deacetylation of crustacean

chitin.37 Positively charged chitosan molecules

readily attract negatively charged red blood

cells and the two form an extremely strong seal

that acts as a primary occlusive barrier for

hem-orrhagic sites With hemorrhaging limited and/

or stopped by this initial seal, the natural

coagu-lation cascade ensues Like oxidized

regener-ated cellulose, chitosan derived products have

locally active antibacterial properties.38 Unlike

oxidized regenerated cellulose which relies on

low pH for its antibacterial activity, however,

chitosan derived products achieve

antibacte-rial properties via active cell wall disruption.39

Tranexamic Acid

Tranexamic acid is an anticoagulant oral rinse

that binds to lysine receptor sites on plasmin

and plasminogen, ultimately inhibiting fibrin

binding and fibrinolysis.40 This rinse is

sup-plied in a 4.8% solution and patients may

be instructed to rinse with 10ml four times

daily for 7 days following surgery.41 Rinsing

with tranexamic acid solution results in

thera-peutic levels ( >100mg/ml) within the saliva

for 2-3 hours Wounds healing in the

pres-ence of tranexamic acid have demonstrated

increased tensile strength, thus making the

Topical Thrombin

Topical thrombin facilitates clot stabilization by

enhancing the conversion of fibrinogen to fibrin

and forming a reinforcing meshwork for initial

platelet plugs Medical grade topical

throm-bin is often bovine derived and is typically plied as a freeze dried sterile powder that must

sup-be reconstituted with sterile saline For eral use in dental applications, a topical throm-bin solution of 100 International Units/ml is recommended.43 Topical thrombin is often deliv-ered via pump/syringe spray or combined with

gen-a cgen-arrier such gen-as gen-a hemostgen-atic gelgen-atin sponge

Electrocautery

Electrocautery involves the application of a frequency electric current to cauterize tissue and induce blood coagulation In dentistry, this pro-cess is typically accomplished with monophasic electrosurgical units In comparison to other local means of hemostasis management, electrocautery may induce collateral thermal damage to adjacent tissues.44,45 As such, this treatment option is typi-cally reserved for severe hemorrhaging scenarios

high-PRACTICAL CASE REPORT

The primary author was contacted by a patient with a chief complaint of “my mouth won’t stop bleeding.” Telephonic interview revealed the patient to be a 22 year old white male with a non-contributory medical history The patient had undergone impacted third molar extractions one week prior and was without complication until the bleeding episode According to the patient, his lower right extraction site began to hemor-rhage during dinner subsequent to traumatic disruption with a piece of partially masticated food The patient had attempted to control the bleeding by biting on moistened paper towels for over 2 hours prior to contacting the clinic Upon arrival of the treatment provider to the dental clinic, the patient appeared ashen, dia-phoretic, and continued to actively bleed from

the mouth The patient was seated in a dental

chair and rapid evaluation revealed fast paced

active hemorrhaging from extraction site 32

and vital signs of the following: blood

pres-sure (90/48), pulse (99), and oxygen saturation

(95%) Using the pace of the active

hemor-rhaging as a guide, it was estimated that the

patient had lost approximately 1000ml of blood

at this point As vital signs were being taken,

the patient began to complain of “dizziness” and

nausea The patient was placed into

Trendelen-burg position, oxygen was administered via nasal

canula at a rate of 6L/min, oral suction was

ini-tiated, and intravenous access was obtained in

the left antecubital vein with an 18 gauge

cath-eter As 2000ml of Lactated Ringers solution

were delivered to the patient, attempts were

made to stop the hemorrhaging The patient

was repositioned and site 32 was generously

infiltrated with 2% lidocaine/1:100,000

epineph-rine As the vasoconstrictor took effect,

bleed-ing from site 32 decreased significantly and the

patient was instructed to bite with positive

pres-sure on moist gauze as he received the

remain-der of the Lactated Ringers solution After 30

minutes of subsequent evaluation, hemorrhaging

from extraction site 32 ceased and the patient’s

vital signs stabilized to within normal limits

CONCLUSION

Dental literature clearly demonstrates that

under most circumstances, and with proper

management, the risk of uncontrolled

hemor-rhage attributed to dental procedures is

mini-mal Proper management in these scenarios

involves adequate pre-operative patient

assess-ment, proficiency with local hemostatic

con-trol measures, and familiarity with hypovolemic

treatment protocols As more general dentists now routinely perform surgical procedures that induce blood loss, such a knowledge base is essential and may one day prove life saving ●

Professional Dental Education and fessional Education Services Group are joint sponsors with The Academy

Pro-of Dental Learning in providing this continuing dental education activity

is an ADA CERP Recognized vider The Academy of Dental Learn- ing designates this activity for two hours of continuing education credits

Pro-ADA CERP is a service of the can Dental Association to assist den- tal professionals in identifying quality providers of continuing dental educa- tion ADA CERP does not approve or endorse individual courses or instruc- tors, nor does it imply acceptance of credit hours by boards of dentistry

The authors report no conflicts of interest with

anything mentioned in this article.

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27 Gores R, Royer R, Mann F Blood loss during operation for multiple extraction with alveoloplasty and other oral surgical procedures

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H Amoxicillin-related postextraction bleeding in

an anticoagulated patient with tranexamic acid rinses Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996; 82(6): 610-2.

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1 The risk of moderate to severe bleeding

induced by dental treatment is less than:

a 1% c 5%

b 2% d 10%

2 An estimate of how many Americans

adhere to a low dose daily aspirin

protocol?

a 2 million c 50 million

b 14 million d 75 million

flap-osseous procedures have found up

to how much blood loss from a single

surgical site?

a 100 ml c 495 ml

b 250 ml d 592 ml

4 Surgeries performed by less experienced

providers have been shown to take

up to how many times longer than

those performed by more experienced

practitioners?

a 2 times longer c 4 times longer

b 3 times longer d 5 times longer

5 In general, most studies have found that

blood loss from dental procedures is:

a 1 ml c 3 ml

b 2 ml d 5 ml

9 Methods of hemorrhage management include which of the following?

a Positive pressure d Electrocautery

b Vasoconstrictor e All of the above

c Absorbable gelatin

sponge

10 Rinsing with tranexamic acid solution results in therapeutic levels (>100mg/ ml) within the saliva for how long?

a 30 – 45 minutes c 3 – 4 hours

b 2 – 3 hours d 5 – 6 hours

Continuing Education JIACD Quiz #4

CliCk hErE to takE thE Quiz

Background: As many as 24 teeth can be

grafted in a single surgical appointment utilizing

the patient’s own palatal tissue If more than a

dozen teeth require grafting, thick free gingival

grafts (FGG’s) can be split and the resulting

subepithelial connective tissue grafts (SCTG’s)

can be utilized in a bilaminar approach The

resultant thinner FGG’s can be used in

conjunc-tion with a retained semilunar flap and marginal

tissue lifting This case series presents 4 cases

in which SCTG’s or a combination of SCTG’s

and FGG’s are utilized for multiple areas of

gin-gival grafting at the same surgical appointment

Methods: Four cases are presented in

which multiple areas of gingival recession are treated in a single surgical appointment uti-lizing autogenous palatal donor tissue His-torical background and clinical descriptions

of the surgical techniques are presented

Results: In all four cases, multiple areas of gingival grafting were accomplished in a single surgery resulting in root coverage and a struc-turally enhanced zone of gingival attachment

Conclusion: With the techniques described in this paper, the palate can provide an adequate amount of donor tissue for single surgery com-prehensive gingival grafting of up to 24 sites

Palatal Donor Tissue

1 Private practice limited to Periodontics, Erie, Pennsylvania, USA, Clinical Associate Professor of Periodontology, Case

University, Cleveland OH, Consultant, Naval Dental Center, Bethesda, MD

2 Private practice limited to Orthodontics, Erie, Pennsylvania, USA, Consultant, Naval Dental Center, Bethesda, MD

Abstract

KEY WORDS: Subepithelial connective tissue graft, free gingival graft

Over the past 45 years, gingival grafting

uti-lizing palatal donor tissue has evolved from

merely a functional application for increasing

the width and thickness of the gingival

attach-ment to also addressing esthetics by

provid-ing for reconstructive root coverage The use

of the subepithelial connective tissue graft

(SCTG) is now widely accepted as the gold

Historical Perspective

The use of the free gingival graft (FGG) was

first reported by Björn in 1963 for repair of a

functionally deficient zone of gingival

by Miller to also provide for root coverage in

Class I and Class II marginal tissue

accomplished through the sharp dissection of a

split thickness flap leaving a very thin exposed

vascular surface overlying the bone onto which

the FGG was sutured The FGG itself included

both the epithelium and underlying connective

tissue and, consequently, the resulting donor

site in the palate was subject to relatively slow

healing through secondary intention The use of

an acrylic palatal stent to cover the donor site

during healing lessened the likelihood of any

sig-nificant postoperative bleeding and discomfort

As the predictability of root coverage became

more of a priority, newer bilaminar techniques

evolved in which palatal connective tissue was

sandwiched between the denuded root surfaces

and overlying partial or full thickness flaps.4-9

Another bilaminar technique using SCTG’s has

The epithelial covering of the free gingival

graft was no longer needed in these bilaminar approaches and, as such, the harvesting tech-nique from the palatal donor site evolved into the excision of connective tissue only, reduc-ing the palatal donor site to an internal pouch This permitted almost complete surface closure and healing of the palatal donor site by primary intention The disadvantage of this technique

is that only a rather limited amount of tive tissue can be retrieved during harvesting

connec-MATERIALS AND METHODS

Single Surgery Comprehensive Grafting

When a pouch technique is utilized for graft harvesting, adequate SCTG can usually be har-vested from one side of the palate to graft about

3 teeth on average, for a total of approximately half a dozen teeth if both sides of the palate are used When SCTG is required for root cov-erage on more than 6 teeth and one wishes

to accomplish the grafting in a single surgical appointment, it is necessary to abandon the internal pouch technique of graft harvesting and instead harvest multiple FGG’s from the palate

If FGG’s are harvested from the palate and epithelialized, enough subepithelial connective tissue can be obtained to perform root cover-age grafting on about a dozen teeth at a single surgical appointment If more than a dozen teeth require root coverage grafting and one wishes to utilize strictly subepithelial connective tissue, grafting can be performed in two sepa-rate surgeries leaving enough time between the surgeries for the palate to regenerate The manner in which single surgery compre-hensive gingival grafting can be accomplished when more than a dozen teeth require gingival grafting is to place the emphasis for root cov-

de-erage on the areas of gingival recession in the

upper arch where esthetics is typically more of

an issue and to place an emphasis on

improv-ing the functional and structural integrity of the

zone of gingival attachment on the areas of

gin-gival recession in the lower arch by striving to

increase the width, thickness, and continuity

of the gingival attachment An attempt is also

made to achieve some degree of root coverage

in the lower arch, but this is presented to the

patient with lower expectations In this manner,

up to two dozen teeth can usually be grafted

in a single surgical appointment utilizing the

patient’s own palatal tissue This is made

pos-sible by removing thick FGG’s from the palate

and then precisely splitting them (figures 1a,1b)

Each thick FGG that is harvested from the

pal-ate is thus transformed into a thinner FGG and

a separate SCTG (figure 1c) By doing so,

the amount of palatal tissue made available for

grafting is quickly doubled with the SCTG’s

utilized in a bilaminar approach in the upper

arch and the FGG’s utilized in the lower arch

Because thick FGG’s are needed, the greater

palatine artery can be inadvertently cut during the graft harvesting This is addressed by using interrupted loop sutures over the area to com-press the tissues and slow the bleeding The donor sites are then covered with an acrylic stent

to apply slight pressure, improve comfort, and reduce the likelihood of postsurgical bleeding

Recipient Site Preperation for SCTGs

The recipient sites for SCTG’s are prepared prior to graft harvest When a bilaminar

Figure 1a: Thick free gingival graft Figure 1b: Carefully splitting thick free gingival graft from

figure 1a.

Figure 1c: Results from splitting graft: (1) thinner free gingival graft and (1) subepithelial connective tissue graft.

approach is being used to maximize root

cover-age, full thickness flap reflection is utilized at the

recipient sites Partial thickness flap reflection

can also be utilized at the recipient sites with

equally good results, but this technique results

in a thinner flap that can easily tear during

reflec-tion Intrasulcular releasing incisions are utilized

in the areas of gingival recession to include the

facial aspects of the interdental papillae

Verti-cal releasing incisions are used at the opposite

ends of the intrasulcular releasing incision and

extended into the alveolar mucosa In the

pos-terior areas, the most distal vertical releasing

incision is frequently omitted and, occasionally

in isolated areas, no vertical releasing incisions

are used Regardless of whether or not

verti-cal releasing incisions are included, a periosteal

releasing incision is always made at the base of

the flap for increased mobility, facilitation of

cor-onal flap advancement, and to assure passive adaptation at closure Following reflection of the flap, intramarrow penetrations or cortical cuts are made interradicularly in the exposed bone

Recipient Site Preparation for FGG’s

When FFG’s are used at recipient sites, ration is done in a very different manner than that

prepa-of SCTG’s A semilunar incision is first made

at the base of the remaining gingival ment If there is insufficient keratinized gingiva, the semilunar incision is made in the mucosal tissue After the scalloped incision is made outlining the base of the semilunar flap, a split thickness flap is apically reflected through sharp dissection leaving the thinnest soft tissue layer possible as the vascular bed for the FGG’s The reflection is carried 3 to 5 mm apical to the anticipated apical edge location of the FGG’s The apical base of the semilunar flap semilunar flap is re-outlined with the tip of

attach-a #12 blattach-ade This releattach-ases the collattach-ar over the root prominences and also slightly loos-ens 1 to 2 mm of the labial interdental papil-lae The semilunar flap is then gently elevated coronally resulting in what is referred to as marginal tissue lifting This is a delicate pro-cess requiring time and patience as care must be taken not to tear the semilunar flap

Considerations for Palatal FGG Harvesting and Preparation

In the typical palate, 4 FGG’s (two from each side) can be harvested (figure 2) The size of the palate will of course determine the maximum width and length of the individual grafts The bigger issue becomes the manner in which the grafts will be utilized If 2 FGG’s are removed

Figure 2: Multiple free gingival grafts harvested from the

palate

from the same side of the palate, 1 to 2 mm of

palatal tissue is left between the donor sites to

reduce healing time It is also important to keep

the border of the donor sites at least two

milli-meters shy of the posterior border of the stent to

prevent exposing the donor site beyond the

con-fines of the stent coverage Generally, it is easier

to remove a thicker FGG from the lateral aspect

of the palate, where there is a thicker zone of

subepithelial connective tissue to work with

Recipient Site Suturing of the FGGs

The superior edge of the FGG is placed at the

inferior border of the semilunar flap For a

start-ing point, one end of the FGG is sutured

inter-proximally The FGG is then stretched and the

opposite end of the FGG is sutured at the most

distant interproximal area This results in the

semilunar flap being elevated to cover some or

all of the exposed root surfaces in the areas of

the gingival recession The FGG is then secured

into position by suturing it at the remaining

interproximal areas Over the root prominences,

the superior edge of the FGG is very carefully sutured to the semilunar flap collars Only the superior edge of the FGG is sutured (figure 3a) The FGG is held in close approximation

to the underlying vascular bed with a tal dressing containing rosin that provides for improved adherence to the teeth (figure 3b)

periodon-Recipient Site Suturing of the SCTG’s

The coronal edge of the SCTG is first sutured interproximally (figure 4a) with a resorbable grafting material; 5-0 plain gut, 5-0 chromic gut, or 4-0 Vicryl (Ethicon) suture materials seem to work equally well The superior edge

of the SCTG must not come to a thin like edge and may need to be trimmed to pro-vide adequate thickness for suturing The full thickness flap is coronally advanced to cover as much of the SCTG as possible (fig-ure 4b) Complete coverage of the SCTG is preferable, but not always possible The flap

knife-is sutured into position with a able suture material such as CV-5 ePTFE, 3-0

non-resorb-Figure 3a: Superior edge of free gingival graft sutured Figure 3b: Periodontal dressing covering free gingival

graft.

PTFE, or 5-0 Polypropylene Preferably, at

least one sling suture should be used around

each grafted tooth, and the SCTG should be

re-engaged No periodontal dressing is used

Post-operative Instructions and Follow up

The patient is instructed to stay on a liquid or

extremely soft food diet until told otherwise

The patient is given a very soft toothbrush

and instructed to brush only the tips of the

teeth A palatal stent is delivered (figure 5)

and the patient is instructed not to remove it

At one-week post surgery any periodontal

dressing remaining is removed in addition to

the sutures at the superior border of the FGG’s

The patient is still cautioned to remain on a very

soft diet The palatal stent is removed, cleaned,

and reinserted after the palate is cleansed

With SCTG’s, the removal of the

non-resorb-able sutures is usually done in stages beginning

two weeks post-operatively Loose sutures are

removed initially, but any tight functional sutures

are left in place until three weeks

postopera-tively when the suture removal is completed

The patient is asked to remain on a very soft diet until all of the sutures have been removed

Patient Awareness and Expectations

A well-informed patient with realistic tations is critically important when treating gingival recession To this end, it is empha-sized to the patient that the most impor-tant aspect of any gingival grafting is to create an environment where additional gingival recession is less likely to occur The most critical pre-treatment marker in determining the likelihood of achieving root cov-erage is the interproximal distance between the alveolar crest and the corresponding cemntoe-namel junctions (CEJ) as seen on the periapical radiographs Generally speaking, approximately 2.5mm is considered to be representative of an

to be an excellent measurement in predicting the likelihood of being able to achieve good root coverage If radiographically the interproxi-mal distance between the alveolar crest and the corresponding CEJ’s is 2.5mm or less, the like-

Figure 4a: Coronal edge of SCTG sutured Figure 4b: Coronally positioned flap covering SCTG.

lihood of achieving fairly complete root

cover-age is high when a bilaminar approach with a

SCTG and coronally advanced flap is utilized

As this interproximal distance increases beyond

2.5mm, there is a proportionate decrease in the

amount of root coverage that can be expected

The most unappealing aspect of the FGG

esthetics is the “tire patch” appearance at the

localized recipient site Extending the FGG’s

to cover large numbers of teeth, even

inter-spersed teeth without gingival recession, can

eliminate this unsightly appearance At times

little or no root coverage is achieved,

espe-cially if the collars of the semilunar flap over the

root prominences are torn Even if the

inter-proximal distance between the CEJ’s and the

corresponding alveolar crest is 2.5mm or less

generally only a couple of millimeters of root

cov-erage can be expected with the semilunar flap

+ free gingival grafts and marginal tissue lifting

regardless of the amount of gingival recession

that is present The resultant enhanced zone of gingival attachment created with this technique

is conducive to coronal advancement at a

Additional Considerations

Wilcko et al first reported on the use of marrow penetrations in conjunction with

Intrama-rrow penetration stimulates a regional eratory phenomenon (RAP) which provides

accel-an increase in hard accel-and soft tissue reorgaccel-ani-zation activity in close approximation to the osseous insult It also provides a pathway for the rapid efflux of pluripotential stem cells and capillary budding from the medullary spaces Other than scaling of exposed root sur-faces prior to flap reflection, no specific root preparation is needed Large cervi-cal restorations are removed following flap reflection and any sharp edges in the areas of cervical abrasion are smoothed

reorgani-CASE REPORTS

Multiple sites of gingival recession are addressed with the FTF/SCTG approach uti-lized in all 6 cases presented in this paper Additionally, a SLF/FGG with MTL approach

is also used in the lower arches of 3 of the cases presented One of the cases was treated in anticipation of possible orthodontic treatment, 1 of the cases was treated as part

of the PAOO treatment, and 3 of the cases had previously had orthodontic treatment

Figure 5: Palatal stent covering palatal donor sites.

Case 1

A female patient, age 54, presented with up to

6mm of Miller Class I-III facial gingival

reces-sion on multiple teeth (figures 6a,6b) Since

less than a dozen teeth required root coverage

grafting, FTFs/SCTGs were utilized in all of the

involved areas Preparation of the recipient sites

involved interproximal intramarrow cuts (figures

6c,6d) Four thick FGG’s were removed from

the palate and de-epithelialized to yield a total

of 4 SCTG’s and 4 FGG’s The 4 SCTG’s were sutured at the recipient sites (figures 6e,6f) and FTF’s were coronally advanced Several sutures were used at the donor sites to lessen the bleeding (figure 6g), and the donor sites were covered with an acrylic stent The donor sites in the palate healed uneventfully (figure 6h) Healing of the recipient sites at 6 months after surgery can be seen in figures 6i and 6j

Figure 6a: Right presurgical view of case 1. Figure 6b: Left presurgical view of case 1.

Figure 6c: Preparation of right side of case 1 Figure 6d: Preparation of left side of case 1.

Figure 6e: SCTG secured on right side of case 1. Figure 6f: SCTG secured on left side of case 1.

Figure 6g: Case 1 palatal donor site immediately post

surgery.

Figure 6h: Case 1 palatal donor site healed after surgery.

Case 2

A female patient, age 46, presented with Miller

Class I and II gingival defects on the facials of

9 maxillary teeth (figures 7a, 7b) Because only

9 teeth were involved, it was decided to strictly

utilize full thickness flaps and SCTG’s Full

thickness flaps were reflected at the 2 upper

recipient sites Sulcular and mesial vertical

releasing incisions were utilized and intramarrow

penetrating was performed interradicularly (figures 7c, 7d) Three thick FGG’s were removed from the palate and de-epithelialized The three resulting SCTG’s were then sutured

at the recipient sites (figures 7e, 7f) The full thickness flaps were coronally advanced to passively cover the SCTG’s Postsurgical results

at 2 years are shown in figures 7g and 7h

Figure 7a: Right presurgical view of case 2. Figure 7b: Left presurgical view of case 2.

Figure 7c: Right view of RAP inducing intramarrow

penetrations of case 2.

Figure 7d: Left view of RAP inducing intramarrow penetrations of case 2.