Loading of Two Implants in the

The Journal of Implant & Advanced Clinical Dentistry

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References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

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The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 3 • JuNe 2014

Table of Contents

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Oralife is a single donor grafting product processed in accordance with AATB standards as well as state and federal regulations (FDA and the states of Florida, California, Maryland and New York). Oralife allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc.1. Data on file at Exactech. 2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96. 3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and

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13 From Maxilla to Zygoma: A Review on Zygomatic Implants Dr. D.R. Prithviraj, Dr. Richa Vashisht, Dr. Harleen Kaur Bhalla

21 Lateral Sinus Augmentation: A Safer Technique Dr. Gregori Kurtzman, Dr. Douglas F. Dompkowski

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Table of Contents

33 Loading of Two Implants in the Mandible and Final Restoration with a Locator: A Case Report and Review Dr. A. Abdulgani, Dr. M. Bajali, Dr. M. Abu-Hussein

43 Smile Makeover with all Ceramic Crowns and Biologic Shaping Dr. Arshad Hasan

53 Occurrence Regions and Sites of Peri-implant Inflammation with Bone Resorption in Japanese Partially-Edentulous Patients Motohiro Munakata, Noriko Tachikawa, Katsuichiro Maruo, Aoi Sakuyama, Yoko Yamaguchi, Shohei Kasugai



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platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

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

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

Editorial Advisory Board

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

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


For more information, contact BioHorizonsCustomer Care: 1.888.246.8338 or shop online at www.biohorizons.com

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Laser-Lok® zoneCreates a connective tissue seal and maintains crestal bone

platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification

Co-Editor in ChiefNick Huang, MD

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Wilcko et al

Background: Patients with moderate to severe atrophy challenge the surgeon to discover alter-native ways to use existing bone or resort to augmenting the patient with autogenous or alloplastic bone materials. The objective was to review the published literature to evalu-ate treatment success with zygomatic implants in patients with atrophic posterior maxilla.

Methods: MEDLINE/PubMed searches were conducted using the terms atrophic maxilla, zygomatic implant, zygomatic bone, grafts, maxillary sinus, as well as combina-tions of these and related terms. The few arti-cles judged to be relevant were reviewed.

Results: Based on the current literature review, zygomatic implants show excellent survival rates ( > 90% ) and a low incidence of complications.

Conclusions: With proper case selection, cor-rect indication, and knowledge of the surgi-cal technique, the use of zygomatic implants associated with standard implants offers advantages in the rehabilitation of severely resorbed maxillae, especially in areas with inadequate bone quality and volume, with-out needing an additional bone grafting surgery, thereby shortening or avoiding hos-pital stay and reducing surgical morbidity.

From Maxilla to Zygoma: A Review on Zygomatic Implants

Dr. D.R. Prithviraj1 • Dr. Richa Vashisht2 • Dr. Harleen Kaur Bhalla3

1. Dean Cum Director, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore

2. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore

3. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore

Abstract

KEY WORDS: Zygomatic dental implants, maxilla, maxillary sinus


14 • Vol. 6, No. 3 • June 2014

Prithviraj et al

INTRODUCTION:Dental implants are now commonly used for replacing missing teeth in various clinical situ-ations. Dental implants are surgically inserted in the jawbones. Unfortunately, restrictions have appeared in the use of oral implants. One of them is the lack of sufficient bone vol-ume, especially in the posterior maxilla.[1]

During the last 3 decades, several surgical procedures have been developed to increase local bone volume in deficient anatomical regions, including total/segmental bone onlays, Le Forte1 osteotomy with interpositional bone grafts, and grafting of the maxillary sinus with autogenous bone and/or bone substitute.[2]

These techniques pose a series of inconve-niences, such as the need for multiple surgical interventions, the use of extraoral bone donor sites (e.g., iliac crest or skull) - with the morbid-ity involved in surgery of these zones - and the long duration during which patients remain with-out rehabilitation during the graft consolidation and healing interval. These factors complicate patient acceptance of the restorative treatment and limit the number of procedures carried out.

In order to overcome such limitations, dif-ferent therapeutic alternatives have been pro-posed, such as, implants placed in specific anatomical areas like the pterygoid region, the tuber or the zygoma. Any of these proce-dures requires considerable surgical exper-tise and has its own advantages, limits, surgical risks and complications involving bio-logical and financial costs. The placement of implants in the zygomatic bone as an alterna-tive to maxillary reconstruction with autoge-nous bone grafts has been considered a viable option in the rehabilitation of atrophic maxillae

(Fig. 1). Anatomical Buttresses of the midface: 1) Frontomaxillary buttress; 2) Fronto-zygomatic buttress; 3) Pterygomaxillary buttress.

ANATOMY OF ZYGOMATIC BONE

The zygoma bone can be compared to a pyra-mid, offering an interesting anatomy for the insertion of implants. In 1993, Aparicio et al. mentioned the possibility of inserting den-tal implants in the zygomatic bone.[3] In 1997, Weischer et al. cited the use of the zygoma as a support structure in the rehabilitation of patients subjected to maxillectomies.[4] Follow-ing Branemark’s description, Uchida et al. in 2001, measured the maxilla and zygoma in 12 cadavers, observing that the apex of a 3.75 mm-diameter implant requires a zygoma of at least 5.75 mm in thickness. With respect to implant placement, they advised that an angu-lation of 43.8º or less increases the risk of perforating the infratemporal fossa or the lat-eral area of the maxilla; if the angulation is more vertical, 50.6º or more, this increases the risk of perforating the orbital floor.[5]

Nkenke et al. used computed tomography and histomorphometry to examine 30 human zygoma, the study revealed that the zygomatic bone consists of trabecular bone, an unfavor-able parameter for implant placement; however, the success of implants placed in the zygomatic bone was achieved by the implant crossing four portions of cortical bone.[6] Kato et al. investi-gated the internal structure of the edentulous zygomatic bone in cadavers using micro-com-puted tomography, finding that the presence of wider and thicker trabeculae at the apical end of the fixture promotes initial fixation.[7]


Prithviraj et al

DESCRIPTION OF THE ZYGOMATIC IMPLANT

The zygomatic implants are self-tapping screws in c.p. titanium with a well-defined machined surface. They are available in eight different lengths ranging from 30 to 52.5 mm. They present a unique 450 angulated head to compensate for the angulation between the zygoma and the maxilla. The portion that engages the zygoma has a diameter of 4.0 mm, and the portion that engages the resid-ual maxillary alveolar process a diameter of 4.5 mm (Fig. 2).[8,9] Radiologic aspect of a patient restored with two zygomatic implants.

PRESURGICAL EVALUATIONClinical examination is not sufficient for this evaluation and radiologic assessment has to be considered. Bedrossian et al. in their study on zygomatic and premaxillary implants used pan-

oramic radiographs, which generally depict the size and configuration of the maxillary sinuses, the height of the residual ridge, and the posi-tion of the nasal floor. The body of the zygoma can usually be visualized.[9] However, OPG can give distorted information and therefore, the examination of choice is the spiral or heli-coid computed tomography (CT) scan, which makes two- and three-dimensional imaging pos-sible with axial cuts every 2 mm parallel to the palatal arch and conventional tomography with frontal tomograms perpendicular to the hard palate every 3-4 mm. The CT scan also gives the opportunity to visualize the health of the maxilla and the sinus. Sinusitis, polyps or any sinusal pathology can be excluded. The density, length and volume of the zygoma can be evaluated and special templates for inserting the zygo-matic implants can be constructed on stereo-lithographic models to facilitate the orientation

Figure 1: Anatomical Buttresses of the midface. 1) Frontomaxillary buttress; 2) Frontozygomatic buttress; 3) Pterygomaxillary buttress.

Figure 2: Radiologic aspect of a patient restored with two zygomatic implants.

16 • Vol. 6, No. 3 • June 2014

of the zygomatic implants during the surgery with minimal errors in angulation and position.[10] Vrielinck et al., presented a planning system for zygomatic implant insertion based on pre-operative CT imaging; they calculated the posi-tion of the implants and fabricated a surgical guide. Using this system they obtained a suc-cess rate of 92% in 29 patients with zygomatic implants (two implants did not reach the zygo-matic arch when using this surgical guide).[11]

PROCEDUREThe original procedure, defined by Brane-mark in 1998, consisted of the insertion of a 35-55 mm-long implant anchored in the zygo-matic bone following an intra-sinusal trajec-tory.[12] Since this description, many authors

have varied the technique slightly. Stella and Wagner described a variant of the technique (Sinus Slot Technique) in which the implant is positioned through the sinus via a narrow slot, following the contour of the malar bone and introducing the implant in the zygomatic pro-cess. In this way, the need for fenestration of the maxillary sinus is avoided, and the implant is caused to emerge over the alveolar crest at first molar level, with a more vertical angula-tion.[13] Penarrocha et al.[12] published in 2007 a series of 21 cases with the “Slot technique” with a 100% survival rate, but the Schneide-rian membrane was perforated in all cases, even though the incidence of sinus pathology was low (two cases).[14] (Fig 3.) Right - Trans-zygomatic implantation following an intrasinusal

Figure 3: (Right): Trans-zygomatic implantation following an intrasinusal path. (Left): The extrasinus technique. Note the implant emergence above the alveolar crest at first molar level, with a more vertical angulation.

Prithviraj et al


Table 1: Success Rate of Zygomatic Implants

No. of Study/ No. of Zygomatic Follow- Success Year Patients Implants up Rate Complication

Sinusitis, loosening of the Aparicio 6- zygomatic implant gold screws et al., 69 131 months 99% in nine patients, fracture of one 200617 5 years gold screw as well as the prosthesis in one patient.

Bedrossian 14 28 12 100% et al., 200618 months

Penarrocha 21 40 29 100% Ecchymosis et al., 200714 months Davo et al,. 42 81 12-42 100% Oroantral fistula and sinsusitis 200819 months was found in one patient

Pi-Urgell 54 101 1-72 96% Sinusitis et al. , 200820 months Balshi et al., 56 110 9 months- 96% 200921 5 years

Aparicio et al., 25 47 2-5 years 100% 201022

Malevez et al., 20 80 6-40 96% 201023 months

Miglioranca 75 150 12 98.7% Two zygomatic implants et al. , 201124 months (1.33%) failed and were removed

Davo et al., 42 81 5 years 98.5% One zygomatic impant was lost. 201325

path; Left - The extrasinus technique. Note the implant emergence above the alveolar crest at first molar level, with a more vertical angulation.

MULTIPLE ZYGOMATIC IMPLANTS

The use of multiple zygomatic implants (i.e. two to three in each side) was suggested by

Prithviraj et al

18 • Vol. 6, No. 3 • March 2014

Bothur et al.[15] In a recent study, Duarte et al. used four zygomatic implants and no premax-illary conventional implants in the prosthetic rehabilitation of 12 patients with edentulous and severely resorbed maxillas. A fixed bridge of a gold framework and acrylic teeth was fab-ricated and delivered shortly after implant sur-gery. The patients were evaluated after 6 and 30 months when the bridges were removed for individual testing of implant stability. One zygo-matic implant was found to be loose at the 6- month follow-up and another one was found to be loose at the 30-month check-up. Thus, the overall survival rate was 95.8% after 30 months of follow-up. No severe complications relating to the sinus or the soft tissues were reported.[16]

COMPLICATIONSThe reported complications associated with zygomatic implants include postoperative sinus-itis, oroantral fistula formation, periorbital and subconjunctival hematoma or edema, lip lacera-tions, pain, facial edema, temporary paresthe-sia, epistaxis, gingival inflammation, and orbital penetration/injury. Postoperative concerns regarding difficulty with speech articulation and hygiene caused by the palatal emergence of the zygomatic implant and its effect on the prosthesis suprastructure have been reported.

CONCLUSIONThe zygomatic implant is an alternative proce-dure to bone augmentation, maxillary sinus lift and to bone grafts in patients with posterior atrophic maxillae. The zygomatic implant tech-nique should be regarded as a major surgi-cal procedure and proper training is of course needed. However, in comparison with bone

grafting procedures, the technique is less invasive and complicated and has a lower risk of morbidity because of the fact that har-vesting of bone graft is usually not needed. Based on the current literature review, zygo-matic implants show excellent survival rates ( > 90 %) and a low incidence of complica-tions, so this should be considered a valid and safe treatment option when dealing with patients with advanced maxillary atrophy. ●

Correspondence:Dr. Richa VashishtPost Graduate StudentDept. of ProsthodonticsGovt. Dental College and Research Institute BangaloreVictoria Hospital CampusFort Bangalore [email protected]

Prithviraj et al


DisclosureThe authors report no conflicts of interest with any-thing mentioned in this article.

References1. Kuabara MR, Ferreira EJ, Gulinelli JL, Paz

LG. Rehabilitation with zygomatic implants: a treatment option for the atrophic edentulous maxilla--9-year follow-up.Quintessence Int. 2010 ;41:9-12.

2. Raghoebar GM, Timmenga NM, Reintsema H, Stegenga B, Vissink A. Maxillary bone grafting for insertion of endosseous implants: results after 12-124 months. Clin Oral Implants Res. 2001;12:279-86.

3. Aparicio C, Branemark P-I, Keller EE, Olive J. Reconstruction of the premaxila with autogenous iliac bone in combination with osseointegrated. Int J Oral maxillofac Implants 1993;8:61-7.

4. Weischer T, Schettler D, Mohr C. Titanium implants in the zygoma as retaining elements after hemimaxillectomy. Int J Oral Maxillofac Implants 1997;12:211-4.

5. Uchida Y, Goto M, Katsuki T, Akiyoshi T. Measurement of the maxilla and zygoma as an aid in installing zygomatic implants. J Oral Maxillofac Surg 2001;59:1193-8.

6. Nkenke E, Hahn M, Lell M, Wiltfang J, Schultze-Mosgau S, Stech B, et al. Anatomic site evaluation of the zygomatic bone for dental implant placement. Clin Oral Impl Res 2003;14:72-9.

7. Kato Y, Kizu Y, Tonogi M, Ide Y, Yamane G. Internal structure of zygomatic bone related to zygomatic fixture. J Oral Maxillofac Surg 2005;63:1325-9.

8. Malevez C, Daelemans P, Adriaenssens P, Durdu F. Use of zygomatic implants to deal with resorbed posterior maxillae. Periodontol 2000. 2003;33:82-89.

9. Bedrossian E, Stumpel L III, Beckely ML, Indresano T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae. A clinical report. Int J Orai Maxiiiofac Implants. 2002;17:861-865.

10. Van Steenberghe D, Malevez C, Van Cleynenbreugel J, Bou Serhal C, Dhoore E, Schutyser F, Suetens P, Jacobs R. Accuracy of drilling guides for the transfer from 3-D CT based planning to placement of zygomatic implants in human cadavers. Clin Oral Implants Res 2003: 14: 131–136.

11. Vrielinck L, Politis C, Schepers S, Pauwels M, Naert I. Image-based planning and clinical validation of the zygoma and pterygoid implant placement in patients with severe bone atrophy using customized drill guides. Preliminary results from a prospective clinical follow-up study. Int J Oral Maxillofac Surg 2003;32:7-14.

12. Branemark P-I. Surgery and fixture installation. Zygomaticus fixture clinical procedures (ed 1). Goteborg, Sweden: Nobel Biocare AB; 1998. p. 1.

13. Stella J, Warner M. Sinus slot technique for simplification and improved orientation of zygomaticus dental implants: a technical note. Int J Oral Maxillofac Implants 2000;15:889-93.

14. Penarrocha M, Garcı´a B, Martı E, Boronat A. Rehabilitation of severely atrophic maxillae with fixed implant-supported prostheses using zygomatic implants placed using the sinus slot technique: clinical report on a series of 21 patients. Int J Oral Maxillofac Implants 2007: 22: 645–650.

15. Bothur S, Jonsson G, Sandahl L. Modified technique using multiple zygomatic implants in reconstruction of the atrophic maxilla: a technical note. Int J Oral Maxillofac Implants 2003: 18: 902–904.

16. Duarte LR, Filho HN, Francischone CE, Peredo LG, Branemark PI. The establishment of a protocol for the total rehabilitation of atrophic maxillae employing four zygomatic fixtures in an immediate loading system – a 30- month clinical and radiographic follow-up. Clin Implant Dent Relat Res 2007: 9: 186–196

17. Aparicio C, Ouazzani W, Garcia R, Arevalo X, Muela R, Fortes V. A prospective clinical study on titanium implants in the zygomatic arch for prosthetic rehabilitation of the atrophic edentulous maxilla with a follow-up of 6 months to 5 years. Clin Implant Dent Relat Res. 2006;8:114-22.

18. Bedrossian E, Rangert B, Stumpel L, Indresano T. Immediate function with the zygomatic implant: a graftless solution for the patient with mild to advanced atrophy of the maxilla. Int J Oral Maxillofac Implants. 2006;21:937-42.

19. Davo R, Malevez C, Rojas J, Rodriguez J, Regolf J. Clinical outcome of 42 patients treated with 81 immediately loaded zygomatic implants: a 12- to 42-month retrospective study. Eur J Oral Implantol. 2008;1:141-50.

20. Pi Urgell J, Revilla Gutierrez V, Gay Escoda CG. Rehabilitation of atrophic maxilla: a review of 101 zygomatic implants. Med Oral Patol Oral Cir Bucal. 2008;13:363-70.

21. Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective analysis of 110 zygomatic implants in a single-stage immediate loading protocol. Int J Oral Maxillofac Implants. 2009;24:335-41.

22. Aparicio C, Ouazzani W, Aparicio A, Fortes V, Muela R, Pascual A, Codesal M, Barluenga N, Franch M. Immediate/Early loading of zygomatic implants: clinical experiences after 2 to 5 years of follow-up. Clin Implant Dent Relat Res. 2010;12:77-82.

23. Stievenart M, Malevez C. Rehabilitation of totally atrophied maxilla by means of four zygomatic implants and fixed prosthesis: a 6-40-month follow-up. Int J Oral Maxillofac Surg. 2010;39:358-63.

24. Miglioranca RM, Coppede A, Dias Rezende RC, de Mayo T. Restoration of the edentulous maxilla using extrasinus zygomatic implants combined with anterior conventionalimplants: a retrospective study. Int J Oral Maxillofac Implants. 2011;26:665-72.

25. Davo R, Malevez C, Pons O. Immediately loaded zygomatic implants:a 5-year prospective study. Eur J Oral Implantol. 2013;6:39-47.

Prithviraj et al

Wilcko et al

The lateral sinus augmentation approach can be challenging as tearing of the sinus membrane often necessitates abandon-

ing the procedure and re-entry at a later date after the membrane has healed. Previous tech-niques involved use of diamonds or carbides in a high speed hand piece or the use of peizo-

surgical units. These approaches had potential for membrane damage (burs in a high speed) or were very slow (peizo). A recently intro-duced drilling kit allows for safe lateral access to the sinus with reduced risk of perforation of the Schneiderian membrane. This case report demonstrates use of this new drilling kit.

Lateral Sinus Augmentation: A Safer Technique

Dr. Gregori Kurtzman1 • Dr. Douglas F. Dompkowski2

1. Private practice, Silver Springs, Maryland, USA

2. Private practice, Bethesda, Maryland, USA

Abstract

KEY WORDS: Dental implants, sinus augmentation, Schneiderian membrane, bone graft


22 • Vol. 6, No. 3 • June 2014

InTRODucTIOnThe posterior maxilla presents with a common problem clinically following tooth extraction or crestal bone loss resulting in loss of osse-ous height sufficient to place implants. Resorp-tive patterns in some patients along with sinus enlargement result in minimal bone that can accommodate implant placement. Maxillary sinus augmentation over the past 18 years with various bone graft materials has become routine treat-ment. Numerous studies have reported highly successful implant survival rates when placed into the augmented sinus.1-3 Transalveolar sinus floor elevation also referred to as subantrial aug-mentation, was first described by Tatum4 and later modified by Summers.5-7 This technique uti-lized a series of osteotomes with a mallet to cre-

ate an osteotomy and subsequent in-fracturing of the sinus floor while elevating the Schneiderian membrane. Following manipulation, the space created in the sinus is augmented with various bone particulate graft materials increasing the volume of bone available for implant placement.

Various studies have reported that when 5 mm of residual alveolar bone is present, simultane-ous implant placement can be preformed achiev-ing adequate primary stability.6, 8, 9 But, when less than 5 mm of residual alveolar bone height is available, a delayed 2-stage approach has been recommended.10, 11 The most common complica-tion of the lateral sinus elevation approach is typi-cally tearing of the Schneiderian membrane which could allow for bacterial contamination or loose particles to gain access to the sinus cavity. A safer

Figure 1: Lateral Approach Sinus Kit (LASK).

Kurtzman et al


lateral window approach sinus augmentation pro-cedure will be discussed using specialized safe cutting end drills with vertical stoppers for osse-ous window formation and subsequent membrane elevation (Lateral Approach Sinus Kit, HIOSSEN).

MATERIAL AnD METHODSThe Lateral Approach Sinus Kit (LAS-Kit) (HIOS-SEN) provides “Dome” drills, “Core” drills, metal stoppers, side wall drill and a bone separator tool (Figure 1). The Dome drill is a unique osse-ous drill allowing removal of the lateral wall of the maxillary sinus while collecting autogenous bone to be added to the material to be placed into the sinus. Macro and micro cutting blades provide excellent cutting of the lateral wall with-out tearing of the sinus membrane. These Dome drills available in both 5.0 and 7.0mm diameter

are run at 1,200 to 1,500 RPM with irrigation in an implant surgical handpiece. Metal depth con-trol stoppers are provided that fit on the Dome drills limiting depth of penetration (0.5, 1.0, 1.5, 2.0, 2.5 and 3.0 mm) and are used sequen-tially to safely expose the sinus membrane.

The Core drill, also available in 5.0 and 7.0 mm diameter differs from the Dome drill in that the cen-ter does not cut, with bone removal resulting in a core of bone being left over the sinus. This boney lid may be elevated with the sinus membrane still attached becoming the new “roof” to the sinus with osseous augmentation being placed below it. This particular drill follows the same design of the CAS Kit (crestal augmentation sinus) drills and is utilized at 1,200-1,500 RPM. The metal drill stoppers also fit these drills allowing controlled sequential depth preparation. The Bone Separator tool is utilized to separate the osseous core cre-ated with the Core drill if removal is desired and is based on the practitioners preferred technique.

The Side Wall drill, may be used to enlarge the osseous window created by the Dome

Figure 2a: CBCT radiograph pretreatment demonstrating insufficient osseous height for implant placement without sinus augmentation in the molar region.

Figure 2b: CBCT radiograph pretreatment demonstrating insufficient osseous height for implant placement without sinus augmentation in the molar region.

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24 • Vol. 6, No. 3 • June 2014

drill if desired. The tip of this drill is smooth and designed to safely push the sinus membrane away from the cutting portion of the drill, which starts 1mm from the safe end. Osseous cut-ting is performed at 1,500 RPM using the side of the rotating drill to enlarge the osseous win-dow. The CAS Kit metal drill stoppers may be placed on this drill to limit accidental penetration too far into the sinus and tearing of the mem-brane during this drills use. As with the other

drills in this kit, irrigation is used during its use.

cASE REpORT A male aged 32, presented with the desire for implant placement in the posterior maxil-lary right quadrant which had been missing the first molar for an extended period of time. The result of long term loss of the tooth resulted in drifting of the second molar into the space which was corrected orthodontically prior to

Figure 3: Buccal concavity evident as a result of long standing loss of the first molar compromising the width of the site.

Figure 4: A trapezoidal shaped flap was created with a scalpel with the crestal incision placed to the palatal aspect of the ridge.

Figure 5: Lateral aspect of the maxillary posterior following elevation of a full thickness flap.

Figure 6: Dome drill with 0.5mm stopper placed on the surgical hand piece.

Kurtzman et al


implant surgery. Radiographically, enlargement of the maxillary sinus was noted with insufficient height in the molar region for implant placement (Figure 2). Resorption was noted compromis-ing the width of the ridge at the buccal leading to a mild concavity (Figure 3). Sinus augmen-tation was discussed to assist in achieving the patients desired treatment goal of implant placement and restoration with a fixed crown.

Following administration of local anesthetic,

a crestal lingual incision was made with verti-cal releasing incisions at the mesial and distal aspect of the site and a full thickness flap was elevated, leaving the attached gingiva undis-turbed on the adjacent teeth (Figure 4). Eleva-tion of the flap extended superiorly to expose the lateral wall of the maxillary sinus up to the inferior aspect of the zygoma (Figure 5).

A 5mm wide Dome drill was placed onto the surgical handpiece with a 0.5mm drill stop-

Figure 7: Lateral sinus approached initiated with the Dome drill and a 0.5mm drill stopper.

Figure 8: The initial Dome drill created an outline into the bony wall.

Figure 9: Lateral sinus approached continued with the Dome drill and a 1.0mm drill stopper.

Figure 10: Bone is collected from the Dome drill to be utilized to augment the graft to be placed.

Kurtzman et al

26 • Vol. 6, No. 3 • June 2014

Figure 11: Following each Dome drill the site is examined for identification of the underlaying membrane which will appear darker as bone is removed over it.



Figure 14: Lateral wall of the maxillary sinus following sequential use of the Dome drill with increasing stopper depth demonstrating no damage to the sinus membrane after bone removal.

per (Figure 6). This would allow initiation of the window without the possibility of excessive pen-etration and subsequent damage to the sinus membrane. The initial Dome drill is placed onto the surgical handpiece with the selected drill stop. The Dome drill with stopper was placed on the lat-eral sinus wall at a height more superior then the current height of the available bone as measured

radiographically (Figure 7). This is done to ensure that the window created has elevated the mem-brane circumferentially. When maximum depth has been achieved with the 0.5mm drill stopper present, the drill stopper is changed to a 1.0mm stopper and drilling is continued (Figure 8). The drill stopper is sequentially increased checking for membrane exposure. Lateral drilling continues

Kurtzman et al


Figure 15: A curette is utilized to separate the sinus membrane from the bone of the maxillary sinus, elevating it superiorly from the inferior floor to the medial wall.

Figure 16: Lateral window completed demonstrating the intact sinus membrane following use of the Dome drills and stoppers.

Figure 17: A collagen membrane is placed into the sinus over the elevated membrane to help confine the graft to be placed should a micro tear be present in the elevated sinus membrane.

Figure 18: Osseous graft material was mixed with the patients donor bone collected from the Dome drills and is gently packed into the sinus.

stepping up to the next drill stop (Figure 9). Bone collected on the Dome drills is removed from the drill and placed into a sterile dish to be added to the graft to be placed, adding the host’s osteo-potential cells to the graft (Figure 10). As bone is removed over the sinus membrane, the area changes in color from the light color of the bone (ivory) to darker gray as the dark sinus begins

to show clinically at the window (Figure 11). Final window creation is made with the

Dome drill, in this particular case with a 2.5mm drill stopper (Figure 13). Some patients may require deeper drilling which is dependant on thickness of the lateral maxillary sinus wall. The intact sinus membrane is noted with no bone over the membrane at the window that has been

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28 • Vol. 6, No. 3 • June 2014

Figure 19: The elevated sinus area has been completely packed with osseous graft material.

Figure 20: Implant placement following osseous graft healing demonstrating the new sinus height achieved.

Figure 21: A resorbable membrane was placed over the boney sinus window to limit soft tissue ingrowth into the graft during the healing phase.

created on the lateral wall (Figure 14). Addi-tional, host bone is collected from the Dome drill.

Sinus curettes are utilized to start the sinus membrane elevation at the inferior aspect, teasing the membrane from the osseous wall of the sinus interiorly (Figure 15). Following elevation of the membrane, the membrane should be intact and free of visible tears that may prevent graft distribu-tion within the sinus during initial healing (Figure 16). It is important that the elevation also include

the medial wall of the sinus so that fills a volume great enough that the implant when placed will be surrounded by bone. Failure to elevate the medial aspect may result in the implant when placed having no osseous contact which may decrease clinical success following loading. Additionally, the authors advise elevation to a greater height then the implant length to be placed when a delayed fixture placement is to be performed. This will allow for possible graft settling during heal-ing that may yield less height then was planned.

An absorbable extracellular membrane (Dynamatrix, Keystone Dental, Burlington, MA) is inserted into the sinus to act as protec-tion containing the graft material and thicken the sinus membrane sealing any micro tears that might be present (Figure 17). The resor-able membrane is cut to size and placed into the sinus dry using the patients blood in the site to wet it as its placed. Once wetted with blood the resorable membrane becomes sticky gluing itself to the sinus membrane.

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Figure 22: The flap was repositioned and closed with a horizontal mattress and interrupted sutures.

Figure 23: I mplant following 8 months healing and exposure to place a healing abutment demonstrating blending of the grafted sinus with the surrounding native bone.

Figure 24a: CBCT demonstrating new volume of bone achieved following sinus augmentation and implant placement which is ready for restoration of the implant.

Figure 24b: CBCT demonstrating new volume of bone achieved following sinus augmentation and implant placement which is ready for restoration of the implant.

Regenform Cortical Cancellous Bone Chips (Exatech, Gainsville, FL) and Sureoss, a freeze-dried cortical allograft (Hiossen, Philadelphia, PA) in a 50:50 ratio in a sterile dappen dish and mixed with the autogenous bone collected from the Dome drill. The osseous graft mixture was carried to the oral cavity and introduced into the elevated sinus and gently condensed with a large plugger, pushing the mixture to the medial wall and filling in a lateral direction until

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30 • Vol. 6, No. 3 • June 2014

the entire cavity was filled (Figure 18). The pro-cess was repeated in the cavity anterior to the septa. Sufficient osseous graft was placed till the sinus was augmented to be flush with the outer aspect of the lateral sinus wall at the window that had been created (Figure 19).

Following sinus grafting the site was pre-pared and an implant (4.5 x 10mm, ETIII, Hios-sen, Philadelphia, PA) was placed and the site. A low profile cover screw was used to allow pri-mary closure of the flap. The radiograph shows initial graft placement and the elevation achiev-ing a site that can accommodate implant place-ment at this surgical appointment (Figure 20).

A long term resorbable membrane (Dyna-matrix) was cut to extend beyond the outline of the lateral window and placed over the osseous graft that had been placed into the sinus (Fig-ure 21). The flap was repositioned and initially closed with a horizontal mattress suture using a 5-0 Cytoplast suture material, (Osteogenics Biomedical, Inc., Lubbock, TX) to achieve pri-mary closure of the flap without tension then the crest was closed with interrupted sutures (Figure 22). This suture serves to resist soft tissue tension that may result due to inflamma-tion and the resulting swelling following surgery. Additional sutures are placed to close the inci-sion line using a simple interrupted technique.

The patient returned 8 months following implant placement. Soft tissue in the site on the lateral aspect demonstrated no inflam-mation and incision lines were not discern-able on the gingiva. The implant was exposed using a disposable tissue punch and the cover screw was replaced by a healing abutment. A radiograph was taken to check and verify the organization of the osseous graft that had

been placed into the sinus, integration of the implant and seating of the healing abutment on the fixture (Figure 23). A CBCT was taken to check the graft and implant integration and the implant is ready to be restored (Figure 24).

cOncLuSIOnEmphasis has moved to the use of a crestal approach to sinus elevation when additional osseous height is required for implant place-ment. This approach works well when at least 5mm of osseous height is present for immediate implant placement. Yet, when less bone height is present, a lateral window approach may be the preferred technique to increase crestal height and geometric vol-ume so that implant fixtures may be placed.

The lateral sinus augmentation approach can be challenging as tearing of the sinus membrane often necessitates abandoning the procedure and re-entry at a later date after the membrane has healed. Previous tech-niques involved use of diamonds or carbides in a highspeed handpiece or the use of peizo surgical units. These approaches had poten-tial for membrane damage (burs in a high-speed) or were very slow (peizo). The LAS Kit, from Hiossen utilizes special designed drills that greatly minimize tearing of the membrane and improve the safety of the procedure. ●

correspondence:

Dr. Gregori Kurtzman

3801 International Drive, Suite 102

Silver Spring, MD 20906

301-598-3500

Kurtzman et al


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

References1. Blomqvist JE, Alberius P, Isaksson S. Two maxillary sinus reconstruction with

endosseous implants: A prospective study. Int J Oral Maxillofac implants 1998; 13:758-766.

2. Valentini P, Abensur DJ. Maxillary sinus grafting with anor-ganic bovine bone: A clinical report of long-term results. Int J Oral Maxillofac Implants 2003; 18:556-560.

3. Tong DC, Drangsholt M, Beirne OR. A review of survival rates for implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral Maxillofac Implants 1998; 13:175-182

4. Tatum OH Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986; 30:207-229

5. Rosen PS, Summers R, Mellado Jr, et al. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac implants 1999; 14:853-858

6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compend Contin Educ Dent 1994; 15:152-162

7. Summers RB. The osteotome technique: part 3- less invasive methods of elevating the sinus floor. Compend Contin Educ Dent 1994: 15:698-710

8. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: a systemic review and meta-analysis. J periodontal 2005; 76:1237-1251

9. Toffler M. Osteotome- mediated sinus floor elevation: a clinical report. Int J Oral Maxillofac implants 2004; 19:266-73

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

11. Peleg M, Mazor Z, Garg AK. Augmentation grafting of the maxillary sinus and simultaneous implant placement in patients with 3 to 5 mm of residual alveolar bone height. Int J Oral Maxillofac implants 1999; 14:549-556

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Wilcko et al

Successful treatment with the two-implant overdenture has been documented with multiple implant designs (ie. hexago-

nal, Morse taper, internal connection) and many implant systems. Clinicians may select implants for retention of the two-implant overdenture according to personal experience and prefer-ence with confidence that treatment success

will not be determined by the selection made. This is due primarily to the anatomy and den-sity of the bone in the anterior mandible. The aim of this case report is to demonstrate the concept of immediate functional loading in the mandible using unsplinted implants to support a locator attachment supported overdenture.

Loading of Two Implants in the Mandible and Final Restoration with a Locator:

A Case Report and Review

Dr. A. Abdulgani1 • Dr. M. Bajali2 • Dr. M. Abu-Hussein3

1. Assist.Professor, Al Quds University, Jerusalem, Palestine

2. Assistant Professor, Al Quds University, Jerusalem, Palestine

3. Visiting Professor, Napoli university, Italy and University of Athens, Greece

Abstract

KEY WORDS: Dental implants, denture, locator attachments, overdenture


34 • Vol. 6, No. 3 • June 2014

Abdulgani et al

IntRODuctIOnDental implants are prosthetic devices, made of alloplastic materials that are inserted into the oral cavity to provide retention and support to removable and fixed dental prostheses.1,2 The concept of using implants to replace teeth is age old. In fact, in ancient history thousands of years ago, ivory teeth were used as implants in Egyptian mummies. However, the era of mod-ern dental implantology began much later, in the 1940’s, with the discovery of screw type implants by Formiggini et al.3,4 The introduc-tion of the concept and the biology of osseoin-tegration, by Branemark et al.5 added another milestone in the history of dental implantol-ogy. Over the years, this field has signifi-cantly evolved and emerged as an extensively used treatment modality for oral rehabilitation.

The first clinical outcome of surgical pro-cedure is the primary stability of the implant. Primary stability is rigid fixation and lack of micro motion of the implant into the bone cav-ity.1,6,7 Absence of stability can lead to exces-sive mobility and cause fibrous tissue formation around the implants inhibiting osseointegra-tion.7,9 Primary stability depends on the surgi-cal technique, implant design and the implant site.9,10 Bone tissue is arranged in two macro architectural forms, trabecular or cancellous and cortical or compact. Leckholm and Zarb (1985) have classified bone types in the oral cavity, depending on the relative proportions of cancellous and cortical bone: A) Class I: predominantly cortical; B) Class II: thick layer of compact bone surrounding a dense cancel-lous core; C) Class III: thin layer of compact bone surrounding a cancellous core; D) Class IV: very thin compact layer around a low den-

sity trabecular bone. Sennerby et al.11 com-pared implants placed in rabbit cortical versus cancellous bone and established that corti-cal bone has a higher modulus of elasticity, is harder to deform and provides greater resis-tance to motion. Hence, Class I and Class II bone would facilitate higher primary stability

The original protocol for loading, as described by Branemark, involved waiting for three months (for mandible) to six months (for maxilla) after implant placement. Such a delayed loading protocol was aimed at allowing undis-turbed healing and complete osseointegra-tion before implants could be loaded. For a long time it was assumed that premature load-ing would limit peri-implant osteogenesis and induce fibrous tissue formation.7,12 Schnitman et al. introduced the concept of immediate loading, which has been described as attach-ment of the prostheses within twenty-four hours to one week after implant placement.13,14 Some of the advantages of immediate load-ing are shortened treatment time and early functional, physiological and psychological rehabilitation of the patient. In addition, there have been some claims made about a biologic advantage in the form of enhanced osteoblas-togenesis with immediate loading. An in-vivo study by Qi et al. evaluated the response of mesenchymal stem cells to mechanical strain and their consequent gene expression pat-terns.15 Their results suggested that mechani-cal strain might act as a stimulator to induce differentiation of stem cells into osteoblasts.15 Indeed, cyclic tensile strain has been shown to increase osteoprotegrin synthesis and decrease soluble receptor activator of nuclear factor kappa-B ligand (RANKL), thus favoring

Abdulgani et al


bone formation.16 This theory was tested in an rabbit model by Duyck et al. who concluded that mechanical loading stimulated bone for-mation and led to a higher bone fraction.17,18

treatment of complete Edentulism with Implant OverdenturesAn overdenture is defined as any dental pros-thesis that covers and rests on one or more remaining natural teeth, the roots of natural teeth, and /or dental implants.2 The concept of overdentures is age old. Ledger as early as 1856, suggested utilizing natural teeth to sta-bilize removable prostheses and after a whole century Miller introduced the concept of tooth retained overdentures.19 The downside of these prostheses was frequent failure of abut-ments caused by periodontal disease, peri-apical lesions, caries and fracture of teeth.20

The introduction of osseointegrated implants and implant-retained prostheses led to a para-digm shift for the management of edentulism. This is true especially for mandibular edentu-lism, where the problem of advanced alveo-lar resorption and difficulty in providing stable, retentive and functionally comfortable prosthe-ses seemed to represent a major challenge.21

A number of randomized controlled tri-als have demonstrated increased patient satisfaction and reduced negative impact on quality of life with implant retained over-dentures as opposed to conventional den-tures in the mandible.22 Other studies have reported an improvement in chewing abil-ity, bite force and in serum nutritional and anthropometric parameters (such as skin fold thickness, waist hip ratio and body mass

index).23,24 The long-term efficacy of implant-supported overdentures has been established in many retrospective and longitudinal trials.25-27

Implant overdentures are used in conjunc-tion with attachments and there are many different attachments provided by a large number of manufacturers around the world. The attachments currently available can be broadly divided into two major categories: A) Splinted / Bar Attachments (Dolder bar and Hader bar are examples of splinted attach-ments); B) Non-splinted / Solitary / Stud Attachments (Ball attachments, magnets and locators exemplify solitary attachments).

Loading of Implant OverdenturesA fairly recent systematic review by Gallucci et al (2009), presented the strength of evi-dence available for different loading protocols (conventional, early and immediate loading) in completely edentulous patients. Their search led to a conclusion that the highest level of scientific and clinical validation was avail-able for conventional loading with mandibu-lar overdentures. However, immediate loading of mandibular dentures was clinically well documented but not scientifically validated.28

Clinical documentation of immediate load-ing can be exemplified by various prospective trials that have been conducted using this pro-tocol for mandibular dentures. For example, a longitudinal study with 3-8 years of follow up by Chiapasco et al.33 looked at success and sur-vival of immediately loaded implants supporting a mandibular overdenture. Four implants were placed per patient, connected by a splinted bar attachment. A cumulative success rate of

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36 • Vol. 6, No. 3 • June 2014

88.2% and survival rate of 96.1% was seen after a mean follow up period of 62 months. The authors concluded that, for about 3 years after immediately loading the implants, the suc-cess and survival were the same as that docu-mented for delayed loading. However, with a longer follow up it became evident that immedi-ately loaded implants had a moderate decrease in success rate.29 Similar results were reported by Kronstrom et al.30 wherein he advised cau-tion in using immediate loading due to a low survival rate of 81.8% at 1 year follow up.

Other investigators have, however, reported higher rates of success and survival using an immediate loading protocol. A cohort study by Gatti et al.31 has shown a cumula-tive survival rate of 100% and minimal bone level changes (0.5–0.9 mm) around immedi-ately loaded implants. Alfadda et al.32 used historical controls with delayed loading in a prospective cohort study and compared it to immediate loading. At 5 years, they found iden-tical success, survival, satisfaction and impact on quality of life between the two groups.

Randomized clinical controlled trials (RCT) are considered as the most reliable (Level I) form of validation in the hierarchy of scien-tific evidence, essentially because they reduce spurious causality and bias. In order to prove the efficacy and safety of an immediate load-ing protocol Chiapasco et al.33 performed a RCT comparing an immediate and a delayed protocol for four splinted implants supporting a mandibular overdenture. They found no dif-ference in cumulative survival rate, bone loss, clinical and radiographic parameters at 2 years between the two groups. A review paper by Gallucci et al (2009) and a 10 years clinical

trial by Meijer et al (2009), among many oth-ers, have shown that there is no difference in the clinical and radiographic performance of two or four implants supporting a mandibular overdenture.27,28 Hence, having established that immediately loaded four implants support-ing a mandibular overdentures are comparable to delayed loaded implants, it would be inter-esting to see if these results can be replicated when two implants were used in conjunction with unsplinted attachments such as locators.

cASE REpORtA 58-year-old female patient without any medical contra-indications for implant therapy presented with an ill-fitting, lower complete denture that she had been wearing for four years. The clini-cal and radiographic findings revealed slight to moderate mandibular ridge resorption with an ill-fitting lower denture (Figs. 1, 2). The patient was given the option of placing two implants to support her existing lower denture. The treatment plan was accepted and included an immediate functional loading by using a locator attachment-supported mandibular overdenture.

At the surgical appointment, following the administration of local anesthetic, a mid-crestal incision was performed and a full-thickness flap was reflected. In addition, osteotomies were prepared in type II bone. Bone taps were used to countersink the sites, after which two ITI Tapered implants (ITI 3.3X14-mm) were placed with the hand piece and hand ratchet. The implants were torqued to 35 N (Figs. 3, 4). Immediately after implant surgery (Fig. 5), the mandibular denture was seated in the patient’s mouth and adjusted to provide clearance in the area of the locators (Fig. 6). Two locators

Abdulgani et al


(4 mm in length) were torqued to 30 N (Figs. 7, 8). Following the suture of the flap with4-0 vicryl, the processing rings were placed over the locators and were picked up directly in the mouth using hard self-curing acrylic (Rebase II, Tokuyama; Fig. 7). The patient was given post-operative instructions, including the use of 0.12 % chlorhexidine gluconate three times a day.

She was furthermore prescribed 500 mg of amoxicillin (to be taken every six hours for seven days). The patient was then informed that the

implant-supported overdenture was to be left in place for 48 hours. Two days later, she was seen for a follow-up visit and the healing pro-cess was uneventful. The black processing rings were switched to blue rings ten weeks after placement. After six months, the patient returned for another follow-up visit and both locators were torqued to 30 N again. It was determined that both implants had achieved full integration. Currently, the patient is on a six-month recall to ensure the proper maintenance

Figure 1: Mandible at the time of implant placement with moderate bone resorption.

Figure. 2: Pre-op panoramic radiograph.

Figure 3: Guiding pins at the time of implant placement. Figure 4: Two tapered implants at placement.

Abdulgani et al

38 • Vol. 6, No. 3 • June 2014

Figure 9: Buccal view of the overdenture in place. Figure 10: Final smile.

Figure 5: Panoramic radiograph immediately after implant placement.

Figure 6: The processing rings were picked up directly in the mouth.

Figure 7: Occlusal view of the locators two weeks post-implant placement.

Figure 8: Buccal view of the locators two weeks post-implant placement.

Abdulgani et al


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of the implants and the prosthesis (Figs. 9, 10). The last maintenance visit was 24 months post-placement and all implants have maintained healthy soft tissue and a stable bone level.

cOncLuSIOnWithin the limits of this interim report, immedi-ate loading of two implants supporting a loca-tor retained mandibular overdenture seems to be a suitable treatment option. The mar-ginal bone level changes around immediately loaded implants are comparable to those seen around implants loaded with a torque do not effect peri-implant bone loss. Implant sur-vival of immediately loaded implants maybe lower than those loaded with a delayed pro-tocol, but this needs to be confirmed in future investigations with a larger sample size. ●

correspondence:Dr. Abu-Hussein Muhamad123 Argus Street10441 [email protected]

Abdulgani et al

40 • Vol. 6, No. 2 • June 2014

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

References1. Meyer U, Joos U, Mythili J, Stamm T, Hohoff A, Fillies T, Stratmann U, Wiesmann

HP: Ultrastructural characterization of the implant/bone interface of immediately loaded dental implants. Biomaterials 2004, 25(10):1959-1967.

2. . The glossary of prosthodontic terms. J Prosthet Dent 2005, 94(1):10-92.

3. 15. Kibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system for an endosteal tooth implant: I. Critical assessment of previous designs. Oral Implantol 1975, 6(2):172-192.

4. Kibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system for an endosteal tooth implant. II. In vitro and in vivo evaluations of a new composite-material design. J Oral Implantol 1977, 7(1):106-123.

5. Branemark PI, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson A: Intra-osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969, 3(2):81-100.

6. Adell R, Lekholm U, Rockler B, Branemark PI: A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981, 10(6):387-416.

7. Marco F, Milena F, Gianluca G, Vittoria O: Peri-implant osteogenesis in health and osteoporosis. Micron 2005, 36(7-8):630-644.

8. Soballe K, Hansen ES, H BR, Jorgensen PH, Bunger C: Tissue ingrowth into titanium and hydroxyapatite-coated implants during stable and unstable mechanical conditions. J Orthop Res 1992, 10(2):285-299.

9. Sevimay M, Turhan F, Kilicarslan MA, Eskitascioglu G: Three dimensional finite element analysis of the effect of different bone quality on stress distribution in an implant-supported crown. JProsthet Dent 2005, 93(3):227-234.

10. Buchter A, Kleinheinz J, Joos U, Meyer U: [Primary implant stability with different bone surgery techniques. An in vitro study of the mandible of the minipig]. Mund Kiefer Gesichtschir 2003, 7(6):351-355.

11. Sennerby L, Thomsen P, Ericson LE: A morphometric and biomechanic comparison of titanium implants inserted in rabbit cortical and cancellous bone. Int J Oral Maxillofac Implants 1992, 7(1):62-71.

12. Albrektsson T: Direct bone anchorage of dental implants. J Prosthet Dent 1983, 50(2):255-261.

13. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV: The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants 2007, 22(6):893-904.

14. Schnitman PA, Wohrle PS, Rubenstein JE: Immediate fixed interim prostheses supported by two-stage threaded implants: methodology and results. J Oral Implantol 1990, 16(2):96-105.

15. Qi MC, Zou SJ, Han LC, Zhou HX, Hu J: Expression of bone-related genes in bone marrow MSCs after cyclic mechanica strain: implications for distraction osteogenesis. Int J Oral Sci 2009, 1(3):143-150.

16. Kusumi A, Sakaki H, Kusumi T, Oda M, Narita K, Nakagawa H, Kubota K, Satoh H, Kimura H: Regulation of synthesis of osteoprotegerin and soluble receptor activator of nuclear factor-kappaB ligand in normal human osteoblasts via the p38 mitogen-activated protein kinase pathway by the application of cyclic tensile strain. J Bone Miner Metab 2005, 23(5):373-381.

17. Duyck J, Slaets E, Sasaguri K, Vandamme K, Naert I: Effect of intermittent loading and surface roughness on peri-implant bone formation in a bone chamber model. J Clin Periodontol 2007, 34(11):998-1006.

18. Vandamme K, Naert I, Vander Sloten J, Puers R, Duyck J: Effect of implant surface roughness and loading on peri-implant bone formation. J Periodontol 2008, 79(1):150-157.

19. Miller PA: COMPLETE DENTURES SUPPORTED BY NATURAL TEETH. Tex Dent J 1965, 83:4-8.

20. Fenlon MR: Periodontal disease, periapical lesions and caries were, in that order, the causes of overdenture abutment loss. J Evid Based DentPract 2005, 5(2):94-95.

21. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R et al: The McGill consensus statement on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants 2002, 17(4):601-602.

22. Thomason JM, Lund JP, Chehade A, Feine JS: Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after delivery. Int J Prosthodont 2003, 16(5):467-473.

23. Morais JA, Heydecke G, Pawliuk J, Lund JP, Feine JS: The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals. J Dent Res 2003, 82(1):53-58.

24. Bakke M, Holm B, Gotfredsen K: Masticatory function and patient satisfaction with implant-supported mandibular overdentures: a prospective 5-year study. Int J Prosthodont 2002, 15(6):575-581.

25. Vercruyssen M, Marcelis K, Coucke W, Naert I, Quirynen M: Long-term, retrospective evaluation (implant and patient-centred outcome) of the two-implants-supported overdenture in the mandible. Part 1: survival rate. Clin Oral Implants Res 2010, 21(4):357-365.

26. Attard NJ, Zarb GA: Long-term treatment outcomes in edentulous patients with implant overdentures: the Toronto study. Int J Prosthodont 2004, 17(4):425-433.

27. Meijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A: Mandibular overdentures supported by two or four endosseousimplants: a 10-year clinical trial. Clin Oral Implants Res 2009,20(7):722-728.

28. Marzola R, Scotti R, Fazi G, Schincaglia GP: Immediate loading of two implants supporting a ball attachment-retained mandibular overdenture: a prospective clinical study. Clin Implant Dent Relat Res2007, 9(3):136-143.

29. Chiapasco M, Gatti C: Implant-retained mandibular overdentures with immediate loading: a 3- to 8-year prospective study on 328 implants. Clin Implant Dent Relat Res 2003, 5(1):29-38.

30. Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L: A prospective randomized study on the immediate loading of mandibular overdentures supported by one or two implants: a 12-month follow-up report. Int J Oral Maxillofac Implants 2010, 25(1):181-188.

31. Gatti C, Chiapasco M: Immediate loading of Branemark implants: a 24-month follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conical transmucosal and standard MK II implants. Clin Implant Dent Relat Res 2002, 4(4):190-199.

32. Alfadda SA, Attard NJ, David LA: Five-year clinical results of immediately loaded dental implants using mandibular overdentures. Int J Prosthodont 2009, 22(4):368-373.

33. Chiapasco M, Abati S, Romeo E, Vogel G: Implant-retained mandibular overdentures with Branemark System MKII implants: a prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Implants 2001, 16(4):537-546.

Abdulgani et al

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Hasan

Background: Smile makeover with the use of All Ceramic restorations is a proven and well accepted modality. When there is a violation of biological width in such cases, soft and hard tissues might be trimmed to achieve a healthy foundation and ideal proportions. Recent publi-cations suggest a more conservative approach to address this situation, namely the Biologic Shaping. A case of biologic width impingement is presented here in which the need for crown lengthening was substantially reduced due to application of principals of biologic shaping.

Methods: A female patient, 24 years old pre-sented with unsightly crowns on teeth no. 13 to 33(FDI). Clinically, the porcelain fused to metal crowns had overhanging and impinging margins, improper proportions and a very monochromatic artificial appearance. The teeth were also end-odontically treated which was also unsatisfac-

tory. All endodontics treatment was repeated and crowns were removed. After reshaping the abutments, temporary restorations were provided and incrementally adjusted which allowed the soft tissues to heal and regain their shape. Minimal gingivoplasty was required on teeth no 11 and 21. A healing period was followed by the final preparations and place-ment of 6 all ceramic (Empress 2) crowns.

Results: The concept of biologic shap-ing allowed to complete the case with mini-mal surgical intervention and resulted in an extremely happy and satisfied patient.

Conclusions: Biologic shaping is a con-servative option to treat cases with bio-logic width impingement and can be successfully used in the aesthetic zone.

Smile Makeover with all Ceramic Crowns and Biologic Shaping

Dr. Arshad Hasan1

1. Associate Professor and Head of Operative Dentistry, Dow Dental College, Dow University of Health Sciences,

Baba-e-Urdu Road, Karachi Pakistan

Abstract

KEY WORDS: Biological width, Biologic shaping, All ceramic restorations, IPS Empress 2, Bleaching, Smile makeover, Golden proportions, Endodontic retreatment


44 • Vol. 6, No. 3 • June 2014

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IntRODuCtIOnBiologic width violation is treated convention-ally by either surgical crown lengthening or orth-odontic extrusion.1 Former procedure requires the operator to remove significant hard and soft tissues, so that a 3mm zone is established from the margin of restoration to the crestal bone as described by Gargiulo.2 This results in significant and often un-necessary removal of soft and hard tissues to achieve the objec-tive. It also doesn’t allow for individual varia-tion of biologic width to exist as it forces a 3mm rule to every tooth.3 Biologic shaping was recently introduced by Melker which allows individual variation in biologic width to exist and significantly reduces the need for soft and hard tissue removal.4 In the first appointment a buccal partial thickness and palatal full thick-ness flap is raised, root surfaces are rendered clean of irregularities, existing restorative mar-gins and calculus. A series of diamonds from coarse to extra-fine are used to give a smooth root surface. This is followed by apically repo-sitioned flap closure and healing by second-

ary intention is encouraged. A provisional restoration with 1mm clearance from gingival margin is placed over the teeth and left there for 3 months. Once the gingival apparatus has healed, permanent restorations are provided with margins just coronal to this newly estab-lished gingiva.3 The case presented here was treated by the author without the knowledge of these principals at the time of treatment. How-ever, the ideology was similar i.e. to allow gin-gival tissues to heal and regain their original dimensions before provision of permanent resto-rations rather than surgical crown lengthening.

Figure 1: Pre-operative view.

Figure 2: Pre-operative view.


Hasan

CASE REpORtA 24 year old medically healthy female presented to the Department of Operative Dentistry, Ham-dard University Dental Hospital in April 2009. Her chief complaint was poor aesthetics of front six maxillary teeth. Clinically there were six indi-vidual porcelain fused to metal crowns pres-ent on teeth no 6, 7, 8, 9, 10, and 11 (FDI tooth numbering system). The crowns were mono-

chromatic and had overhanging and impinging margins. The soft tissues adjacent to these res-torations were edematous and bled on prob-ing (Figure 1). There was an asymmetry of papilla between teeth 7-10. An adequate band of attached gingiva was present. Radiographic evaluation revealed inadequate endodontic treat-ment of all restored teeth (Figure 2). A diagnosis of biologic width impingement was made based

Figure 3: Assessment of teeth proportions.

Figure 4: Endodontic retreatments. Figure 5: Putty stent for temporization.

46 • Vol. 6, No. 3 • June 2014

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on clinical findings and probing depths. Further digital smile analysis revealed that teeth 8 and 9 had improper width to length ratio and were shorter than the smile arc (Figure 3). The treat-ment plan included retreatment of inadequate endodontics, tooth reshaping, long term provision-alization, reassessment of aesthetic proportions and delivery of final all ceramic (IPS EMPRESS 2, Ivoclar Vivadent, Liechtenstein) restorations.

The endodontic retreatments were performed through the existing crowns to facilitate place-ment of rubber dam (Figure 4). Once endodon-tics was complete, a putty stent (Express STD,

3M ESPE, Seefeld Germany) of existing restora-tions was made (Figure 5). The existing crowns were removed by cutting a groove through the facial surface and twisting with a plastic instru-ment. Once removed the damage to the soft tis-sues was evident (Figure 6). A soft tissue flap was not raised as the author was not aware of the principals of biologic shaping at that time. However, a plan was made to allow the soft tis-sues to heal, recoil and regain its natural dimen-sions without dictating any dimensions. The teeth were lightly prepared with a chamfer bur to remove the debris (Figure 7). The putty stent

Figure 6: Extensive damage to soft tissues revealed. Figure 7: Initial preps and cleaning of debris.

Figure 8: Fabrication of temporary restoration using the putty stent.

Figure 9: Adjustment of contours of temporary restoration.


Hasan

Figure 10: 1 week healing after temporization.

Figure 11: Biologic shaping, gradual relief of temporary restoration to allow the soft tissues to regain health.

Figure 12: Non-vital bleaching to lighten discolored teeth no. 9 and 10.

was used to fabricate a provisional using an auto polymerizing resin (Protemp, 3M ESPE, Seefeld Germany) (Figure 8). The margins of the provi-sional restoration were kept short of the gingi-val margins to facilitate healing (Figure 9). The results were immediately evident at 1 week recall as there was excellent tissue healing (Figure 10). The margins of provisional were further modi-fied over a period of 3 appointments and papilla between teeth 8 and 9 was allowed to become symmetrical with its counterpart (Figure 11). Dur-ing these appointments teeth 9 and 10 were also bleached since they exhibited discoloration (Figure 12). A classic walking bleach technique was used here with a mixture of sodium perborate (Nanchang Dental Bright Technology, China) and hydrogen peroxide (Hydrogen Peroxide Solution, Karachi Pharmaceutical Laboratories, Karachi).

After the completion of bleaching and soft tissue healing, the dimensions were once again assessed. Teeth 8 and 9 were found to have improper width to length ratio (Figure 13). This evaluation showed that both central incisors could be lengthened incisally and cervically. The teeth were probed to reveal an adequate sulcus depth, a gingivectomy was performed to bring the gingi-

val margins to correct a level, as determined by the post provisionalization aesthetic evaluation (Fig-ure 14). Once this surgical site healed, the cor-onal structure of teeth 9 and 10 were reinforced with fiber posts (Rebuilda Post, Voco Germany). The posts were luted with a self-adhesive resin (Breeze, Pentron Clinical Technologies, Walling-

48 • Vol. 6, No. 3 • June 2014

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Figure 13: Final assessment of proportions after biologic shaping.

Figure 14: Aesthetic crown lengthening, 1 week post-operative healing.

Figure 15: Fiber posts placed in teeth no 9 and 10.

ford, Connecticut, USA)(Figure 15). Core build-ups were performed with a fiber reinforced dual cure core buildup resin (Buildit FR, Pentron Clini-cal Technologies, Wallingford, Connecticut, USA).

The teeth were now ready for final prepara-tions. The finish line was at the level of gingival margin in teeth 8 and 9, however it was subgin-gival in rest of teeth (Figure 16). An impression was recorded with an addition silicon material in a stock tray. The impression of opposing arch was recorded with alginate in a stock tray. Bite registration paste was used to register the centric occlusion. Shade A1 was selected for body of crowns and A2 for the gingival third. Slight inci-sal translucency was requested since patient was still young. The case was then sent to lab for fab-rication of All Ceramic crowns (IPS EMPRESS 2, Ivoclar Vivadent, Liechtenstein). The case was received from the lab 2 weeks later (Figure 17). It was first tried in and was found to be adequate with respect to occlusion, margins, contact, emergence profile and aesthetics. The restora-tions were luted with dual cure luting resin of A1 shade (RelyX Unicem, 3M ESPE, Seefeld, Ger-many) (Figure 18). The cement was cured with

a light curing unit (Elipar Freelight, 3M ESPE, Seefeld Germany), excess removed and patient was dismissed with home care instructions.

The patient returned on a follow up visit 2 months later (Figure 19). The gingival tis-


Hasan

Figure 16: Final teeth preparations for All ceramic crowns.

Figure 17: All ceramic IPS Empress 2 crowns on cast, (Ceramist, Mohammad Ali Khan, Khan Dental Laboratories, Karahi).

Figure 18: Front and side profile after final cementation.

sues exhibited excellent health. There was complete papilla fill in all embrasures. How-ever a slight swelling in interdental papilla was noticed between teeth 7 and 8. Since there was no bleeding on probing and probing depths were within normal limits, no further action was taken. Also the gingiva on tooth 9 had grown over the crown margin and altered the width to length ratio. The patient returned on a sec-ond follow-up a year later and presented a simi-lar healthy gingival tissue except between teeth 7 and 8 (Figure 19). The patient was extremely satisfied with the results, while operator was concerned about the slight gingival swelling.

DISCuSSIOn

Health, function and aesthetics are the three most important aspects of Aesthetics Dentistry which must be addressed to obtain exceptional results.

50 • Vol. 6, No. 3 • June 2014

Hasan

Figure 19: 2 month and 1 year recall. Figure 20: Before and after.

While health and function can exist indepen-dently, aesthetics cannot be achieved unless the former two are obtained.5 Aesthetic cases with biologic width violation are most challenging to treat, since there is not only an unhealthy soft tis-sue response, tooth to tooth proportions are also usually incorrect. Traditionally, these cases have been treated with surgical crown lengthening alone. Major disadvantage of crown lengthening procedure is the need to remove bone and gin-giva, sometimes unnecessarily to fulfill biological objectives. Another shortcoming is that it brings the narrower part of root more coronally and this results in compromised emergence profile, tri-angular gingivae and possible black triangles.1

Biologic shaping was introduced by Melker to address the shortcomings of surgical crown lengthening. The benefits of this procedure have been explained by Melker.4 The author was not aware of this technique since the case was treated in 2009 and hence could not apply all the principals of this novel concept. We cleaned the tooth surface and provided a long term provi-sional with margins short of gingiva as proposed by Melker.3 Definitive restorations were placed

(IPS EMPRESS 2, Ivoclar Vivadent, Liechten-stein) after ensuring adequate healing of soft tis-sues. However two undesirable events occurred on follow up. The interdental papilla between teeth number 7 and 8 exhibited slight swelling but did not bled on probing. Also the gingiva on tooth 9 had grown over the crown margin and altered the width to length ratio. Both the events were not expected. However, the patient was not both-ered about either and no further action was taken.

COnCluSIOn Biologic shaping is a conservative option to treat cases with biologic width impingement and can be successfully used in the aesthetic zone. ●

Correspondence:Dr. Arshad Hasan Dow Dental College, Dow University of Health SciencesBaba-e-Urdu Road, Karachi PakistanPhone Office: 009221-99215754 ext 324Cell No. 0092321-2437304Email: [email protected]


Hasan

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

References1. Sadan A, Adar P. Esthetic proportions versus biologic width considerations: a

clinical dilemma. J Esthet Dent. 1998;10(4):175-81.

2. Gargiulo A, Wentz F. Dimensions of the dentogingival junction in humans. J Periodontol. 1953;32:261-7.

3. Melker DJ, Richardson CR. Root reshaping: an integral component of periodontal surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296-304.

4. Melker DJ. Biologic shaping from a restorative prospective. J Implant Adv Clin Den. 2013;5(8):27-32.

5. Ahmad I. The Health, Function and Aesthetic Triad. Protocols for Predictable Aesthetic Dental Restorations: Blackwell Munksgaard; 2008. p. 21-54.


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Munakata et al

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Munakata et al

Background: The aim of this study was to clarify the occurrence regions and sites of peri-implant bone resorption and inflamma-tion in Japanese partially-edentulous patients.

Methods: Five hundred one partially-edentu-lous patients with 738 implants in function for more than 5 years, were included in this study for the evaluation of the bone resorption by using dental radiograph and probing. Con-sidering physiological bone remodeling, the mean mesio-distal bone resorption around the implant was measured on dental radiograph.

Results: In 65 patients (13.0% of the total patients) with 76 implants (10.3% of the total implants), peri-implant bone resorption

was identified. The mean functional loading time of these implants was 8.4 years. Occur-rence regions were frequently found in the molar regions in maxilla (15.4%) and the molar region in mandible (10.0%). In these lesions detected radiologically, the bleeding on prob-ing was seen in 95.2% of the buccal sites in mandibular molar regions, 70.0% of the palatal sites in maxillary molar regions and 56.7% of the buccal sites in maxillary molar regions with statistically significant differences.

Conclusions: From the limitation of the infor-mation in this study, it was concluded that the sites that tend to be vulnerable to peri-implant inflammation were the buccal site in mandi-ble, and the buccal and palatal sites in maxilla.

Occurrence Regions and Sites of Peri-implant Inflammation with Bone Resorption in Japanese Partially-Edentulous Patients

Motohiro Munakata1• Noriko Tachikawa1 • Katsuichiro Maruo2, Aoi Sakuyama1 • Yoko Yamaguchi1 • Shohei Kasugai1

1. Oral Implantology and Regenerative Dental Medicine, Tokyo Medical and Dental University, Tokyo, Japan, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan.

2. Department of Prosthodontic Dentistry for Function of TMJ and Occlusion, Kanagawa Dental University

Abstract

KEY WORDS: Dental implants, peri-implantitis, bone loss


54 • Vol. 6, No. 3 • June 2014

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IntRODuCtIOn Dental implants have been successfully used in the treatment of complete and partial edentulous patient subjects.1 Nevertheless, dental implant failures have also been reported.2,3 These fail-ures are classified on the basis of chronology, i.e. early or late failure. Early dental implant failures are attributed to surgical trauma, inadequate bone volume, lack of primary stability, intra-osse-ous infection, and bacterial contamination of the recipient site.3,4 Late dental implant failures are associated with peri-implantitis and/or biome-chanical overload.2,3,5 In the Sixth European Work-shop on Periodontology, peri-implant disease was a collective term for inflammatory reactions in the tissues surrounding an implant.6,7 “Peri-implant mucositis” is defined as inflammation of the mucosa around an implant without loss of supporting bone, while “peri-implantitis” is char-acterized by loss of supporting bone together with mucosa inflammation. It has been reported that peri-implant mucositis occurs in 80% of the subjects and in 50% of the implant sites and that peri-implantitis is identified in 28% and 56% of subjects and in 12% and 43% of implant sites, respectively.7 As potential risk factors for peri-implantitis, Heitz-Mayfield8 listed the history of periodontal disease, diabetes mellitus, smoking, oral hygiene condition, alcohol intake, genotype, presence of cornified mucosa, and the implant surface property. Oral hygiene condition, history of periodontal disease, smoking, and diabetes mellitus, etc., have been reported as related risk factors. Thus, the disease will be obviously more frequent in the future, as long as a specific ther-apy or prevention will not established. Clinically, bleeding and/or suppuration following probing has been proposed as a valuable clinical sign for

the diagnosis of both peri-implant mucositis and peri-implantitis, while the concomitant detection of marginal peri-implant bone loss in radiographs will distinguish peri-implantitis from mucositis.7 Radiographic techniques including panoramic tomography and intra-oral radiography with long cone paralleling techniques have been widely used to monitor marginal bone levels around implants and diagnose interproximal bone loss.9 However, conventional radiography does not enable to monitor facial and lingual/palatal bone levels (Photo 1) around the implants being insensitive in detecting early bone changes and underestimating bone loss.10,11 In clinical situa-tions, cases where suppuration is found only on the buccal side or lingual/palatal sites, cases with BOP, or cases with advanced bone resorp-tion on the buccal and lingual/palatal sites are often experienced (Fig. 1). The aim of this study was to clarify the occurrence regions and sites of peri-implant bone resorption and inflamma-tion in Japanese partially-edentulous patients.

Photo 1: Dental implant with significant facial bone loss.


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MAtERIAl AnD MEthODS The present clinical study was approved by the Ethical Committee, Faculty of Dentistry, Tokyo Medical and Dental University, and the writ-ten informed consents were obtained from all the patients. Subjects were 501 partial eden-tulous Japanese patients (738 implants) who received superstructure more than 5 years ago. All the patients who had implants inserted and superstructures made at Dental Hospital, Tokyo Medical and Dental University, between 1999 and 2006, were examined. Severe illness, uncontrolled diabetes, untreated periodontal disease and a history of head and neck radia-tion were excluded from the analysis. Probing pocket depth (PPD) and bleeding on probing (BOP) in the peri-implant sulcus where bone resorption was observed on the dental radio-graph were explored with the 4-point method. In addition, the mean height of vertical bone defects at the both sites of the mesial and distal areas of implants was measured from the den-

tal radiographic evaluation at least 1 year after the placement of the superstructures, since the reference time point should be considered of the bone remodeling within one year after load-ing. In the radiographs the distance between the reference point and the most coronal posi-

Figure 1: Frequent implant regions. Figure 2: Frequent implant sites of inflammation in maxillary molar region.

Figure 3: Frequent implant sites of inflammation in mandible molar region.

56 • Vol. 6, No. 3 • June 2014

tion of bone to implant contact was assessed at the both of mesial and distal aspects of the 76 implants using a magnifying lens (×10) with a 0.1mm graded scale. Peri-implantitis was diag-nosed when the bone resorption was pictured as 2 mm or larger on dental radiograph and further BOP was observed in the peri-implant sulcus.

Data Analyses ● Reference of peri-implantitis in different

four regions● Examination of BOP in implant sites● Man-Whitney U-test was conducted for

comparisons between different regions and sites. A p-value less than 0.05 was considered statistically significant. All statistical analyses were performed using the IBM SPSS Statistics.21

RESultS Peri-implantitis was diagnosed in 65 patients (76 implants) of the 501 patients (738 implants). The patient related prevalence rate of peri-implantitis was 13.0% (smokers history: 25%). The implant related prevalence rate of peri-implantitis was 10.3%.

Forty-two women and 23 men of 65 peri-implan-titis were included in this study with the mean age of 62.5 years. The mean time period after the place-ment of the superstructure was 8.4 years. The mean bone resorption in peri-implantitis was 3.8 ± 1.5 mm. The mean PPD was 5.6 ± 1.5 mm (Table 1).

Occurrence regions were frequently found in the molar regions in maxilla (15.4%, p < 0.01) and the molar region in mandible (10.0%) (Fig. 2).

BOP around implant sites was observed in the buccal sites of the molar regions in man-dible with 95.2% of the rate (p < 0.01), and in the palatal and buccal sites of the molar

Figure 4: Morphological change of the bone due to peri-implantitis in a case with sufficient width. Saucer-shaped bone resorption occurs evenly toward the mesio-distal and bucco-lingual directions.

Figure 5: Morphological change of the bone due to peri-implantitis in a case with insufficient width. Defect of the bucco-lingual bone wall and thread exposure are induced during the process of developing saucer-shaped bone resorption.

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regions in maxilla with 70.0%(p < 0.01) and 56.7%(p < 0.01) of the rate, respectively (Fig. 3).

DISCuSSIOnOccurrence regions and sites, usefulness of radiographyFransson et al 12 reported that peri-implantitis was found in about 40% of implants in a 5- to 23-year observation period. As for regions of onset, the rate in the maxillary molar region was as low as 30% and 52% in the mandibular molar region. They reported that implants placed in the anterior region

were vulnerable regardless of the failure pattern.The present study resulted in very frequent

onsets molar regions in the maxilla and mandibular where plaque control is difficult, similar to that in nat-ural teeth. The different results were found possibly because Fransson et al studied the peri-implantitis rate in total implants including healthy implants, the rate of implant-supported fixed complete dentures (FCD) without remaining tooth was remarkably high (74%), and bone loss in 3 threads or more and PPD of 6 mm or more were classified as peri-implantitis.16

The presence of BOP, suppuration, and peri-

Figure 6: Decision tree for the diagnosis of peri-implant bone loss.

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58 • Vol. 6, No. 3 • June 2014

No. of patients 65

Mean Age 62.5

No. of Female 48

% of smokers 25

% of diabetes 12

No. of implants 76

Time in function (year) 8.4±3.1

Probing depth (mm) 5.6±1.5

Bone loss (mm) 3.8±1.5

Table 1: Subject Data

implant bone resorption found by radiographic evaluation are listed as clinical diagnosis of peri-implantitis. Radiographic evaluation is indis-pensable for a definite diagnosis, among others, although the use of panoramic tomography and intra-oral radiograph, which are broadly used in clinical settings, does not allow the evaluation of the bucco-palatal bone levels, but only for the observa-tion of mesio-distal bone absorption. Furthermore, the evaluation with CT or cone beam radiography allows no accurate evaluation because of the metal artifacts from implant body and superstructure. Isidor et al reported the development of the saucer-shaped bone resorption in the implant in the plaque group.13 However, it is believed that the saucer-shaped bone resorption occurs in cases with large buccolingually-wide ridge, while the decent lin-gual/palatal thread exposure of the implant surface occurs during the development process of saucer-shaped bone resorption in cases with a narrow ridge (Figs. 4,5). Thus, particularly, the buccopala-tal bone resorption even with light or no mesiodistal

bone resorption or sometimes severe bone resorp-tion were frequently observed in the cases with a narrow pyramid-shape ridge. Moreover, DeSmet et al reported that the conventional radiograph included the inability to monitor both of the facial and lingual/palatal bone levels, the low sensitivity for the detection of early bone changes, and the underestimation of bone loss around implants.11 In the present study, the implant sites with BOP were examined to observe a number of BOP in the buccal sites of mandibular molar regions and the bucco-palatal sites of maxillary molar regions. Possible reasons for the frequent BOP are narrow ridge that may be found in cases with the mandibu-lar molar region BOP often inducing buccal thread exposure at the time of implantation surgery, great buccolingual thread exposure that tends to occur when saucer-shaped bone resorption occurs in cases with a narrow bone, and small immobilized mucosa. Problems in buccal immobilized mucosa for the maxillary molars and palatal mucosa thicker than other mucosa with little changes in muco-sal thickness in response to placement of upper structure were considered vulnerability to inflam-mation. These facts also suggest that dental radi-ography is not always useful in the early diagnosis of peri-implantitis. We would like to continue to develop the measurement that allows the diagno-sis of buccal and lingual/palatal bone resorption and its severity other than radiography in the future.

Proposal of Decision tree for the Diagnosis and Management of Peri-implant Bone lossPeri-implantitis is one of the main concerns in implant therapy. The management of peri-implant bone loss is still challenging because of its diffi-culty and unpredictability. To manage peri-implant diseases properly, a decision tree that can be

Munakata et al


used as a guide to assist clinicians in dealing with this increasing challenge was developed. To treat this problem properly, clinicians have to identify the extent of bone loss at the first. The more bone resorption increases, the more dif-ficult the replacement of implants will be due to the anatomical problems. Remaining bone quantity associated with the implants under the continu-ous bone resorption should also be considered because a number of reports on the prognosis for short implants have been published, such as a review by Renouard reporting that the use of implants with a coarse surface resulted in high success rates with 94.6% to 99.4% survival rates of implants with lengths less than 10 mm.14 Fur-thermore, a review by Telleman et al reported that the survival rate of short implants with 5 to 9.5 mm length was 93.1% to 98.6% in partial failure patients.15 Thus, the decision tree was developed by defining 5 mm of remaining bone length as the criteria, because we consider it is appropriate that the decision whether clinicians has to remove the implant based on the premise of re-implan-tation or to conduct conservative therapy should be based on the remaining bone height (Fig.6).

In such situations as either remaining bone height with less than 5 mm or the movement of implants, the re-insertion of implants with the bone augmentation following the removal of the implant and the site development is highly recom-mended, regardless of implant length. Although this condition can also be treated with guided bone regeneration, according to the literature, it is very difficult to regain osseointegration.

In regard to implants with remaining bone height with more than 5 mm, it is recommend examining the amount of bone loss. Also, it is suggested to diagnose the bone loss with less

than 2 mm as light, with between 2 mm and 5 mm as moderate, and more than 5 mm as severe.

Renvert et al stated in their review, “In peri-implantitis lesions non-surgical therapy was not found to be effective.16 Adjunctive chlorhexidine application had only limited effects on clinical and microbiological parameters. However, adjunc-tive local or systemic antibiotics were shown to reduce bleeding on probing and probing depths. Minor beneficial effects of laser therapy on peri-implantitis have been shown; this approach needs to be further evaluated.” Thus, surgical treatment is considered necessary in current therapies even in mild cases. Implant surface decontamination and regenerative procedures are considered important in surgical treatment. However, there are a variety of different procedures with different success rates without a definitely established therapeutic proce-dure.17 Thus, our decision tree involves no therapy. Our study will clarify such issues in the future.

COnCluSIOn From the limitation of the information in this study, it was concluded that the sites that tend to be vulnerable to peri-implant inflam-mation were the buccal site in mandible, and the buccal and palatal sites in maxilla. ●

Correspondence:Motohiro Munakata, DDS, Ph.DOral Implantology and Regenerative Dental Medicine, Tokyo Medical and Dental University, Tokyo, Japan. 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, JapanPhone: +81-3-5803-4664FAX: +81-3-5803-4664E-mail: [email protected]

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60 • Vol. 6, No. 3 • June 2014

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

References1. Ivan Steenberghe D, Quirynen M, Naert I. Survival and success rates with

oral endosseous implants. Proccedings of the 3rd European Workshop on Periodontology. Berlin,Quintessence Books, 1999:242–254.

2. Roos-Jansåker A-M, Lindahl C, Renvert H, Renvert S. Nine- to fourteen-year follow-up of implant treatment. Part II: presence of peri-implant lesions. Journal of Clinical Periodontology. 2006;33(4):290–295.

3. Quirynen M, De Soete M, van Steenberghe D. Infectious risks for oral implants: a review of the literature. Clin Oral Impl Res. 2002;13(1):1–19.

4. Shibli JA, Marcantonio E, d’Avila S, Guastaldi AC, Marcantonio EJ. Analysis of failed commercially pure titanium dental implants: a scanning electron microscopy and energy-dispersive spectrometer x-ray study. Journal of Periodontology. 2005;76(7):1092–1099.

5. Mombelli A. Prevention and therapy of periimplant infections. Proccedings of the 3rd European Workshop on Periodontology. Berlin, Quintessence Books, 1999:281–303.

6. Lindhe J, Meyle J. Peri-implant diseases: Consensus Report of the Sixth European Workshop on Periodontology. Journal of Clinical Periodontology. 2008;35(8 Suppl):282–285.

7. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. Journal of Clinical Periodontology. 2008;35(8 Suppl):286–291.

8. Heitz-Mayfield LJA. Peri-implant diseases: diagnosis and risk indicators. Journal of Clinical Periodontology. 2008;35(8 Suppl):292–304.

9. Kullman L, Al-Asfour A, Zetterqvist L, Andersson L. Comparison of radiographic bone height assessments in panoramic and intraoral radiographs of implant patients. Int J Oral Maxillofac Implants. 2007;22(1):96–100.

10. Braegger U, Pasquali L, Weber H, Kornman KS. Computer-assisted densitometric image analysis (CADIA) for the assessment of alveolar bone density changes in furcations. Journal of Clinical Periodontology. 1989;16(1):46–52.

11. De Smet E, Jacobs R, Gijbels F, Naert I. The accuracy and reliability of radiographic methods for the assessment of marginal bone level around oral implants. Dentomaxillofacial Radiology. 2002;31(3):176–181.

12. Fransson C, Wennstrom J, Tomasi C, Berglundh T. Extent of peri-implantitis-associated bone loss. Journal of Clinical Periodontology. 2009;36(4):357–363.

13. Isidor F. Histological evaluation of peri-implant bone at implants subjected to occlusal overload or plaque accumulation. Clin Oral Impl Res. 1997;8(1):1–9.

14. Renouard F, Nisand D. Impact of implant length and diameter on survival rates. Clin Oral Impl Res. 2006;17 Suppl 2:35–51.

15. Telleman G, Raghoebar GM, Vissink A, Hartog den L, Huddleston Slater JJR, Meijer HJA. A systematic review of the prognosis of short (. Journal of Clinical Periodontology. 2011;38(7):667–676.

16. Renvert S, Roos-Jansåker A-M, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: a literature review. Journal of Clinical Periodontology. 2008;35(8 Suppl):305–315. doi:10.1111/j.1600-051X.2008.01276.x.

17. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. Journal of Clinical Periodontology. 2008;35(8 Suppl):316–332.

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