Sinus Membrane Perforation Repair - pub html5online.pubhtml5.com/tyce/wbra/wbra.pdf · Sinus...

The Journal of Implant & Advanced Clinical Dentistry

Volume 6, No. 8 NoVember 2014

Sinus Membrane Perforation Repair

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High initial stability, even in compromised

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Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

NobelActive equally satisfies surgical and restorative clinical goals. NobelActive thread design progressively condenses bone with each turn during insertion, which is designed to enhance initial stability. The sharp apex and cutting blades allow surgical clinicians to adjust implant orientation for optimal positioning of the prosthetic

connection. Restorative clinicians benefit by a versatile and secure internal conical prosthetic connec-tion with built-in platform shifting upon which they can produce excellent esthetic results. Based on customer feedback and market demands for NobelActive, theproduct assortment has been expanded – dental professionals will

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 8 • NoVember 2014

Table of Contents

Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

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11 Open Sinus Lift Healing Comparison between a Non-Perforated Schneiderian Membrane and a Perforated Schneiderian Membrane Repaired with Amnion-Chorion Allograft Barrier: A Controlled, Split Mouth Case Report Dr. Dan Holtzclaw

23 Implant Placement Emulating Natural Esthetics: Appropriate Diagnosis, Treatment Planning and Communication Tak On Ryan Tse

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

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

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

Co-Editor in ChiefNick Huang, MD

The Journal of Implant & Advanced Clinical Dentistry

Holtzclaw

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Background: Schneiderian membrane perfora-tion is the most common complication of maxil-lary sinus augmentation and has been associated with a variety of post-surgical problems including infections, failed grafts, and grafts of inadequate magnitude to facilitate the placement of dental implants. The effects of perforated Schneiderian membranes can be somewhat mitigated through repair with a variety of different membrane mate-rials. A number of studies have presented data comparing dental implant success with repaired Schneiderian membranes to non-perforated membranes, but no studies have shown a direct split-mouth comparison within a single sub-ject. The following Case Report shows a single patient who received bilateral maxillary sinus lifts in which one side was unintentionally perforated and repaired with amnion-chorion barrier while the other side was non-perforated. Complications, implant survival, clinical, and radiographic heal-ing comparisons are presented and discussed.

Methods: In a single patient, bilateral maxillary sinus lifts were performed via the lateral window method. Both sinuses were treated in the same exact fashion. During instrumentation for sinus membrane elevation, the right sinus membrane was unintentionally perforated and repaired with an amnion-chorion barrier while the left sinus mem-brane was not perforated. Both sinuses were then grafted with a combination of bone xenograft/

allograft and the lateral windows were covered with amnion-chorion membranes. After four months of healing, a cone beam computed tomography scan was utilized to assess the results of healing and plan a guided dental implant surgery. Following place-ment of dental implants, the case was immediately loaded with a transitional prosthesis for four months and ultimately restored with a zirconia restoration.

Results: The non-perforated sinus lift healed with more bone height and a denser, more uni-form fill compared to the sinus lift repaired with amnion-chorion barrier. Both sides, however, had adequate healing to permit placement of multiple dental implants to support an immediately loaded restoration. After two years of function, implants in both sinuses have demonstrated zero compli-cations and the prosthesis is functioning well.

Conclusions: This is the first known study to document direct healing comparisons between a repaired perforated maxillary sinus membrane versus a non-perforated sinus membrane when sinus augmentations were performed in the same person at the same time. Amnion-chorion barriers have unique properties that make them ideal for repair of perforated maxillary sinus membranes. This direct split mouth comparison Case Report demonstrates that these barriers can produce healing results that allow for long term func-tioning of dental implants without complication.

Open Sinus Lift Healing Comparison between a Non-Perforated Schneiderian Membrane and a Perforated Schneiderian Membrane Repaired with

Amnion-Chorion Allograft Barrier: A Controlled, Split Mouth Case Report

Dan Holtzclaw, DDS, MS1

1. Consultant Faculty, Department of Periodontics, US Naval Post-Graduate Dental School, Bethesda, Maryland, USA. Private Practice, Austin, Texas, USA

Abstract

KEY WORDS: Maxillary sinus, sinus floor augmentation, nasal mucosa, dental implants, amnion, chorion


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INTRODUCTIONPneumatization of the maxillary sinus is a com-mon finding with edentulism of the posterior maxilla and often requires augmentation to facili-tate the placement of dental implants.1 Perfora-tion of the Schneiderian membrane is the most common complication associated with maxil-lary sinus augmentation procedures2 with rates ranging from 11% to 56%.3,4 Multiple tech-niques have been presented in dental literature for repair of perforated sinus membranes includ-ing the use of palatal flaps,5 buccal fat pads,6 Lambone,7 specialized suturing techniques,8 and fixed membrane pouches.9,10 With excessively large perforations, however, reparative techniques are sometimes not feasibly and the procedure must be aborted. When sinus membrane repair is achievable, these studies, and multiple other conformational studies,11-13 show that perforation and subsequent repair of the Schneiderian mem-brane does not compromise the final success of dental implant survival. None of these studies5-13 however, show any cases with direct split-mouth

intrapatient healing comparisons of repaired per-forated sinus membranes versus non-perforated sinus membranes. This Case Report presents a situation in which a patient receiving bilateral max-illary sinus lifts had perforation and repair of one sinus membrane while the other side remained intact. With these sinus lifts being performed in the same patient at the exact same time, a unique opportunity presented itself for direct observation and comparison of healing results for a repaired versus a non-perforated sinus lift and the dental implant survival that followed.

METHODSA 52 year old Caucasian female was referred to our periodontal specialty clinic for evaluation and treatment of long standing chronic periodontal disease. Over the past fifteen years, the patient had undergone a variety of procedures to treat her

Figure 1: Presurgical CBCT scan of patient showing bilateral pneumatized maxillary sinuses and severe bone loss secondary to periodontal disease.

Figure 2: Presurgical CBCT scan showing minimal bone thickness in the maxillary anterior sextant.


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condition including non-surgical scaling and root planing, open flap debridement, bone grafting with guided tissue regeneration, and three month peri-odontal maintenance. In spite of these efforts and the patient’s meticulous home oral hygiene mea-sures, she continued to have pocket depths rang-ing from 2-8mm with excessive mobility in many of her teeth, particularly in the maxilla. Although the mandible demonstrated moderate to severe horizontal bone loss from her past history of peri-odontal disease and surgical procedures, prob-ing depths in this arch only ranged from 2-5mm and tooth mobility, although present, was not as significant as that seen in the maxilla. The patient was frustrated with the continued deterioration of her periodontal condition, the esthetics of her maxillary teeth, and her inability to eat many foods due to the excessive mobility of her maxillary teeth. After discussing multiple treatment options with

the patient, she requested to have dental implant restoration of her maxillary arch. While it would have been more ideal to treat both the maxillary and mandibular arches simultaneously, the patient elected for treatment of only the maxillary arch. The patient did express that she would like to have the mandibular arch treated in a similar fashion to the maxilla in the future when her finances permitted.

To accommodate the patient’s desires for a dental implant supported fixed restoration of the maxilla, the patient’s significant bone deficien-cies had to be addressed. A cone beam com-puted tomography (CBCT) scan revealed that the patient not only had significantly pneumatized maxillary sinuses bilaterally (Figure 1), she also had minimal bone height and width in the ante-rior maxillary sextant (Figures 2, 3). Because of these findings, it was decided that bilateral maxil-lary open sinus lifts would be performed to gain as much bone height as possible in the posterior and mid maxilla. Once these bone augmenta-tions healed, the patient would receive an addi-tional CBCT scan and a guided dental implant surgery would be planned with at least 3-4 dental implants being placed into each augmented sinus.

The first procedure involved extraction/site preservation of teeth 2, 3, 4, 13, 14, and 15 with simultaneous bilateral maxillary sinus lifts. Because these sinus augmentations were going to heal for at least 4-5 months prior to the sec-ond surgical phase, teeth 5-12 were left in place at the patient’s request to “give me something to smile and chew with while everything is heal-ing.” Although the option of a temporary complete denture was offered to the patient, she declined noting that she did not want to wear any remov-able prostheses at any time during her treatment. Following the administration of local anesthesia

Figure 3: Presurgical CBCT scan (alternate view) showing minimal bone thickness in the maxillary anterior sextant.

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and intravenous conscious sedation, full thickness mucoperiosteal flaps were elevated bilaterally and teeth 2, 3, 4, 13, 14, and 15 were elevated/extracted. Following removal of these teeth, all sockets were degranulated with hand instru-ments and sharp bony spurs were recontoured with a rotary bur. For the sinus lift procedures, a piezoelectric hand piece (DoWell Dental, Cali-

fornia, USA) was utilized to create a lateral win-dow into both the left and right maxillary sinuses. Next, piezoelectric sinus elevation tips were uti-lized to begin elevation of the Schneiderian mem-branes. After initial mobility of the Schneiderian membranes were achieved, hand instrumentation was used to perform the remainder of the sinus membrane elevation. While the left Schneiderian

Figure 4: Large perforation of Schneiderian membrane in the right maxillary sinus.

Figure 5: Amnion-Chorion barrier placed onto sinus membrane perforation. Note that no stabilizing sutures are required as the barrier self-adheres to the Schneiderian membrane.

Figure 7: Amnion-Chorion barrier used to cover the lateral access window and grafted sockets.

Figure 6: Placement of bone xenograft/allograft combination into the maxillary sinus and extraction sockets.


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membrane was elevated without complication, a large perforation occurred (Figure 4) during elevation of the right sinus membrane. To repair the sinus membrane perforation, a large piece of amnion-chorion barrier (BioXclude, Snoasis Medi-cal, Denver, Colorado, USA) was placed directly onto the Schneiderian membrane (Figure 5). Care was taken to make sure that the amnion-chorion

barrier completely covered the sinus membrane perforation with extension of the barrier at least 3mm beyond the lateral borders of the defect. The amnion-chorion barrier was initially placed into the maxillary sinus dry (non-hydrated) which allowed for easy manipulation and movement of the barrier. Once placed into the desired position, the patient’s own blood was utilized to hydrate

Figure 8: Placement of eight dental implants with multi-unit abutments and white healing caps.

Figure 9: Immediately loaded maxillary transitional prosthesis.

Figure 11: Final zirconia restoration after delivery.Figure 10: Final zirconia restoration prior to delivery.

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Figure 12: Presurgical CBCT scan prior to maxillary sinus augmentations (coronal view).

Figure 13: Postsurgical CBCT scan after maxillary sinus augmentations (coronal view).

Figure 14: Presurgical CBCT scan prior to maxillary sinus augmentations (transverse view).

Figure 15: Postsurgical CBCT scan after maxillary sinus augmentations (transverse view).


Holtzclaw

Figure 16: Postsurgical CBCT scan after maxillary sinus augmentation (transverse view) showing radiolucent area in the right sinus where Schneiderian membrane perforation occurred.

Figure 17: Presurgical CBCT scan of left maxillary sinus showing sinus pneumatization.

Figure 19: Presurgical CBCT scan of right maxillary sinus showing sinus pneumatization.

Figure 18: Postsurgical CBCT scan of the left maxillary sinus showing bone fill at 120 days.

the amnion-chorion barrier. Upon hydration, the amnion-chorion barrier became very tacky and self-adhered to the Schneiderian membrane, thus eliminating any need for stabilizing sutures. Fol-lowing repair of the perforated sinus membrane, a mixture of bone xenograft (Bio-Oss, Geistlich Pharma North America, Princeton, New Jersey,

USA) and bone allograft (Maxxeus, Dallas, Texas, USA) was placed into the sinus cavity (Figure 6) and the lateral windows were covered (Figure 7) with amnion-chorion barriers (BioXclude, Snoasis Medical, Denver, Colorado, USA). The mucoperi-osteal flaps were then reapproximated with 4-0 polytetrafluoroethylene sutures. Post-surgically,

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Figure 20: Postsurgical CBCT scan of the right maxillary sinus showing bone fill at 120 days.

Figure 21: Radiograph of dental implants and final restoration immediately after initial delivery.

Figure 23: Final restoration after 2 years in function (intraoral view).

Figure 22: Final restoration after 2 years in function (extraoral view).

the patient was prescribed pain medications, anti-biotics, and steroids. The patient was seen for follow-up visits at 10, 21, 42, 90, and 120 days.

After 120 days of uneventful healing, the patient was sent for a CBCT scan. The CBCT scan was evaluated for healing of the bilateral sinus augmentations and a guided surgical stent was planned (NobelGuide™, Nobel Biocare, Yorba Linda, California, USA). The second surgi-


Holtzclaw

Figure 24: Radiograph of dental implants and final restoration after 2 years of function.

cal procedure was carried out 150 days after the original surgical procedure. Following the admin-istration of local anesthesia and intravenous con-scious sedation, all remaining maxillary teeth were extracted and the surgical guide was affixed with three strategically placed pins. A total of 8 den-tal implants (NobelActive, Nobel Biocare, Yorba Linda, California, USA) were placed utilizing the surgical guide. Following removal of the guide, multi-unit healing abutments were placed on all implants with 15 Ncm of torque and white heal-ing caps were screwed into the abutments (Fig-ure 8). The patient was then released to the prosthodontist who adjusted and delivered an immediately loaded full-arch transitional prosthe-sis (Figure 9). The patient wore the transitional prosthesis for four months and then received a zirconia final restoration (Figures 10, 11).

RESULTSThe patient healed uneventfully and reported no differences in pain or other symptoms between the two sinuses. The CBCT scan taken at 120

days was compared to the pre-surgical CBCT scan for healing evaluation and comparison of the non-perforated augmented sinus versus the perforated repaired augmented sinus. In gen-eral, the non-perforated sinus showed a more dense bone fill compared to the repaired perfo-rated side (Figures 12-15). When the area of the repaired sinus membrane perforation was exam-ined in a transverse view via the CBCT scan, a well-defined radiolucent area was clearly visible (Figure 16). The non-perforated sinus had more bone fill vertically than the repaired perforated side (Figures 17-20). Although the repaired sinus did not achieve bone fill as robust or dense as the non-perforated side, adequate bone was still present for the placement of dental implants which were 11.5mm in length (Figure 21). All den-tal implants achieved at least 35 Ncm of torque at placement and allowed for immediate load-ing of a transitional prosthesis. The transitional prosthesis was placed in function for a total of four months without complication prior to the fabrication and delivery of a zirconia final resto-ration. After two years in function with the zirco-nia restoration, the patient has experienced no complications (Figures 22, 23). Comparisons of bone levels around the dental implants after two years in function revealed no difference in bone loss between the repaired perforated side versus the non-perforated side (Figure 24).

DISCUSSIONMultiple studies have demonstrated that it is pos-sible to repair perforated maxillary sinus mem-branes and still achieve later success with dental implants.5-10 These studies base their conclu-sions on success comparing perforated versus

20 • Vol. 6, No. 8 • November 2014

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non-perforated cases in different individuals. While these studies demonstrate that repaired perforated sinus membranes do allow for den-tal implant success in augmented sinuses, they do not show direct healing comparisons to non-perforated membranes. Do non-perforated sinuses heal with more bone than repaired per-forated sinuses? Do non-perforated sinuses heal with denser bone fills than repaired perfo-rated sinuses? The present case report is unique because it shows direct split mouth healing com-parisons in the same person with procedures performed at the exact same time. Addition-ally, this study is unique in the fact that it shows repair of a perforated Schneiderian membrane with an amnion-chorion barrier. To the author’s knowledge, this is the first study to demonstrate repair of a sinus membrane with such a material.

Amnion-chorion barriers inherently possess a number of unique properties that make them suitable candidates for repair of sinus membrane perforations. First and foremost, amnion-chorion barriers are extremely thin averaging approxi-mately 300 µm in cross sectional thickness14 compared to Schneiderian membranes that can average as little as 800µm in thickness.17 The thin nature of amnion-chorion barriers makes them easy to place into tight maxillary sinuses and their self-adherent properties upon hydration eliminates the need for stabilization with sutures8 or tacks9,10 as is required with previously published methods. Additionally, the translucency of amnion-chorion barriers makes it easy to see if the sinus mem-brane perforation has been completely covered (Figure 5). Amnion-chorion barriers also contain a variety of proteins including collagen types I, III, IV, V, and VI, laminin-5, platelet-derived growth factor-a (PDGF-a), PDGF-b, fibroblast growth

factor; and transforming growth factor-b that help to facilitate wound healing.18 A recently published study utilizing amnion-chorion barriers for guided tissue regeneration of periodontal defects noted rapid epithelial granulation coverage of exposed graft material14 while an additional study in which amnion-chorion barriers were intentionally left exposed to the oral cavity showed similar findings of rapid epithelial granulation formation over graft material.15 Both of these studies suggest that the various proteins found in amnion-chorion barriers, Laminin-5 in particular, may be responsible for this rapid epithelial granulation formation. Laminin-5 is an extracellular matrix component prominent in basement membranes and has been shown to stimulate epithelial cell migration.19 Immunohis-tochemical analysis of amnion-chorion barriers used for dental applications such as those pub-lished for guided tissue regeneration and extrac-tion site preservation have shown extremely high concentrations of Laminin-5.20 It is possible that the high concentration of Laminin-5 found in amnion-chorion barriers is contributing factor to the rapid epithelial granulation formation seen with the previously published guided tissue regenera-tion and extraction site preservation studies. As the Schneiderian membrane is epithelial in nature, repair of perforations in this membrane via amnion-chorion barriers provides a bioactive matrix sub-strate across which epithelial cells of the host sinus membrane may rapidly migrate across.

CONCLUSIONS While repaired perforated Schneiderian mem-branes do allow for successful placement and ulti-mate survival of dental implants, bone fill and bone density in these augmented sinuses do not appear to be as robust as that which is seen in non-perfo-


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rated maxillary sinuses. Although the quantity and quality of bone in non-perforated augmented max-illary sinuses appears to be superior to that which is seen in repaired perforated augmented maxillary sinuses, implant success does not appear to differ between the two. In the end, dental implant sur-vival is the true measure of success as the goal of the surgery is long term surviving dental implants.

Finally, this case report demonstrates that amnion-chorion barriers are uniquely suited for the repair of perforated maxillary sinus membranes. ●

Correspondence:Dan Holtzclaw, DDS, [email protected]

DisclosureDr. Holtzclaw is on the Clinical Advisory Board of Snoasis Medical and has a financial interest in the company.

References:1. Sharan A, Madjar D. Maxillary sinus

pneumatization following extractions: A radiographic study. Int J Oral Maxillofac Implants 2008; 23:48-56.

2. Toscano N, Holtzclaw D, Rosen P. The effect of piezoelectric use on open sinus lift perforation: A retrospective evaluation of 56 consecutively treated cases from private practices. J Periodontol 2010; 81(1):167-171.

3. Proussaefs P, Lozada J, Kim J, Rohrer M. Repair of perforated sinus membrane with resorbable collagen membrane: A human study. Int J Oral Maxillofac Implants 2004; 19(3):413-420.

4. Hernandez-Alfaro F, Torradeflot MM, Marti C. Prevalence and management of Schneiderian membrane perforations during sinus lift procedures. Clin Oral Implants Res 2008; 19:91-98.

5. Gehrke S, Taschieri S, Del Fabbro M, Corbella S. Repair of a perforated sinus membrane with a subepithelial palatal conjunctive flap: Technique report and evaluation. Int J Dent 2012;12:1-7.

6. Kim Y, Hwang J, Yun P. Closure of large perforation of sinus membrane using pedicled buccal fat pad graft: A case report. Int J Oral Maxillofac Implants 2008; 23(6):1139-1142.

7. Shlomi B, Horowitz I, Kahn A, Dobriyan A, Chaushu G. The effect of sinus membrane perforation and repair with Lambone on the outcome of maxillary sinus floor augmentation: a radiographic assessment. Int J Oral Maxillofac Implants 2004; 19(4):559-562.

8. Clemintini M, Ottria L, Pandolfi C, Bollero P. A novel technique to close large perforations of sinus membrane. Oral Implantol 2013; 6(1):11-14.

9. Fugazzotto P, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol 2003; 74(10):1534-1541.

10. Testori T, Wallace S, Del Fabbro M, Taschieri S, Trisi P, Capelli M, Weinstein R. Repair of large sinus membrane perforations using stabilized collagen barrier membranes: Surgical techniques with histologic and radiographic evidences of success. Int J Periodontics Restorative Dent 2008; 28(1):9-17.

11. Froum S, Khouly I, Favero G, Cho SC. Effect of maxillary sinus membrane perforation on vital bone formation and implant survival: A retrospective study. J Periodontol 2013; 84(8):1094-1099.

12. Ardekian L, Oved-Peleg E, Mactei EE, Peled M. The clinical significance of sinus membrane perforation during augmentation of the maxillary sinus. J Oral Maxillofac Surg 2006; 64(2):277-282.

13. Karabuda C, Arisan V, Ozyucaci H. Effects of sinus membrane perforations on the success of dental implants placed in augmented sinuses. J Periodontol 2006; 77(12):1191-1997.

14. Holtzclaw D, Toscano N. Amnion–Chorion Allograft Barrier Used for Guided Tissue Regeneration Treatment of Periodontal Intrabony Defects: A Retrospective Observational Report. Clin Adv Periodontics 2013; 3(3):13-137.

15. Holtzclaw D. Extraction site preservation using new graft material that combines mineralized and demineralized allograft bone: a case series report with histology. Compend Contin Educ Dent 2014; 35(2):107-112.

16. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Maxillofac Implants 1986;1:11–25.

17. Pommer B, Dvorak G, Jesch P, Palmer R, Watzek G, Gahleitner A. Effect of maxillary sinus floor augmentation on sinus membrane thickness in computed tomography. J Periodontol 2012; 83(5):551-556.

18. Chen E, Tofe A. A literature review of the safety and biocompatibility of amnion tissue. J Implant Adv Clin Dent 2010; 2(3):67-75.

19. Hintermann E, Quaranta V. Epithelial cell motility on Laminin-5: Regulation by matrix assembly, proteolysis, integrins, and erbB receptors. Matrix Biol 2004;23(2):75-85.

20. Xenoudi P, Lucas M. Immunohistochemistry Analysis of Amnion Chorion and Porcine Membranes. Poster presentation 146797, Annual Meeting of the International Association of Dental Research, March 16-19, 2011, San Diego, CA.

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Achieving excellent esthetic outcomes after extraction and implant replacement in the esthetic zone is one of the biggest

challenges for the cosmetic dentist. The problem is amplified in cases where immediate implant placement is indicated after extraction of the fail-ing tooth as the resorption of the bundle bone can result in mucosal recession after immedi-

ate implant placement. The margin of error has to be decreased by meticulous planning. Accu-rate diagnosis and treatment planning with 3D implant placement and close communication with the ceramist are keys to a successful outcome. In this article implant placement and immedi-ate provisionalization as well as laboratory com-munication and final restoration are discussed.

Implant Placement Emulating Natural Esthetics: Appropriate Diagnosis, Treatment

Planning and Communication

Tak On Ryan Tse, BDS, MFGDP, MGD, MsC1

1. Private practice, Hong Kong

Abstract

KEY WORDS: Dental implant, immediate placement, esthetics, prosthetics, case report


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INTRODUCTION Extraction and implant placement has proven to be a predictable treatment with regards to surgical success but the esthetic outcome of implants in the esthetic zone continues to be a challenge.1,2 Staging of implant placement was proposed and classified by Hammerle in 20043 as immediate implant placement, early and delayed implant placement depending on the days of implant placement. Immediate implant placement was first presented by Schulte et

al in 19784 and recommended by Lazzara in 19895 and others.6,7 This procedure is can be used in esthetic zone but some studies ques-tion it is a suitable method for esthetic success.

From a patient’s point of view immediate placement procedures reduce treatment time, number of surgeries required and add psycho-logical value as the patient receives a provisional immediately.. Some authors have also claimed that immediate implant placement provides numerous advantages: Reduction of post extrac-

Figure 1a: Pre-operative extraoral photo. Figure 1b: Pre-operative extraoral smile photo. .

Figure 2: Pre-operative intra-oral photo. Figure 3: Pre-operative intra-oral lateral view.


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tion ridge resorption, better maintenance of the buccal plate, and as a consequence improved tissue esthetics and papilla preservation by pre-venting unfavorable soft tissue changes resulting from changes of crestal bone (Lazzara 1989)5

Kan et al 20078 and Chen et al 20079 dis-agreed and opined that immediate implant will result in mucosal recession. In an animal study in dogs, Araujo et al 2005,200610,11 have shown that immediate implant placement failed to pre-serve the hard tissue dimension of the ridge fol-

lowing extraction. The buccal as well as the lingual bone walls resorbed. On the buccal aspect this phenomenon even resulted in slight loss of bony osseointegration. The paper concluded that the ridge alteration progressed following extraction as bundle bone structure resorbs irre-spective of therapy and results in mucosal reces-sion which affects the esthetic outcome.12-15

Delayed implant placement and various ridge preservation techniques have been suggested to minimize ridge resorption before implant place-

Figure 4: Pre-operative occlusal view. Figure 5: Pre-operative radiograph.

Figure 6: Tooth #9 oblique fracture. Figure 7: Tooth #9 fractured restoration.

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ment. Clinical studies16 and experimental animal studies17-19 have shown that the dimension of the alveolar process as well as the profile of the ridge could be better preserved this way. In order to minimize buccal tissue recession, immediate bone grafting is proposed by some authors to fill the gap between the implant and the labial bone plate.20 Bio-oss particles(Geistlich Pharma AG)is a bovine bone material with slow resorption rate.

It have been shown to be the best option and can significantly reduce horizontal resorption of buc-cal bone and preserve 70% of the labial bone.21 The platform switching concept adds further advantage to preserve crestal bone and achieving more predictable long-term soft tissue levels.22-24

In this article, the author describes a case utilizing immediate implant place-ment in combination with a platform switched

Figure 8: The socket after extraction with granulation tissue at the distal side.

Figure 9: The implant was with placed abutment installation to the immediate implant at slight palatal position.

Figure 10: The socket was filled with bovine xenograft. Figure 11: Provisional crown placement.


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implant and various preservation tech-niques for an optimized esthetic outcome.

CASE REPORT A 45 years old male patient with an unremark-able medical history presented in the office with a cosmetic chief concern complain-ing about a protruded upper left central inci-sor with spacing (Fig 1a&b). The tooth #9 had

fractured due to an accident 20 years ago and had been root canal treated and crowned.

CLINICAL EXAMINATION AND DIAGNOSTIC FINDINGS

The patient presented with very mild general-ized horizontal bone loss and was classified as an AAP Type II patient. The gingival margin of tooth #9 was incisal to the contralateral tooth

Figure 12: Post-surgical photo of provisional crown (lateral view)

Figure 13: Post-surgical photo of provisional crown (alternate lateral view).

Figure 14: The fibre reinforced composite crown with wing.

Figure 15: The crown was relined with luxatemp and modified by flowable composite.

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#8 which is favorable for the option of immedi-ate implant placement and treatment outcome. He had a Class1 canine and molar relation-ship with 50% overbite and normal overjet. Static and dynamic occlusion was checked and no signs of parafunctional habits were noted.

The biomechanical part of the examina-

tion noted an insufficient crown at upper left central incisor an. A bur mark was detected at the incisal third of the existing crown and the crown margin was noted to be defective (Fig 2). A dark triangle was very noticeable on the distal of tooth #9 (Fig 3). Viewing the #9 from the occlusal it was too labially placed

Figure 16: The periapical radiograph immediately after surgery showing that the bovine filler particle was placed over the implant shoulder.

Figure 17: Intra-oral photo three months after immediate implant placement and provisionalization.

Figure 18: Er.Cr:YSGG laser was used to recontour the gingiva and the crown was modified by flowable composite.

Figure 19: Intra-oral photo with shade tabs


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Figure 20: Black and white photo with shade tab. Figure 21: Under-exposure photo shown more detail of the natural tooth.

Figure 22a: Digital shade matching with detail shade mapping

Figure 22b: Digital shade matching with detail shade mapping.

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Figure 23: The first crown was fitted and used as a custom shade guide, photo taken and send to the ceramist for shade modification.

Figure 24: The ‘LuxaTemp replica’ used to remove the excess cement indirectly prior to intra oral seating of the crown.

Figure 25: Abutment torqued into place. Figure 26: Full zirconia crown

and a size discrepancy was noted when com-pared to #8. Furthermore 6 mm pocket was detected at the palatal side (Fig 4) and Grade II mobility was noted. Radiographic examina-tion (Fig 5) revealed that #9 was root canal treated and had been fitted with a post crown. Bone defects were noted at both mesial and distal area of the #9 and the lamina dura was

widened especially on the mesial surface of the root. The tooth was diagnosed with a hori-zontal fracture. Prognosis was considered hopeless and extraction and implant place-ment was proposed to the patient. The patient had high esthetic expectations and medium lip mobility revealing all papillae in a full smile.


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Figure 27: Final restoration of implant #9 (facial view). Figure 28: Final restoration of implant #9 (lateral view).

Figure 29: Final restoration of implant #9 (alternate lateral view).

Figure 30: Final photo two weeks after the relapse of the tooth whitening.

TREATMENT PLANImplant replacement of tooth #9 was planned as opposed to a bridge or resin bonded bridge based on the success rates suggested by Pje-tursson.25 The gingival margin of tooth #9 was placed in a favorable position coronal to #8. Bone sounding was carried out and the position of the osseous crest was found to

be 3mm from the free gingival margin on the facial and considered favorable. The triangular crown shape and high gingival scallop of the #’s 8 and 9 and the lateral angulation of #10 contributing to the lack of distal papilla on #8 were considered unfavorable factors. Thin bio-type further increased the risk of facial reces-sion and interproximal loss of papilla. Immediate

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Figure 31a: Extra-oral smile photo of final restoration. Figure 31b: Extra-oral smile photo of final restoration (alternate view).

Figure 32: The post op radiograph showing the bone around the implant shoulder.

Figure 33: Full zirconia crown

implant placement was chosen in this case on account of the favorable labial gingival mar-gin of tooth #9 and as it can preserve the papilla and thus enhance the esthetic outcome.

TREATMENTImmediate implant placement in conjunction with bone grafting and placement of an “Imme-diate Provisional Seal”26,27 had been planned

for the #9 site. Tooth #9 was extracted atrau-matically using a periotome so as to not dam-age the labial plate(Figs 6 &7). The socket was curetted and disinfected28,29 with an Er Cr: YSGG laser.30 The extraction socket was then examined (Fig 8) and the labial bone was measured again with a periodontal probe and make sure that the labial bone was intact and favorable for immediate implant placement.31,32


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A platform switched implant (Ankylos plus, Dentsply Friadent, German) with 14mm length and 3.5 diameter was placed. Posi-tioning of the implant is tremendously impor-tant and usually placed in a palatal position (Fig 9), that leaves a gap between the labial bone and the dental implant. After an appro-priate temporary abutment had been chosen and fitted on the implant, bovine filler particle (Bio-Oss, Geistlich Pharma AG) was placed to fill this gap33,34 and the sulcus area above the socket (Fig 10). Many authors have shown that this technique aids to maintain the buc-cal bone and labial soft tissue profile.26,27

An immediate provisional crown was then fit-ted onto the top of the implant and fitted into the surrounding extraction socket preventing tissue collapse during healing and used as an immediate seal to hold the bovine particle inside the extraction socket and protect the blood clot (Fig 11). The provisional crown was modi-fied after connected it to the temporary abut-ment to replicate the cervical anatomy of the extracted tooth. It was extended about 3mm into the extraction socket and relined with Luxatemp (DMG American) and connected to the temporary abutment (Fig 12). The sub-gingival emergence profile was then further modified by adding flowable composite care-ful not to over contour the provisional as this would result in gingival recession. Under-contouring would have been equally undesir-able, as it will affect the provisional seal and the support of the peri-implant tissues, which in turn will cause collapse of the papilla and gingival contour. The author suggests observ-ing blanching of the soft tissues when adding to the provisional restoration. A ‘bottle-neck’

suture was then placed with minimal ten-sion to hold the gingiva to the provisional and ‘seal’ the bone graft and blood clot (Figs 13 & 14). A periapical radiograph was taken showing the bovine bone particle filler in the socket and over the implant shoulder (Fig 15).

A fiber-reinforced wing had been designed for the provisional crown to bond the adja-cent tooth (Fig 16).The rationale for using this wing design was to splint the provisional to the adjacent #10 and thus minimize the load to the implant. The wing was then bonded with Rely-X (3M ESPE, Seefeld, Germany) and the implant crown was fitted to the tem-porary abutment without cement. The occlu-sion of the immediate implant crown was then checked with thick articulating paper in static and dynamic occlusion and relieved. The patient was instructed to extremely carefully brush the area for 1 week. Suture removal was scheduled one week after surgery. One month and three month follow-ups were performed.

Three months after immediate implant placement and provisionalization (Fig 17), an Er.Cr:YSGG laser35 was used to recon-tour the gingiva (Fig 18) and the provi-sional crown was modified by adding flowable composite to the subgingival part in order to shape the gingival architecture.

After 6 weeks of gingival maturation addi-tional procedures improve the overall smile esthetics were scheduled. First Laser bleaching (Ezylase, Biolase) was used for tooth whitening to lift the overall shade. In a subsequent appoint-ment 2 weeks later to allow for shade settling and to avoid adhesion problems.36,37 Compos-ite (Miris, Coltene, Whaledent Switzerland) was used in a layering technique to modify the

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mesial surface of tooth #8 before the impres-sion taking. The reasons for adding composite to #8 were to widen the #8 to better balance it with #9, to minimize the canted midline, and to close the black triangle between #8 and #9.

The fabrication of a single ceramic restora-tion in the anterior esthetic zone is extremely challenging for both dentist and ceramist. The artistic skill of the ceramist plays an impor-tant role for the esthetic outcome and the dentist needs to be able to communicate the individual patient factors to his ceramist.

After the ideal tissue contours had been developed and matured with the provisional crown, the provisional crown was removed and the gingival third of the crown was dupli-cated by taking an impression of the provi-sional crown’s gingival third to replicate a custom impression coping. This custom impres-sion coping was used for the impression tak-ing of the final restoration. This method can replicate the true soft tissue contour into the working cast and to give the ceramist detailed information to fabricate the emergence profile.

To fabricate a single restoration that blends harmoniously with the adjacent dentition the shade matching procedure is of utmost impor-tance. Shade matching is recommended at the start of the appointment, as dehydrating teeth will change their color. Appropriate documen-tation and photography is critical. Photos must neither over nor underexposed. The camera must be angled in the correct position towards the tooth perpendicular to the long axis, as ring and even dual flashes will otherwise produce undesirable highlights. The correct placement of shade tabs in the same plane as the tooth to be matched must also be observed. Correct room

lighting color temperature is recommended as it influences the perception of color. An the ideal light color temperature of 5500-6000K is recommended. The author uses the DIAL-ITE with two 5500k bulbs that provides a cor-rect environmental light for the shade matching.

The Vita 3-D Master Linearguide was used in this case. It consist of two steps: First the right value from five value tabs is chosen, then the proper mix of chroma and hue is selected within the chosen value range. Once the gingi-val, body and incisal shade tabs were selected, photographs of each of the tabs were taken next to the tooth to be matched. Additionally one photograph of all three tabs was taken (Fig 19). Black and white photographs with shade tabs were also taken to allow for accurate evaluation of value (Fig 20). One deliberately under-exposed photograph was taken in order to show maximum detail of the natural tooth (Fig 21). Finally a spectrophotometer (Spec-troShade system, Clon 3D) was used for final shade matching. With the help of a digital shade analysis, a more accurate shade match and detail shade mapping prescription was produced for the ceramist (Fig 22 a&b). Pho-tographs and study models of the patient approved provisional were all sent to laboratory.

The technician had customized a CERCON ceramic abutment (Dentsply, Friadent Germany)to fit the gum contour obtained by the custom impression coping. A zirconia coping (3M, Lava) was designed to fit onto the abutment and built up with VM 9 porcelain (Vita, Germany).

At the try-in appointment the abutment was fitted and hand tightened. Then the crown was tried in and photos with and with-out shade tabs were taken. Numerous pho-


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tographs and comments on form where communicated to the ceramist .As it is often the case with single anterior units the first crown was used as a custom shade guide for the final restoration by the ceramist (Fig 23).

The cercon abutment was torqued with15 Ncm (Fig 24) and the final crown (Fig 25) was cemented with Temporary cement (Temp-Bond NE, Kerr Dental). As the crown mar-gin was placed 2mm subgingivally, removal of excess cement after final cementation is dif-ficult and the risk of peri-implantitis due to residual cement left in the implant gingival sul-cus is high. It is beneficial to prepare a dupli-cate cementing die replica that will remove excess cement before the crown is seated. The internal surface of the crown was isolated by brushing it with petroleum jelly and injected with bis-acryl material (LuxaTemp, DMG Amer-ica)into which a plastic pin was inserted. The ‘LuxaTemp replica’ was removed from the crown after full set of the bis-acryl material. The crown was then filled with the temporary implant cement and seated on the die replica prior to intra oral seating of the crown (Fig 26).

Static and dynamic occlusion was checked and the required adjustments were carried out. Photographs were taken and a slightly low value and size discrepancy of the implant crown was noted, this was due to the patient having started bleaching again against the advice of the dentist (Figs 27-29). Although there was a slight size discrepancy between 8 and 9 the patient and the dentist felt the res-toration blended harmoniously with existing dentition. The patient was happy and insistent on cementation. The photos taken two weeks after the fitting appointment show excellent

color integration after slight bleaching relapse. (Fig30) The extra oral and smile photo shown that the crown harmonized the natural denti-tion (Figs 31a&b). The radiograph was taken 3 months after crown cementation show-ing bone growth over the implant shoulder and the stability of the gum tissue (Fig 32).

CONCLUSIONReplacement of a single tooth in the esthetic zone is one of the biggest challenges the esthetic dentists face, but can also offer the biggest rewards. This case demonstrates how meticulous diagnosis and treatment plan-ning in conjunction with excellent labora-tory support can produce a beautiful white and pink result. This patient was extremely pleased with the outcome and appreciated the dentists’ hard work contributing a beau-tiful tissue result that continues to be stable 18 month after implant placement (Fig 33). ●

Correspondence:

Dr. Tak On Tse Ryan

Rm 818, Leighton Centre, 77 Leighton Road,

Causeway Bay HK

Tel:+852 2881 6929

Fax: +852 2881 6619

[email protected]

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Acknowledgments:The author thanks his master ceramist, Mr Chang-Lu RDT (Dental Essence, LA), for the artistic work; and his many mentors (especially Dr.Ed Mclaren, Dr Richie Yeung) of his career. He also gives special thanks to his wife, Venus, and to his wonderful staff for their never-ending support. He would also like to thank Dr.Sandra Hulac- without her encouragement and assistance this article would not have been submitted.

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

References1. Levin L etal. (2005) Aesthetic versus surgi-

cal success of single dental implants: 1-to 9-year follow-up. Pract Proced Aesthet Dent. 2005 Sep;17(8);quiz 540,566

2. Esposito M etal. (2010)Timing of implant placement after tooth extraction:immediate, immediate-delayed or delay implants? A Cochrane systematic review. Eur J Oral Implantol. 2010 Autumn;3(3):189-205

3. Hammerle CHF,Chen ST, Wilson TG jr. (2004) Consensus statements and recom-mend clinical procedures regarding the place-ment of implants in extraction sockets. Int J Oral Maxillofac Implants 2004:19:26-28

4. Schulte W, Kleineikenscheidt H, Lind-ner K, Schareyka R. (1978)The Tübin-gen immediate implant in clinical studies Dtsch Zahnarztl Z. May;33(5):348-59.

5. Lazzara RM. (1989)Immediate implant placement into extraction sites: Surgi-cal and restorative advantages. Int J Peri-odontics Restorative Dent;9:333-343

6. Kan JY, Rungcharassaeng K, Lozada J.(2003)Immediate placement and provisionaliza-tion of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxil-lofac Implants. 2003 Jan-Feb;18(1):31-9.

7. Chen ST, Wilson TG Jr, Hämmerle CH. (2004) Immediate or early placement of implants fol-lowing tooth extraction: review of biologic basis, clinical procedures, and outcomes Int J Oral Maxillofac Implants. 2004;19 Suppl:12-25.

8. Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. (2007)Effects of the facial osseous defect morphology on gingival dynamics after imme-diate tooth replacement and guided bone regeneration: 1-year results. J Oral Maxil-lofac Surg. 2007 Jul;65(7 Suppl 1):13-9.

9. Chen ST, Darby IB, Reynolds EC.(2007) A prospective clinical study of non-submerged immediate implants: clinical outcomes and esthetic results. Clin Oral Implants Res. 2007 Oct;18(5):552-62. Epub 2007 Jun 30.

10. Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. J Clin Periodontol. 2005 Jun;32(6):645-52.

11. Araújo MG, Wennström JL, Lindhe J. (2006) Modeling of the buccal and lin-gual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res. 2006 Dec;17 (6):606-14.

12. Schropp, L., Wenzel, A., Kostopoulos, L. & Kar-ring, T. (2003) Bone healing and soft tissue con-tour changes following single-tooth extraction: a clinical and radiographic 12month prospective study. The International Journal of Periodon-tics & Re- storative Dentistry 23: 313–323.

13. Botticelli D, Berglundh T, Lindhe J. (2004) Hard-tissue alterations following immedi-ate implant placement in extraction sites. J Clin Periodontol. 2004 Oct;31(10):820-8.

14. Araujo, M.G. & Lindhe, J. (2005) Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of Clinical Periodontology 32: 212–218

15. Fickl, S., Zuhr, O., Wachtel, H., Bolz, W. & Huer- zeler, M. (2008) Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. Journal of Clinical Periodontology 35: 356–363.

16. Darby I, Chen ST, Buser D. (2009)Ridge preser-vation techniques for implant therapy. Int J Oral Maxillofac Implants. 2009;24 Suppl:260-71.

17. Araújo M, Linder E, Wennström J, Lindhe J. (2008)The influence of Bio-Oss Collagen on healing of an extraction socket: an experi-mental study in the dog. Int J Periodontics Restorative Dent. 2008 Apr;28(2):123-35.

18. Araújo MG, Lindhe J. (2009)Ridge pres-ervation with the use of Bio-Oss collagen: A 6-month study in the dog. Clin Oral Implants Res. 2009 May;20(5):433-40.

19. Araújo MG, Liljenberg B, Lindhe J. (2010)Dynamics of Bio-Oss Collagen incor-poration in fresh extraction wounds: an experimental study in the dog. Clin Oral Implants Res. 2010 Jan; 21(1):55-64.

20. Araújo MG, Linder E, Lindhe J.(2011)Bio-Oss collagen in the buccal gap at immediate implants: a 6-month study in the dog. Clin Oral Implants Res. 2011 Jan;22(1):1-8.

21. Cornelini R, et al. Deproteinized bovine bone and biodegradable barrier membranes to support healing following immediate place-ment of transmucosal implants: a short-term controlled clinical trial.Int J Periodontics Restorative Dent. 2004 Dec;24(6):555-63.

22. Baumgraten H, et al. (2005) A new implant design for crestal bone preservation:initial observations and case report. Pract Proced Aesthet Dent 2005;17:735-740.

23. Lazzara RJ,Porter SS. (2006) Platform switch-ing: A new concept in implant dentistry for con-trolling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9–17.

24. Michele Cappiello,(2008)Evalua-tion of Peri-implant Bone Loss Around Platform-Switched Implants. The Int. Journal of Periodontics & Restorative Den-tistry. 2008 Vol 28, (4);r5347-355

25. Pjetursson BE.(2008)Prosthetic treatment planning on the basis of scientific evidence.J Oral Rehabil. 2008 Jan;35 Suppl 1:72-9.

26. Chu SJ et al. (2012)The dual-zone therapeu-tic concept of managing immediate place-ment and provisional restoration in anterior extraction sockets. Compend Contin Educ Dent 2012 Jul-Aug:33(7)524-32,534

27. Caiazzo A et al.(2013) Buccal plate preserva-tion with immediate post-extraction implant placement and provisionalization: preliminary results of a new technique.Int J Oral Maxil-lofac Surg. 2013 May:42(5)660-70

28. Lindeboom JA etal. (2006) Immediate place-ment of implants in periapical infected sites: a prospective randomized study in 50 patients.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006 Jun;101(6):705-10.

29. Siegenthaler DW.(2007)Replacement of teeth exhibiting periapical pathology by immediate implants: a prospective, controlled clinical trial.Clin Oral Implants Res. 2007 Dec;18(6):727-37.

30. Kusek ER. (2011)Immediate implant place-ment into infected sites: bacterial studies of the Hydroacoustic effects of the YSGG laser.J Oral Implantol. 2011 Mar;37 Spec No:205-11.

31. Elian N.(2007) A simplified socket clas-sification and repair technique.Pract Proced Aesthet Dent. 2007 Mar;19(2):99-104

32. Kan JY.(2007) Effects of the Facial Osseous Defect Morphology on Gingival Dynamics After Immediate Tooth Replacement and Guided Bone Regeneration:1-Year Results.J Oral Maxil-lofac Surg. 2007 Jul;65(7 Suppl 1):13-9

33. Botticelli D. (2003) The jumping distance revisited: An experimental study in the dog. Clin Oral Implants Res.2003 Feb;14(1):35-42

34. Ortega-Martinez J.(2012) Immediate implants following tooth extraction. A sys-tematic review.Med Oral Patol ORal Cir Bucal. 2012 Mar 1: 17(2) 2 256-61

35. Lowe RA(2006). Clinical use of the Er,Cr: YSGG laser for osseous crown lengthening: redefining the standard of care. Pract Proced Aesthet Dent. 2006 May;18(4):S2-9; quiz S13.

36. Metz MJ.(2007)Clinical evaluation of 15% carbamide peroxide on the surface microhard-ness and shear bond strength of human enamel.Oper Dent. 2007 Sep-Oct;32(5):427-36.

37. Barbosa CM.(2008)Influence of time on bond strength after bleaching with 35% hydrogen peroxide.J Contemp Dent Pract. 2008 Feb 1;9(2):81-8.Neale D, Chee WW. (1994)Devel-opment of implant soft tissue emergence profile: a technique. J Prost Dent 1994;71(4):364-8

38. Elian N. (2007) Accurate transfer of peri-implant soft tissue emergency profile from the provisional crown to the final pros-thesis using an emergence profile cast. J Esthet Restor Dent 2007;19(6)306-14

39. Azer SS.(2010) A simplified technique for creating a customized gingival emergency profile for implant-supported crowns. J Prosthodont 2010, Aug:19(6):497-501

Tse

Wilcko et al

Patients with a somatic malady usually seek care from a health professional. Treat-ment often includes a written or com-

puter-generated prescription for medication(s). Most of the time, a medication prescribed is for an antibiotic, often one from the Penicillin fam-ily (e.g., Penicillin V, Ampicillin, Amoxicillin) or from the Macrolide/mycin family (e.g., Clindamy-cin, Azithromycin, Clarithromycin). However, the antibiotic prescription may itself be a placebo, especially when prescribed for a viral or fun-

gal infection (e.g., treatment of upper respira-tory infections which are usually viral in origin). It is generally a patient expectation (and part of the satisfaction with healthcare treatment) to receive an antibiotic prescription when present-ing with most illnesses. The health care profes-sional, practicing in this person-to-person and treatment environment of the doctor-patient rela-tionship, will often accede to this expectation by the patient for an antibiotic prescription (i.e., even though the doctor deems it unnecessary).

Expectations and Satisfaction: The Psychology of Antibiotics

Paul J. Flaer, DDS, EdD, MPH1 • Jai Parkash, PhD2

1. Florida Institute for Advanced Dental Education, Miami, Florida, USA

2. Biomedical Science Faculty, Keiser University, Fort Myers, Florida, USA

Abstract

KEY WORDS: Antibiotics, placebo, psychology


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INTRODUCTIONAntibiotics are employed by health care practitio-ners as necessities for the treatment of many infec-tions. However, antibiotic treatment is sometimes the vehicle of risky misuse or harm to the individual and general population. What are the ethics and medico-legal ramifications of such misuse of these medications? What are the psychological expec-tations of patients being prescribed antibiotics? Are antibiotics commonly prescribed as “place-bos” instead of required treatment by physicians and dentists? From an epidemiological stand-point, is there an overuse or misuse of antibiotics in the United States? In practice, patients expect a cure for their illness when receiving and filling prescriptions for antibiotics, whether they were deemed necessary or not. Expectations to receive prescriptions exceed healthcare practitioners’ per-ceptions of the wants of patients and influences actual decisions to provide needed medications.1

DEVELOPMENT OF RESISTANT BACTERIAL STRAINS

Patients obtain antibiotics and contribute to mis-use in several ways2: they may exaggerate their symptoms when describing their conditions to healthcare workers, visit multiple healthcare sites for the same ailments, actually pressure their doc-tors for drugs, under-dose during the course of therapy and hoard the remaining doses, or obtain the medications illegally (i.e., mostly “under-the-table” from pharmacists or via the Internet). In the conduct of healthcare in the U.S., an unwritten rule of practice is “antibiotics on demand”—denying this axiom often leads to low satisfaction ratings from patients.3 Although meeting patient expecta-tions and maintaining satisfaction are necessary in practice, over-prescribing antibiotics by healthcare

practitioners and misuse by patients fosters the development of resistant strains of microorganisms in both the individual and in the general population.4

An active, interacting microflora of bacteria, viruses, and fungi exist in the bodies of each given population of patients. With an overuse of antibi-otics, infections by these competing microorgan-isms proliferate that normally are in held in check by balanced interactions with other microorgan-isms or bodily tissues. In the condition thrush (oral candidiasis) disruption of the interrelationships of the normal flora of microorganisms in the oral cavity leads to the overgrowth of the opportunistic fungi Candida albicans. Unfortunately, the devel-opment of new antibiotics by the pharmaceutical industry has been outpaced by the development of drug resistance.5 Penicillin in long-time and common use for many infections has lead to the proliferation of penicillin resistant bacteria—thereby impacting the activity, metabolism, and detoxica-tion of the antibiotic in the general population.6

The sensitivity of resistant bacterial strains to antibiotics is a function of both genetics and epide-miology.7 According to these authors, resistance of certain bacteria to antibiotics may be chromosomal bound. Furthermore, lowered antibacterial or antifun-gal action of antibiotics and subsequent resistance can be attributed to chronicity of use and the over-use of these medications in the general population.8

ANTIBIOTICS AS PLACEBOSMost healthcare practitioners likely would agree that use of a placebo is better than denying the patients’ expectations of receiving a prescription.9 Studied widely under the realm of psychosomatic medicine, the placebo can be a significant force in the healing arts.10 However, the appropriateness of the use of placebos (including antibiotics) in patient


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Figure 1: Flow Diagram of Antibiotic Use and Misuse

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Table 1: Medical/Dental Therapeutics: Antibiotics for Somatic Infectionss

Penicillin Family

Penicillin VK (choice as initial anti-infective)

Ampicillin (choice in treatment of infections caused by Enterococci)

Amoxicillin (choice as initial anti-infective; drug of choice for prophylaxis for prevention of\bacterial endocarditis)

Amoxicillin/clavulanic acid (Augmentin)

Macrolide (mycin) Family

Clindamycin (Cleocin) (Drug of choice with Penicillin allergy: 1- for infections 2- for prophylaxis in the prevention of bacterial endocarditis)

Erythromycin (obsolete due to wide presence of resistant organisms in oral infections)

Clarithromycin (Biaxin) (alternative for prevention of bacterial endocarditis)

Azithromycin (alternative for prevention of bacterial endocarditis)

Tetracycline Family (orally active--secreted through the salivary glands)

Tetracycline (Broad-spectrum antibiotic)

Deoxycycline (Treatment of periodontal disease)

Minocycline/Minocin: (Arestin) (Treatment of periodontal disease)

Cephalosporin Family (Bactericidal) Keflex (Cephalexin) (most active against Gram-positive cocci; used in the prevention of bacterial endocarditis)

Duricef (treatment of strep throat & urinary tract infections)

Velosef (useful in prolonged antibiotic therapy; prevention of Rheumatic fever)

Ceclor (treatment of a wide variety of bacterial infections)

AntimetabolitesMetronidazole (Flagyl) (active against anaerobic bacteria proven susceptible)Chlorhexidine (Peridex) (Oral antibiotic & anti-viral rinse)


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treatment remains an ethical question.10 According to a 2007 policy statement by the American Medi-cal Association about the ethics of prescribing pla-cebos11: “In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relation-ship and result in medical harm to the patient.”

HOSPITAL-BASED INFECTIONSLower socioeconomic status (SES) groups often use hospital emergency rooms by “default” (or maybe cultural preference?) for medical and dental care.12 Higher hospital utilization by SES patients as compared to obtaining healthcare in ambulatory venues is often associated with poor healthcare outcomes.13 A formidable presence in the hospital environment is the propensity for development and subsequent transmission of resistant microorgan-isms.14 Subsequently, many hospitals have a high morbidity and mortality of infections.15 For exam-ple, the highly contagious and lethally infective Carbapenem-resistant Enterobacteriaceae (CRE) bacteria present in some hospitals are resistant to most antibiotics.16 According to the CDC in 2014, patterns of antibiotic resistance should be deter-mined and tracked locally at every area hospital (a program that is entitled “antibiotic stewardship”).17 Undoubtedly, the development of hospital-based “super” infections (via resistant “super bugs”) con-stitutes a clear danger to the nation’s public health.18

DISCUSSIONUpper respiratory infections (including the com-mon cold and sinusitis), viral pneumonia, influenza, and bronchitis have a non-bacterial etiology and are usually self-limiting or self-resolving.19 Antibi-otics should not be used to treat viral or allergic

infections except those with a secondary bacterial etiology.20 In a 2012 controlled and randomized study, Garbutt, Banister, Spitznagel, and Piccirillo found Amoxicillin, a widely prescribed member of the Penicillin group of antibiotics, to have no effect on acute sinus infection.21 Antiviral medicines have recently been developed and are sometimes pre-scribed alternatively to antibiotics; for example, use of the drug Virazole in respiratory infections.22 Besides the viral etiology, causes of upper respira-tory infections include airborne pollution, allergies, a compromised immune system, or fungal mycosis.19

Bacterial pneumonia (also known as commu-nity-acquired pneumonia) is as prevalent as its viral counterpart although the bacterial-caused variety is generally more virulent.23 However, antibiotic treat-ment of bacterial pneumonia may be unresponsive if the infection is metastatic from empyema (exu-date in the pleural space), bacterial meningitis, acute endocarditis, or arthritis.24,25 Pneumonia transmitted within the hospital is often the cause of morbidity and mortality from infectious disease in those patients admitted for other causes.26

According to Rao in 1998, prescribing of antibiotics should be based upon local patterns of the presence of resistant microorganisms in a given population (termed “genomic mapping”).27 Conservative prescribing in general should favor the use of narrow spectrum rather than broad spectrum antibiotics to reduce the development of resistant strains of microorganisms.28 How-ever, extensive research evidence and subse-quent information dissemination concerning antibiotic inaction in upper respiratory or other viral infections usually does not deter patients from asking for (or often demanding) them from healthcare workers.3 Pharmaceutical prescrib-ing and subsequent usage in our society may be

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suffering from a cultural problem—we expect a prescription (i.e., often an antibiotic) almost every time that we go to the doctor and often get one.

CONCLUSIONSPrograms that counter negative attitudes and inform the public about the crisis in anti-biotic therapy in the United States should engage the following organizations including: ● Healthcare professions● Mass media (e.g., articles/advertisements

in print and broadcast)● Educational systems (e.g., K-12 and

colleges/universities)● Government at all levels● Community groups (e.g., Medical and

Dental societies; Kiwanis)● Insurance companies● Pharmaceutical industries

Healthcare organizations must confront the prescribing problems with antibiotics and pro-mote their judicious use. Research to promote the development of new antibiotics and therapy modes to counter drug resistance should be conducted and adequately funded.17 Regula-tion of antibiotic usage is best achieved through interventions and information dissemination to change expectations of patients about what constitutes appropriate antibiotic therapy.29 ●

Correspondence:Dr. Paul Flaer750 N.W. 20th Street, Bldg. G-110Miami, Florida 33127305-348-6070 x7052 (phone)786-364-7463 (FAX)[email protected]

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

References1. Cockburn and Pit (1997). Prescribing behavior in clinical practice: patients’

expectations and doctors’ perceptions of patients’ expectations—a questionnaire study. BMJ 315: 520-3.

2. Pechère J (2001). Patients’ interviews and misuse of antibiotics. Clin Infect Dis 33(Suppl 3): S170-3.

3. Stokowski LA (2014). Can we stop overprescribing antibiotics? Readers speak out. Available from http://www.medscape.com/viewarticle/827888.

4. Sterns CR, Gonzales R, Camargo CA, Maselli J, and Metlay JP (2009). Antibiotic prescriptions are associated with increased patient satisfaction with emergency department visits for acute respiratory tract infections. Acad Emerg Med 16(10): 934-41.

5. Planta MB (2007). The role of poverty in antimicrobial resistance. J Am Board Fam Med 20(6): 533-39.

6. www.drugs.com (2014). Penicillinase resistant penicillin. Available at: http://www.drugs.com/drug-class/peniicillinase-resistant-penicillins.html.

7. Ison CA, Gedney J, and Easmon CS (1987). Chromosomal resistance of gonococci to antibiotics. Genitourin Med 63: 239-43.

8. Mayo Clinic (2012). Antibiotics: Misuse puts you and others at risk. Available at: http://www.mayoclinic.org/healthy-living/consumer-health/in-depth/antibiotics/art-20045720?footprints=mineandp=1.

9. Associated Press (2008). Half of U.S. doctors often prescribe placebos. Health Care on NBC News, 10/23/2008. Available at: http://www.nbcnews.com/id27342269/ns/health-health_care/t/half-us-doctors-often-prescribe-placebos.

10. Harris G (2008). Half of doctors routinely prescribe placebos. The New York Times, October 24, 2008. Available at: http://www.nytimes.com/2008/10/24/health/24placebo.html.

11. American Medical Association (2007). Opinion 8.83 – Placebo use in clinical practice. AMA code of medical ethics. Available from: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion8083.page?#.

12. Kangovi S, Barg F, Carter T, Long J, Shannon R, and Grande D (2013). Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff 32(7): 1196-1203.

13. Laditka, J.N., S.B. Laditka, and M.P. Mastanduno (2003). Hospital utilization for ambulatory care sensitive conditions: Health outcome disparities associated with race and ethnicity. Soc Sci Med 57(8): 1429-1441.

14. Levin SA and Andreasen V (1999). Disease transmission dynamics and the evolution of antibiotic resistance in hospitals and communal settings. Proc Natl Acad Sci USA 96: 800-1.

15. Adler NE and Ostrove JM (1999). Socioeconomic status and health: What we know and what we don’t. Ann NY Acad Sci 896: 3-15.

16. Preidt R (2014). Drug-resistant superbug increasing in Southeast U.S. hospitals. Everyday Health. http://health.usnews.com/health-news/articles/2014/07/18/drug-resistant-superbug-increasing-in-southeast-us-hospitals.

17. CDC (2014a). CDC director warns of ‘post–antibiotic era’. Centers for Disease Control. Available from: http://www.healthfreedoms.org/cdc-director-warns-of-post-antibiotic-era/.

18. Nordmann P, Naas T, Fortineau N, and Poirel L (2007). Superbugs in the coming new decade; multidrug resistance and prospects for treatment of Staphylococcus aureus, Enterococcus spp. and Pseudomonas aeruginosa in 2010. Curr Opin Micro 10(5): 436-40.

19. CDC (2013). Sinus infection: Overview of a sinus infection. Centers for Disease Control. Available at: http://www.cdc.gov/getsmart/antibiotic-use/uri/sinus-infection.html.

20. CDC (2014b). Get smart: Know when antibiotics work. Centers for DiseaseControl. Available at: http://www.cdc.gov/getsmart/.

21. Garbutt JM, Banister C, Spitznagel E, and Piccirillo J (2012). Amoxicillin for acute rhinosinusitis: A randomized controlled trial. JAMA 307(7): 685-92.

22. RxList (2014). Virazole. Available from: http://www.rxlist.com/virazole-drug/htm.

23. American Lung Association (2009). Pneumonia fact sheet. Available from: http://www.lung.org/lung-disease/influenza/in-depth-resources/pneumonia-fact-sheet.html.

24. Watkins RR and Lemonovich TL (2011). Diagnosis and management of community-acquired pneumonia in adults. Am Fam Physician 83(11): 1299-1306.

25. Ceccarelli G, d’Ettorre G, and Vullo V (2011). Purulent meningitis as an unusual presentation of Staphylococcus aureus endocarditis: A case report and literature review. Case Rep Med (Article ID 735265): 5 pages.

26. NIH (2013). Hospital-acquired pneumonia. National Institutes of Health. Available from: http://www.him.nih.gov/medlineplus/ency/article/000146.htm.

27. Rao GG (1998). Risk factors for the spread of antibiotic-resistant bacteria. Drugs 55(3): 323-30.

28. Beveridge LA, Davey PG, and McMurdo M (2011). Optimal management of urinary tract infections in older people. Clin Interv Aging 6: 173-80.

29. Lambert MF, Masters GA, and Brent SL (2007). Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother 59(3): 537-43.

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Wilcko et al

T reatment with dental implants in the esthetic zone can be complicated especially when there is a deficiency

in the normal anatomic hard and soft tis-sue contours as a result of a history of peri-odontal disease or trauma. When a patient presents with severe vertical bone loss with subsequent soft tissue recession and shrink-age, it is necessary to perform multiple pro-

cedures to augment the hard and soft tissue contours to recreate natural anatomy and provide a framework for subsequent reha-bilitation and an esthetically pleasing result.

The following case report demonstrates the treatment of such a complicated case where an extensive amount of vertical bone loss as well as a significant soft tissue deficiency was present in the esthetic zone prior to treatment.

Soft Tissue Management of a Complicated Case in the Esthetic Zone

Taeheon Kang, DDS, MS1• Matthew J. Fien, DDS2 • Nina Cunningham, DMD3

1. Private practice, Fairfax, Virginia, USA

2. Private practice, Plantation, Florida, USA

3 Resident, Department of Periodontology, Nova Southeastern University, Fort Lauderdale, Florida, USA

Abstract

KEY WORDS: Dental implants, bone graft, esthetics


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INTRODUCTIONAlveolar ridge defects are a result of tooth loss that leads to dimensional reduction of bone and soft tissue surrounding the alveo-lus. Alveolar ridge defects often present as unaesthetic depressions, clefts or creases in the gingiva, which frequently trap food. A deficient edentulous ridge in the esthetic zone can be a challenge for the dental prac-titioner, both in restoring the anatomic con-tours surgically as well as meeting the patient’s esthetic demands restoratively.

Patients, who don’t wish to have their miss-ing teeth and soft tissue to be replaced with removable prosthesis, have the option of fixed partial dentures or implant supported restora-tions. However, without re-establishing ana-tomic hard and soft tissue contours, these prosthetic restorations have a tendency to appear too long in inciso-occlusal and/or too wide and bulky in bucco-lingual dimensions giving an unnatural and frequently unappeal-ing appearance. Attempts have been made to compensate for the collapsed ridge by apply-ing either pink acrylic or pink porcelain to res-torations, which often pose a challenge for oral hygiene measures and can lead to esthetically unsatisfactory outcomes because of the pres-ence of a noticeable interface between the tissue-colored restoration and the gingiva.

There have been several surgical techniques described in literature to restore missing soft and hard tissues. Guided bone regeneration is commonly applied, which uses either resorb-able or nonresobable barrier membranes, bone graft materials or tenting screws and has been proven successful in repairing bone defects.1-4 Soft tissue deficiencies of the alveolar ridge

have been reconstructed with autogenous graft or allograft materials. Ridge augmentation with a thick free epithelialized graft was first published by Meltzer (1979) to correct an esthetic anterior vertical ridge defect5 and later in 1980, the roll-technique was described by Abrams using a de-epithelialized pedicle graft taken from the palate and placed on the edentulous ridge.6 Seib-ert confirmed the predictability of free gingival grafts and described his technique and appli-cation of the soft tissue onlay graft in a series of articles to rebuild edentulous ridge defor-mities.7,8 Langer and Calagna introduced the subepithelial connective tissue graft and ratio-nalized the addition of the graft beneath a partial thickness flaps for ridge augmentation9. Advan-tages of connective tissue grafts compared to free gingival grafts are less postoperative discomfort at the donor site, more predictable revascularization and improved esthetics.10

Besides Abrams, Wang also described a technique that utilized a pedicle graft, in his case a connective tissue pedicle graft, which was taken from an adjacent surgi-cal site and rolled into the anterior eden-tulous ridge to restore the ridge defect.11 Pedicle grafts have the same donor and recipi-ent site thereby leading to less patient dis-comfort and morbidity compared to free soft tissue grafts. Also, with the additional blood supply through the pedicle, graft survival and vascularization is more predictable as opposed to free soft tissue graft procedures.

The following case report demonstrates a surgical technique to simultaneously aug-ment both hard and soft tissues, using a double palatal pedicle graft and bone aug-mentation with particulate grafting material to


Kang et al

restore normal anatomical contours prior to implant placement. These procedures were indicated to minimize the severe soft and hard tissue defects present and rehabilitate anatomical contours to achieve an estheti-cally pleasing outcome in the anterior maxilla.

CASE REPORTA 35-year-old male patient presented to the fac-ulty practice at Nova Southeastern University in 2010 with a chief complaint that he didn’t want to smile because of the unaesthetic appearance of his front teeth. He had a history of trauma and extensive dental treatment of the anterior max-

Figure 1: Patient’s preoperative smile. Figure 2: Intraoral preoperative buccal view.

Figure 3: Preoperative periapical radiographs. Figure 4: View of sockets of teeth Nos. 8, 9 and 10 right after extraction.

50 • Vol. 6, No. 8 • November 2014

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illary teeth which included previous endodon-tic treatment of teeth Nos. 8, 9 and 10 as well as severe horizontal bone loss of these teeth. Crowns had been placed on teeth Nos. 8, 9 and 10 more than 10 years prior to our evalua-tion. Due to the patient’s high smile line, the pre-vious restorative dentist attempted to mask the severe vertical hard and soft tissue deficiency with restorations (pink porcelain) (Figure 1). The patient’s medical history was noncontributory.

Intraoral examination revealed severe, asym-metrical soft tissue recession of the gingiva of teeth Nos. 8, 9 and 10. Recession of greater than 7 mm was noted on teeth Nos. 8 and 9 and recession of 3 mm was noted on tooth No. 10. In addition, soft tissue recession on teeth Nos. 8 and 9 extended past the mucogingival junc-tion, leaving 0 mm of attached, keratinized tissue apical to the recession defects of these teeth. Marginal soft tissue presented red, rolled and edematous and there was an obvious loss of stipple and normal anatomy of the gingiva around teeth Nos. 8 and 9 (Figure 2). Periodontal evalu-ation revealed that teeth Nos. 8-10 presented with severe periodontal probing depths ranging from 9-11 mm and suppuration was noted upon palpitation of the marginal gingiva associated with these teeth. Significant mobility (Grade II and III) was detected on teeth Nos. 8, 9 and 10 and mild mobility (Grade I) was noted on tooth No. 7. Radiographic examination revealed severe horizontal bone loss of teeth Nos. 8-10 and peri-apical pathology consistent with chronic apical periodontitis as well as internal and external root resorption of the apices of these teeth (Figure 3).

A diagnosis of localized severe chronic periodontitis and chronic apical periodonti-tis was made for teeth Nos. 8-10. Tooth No.

7 was diagnosed with localized mild chronic periodontitis.12 Prognosis of tooth No. 7 was poor at the time of initial evaluation while teeth Nos. 8-10 were deemed hopeless.13

Treatment sequence● Treatment planning for the anterior maxilla was

completed and the following treatment sequence was developed.

● Extraction of hopeless teeth (Nos. 8-10) and soft tissue augmentation

● Guided bone regeneration for site development in preparation for future implant placement

● Re-evaluation of tooth No. 7● Implant placement at sites 7 and 10 following

extraction of tooth No. 7 with additional bone grafting

● Apically positioned flap and place-ment of extracellular matrix membrane to increase keratinized gingiva

● Uncovering of implants Nos. 7 and 10● Final restoration

SURGICAL PROTOCOLFollowing administration of local anesthesia, teeth Nos. 8-10 were extracted with forceps only. Due to long-standing inflammation, infec-tion and tooth mobility, the sockets of teeth Nos. 8-10 were epithelialized internally (Figure 4). Fol-lowing extraction, the sockets were de-epitheli-alized prior to flap elevation. Bone sounding and evaluation of the position of the buccal plate of bone was performed and confirmed the radio-graphic findings of severe horizontal bone loss of teeth Nos. 8-10. Due to the severe soft tissue defects present at this time, soft tissue grafting was initiated following the protocol listed above.

A 15c blade was used to place a beveled ver-


Kang et al

tical incision in a curved fashion mesial to teeth Nos. 7 and 11 followed by full thickness flap reflection. All remaining granulomatous tissue and foreign materials were then carefully and meticu-lously debrided from the site with curettes and bone files. Irrigation with copious saline solution

was also performed. A bilateral palatal pedicle graft was harvested using previously described techniques to provide as much soft tissue aug-mentation as possible.11,14-16 Prior to fixation of the palatal pedicle grafts, bone augmentation with particulate grafting material such as RegenerossÒ

Figure 5: Placement of double palatal pedicle graft and bone augmentation with particulate grafting material (FDBA and bovine bone xenograft).

Figure 6: Healing after soft tissue augmentation.

Figure 7: Placement of implants 7 and 10, 6 weeks after soft and hard tissue augmentation.

Figure 8: 4 months healing after implant placement with bone grafting.

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freeze dried bone allograft (BIOMET 3iÒ, Palm Beach Gardens, FL) and Bio-OssÒ bovine bone xenograft (GeistlichÒ, Princeton, NJ) was com-pleted by packing the graft material into the sock-ets and the residual buccal plate of teeth Nos. 8, 9 and 10 (Figure 5). It should be noted that no membrane was used at this time, as the authors did not expect to obtain primary closure over graft due to the severe soft tissue deficiency, which was present at the surgical site. Suturing of the pala-tal pedicle grafts was completed with resorbable sutures to the buccal defects of the newly eden-tate sites of teeth Nos. 8 and 9, which presented with the most severe soft tissue deficiencies. A periosteal releasing incision was completed and the overlying buccal flap was coronally positioned to obtain tension free closure over the bone graft material and overlying palatal pedicle grafts.

Healing following this initial treatment pro-tocol was uneventful. It should be noted that while soft tissue closure was obtained, the coro-nal flap repositioning that was employed led to a significant coronal migration of the muco-gingival junction at sites 8, 9 and 10 (Figure 6).

Following 6 weeks of healing, a second pro-cedure was initiated with the primary objective of augmenting the underlying bone in preparation for implant placement. Following local anesthe-sia, a 15c blade was used again to place a bev-eled vertical incision mesial to teeth Nos. 6 and 11 and a full thickness flap was elevated. At this time, tooth No. 7 was re-evaluated in terms of long term prognosis and the decision was made to extract this tooth due to its history of mild to moderate horizontal bone and mobility. Evaluation of the alveolar ridge at sites 7 and 10 revealed adequate ridge width to support implant place-ment at this time. Therefore, implant placement

was completed using bone level endosseous implants (Figure 7). Following implant placement, guided bone regeneration was performed with particulate graft material and placement of a resorbable cross-linked collagen barrier mem-brane. Tension free primary closure was achieved.

Following another 4 months of uneventful heal-ing, intraoral examination revealed that the muco-gingival junction was significantly more coronal as a result of the previous surgical protocol that was employed. Therefore an additional procedure was planned to correct this deformity (Figure 8). Following adequate local anesthesia, a split thick-ness flap was elevated and apically positioned in the area of teeth Nos. 7-10. To minimize potential shrinkage of the remaining soft tissue covering the underlying alveolar bone, a DynamatrixÒ extracellu-lar matrix membrane (KeystoneÒ, Burlington, MA) was utilized to cover the exposed partial thick-ness reflection. This dermal matrix was sutured in place with single interrupted sutures (Figure 9). Healing of this procedure revealed a steady, grad-ual migration of keratinized tissue to the surgical site. Six weeks following this procedure implants were uncovered with standard techniques and a final impression was taken 2 months later.

RESULTSFollowing surgical treatment, the patient received an implant retained fixed porcelain fused to metal bridge fabricated from sites 7-10 (Figures 10, 11 and 12). Final crown dimensions were sym-metrical and offered a significant improvement when compared to the patient’s pre-treatment presentation. The associated gingiva was firm and keratinized and the mucogingival junction was more than 4-8 mm apical to the margin of the crowns of implants Nos. 7 and 10 (Figure


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Figure 8: 4 months healing after implant placement with bone grafting.

Figure 9: Placement of an extracellular matrix membrane combined with apically positioned flap.

Figure 10: Buccal view of the final restoration.

Figure 11: Final periapical radiographs.

10). The crowns Nos. 7-10 were fabricated with long contacts and rectangular forms to minimize the appearance of black triangles (Figure 12).

DISCUSSIONTreatment of cases in the esthetic zone that pres-ent with a severe history of disease or trauma often require multiple procedure to augment the

54 • Vol. 6, No. 8 • November 2014

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Figure 12: Picture of patient’s smile after placement of the final restoration.

hard and soft tissue contours.16 Prior to guided bone regeneration, it is often necessary to aug-ment the soft tissue volume in order to satisfy the prerequisites for successful bone regenera-tion and healing.17,18 In this case a bilateral palatal pedicle graft was employed at the time of extrac-tion to increase the shear bulk of tissue available and to obtain tension free primary closure during subsequent implant placement and bone graft-ing procedures. Furthermore, the palatal pedi-cle grafts were used to provide as much of an improvement in soft tissue anatomy as possible to mimic normal anatomical contours. While par-ticulate bone grafting material was adapted to the residual sockets and buccal plate prior to fixation of the palatal pedicle grafts, no membrane was employed because the author originally planned to re-enter the site 6 weeks after extraction and soft tissue augmentation, following soft tissue healing, to perform guided bone regeneration.

It should be noted that prior to flap eleva-tion of the second procedure (implant place-ment and guided bone regeneration), the authors were uncertain as to whether implants

would be able to be placed at the time of guided bone regeneration. Once adequate alveolar bone width was visualized, implant placement with simultaneous guided bone regen-eration was employed to minimize the number of procedures the patient would have to endure.

Following 4 months of healing of the implants and the guided bone regeneration, an additional procedure was performed to correct the posi-tion of the mucogingival junction for long term stability and color matching of the adjacent gin-giva as this patient presented with a very high smile line. A free gingival graft may have accom-plished the same functional result but with a poor color match.19 Treatment with an apical posi-tioned flap alone may also have been success-ful but would have risked substantial shrinkage of the valuable buccal hard and soft tissue. It is the author’s opinion that treatment with an api-cal positioned flap and use of an extracellular matrix membrane, a natural gingival appearance by way of exposing the desired keratinized area can be promoted and provide a matrix to allow for migration of keratinized tissue to the surface.

CONCLUSIONRehabilitation of a previously diseased alveo-lar ridge segment in the anterior maxilla can be very complex and complicated. While regen-eration of lost bone height is the ultimate goal, vertical bone regeneration is often unpredict-able and difficult to achieve. Therefore, it is often necessary to plan for substantial soft tis-sue augmentation to help provide contours that mimic normal anatomy. Also, soft tissue augmentation prior to guided bone regenera-tion is often indicated to allow for tension free closure over future bone grafted sites.20 Fur-


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thermore, It is not only important to provide an increase in volume of soft tissue; it is of equal importance that the texture, tone, and color of this tissue mimic normal anatomical parameters to achieve an esthetically pleasing outcome. ●

Correspondence:Dr. Nina CunninghamEmail: [email protected]

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

References1. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of

bone defects by guided tissue regeneration. Plast Reconstr Surg. May 1988;81(5):672-676.

2. Linde A, Thoren C, Dahlin C, Sandberg E. Creation of new bone by an osteopromotive membrane technique: an experimental study in rats. J Oral Maxillofac Surg. Aug 1993;51(8):892-897.

3. Fugazzotto PA. GBR using bovine bone matrix and resorbable and nonresorbable membranes. Part 1: histologic results. Int J Periodontics Restorative Dent. Aug 2003;23(4):361-369.

4. Doblin JM, Salkin LM, Mellado JR, Freedman AL, Stein MD. A histologic evaluation of localized ridge augmentation utilizing DFDBA in combination with e-PTFE membranes and stainless steel bone pins in humans. Int J Periodontics Restorative Dent. Apr 1996;16(2):120-129.

5. Meltzer JA. Edentulous area tissue graft correction of an esthetic defect. A case report. J periodontol. Jun 1979;50(6):320-322.

6. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent. May-Jun 1980;1(3):205-213.

7. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Gen Dent. Sep-Oct 1983;4(5):437-453.

8. Seibert JS, Louis JV. Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure: a case report. Int J Periodontics Restorative Dent. Aug 1996;16(4):310-321.

9. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthet Dent. Oct 1980;44(4):363-367.

10. Takei HH, Scheyer ET, Azzi RR, Allen EP, Han TJ. Carranza’s Clinical Periodontology. 11th ed: Elsevier Saunders; 2012:595-600.

11. Wang PD, Pitman DP, Jans HH. Ridge augmentation using a subepithelial connective tissue pedicle graft. Pract Periodontics Aesthet Dent. Mar 1993;5(2):47-51; quiz 52.

12. Armitage GC. Development of a classification system for periodontal diseases and conditions. Ann Periodontol. Dec 1999;4(1):1-6.

13. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J periodontol. Jul 1996;67(7):658-665.

14. Veisman H. “The palatal roll”. Soft tissue ridge augmentation using a subepithelial connective tissue pedicle graft. Oral health. Mar 1998;88(3):47, 49-51; quiz 53.

15. Khoury F, Happe A. The palatal subepithelial connective tissue flap method for soft tissue management to cover maxillary defects: a clinical report. Int J Oral Maxillofac Implants. May-Jun 2000;15(3):415-418.

16. Mathews DP. The pediculated connective tissue graft: a technique for improving unaesthetic implant restorations. Pract Proced Aesthet Dent. Nov-Dec 2002;14(9):719-724; quiz 726.

17. Buser D, Dula K, Belser U, Hirt HP, Berthold H. Localized ridge augmentation using guided bone regeneration. 1. Surgical procedure in the maxilla. Int J Periodontics Restorative Dent. 1993;13(1):29-45.

18. Fugazzotto PA. Maintenance of soft tissue closure following guided bone regeneration: technical considerations and report of 723 cases. J periodontol. Sep 1999;70(9):1085-1097.

19. Carnio J, Camargo PM, Passanezi E. Increasing the apico-coronal dimension of attached gingiva using the modified apically repositioned flap technique: a case series with a 6-month follow-up. J periodont. Sep 2007;78(9):1825-1830.

20. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: a randomized controlled clinical study. J periodont. Feb 2000;71(2):188-201.

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