Journal of Implant and Advanced Clinical Dentistry August 2013

Volume 5, No. 8 August 2013 The Journal of Implant & Advanced Clinical Dentistry Treatment of OralMaxillofacial Trauma Biologic Shaping for Prosthetic Treatment

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 8 • August 2013 Table of Contents10 Case of the Month Comprehensive Treatment for Maxillary Locator Implant Retained Denture in the General Practitioner’s Office Ara Nazarian17 P redictable Immediate Implant Stabilization and Restoration Charles D. Schlesinger The Journal of Implant & Advanced Clinical Dentistry • 3



The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 8 • August 2013 Table of Contents27 Biologic Shaping From a Restorative Prospective Danny A. Melker35 C ontemporary Surgical Care of a Traumatic Oral Maxillofacial Injury in a Very Remote Location William Hartel, Steven Keir, Callief Shand, Ben Smith, Ralph Pickard The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 8 • August 2013Publisher Copyright © 2013 by LC Publications. All rightsLC Publications reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 • [email protected] the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company LC Publications (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by LC Publications, Las Vegas, Nevada, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDSMichael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MSThomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMDJohn Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDSLeon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMDStepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMDDavid Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhDCharles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDSSpyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDSSally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MATomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDSMassimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDSDouglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhDAlex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhDNicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhDPaul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDSDavid Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhDRonald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSDavid Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDSKenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDSIstvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 9

Case of the MonthComprehensive Treatment for Maxillary Locator Implant Retained Denture in the General Practitioner’s Office Ara Nazarian, DDS1 AbstractThe ability for the general practitioner to was fabricated to assist in the placement of deliver comprehensive dental care under dental implants. Following an osseointegra- one roof, in many cases, increases patient tion healing phase, locator attachments wereacceptance of treatment. The following case placed onto the healed dental implants anddemonstrates patient treatment with a maxillary the maxillary denture was modified to securelocator implant retained denture. The patient to these attachments. All care was deliveredhad all hopeless maxillary teeth removed and in one office, by one practitioner. Care in thissite preservation was performed at the time of manner streamlined the patient’s visits andsurgery. After a healing phase, a surgical guide allowed faster delivery of the final prosthesis.KEY WORDS: Dental implants, dentures, maxilla, prosthetics 1. Private Practice, Troy Michigan, USA10 • Vol. 5, No. 8 • August 2013

WiNlcakzoaeritaanlThe Journal of Implant & Advanced Clinical Dentistry • 11

Nazarian12 • Vol. 5, No. 8 • August 2013

NazarianThe Journal of Implant & Advanced Clinical Dentistry • 13

Nazarian14 • Vol. 5, No. 8 • August 2013

Nazarian Disclosure Dr. Nazarian reports no financial disclosures for this article. Correspondence: Dr. Ara Nazarian 1857 East Big Beaver Rd Troy, Michigan 48083 USA 248-457-0500The Journal of Implant & Advanced Clinical Dentistry • 15



Predictable Immediate Implant Wilcko et al Stabilization and Restoration Charles D. Schlesinger, DDS1 AbstractBackground: This paper describes the Results: By attaining an ISQ reading of 62,use of a dental implant with dual sta- an insertion torque of 50 N/cm at the time ofbilization technology to immediately placement due to the unique features of therestore a single tooth edentulous space. dual stabilization implant used in this paper, an immediate restoration was possible.Methods: A dual stabilization dentalimplant was placed using a flapless tech- Conclusions: Primary stability is a neces-nique. After placing this one piece implant, sary tenant for implant survival and it is evenan immediate impression for the final res- more crucial when immediately loading a den-toration was taken and full contour tempo- tal implant. The macro structure of the dentalrary restoration was put into full function. implant used in this paper allowed for immedi- ate loading capability for this particular case.KEY WORDS: Dental implants, immediate load, prosthetics1. Director of Education and Clinical Affairs, OCO Biomedical The Journal of Implant & Advanced Clinical Dentistry • 17

Schlesinger Background two ways; short-term stability (primary stability) and long-term stability(secondary stability). Pri-In 2000, Buser and Schenk postulated that pri- mary stability is dependent on the macro struc-mary stability was a necessary tenant for an ture of the implant while long-term stability isimplant to be successful.1 Stability at the time dependent on the microstructure of the implantof placement must be sufficient to enable the and its ability to promote laminar bone growth.implant to resist micro-movement until sufficientbiologic stability (secondary stability) is ade- Primary stability can be improved by adapt-quately established.2 During this period of transi- ing the surgical technique and by implant selec-tion between primary and secondary stability, the tion. For instance, the use of thinner drills andimplant faces the greatest risk of micro-motion wider and tapered implant designs will result inand potential failure. Extrapolating from research a high primary stability. This improvement is duein dogs, it is estimated that this period in humans to lateral compression of the bone trabeculaeoccurs roughly two to three weeks after implant and an increase of the interfacial bone stiffness.placement.3 A micro-movement of more than A high ISQ value achieved after such a proce-50-150 microns will disrupt Osseointegration.4 dure should not be relied upon as an indica- tion for immediate loading, since this value may Primary stability can be characterized by decrease over time as a result of mechanicaltwo different methods; insertion torque value relaxation. This means that a high ‘manipulated’and ISQ readings. An insertion torque value of ISQ value after using thinner drills and wider> 35N/cm is considered stable enough to load and tapered implants describes a temporaryclinically. Johansson & Strid described a tech- increase of stiffness rather than the true load-nique whereby bone quality as a function of bearing capacity of the bone-implant complex.5density and hardness could be derived from thetorque forces needed during the implant inser- In a review of the literature focusing on earlytion.5 ISQ readings (RFA-resonance frequency wound healing adjacent to endosseous den-analysis) utilizing an Osstell unit have been tal implants, Raghavendra et al9 point out that aproven to be a reliable indicator of implant sta- critical period occurs after implant placement,bility. Implant stability above 65 ISQ should be when osteoclastic activity has decreased the ini-regarded as optimal, above which few failures tial mechanical stability of the implant, but notshould be expected.6 An ISQ of < 50 may indi- enough new bone has been produced to providecate potential failure or increased risk of failure.7 an equivalent or greater amount of compensa- tory biological stability. ISQ values significantly Research has shown a relevant depen- decreased at 3 weeks and increased at 6 weeks10dency between insertion torque and bone qual-ity and a very weak dependency between RFA The dental implant used in this case reportand bone quality. Again, the statistical analy- (OCO Biomedical, New Mexico, USA) uses asis shows a quite weak correlation between patented macro structure to not only providelength or diameter and insertion torque, but it exceptional primary stability, but maintain thatshows a relevant correlation between length and stability while biological healing occurs. TheRFA.8 Implant stability can be categorized in combination of the imbedded tapered platform18 • Vol. 5, No. 8 • August 2013

SchlesingerFigure 1: Pre-op edentulous space #20. Figure 2: CBCT scan image of intended implant site.Figure 3: 1.8mm pilot drill with 8mm depth stop. Figure 4: Paralleling pin placed for position verification.and the auger tip place healing bone under ten- Clinical Casesion. This tension potentially speeds up thehealing of bone and decreases remodeling by A 33 year old female presented to the clinic withincreasing the expression of TGF-β1/OPG and an edentulous space at #20. The bicuspid hadresults in the disappearance of osteoclasts.11 been extracted approximately 17 years prior with- out socket preservation and her previous dentist In this paper, a case is presented which had placed a banded orthodontic retention devicenot only results in outstanding primary sta- at the time of extraction, thus resulting in a nar-bility, but allows at the time of surgery to rowed ridge. This was confirmed by CBCT scan.take the final impression, immediately loadwith a temporary restoration and allowed After local infiltrate anesthesia was achievedthe patient to leave the office without using Septocaine with 1:100,000 epinephrinethe need for an acrylic temporary partial. (Septodont Inc., New Castle, Delaware) a flapless approach was decided upon to gain access. The The Journal of Implant & Advanced Clinical Dentistry • 19

SchlesingerFigure 5: Guided tissue punch. Figure 6: Pilot drill with 10mm depth stop to create final depth and direction of osteotomy.Figure 7: Verification and adjustment of depth indicator Figure 8: Final osteotomy former to depth.on final osteotomy former. ate the mesiodistal space requirements.osteotomy position was marked using a #8 surgi- A 3.0 guided tissue punch was used tocal round bur through the gingival complex andmaking a purchase point in the crestal bone. This remove a plug of keratinized tissue and exposeis important in order to avoid having the pilot drill the osseous crest. A 3.25mm countersink wasskip across the crestal bone prior to engaging it. used to the appropriate platform depth to pre- pare the upper portion of the osteotomy to Orientation in 3 dimensions was estab- accept the imbedded tapered platform of thelished, and a 1.8mm pilot drill with an 8mm 3.0 Mini implant. The countersink also negateddepth stop was used to establish the path any variations in ridge topography. The combi-of the osteotomy. A paralleling pin with a nation of the embedded tapered platform, cor-3.25mm platform was inserted into the pilot tico micro threads and the patented auger tip ofhole to verify position, trajectory and evalu-20 • Vol. 5, No. 8 • August 2013

SchlesingerFigure 9: 3.0 Mini implant. Figure 10: Ratchet used to drive implant.Figure 11: Final torque reading of 50N/cm. Figure 12: ISQ reading of 62 on Osstell unit.the implant, makes dual stabilization possible. wheel. Once resistance was encountered, it Once the countersink procedure was was driven to its final position with a ratchet and finally a torque driver. A final torque value ofcompleted, the 1.8mm pilot with a 10mm 50N/cm was achieved. An ISQ reading of 62depth stop was taken to the intended implant for both M-D and B-L direction was recorded.length. It was determined that the bone den-sity was of a Type 3 variety. The black O-ring Since such a high primary stability wasdepth indicator was adjusted to approxi- attained and ideal soft tissue architecture wasmate the proper depth/length of the implant present, the decision to immediately restoreto compensate for the soft tissue thickness. was decided upon. The 3.0 Mini is a one piece implant with a 5.5mm tall abutment. A TRIP (tis- A 3.0 x 10mm mini-implant is taken to the sue retraction impression pickup) was snappedmouth utilizing an insertion driver and thumb- The Journal of Implant & Advanced Clinical Dentistry • 21

SchlesingerFigure 13: Fully seated implant. Figure 14: Final impression taken with TRIP.Figure 15: Final impression. Figure 16: Acrylic coping in place.into place and a polyvinylsiloxane (PVS) Two weeks post implant placement, theimpression taken along with a bite registra- patient returned to the clinic in order totion. The impression was kept in the clinic evaluate the soft tissue for esthetics anduntil the two week follow-up appointment just any possible change. At that point the finalin case soft tissue changes were present. impression was sent to the laboratory for fab- rication of the definitive restoration. If any A full contour temporary was fabricated significant changes in soft tissue architec-with a Protemp crown (3M ESPE, Irvine, ture were observed, the patient would haveCA). This temporary crown is made of unpo- been reappointed in one month for re-eval-lymerized Protemp material and once con- uation and possibly take a new impression.toured to the abutment, it can be polymerizedusing a standard curing light. Once occlu- The final IPS e.max crown (Ivo-sion was adjusted, the patient was dis- clar Vivadent, Amherst, NY) was tried-missed with a temporary under full function. in. Once the occlusion was properly22 • Vol. 5, No. 8 • August 2013

SchlesingerFigure 17: Fabrication of temporary with Protemp crown. Figure 18: Final impression taken with TRIP.Figure 19: Final crown delivered. Figure 20: Final X-ray at delivery.adjusted, the restoration was cemented Correspondence:with RelyX (3M ESPE, Irvine, CA) cement. Dr. Charles Schlesinger 9550 San Mateo Blvd. NE, Suite C Discussion Albuquerque, NM 87113 1-800-228-0477In this world of immediate gratification, somepatients are demanding shorter durations priorto final implant restoration. Up until now, withtypical implant protocols, the pros and consof immediate loading made this a risky proce-dure which many practitioners were unwilling toexperiment with. The case shown in this paperdemonstrates that immediate implant loadingmay be a possible option for some patients. ● The Journal of Implant & Advanced Clinical Dentistry • 23

Schlesinger The Journal of Implant & Advanced Clinical Dentistry Disclosure Dr. Schlesinger is an employee of OCO Biomedical. ATTENTIONPROSPECTIVE References 1. S henk, RK, Buser, D, Osseointegration: A Reality. Periodontology 2000 vol.17 AUTHORS issue1, 1998 (22-35) JIACD wants 2. S zmukler-MonclerS,SalamaH,ReingewirtzYetal. Timing of Loading and the to publish your article! Effect of Micro-Motion on Bone-implant Interface: a review of experimental literature. J Biomed Mat Res 1998;43:192-203. For complete details 3. M eltzer, Allen M, Primary Stability and Initial Bone-to-Implant contact: The regarding publication in Effects on Immediate Placement and Restoration of Dental Implants. Journal of Implant and Reconstructive Dentistry. 2009 vol.1, issue 1 JIACD, please refer 4. S zmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations to our author guidelines at Preliminary to Application of Early and Immediate Loading Protocols in Implant Dentistry. Clin Oral Implants Res 2000;11:12-25 the following link: 5. J ohansson P, Strid KG. Assessment of Bone Quality From Placement Resis- http://www.jiacd.com/ tance During Implant Surgery. Int J Oral Maxillofac Implants 1994;9:279-88. 6. G lauser R, Portmann M, Ruhstaller P, Gottlow J, Schδrer P. Initial Implant Stabil- authorinfo/ ity Using Different Implant Designs and Surgical Techniques. A comparative author-guidelines.pdf clinical study using insertion torque and resonance frequency analysis. Appl Osseointegr Res 2001;2:6-8. or email us at: 7. G ahleitner A, Monov G, Assessment of Bone Quality: Techniques, procedures, [email protected] and Limitations. In: Watzek G(ed). Implants in Qualitatively Compromised Bone. Chicago: Quintessence, 2004: 55-66 8. D egidi M, Daprile G, Piattelli A., Primary Stability Determination by Means of Insertion Torque and RFA in a Sample of 4,135 Implants. Clin Implant Dent Relat Res. 2010 Sep 17. doi: 10.1111/j.1708-8208.2010.00302.x. [Epub ahead of print] 9. R aghavendra S, Wood MC, Taylor TD. Early Wound Healing Around En- dosseous Implants: a review of the literature. Int J Oral Maxillofac Implants 2005:20:425-431. 10. M akary C, Rebaudi A, Sammartino G, Naaman N., Implant Primary Stability Determined by Resonance Frequency Analysis: correlation with insertion torque, histologic bone volume, and torsional stability at 6 weeks. Implant Dent. 2012 Dec;21(6):474-80 11. Kobayashi,Y et al., Force-Induced Osteoclast Aptosis in Vivo is Accompanied by Elevation in Transforming Growth Factor and Osteoprotegerin Expression. Journal of Bone and Mineral Research. Volume 15, Number 10, 2000.24 • Vol. 5, No. 8 • August 2013

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Biologic Shaping From Melkera Restorative Prospective Danny A. Melker, DDS1 AbstractThe following paper presents the concept technique that is significantly different than tra- of biologic shaping to facilitate the place- ditional crown lengthening. This paper will pres- ment of restorations without impingement ent the advantages of biologic shaping alongof biologic width. Biologic shaping is a surgical with photographic examples of the technique.KEY WORDS: Biologic width, osseous surgery, crown lengthening, dental prosthetics 1. Private practice, Clearwater, Florida, USA The Journal of Implant & Advanced Clinical Dentistry • 27

MelkerFigure 1: This patient will undergo a maxillary full-arch Figure 2: Upon reflection of the tissue with a full-thicknessrestoration to correct occlusal issues and mild periodontal flap due to the existing thick bone, the tooth surfacesdisease. When performing definitive restorative exhibited calculus located in concavities.procedures, it is critical to have an ideal periodontalfoundation to restore. There was an initial discussion onwhether to restore the bicuspids. After review of occlusalissues, it was decided to include the bicuspids in theprovisional phase of treatment.In today’s world of advanced dental procedures Often our restorative treatment plans lead and technology, traditional or classic dental us to subgingival margins, furcation involve- principles can easily be lost. This may espe- ment, root flutes and concavities, in additioncially be true with the decision-making process of to a multitude of complex issues. Many of thesaving teeth. Implants are wonderful options when issues we face are in the subgingival environ-appropriate, but they should not be selected when ment and require periodontal corrective proce-a tooth can be saved using a predictable peri- dures to return the foundation to a healthy state.odontal or restorative protocol that yields excel- Traditionally, crown lengthening was indicatedlent long-term prognoses. Too often today, good for deep subgingival margins, not only to facili-teeth are being removed in favor of implant place- tate impression making but also to correct bio-ment that is occurring in a clinical environment of logic width infringements. Biologic shaping isinadequate bone and soft tissue, as well as biome- a periodontal corrective procedure reported inchanical compromise. Biologic shaping and soft the literature1 that may complement traditionaltissue grafting offer a classic, proven methodol- crown lengthening, yet it differs from tradi-ogy for treating teeth with absolute predictability. tional crown lengthening in the following ways.28 • Vol. 5, No. 8 • August 2013

Melker● Traditional crown lengthening moves the aspect of the procedure is to remove any con- bone away from the margin. Biologic shap- cavities or furcation involvements. Once the ing moves the margin away from the bone. root surfaces are perfectly smooth, the flap is placed just coronal to the osseous surface and● Traditional crown lengthening requires osse- sutured in place. After 12 to 14 weeks of heal- ous surgery to re-establish the biologic ing, the restorative dentist simply places a new width. Biologic shaping may require minor margin just coronal to the gingival collar, which osseous surgery, but it generally avoids major allows for a perfect impression to be taken. This osseous surgery and still re-establishes bio- case also features the specific correction of a logic width because you have the choice mesial concavity on an upper first bicuspid ● to locate your restorative margin coronal to the old restorative margin (0.5 mm api- Article continues on following pages cal to the core is the coronal extent).● Traditional crown lengthening may open furcations and render a poor prognosis. Biologic shaping preserves the integrity of the furcation because aggressive osseous surgery was not needed. Traditional crown lengthening does not eliminate flutes, con- cavities or root clefts, leaving the postopera- tive lengthened crown at risk for disease recurrence due to increased susceptibility for plaque, calculus and caries formation. Biologic shaping leaves the subgingival area as smooth as glass; there are no areas for plaque, calculus or caries to hide.● Traditional crown lengthening worsens crown-to root ratio. Biologic shap- ing maintains crown-to-root ratio.● Traditional perio is about pockets and prob- ing. Biologic shaping is about preserving bone, smoothing out the rough spots, and making restorative dentistry predictable and a joy to perform.The concept of biologic shaping is presented inthe case that follows. The procedure stressesa 360-degree removal of tooth surface irregu-larities as well as all cementoenamel junctions(CEJs) and existing margins. An important The Journal of Implant & Advanced Clinical Dentistry • 29

MelkerFigure 3: From a slightly different angle, the irregular Figure 4: Using a C847-016 diamond bur (Axis Dental;contours of the bone can be seen. Osseous contouring will Coppell, Texas), the tooth surface is gently smoothed tobe necessary to create contours that will be compatible remove any irregularities of the root surface, as well aswith the soft tissue when it is replaced. Once the flap is all CEJs. The concavity on the upper first bicuspid is alsoreflected, a split-thickness dissection is used to preserve removed by gently blending the line angles approximatingthe periosteum for suturing of the flap and for stability. the concavity. Removal of the middle tooth surface of the bicuspid was avoided so as not to deepen the concavity.Figure 5: Once the gross removal of tooth structure is Figure 6: A C801L-023 diamond round bur (Axis Dental) iscompleted, an F847-016 diamond bur (Axis Dental) is used then used to properly contour the bone to mimic the softto smooth the root surface. tissue. The term for this procedure is “creating a parabolic architecture,” and it is the key to forming an ideal interface between bone, tooth and tissue. This phase of the surgery helps to avoid the formation of pockets between the bone and soft tissue when the tissue is replaced.30 • Vol. 5, No. 8 • August 2013

MelkerFigure 7: Upon completion of the biologic shaping and Figure 8: 5-0 chromic gut suture material is used toosseous contouring, an ideal foundation is created over replace the flap just coronal to the osseous underlyingwhich the soft tissue can be sutured in place. foundation. An important aspect of suturing the flap is to involve the periosteum as an attachment apparatus for the suture. The suture grabs the periosteum apically to allow for perfect placement of the flap so that no movement or displacement of the flap can occur. There is no need for any dressing to be placed.Figure 9: An occlusal view showing as much primary Figure 10: The day of the reline appointment after fourclosure of the flaps as possible. This allows for decreased weeks of healing. The provisionals will be closed to fit thediscomfort in the healing phase. Also note that no CEJs are teeth, leaving 1 mm of space between the provisional andpresent on any of the teeth. A recent article by Rapley and the tooth surface to allow for future biologic width growthCobb, et al.2 demonstrated with electron microscopy that in a coronal direction. No prepping of the tooth surface isthe CEJs tend to hold biofilm and that these areas can be done at this appointment.a source of periodontal breakdown. It is the belief of theauthor that by removing the CEJs, we are treating a cause The Journal of Implant & Advanced Clinical Dentistry • 31of future breakdown, thus changing the environment forlong-term maintenance.

Melker Figure 12Figure 11: Impressions day, 12 weeks post-op. All margins Figure 13are placed just coronal to the gingival collars. A size 7/00SilTrax® cord (Pascal International; Bellevue, Wash.) isplaced in the sulcus to allow for the lab technicians to trimthe dies. Correspondence: Dr. Daniel Melker is in private practice in Clearwater, FL and lectures nationwide on periodontics and prosthodontics. Contact him at 727-725-0100.Disclosure Figure 14The author reports no conflicts of interest with anything mentioned in this article. Figures 12–14: Final restorations placed. All are IPS e.max®References crowns (Ivoclar Vivadent; Amherst, N.Y.) with the exception1. M elker DJ, Richardson CR. Root reshaping: an integral component of of full-coverage gold on the second molars. All margins are supragingival. Ideal health exists between the crowns and periodontal surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296- the soft tissue with no inflammation present. (Restorations 304. courtesy of Dr. Howard Chasolen of Sarasota, Fla.)2. S atheesh K, MacNeill SR, Rapley JW, Cobb CM. The CEJ: a biofilm and calculus trap. Compend Contin Educ Dent. 2011 Mar;32(2):30, 32-7.32 • Vol. 5, No. 8 • August 2013

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Wilcko et al Contemporary Surgical Care of a Traumatic Oral Maxillofacial Injury in a Very Remote LocationWilliam Hartel, DMD1 • Steven Keir, DDS2 • Callief Shand, DDS3 Ben Smith4, DDS, MD • Ralph Pickard, MD5 AbstractThis case report is of a mid-20 year old and 12. The bullet exited the oral cavity barely male of slight build with an unknown grazing the superior labus. The patient suffered medical history. The patient was involved a fracture of the right mandibular body, per-in a firefight while patrolling an unstable area of haps in his fall or possibly as a result of blunta Middle Eastern country. He was struck from force trauma following the gunshot wound.behind with by a small caliber projectile in theright lower occipital region. The bullet entered Due to the remote location where the injuryinferior to the occipital bone, posterior to the occurred, limited prosthetic care was avail-right ear, slightly lateral to the mastoid pro- able. The patient’s injuries were diagnosedcess. The projectile transected the right lat- clinically and with state of the art radiographiceral pharangeal space, entering the oral cavity techniques. Once medically stabilized, thesuperior to the tongue, entered the mid hard patient’s oral maxillofacial deficiencies werepalate obliterating a section of the palate as treated with a prosthetic obturator. This treat-well as the maxillary alveolus and teeth 10, 11 ment provided the patient with a suitable aes- thetic outcome and improved his functionality.KEY WORDS: Trauma, prosthetics, maxillofacial surgery The Journal of Implant & Advanced Clinical Dentistry • 35

Hartel et al CASE REPORT the resulting impression separated upon removal due to undercuts in the sinus and the fact that theMr. G, a thin, twenty-something year old man serv- impression material extruded from the nose. Arching with the XXX National Police in XXX (Coun- bars were placed on teeth #s 3, 4, 5, 6, and 13,try location removed for security reasons), was 14 and ligated into position with circumdentalinvolved in a fire fight with members of an insur- wires. The mandible fracture was reduced andgent group. In the fight, he was shot in the back fixated and the external soft tissue injuries closed.if the head by a small caliber bullet. Within min-utes, medics performed an emergency cricothy- In the dental clinic, the alginate impressionroidotomy in the field to facilitate respiration. The was reassembled using cyanoacrylate glue, thepatient was evacuated by helicopter to a Com- excess material trimmed with a scalpel. It wasbat Hospital arriving in less than an hour from the then poured with dental stone in the usual man-time of his injury. He was stabilized in the trauma ner. After setting, the resulting cast was sepa-bay and taken to radiology where a 64 slice CT rated and trimmed, leaving a hole in the basescan was exposed. The resulting study revealed for access to the planned obturator. The entirethat the bullet entered just below right occipi- treatment team evaluated the resulting cast total bone, missing the right lateral process of the permit surgeons to determine how to revise theC1 by millimeter, fracturing the styloid process. wounds and dentists to determine a method toThree dimensional reconstructions showed the fabricate a prosthesis. The model was modifiedprojectile transected the lateral pharyngeal space, to match the anticipated outcome of the surgeryentered the oral cavity, and obliterated the left and a duplicate made reflecting those changes.anterior hard palate and floor of the left maxil-lary sinus as well as teeth 10, 11 and 12 and the While the patient convalesced in the ICU,associated alveolus as it exited the oral cavity. The the dentist mixed denture repair acrylic creatingpatient also suffered a fracture of the right man- a 3 x 4cm ball which was inserted into the sinusdible. This wound was treated successfully dur- void of the duplicate model. After initial curing,ing his initial surgery and is not addressed here. the mass was removed and allowed to bench cure. This portion was adjusted to permit inser- Within hours, the patient was taken to the tion on and removal from the cast. Denture teethoperating room where the surgical team replaced were chosen from a very limited selection andthe field tracheostomy with conventional tracheal affixed to the cast with self-cure acrylic “dots.”apparatus. Pulsating hemorrhage in the pharynx Using a “salt and pepper technique,” the palatalmade examination impossible. Once the arterial portion of the obturator/partial denture was fab-source was located, sutured and cauterized, intra- ricated, extending the borders into the interproxi-oral examination was performed revealing a 4x5 mal embrasures. After curing was complete, thecm oblong communication between the oral cav- device was removed from the cast by finger pres-ity and the left maxillary sinus. An alginate impres- sure from the underside of the model where asion was made of the upper arch using twice the hole had been made for that purpose. The devicenormal volume of impression material to fill the was then seated on the original model whereupper arch and left maxillary sinus. As anticipated, the labial extension was added. Upon comple-36 • Vol. 5, No. 8 • August 2013

Hartel et altion, four small holes were made along the sides prosthesis in the OR with a fissure burr. Wiredof the sinus extension of the acrylic and den- to teeth #’s 7, 8 and 13, the prosthesis servedtal amalgam was condensed so the appliance as a surgical stent to permit healing. Solidcould be visualized during radiologic examination. occlusion was verified on the right side. ● Several days later the patient was returnedto the operating room and anesthetized via thetracheostomy. The wounds were surgicallymodified, eliminating some boney undercuts asplanned on the cast. The obturator was insertedinto the oral/nasomaxillary defect with excellentapproximation. Because the right and left por-tions of the remaining hard palate were quitemobile, the obturator appliance was wired intoposition with 25 gage stainless steel circum-dental wires utilizing holes drilled through the The Journal of Implant & Advanced Clinical Dentistry • 37

Hartel et al38 • Vol. 5, No. 8 • August 2013

Hartel et al Disclosure The information contained in this article is the opinion of the author and does not reflect the views of the United States Army, United States Department of Defense, nor the United States Government. Correspondence: Dr. William Hartel  Role 3 MMU APO AE 09355The Journal of Implant & Advanced Clinical Dentistry • 39