Volume 3, No. 5 July/August 2011 The Journal of Implant & Advanced Clinical Dentistry CAD/CAM Veneers and Crowns Nano-Crystalline Calcium Sulfate Site Preservation
New ad To comeNobel BioCare
OsteogenicsPick up Flash file from May/June issue page 1
SURGICAL SUPPLY CO., INC.800.441.3100 BUY any 5 NuOss DS Syringes Get 1 FREE* August 2011 only. Must mention this ad. DELIVERY SIMPLIFIEDwww.acesurgical.com A NATURAL BONE MINERAL MATRIX DELIVERY SYRINGE SYSTEM NuOss™ – A natural, porous bone mineral matrix. It is produced by removal NuOss™ DS – Our NuOss™ of all organic components from bovine bone. Due to its natural structure the anorganic cancellous granules are now available bone mineral of NuOss™ is physically and chemically comparable to the mineralized pre-loaded into a delivery syringe matrix of human bone. for ease of product placement. NuOss™ DS Price *Clinical Histology: 5 Months Vital bone apposition can DELIVERY SYRINGE $54.99 be seen directly on the 79.99 Area of newly formed woven particles of NuOss. • Cancellous Granules 121.99 bone with osteoblasts lining • New Vital Bone - red • Particle size = .25-1.0mm the bone. • NuOss - tan Number Description – Volume • Osteoblasts - blue 509-9025 NuOss™ DS – .25cc • Soft Tissue - white/grey 509-9050 NuOss™ DS – .50cc 509-9010 NuOss™ DS – 1.0cc * Rohrer, Michael, DDS, MS; Prasad, Hari, BS, MDT; University of Minnesota, Hard Tissue Research Lab Stevenel’s Blue and Van Gieson’s Picro Fuchsin, 100x magnification Manufacturer: Collagen Matrix, Inc., 15 Thornton Road, Oakland, NJ ACE Surgical Supply Company, Inc., 1034 Pearl Street, Brockton, MA 02301 • Call 1.800.441.3100 • Order online @ www.acesurgical.com *Buy 5 and get the 6th NuOss DS FREE. Mix and match, lowest priced item is FREE. All items must be on the same order. • Valid only August 1st - 31st, 2011
Guided implantdentistry withoutsoftwareinvestment.Buy 1 PFlRanEAE sSsuisrtgi(G$5u1id7e)®Get 1Msuomreminefrodoeanl?this Use promocode JIACDPA when placing a PlanAssist order. Offer valid until September 30th 2011. SurgiGuide® voucher valid for up to 3 months from the PlanAssist order date.www.dentalplanit.com/microsite
INNOVATION It’s Free. Just Ask for It!Purchase any MIS implants in multiples of 5 (minimum10 implants) and receive one free CPK - CompleteProsthetic Kit, with each implant. MIS’ Complete Prosthetic Kit (CPK) contains the components you need to restore a \"straightforward\" implant case.First time MIS user? *The offer cannot be combined with other offers. Free items may not be returned or exchanged.Ask for our free implant delivery system.© MIS Corporation. All rights Reserved. MIS offers a wide range of innovative kits and ® accessories that provide creative and simple solutions for the varied challenges encountered USA in implant dentistry. To learn more about MIS visit our website: misimplants.com or call us: Make it Simple 866-797-1333 (toll-free)
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 5 • July/August 2011 Table of Contents21 Case of the month Restoration of Anterior Ridge Deficiency with Block Allograft and Dental Implants: A Visual Case Report Sammy S. Noumbissi29 C AD/CAM Dentistry - Computerized Anterior Restorations Part 1: CAD/CAM Veneers and Crowns Dean C. Vafiadis The Journal of Implant & Advanced Clinical Dentistry • 5
All-Natural, Bioactive ProductsDesigned to Stimulate the Healing Process DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1 Biopsy of Biopsy of • The signaling proteins (growth factors,DynaMatrix autogeneous glycoproteins, glycosaminoglycans) gingival graft communicate with the body to help treated site stimulate the natural healing process2 Accell is an all-natural concentration • Accell has nearly 5 times more BMPs of Bone Morphogenetic Proteins than DBM alone and each lot is validated (BMPs) and Growth Factors with for osteoinductive properties 3,4 Demineralized Bone Matrix (DBM) that directs and charges stem cells • Accell in delivered as an easy-to-handle to acclerate the body’s natural putty in a pre-filled syringe healing response. • Accell is the only allograft product that contains this powerful combination of DBM, BMPs and Growth Factors 1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543. 2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5. 3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract). 4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract). Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Burlington, MA 01803 USA Call: +1-781-328-3490 Call: 1-866-902-9272 / Fax: 1-866-903-9272 Fax: +1-781-328-3400 [email protected] www.keystonedental.com
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 5 • July/August 2011 Table of Contents39 T he Use of a Novel Nano-Crystalline Calcium Sulfate for Bone Regeneration in Extraction Socket Ziv Mazor, Robert Horowitz, John Ricci, Harold Alexander, Ioana Chesnoiu-Matei. Sachin Mamidwar51 T he Influence of Smoking on Moderately Rough-Surfaced Dental Implants: A Literature Review Osama Noorwali, Hassan Ali Alremthi, Douglas Deporter The Journal of Implant & Advanced Clinical Dentistry • 7
Introducing the FeaturesPLANMECA® ProMax® 3D • 5 selectable, single scan fields of viewMax... Most common uses: ø5 x 5.5 cm - Individual tooth or other point of interest ø10 x 5.5 cm - Mandible or maxilla ø10 x 9 cm - Mandible and maxilla ø10 x 13 cm - Mandible or maxilla and sinus ø23 x 16 cm - Full maxillofacial image, upper or lower skull • The smallest and largest fields of view on the market giving the ProMax 3D Max more versatility then any other comparable X-ray unit • Large view, single acquisition - dual scan for full maxillofacial and skull imaging ø23 x 26 - Full skull covers the whole head and is therefore extremely useful for surgical and orthodontic procedures, as well as TMJ, ear, sinus, and airway studies. Using the large volume size, it is possible to generate a 2D cephalometric image with a single mouse click. • Automatically adjusts volume sizes for children When the child patient size is selected, the fields of view (volume sizes) and the dosage parameters are slightly reduced • More than 36 pre-programmed targets From a single tooth scan to the whole skull, the ProMax 3D Max has 18 pre-programmed targets, 5 adult fields of view, 5 child fields of view, and more • Patented SCARA technology allows limitless imaging possibilities • Full view, open patient positioning for standing, sitting, and wheelchair accessibility • Space saving A small footprint and compact design make the ProMax 3D Max the smallest large FOV on the market • High resolution, flat panel technology • Now compatible with Mac OS environment PLANMECA®PLANMECA® For more information on PLANMECA ProMax 3D MaxProMax® 3D Max please call... 1-630-529-2300 or visit us on the web @ www.planmecausa.com
Implant Planning in 20 seconds withHigh quality 3D Implant planning system from CA, USA.• Extremely fast and easy • Software developed from Silicon Valley,• High quality and accurate visualizations • Surgical Guide made from California• No conversion, pre-processing, • Expert support provided from or preparationFind out why so many doctors choose Invivo5. Call for a demonstration today! www.anatomage.com Tel) 408-885-1474 Fax) 408-295-9786 111 N. Market St. #800 San Jose, CA 95113
Treat small spaces with confidence Laser-Lok 3.0 placed in Radiograph shows proper esthetic zone. implant spacing in limited site. Image courtesy of Cary Shapoff, DDS Image courtesy of Michael Reddy, DDSIntroducing the Laser-Lok® 3.0 implantLaser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal boneon the implant collar1. Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array ofprosthetic options making it the perfect choice for high profile cases. • Two-piece 3mm design offers restorative flexibility in narrow spaces • Implant design is more than 20% stronger than competitor implant2 • 3mm threadform shown to be effective when immediately loaded3 • Laser-Lok microchannels create a physical connective tissue attachment (unlike Sharpey fibers) 4 For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010.2. Implant strength & fatigue testing done in accordance with ISO standard 14801.3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC.Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288.4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim.International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP10109 REV D SEP 2010
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 5 • July/August 2011Publisher Copyright © 2011 by SpecOps Media, LLC. All rightsSpecOps Media, LLC 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 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 SpecOps Media, LLC (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 SpecOps Media, LLC, Saint James, New York, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 11
one Graft by Any OtherB Name Wouldn’t be Fact not fiction... Scientifically-proven in vivo rat model to confirm osteoinductivity (Urist’s model) • Precisely sized mineral-retained cortical cancellous bone chips– osteoconductive • Biocompatible inert biological carrier that offers exceptional handling and stability at the graft site • Some clinicians report stabilized implant placement at 5.5-6 month re-entry.1 The moral of the story... Don’t be persuaded by tales that other products offer the same predictable results you’ve come to expect from Regenaform®.Regenafil®, Regenaform®, pericardium and cortical allograft bone pins are processed by RTI Biologics, www.exac.com/fact © 2011 Exactech, Inc.Inc. and are distributed by Exactech, Inc. Oralife® allografts are processed by LifeLink Tissue Bank and 1-866-284-9690distributed by Exactech, Inc.1. Publications on file at Exactech.
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 Robert Horowitz, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Michael Huber, DDS Terry Rees, DDSMichael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MSThomas Balshi, DDS Tassos Irinakis, DDS, MSc 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, MScDDonald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDNicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDSDaniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMDGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDSStepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMDDavid Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhDSpyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDSSally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDSTomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MAMassimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDSDouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDSNicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhDPaul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhDScott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhDDavid Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDSRonald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhDDavid Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSKenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDSIstvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDSMichael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 13
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 mostsafe, reliable and successful manner for their patients.The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implantplacement to final crown restoration. The natural profile developed during healing is matched perfectly in permanentrestorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAMsolutions.Neoss Inc., 21820 Burbank Blvd. #220, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com
Editorial Commentary Innovation StifledDo me a favor. If you still have your old literature files from the time when you support team and financial backing to assist you were a resident, dust those bad boys with your work? Most of the lit we see published today comes from universities or by companyoff and take a long hard look at them. What do sponsored individuals. Why? Because theseyou see? You probably see some great classic lit are the only people that can afford to put suchthat brings back memories of staying up all night studies together. Who is going to pay for an IRBcramming your noggin full of knowledge. You membership and private statistician on their ownprobably also remember analyzing each article dime? No one, that’s who.for its scientific merit, its pros and cons, and its The net result of this new direction ofsignificance to our profession as dental surgeons. literature publication is that innovative articles andNow, I want you to compare much of this publications from private practitioners are quicklyliterature to some of the lit that we see today. disappearing. Many journals are simply no longerLook closely. Carefully compare the two. Do you publishing these types of articles. They are beingnotice anything different between the old lit and rejected because they are not perfect studies. Ithe new lit? Well, as a Co-Editor-in-Chief of a know this personally, because I have my fair sharedental journal and a prodigious publisher of dental of personal articles rejected for all of the reasonslit, I noticed something very quickly. I mentioned before. Some of my articles wereAfter scrutinizing and comparing much of set up as darn near mirror images of some of ourthe literature from yesteryear to that which is classic lit. They had the same statistical analysis,being published today, I came to the unsettling the same methods (with newer materials andconclusion that most of the older lit would never updated technique modifications), larger ‘n’ size,be published today. Yes, it is true. Check out and expanded reviews of the lit. Many of thesesome of the older studies that we consider articles did not even make it to review. They wereclassic literature. No controls. Small ‘n’. No IRB. rejected because the statistical analysis was notMinimal statistical analysis. The list goes on and adequate or the ‘n’ was too small (even thoughon. In spite of these shortcomings, we consider they were larger than older studies).many of these articles to be gospel and teach So, apparently, what was good enough in thethem as so in our residency programs. past is not good enough for today? If so, why doNow, look even more closely at the two groups we continue to base much of our teachings andof lit and see if you notice anything else. If you current surgical techniques on these “inadequate”look at our newer literature, you will notice that publications of the past? Are we beingmany studies have improved on the shortcomings hypocritical? I think so. ●of the past. Huge ‘n’, double controls, split mouth,statistical analysis performed by supercomputers,IRB approval, disclosure, etc. Yes, these are allimprovements for the scientific merit and validityof the research. However, do you notice anythingelse? Do you notice that in order to publish such Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MSstudies as we see today, you need to have a Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 15
GUIDOR® Bioresorbable Matrix BarrierBarrier function is maintained for 6 weeks after surgery and gradually degrades until the matrix is fully absorbed in 6 to 12 months. 15.00mmIndications 20.00mmThe use of GUIDOR to aid in bone regeneration and augmentation should be limited to defects and concavities within skeletalcontours and to defects/situations where moderate increase of bone volume beyond the skeletal contours is desirable. In all cases,appropriate space making support should be used.ContraindicationsGUIDOR is contraindicated in those situations where general periodontal surgery should not be performed. Currently there are noknown additional contraindications to the use of GUIDOR.For Excellent predictability and ease of use in GBR SPrecautions 5090GUIDOR is not intended for use in cases other than those described under indications and has not been clinically tested in patients P3 - 15mm x 20mm Matrix Barrierwith extra large defects, for extensive bone augmentation, or for use in the treatment of failing implants.GUIDOR has not been clinically tested in pregnant women or in immunocompromised patients (patients with diabetes, HIV,undergoing chemotherapy or irradiation).Adverse ReactionsPossible complications following any oral surgery include thermal sensitivity, ap sloughing, some loss of crestal bone height, abscessformation, infection, pain, and complications associated with the use of anesthesia; the patient may experience minor discomfort fora few days. 12 GUIDOR® has a double layered matrix with two uniquely perforated layers: The two layers are separated by inner spacers (1) to form an interspace (2) into which tissues can grow. SPECIAL PROMOTION! A $90.00Buy 3 P3s get 1 P3 FREE!* Value *This o er ends 1/31/11ORDER TODAY! 1-877-GUIDOR1 (1-877-484-3671)www.GUIDOR.com ©2010 Sunstar Americas, Inc. GDR10038 10272010 V1
... over 1 ROXOLID®sold! THE NEW “DNA” OF IMPLANT MATERIALS ROXOLID – the first TiZr material developed for dental implantology. Confidence when placing small diameter implants Flexibility of having more treatment options Designed to increase patients’ acceptance of implant treatment Straumann® SLActive million im plants Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us
Less pain for your patients.1 Less chair side time for you.1 IntroducIng Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits: For your patients... Patients treated with Mucograft® require 5x less Ibuprofen than those treated with a connective tissue graft1 Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2 For you... Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1 Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery Ask about our limited time, introductory special! Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. GeistlichSöhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010
It’s Like a Magnetfor New BoneHEALOS® is an attractive choice for building new bone. © OraPharma, Inc. 2011 Rx only. Please refer to the package insert for further details. Distributed by: OraPharma, Inc. Manufactured by: DePuy Spine, Inc.HEALOS® Bone Graft Substitute for Dental Applications is intended to HEALOS® is a registered trademark of DePuy Spine, Inc.fill, augment, or reconstruct periodontal and/or bony defects in the HEA-178-10 3/11upper or lower jaw.• Excellent clinical handling properties• Provides an osteoconductive scaffold that supports cell adhesion• Biomimetic composition (70% collagen, 30% mineral) mimics immature bone to encourage new bone growth• 98% porosity allows material to soak up endogenous blood and draw in osteoprogenitor cells comprehensively within the material• Radiolucent so new bone is easily distinguished on a radiographHEALOS® is intended to fill, augment, or reconstruct periodontal and/or bonydefects of the upper or lower jaw. HEALOS® is a bone graft substitute that isresorbed and remodeled into new bone as part of the natural healing process.Order HEALOS® Bone Graft Substitute Today!Call a HEALOS® representative: 1-866-273-7846or visit us at www.healosfordental.com
Case of the month NoumbissiRestoration of Anterior Ridge Deficiency with BlockAllograft and Dental Implants: A Visual Case ReportSammy S. Noumbissi, DDS, MS1 AbstractThe aim of this case report is to demon- cal site that creates additional patient morbidity. strate an alternative technique for res- Utilization of block allografts, as described in toration of an anterior ridge deficiency this case report improves patient post-surgicalto facilitate placement of dental implants. Tra- recovery by elimination of the secondary surgi-ditionally, deficiencies of this magnitude have cal site for autograft harvest. The block and par-been restored with autografts such as ramus ticulate allograft used in this case report healedblocks, symphysis blocks, iliac crest bone, or uneventfully and allowed for placement of multipletibial bone. These traditional regenerative tech- dental implants which have been successfullyniques have the drawback of a secondary surgi- restored and in function for more than 2 years.KEY WORDS: Dental implants, bone graft, block graft, guided bone regeneration 1. Private Practice Limited to Implant Dentistry, Silver Spring, Maryland, USA The Journal of Implant & Advanced Clinical Dentistry • 21
NoumbissiInitial presentation Siebert 1 Ridge deficiencyPreparation of recipient site22 • Vol. 3, No. 5 • July/August 2011
Noumbissi Block allograft try-inBlock allograft fixaton andparticulate grafting Percicardium membrane The Journal of Implant & Advanced Clinical Dentistry • 23
NoumbissiTemporization during healing One month healingFive months healing24 • Vol. 3, No. 5 • July/August 2011
Noumbissi Re-entry flapImplant placement. Additionalparticulate bone was placed overexposed implant.Correspondence: Final prosthetic restoration. (Dr. D. Simpson)Sammy S. Noumbissi, DDS MS The Journal of Implant & Advanced Clinical Dentistry • 25801 Wayne Avenue, Suite G200Silver Spring, MD 20910Tel: 301 588-0768Fax: 301 588-0873E-Mail: [email protected]: www.maryland integrativedentistry.net
BTI SURGICAL EXPLANTATION KIT PATENTED This innovative system ensures a non-traumatic extraction of both internal and external connection implants.200 Ncm counter-torque wrench. Implant extractors Set of extensors for Handle for Torque for external and counter-torque wrench tips to carry internal connection. wrench for the the extractor. different clinical situations. The extractor is fixed to the implant following its axial direction (after selecting the extractor according the connection). Next, torque is applied gently in counterclockwise direction until the implant is fully extracted.Set of non-traumatic trephine drills www.bti-implant.com / www.endoret.usBTI of North America Biotechnology Institute BTI Deutschland GmbH. BTI Implant Italia Srl. BTI de México BTI Portugal1730 Walton Road San Antonio 15 - 5º Mannheimer Str. 17 Piazzale Piola n.1 Lope de Vega 117, 701-702 R. Pedro Homem de MeloSuite 110 01005 Vitoria (ALAVA) 75179 Pforzheim 20131 Milano 11570 Col. Chapultepec Morales 55 S/6.03Blue Bell, PA 19422-1802 US SPAIN GERMANY ITALY México DF • MEXICO 4150-000 Porto • PORTUGALTel: (1) 215 646-4067 Tel.: (34) 945 140 024 Tel: (49) 7231 428060 Tel.: (39) 02 70605067 Tel.: (52) 55 52502964 Tel: (351) 22 618 97 91Fax: (1) 215 646-4066 Fax: (34) 945 135 203 Fax: (49) 7231 4280615 Fax: (39) 02 70639876 Fax: (52) 55 55319327 Fax: (351) 22 610 59 [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]
CAD/CAM Dentistry - Computerized Vafiadis Anterior RestorationsPart 1: CAD/CAM Veneers and Crowns Dean C. Vafiadis, DDS1 AbstractRecently, an influx of computer technologies ventional techniques with high level of precision. and CAD/CAM designs have been intro- Using a combination CAD/CAM and robotics, duced to the restorative dentist. These the technology of final implant abutment fabrica-technologies have helped streamline our fabrica- tion and final CAD/CAM restoration is predict-tion protocols, reduced clinical chair-time and able for the clinician. The aim of this article is toreduced laboratory costs. In addition, the accu- demonstrate cases in which CAD/CAM technol-racy of these techniques have equaled our con- ogy was utilized for esthetic anterior restorations. KEY WORDS: CAD/CAM, dental prosthetics, veneers, esthetics1. Clinical Associate Professor of Prosthodontics, New York University School of Dentistry; Private Practice, New York, New York, USA. The Journal of Implant & Advanced Clinical Dentistry • 29
VafiadisFigure 1: Case 1 fractured lateral incisor. Figure 2: Close up of fractured lateral incisor from Case 1. Background Figure 3: Ideal contour composite (ICC).Over the past few years, an influx of computer CASE REPORT 1technologies and CAD/CAM designs have been Cad/Cam Veneerintroduced to the restorative dentist.1-3 Thesetechnologies have helped streamline our fab- A patient presents with her anterior left lateralrication protocols, reduced clinical chair-time incisor fractured due to a traumatic incident andand reduced laboratory costs. In addition, the one-half of the incisal edge remaining, radiographaccuracy of these techniques have equaled our evidence and peri-apical pathology was not evi-conventional techniques with high level of pre-cision.4-5 Using a combination CAD/CAM androbotics, the technology of final implant abut-ment fabrication and final CAD/CAM restoration ispredictable for the clinician.6-7 In addition, it hasenhanced the education experience of our newlytrained professionals. Anterior restorations cannow be fabricated in a one-visit protocol.8 Theshade matching characteristics that were verydifficult, and required many patient visits can bepredictably performed, chair-side by the clinician.The use of in-office CAD/CAM digital acquisi-tion units and scanners like Sirona/Cerec andE4D/D4D will be highlighted. The fabrication ofcrowns and veneers that are life-like in color andtranslucency as well excellent marginal integritywill be demonstrated. Computerized restorativedental restorations for our patients can be moreefficient, more predictable and save chair time.30 • Vol. 3, No. 5 • July/August 2011
VafiadisFigure 4: “Occlusion Window” used with a replicating Figure 5: “Occlusion Window” used with a replicatingmode in a facial view, that captures shape, incisal edge mode in a facial view, that captures shape, incisal edgeposition, and texture created from the ICC position, and texture created from the ICC.Figure 6: Preparation window. Figure 7: Margination window.Figure 8: Restoration design window. dent (Figures 1,2). After anesthesia was given, an Ideal Contour Composite, (ICC) was created intra-orally (Figure 3). It was scanned (6 views in total) with an intra-oral scanner (Cerec AC, Sirona dental systems, Charlotte, NC) in cor- relation mode. This is in the “Occlusion Win- dow” and uses a replicating mode in a facial view, that captures shape, incisal edge position, and texture created from the ICC (Figures 4,5). Preparation for porcelain veneer resto- ration was completed and the scan of the preparation (7 views in total) was captured in “Preparation Window” (Figure 6). In addi- The Journal of Implant & Advanced Clinical Dentistry • 31
Vafiadistion with the facial scan and preparation scan, and parameters. The main parameters for thean additional scan (6 views in total) was cap- porcelain laminate veneer were set as follows:tured of a wax bite registration in MIP posi- Marginal Thickness:............................................. 70tion (maximum inter-cuspal position) from an Occlusal offset:....................................................... 50occlusal vantage point, “Antagonist Window”. Cement thickness: ............................................... 30 Minimal Occlusal thickness:.......................... 750 The next window is called “Margination”,where the clinician carefully chooses the mar- Although the learning curve on these designgin of the restoration as well as the EDIT mode applications and design tools may take a fewwhere we can see through the restoration (Fig- days to master, the results are worth the efforture 7). This can be viewed in 10-15 X magnifi- spent. Once the final design is approved andcation. The clinician chooses the correct margin the slight changes have been made the fol-circumferentially around the preparation. In this lowing window will ask the clinician to choosemargination method the clinician marks the fin- the correct block size and type. In this patientish line of the preparation. This may be more treatment an Empress- Multi-Cad (Ivolclar-accurate than the pindex method of die prepara- Vivadent, Amherst, NY) block was chosen.tion, because there may be errors in pouring ofthe cast, ditching of the die, and it may be dif- CAD Block Selectionficult to read. This will give increase precisionof all restorations. After this is approved for The advantages of in-office fabrication includeaccuracy, the design advances to the following the clinican making the decisions to get thewindow. The next window shows the path of color, value and hue exactly they way he orinsertion and reveals any undercuts in the prep- she sees it. First, the dentin or backgroundaration. If deficiencies in the preparation are tooth shade must be matched. If this has a lowevident, this would be the best time to re-pre- value or dark (C4-D2 range) and needs to bepare and make any corrections. If this is neces- lightened, then a more opacious block maysary, new scans of preparation must be made be selected (ie. Vita Mach II, VITA Porcelain,at this time. If the path of insertion is approved VIDENT, Brea Ca.). If the dentin shade hasthe program will continue to the design window. good value (A3–B2 range) then a more trans- lucent block may be chosen (ie. Vita-Tri-lux During the restoration design window the forte or Empress Cad multi-block). Secondly,computer software will give the clinician a the clinician must choose the best match ofdesign based on the correlation scanned ICC the adjacent tooth using a digital shade guideand the data base of lateral incisors installed or a universal shade guide. When the finalin the software (Figure 8). It is up to the cli- shade has been selected, then a correct blocknician to evaluate the proper position, incisal of the same shade must be selected taking intoedge, line angles, occlusal clearance and length account for the dentin shade. Usually the finalof the restoration. Several windows of this soft- block chosen will be one shade lower valueware help the clinician see the design in dif- than the desired shade. This is because as theferent vantage points as well as edit buttons block gets milled, the amount of porcelain mate-32 • Vol. 3, No. 5 • July/August 2011
Vafiadisrial becomes thinner and therefore increases Stain and Glazethe value. For example, a dentin shade of A3,final desired shade A1, the correct block should Each manufacturer has a specific stain andbe A2 (Vita-triflux, or Empress Multi-cad). If glaze kit. It is highly recommended to fol-the Dentin shade is D3 and final shade is B1, low the specifications of the manufacturesthen a Vita Mark II block final shade A1 would steps in staining and glazing. It may be abe the correct choice. These blocks are best good idea to test the porcelain oven set-for translucent and teeth in the Vita shade A-1 tings to make sure they are increasing andand B-1 ranges. They pick up colors from the decreasing at the proper time and tempera-adjacent teeth and are reflective in this nature ture as specified. In this patient treatmentand result in a very aesthetic restoration. we used the Empress Multi-Cad block, so the stain and glaze with the Ivoclar Empress Once the correct cad block is chosen, it is simple staining kit was used. Colors usedplaced in the milling machine (MC XL, Sirona in this restoration are applied as follows:Systems). The total milling time for this restora- ● U niversal Glaze: thin layer, 2- 3 timestion was 8.5 minutes. After the milling processhas been completed the restoration is tried in with ultra-thin brushwith water for marginal integrity, occlusion, ● A -1 shade: thin area at cervical, to addinter-proximal contacts. Any adjustments thatare necessary are made, intra-orally with high- slight pigmentspeed rotary instrument (Brasseler #8862-012 ● B lue shade: thin spots on the lingual(red stripe) Brasseler, USA) with high watervolume. Depending on the patients’ natural surface of the incisal edge areaenamel on the adjacent teeth, it may be nec- ● W hite Shade: thin layer over theessary to add the following contour changes:● Line Angles, distal and mesial mid portion of restoration to● Mamelons match adjacent central incisor.● Incisal line angles and characteristics● Differentiations in texture Note: If the color is not correct when held● Third dimensional shaping next to adjacent natural teeth. Rinse with dis-● Cervical thinning tilled water and re-apply all steps until the● Horizontal lines on facial/incisal areas match is acceptable. Digital shade guides and digital photography will help evaluate color. After all the contouring and shaping iscompleted, the final try-in with water is con- Once the color and stain is acceptablefirmed with digital photography. This will allow it is placed on the wafer shelf of the porce-the clinician a true representation of the con- lain oven (VITA Vacumat, 40T, Vident, Breatours as the light is reflected off of the facial, CA.) and glazing cycle will begin. This resto-mesial and distal surfaces. If this is acceptable ration glazing cycle was 12 minutes. Oncethen the glazing and staining phase may begin. the glazing has been completed the restora- tion is allowed to cool to room temperature, and the it is etched with 25% hydrofluoric acid porcelain etch (LabETCH, PULPDENT Corporation, Watertown, MA) for 5 minutes. The Journal of Implant & Advanced Clinical Dentistry • 33
Vafiadis At this time the restoration is ready for CASE REPORT 2cementation. CAD/CAM Crown The following steps were used for Anterior central incisor fractured dis-cementation: tal edge (Figure 10). Full crown prepa-1. T he prepared tooth is etched with 20% ration, margination and design (Figures 11,12). 2 Weeks post insertion (Figure 13). phosphoric acid for 15 seconds.2. D entin bond solution (Ivoclar, Excite-pen) DISCUSSION is placed for 20 seconds, air dried, and In a one-visit protocol many anterior restorations cured 20 sec. on teeth and implants can be completed pre-3. O pti-bond Solo-plus 1, thin layer 20 dictably with patient chair time reduced by up to seconds, air dried, cured 15 sec. 50% and laboratory costs reduced as much as4. O pti-bond 2 FL, thin layer on the inter- 70%. Although there is a cost for the monthly nal surface of veneer (not cured) payment of the intra-oral scanner and Cam mill-5. F lowable composite, shade B1 (Luxa-Flow, ing machine, there is no limit to the amount of Zenith-DMG, Englewood, NJ) flowed onto restorations that can be fabricated within that preparation and internal surface of veneer. one month period. The cost of supplies, lab6. Veneer is placed in proper position, time, casts, mounting, pick-ups and deliveries, excess is wiped with small brush, cer- and re-makes due to color and fit, may be more vical, lingual and inter-proximal. costly than one monthly payment. The time and7. T ack cure on cervical area with 3 mm effort by all parties involved makes the anterior light tip (Practicon, Greenville, NC) tooth one of the most difficult to match. Shade8. Inter-proximal serrated blades are taking and shade selection has been difficult placed on the mesial first, cured, to reproduce using conventional laboratories, then on the distal area. especially when one anterior tooth is involved.9. C leaning with small scaler on the lingual, Too often this requires many visits and many and cured anxious moments of the patients and clinician10. Full cure the entire restoration to see if it will look pleasing and natural. It is11. Trim off excess with rotary instrument definitely an art form within itself and needs personal and custom education to become pre- H-132-008, (red band) carbide dictable. Although these technologies have (Brasseler, USA) been perfected over the past 5 years, the true12. Polish with high speed, gray and yellow reason for the highly aesthetic restoration has band porcelain polishing bur (# 136c to do with the new block choices that allow for Mini, Shofu, San Marco, California, USA) translucency, fluorescence, gradient color, and 2 weeks post insertion is shown in Figure 9. life- like hues and values. A list of the blocks most commonly used by the author is listed in Table 1. To ensure long-lasting restorations, a34 • Vol. 3, No. 5 • July/August 2011
VafiadisFigure 9: Case 1 two weeks post insertion of final Figure 10: Case 2 fractured central incisor.restoration.Figure 11: Case 2 full crown preparation. Figure 12: Case 2 margination window. Figure 13: Case 2 two weeks post insertion of final restoration. The Journal of Implant & Advanced Clinical Dentistry • 35
Vafiadis Table 1: Blocks Most Often Used in CAD/CAM Dentistry Ivoclar Vivadent VITA Vident Empress CAD Multi - inlays, crowns Vita Real Life CAD - ant. crowns, veneers Empress CAD LT, HT - crowns, veneers Vita TriLux Forte - ant. post, crowns E-max CAD - post. crowns, implant crowns Vita Mark ii CAD - post. Crowns, implant crownsfinal analysis of the occlusion will be evaluated Correspondence:so that on all excursive movements there are Dr. Dean Vafiadisno excessive forces on the porcelain veneer. In New York Smile Instituteright and left working movement it is assured 693 Fifth Avenue @54th Street - 14 Floorthat the lower left canine does not come in New York, NY 10022contact with the lateral incisor restoration. Phone: (212) 319-6363 (800) 998-NYSI: Author Commentary [email protected] takes approximately 12 individuals and 18 Disclosuresteps to fabricate a single unit ceramo-metal The author reports no conflicts of interest with anything mentioned in this article.restoration. The hours spent by the labora-tory, staff members and clinicians needs to be Referencesre-evaluated. CAD/CAM technology is avail- 1. B irnbaum, NS. Aaronson, HB. Digital Impressions Using 3D Digital Scanners.able to predictably fabricate anterior resto-rations. The business model for single unit Compedium 2008; Vol 29:Issue 8.restorations has now been challenged with this 2. Patel, N. Integrating three-dimensional digital technologies for comprehensivetechnology. The question is not which scan-ner the clinician should purchase, but rather implant dentistry J Am Dent Assoc 2010; 141(6 Suppl); 20S-24S.when this purchase will take place. In addi- 3. F asbinder DJ. Clinical performance of chairside CAD/CAM restorations. JADAtion, when will all clinicians embrace of thistechnology and how long will it take to become 2006;139 (9 Suppl) 22S-31S.the standard of care? It is the author’s posi- 4. G uess, P.C. , Zavanelli, R.A., Nelson R., Silva, F.A., Bonfante, E.A., Coelho,tion that sooner rather than later may be ben-eficial for our patients and our profession. ● P.G., Thompson, V.P. Monolithic CAD/CAM Lithium Disilicate Versus Veneered Y-TZP Crowns: Comparison of Failure Modes and Reliability After Fatigue Int J Prosthodont 2010;23:434–442. 5. Poticny DJ, Klim J. CAD/CAM in office technology; Innovations after 25 years for predictable, esthetic outcomes. J Am Dent Assoc 2010;141:5S-9S. 6. Drago, CJ. Two new clinical/laboratory protocols for CAD/CAM implant restorations JADA 2006;Vol.137:7994-800. 7. Vafiadis, DC. Computer generated abutments using a coded healing abutment. PPAD 2007; 19(7);443-448. 8. W eidhahn K, Kerschbaum T, Fasbinder DJ. Clinical long-term results with 617 cerec veneers: A nine year report. Int J Comput Dent 2005;8:233-246.36 • Vol. 3, No. 5 • July/August 2011
By avoiding a lateral window procedure, the MIAMBE system: Shortens chair time Accounts for fewer complications Minimizes patient’s post surgical pain and discomfort Achieves greater bone augmentation levels 12 S 3002 1023 EN ISO 13485:2003 34Classes offered by Dental Implant Training Center 201-710-6321Sold in the USA by MIS Implants Technologies, Inc. 866-797-1333www.miambe.com
505 Morris Avenue, Suite 104 Nanotechnology for Bone Regeneration Springfield, NJ 07081 NanoGenInformation Technology SolutionsTESTIMONIAL STARTING AT US $55.00NanoGen serves as an FIRST NANOTECHNOLOGY- BASEDexcellent bone graft BONE GRAFTproduct to treat molarextraction sockets in PARTICLES COMPOSED OFmy patients. Up to 60% NANOCRYSTALLINE CALCIUM SULFATEnew bone was Particles composed of nanocrystallineobserved in the sockets calcium sulfate grains manufactured usinggrafted with NanoGen proprietary technology.of which 100% was vitalbone. Implants are BIODEGRADBLE, OSTEOCONDUCTIVE,subsequently placed in GUIDED BONE REGENERATIONthe healed sockets and MATERIALhave also shown a As it undergoes controlled degradation100% success rate one NanoGen encourages mineralization of(1) year post newly regenerated bone.implantation. SIMPLE TO USE, EXTREMELY COSTI highly recommend EFFECTIVEusing NanoGen for Add saline to NanoGen to form a putty, graftthe treatment of it into the defect and close the defect.extraction sockets.” NANOGEN CAN BE USED ALONE OR IN COMBINATION WITH OTHER BONE GRAFTS High magnification SEM of NanoGen grafted in molar Clinical picture showing well NanoGen particles extraction socket. regenerated bone 6 months showing the following socket grafting. nanocrystalline structure of the grains.Ziv Mazor, DMDPrivate Practice,Ra’anana, Israel Histology section of Periapical radiograph showing Periapical radiograph showing regenerated vital bone extraction socket. implant, abutment and crown 4 obtained 6 months after months after implant placement. extraction socket grafting with Good bone density and height NanoGen. are observed.To place an order call 877-336-8643 or visit http://shop.orthogencorp.com
The Use of a Novel Nano-Crystalline Calcium SulfaMteazor et al for Bone Regeneration in Extraction SocketZiv Mazor, DDS1 • Robert Horowitz, DDS2 • John Ricci, PhD4Harold Alexander, PhD3 • Ioana Chesnoiu-Matei. DDS, MS4 Sachin Mamidwar, MBBS, MS3AbstractBackground: Adequate vital bone volume (BV) is Results: Clinical, radiographic and CT scanessential for successful dental implant placement inspection at 6-months following graftingwith satisfactory esthetic results. Calcium sulfate revealed keratinized soft tissue and ideal BV for(CS) has osseoconductive, angiogenic, biocom- implant placement. Histomorphometric analysispatible and barrier properties. As CS dissolves it of core extracted from the regenerated socketleads to formation of biological apatite and causes showed 47% vital BV, with osteoclasts anda local release of growth factors. NanoGen (nCS) osteoblasts, remodeling trabecular bone. Radio-is a granular material comprised of tightly com- graphs obtained at 5-months following implantpressed nanocrystalline CS that undergoes con- placement showed alveolar bone height andtrolled degradation. This case report uses nCS for soft tissue retained around the implant. Pros-the regeneration of bone in an extraction socket. thetic restoration was then completed. Radio- graphs showed minimal marginal bone loss andMethods: A 55 year-old female patient required intimate BIC 1-year after implant placement.extraction of tooth #31. Following socket debride-ment, nCS was mixed with saline, packed into the Conclusions: nCS could become an alterna-extraction defect and contained with a non-resorb- tive to other graft materials in treating extrac-able membrane. After flap elevation, 6-months tion sockets. The combination between thefollowing grafting, a bone core was collected for nano-crystalline structure and angiogenichistological and histomorphometrical analysis. A potential of CS adequately supported bonedental implant was placed and restored 4-months regeneration and implant osseointegration.later. The patient was monitored clinically andradiographically over the subsequent 2 years.KEY WORDS: Calcium sulfate, bone graft, tooth extraction, socket bone regeneration, wound healing, ridge preservation1. Private Practice, Ra’anana, Israel • 2. Private Practice, Scarsdale, NY, USA • 3. Orthogen LLC, Springfield, NJ, USA 4. New York University College of Dentistry, New York, NY, USA The Journal of Implant & Advanced Clinical Dentistry • 39
Mazor et al Introduction Alloplast materials have been frequently used in dentistry to increase or maintain bone vol-Tooth replacement by different materials has ume for over 100 years.15 While autografts arebeen a common practice since ancient times.1,2 considered the gold standard for bone graft-Tooth loss can be due to many causes. Left ing, several drawbacks, such as the need for auntreated, periodontal disease leads to tooth second surgery site and limited graft availability,loss due to diminished periodontal ligament make clinicians less inclined to use them. Alter-and bone support. Factors such as smoking,3 nate grafting materials were attempted, such asgenetic disorders,4 and other coexisting sys- allografts (DFDBA, FDBA). They are biocom-temic diseases5 may hasten the effects of peri- patible and do not require a second surgery.odontitis, causing the loss of affected portions Bovine bone grafts are among the most com-of the dentition. Non-restorable teeth, owing to monly used bone grafts in dentistry. However,carious lesions, failed endodontic treatment or reports have shown the presence of residualother reasons are extracted.6 As other studies xenograft material at the site 8 years after graft-have mentioned, defects resulting from extrac- ing.16 This fact indicates that xenografts aretions require grafting so that the adequate neither resorbed nor replaced by bone.17 Ridgebone levels for implant placement and optimal height and width were maintained with minimalsupport for gingival tissues are maintained.7,8 bone loss when allografts were used for socketWhen restoring partially or completely edentu- preservation.13,18 However, in these studies, thelous patients with dental implants, vital bone quality of bone was compromised. The qual-volume is a key factor.9 Following tooth extrac- ity of bone at the grafted socket is of maximaltion, alveolar bone decreases in height and importance due to its effect on primary implantwidth, a fact that poses a problem in implant stability. In sites grafted with DFDBA, one-dentistry. The esthetic function of the implant stage implant placement was not possible incan be affected by the inadequate volume of more sites than control sites18 due to lack of pri-bone and soft tissue, endangering the treat- mary stability. Furthermore, histological assess-ment outcome.8 The buccal plate, especially in ments of sockets grafted with allografts showedthe maxilla, is the thinnest and weakest alveolar entrapment of the implanted particles by densewall, which gives it the highest resorption rate.10 connective tissue,7,19 which may interfere withIn order to overcome these drawbacks, atrau- the healing process around an inserted implant.7matic extractions and subsequent bone grafting When grafting with allografts and xenografts,are used to achieve socket volume preservation. non-vital bone was reported at the healed siteStudies have reported that grafting the sock- over a period ranging from 9 months17 to 8+ets with bone graft materials does preserve the years.16 New bone regenerates primarily atridge post-extraction.11-13 As reported by sev- the periphery of the defect, where the grafteral clinicians and researchers,7,14 fibrous tis- comes in contact with the host bone.20 How-sue invades the grafted socket when no barrier ever, recently, there has been a trend towardsis used, which compromises bone quality, vol- development of bone graft materials that pro-ume and subsequent implant osseointegration.40 • Vol. 3, No. 5 • July/August 2011
Mazor et alFigure 1: SEM image showing nanocrystalline structure of Figure 2: Periapical radiograph showing periapicalnCS (NanoGen, Orthogen, Springfield, NJ). involvement of the mesial root of tooth #31.Figure 3: nCS granules and saline mixture. alloplasts. Use of calcium sulfate (CS) as a successful bone graft material has been docu-mote bone regeneration throughout the entire mented for 119 years.21 It is biocompatibledefect at a quicker rate than was seen with ear- and it dissolves completely, leaving new bonelier bone replacement grafts. These materials behind. This can be attributed to the increasedegrade after implantation in the bone defect, in the concentration of Ca+ ions as CS dis-provide stimulus for bone formation and are solves. The released Ca+ ions react with theeventually replaced by newly regenerated bone. PO4 ions in the body, re-precipitating as cal-Considering the disadvantages of autografts, cium phosphate, which stimulates osteoblas-allografts and xenografts in certain defect tic activity.22,23 Other studies suggested thesites, and the inability to utilize some of these angiogenic potential of CS24 and its anti-inflam-materials in numerous countries, alternative matory potential. In their study, Strocchi et al.materials have received renewed interest: compared the growth of blood vessels in bone defects grafted with CS and autograft. They found that significantly more blood vessels grew in defects grafted with CS compared to those grafted with autograft. Blood vessels pro- vide nutrition for growing bone and hence fur- ther promote bone formation inside the defect. A possible reason for the anti-inflammatory properties of CS is that it dissolves rap- idly and is washed away before infection can occur.25 The oral cavity is exposed to bacte- ria, so a material that can resist infection such The Journal of Implant & Advanced Clinical Dentistry • 41
Mazor et alFigure 4a: Clinical picture showing the barrier on the Figure 4b: Grafted socket is covered with barrier and thelingual wall and nCS graft packed to ideal contour. site is closed with single-interrupted suture.Figure 5: Periapical radiograph of socket filled with nCS Figure 6: Clinical image of regenerated ridge 6-monthsgranules. after grafting. There is no evidence of graft or infection.as CS can be successfully used as a graft for grafts used alone.28 In spite of these uniquesocket preservation26,27 or as a barrier for the properties, CS degrades quickly in the body,prevention of soft-tissue infiltration,25 espe- which limits its use as a bone graft material. Itcially in cases when primary closure can- degrades over a period of 4 to 6 weeks andnot be achieved. CS has also been used in hence has limited success as a bone graft forcombination with other bone grafts materi- large defects (like molar extraction sites orals. The combination of CS with allograft or sinus augmentation site) unless special tech-xenograft worked better compared to the same niques are followed.29 To address this prob-42 • Vol. 3, No. 5 • July/August 2011
Mazor et alFigure 7a: Cone-beam volumetric panoramic scan of the Figure 7b: Periapical radiograph showing extractionextraction site 6-months after grafting shows good healing site 6-months after grafting. Bone has similar density asof the socket. surrounding, native bone.Figure 8: Periapical radiograph of implant immediately Materials and Methods:after placement. This report presents clinical and histologic evalu-lem, a unique nanocrystalline version of CS ation of a case where a defect resulting from thewas developed. Using a proprietary technol- extraction of a molar tooth was grafted with gran-ogy, the nanocrystalline CS was compressed ules of nanocrystalline CS (NanoGen, Ortho-into granules (nCS). The present study is a gen, Springfield, NJ) (Figure 1). A 55-year-oldcase report on the preservation of socket vol- female presented to a private dental office withume using nCS granules as bone-graft mate- a complaint of pain in the lower right posteriorrial and a non-resorbable PTFE membrane quadrant. After clinical examination, tooth #31for the prevention of soft-tissue in-growth. was shown to be the cause of the pain due to advanced carious lesion and periapical involve- ment (Figure 2). Since it was deemed non- restorable, the recommended treatment plan was extraction of tooth #31 followed by socket bone regeneration with granules of nanocrystalline CS protected by a barrier, and prosthetic restoration through implant surgery. After patient consent, local anesthesia was administered and the tooth was extracted using the atraumatic technique. After socket debridement, granules of nanocrys- talline CS were mixed with saline (Figure 3) and packed into the defect, filling it to ideal contour The Journal of Implant & Advanced Clinical Dentistry • 43
Mazor et al Figure 9b: High-magnification histology picture showing active osteoblasts and osteoclasts.Figure 9a: Histological evaluation of core obtained tion of the buccal plate and for better graft con-6 months after grafting demonstrates robust bone tainment (Figure 4b). It was placed under theformation. buccal periosteum, on the lingual side of the alveolus and the gingival tissues, extending 2(Figure 4a). A non-resorbable barrier (Cyto- – 3 mm beyond the defects. The gingival tis-plast® Ti-250 Titanium-Reinforced, Osteo- sues were repositioned with a single interruptedgenics, Lubbock, Tx) was positioned over the resorbable suture, but no attempt was made tografted material in order to assist in augmenta- obtain primary closure. A radiograph was taken to record socket fill with the nCS granules (fig- ure 5). The membrane was removed after 3 weeks and the site was allowed to heal for 6 months (Figure 6). Six months following graft- ing, after flap elevation, a bone core was col- lected for histological and histomorphometrical analysis. A cone beam volumetric tomographic scan was performed at 6 months after socket grafting, immediately prior to implant place- ment (Figure 7a). A periapical radiograph was also taken at this time demonstrating similar findings (figure 7b). A single two-stage den-44 • Vol. 3, No. 5 • July/August 2011
Mazor et alFigure 10a: Clinical photograph of prosthetic restoration, Figure 10b: Periapical radiograph showing implant,4-months after implant placement. abutment and crown 4-months after implant placement. Good bone density and height observed.Figure 11a: Periapical radiograph showing stable implant, Figure 11b: Clinical photograph of the restored site withabutment and crown10-months after implant placement. crown: 10-months after implant placement.tal implant (Intra-Lock, Boca Raton, FL) was Histological Analysisplaced to restore the site to function and wasrestored 4 months later. (Figure 8). The patient The core was fixed in 10% formalin and thenwas monitored, clinically and by periapical digi- transferred to different gradients of alco-tal radiographic inspection, for two years fol- hol concentrations (70% Ethanol for 24hrs,lowing surgery. Radiographs were taken at 1, 95% Ethanol for 24hrs, 100% Ethanol (x2)2, 6, 12 and 15 months after socket grafting. 48hrs). After dehydration, the sample was infil- trated and embedded in PMMA. Sectioning was performed with a low-speed saw (Isom- The Journal of Implant & Advanced Clinical Dentistry • 45
Mazor et aletTM, Buehler, Lake Bluff, IL). The slide was 9b). Quantitative analysis of the bone coreground and polished to a thickness of 100μm collected 6 months following socket graft-and then stained with Stevenel’s blue and Van ing revealed a 47% vital bone content.Gieson’s picro fuchsine stain. A slide scan-ner (ScanScope GL, Aperio, Vista, CA) was At 4 months following implant placement,used to image the sample and Leica QWin clinical inspection and radiographs showedsoftware was used for the histomorphometrical that alveolar bone height and soft tissue wasassessment of bone formation. Histomorpho- retained around the implant (Figures 10a,metrical analysis was conducted to quantify the 10b). Prosthetic restoration was then com-amount of total vital bone present in the core. pleted. Radiographs 10 months after the implant was placed, showed minimal marginal Results bone loss and intimate contact between the bone and implant surface (Figures 11a, 11b).Immediate post-grafting radiographs showedthe defect was completely filled with gran- Discussionules of nanocrystalline CS. Wound mar-gins presented as clean and almost adjoined A satisfactory esthetic profile in implant den-at the coronal part with no sign of inflam- tistry depends on several factors, such as themation one month post-grafting. Radio- thickness of the underlying bone and the gin-graphic analysis over the next few months gival biotype.30 However, determining theshowed graft resorption and the appearance adequate thickness of the buccal plate andof new bone formation in the treated site. biotype is difficult. Due to the anatomical char- acteristics of the alveolar bone, the thin labial At 6 months post-grafting, clinical inspection walls of the alveoli resorb the fastest; morerevealed a healed site with fully keratinized soft so in the maxilla than the mandible.31 Gingi-tissue. The clinical examination of the newly val soft tissue contour is strictly dependentformed bone showed a ridge with bone suitable on the underlying bone. A 12-month pro-to support the placement of a single two-stage spective study by Schropp et al.32 reportedimplant; there was no sign of grafted material or a decrease of 50% in bone width followinggranulation tissue remaining. CT scan and addi- single-tooth extraction when the alveolar sitetional radiographic examination of the extraction was not grafted. In order to prevent future tis-area at the 6-month time-point showed a fully sue loss, most clinicians opt for grafting inhealed socket with suitable bone height and extraction sockets before placing implants.bone density similar to the surrounding bone. Vital bone-to-implant contact (BIC) is one cri- terion affected by vital bone content in a site, Histological analysis of the core extracted and used for selecting different bone-graftingfrom the healed socket showed forma- materials. Becker et al,. showed that 36 monthstion of new trabecular bone and osteoid after implanting xenografts or DFDBA in extrac-tissue (Figure 9a) with marked bone turn- tion sockets, minimal vital bone formation wasover, evidently due to the presence of osteo- achieved.7 A different study looking at healingclasts, and also active osteoblasts (Figure46 • Vol. 3, No. 5 • July/August 2011
Mazor et alof an extraction socket grafted with bioactive has been documented extensively for differ-glass showed that the material was present at ent procedures such as socket grafting,26the site for up to 2–3 years.33 Synthetic mate- sinus augmentation,37 and as a membrane.25rials such as Ca3(PO4)2 and CaSO4-basedmaterials have been successfully used for bone The microscopic structure of nCS is nano-regeneration. They degrade completely at a crystalline CS. The nano-crystals are tightlyfaster rate and can influence bone remodel- compressed together forming a granule. Thising.34 The use of CS for bone grafting purposes structural pattern results in controlled degra-showed better results than other graft materials dation of the CS granules. Rapid degradationused alone.35 As CS dissolves, it leads to for- of traditional forms of CS was a limiting factormation of calcium phosphate and also causes for its use in bone grafting applications. Thea local release of growth factors from the sur- unique nanocrystalline structure of CS granulesrounding bone. Both of these mechanisms used in this study allows the material to havehelp in bone regeneration in the extraction site. a controlled degradation over 10 to 12 weeksCS is the only bone graft known to have bar- (compared to traditional CS, which degradesrier, hemostatic and angiogenic properties and in 4 to 6 weeks). Radiographic and histologi-possibly effect a local release of growth fac- cal investigations showed that the extractiontors.23 This novel version of CS was devel- socket grafted with nCS had fully regener-oped to preserve these unique properties of ated with vital bone by 6 months. Therefore,CS while overcoming its fast degradation rate. it helped provide the ideal bone volume for implant placement. The combination between This case shows that using novel CS, in the the controlled degradation of nCS and theform of granules made up of nano-crystals of excellent properties of CS adequately supportsCS, to regenerate extraction socket can offer graft resorption and bone remodeling. nCS canan alternative to other currently investigated be a suitable dental bone-grafting option whengraft materials in treating dental bone defects. a shorter healing time is desired. Its propertiesThe final goal when using any bone graft mate- to generate vital bone and to completely resorbrial should be the complete resorption of the are qualities much needed in the clinical field.grafted material and bone regeneration in thedefect site prior to, or at the time of implant Conclusionplacement. As reported by others,7,33,36 materi-als such as DFDBA, xenografts, and bioactive The material investigated in this case report,glass render a smaller amount of vital bone and nCS, is calcium sulfate (CS) with a uniquethe resorption rate is more than 6 months, if nanocrystalline granular structure that allowsthey resorb at all. In contrast, CS pre-hardened for a controlled dissolution that leads to com-particles grafted in fresh extraction sockets plete graft resorption. The granules that formwere shown to allow for full material resorption the material consist of smaller, agglomeratedand vital bone regeneration has been observed particles that increase the surface area ofas early as 3 months after placement.26 CS the material. As the calcium sulfate granules undergo controlled degradation, the formation The Journal of Implant & Advanced Clinical Dentistry • 47
Mazor et alAADDVVERETIRSETWISITHE of a calcium phosphate layer on their surface stimulates bone regeneration. An extraction TODAY! socket grafted with this granular material pre- vented the resorption of the alveolar bone and Reach more customers provided an ideal vital bone volume for implant with the dental placement. At the one-year follow-up the profession’s first patient presents good implant osseointegra- truly interactive tion with esthetically satisfactory gingival pro- file. This case demonstrates clinical success paperless journal! when using nCS and a dense PTFE barrier for extraction socket alveolar regeneration proce- Using recolutionary online technology, dures. Future studies will be undertaken to fol- JIACD provides its readers with an low alveolar volume preservation and vital bone formation in similar extraction socket defects. ● experience that is simply not availablewith traditional hard copy paper journals. Correspondence: Sachin Mamidwar 505 Morris Avenue, Suite 104 Springfield, NJ, 07081 P: 973-467-2404 F: 973-467-1218 e-mail: [email protected] WWW.JIACD.COM48 • Vol. 3, No. 5 • July/August 2011
Search
