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VOLUME 2, NO. 7 SEPTEMBER 2010 The Journal of Implant & Advanced Clinical Dentistry GTR and GBR with Polylactic Acid Barriers Crestal Core Elevation Sinus Augmentation

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 7 • SEPTEMBER 2010 Table of Contents 15 Case of the Month Dental Erosion Caused by Aspirin Swishing and GERD: A Clinical Report on Full Mouth Rehabilitation Reshma Jacob Thomas, Donald M Belles 27 Staged Sinus Floor Elevation Using the Crestal Core Elevation (CCE) Procedure: A Review of the Technique Michael Toffler 45 Orthodontic Extrusion, Immediate Tooth Replacement, and Removal of Gingival Discolorization: A Case Study Presiyan St. Krastev, Svetoslava Stefanova, Sascha A. Jovanovic The Journal of Implant & Advanced Clinical Dentistry • 5



The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 7 • SEPTEMBER 2010 Table of Contents 55 The Combined Use of Allograft and a Polylactic Acid Barrier for GTR and GBR E orts: 2 Case Reports Paul S. Rosen 65 Atraumatic Implant Explantation, is it Possible? Description of a Novel Technique and a Case Series Study Eduardo Anitua, Gorka Orive 75 The Dilemma of Extract or Mantain in the Piero-Ortho Scenario. A Case Report Manuel de la Rosa, Marcela de la Rosa 87 Orthodontic-Surgical Removal of Impacted 3rd Molars with Apices in Close Proximity to the Mandibular Canal: Two Case Reports Dennis Flanagan The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 7 • SEPTEMBER 2010 Publisher Copyright © 2010 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell 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 liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The 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 result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can 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 • 9



The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory Board Tara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Michael Huber, DDS Terry Rees, DDS Michael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDS Daniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMD John Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDS Stepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMD David Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMD Charles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDS Sally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDS Tomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Alex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDS Nicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhD David Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDS Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDS Ronald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 11





Case of the Month Thomas et al Dental Erosion Caused by Aspirin Swishing and GERD: A Clinical Report on Full Mouth Rehabilitation Reshma Jacob Thomas DDS, MS1 • Donald M Belles DDS, MS2 Abstract Dental erosion is the progressive ronmental and behavioral factors and are esti- loss of tooth structure by chemi- mated to occur in 2-18% of the population. cal processes that do not involve The cause of dental erosion is varied. Relationship of aspirin to dental erosion has been reported. bacterial action producing defects that are The patient described in this report demon- strated severe erosion of all teeth caused sharply defined, wedge-shaped depressions by effect of acid reflux and chronic swish- ing of aspirin powder dissolved in water. often in the facial and cervical areas. Preva- lence, distribution and clinical appearance of dental erosion vary due to regional, envi- KEY WORDS: Dental erosion, acid reflux, aspirin swishing, tooth wear 1. Prosthodontist, Private practice, Virginia 2. Program director, Graduate Prosthodontics UTHSC at Houston The Journal of Implant & Advanced Clinical Dentistry • 15

Thomas et al INTRODUCTION The patient described in this report dem- onstrated severe erosion of all teeth caused Dental erosion is the progressive loss of tooth by effect of acid reflux and chronic swish- structure by chemical processes that do not ing of aspirin powder dissolved in water. involve bacterial action producing defects that are sharply defined, wedge-shaped depres- CASE REPORT sions often in the facial and cervical areas.1 Prevalence, distribution and clinical appear- A 58 year old Caucasian male presented to the ance of dental erosion may vary due to regional, Prosthodontic clinic in 2008 with a chief com- environmental and behavioral factors and are plaint that his teeth were wearing away rapidly. estimated to occur in 2-18% of the popula- The patient’s medical history revealed a history tion.2 The cause of dental erosion is varied and of gastroesophageal reflux disease (GERD) the effect of intrinsic acid has long been rec- for which he was on medication (Omepra- ognized and studied.3 Acids with a pH below zole 20mg once a day for 4 years). Also, the the critical pH of enamel (5.5) can dissolve patient reported swishing aspirin (BC pow- the hydroxyapatite crystals in the enamel lead- der) dissolved in water 3-4 times a week for ing to dissolution of the surface layers and headaches. Each dose of BC powder con- subsequent loss of tooth structure.4 Verret tained 650mg of aspirin, 195mg of salicyl- has analysed the patterns of erosion in reflux amide, and 33.3mg of caffeine. He denied patients and concluded that lingual surfaces any history of bulimia or lemon sucking habit. of maxillary anteriors are mainly affected.10 On examination, generalized erosion of A relationship of aspirin (ASA) to den- the teeth was noted affecting occlusal, lin- tal erosion has been reported. An in vitro gual and facial surfaces (Figures 1-6). Ero- study by Rogalla and Finger5 investigating sion was more pronounced in the anterior and the erosive effect of ASA on enamel and den- premolar regions and it was noted that many tin revealed that unbuffered aspirin had pro- restorations projected above adjacent tooth gressive corrosive effects proportional to time surfaces. The patient’s periodontal condition of contact. Placing aspirin powder or tab- was acceptable with mild marginal gingivitis in lets sublingually and crushing tablets between the mandibular anterior region. As part of the teeth have resulted in severe erosion of lingual patient’s dental counseling, he was instructed surfaces of anterior teeth, and occlusal sur- to elevate his head with pillows and limit eat- faces of mandibular molars and premolars.6-8 ing fatty and spicy meals before bed time. He was also instructed to stop aspirin swishing. Aspirin is mainly available as tablets and in powder form. Both forms, when in con- A full-mouth reconstruction was required tact with tooth structure, have resulted in due to the amount of tooth structure that was erosion. However swallowed aspirin tab- lost. Also it was necessary to restore the lets have not been found to cause erosion, patient’s occlusal vertical dimension (OVD) to which led to the conclusion that erosions allow the fabrication of cast restorations. OVD were due to the topical effect of aspirin.9 was assessed based on esthetics and phonet- 16 • Vol. 2, No. 7 • September 2010

Thomas et al ics. Patient belonged to ACP class IV because DISCUSSION he had severely compromised occlusal scheme and required new occlusal vertical dimension. A wide variety of etiological factors contrib- ute to dental erosion being broadly classified Maxillary and mandibular impressions as extrinsic and intrinsic factors. Extrinsic fac- were made in alginate. Diagnostic casts were tors, which are mainly dietary in nature, include mounted in centric relation (CR) on a semi heavy consumption of acidic fruit juices and adjustable articulator with a custom incisal carbonated drinks with low pH. Habits like fruit guide table and condylar guidance was set mulling and lemon sucking have contributed to using protrusive records. A full contoured tooth erosion in specific patterns. Occupational diagnostic wax up (Figures 7-11) was made to dental erosion is reported in wine tasters12 evaluate the dimensions of the teeth in order and industrial workers. People working in the to obtain optimum esthetics and function and lead sealing industry and battery factories are a processed acrylic occlusal guard was deliv- prone to dental erosion of the facial surfaces of ered to assess the changes in the OVD. The the teeth from the acidic fumes they breathe.13 patient was instructed to wear the appliance Swimming in highly chlorinated swimming pools day and night for three weeks except while eat- has resulted in specific patterns of erosion in ing and performing oral hygiene procedures. swimmers where erosion is seen on the facial He did not experience any muscle tenderness surfaces of teeth on the side of the mouth or temporomandibular joint (TMJ) discomfort. where the swimmer breathes.11 Medications All of the teeth in both maxillary and mandibu- that contribute to dental erosion can include lar arches were prepared for fixed restorations aspirin, iron preparations, and chewable vitamin and provisionals were fabricated at the new C tablets. Also, developmental anomalies like OVD. All 4 third molars were extracted and amelogenesis imperfecta and dentinogenesis crown lengthening procedures were performed imperfecta have been reported to be associ- surgically in both arches to compensate for the ated with dental erosion. Here, the enamel has loss of tooth structure (Figures 12-15). Final a tendency to chip away exposing the dentin teeth preparations were accomplished after which wears seven times faster than enamel. eight weeks of healing and final impressions were made in polyvinylsiloxane (PVS). Tempo- Intrinsic factors include gastrointestinal rary restorations were modified to fit the new disorders such as GERD, obstipation, hiatal margins (Figures 16-20). The definitive resto- hernia, and duodenal/peptic ulcers. GERD rations (PFM crowns) were fabricated for the involves involuntary muscle relaxing of the lower maxillary and mandibular arches (Figures 21-24) esophageal sphincter, which allows refluxed and cemented on with FujiCem (GC America, acid to move upward through the esopha- Alsip, Illinois, USA). An occlusal guard (Figure gus into the oral cavity. Factors such as diet, 25) was fabricated after the occlusal adjust- alcohol, posture, and drugs can precipitate ments were completed on the final restorations. GERD. A variant of GERD, silent GERD, may have no obvious systemic symptoms with unex- plained erosion and sensitivity of the teeth.14 The Journal of Implant & Advanced Clinical Dentistry • 17

Thomas et al The Journal of Implant & Advanced Clinical Dentistry Bulimia and anorexia nervosa are two pathologi- cal conditions that produce a wear pattern on ATTENTION the palatal surfaces of upper incisor teeth. The PROSPECTIVE site and pattern of erosion is caused by delib- erate and self induced vomiting of gastric con- AUTHORS tents.15 Chronic alcoholism causes chronic gastritis and this is the cause of recurrent JIACD wants vomiting or regurgitation and erosion. Acid in to publish motion erodes teeth faster than passive acid. your article! Hence in this case, swishing with aspirin pow- der dissolved in water eroded teeth faster. For complete details regarding publication in Correspondence: Dr. Reshma Jacob Thomas JIACD, please refer Address: 9 Chichester Dr. Apt #304 to our author guidelines at Stafford VA, 22554 Phone: 469-855-7822 the following link: Fax: 540-720-7728 http://www.jiacd.com/ Email: [email protected] authorinfo/ Disclosure author-guidelines.pdf The authors report no conflict of interest with anything mentioned in this article. References or email us at: 1. Glossary of Prosthodontic terms vol.94, Issue1, Pages 10-92 (July 2005) [email protected] 2. Eccles JD. Dental erosion of non-industrial origin: a clinical survey and classification. J Prosthet Dent 1979; 42:649-653. 3. Scheutzel P. Etiology of dental erosion-intrinsic factors. Eur J Oral Sci 1996; 104:178-190. 4. Lazarchik DA, Filler SJ. Dental erosion: predominant oral lesion in gastro esophageal reflux disease. Am J Gastroenterol 2000; 95(8suppl): S33-38. 5. Rogalla K, Finger W, Hannig M. Influence of buffered and unbuffered acetyl salycilic acid on dental enamel and dentine in humanteeth: an invitro pilot study. 1992;14:339-346. 6. Mc Cracken M, O’Neal SJ. Dental erosion and aspirin headache powders: a clinical report. J Prosthodont 2000;9(2):95-98. 7. Bull AW, Corbett JR. Erosion: case report Aust Dent J 1968;13(2):164. 8. Sullivan RE, Kramer W. Iatrogenic erosion of teeth. ASDC J Dent Child 1983;50(3):192-196. 9. Grace EG, Sarlani E Tooth erosion caused by chewing aspirin. J Am Dent Assoc 2004;135:911-914. 10. Verrett R: Analysing the etiology of an extremely worn dentition. J Prosthodont.2001; 10:224-233. 11. Ceterwall BS, Armstrong CW. Erosion of dental enamel among competitive swimmers at a gas-chlorinated swimming pool. Am J Epidemiology 1986; 123(4): 641-647. 12. Gray A, Ferguson MM, Wall JG. Wine tasting and dental erosion. Case report. Aust Dent J 1998;43:32-34. 13. Tuominen M, Tuominen R. Association between acid fumes in the work environment and dental erosion. Scand J Work Environ Health 1989;15:335- 338. 14. Ajagbe O, Brown RS, Krakow AM, Choksi S. Dental erosion caused by gastric reflux: a report of two cases. Am Dent Inst Cont Ed 1998;66:9-14. 15. Hazelton LR. Faine MP: Diagnosis and dental management of eating disorder patients. Int J Prosthodont 1996;9:65-73. 18 • Vol. 2, No. 7 • September 2010

Thomas et al Figures 1-6 The Journal of Implant & Advanced Clinical Dentistry • 19

Thomas et al Figures 7-11 20 • Vol. 2, No. 7 • September 2010

Thomas et al Figures 12-15 The Journal of Implant & Advanced Clinical Dentistry • 21

Thomas et al Figures 16-20 22 • Vol. 2, No. 7 • September 2010

Thomas et al Figures 21-25 The Journal of Implant & Advanced Clinical Dentistry • 23

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Staged Sinus Floor Elevation Using the To er Crestal Core Elevation (CCE) Procedure: A Review of the Technique Michael To er, DDS Abstract In the moderately to severely atrophic max- to minimize membrane perforation and the mal- illa, trephined cores measuring 3 to 6 mm leting force associated with core intrusion. in height and 5 to 6 mm in diameter may This report reviews the technique, instrumen- be apically displaced to facilitate sinus aug- tation and indications for CCE and presents mentation and staged implant placement. The two clinical cases clearly demonstrating the crestal core elevation (CCE) procedure incor- efficacy of this less invasive alternative to the porates specially designed core osteotomes more commonly used lateral window osteotomy. KEY WORDS: Maxillary sinus, bone graft, dental implant, platelet rich fibrin, PRF 1. Private practice limited to periodontics and dental implants, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 27

To er INTRODUCTION Figure 1: Dental scan taken in 1998 prior to performing future-site development (FSD) procedure revealed 3 mm of A residual subantral deficiency of bone volume subantral bone at site #14. can be predictably augmented by a variety of sinus floor elevation (SFE) techniques incorporat- tages of a staged crestal approach using the ing a wide range of graft materials in a delayed or FSD procedure included decreased morbidity, a simultaneous approach to implant placement.1-9 reduced healing time and avoiding direct contact The lateral window osteotomy (LWO) is certainly of the sinus membrane with dental instruments.4 the most frequently reported technique, producing Since the introduction of the future site develop- reliable long-term results in reconstruction of the ment (FSD) procedure,4 there have been no pub- atrophic posterior maxilla.6,10-11 While the quan- lished reports on the success, predictability or tity of preexisting bone required for successful complications experienced with the technique. simultaneous implant placement has not yet been determined, adequate bone should be available to A modification of the FSD procedure, provide primary implant stability.12 A staged lateral crestal core elevation (CCE) was introduced by window osteotomy (LWO) is most often advised Toffler,12,17 incorporating specially designed core when less than 5 mm of residual subantral bone osteotomes and barrier membrane placement height (RSBH) is present8 although successful over the core prepation(s). These modifications, results have been reported in 2 to 3 mm of sub- antral bone.13 Sites with less than 5 mm of RSBH have also demonstrated an increased failure rate when treated with osteotome-mediated sinus floor elevation (OMSFE).14-16 Summers’3 bone-added osteotome sinus floor elevation (BAOSFE) proce- dure was originally recommended at sites with at least 5 to 6mm of RSBH, limiting this treatment to patients with only a moderately atrophic pos- terior maxilla. Summers4 introduced the future site development (FSD) procedure as an alterna- tive to the lateral window approach in the more severely resorbed posterior maxilla where there was inadequate crestal bone present for primary stabilization of implants. In the FSD procedure, the residual subantral bone is imploded in the form of a “plug” with the aid of wide diameter (5 to 6mm) osteotomes and trephines as needed. The attached “plug” or core of native bone and added graft materials are used to elevate the sinus floor (Figures 1-5). The reported advan- 28 • Vol. 2, No. 7 • September 2010

To er Figure 2: 6 mm diameter cores prepared at site #s 14 and Figure 3: After signi cant malleting force, cores were 15. elevated and membrane inspected for perforation. Figure 4: Core osteotomies grafted with bovine bone Figure 5: Periapical radiograph from 2002 after mineral (BBM) and apically displaced to further elevate restorations in function for 3 years. sinus oor. with an osteotome. Core elevation requires sig- when applied to the FSD procedure, simplified nificant malleting force unless the core has been the technique, minimized membrane perforation prepared to within 1 mm of the sinus floor along and improved bone quality and healing. Using its entire perimeter (Figure 6). Trephine prepara- only a trephine for core preparation as described tion is most certainly complicated by variations in the FSD technique4 and later in the modified in the topography of the residual alveolar ridge trephine osteotome technique,18 it is difficult to and sinus floor (Figure 7) that can lead to under- uniformly prepare the core close enough to the preparation at points along the core perimeter, sinus floor so that the core can be gently intruded The Journal of Implant & Advanced Clinical Dentistry • 29

To er Figure 6: Trephine must ideally prepare cores to within 1 Figure 7: Trephine preparation is complicated by mm of the sinus oor to facilitate core intrusion. variations in the topography of the residual ridge and sinus oor, making it hard to uniformly prepare the core to ideal working depth. Figure 8: The core osteotome (H & H Co, Ontario, CA) is Figure 9: The #6 core osteotome is pictured with a 6 mm one-third round with a 0.5 mm thick curved tip designed to diameter trephine. Both have 2 mm markings. t around the 5 mm or 6 mm core preparation. 30 • Vol. 2, No. 2 • September 2010

To er Figure 11: 5 mm cores have been prepped at site #s 14 and 15 to a depth of 3 to 4 mm Figure 10: After a 5 mm core has been prepared to within 1 to 2 mm of the sinus oor, the #5 core osteotome is rotated around the 5 mm diameter core and gently malleted to directly infracture the sinus oor along the core perimeter. There is 4 mm of RSBH; therefore, the osteotome will be inserted to the second line (4 mm). preventing controlled intrusion of the core. Con- Figure 12: Apical displacement of the cores to the depth versely, in an effort to more closely approach the of the sinus oor (4 mm). Osteotome-mediated sinus oor sinus floor, additional trephine preparation can elevation (OMSFE) performed at site #13. result in severe laceration of the sinus membrane and possible core removal or displacement into of the core preparation.12 The core osteotomes the sinus cavity. To further simplify core prepara- directly infracture the sinus floor along the core’s tion and reduce the risk of membrane laceration, periphery significantly lessening the apical force Toffler12,17 designed core osteotomes (H & H Co, required for core displacement. Toffler12 reported Ontario, CA) which are used to prepare the api- on 43 partially edentulous patients with a mean cal 1 to 2mm of the core as it approximates the age of 56 (range 36 to 72 years). Staged sinus sinus floor. These instruments are one-third round augmentation using CCE was performed at 73 and 0.5 mm thick and fit precisely around the sites where there was a minimum residual ridge 5.0 or 6.0mm core preparation (Figures 8-10). width (RRW) of 6mm and a RSBH 5mm or less While gently malleting these instruments, the clini- cian retains the tactile sensation lost when using a trephine to complete the most delicate aspect The Journal of Implant & Advanced Clinical Dentistry • 31

To er Figure 13: Positioning of 5 mm core preparations at site #s Figure 14: 6 mm core preparation at site #3 into the facial 13, 14 & 15 marked with a round bur using a surgical guide. and palatal plates of bone not only increases the risk for crestal bone loss, but also makes core elevation more di cult. Figure 15: Core preparation is initiated with a trephine either an e-PTFE membrane or a bioabsorbable with an internal diameter of 5.0 or 6.0mm and markings at collagen membrane. In all cases where implants 2.0, 4.0, 6.0, and 8.0mm (H and H Co. Ontario, CA) were placed, the distance between the healed alveolar crest and sinus floor was at least 8 to 9 (mean 3.2 mm). Multiple sites were treated in mm. Radiographic analysis of the areas treated 22 patients. The core osteotomies were grafted with CCE showed a 6 mm to 12 mm increase in with a composite of 20% to 60% autogenous available bone height for implant placement. The bone mixed with bovine bone and covered with resistance of the regenerated tissues was typi- cal of type III to IV bone. In areas where 8 to 9 mm of subantral bone height was present, addi- tional OMSFE was performed to allow for place- ment of an implant 10 to 11.5 mm in length. At the time of clinical review, adequate healing (5 to 7 months) had allowed for placement of 57 threaded implants in 33 of 43 patients. Implant length ranged from 10 mm to 13 mm (mean: 11.3mm) and the diameter 3.75 to 5.5mm (mean: 4.6mm). Thirty-seven of the 57 implants placed had been loaded for 3 to 35 months (mean 15.5 months) with no failures during the study period.12 This report will review and update the technique, demonstrating the effi- cacy of the procedure in two clinical cases. 32 • Vol. 2, No. 7 • September 2010

To er Figure 16: At site #3 with a RSBH of 6 mm, a #5 core Figure 17: The core osteotome is then rotated a one- osteotome malleted to a depth of 6 mm on the facial third turn and advanced to 6 mm depth on the mesial and aspect of a 5 mm core at site #3. mesiopalatal aspect. One more rotation completes the apical preparation. MATERIALS AND METHODS pO2 are closely monitored throughout the proce- Staged sinus grafting using CCE is traditionally dure. After obtaining adequate local anesthesia, performed at maxillary premolar and molar implant a crestal incision is made throughout the entire sites with a RSBH of 3 to 6 mm and a residual edentulous area. An anterior releasing incision is ridge width (RRW) 7mm to retain at least 0.5 made on the mesial aspect of the adjacent tooth. to 1.0 mm of crestal bone facial and palatal to a 5 The posterior releasing incision is placed distal to mm or 6mm core preps which have external diam- the tuberosity in those patients where autogenous eters of 6 mm and 7 mm respectively (Figures bone will be obtained. A surgical guide and 2mm 11-12). If multiple sites are treated, then sites round drill may be used to locate the center of the with as little as 2 mm RSBH may be successfully crestal core at the site of future implant placement augmented as well, but the author prefers per- (Figure 13). Core diameter is based on the RRW forming a LWO with less than 3 mm of RSBH. All and ideally, there should be at least 1.0 mm of pal- patients undergoing CCE receive a 1 to 2 hour atal and facial bone outside the core preparation. preoperative dose of an antibiotic and 8 mg dexa- Core preparation into the facial and palatal plates methasone sulfate which is tapered to 4 mg the of bone will not only jeopardize their survival but following 2 days and 2 mg on the third postopera- also make core elevation more difficult (Figure tive day. The majority of patients are sedated with 14). Core preparation is initiated with a trephine midazolam and their blood pressure, pulse and with an internal diameter of 5.0 or 6.0mm and The Journal of Implant & Advanced Clinical Dentistry • 33

To er Figure 18: Apical preparation with the core osteotome Figure 19: The core osteotomy has been grafted with simpli es core intrusion to a depth of 6 mm, e ectively mineralized freeze-dried bone allograft (MFDBA) in doubling the height of the subantral bone. advance of collagen membrane coverage. Figure 20: An autologous “plug” of platelet-rich brin 0.5mm thick tip and fits around the 5.0 or 6.0mm (PRF) may be used to ll the osteotomy or inserted as core (Figure 16-17). While gently malleting and membrane protection prior to additional sinus elevation rotating the core osteotome, the clinician retains with particulate materia the tactile sensation lost when using a trephine in close approximation to the sinus floor. The sinus markings at 2.0, 4.0, 6.0, and 8.0mm (H and H floor can now be directly infractured along the Co. Ontario, CA) (Figure 15). The initial “bite” of perimeter of the core to facilitate apical displace- the trephine is created by operating the trephine in ment. Using a 5mm or 6mm diameter concave- reverse at 500 RPM with external irrigation. The tipped osteotome with 2mm markings up to 8mm core is then prepared with the trephine (forward at (H & H Co, Ontario, CA), the core is displaced 850RPM) to the desired “working depth” of 1 to to the original level of the sinus floor (Figure 18). 2 mm from the sinus floor in the area of most lim- The integrity of the sinus membrane must then be ited bone height. The one-third round #5 or #6 confirmed by visual inspection. At this point you core osteotome (H & H Co, Ontario, CA) has a have technically doubled the amount of subantral bone by apically displacing the full length of the bone cylinder. If this RSBH is sufficient (at least 8.0 to 9.0 mm) then the osteotomy may be grafted with a particulate material (Figure 19) or platelet- rich fibrin (PRF) (Figures 20-22). If the estimated bone augmentation has created less than 8.0mm of subantral bone then PRF is placed in the oste- otomy in advance of 2 to 3 loads bovine bone mineral or mineralized freeze-dried bone allograft 34 • Vol. 2, No. 7 • September 2010

To er Figure 21: A 6 mm core displaced 4 to 5 mm at site #3. Figure 22: A PRF plug has been inserted to ll the osteotomy prior to membrane placement. Figure 23: The grafted osteotomy has been covered with Figure 24: An immediate postoperative radiograph a bioabsorbable porcine type I collagen membrane (OSSIX- taken to con rm successful core intrusion at site #s 3 & 4. PLUS, OraPharma, Warminster, PA). Overlying membrane was stabilized by 3 tacks to aid in ridge augmentation site #5. (FDBA) and similar to the BAOSFE procedure, barrier function for up to 29 weeks as well as the graft materials are displaced to the original ossification of its cross-linked collagen.19 To sta- level of the sinus floor to achieve an additional bilize the membrane and facilitate primary clo- 2.0 to 3.0mm of SFE. The grafted osteotomy is sure, a combination of horizontal mattress and then covered with a bioabsorbable porcine type I interrupted sutures are placed using PTFE mono- collagen membrane (OSSIX-PLUS, OraPharma, filament suture (Osteogenics Biomedical Inc, Warminster, PA), (Figure 23). This collagen mem- Lubbock, TX). Tension-free closure of the flap is brane has recently demonstrated fully submerged obtained with the aid of vertical releasing incisions The Journal of Implant & Advanced Clinical Dentistry • 35

To er Figure 25: Site #3 with a RSBH of 3 to 5 mm and sinus septa. Figure 26: 6 mm core preparation to a depth of 3 mm. Note buccal defect. at the mesial and distal extremes and/or perios- teal releasing incisions, if necessary. Sutures are less than the implant diameter) at a depth of 5 to removed 10 to 14 days later. An immediate post- 6mm then osteotomes are used to further consoli- operative radiograph is taken to confirm graft date the bone apically. They may also provide for containment and to determine the extent of sinus additional sinus elevation, if needed, to allow for floor elevation (Figure 24). Postoperative care the placement of a 10mm to 11mm long implant. If consists of an antibiotic (amoxicillin 500mg three excellent primary stability is achieved (30 Ncm of times daily for 7 days), a decongestant (pseu- insertion torque or a favorable ISQ reading), then doephedrine 120mg two times daily for 3 days), healing caps are immediately placed otherwise the and rinsing with 0.12% chlorhexidine mouth- implants will heal in a submerged fashion. Heal- wash twice daily until the patient returns 10 day ing progresses for another three to five months, later for suture removal. Additionally, the patient at which time, those implants placed using a sin- is instructed not to blow their nose and to sneeze gle-stage protocol are restored or the submerged with an open mouth. Patients are also advised to implants are uncovered and healing caps placed. refrain from using any removable prostheses until the sutures are removed. After a healing period of CASE PRESENTATIONS 4 to 5 months, a periapical radiograph is taken to estimate the available bone height prior to implant Case 1 placement. A crestal incision is used to expose A 61 year-old male recently lost tooth #3 due the healed ridge. The implant sites are marked to mesiobuccal root fracture and extensive fur- with a 2mm round drill using a surgical guide. The cal bone loss. He sought a second opinion augmented site generally demonstrates type III or after a lateral window osteotomy (LWO) and IV bone quality and presents minimal resistance to drilling. Most often, drills are utilized to prepare the osteotomy to its final diameter (0.7 mm to 1mm 36 • Vol. 2, No. 7 • September 2010

To er Figure 27: Apical core displacement to a depth of 5 mm. Figure 28: BBM was packed into osteotomy and apically displaced to achieve additional sinus oor elevation. Figure 29: Postoperative radiograph demonstrates 8 mm Figure 30: Five months later, the ridge had completely of SFE. healed and the implant osteotomy was prepared with a combination of drills and osteotomes. staged implant placement had been recom- mended. The periapical radiograph reveals 3 to 5 mm of RSBH as well as a sinus septum which certainly increases the risk for membrane perforation using a lateral approach (Figure 25). In addition, a thick lateral sinus wall and mem- The Journal of Implant & Advanced Clinical Dentistry • 37

To er Figure 31: Single stage implant placement of a 6 x 11.5 Figure 32: Implant-supported restoration site #3 after 5 mm tapered implant. years in function Figure 33: Periapical radiograph of implant after 5 years of ted preparation of a 6 mm diameter core (Figure loading. 26). The core was prepared with a trephine to a depth of 3 mm, and then the #6 core osteo- brane dissection around the roots of #2 also tome was used to advance the preparation an increased the degree of difficulty in perform- additional 1 to 2 mm and infracture the sinus ing a LWO. As a less invasive and less costly floor around the core perimeter. This facilitated alternative, CCE was recommended in com- simple core intrusion to a depth of 4 to 5 mm bination with staged implant placement. Flap using a 6 mm diameter concave-tipped osteo- elevation revealed a residual buccal defect tome (Figure 27). The osteotomy was packed and a 10 to 11 mm wide ridge which permit- with bovine bone mineral (BBM) and apically displaced 3 to 4 mm to achieve some additional sinus floor elevation (SFE). At present, PRF is always placed in advance of any graft mate- rial, but this autologous product was not avail- able at the time this patient was treated. The osteotomy was then back-filled with BBM (Fig- ure 28), covered with a bioresorbable collagen membrane and the tissues primarily closed. An immediate postoperative radiograph revealed graft containment and 7 to 8 mm of SFE (Fig- ure 29). Five months later the ridge had com- pletely healed and the implant osteotomy was prepared with a combination of drills and 38 • Vol. 2, No. 7 • September 2010

To er Figure 34: Dental scan, panoramic view of URQ reveals missing teeth #s 4 & 5, a sinus septa and membrane thickening. Figure 35: Dental scan, cross section site #4 shows septa, which certainly makes a lateral approach di cult Figure 36: Core elevation site #4 and OMSFE site #5. Figure 37: Grafting site #s 4 & 5 with mineralized freeze- dried bone allograft (MFDBA). Figure 38: Immediate postoperative radiograph shows Figure 39: 6 months later, 4 mm diameter implants placed core intrusion #4 and OMSFE #5 into the healed ridge. The Journal of Implant & Advanced Clinical Dentistry • 39

To er Figure 40: Radiograph taken 4.5 months later at implant Figure 41: A LWO is more di cult to perform at single uncovering reveals substantial SFE. molar sites due to restricted access, a thicker lateral sinus wall and the presence of adjacent tooth roots. osteotomes (Figure 30) to allow for the place- ment of a 6 x 11.5 mm tapered implant (Fig- cross-section at site #4 shows the septa clearly ure 31). The implant supported restoration has with 3 to 4 mm of RSBH (Figure 35). A lateral now been in function for 7 years (Figures 32-33). approach at this site would most likely result in significant membrane perforation. Flap eleva- Case 2 tion allowed for the preparation and 4 to 5 mm A 57 year-old female had recently lost tooth apical displacement of a 5 mm core at site #4 #5 contributing to failure of a fixed prosthe- and simple OMSFE at site #5 (Figure 36). The sis incorporating tooth #s 3 and 6, replacing core osteotomy at #4 and the buccal defect at missing #4. Replacement of the fixed prosthe- site #5 were grafted with MFDB (Figure 37) sis was not considered as #3 demonstrated and covered with PRF and a bioresorbable col- a moderate degree of bone loss and furcation lagen membrane. The immediate postoperative involvement. The panoramic view from the den- radiograph clearly demonstrated apical core tal scan revealed a sinus septa at site #4 and dipsplacement at #4 and localized OMSFE at a residual defect and thickened sinus mem- #5 (Figure 38). Five months later, 4 mm diam- brane at site #5 (Figure 34). A radiographic eter implants were placed into the healed ridge with excellent primary stability (Figure 39). 40 • Vol. 2, No. 7 • September 2010

To er Four months later SFE and successful integra- tomy, increased thickness of the lateral sinus tion was demonstrated radiographically around wall (Figure 41) and the presence of adjacent the 9mm and 13 mm long implants (Figure 40). teeth. CCE has proven to be a most effective alternative to the LWO at these sites where DISCUSSION quite often patients can provide only limited access to successfully utilize a lateral approach. The author has nearly completed analyzing the data on sites treated using the CCE procedure CONCLUSION with implants in function from 1 to 10 years. As of September 2009, 125 patients have been The author presently uses the CCE proce- treated with CCE performed at a total of 152 dure as a less invasive alternative to the lat- sites. Implant survival with up to 10 years of eral window osteotomy (LWO) for staged loading is approximately 94%, certainly equal- sinus floor elevation at sites where the ridge ing that reported for sinus floor elevation using width is 7mm or more and the RSBH is 3mm a lateral approach.10,11 A full clinical report on to 6mm. Unlike SFE using a lateral approach, implants placed using CCE is in press and the extent of SFE facilitated by core intrusion should be published shortly. This report updates is usually limited by the height of the preexist- the technique the author introduced in 200117 ing crestal bone unless the core(s) are intruded and reviewed in 200212 and 2004.20 The CCE well beyond the level of the original sinus floor procedure incorporates modifications to Sum- which increases the risk of membrane lac- mers’(1995) original FSD procedure designed eration; therefore, CCE is contraindicated at to reduce potential complications and provide sites where there is less than 3 mm of RSBH more predictable, rapid healing while using the or ridge width does not permit core prepara- more conservative crestal approach to staged tion. In these instances the author routinely uti- sinus augmentation surgery. SFE using the lizes and recommends a lateral approach. CCE procedure requires significantly less flap elevation and graft materials resulting in reduced Correspondence: postoperative pain, bruising and swelling. Dr. Michael Toffler 116 Central Park South, Suite 3 The LWO is easiest to perform in the totally New York, NY 10019 edentulous posterior maxilla, but it is techni- 212-581-4646 cally more difficult at single molar sites where mtoffl[email protected] a membrane perforation rate of 40% to 58% has been reported.21,22 The introduction of piezosurgical instrumentation has reduced the incidence of membrane perforation dur- ing window preparation,23 but a higher inci- dence of intraoperative complications would still be expected at single tooth sites due to restricted access, limited size of the antros- The Journal of Implant & Advanced Clinical Dentistry • 41

To er AADDVVERETIRSETWISITHE Disclosure The author reports no conflicts of interest with anything mentioned in this article. TODAY! References Reach more customers 1. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous with the dental profession’s first marrow and bone. J Oral Surg 1980;38:613–616. truly interactive 2. Tatum, OH. Maxillary and sinus implant reconstruction. Dental Clinics of North paperless journal! America 1986;30:207–229. 3. Summers, R. The osteotome technique: Part 3—Less invasive methods of Using recolutionary online technology, JIACD provides its readers with an elevating the sinus floor. Compend Contin Educ Dent 1994;15:698–704. 4. Summers, R. The osteotome technique: Part 4—Future site development. experience that is simply not available with traditional hard copy paper journals. Compend Contin Educ Dent 1995;16:1080–1092. 5. Smiler DG. The sinus lift graft: Basic techniques and variations. Pract WWW.JIACD.COM Periodont Aesthet Dent 1997;9(8):885-893. 6. Jensen, O.T., Shulman, L.B., Block, M.S. & Iacono, V.J. Report of the Sinus Consensus Conference of 1996. International Journal of Oral & Maxillofacial Implants 1998;13 (Suppl.): 11–32. 7. Garg AK, Quinones CR. Augmentation of the maxillary sinus: A surgical technique. Pract Periodont Aesthet Dent 1997;9(2):211-219. 8. ten Bruggenkate CM, van den Bergh JPA. Maxillary sinus floor elevation: A valuable preprosthetic procedure. Periodontol 2000 1998;17:176–182. 9. Thor A, Sennerby L, Hirsch J-M, Rasmusson L. Bone formation at the maxillary sinus floor following simultaneous elevation of the mucosal lining and implant installation without graft material – an evaluation of 20 patients treated with 44 Astra Tech implants. J Oral Maxillofac Surg 2007;7(Suppl 1):64–72. 10. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-343 11. Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent 2004;24:65-577. 12. Toffler M. Staged sinus augmentation using a crestal core elevation procedure (CCE) to minimize membrane perforation. Pract Proced Aesthet Dent 2002;14:767–774. 13. Peleg M, Sawatari Y. Sinus Floor Augmentation With Simultaneous Implant Placement in the Severely Atrophic Posterior Maxilla J Oral Maxillofac Surg 2007;65(9)Supp 1:98-99. 14. Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH. The bone-added osteotome sinus floor elevation technique: Multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants 1999;14:853–858. 15. Toffler, M. Osteotome-mediated sinus floor elevation: A clinical report. Int J Oral Maxillofac Implants 2004;19:266–273. 16. Ferrigno N, Laureti M, Fanali S. Dental implants placed in conjunction with osteotome sinus floor elevation: a 12-year life-table analysis from a prospective study on 588 ITI implants. Clin Oral Impl Res 2006;17:194-205. 17. Toffler M. Site development in the posterior maxilla using osteocompression and apical alveolar displacement. Compend Contin Educ Dent 2001;22:775– 790. 18. Fugazzotto PA. The modified trephine/osteotome sinus augmentation technique: Technical considerations and discussion of indications. Implant Dent 2001;10:259–262. 19. Zubery Y, Nir E, Goldlust A. Ossification of a collagen membrane cross-linked by sugar: A human case series. J Periodontol 2008;79:1101-1107. 20. Toffler M. Minimally invasive sinus floor elevation procedures for simultaneous and staged implant placement. New York State Dent J 2004;Nov:38-44. 21. Mazor Z, Peleg M, Gross M. Sinus augmentation for single-tooth replacement in the posterior maxilla: A 3-year follow-up clinical report. Int J Oral Maxillofac Implants 1999;14:55-60. 22. Krennmair G, Krainhofner M, Schmid-Schwap M, Piehslinger E. Maxillary sinus lift for single implant-supported restorations: A clinical study. Int J Oral Maxillofac Implants 2007;22:351-358. 23. Wallace S, Mazor Z, Froum S, Cho SC, Tarnow DP. Scneiderian membrane perforation rate during sinus elevation using piezosurgery: Clinical results of 100 consecutive cases. Int J Periodontics Restorative Dent 2007;27(5):413-419. 42 • Vol. 2, No. 7 • September 2010



Krastev et al

Orthodontic Extrusion, Immediate Krastev et al Tooth Replacement, and Removal of Gingival Discolorization: A Case Study Presiyan St. Krastev, DDS1 • Svetoslava Stefanova, DDS2 Sascha A. Jovanovic, DDS, MS3 Abstract In implant dentistry, an esthetic result can to minimize the invasiveness of the total treatment. be achieved successfully through mini- mally invasive surgery, especially in the anterior region. This concept reduces surgi- cal time, trauma, complications, scarring, and preserves soft tissue architecture. Proper treatment planning is essential and may take advantage of the patient’s regenerative capacity KEY WORDS: Dental implants, orthodontics, Periodontics, gingivectomy, prosthodontics 1. Varna, Bulgaria; Private Practice 2. Varna, Bulgaria; Private Practice 3. Los Angeles, CA; Lecturer UCLA CDE and Chair gIDE Institute The Journal of Implant & Advanced Clinical Dentistry • 45

Krastev et al Figure 1: View of patient’s dentition at rst exam. Figure 2: Close-up view of tooth 8 with gingival discolorization and temporary restoration. BACKGROUND Figure 3: Smile line at the beginning of treatment. In implant dentistry, an esthetic result can be achieved successfully through minimally invasive to be within normal limits. The analysis of the smile surgery, especially in the anterior region. This con- and soft tissues revealed: high lip line, tapered cept reduces surgical time, trauma, complications, crown shape of tooth 8, average gingival biotype, scarring, and preserves soft tissue architecture. average scalloping of the gingival margin around Proper treatment planning is essential and may take tooth 9, even levels of the free gingival margin and advantage of the patient’s regenerative capacity to papillae around teeth 8 and 9, and an harmoni- minimize the invasiveness of the total treatment. ous relationship with the other front teeth (Fig. 3). The patient in this case study was seen in After the removal of the temporary restora- 2007 with a chief complaint of grayish discolor- tion (Fig. 4) the root was deemed irrestorable ation of the gingiva around tooth 8 (Fig. 1). She due to deep subgingival caries, endodontic over was satisfied with the overall esthetic appear- instrumentation (Fig. 5) and a high risk for future ance of her remaining dentition and smile but root fracture. The treatment plan was to extract was concerned about the treatment options the root and replace with an immediate implant. for tooth 8 and the effect on her smile line. This treatment would support the interdental and The dental history revealed that at age 8, tooth 8 fractured and received a post and core resto- ration made of silver alloy. A porcelain-fused-to- metal (PFM) non-precious crown was cemented with zinc phosphate cement. A grayish gingival color display was noted shortly after. The patient received later a second carbon post with compos- ite core and a ceramic crown in an attempt to alle- viate the discoloration. The patient presented with an acrylic temporary restoration on tooth 8 (Fig. 2). The clinical exam found no problems relevant to the oral health and found the periodontal condition 46 • Vol. 2, No. 7 • September 2010

Krastev et al Figure 4: Tooth 8 after removal of temporary crown. Figure. 6: The start of the orthodontic eruption process. Figure 7: The eruption process displaying a coronal gingival margin. Figure 5: Radiographic view of tooth 8. Figure 8: Internal bevel gingivectomy. The Journal of Implant & Advanced Clinical Dentistry • 47

Krastev et al Figure 9: Metal particles in the lamina propria of the Figure 12: Palatal torque and trimmed palatal and incisal excised gingiva. surface of #8. Figure 10: Healing 2 weeks post operative. Figure 13: End of orthodontic extrusion after 6 months. Figure 11: New temporary crown xed to tooth 8. ered: tissue grafting or periodontal orthodontics. Periodontal orthodontic development of the buccal gingival architecture and provide a pleas- ing esthetic result, while reducing the number of site was chosen as the preferred treatment option surgical procedures and overall treatment time. to increase the vertical bony housing and gingi- val tissue. This would allow a simple gingivec- In light of the patients high smile line, the poten- tomy to remove the grey gingival discolorization tial risk of buccal gingival recession after immedi- and reduce the risk of creating gingival recession. ate implant placement and the need for removal of the gingival discolorization, two options for an The orthodontic treatment was divided in two increase of soft and hard tissues were consid- stages. The first stage was forced rapid tooth erup- tion resulting in a vertical positioned gingival margin which would allow the removal of the discoloration through a gingivectomy. Anchorage was achieved with brackets bonded to the six anterior teeth and a main .017”x.025” TMA archwire. The bracket of tooth 8 was positioned 2 mm apical to the adjacent brackets and a segmental .014”NiTi, attached to teeth 7-10 was activated for extrusion of 8 (Fig. 48 • Vol. 2, No. 7 • September 2010

Krastev et al Figure 16: Implant placement in the optimal 3-D position. Figure 17: The day after implant placement and temporization. Figure 14: End of orthodontic extrusion demonstrating coronal periodontal tissues. Figure 18: Four months after the implant placement. Figure 15: The atraumatic extracted root. Figure 19: Four months after the implant placement, note remaining palatal gingival discolorization. The Journal of Implant & Advanced Clinical Dentistry • 49