GTR and GBR with Polylactic Acid Barriers

Krastev et al Figure 20: Four months after the implant placement showing the cord impression step. Figure 23: Radiograph after implant crown placement. Figure 21: Soft tissue stability four months after the implant placement. Figure 22: Eight months after the implant placement Figure 13: End of orthodontic extrusion after 6 months. showing stable soft tissue for cementation. 6). The patient was seen every 1 to 2 weeks to 50 • Vol. 2, No. 7 • September 2010 reduce the incisal edge and the palatal surface of tooth 8 and to activate the segmental archwire by attaching it over the gingival tie wings of the bracket of 8 or repositioning the bracket more gin- givally. Special attention was given that the adja- cent teeth would not move, or tip toward the space

Krastev et al of the extruding tooth. Extrusion was as rapid as 1 Figure 24: Three days after cementation of the crown and mm per week and was continued until the grayish the veneer. discoloration was coronal to the gingival line of the adjacent teeth (Fig. 7). After the active tooth move- Figure 25: 14 months after implant placement with stable ment was completed, a 3 week period was allowed soft tissue margin (facial view). for reorganization of the periodontal ligament. Figure 26: 14 months after implant placement with stable The total time of forced eruption was 10 weeks. soft tissue margin (lateral view). At this stage an internal bevel gingivectomy (Fig. 8) was performed and all tissue metal particles were removed (Fig. 9). Healing was uneventful with no signs of remaining discolorization (Fig. 10). The second stage of orthodontic treatment was a long-term extrusion of the root resulting in excess of hard and soft tissues to compen- sate for potential gingival recession after implant placement and restoration. A new temporary crown on tooth 8 was fixed (Fig. 11). The bracket on 8 was positioned 1 mm apical to the other brackets and turned upside down to produce palatal crown torque. At the beginning the tooth was extruded through the segmental archwire, but later the main archwire was adjusted into the slot of the bracket of 11. In this way the clini- cal crown of 11 was extruded and inclined pala- tally. The palatal surface of the temporary crown was gradually trimmed (Fig. 12) until it became almost a laminate. The aim of this movement was to obtain thicker alveolar bone margin. Ulti- mately this was accomplished, but as the palatal crown torque resulted in buccal root torque, an apical buccal fenestration was found during the implant surgery. The second stage of the orth- odontic extrusion phase took 26 weeks (Fig. 13). The orthodontic movement during both stages was the same but its effect on the surrounding tissues was different depending on the level and the duration of the force applied. When the orth- odontic extrusion was carried out with low force The Journal of Implant & Advanced Clinical Dentistry • 51

Krastev et al (about 30 – 35 gm) for a longer period of time, ment was prepared and a new temporary crown the root moves while bringing alveolar bone with placed. After another four months the abutment it (Fig. 14). The height of the bone attachment was reprepared and a classic cord impression along the root will be about the same at the end technique was taken (Fig. 20). The aim was for of the movement as at the beginning. When the the abutment to stay in place in order to avoid tooth is extruded with higher force, applied for a disruption of the epithelial hemidesmosomal short period, the bone doesn’t have enough time attachment to the zirconia’s surface, providing to regenerate and mature and the tooth moves stability of the periimplant mucosa (Fig. 21). out of it while only the attached gingiva follows the CEJ. This movement is called “eruption” The timing of the implant temporaries was because it resembles the natural eruption of teeth based on the fact that the most important tis- and “forced” because the applied forces are sue changes occur in the first 6 months higher than for standard orthodontic extrusion. after implant uncovering. Taking the mas- ter impression nearly 8 months after implant The removal of the root was atraumatic (Fig. placement (Fig. 22) assured soft tissue sta- 15) and preserved all socket walls allowing an bility and predictability of an esthetic result. immediate implant placement (Fig. 16). The fix- ture 5/4x15mm (Biomet 3i NanoTite Certain Due to a buccal implant inclination, a PREVAIL Implant 5/4X15mm) was inserted cemented crown option was selected (Fig. 23). with 50N/cm. An optimal 3-D implant position The emergence profile was developed at the was achieved with a vertical platform position margin of the periimplant mucosa around a stock 2.5mm deeper than the contra lateral central zirconia abutment preventing a deep crown incisor free gingival margin. Hence the implant cementation. However, a solution to this prob- platform was 3.5mm below the extruded gin- lem exists. An Empress II crown and a veneer giva as we had 1mm bone and soft tissue in were created and cemented with Multilynk T, excess, due to the slow orthodontic extrusion. Ivoclar- Vivadent eight months after implant placement. The final result achieved the goals The fenestration in the buccal bone plate of treatment: elimination of the discolored gin- was covered with a collagen barrier membrane giva, preservation of esthetics, and maintenance (Geistlich Biomaterials; Bio-Gide) from inside of the smile line (Figs. 24-26). The patient was and the gap between the implant and the bone very satisfied with the final result of treatment. wall was filled with an anorganic bovine bone graft (Geistlich Biomaterials; Bio-Oss). The GBR and Disclosure bone graft was placed in order to obtain a more The authors report no conflicts of interest with anything mentioned in this article stable buccal soft tissue margin. A Certain ZiReal Post (Biomet 3i) was modified with a concave Acknowledgement buccal surface and a temporary crown placed This case was selected as the Best Alumni Case Presentation in the gIDE/UCLA (Fig. 17). A slow resorbing suture (Vicryl rapide 1-year Master Program in Implant Dentistry for the year 2007. 5/0) was placed to hold the free marginal gingiva. Correspondence: After four months (Figs. 18, 19) the abut- Dr. Sascha Jovanovic Email: [email protected] 52 • Vol. 2, No. 7 • September 2010

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The Combined Use of Allograft and a Polylactic Rosen Acid Barrier for GTR and GBR E orts: 2 Case Reports Paul S. Rosen, DMD, MS1 Abstract The use of a combined regenerative tive outcomes presented. The unique feature of approach that incorporates a bone this absorbable polymer is its ability to allow replacement graft overlain by a poly- for the exchange of fluids between the overly- lactic acid-citric acid ester barrier for the pur- ing flap and underlying regenerative environ- poses of GBR and GTR is presented. The ment along with the ingrowth of connective versatility of this bioabsorbable barrier material tissue into the barrier’s open pore structure is demonstrated by the successful regenera- while being exclusive and bioabsorbable. KEY WORDS: Guided tissue regeneration, guide bone regeneration, bone graft, periodontics 1. Private practice limited to Periodontics and Dental Implants, Yardley, Pennsylvania, USA, Clinical Associate Professor of Periodontics, Baltimore College of Dental Surgery, University of Maryland Dental School, Baltimore, Maryland, USA The Journal of Implant & Advanced Clinical Dentistry • 55

Rosen INTRODUCTION speculated that the favorable gains seen in clini- cal attachment level gain may have been related The use of exclusionary barrier materials either to the barrier’s multi-layered matrix design which alone or in combination with bone replacement enabled the ingrowth of gingival connective tis- grafts have proven to be a predictable method sue into the barrier for tissue integration while for regenerating the periodontium or the alveo- providing the space necessary for regeneration. lus subsequent to their destruction from either A human case report by Harris14 provided histo- disease or trauma.1-4 The original barrier materi- logic evidence that regeneration is possible when als were nonabsorbable5,6 and provided the abil- this barrier is used in combination with allograft ity to maintain space, stabilize the clot, exclude in a class II furcation. This polylactic acid barrier unwanted cells such as epithelium and, when has also been successfully employed for guided used, contain any graft materials.7 While nonab- bone regeneration (GBR) either in prepara- sorbable membranes or combined approaches tion for or concurrent with implant placement.15 have demonstrated some outstanding successes, these devices have fallen out of favor due to their For years, this barrier was not available for high rate of infection,8,9 the need for a second use and only recently has it been rereleased. In staged procedure to remove them and/or the dif- the meantime, clinicians may have forgotten the ficulty/technique sensitive nature to their handling. outstanding clinical results that this resorbable polymer barrier could achieve for both GBR and The evolutionary step to barrier therapy was GTR. The following case reports are presented the development of materials that presented the of patients who have been treated since the bar- characteristics consistent with achieving a favor- rier’s rerelease attesting to its beneficial use. able regenerative outcome while allowing for their bioabsorbtion which did not adversely impact CASE 1 healing.10,11 One such barrier is comprised of polylactic acid with citric acid ester. The advan- This 65 year old Caucasian male was referred for tages to this composition is that the barrier has the replacement of his mandibular right first and good handling characteristics while biodegrad- second premolar. His medical history was unre- ing into water and carbon dioxide when breaking markable. The first premolar had been the ante- down, which can readily be handled by the body. rior supporting abutment for a three unit bridge This polymer barrier maintains it’s exclusive func- and had experienced a combined endodontic- tion for at least 6 weeks when fully covered.12 A periodontal lesion which left it untreatable (Fig- randomized controlled multi-center trial has dem- ure 1). Treatment called for its extraction (Figure onstrated that the use of this barrier enhanced 2) after the bridge was resected mesial to the success versus flap management alone, that it first molar and the area was decontaminated by handled well as demonstrated by 98% of the sites removing any residual soft tissue with curettes achieving primary closure at flap suturing and was and by locally irrigating the socket with povi- relatively tissue friendly since soft tissue coverage done iodine. Any residual iodine solution was was maintained throughout the healing period flushed away with copious irrigation with sterile in approximately 46% of the sites.13 The authors water and guided bone regeneration was per- 56 • Vol. 2, No. 7 • September 2010

Rosen Figure 1: Preoperative radiograph of the mandibular right Figure 2: Clinical view after the bridge has been resected rst premolar. There is a large post present in this tooth mesial to the rst molar and the rst premolar has been extracted. There is a signi cant dehiscence of the labial which may have contributed to the vertical fracture. plate. The socket has been thoroughly debrided of any soft tissue and irrigated with povidone iodine solution. Figure 3: Freeze-dried bone allograft that has been placed Figure 4: The barrier has been trimmed to t the site and into the defect. overlap the bony walls by 2-3 mm and has been placed according to the manufacturer’s instructions. formed. The socket was first filled with mineral- ized freeze-dried bone (LifeNet Health, Virginia extraction, a flap was elevated that was both full Beach, Virginia) (Figure 3) using light incremental and partial thickness to allow for primary cover- pressure to completely fill the socket and then a age of the membrane and the site was sutured barrier of polylactic acid-citric acid ester (Guidor® with 6-0 expanded polytetrafluoroethylene (ePTFE was trimmed to fit over the graft, overlapping the W.L. Gore & Associates, Flagstaff, Arizona) (Fig- edges of the socket (Figure 4). In performing the ure 5). The patient was placed on an antibiotic of amoxicillin 875 mg twice daily for seven days The Journal of Implant & Advanced Clinical Dentistry • 57

Rosen Figure 5: The site has been sutured with 6-0 expanded Figure 6: Flap elevation at 4 months reveals favorable polytertra uoroethylene and primary closure has been regeneration of the site. achieved. Figure 7: Temporary polyethylether ketone transgingival Figure 8: Flaps have been sutured around the implants abutments have been placed on the implants. Bone quality with 6-0 ePTFE. The abutments are left exposed. at both sites is type II. to allow for adequate healing of the site. After along with the topical application of chlorhexidine obtaining local anesthesia, full thickness flap ele- 0.12% swabbing the area twice daily for the first vation revealed good regeneration (Figure 6) and 21 days. Pain management was achieved with this was evidenced upon drilling where the bone the use of ibuprofen 600 mg being taken up to encountered was suggestive of it being Type five times daily as needed. At two weeks post II. Implants were placed at the first and second surgery, the patient had his sutures removed premolar sites with both achieving good primary and the site demonstrated good maintenance of stability as evidenced by insertion torques of the primary closure. Implant placement was per- better than 32 N/cm2 and resonance frequency formed at four months following the extraction 58 • Vol. 2, No. 7 • September 2010

Rosen Figure 9: Preoperative radiograph of the maxillary left Figure 10: Preoperative clinical view of the maxillary left second molar suggests moderate to advanced bone loss at second molar in this 41 year old female patient. Clinical its distal. attachment loss and probing depth are both 8 mm. readings of better than 70 in both buccal-lingual a combined regenerative approach of graft- and mesial-distal directions. Abutments were biologic and membrane. The patient was pre- screwed onto the implants to allow for their being rinsed immediately prior to the procedure with kept transgingival (Figures 7 and 8). Due to the chlorhexidine 0.12% and sulcular full thickness high stability of the implants, their restoration flaps were elevated from the distal of the maxil- was possible after one month of healing since lary left first molar to the distal of the second RFA analysis suggested that they were stable. molar with a straight distal incision placed that would preserve all the tissue. Upon reflection CASE 2 of the flaps, the lesion was debrided of its soft tissue, the roots were scaled and planed using This 41 year old Caucasian female was referred ultrasonic and hand instrumentation. The lesion for evaluation and treatment of an isolated at the distal of the second molar was some- advanced periodontal lesion at the distal of her what broad and was essentially three walls with maxillary left second molar (Figures 9 and 10) some slight beginnings of a palatal moat (Fig- which demonstrated clinical attachment loss ure 11). Fortunately, the furcation had not been and probing depths of 8 mm. The bone loss was invaded. The root surface was modified/decon- suggestive of an impacted third molar which taminated with a solution of tetracycline which had closely approximated the adjacent second was prepared by taking a 250 mg capsule and molar and communicated to the oral cavity. The suspending its contents in 5 milliliters of ster- patient’s medical history was unremarkable and ile water. The roots were burnished for approxi- her plaque control efforts were good based on a low plaque index. Treatment consisted of review and reinforcement of good oral hygiene followed by surgical therapy which included The Journal of Implant & Advanced Clinical Dentistry • 59

Rosen Figure 11: View of the lesion at the distal of the molar Figure 12: After thorough root management, freeze-dried suggests that it is both moderately deep and wide. There is bone allograft that has been rehydrated with platelet 3-4 mm of intrabony component to this 3-wall lesion. derived growth factor-BB has been placed using light incremental pressure. mately 2 minutes using cotton pellets saturated The flaps were secured over the defect with 6-0 with this solution after which the site was copi- ePTFE sutures, obtaining both complete cov- ously flushed with sterile water. The root surface erage of the barrier and primary closure (Fig- had recombinant platelet derived growth fac- ure 14). The patient was prescribed amoxicillin tor applied to it and the periodontal lesion was 2 grams immediately postoperative, then 875 decorticated using a scaler. During this time, mg twice daily for 7 days. Chlorhexidine gluco- freeze-dried bone allograft (LifeNet Heath, Vir- nate 0.12% mouth rinse was prescribed to be ginia Beach, Virginia) was rehydrated by adding topically applied to the site twice daily for infec- the PDGF-BB (Osteohealth, Shirley, NY) solu- tion control as the patient was instructed to tion to it and allowing it to stand for 5 minutes. avoid brushing and flossing at the site for one This was placed into the lesion with light incre- month. Pain management was accomplished by mental pressure until it was slightly overfilled ibuprofen 600 mg being taken up to five times (Figure 12). A posterior wrap-around Guidor® daily. The patient was seen at 14 days post sur- membrane was trimmed to fit the site and then gery at which time the sutures were removed, secured over this area using the supplied suture plaque was lightly curetted from the site and material (Figure 13). Care was used to follow topical chlorhexidine was placed. She was then the manufacturer’s instructions, allowing the seen approximately every 10-14 days for the barrier to warm to room temperature prior to first two months for postsurgical visits at which trimming it to avoid any cracking/deformation. similar plaque debridement occurred. These 60 • Vol. 2, No. 7 • September 2010

Rosen Figure 13: The polymer barrier has been trimmed to Figure 14: Primary closure of the aps has been achieved overlap the lesion’s edges by 2-3 mm and has been secured and they have been secured with 6-0 e-PTFE using and at the mesial of the tooth using the suture that comes interrupted technique. attached the barrier. Figure 15: Clinical view at 1 year following the surgery. Figure 16: Radiograph taken at 1 year suggests favorable The distal of the second molar probes 3 mm and there has bone gain at the distal of the second molar. been 4 mm of gain in clinical attachment level. DISCUSSION visits then occurred at 3 months, 6 months, 9 months and 1 year post surgery (Figure 15). A These case reports demonstrate the favor- gain of 4 mm in clinical attachment was seen able results that can be achieved if a com- at one year along with a reduction in probing bined regenerative approach incorporating depth of 5 mm. A periapical radiograph of the both allograft and absorbable barrier are used. site suggested favorable bone fill (Figure 16). There was robust bone suggested by clinical The Journal of Implant & Advanced Clinical Dentistry • 61

Rosen reentry for the GBR case while the GTR case A degradation process which minimizes suggested good bone fill on the radiograph. inflammation at the healing site. The Guidor® membrane seems to fulfill all of these Concerns have arisen that polymer barriers requirements. Handling features of this barrier are may have an adverse affect on the graft material such that it can be trimmed rather easily, holds beneath them particularly those that are either its shape well for space maintenance while con- synthetic or complexed with a biologic agent. This touring well to the site without rebound so that may reduce the graft’s ability to maintain space a flap perforation complication is avoided. The and thereby diminish the potential regenerative fact that this barrier allows for soft tissue growth outcome. Such may be the case when the graft into its porous outer structure may help dimin- is beta tricalcium phosphate, a synthetic mate- ish micromotion and allow for optimal hard tis- rial which can break down prematurely when sue regeneration. The ability for tissue fluid to exposed to lactic acid, a byproduct of the deg- pass through the barrier may also explain some radation of some of the polymer barriers. There of the favorable soft tissue response to it despite have also been anecdotal reports of increased the degradation of the barrier into an acid. inflammation when a biologic agent has been incorporated with a graft and layered by a poly- The combination of an allograft of freeze-dried mer barrier. In two of these case reports, no such bone complexed with a biologic agent like plate- attendant inflammation was seen by complexing let derived growth factor-BB, in an off label use a mineralized bone allograft with platelet derived may be more consistent with a favorable result. growth factor with the Guidor™ membrane. Certainly, the combination of allograft with bio- logic has demonstrated regenerative efficacy.16 The characteristics that a membrane However, in larger less space maintaining defects should demonstrate if it is to be selected there may be a need to better contain the graft- for use with either GBR or GTR include: biologic complex. The use of a barrier that breaks down more slowly may give the graft-biologic Configurations which can be well adapted to complex the time needed to maintain space and the defect to be treated. provide the scaffold necessary for regeneration. Ease of clinical handling. The ability to be trimmed and reshaped without The current case series adds further evidence shredding. to the literature that this membrane can be used Sufficient body and memory to maintain the to achieve successful GTR14,17-21 and GBR15 established morphology during placement outcomes which merits its consideration to be and suturing. a part of one’s regenerative armamentarium. Selective occlusivity while allowing for fluid exchange that enables flap viability on top of it. Correspondence: The ability to maintain structural integrity for Dr. Paul Rosen four to eight weeks depending upon the size of 907 Floral Vale Blvd. the defect treated, thus affording pluripotent Yardley, Pennsylvania 19067, USA cells the time necessary to repopulate the area treated. 62 • Vol. 2, No. 7 • September 2010

Rosen Disclosure: The Journal of Implant & Advanced Clinical Dentistry The author reports no conflicts of interest with anything mentioned in this article. ATTENTION References: PROSPECTIVE 1. McClain PK, Schallhorn RG. Long-term assessment of combined osseous AUTHORS grafting, root conditioning and guided tissue regeneration. Int J Periodontics Restorative Dent 1988;8(4):9-32. JIACD wants 2. Rosen PS, Marks MH, Bowers GM. Regenerative therapy in the treatment of to publish maxillary molar class II furcations: case reports Int J Periodontics Restorative your article! Dent 1997;17:517-527. 3. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane For complete details technique associated with osseointegrated implants. Int J Periodontics regarding publication in Restorative Dent 1994;14:496-511. 4. Fugazzotto PA Shanaman R, Manos T, Shectman R. Guided bone regeneration JIACD, please refer around titanium implants: report of the treatment of 1,503 sites with clinical to our author guidelines at reentries. Int J Periodontics Restorative Dent 1997;17:293-299. 5. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical the following link: treatment of periodontal disease. J Clin Periodontol 1982;9:257-265. http://www.jiacd.com/ 6. Lazarra R. Immediate placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:333-344. authorinfo/ 7. Scantlebury TV. 1982-1992: a decade of technology development for guided author-guidelines.pdf tissue regeneration. J Periodontol 1993;64:(11 suppl.),1129-1137. 8. Nowzari H, Slots J. Microbiologic and clinical study of poly tetrafluoroethylene or email us at: membranes for guided bone regeneration around implants. Int J Oral Maxillofac [email protected] Implants;10:67-73. 9. Simion M, Baldoni M, Rossi P, Zaffe D.A comparative study of the effectiveness of e-PTFE membranes with and without early exposure during the healing period. Int J Periodontics Restorative Dent1994;14(2):166-180. 10. Lu S-P. Guided bone regeneration using an absorbable membrane combined with a one-stage implant into an extraction site: a case report. Quintessence Int 2003;34:253-257. 11. Schmitz JP, Lemke RR, Zardeneta G, Hollinger JO, Milam SB. Isolation of particulate degradation debris 1 year after implantation of a Guidor membrane for guided bone regeneration. Case report. J Oral Maxillofac Surg 2000;58:888-893. 12. Gottlow J, Laurell L, Lundgren L, Mathisen T, Nyman S, Rylander H, Bogentoft C. Periodontal tissue response to a new bioresorbable guided tissue regeneration device: a longitudinal study in monkeys. Int J Periodontics Restorative Dent 1994;14:437-449. 13. Cortellini P, Tonetti MS, Lang NP, Suvan JE, et al. The simplified papilla preservation flap in the regenerative treatment of deep intrabony defects: clinical outcomes and postoperative morbidity. J Periodontol 2001;72:1702- 1712. 14. Harris R. Treatment of furcation defects with an allograft-alloplast-tetracycline composite bone graft combined with GTR: human histologic evaluation of a case report. Int J Periodontics Restrorative Dent 2002;22(4):381-387. 15. Christensen DK, Karoussis IK, Joss A, Hämmerle CHF, Lang NP. Simultaneous or staged installation with guided bone augmentation of transmucosal titanium implants. A 3-year prospective cohort study. Clin Oral Impl Res 2003;14:680-686 16. Nevins M, Camelo M, Nevins ML, Schenk RK, Lynch SE. Periodontal regeneration in humans using recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and allogenic bone. J Periodontol. 2003;74:1282- 92. 17. Falk H, Laurel L, Ravald N, Teiwik A, Persson R. Guided tissue regeneration of 203 consecutively treated intrabony defects using a bioabsorbable matrix barrier: Clinical and radiographic findings. J Periodontol 1997; 68: 571-581. 18. Hugoson A, Ravald N, Fornell J, Johard G, Teiwik A, Gottlow J. Treatment of class II furcation involvements in humans with bioresorbable and nonresorbable guided tissue regeneration barriers. A randomized multi-center study. J Periodontol 1995; 66: 624-634. 19. Lundgren D, Mathisen T, Gottlow J. The development of a bioresorbable barrier for guided tissue regeneration. J Swed Dent Assoc 1994; 86: 741- 756. 20. Gottlow J, Laurell L, Teiwik A, Genon P. Guided tissue regeneration using a bioresorbable matrix barrier. Pract Periodontics Aesthetic Dent 1994; 6: 71-80. 21. Gottlow J, Guided tissue regeneration using bioresorbable and nonresorbable devices: Initial healing and long-term results. J Periodontol 1993; 64: 1157-1165. The Journal of Implant & Advanced Clinical Dentistry • 63

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Atraumatic Implant Explantation, is it Possible?Anitua et al Description of a Novel Technique and a Case Series Study Eduardo Anitua, DDS, MD1 • Gorka Orive, PhD1 Abstract Background: This study reports a new approach Results: All implants could be removed using for implant extraction. The new technique facili- the BTI extraction kit. The extraction torque tates extraction in a convenient, fast and atrau- ranged from 80 to 200 Ncm. In those cases matic way preserving the walls of the alveolar in which implant removal torques exceeded housing intact and allowing the placement of 200 Ncm, a 2 mm depth incision was done a new implant during the same surgical time. using a new set of atraumatic trephines and the extractor with the aim of avoiding too high Methods: The new BTI extraction kit consists on counter torque forces. The small trephine inci- a new wrench that allows a counter torque force sion around the implant was enough to reduce of 200 Ncm (the wrench breaks back at that the removal torque by half. In twenty cases a force and alerts us when that value is exceeded), new implant was placed in the extraction sites. an internal connection extractor, an extractor for external connection, and a set of ratchet handle Conclusions: The possibility of extracting extension pieces to adapt into different clini- osseointegrated implants opens new doors in cal situations. In this study, a total of fifty-eight oral implantology. The new extraction kit allows cases showing extraction of different types of dentists to retreat cases and improve the final implants using the BTI extraction kit are reported. results, achieving the best outcomes for patients. KEY WORDS: Explantation, dental implants, torque removal, peri-implantitis The Journal of Implant & Advanced Clinical Dentistry • 65

Anitua et al INTRODUCTION necrosis at the bone-implant interface. The thermo necrosis was provoked using an The success of dental implants is fairly well ultra-high frequency electrosurgical device.13 documented, with a general success rates around 90-99%.1-4 However, despite this high In contrast to other previous proce- rate of success some implants are always lost. dures, in the present study, we report These failures are in general caused by three a new implant removal system that pre- factors: bacterial infection, possible technical serves the bone around the implant allow- errors and occlusal load.5-7 Implants affected by ing the safe and predictable placement of peri-implantitis have conventionally been treated implants in the same location of the extraction. by various procedures armed to eradicate the infection and thus allowing the osseointegration MATERIAL AND METHODS of the affected area. The most common tech- niques used to treat peri-implantitis include the Fifty-eight consecutive implants were removed use of mechanical debridement, the use of the with new BTI extraction kit (Biotechnology Er:YAG laser, the use of mechanical debride- Institute, Vitoria, Spain). Reasons for extrac- ment combined with antiseptic agents and the tion include infection (peri-implantitis), frac- use of mechanical debridement combined with ture or incorrect position. Vertical and local application of antibiotics and the surgi- releasing incisions were made in some cases cal treatment.8,9 When these treatments fail to raise a mucoperiosteal flap that extends and bone destruction progresses, the implant over the mucogingival junction. Removal needs be removed. Another etiologic factor of implants was made using the BTI extrac- associated with implant failure is the adverse tion kit. The new BTI extraction kit consists occlusal load that may result in mechani- on a new wrench that allows a counter torque cal complications including implant fracture. force of 200 Ncm (the wrench breaks back at that force and alerts us when that value is In many of these situations, although the exceeded), an internal connection extractor, implant is successfully osseointegrated, it an extractor for external connection, and a set must be removed due to an incorrect inclina- of ratchet handle extension pieces to adapt tion or the impossibility to be rehabilitated. into different clinical situation14 (see Figure 1). vThe conventional technique to remove den- tal implants uses a trephine to remove the To proceed with the extraction of an bone cylinder surrounding the osseointegrated implant, the extractor is inserted into the inter- implant or a thin bur at low speed with irriga- nal thread of the implant, which is removed tion.10,11,12 This type of extraction may limit the following an anti-clockwise movement. Once placement of a new implant in the same loca- it is positioned, a maintained and controlled tion where it has previously been extracted. counter torque (to avoid bending forces) on In 2004, Massey and colleagues reported an the implant is applied (Figure 2). The lat- approach to remove osseointegrated implants ter will remove the osseointegrated implants. based on the induction of a localized thermo- In those cases where the removal torque exceeds 200 Ncm (maximum counter torque 66 • Vol. 2, No. 7 • September 2010

Anitua et al Figure 1: The new BTI extraction kit consists on a new Figure 2: a) The extractor is screwed in counterclockwise. wrench that allows a counter torque force of 200 Ncm b) Counter-torque is now applied slowly, taking care that (the wrench breaks back at that force and alerts us when no exion forces are introduced. c) The diagram shows the that value is exceeded), an internal connection extractor, operation of the unit. an extractor for external connection, and a set of ratchet handle extension pieces to adapt into di erent clinical situations. force allowed by the wrench) a combination of the extractors with a new trephines kit (Bio- technology Institute, Alava, Spain) designed for this technique is required. These new tre- phines have been designed following the phi- losophy of atraumatic explantation. They have a thin area of 5 mm to produce a cut around the initial millimeters of the implant (Figures 3, 4 and 5). In general, by cutting 2 to 3 mm of bone around the implants, it is possible to reduce drastically the removal torque force. In fact, in most of the cases we will reduce the counter torque force by half. After removing the implants in some cases, new implants can be placed during the same surgical procedure, using the biological drilling at low speed (50-100 rpm) and a new implant with larger diameter than the extracted one (Figures 6, 7 and 8). Implants placed in the extraction site were left submerged following a The Journal of Implant & Advanced Clinical Dentistry • 67

Anitua et al Figure 3: Set of explantation trephine drills. It is observed Figure 4: The new trephine drills work out in a more how the 5 mm section closest to the apex is thinner. atraumatic manner, removing a very little bone around the implant. In many cases, it is enough to drill a depth of 2 mm 2-stage surgical procedure. Loading of these to retrieve the implant easily. implants was performed at three months both in the mandible and the maxilla. In those situ- Figure 5: The situation of the alveoli after implant removal. ations where the placement of a new implant in the same position was not required, the ity of implants ranged between 51-100 Ncm extraction site was filled with ENDORET™- (46.5%) and 101-150 Ncm (36.4%). Only Plasma Rich in Growth Factors (PRGF Sys- 17.1% of the extraction forces were higher than tem®, Biotechnology Institute, Vitoria, Spain) 150 Ncm (Figure 9). Regarding the types of with the aim of accelerating bone regeneration. implants removed, twenty of them were from 3i brand (34.4%), fifteen were from Astra Finally, flaps were repositioned to obtain a (25.8%), ten were from Nobel (17.2%), eleven primary wound closure and were sutured using of the implants were from of an unknown brand monofilament suture 5/0. The medication pre- (18.9%) and two of the implants removed scribed to all patients consisted of antibiot- were from BTI brand (3.4%) (Figure 10). ics, anti-inflammatory drugs, and chlorhexidine mouthwash. All the extracted implants were analyzed in the laboratory and their extrac- tion torques determined with precision. RESULTS A total of fifty-eight implants were consecu- tively removed in forty-five patients. Reasons for extraction include peri-implantitis (80%), incorrect angle or inability to rehabilitation (15%) and biomechanical failure or fracture of implants (5%). The maximum counter torque force needed to remove an implant was 200 Ncm. The counter torque applied in the major- 68 • Vol. 2, No. 7 • September 2010

Anitua et al Figure 6: Patient with a lower prosthesis on top of implant Figure 7: Placement of the extractor. installed 15 years ago. placed in the extraction site whereas in thirty- Figure 8: Three implant were kept in place for the eight cases (65.6%) it was not necessary. provisional prosthesis, and after 3 months the new implants will be inserted and the old ones extracted. DISCUSSION The trephines were only used in the removal In this study a new technique for atrau- of 4 implants (6.8%), being all them located in matic implant extraction is presented. The the anterior mandible. The initial removal torque new approach facilitates implant extrac- in all cases exceeded 200 Ncm, as evidenced tion in an easy, fast and predictable way, by the breaking of the wrench during the extrac- preserving the walls of the alveolar hous- tion. Once the trephine was introduced two ing intact and allowing the placement of a millimeters into the bone, the removal torque new implant during the same surgical time. was markedly reduced, as shown in Figure 11. Using the new BTI extraction kit a total of fifty- In twenty cases (34.4%) a new implant was eight implants were retrieved atraumatically. There are few studies in humans report- ing techniques that achieve successful atrau- matic implant extraction and which preserve the bone around the implants intact. For example, Covani et al.10,11 in 2006 and 2009 showed an approach that allowed removal of the implant, but the procedure differed from that presented in this work, as they used a thin bur at low speed under cooling water to remove the bone around the implant. Despite being a different method, it was also capable The Journal of Implant & Advanced Clinical Dentistry • 69

Anitua et al Figure 9: Relation of the removal torque used to retrieve Figure 10: Di erent types of implants can be easily the implants. retrieved using the new BTI kit. Figure 11: The new set of trephines allow to drill 2-3 mm or who have implants that can not be rehabili- in depth to facilitate the posterior extraction with the tated. The most important advantage is that BTI extractors. Using this tool, it is possible to reduce the it preserves the alveolar bone volume after removal torque by half. implant removal. Further advantages include: providing immediate solutions to clinical com- of maintaining a sufficient bone bed to allow plications, shortening treatment duration and the placement of new implants in the extrac- reducing the number of surgical procedures.11 tion site. However, the new technique pre- sented herein, provide additional benefits In the other hand, the use of a counter when treating patients whose implants failed torque extraction is well documented in the removal of orthodontic mini-implants,12,15,16 although the removal torques of these implants are smaller than those needed for conventional dental implants. In addition, it has been shown that removing orthodontic mini-implants is eas- ier due to their small diameter and length and due to the orthodontic forces they are subjected to.17 Simon et al.18 used the transitional coun- ter torque to remove small-diameter implants in four patients. Removal of implants was per- formed with a counter torque device without the use of an extractor. Authors reported some complications in the extraction process includ- ing fracture, deformation of the structure of the 70 • Vol. 2, No. 7 • September 2010

Anitua et al implant and detachment of bone fragments that Disclosure remained between the spires.18 These problems The authors report a financial interest in Biotechnology Institute. were a consequence of the flexor moment gen- erated by not using the extractor even though References the implants were removed with a low removal 1. Berglundh T, Persson L, Klinge B. A systematic review of the incidence torque (maximum torque removal 35.4 Ncm). It should be stressed that such a complication of biological and technical complications in implant dentistry reported could be more remarkable if the implant to be in prospective longitudinal studies of at least 5 years. Journal of Clinical extracted would be conventional and thus the Periodontology 2002;29:527-551. requirement for removal torque forces higher. 2. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors contributing CONCLUSIONS to failures of osseointegrated oral implants (I). Success criteria and epidemiology. European Journal of Oral Sciences 1998a ;29:197-212. Results of this study suggest that BTI extrac- tion kit is a safe and effective approach to 3. Roos-Jansaker AM, Lindahl C, Renvert H, Renvert S. Nine to fourteen year remove different types of implants including follow-up of implant treatment. Part I: implant loss and associations to various implants with different diameters, lengths and factors. Journal of Clinical Periodontology 2006;33:283-289. morphologies. One of the main conclusions of using this technique is that it is conservative 4. Anitua E, Orive G, Aguirre JJ, Ardanza B, Andía I. 5-year clinical experience to the bone that is osseointegrated. The pos- with BTI dental implants: risk factors for implant failure. Journal of Clinical sibility of reversing the osseointegration with- periodontology. 2008;35:724-32. out negative consequences opens a new door in oral implantology and provides us a new 5. Sbordone L, Barone A, Ramaglia L, Ciaglia RN, Iacono VJ. Antimicrobial tool to use in our daily clinical practice. In susceptibility of periodontopathic bacteria associated with failing implants. addition of being able to place implants at the Journal of Periodontology. 1995;66:69-74. extraction site during the same surgical stage, the new BTI extraction kit reduces treatment 6. Isidor F. Loss of osseointegration caused by occlusal load of oral implants. times and minimizes costs to the patient. A clinical and radiological study in monkeys. Clinical Oral Implants Research 1996;7:143-52. Correspondence: Dr. Eduardo Anitua 7. Tonetti M, Schmidt J. Pathogenesis of implant failure. Periodontology 2000 Instituto Eduardo Anitua 1994;4:127-138. c/o Jose Maria Cajigal 19 10005 Vitoria (Spain) 8. Kotsovilis S, Karoussis IK, Trianti M, Fourmousis I. Therapy of peri-implantitis: a Phone: +34 945160652 systematic review. Journal of Clinical Periodontology 2008;35:621-629. Fax: +34 945155095 [email protected] 9. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of peri-implantitis. Journal of Clinical periodontology 2008;35 (Suppl.8): 316-332. 10. Covani U, Barone A, Cornelini R, Crespi R. Clinical Outcome of implants placed immediately after implant removal. Journal of Periodontology 2006;4:722-727. 11. Covani U, Marconcini S, Crespi R, Barone A. Immediate implant placement after removal of failed implant: a clinical and histological case report. Journal of Oral Implantology 2009;4:189-195. 12. Favero GL, Pisoni A, Paganelli C. Removal torque of osseointegrated mini-implants: an in vivo evaluation. European Journal of Orthodontics 2007;29:443-448. 13. Massei G, Szmukler-moncler S. Thermo-explantation. A novel approach to remove osseointegrated implants. Eur Cells Mater 2004;7:48. 14. Anitua E. ¿Es posible la reversibilidad de la osteointegración?. Dental Dialogue 2010;1:1-13. 15. Hohlt WF. How to remove an osseointegrated palatal implant. American Journal of Orthodontics and Dentofacial orthopedics 2004;126:19 A. 16. Chen YJ, Chen YH, Lin LD, Yao CC. Removal torque of miniscrews used for orthodontic anchorage- a preliminary report. International Journal of Oral and Maxillofacial Implants 2006;21:283-289. 17. Okazaki J, Komasa Y, Sakai D, Kamada A, Ikeo T et al. A torque removal study on the primary stability of orthodontic titanium screw mini-implats in the cortical bone of dog femurs. International Journal of Oral and Maxillofacial Surgery 2008;37:647-650. 18. Simon H, Caputo AA. Removal torque of immediately loaded transitional endosseous implants in human subjects. International Journal of Oral and Maxillofacial Implants 2002;17:839-845. The Journal of Implant & Advanced Clinical Dentistry • 71

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de la Rosa et al R

The Dilemma of Extract or Mantain in de la Rosa et al the Piero-Ortho Scenario. A Case Report Manuel de la Rosa DDS,MS1 • Marcela de la Rosa DDS,MS2 Abstract Background: With the increase ease of use of and described. The treatment plan included Peri- dental implantology, tooth preservation has been odontics, Orthodontics and Prosthodontics. questioned as if it still remains as one of the best treatment approaches in clinical dentistry today. Results: The results obtained with the inter- The interrelationship between Periodontics and disciplinary treatment were a resolution of the Orthodontics has widened in its approach to space problem with the Orthodontic treatment. resolve clinical situations which contain a diffi- Two Biohorizons One-Piece implants were cult scenario on the concept of “space available”. placed on #7 and #10, achieving excellent oclu- ssion, esthetics and comfort for the patient. Methods: The following paper describes a review of the steps considered in the elaboration of an Conclusions: Within the limits of this article, interdisciplinary treatment plan on a patient with we can conclude that interdisciplinary treat- needs of a Periodontal-Orthodontic-Prosthodon- ment is a predictable approach to confront a tic Treatment. An interdisciplinary treatment plan difficult case in terms of space managing and approach as well as treatment were performed decisions on weather extract or maintain teeth. KEY WORDS: Periodontics, Orthodontics, Interdisciplinary treatment plan, dental implants, Bolton analyses, immediate restored implants 1. Private Practice limited to Periodontics and Implants in Monterrey, Mexico 2. Private Practice limited to Orthodontics in Monterrey, Mexico The Journal of Implant & Advanced Clinical Dentistry • 75

de la Rosa et al INTRODUCTION teeth should be extracted or maintained. The first step while evaluating a patient from an One of the long term objectives in clinical den- interdisciplinary approach is to evaluate the tistry has been tooth preservation. Although periodontal condition of the patient. Periodon- not always possible, it has certainly repre- tally, the following parameters should be evalu- sented the final objective of many dental treat- ated: 1) probing depth, 2) clinical attachment ments. In periodontics there have been many level, 3) mobility, 4) free gingival margin loca- techniques and clinical alternatives that have tion, 5) radiographic bone level, 6) furcation made more predictable the preservation of involvement, 7) oral hygiene, 8) the patient’s teeth. Even with new techniques and its facil- interest in dental treatment, 9) the patient’s ity of achievement, there are some cases in general health. It is also necessary to evalu- which we still have doubts whether we should ate the patient’s occlusion, tooth position maintain a tooth or extract it. The evolution and function. Once we have evaluated and of implantology in the late years is giving us registered this information, we are ready to a very different scenario to consider when discuss it with our treatment members and elab- we have a situation in which tooth replace- orate a comprehensive dental treatment plan. ment is being considered. The strong long term predictability of implants, functionally and From the Orthodontic treatment perspective, esthetically, has made the alternative of sub- the evaluation should consider: 1) Facial analy- stituting of a tooth with fair to poor progno- sis, 2) Skeletal Analysis 3) Occlusal analysis, 4) sis a very predictable treatment approach.1-3 Profile, 5) Lip position at rest and at smiling, 6) Tooth position 7) root’s position, 8) Tooth struc- Longitudinal Studies have demonstrated ture, 9) Occlusal function, 10) Periodontal how implantology, driven properly, has a very Prognosis of Teeth involved, 11)Age of patient, good prognosis (over 15 years in function)4, 12) Patient’s interest in orthodontic treatment. while the reports over natural teeth treated with endodontics and crown and bridge, specially In terms of Prosthodontics, any pretreatment when these teeth have undergone periodontal evaluation should consider the following param- disease, do not show the same solid results. eters: 1) Teeth present and absent, 2) Periodon- Even when we have today a high success per- tal condition of the teeth present, 3) Dental centage in dental implants, we should be very occlusion, 4) Anterior guidance, 5) Patient’s careful in mantaining a fine line between extract- overbite and overjet, 6) Tooth structure, 7) Tooth ing or preserving a tooth.5 We should consider position and its relevance to dental function and implantology as one more approach in den- esthetics, 8) Tooth color, and 9) Tooth shape. tal treatment, but never as the only approach. All these different factors play a crucial It is very important to review the diagnos- role in the decision of either maintaining or tic tools that will give us the more certain extracting a tooth. The question that always diagnostic and treatment plan. The question follows is which one of all the above men- that always rises is what parameters should tioned factors play the strongest influence in we consider with more weight to decide what our decision taking process? For many years 76 • Vol. 2, No. 7 • September 2010

de la Rosa et al periodontics has tried to behave from an objec- to integrate an interdisciplinary treatment in a tive perspective, although it is not easy to pre- periodontics-orthodontics patient. We start by dict the future of a tooth or a group of teeth having the periodontist and the orthodontist elab- in different situations. Studies performed by orate a list of dental problems to be considered McGuire,6-9 Becker,2 among others have dem- during treatment (problem list). This list comes onstrated that even when there is a strict peri- as a result of the initial visit of the patient to the odontal control with frequent maintenance dental office. The periodontist, as well as the visits, it is quite difficult to predict the evolu- orthodontist, and any other dentist involved in tion of periodontal health after treatment. It is the treatment, will contribute to the problem list for this reason that we recommend being the to consider in the dental treatment of the patient. most objective at the time of assigning a peri- This list should include every aspect diagnosed odontal prognosis. It is as well important to during the clinical and radiographic examinations. apply the dental interdisciplinary concepts at Following this list of dental problems, we will then the time of assigning a comprehensive dental elaborate a list of probable treatment options to prognosis, as described by De la Rosa et al.10 address the problem list. This new list of den- tal treatment proposals should include the most Since the vast majority of a periodontal objective and predictable treatment options from treatment represents the initiation of a mul- the different disciplines in dentistry involved in the tidisciplinary treatment, we have started this case to be treated. It is quite possible to end up case report with a description of the peri- with more than one treatment plan. This is nor- odontal analysis, which represents itself as mal and positive for the case, so that the patient the biological part of interdisciplinary treat- has at least a few options to decide what treat- ment. An interdisciplinary treatment can be ment plan he or she considers best for his mouth. divided in four categories: 1) Biology, 2) Structure, 3) Function, and 4) Esthetics.11 Once we have 2 or 3 options of treatment plans, we should consider which is the best in As part of the evolution that every dis- terms of prognosis, patient compliance and eco- cipline in dentistry has gone through in nomic possibilities for the patient. We will then recent years, an interdisciplinary treatment coordinate a meeting with the patient to discuss plan is considered today the most appropri- the treatment options. It is important to remem- ate approach.12 An independent treatment ber that the treatment plan we choose should plan should be analyzed by different special- be a treatment plan aiming at a 20 year good ists involved in the case to be treated, in such prognosis. This does not mean that we assure a way that an interdisciplinary treatment plan the patient that he(she) will have their teeth in can end as a result of this interaction. The mouth for 20 years, but that if the treatment is question that always rises is how can we unite performed as planned and if maintenance ther- concepts in different fields of dentistry? How apy is followed, the results of treatment have can we make a periodontal prognosis accu- the possibility of functioning for 20 years. It is rate and applicable for orthodontic treatment? therefore very important to understand what We will start by defining step by step how The Journal of Implant & Advanced Clinical Dentistry • 77

de la Rosa et al Figure 1: Pre-operative frontal image (Intraoral). Figure 2: Pre-operative frontal facial view. a “good prognosis” means,6-10 not only in be analyzed. If the teeth are present in a wrong terms of periodontics or orthodontics alone, position, the option of orthodontic treatment will but as a whole interdisciplinary prognosis. At be one to be discussed with the patient. If, on the this time in the treatment we will connect the other hand, the teeth are present in a good posi- periodontal prognosis, with the restorative tion, but the occlusion is not the ideal for func- and orthodontic prognosis, so we achieve tion on the patient, then complete prosthodontic a whole dental prognosis for the patient. treatment will be discussed with the patient. Once the patient has accepted the treatment Once all 3 of the initial aspects of interdisci- plan, we will start elaborating the treatment plan. plinary treatment are concluded (Biology, Struc- The first step in the elaboration of the treatment ture, and Function), we will go to the final and plan will always be the Biological aspect of the more visible aspect of dental treatment: Esthet- case. The biological aspect will always be based ics. This is the last part of treatment in chronol- in the periodontal condition and treatment. Once ogy of working direction, but by no means the the periodontal tissues are free of active disease, least important of all 4 areas of treatment. We and the periodontal destruction is arrested, we will concentrate on the small details to end up can go ahead with the Structural part of treat- with an improved esthetic result. Most of the ment. During this part of treatment we will work work in this part of treatment is performed by on the structure of the tooth. New resins, com- posites, etc will be performed where needed to give a better structure to the teeth. Caries, abfrac- tures, fractures, ill fitting removable or fixed res- torations will also be changed. Once this aspect is addressed, the functional part of treatment will now begin. The functional aspect of treatment, as its name implies, is totally related to the occlu- sal function of the patient. Patients’ occlusion, tooth position and form, as well as alignment will 78 • Vol. 2, No. 7 • September 2010

de la Rosa et al Figure 3: Pre-operative lateral facial view. odontal condition with crowding of lower anterior teeth. He has a history of root amputation in the the Restorative Dentist. It is during this phase of lower left first molar, multiple tooth restorations, treatment that the final crowns replace the pro- and worn anterior teeth. At the initial examination visionals. A periodontal plastic procedure might it is obvious the absence of maxillary lateral inci- be performed at this part of treatment to increase sors, as well as one of the mandibular incisors, the quality of the patient´s smile. Tooth whiten- which creates a Bolton Discrepancy. There are ing treatments, as well as orthodontic retention spaces distal to the upper cuspids. Evaluat- are also common to have in this part of treatment. ing his profile, we can see lack of lip eversion, This will conclude the active part of treatment. -2mm of tooth at rest, tooth display at smiling is 1mm. He has good posterior interdigitation, and CLINICAL CASE lack of overbite and overjet. His lower right first molar was endodontically treated and required A 55 year old white male, in excellent health, with retreatment. During retreatment, a perfora- no drug allergies or medications presented for ini- tion of the root occurred, and the molar had to tial treatment evaluation. The patient was referred be extracted. The extraction was performed to the Orthodontist (MR) with a Chief Complaint doing a ridge preservation extraction in order of crowding of lower anterior teeth that interferes to create the ideal scenario to place an implant. with his daily practice of oral hygiene. Initial pho- tographs (Figures 1-3) show he has a good peri- There are 2 treatment approaches from an Orthodontic perspective. The easy way of treat- ment would be to extract a lower incisor, align the other incisors, close the open spaces between upper teeth and finish treatment. This approach unfortunately has some pitfalls. The first is that since there is already one mandibular incisor miss- ing, a second missing incisor, combined with a maxillary absence of lateral incisors, would rep- resent a great limitation on the function of cut- ting food, since this working area is going to be affected. Normally the incisors are responsible for the cutting part of the chewing cycle, and if we reduce the working area 50% this will certainly have a negative effect on the chewing capaci- ties of the patient. The second point is his flat lips. By treating him with this approach, his lips will remain as they are, due to the arch crowd- ing. The advantage with this treatment, is timing, since we would align once the tooth is extracted The Journal of Implant & Advanced Clinical Dentistry • 79

de la Rosa et al Figure 4: Orthodontic initiation of treatment, frontal view. Figure 5: Orthodontic nal view (mandibular) prior to bracket removal. and it would be a straight forward treatment. The second treatment approach would be to Figure 6: Orthodontic nal view (maxillary) prior to bracket removal. open spaces to accommodate the mandibular inci- sor which is ectopic, and accommodate spaces the analysis, it was found that even when align- in the maxilla to further place maxillary lateral inci- ment was completed, there would still be a lack sors. Apparently this is a simple option, but there of ideal space, which, in this case, would be is one main concern with this treatment approach: obtained by Inter Proximal Reduction of upper he only has 3 lower incisors, which means he has teeth. It has to be done minimal, so we won´t a Bolton Discrepancy.13 This is the treatment affect the interdigitation of posterior teeth. option that will give the patient a better result in terms of function and esthetics, but it is the most After reviewing both treatment options with difficult and challenging treatment option. Why? the patient, the second option was selected. With this Bolton discrepancy, the space obtained Orthodontic therapy started and after 4 months for the maxillary lateral incisors will be diminished. The challenge is to open the space in the maxilla at least 5.5mm in each lateral incisor. A down- side of this treatment approach is timing. It is of high importance to be sure the patient is a good candidate for this option, as it will take more time than the treatment approach discussed earlier. Orthodontic treatment started with a Bolton analysis, as well a diagnosis wax set- up and Orthodontic treatment plan. After evaluating the treatment options above mentioned, and discussing them with the Periodontist, it was decided to open spaces and aim at treating the spaces for maxillary lateral incisors and accom- modate the mandibular ectopic incisor. From 80 • Vol. 2, No. 7 • September 2010

de la Rosa et al Figure 7: Radiographic image of implant placement at site Figure 8: Radiographic image of implant placement at site #7. #10. of treatment, the mandibular ectopic incisor was implant diameters, prosthetics options and long- no longer out of alignment, and was now part of term maintenance of the results obtained with a regular positioned mandibular incisor (Figure 5). implant placement. The final space created with During the ensuing months, we worked on cre- orthodontic treatment was a 5.5mm mesio-distal ating the necessary space in the maxillary arch. distance between central incisor and canines. The spaces created for the lateral incisors were: 5.5mm in the upper right and 5.7mm for the upper The final treatment plan decided to perform left (Figures 4 and 6). According to the Ortho- on this case was the placement of 2 Biohorizons dontist, this was the maximum space which could One-Piece dental implants. The Biohorizons One- be created with treatment. With this condition, it Piece implants are implants with a body and neck was now referred back to the Periodontist to eval- diameter of 3mm. This implant has as well the uate the probable implant placement. After evalu- prosthetic part of the implant in a different color ation of the quality and quantity of bone present, than the implant, but is all one piece. There are a thorough evaluation was performed regarding no connections between the implant body and the prosthetic abutment. Therefore, it is an implant The Journal of Implant & Advanced Clinical Dentistry • 81

de la Rosa et al Figure 9: Final frontal image after 2 years of function. Figure 10: Final lateral facial view. designed to have a provisional restoration placed ning, a good surgical stent, and a good surgical on the day of the surgery. It is extremely important planning, the probabilities of failure are not great. to have an implant with a body as well as a neck of 3mm. By doing so, we will secure the implant The patient was anesthetized by infiltration. space of 3mm continuously. There are many differ- One carpule of Lidocaine 2% (20mg/ml) with ent implant options in the market today, but many 1:100,000 epinephrine (0.01mg/ml) with pre- implants have a different width in the body than vious use of topical anesthetic gel was used. A in the neck. Since the patient has only 5.5mm full thickness flap was raised on each site, the of space available, a 3mm implant is crucial or is implant placement went without complications the only way out to perform and end with a pleas- following the position parameters indicated by ing result functionally and esthetically.14,15 A very the surgical stent. Implants were placed in the important aspect to consider is to respect the planned and desired location (Figures 7 and space needed for the papilla between the lateral 8). The provisional restorations were placed incisors and the central incisors, as well as with over the implant, and the flap was sutured with the canines. As previously demonstrated by Tar- 5-0 polyglicolic suture. Patient was given amoxi- now16,17 a minimum of 1mm bone crest should be cillin 500mgs TID for 7 days, as well as anal- left between an implant and a tooth, if 1.5mm can gesic and instructed on Chlorohexidine rinses be left, the long term prognosis of the bone crest bid for 15 days. Provisional restorations were will be better. If the total space is 5.5mm, we subtract 3mm from 5.5 and we will have 2.5mm to divide for both mesial and distal papillae. This will in turn give us a final space of around 1.7mm for each bone crest between the implant and the neighboring teeth, which in turn follow the recom- mendations suggested by the teams of Salama, Tarnow and Kois.14,16,19 The only adverse part of this treatment plan is that our margin of error is almost “0”. Regarding a good prosthetic plan- 82 • Vol. 2, No. 7 • September 2010

de la Rosa et al changed after 8 weeks for further aid in the soft In the previous case we were confronted with tissue response to the crown margins. After 12 several obstacles during treatment that made the weeks of healing, the final prosthetic restora- entire treatment challenging. Space for tooth tions were performed. Notice the changes in alignment, type of anterior occlusal relationship, his profile, regarding lip eversion (Figure 10). lip position, lateral profile, among other aspects were entirely considered and discussed towards The patient has been maintained in a sup- the achievement of an excellent result after treat- portive periodontal therapy regimen ever ment. It is very clear that when we build together since.19 Two years have gone after the sur- an interdisciplinary treatment plan together with gical placement of the implants, and the the different team members, the results are much gingival margin around the final crowns better in terms of esthetics, function and com- over the implants remain stable (Figure 9). fort for the patient. The availability of an implant system with the space requirements, quality of DISCUSSION implant surface, and ease of use certainly made a strong difference in the results of our treatment. Management of a patient with a complex den- tal situation involving different disciplines in CONCLUSION dentistry has always been a difficult task. Fortu- nately the progress in dental research has given Within the limits of this case report, we can con- us the opportunity to have different predict- clude that management of an interdisciplinary able treatment options for this type of cases. treatment is strongly based on a well documen- The interrelationship between periodontics tation, strong communication and strict adher- and orthodontics is a constantly evolving area ence to the treatment plan proposed. The use of dentistry in which the introduction of den- of a one-piece implant positively influences the tal implants has improved the long term prog- final result of treatment in cases were space is nosis of treatment. One of the biggest issues not ideal. Time and patience become a standard in this type of cases is the space scenario. It is of work with these types of treatments. There- quite common to have a scenario in which “ideal” fore they are not treatments for every patient. space in terms of orthodontics does not meet the periodontal criteria considered as “ideal”. Correspondence: Dr. Manuel De la Rosa-G. Communication is a profound tool that must Calzada San Pedro # 1000-3 be used constantly during treatment, not only Col. Fuentes del Valle between peer dental specialists, but with the Garza Garcia, N.L. Mexico patient as well. Good communication will reduce Phone (81)8401-8119 the probable error margin. Good communica- Fax (81)8401-8120 tion is as well a very important base over which email: [email protected] we could prevent disappointments at the end of treatment with unmet results. In treating dental cases with an interdisciplinary approach, com- munication represents a solid part of treatment.21 The Journal of Implant & Advanced Clinical Dentistry • 83

de la Rosa et al AADDVVERETIRSETWISITHE Disclosure The authors report no conflicts of interest with anything mentioned in this article. TODAY! Acknowledgements Reach more customers The authors would like to thank Dr. Alma Zuñiga for referring and participating with the dental on the patient’s treatment, as well as Dr. Hector Villarreal for performing the final profession’s first restorations of the patient. truly interactive References paperless journal! 1. Avila G, Galindo-Moreno P, Soehren S, Misch C, Morelli T,Wang H. A Novel Using recolutionary online technology, Decision-Making Process for Tooth Retention or Extraction. JPeriodontol 2009; JIACD provides its readers with an 80(3): 476-491. experience that is simply not available 2. Becker W. Tooth Loss Significantly Reduced With Non-Surgical Therapy. J with traditional hard copy paper journals. Periodontol 2000; 71(5): 845. WWW.JIACD.COM 3. Greenstein G. The Use of Surrogate Variables to Reflect Long-Term Tooth Survivability J Periodontol 2005; 76(8): 1398-1402. 4. Noack N, Willer J, Hoffmann J. Long-term results after placement of dental implants: Longitudinal study of 1,964 implants over 16 years. Int J Oral Maxillofac Implants 1999;14: 748-755. 5. Richard T. Kao. Strategic Extraction: A Paradigm Shift That Is Changing Our Profession. J Periodontol 2008; 79(6): 971-977. 6. McGuire MK. Prognosis versus actual outcome: A long-term survey of 100 treated patients under maintenance care. J Periodontol 1991;62: 51-58. 7. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of commonly taught clinical parameters in developing an accurate prognosis. J Periodontol 1996;67: 658-665. 8. McGuire MK, Nunn ME. Prognosis versus actual outcome. III. The effectiveness of clinical parameters in accurately predicting tooth survival. J Periodontol 1996;67: 666-674. 9. McGuire MK , Nunn ME. Prognosis Versus Actual Outcome. IV. The Effectiveness of Clinical Parameters and IL-1 Genotype in Accurately Predicting Prognoses and Tooth Survival. J Periodontol 1999; 70(1): 49-56. 10. De la Rosa-G M, Cepeda JA. Pronóstico Periodontal y su evolución. SEPA Nov 2005. 11. Spears F. CE Course lecture. Advance Esthetic and Restorative Management. 2004. 12. Spear F, Kokich VG, Mathews D. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137: 160-169. 13. Bolton W. Disharmony in the Toothsize and its Relation to the Analysis and Treatment of Malocclusion. Am J Orthod 1958; 14: 67. 14. Salama H, Salama Ma, Garber D, Adar P. The interproximal height of bone: A guidepost to predictable aestethic strategies and soft tissues contours in the anterior tooth replacement. Pract Proced Aesthet Dent 1998;10(9): 1131-1141. 15. Smukler H, Castelluci F, Capri D. The role of the implant housing in obtaining esthetics: Generation of peri-implant and papillae part 1. Pract Proced Aesthet Dent 2003;15(2): 141-149. 16. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant bone crest. J Periodontol 2000;7(4): 546-549. 17. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from de contact point to the crest of the bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63: 995-996. 18. Mathews DP. Soft tissue management around implants in the esthetic zone. Int J Periodontics Rest Dent 2000;20(2):141–149. 19. Kois JC. Predictable single-tooth peri-implant esthetic; five diagnostic keys. Compend Contin Edu Dent 2004;25(11): 141–149. 20. Miyamoto T, Kumagai T, Jones J, Van Dyke T, Nunn M. Compliance as a Prognostic Indicator: Retrospective Study of 505 Patients Treated and Maintained for 15 Years. J Periodontol 2006; 77(2): 223-232. 21. Kokich VG, Spears F. Guidelines for treating the orthodontic-restorative patient. Semin Orthod 1997;3: 3-20. 84 • Vol. 2, No. 7 • September 2010

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Orthodontic-Surgical Removal of Impacted Flanagan 3rd Molars with Apices in Close Proximity to the Mandibular Canal: Two Case Reports Dennis Flanagan DDS, ABGD1 Abstract Background: Patients can present for a potential for postoperative neural sequellae. third molar removal with the apex located in very close proximity to the mandibu- Results: These patients had no lar canal. There is a risk for a post surgi- adverse post operative sequellae. cal nerve altered sensation in these cases. Conclusions: This orthodontic/surgical tech- Methods: This article discusses two cases nique may be useful to prevent post opera- where impacted mandibular third molars tive altered nerve sensation especially in older were located in close proximity to the man- patients with root apices that approximate or dibular canal as determined on plane film are actually located in the mandibular canal. panoramic scan. The teeth were orthodon- Additional studies of this technique are needed. tically moved mesio-coronally to move the There is a potential for neural consequences apices away from the mandibular canal for from the apical orthodontic movement away subsequent extraction and to reduce the from or through the canal during treatment. KEY WORDS: Orthodontics, nerve damage, wisdom teeth 1. Private practice, Willimantic, Connecticut, USA The Journal of Implant & Advanced Clinical Dentistry • 87

Flanagan INTRODUCTION the tooth requires removal later in the patient’s life, then there may be a higher risk for inferior Third molar removal is a controversial topic.1 alveolar nerve damage. If the nerve is dam- Impacted third molar surgery can be compli- aged during surgical extraction there may be cated with the proximity of anatomical land- adverse neural sequellae. In fact, third molar marks. Like all surgeries, more complex removal is the most common reason for post- procedures will have increased associated operative altered nerve sensation of the infe- complications and morbidity.2 The third molar rior alveolar nerve and the associated law removal controversy involves the physiologic suits.4 Altered sensation includes anesthesia, necessity for removal of these teeth and the paresthesia and other disturbances of neu- economic and quality of life issues for patients ral conduction. Altered nerve sensation may and society. Consideration of these param- occur for several reasons: physical damage eters should be discussed before extrac- from the tooth removal, infection, inflammation tion is decided upon. When these teeth are and instrument trauma.4,5 The extraction of a deemed necessary for extraction, another third molar in close proximity to the mandibu- concern is the location of the tooth apices. lar canal can expose the inferior alveolar nerve In the maxilla, close proximity to the antrum and produce an altered sensation of the distri- may result in an intra-operative communica- bution of the inferior alveolar nerve. Many of tion to the sinus. Generally, with appropri- these patients have a permanent neural deficit.5 ate treatment these heal uneventfully. Close proximity of the tooth apex to the mandibu- There needs to be enough space from the lar canal is another concern for consideration. distal of the second molar to the anterior bor- der of the ramus in order for the third man- The classification of impacted third molar dibular molar to erupt into the occlusal plane.5 apical positions in relation to the mandibular There is a consensus that third molars do canal on plane film radiography is: 1)super- play some undetermined role in lower anterior imposition of the apex on the canal; 2)api- tooth crowding.5 When the root apex is close cal radiolucency; 3)incomplete radiographic to the mandibular canal, an alternative proce- canal border; 4)a bend in the radiographic dure to surgical extraction may be appropriate, canal and a narrowing of the canal.3 However, such as coronotomy or orthodontic distrac- these classes of position may not accurately tion.5,6 If the nerve is exposed during the sur- portray the actual apical position as deter- gical extraction, about 50% of these patients mined by a computerized tomogram or pre- will recover neural function spontaneously. If dict the incidence of postoperative sequellae. there is a surgical repair, after between 4.5 and 7 months most patients will show improve- When a third molar is not removed while ment.5 Computerized tomograms (CT) can be the apex is immature, it can develop and helpful but may not provide definitive informa- extend deeper into the mandible and the fully tion to prevent an adverse neural outcome.5 formed root tip approach or enter the man- dibular canal. This anatomical canal contains It may be that the optimal time for third molar the inferior alveolar nerve, artery and vein. If 88 • Vol. 2, No. 7 • September 2010

Flanagan removal is when the tooth has immature roots the mandible on the CBCT is associated with with little or no osseous covering and before a higher incidence inferior alveolar nerve injury.9 age 24.3,7 Many dentists and patients opt not to remove asymptomatic third molars with no Another study examined mandibular third history of pericoronitis and indeed, these teeth molar root apices in apparent contact with the may not require removal. However, an asymp- mandibular canal on computerized tomograms. tomatic third molar does not mean there is an When there was apparent contact between absence of infection.5 Some patients may the apex of the mandibular third molar and the develop clinical pericoronitis infections around mandibular canal there was found a 49% risk these teeth later in life. Additionally, caries of nerve exposure. Additionally, there was can occur at the distal aspect of the adjacent 23% risk for postoperative altered sensation second molar especially where the mesial mar- of those cases where there was apex-canal ginal ridge of the mesio-angular impacted third contact. If there is an exposure of the man- molar contacts the cement-enamel junction. dibular canal in apex-canal contact cases there Caries in this location can advance rapidly and is a 37% risk for postoperative altered sensa- quickly endanger the pulp of the second molar. tion.10 Although a surgical nerve exposure can- not be accurately predicted, the radiographic In the mandible, one study found that evidence of apex-canal contact demonstrated a without an impacted third molar, distal sec- higher risk for postoperative nerve involvement. ond molar caries occurred in about 20% of patients.8 When there was an impacted third Postoperative complications from third molar at a mesio-angulation of 31-70 degrees molar removal are localized osteitis, infec- distal second molar caries occurred in 47% tion and nerve damage to the inferior alveo- of the patients and when there was an impac- lar and lingual nerves.10-12 More unusual tion at 71-90 degrees the caries prevalence complications are severe hemorrhage, epi- was 43%. A 90 degree impaction is a hori- dural abscess, subdural hematoma, benign zontal impaction. Additionally, there was a sig- positional vertigo, tissue emphysema, fracture nificant effect on increased caries when there and hematoma related asphyxiation.11-13 A 2 was distal interproximal contact at the cement- gm preoperative oral dose of amoxicillin may enamel junction of the second molar and this reduce postoperative pain in younger patients risk also increased with the patient’s age. aged 12-19 who have third molars removed.14 Cone beam radiography (CBCT) can be A patient faced with recurrent bouts of used to demonstrate the position of the man- pericoronal infections can be offered surgical dibular canal in the mandible and the position removal of the offending tooth, but the issue of the third molar apices. However, the cone of informed consent enters. This discussion beam radiography may not predict an inferior addresses the potential for a temporary or per- nerve surgical exposure any more accurately manent altered sensation of the distribution of than a panoramic plane film.8 Additionally, a the mental nerve and the lower lip. This dis- mandibular canal that is lingually positioned in cussion must take place and the patient should understand the risks for the consequences. An The Journal of Implant & Advanced Clinical Dentistry • 89

Flanagan Figure 1: Panoramic radiograph demonstrated the root Figure 2: The computerized tomogram demonstrated apex in close proximity to the mandibular canal. the root apex located in the lingual rim of the mandibular canal. impacted mandibular third molar that has root apices in close proximity to the mandibular impacted while the right third molar was hori- canal can be decoronated and the roots left in zontally impacted. The patient desired to be the mandible. The contact to the second molar rid of these teeth and these painful episodes. is relieved and the potential for nerve damage is not an issue.15 However, the potential for The plane film panoramic radiograph showed infection and caries remains. Another solu- that the root apices of the mandibular third tion for removal of dangerously impacted teeth molars were in very close proximity or actually is orthodontic extrusion that moves the apices in contact with the mandibular canal (Fig. 1). A away from the mandibular canal for subse- computerized tomogram was made. The apex of quent extraction.16,17 This procedure may defini- the left mandibular third molar (#17) was found tively relieve the potential for neural damage. not to be in contact with the mandibular canal and was extracted uneventfully. However, the CASE REPORT #1 right third molar tooth (#32) apex appeared to be located in the lingual radiopaque rim of the A 29 year old Chinese male presented for rou- tine dental treatment. He had an unremark- able medical history. The clinical examination and radiographs revealed the presence of four third molars. The patient had a history of recur- rent episodes of pericoronitis of both man- dibular third molars, which had been treated in the past with orally administered antibiot- ics. The left third molar was mesioangularly 90 • Vol. 2, No. 7 • September 2010

Flanagan Figure 3: The elastic chain was anchored to the maxillary Figure 4: After 6 weeks, the periapical radiograph molars and attached by a composite resin hook to the demonstrated a radicular osseous radiolucency. third molar. This allowed for orthodontic extrusion mesiocoronally which moved the root apex away from the mandibular canal. canal (Fig. 2). The patient was informed of the to provide the force for movement. Attention potential for inferior alveolar nerve damage and was then directed to the impacted mandibular the altered neural sensation outcome. He was third molar. The right side mandible was locally concerned for any postoperative altered nerve anesthetized with an inferior alveolar nerve sensation. After a discussion of the options, block using 3.6 ml articaine. A facial triangu- including no treatment, he accepted an orth- lar incision, to avoid the variable course of the odontic forced eruption of the right third molar lingual nerve, was made to expose the hori- (#32), and subsequent extraction after the apex zontally impacted third molar. Taking care not was moved away from the mandibular canal. to damage the distal of the second molar, the third molar was partially decoronated with a sur- To provide orthodontic anchorage, the max- gical #558 bur in a high speed surgical hand illary first and second molars were bracketed piece to provide space for the tooth movement. with direct bonded orthodontic brackets and A small amount of bone covering the crest of connected with a straight wire. An elastic the ridge overlying the molar was then removed chain was to be connected from the maxillary to facilitate the movement of the tooth and to bracketed teeth to the impacted third molar. induce a regional acceleratory phenomenon. The patient would be instructed to place ten- Since an orthodontic button was inadequate sion on the elastic chain by opening his mouth The Journal of Implant & Advanced Clinical Dentistry • 91

Flanagan for retention, a mound of composite resin (Fil- afford a computerized tomography to determine Tek, 3-M) was then bonded to the facial aspect the location of the tooth apex. An orthodontic of the third molar and then shaped to act as a treatment option for the extrusion of this tooth hook retainer for the elastic chain that was con- was decided upon to preclude the potential for nected to the maxillary molar brackets (Fig. 3). nerve damage. The maxillary left premolar and This applied a mesio-coronally directed force two molar teeth with were bracketed in prepara- to effect a mesio-coronal eruptive movement tion for placement of an elastic chain. The man- of the tooth away from the mandibular canal. dibular third molar was anesthetized by means of a mandibular block and the overlying bone The patient’s progress was followed every removed, a coronal odontotomy was performed two weeks and adjustments were made as and a dental retention screw placed and bent to required. After 6 weeks the molar had moved accept the elastic chain. The elastic chain was approximately 1.5 mm and demonstrated a attached to the mandibular left third molar with a radiolucent area around the root. The apex TMS dental screw pin (Whaledent). The patient was now located demonstrably, by periapical was followed every two weeks for observation radiograph, away from the mandibular canal and adjustments. After 8 weeks the third molar (Fig. 4). A new informed consent was obtained had moved approximately 1.5mm. The patient from the patient and the third molar was easily was anesthetized locally and the impacted surgically removed under block local anesthe- tooth was easily removed. The patient returned sia. The socket was gently curetted, a resorb- one week later and reported normal sensation. able collagen plug (Salvin Dental) was placed into the extraction socket, and 3-0 chromic DISCUSSION sutures were placed. The patient was given postoperative instructions and prescribed The patient over the age of 24 with a recurrently hydrocodone (Vicodin ES, Abbot Laborato- symptomatic third molar with an apex in close ries) for pain control. He returned for a one proximity to the mandibular canal, that requires week follow-up appointment and reported no removal, is a surgical concern. The patient wants altered sensations. Healing was uneventful. relief from the episodes of pain and infection but the potential for post operative morbidity is a CASE REPORT #2 serious consideration. Generally, patients over the age of thirty years may not have appropriate A 32 year old Latino male presented with peri- healing of the epithelial attachment at the distal coronitis of the mandibular left third molar. A of the second molar after third molar removal.5,18 regimen of amoxicillin 875mg bid was pre- This may create a periodontal issue at the dis- scribed. Clinical and radiographic examination tal aspect of the second molar. There may be revealed a mesioangular impacted mandibular a poor healing of the attachment in this area left third tooth with an apex that appeared to be that can result in a periodontal pocket. These very close to the mandibular canal. The poten- defects may be successfully treated with scal- tial for a post operative altered sensation was ing and root planing or barrier membrane tissue discussed. The patient could not economically 92 • Vol. 2, No. 7 • September 2010

Flanagan guided regeneration.18-20 If the third molar is not CONCLUSIONS removed, distal caries may develop at the distal of the second molar.8 Thus, the risk of postop- The apices of impacted mandibular third molars erative neural sensory alteration and periodon- can be located in close proximity to the man- tal loss of distal attachment is weighed with the dibular canal as determined on CT scan or pan- benefits of relief of pain and prevention of sec- oramic plane radiographic films. These teeth ond molar distal caries and recurrent infections. can be orthodontically moved mesio-coronally to move the apices away from the mandibu- An amount of bone covering the crest of the lar canal for subsequent extraction to reduce ridge was removed in these reported cases to the potential for postoperative neural sequel- facilitate the orthodontic movement of the tooth lae. The corona is partially removed to facilitate and to induce a regional acceleratory phenom- orthodontic movement. Additionally, overlying enon that increases osseous turnover.21 Work bone is removed to induce the regional accel- by Wilkco et al has shown that removal of eratory phenomenon to increase bone turn- local osseous cortex can facilitate and speed over rate. The teeth can then be successfully orthodontic movement.22 However, the orth- extracted with minimal postoperative conse- odontic forces must be applied immediately quences. This technique may be useful in an after osseous surgery to take full advantage older patient with a mature elongated root apex of this phenomenon. After two to three weeks that approximates or is actually located in the the physiologic mechanisms may attenuate. mandibular canal. Additional study of this tech- nique is needed. There is a potential for neu- The CT scan demonstrated that the man- ral consequences from the apical orthodontic dibular canal was located to the facial aspect of movement away from or through the mandibu- the third molar root apex in case #1. This may lar canal during treatment. Third molar teeth not be associated with a dramatic increased with apices in close proximity to the mandibu- risk for surgical nerve exposure during a sur- lar canal may be successfully removed with a gical extraction.9,10 The close proximity of the combination of orthodontic and surgical treat- canal may indicate a potential for neural surgi- ment. The regional acceleratory effect needs cal trauma. There is no evidence that the orth- to be induced by removal of any overlying odontic movement of the root apex away from bone to promote the orthodontic movement. the canal will indeed prevent neural damage. Additionally, the orthodontic movement of the Correspondence: tooth apex itself may potentially produce a neu- Dr. Dennis Flanagan ral event in a case where the apex is located 1671 West Main St. actually inside the mandibular canal or if the Willimantic, CT 06226 apex moves through the canal. If the apex is 860-456-3153 actually located in the mandibular canal space, FAX: 860-456-8759 any tooth movement may occur too quickly [email protected] to allow for neural sheath accommodation and potentially produce an altered sensation. The Journal of Implant & Advanced Clinical Dentistry • 93

Flanagan The Journal of Implant & Advanced Clinical Dentistry Disclosure The author reports no conflicts of interest with anything mentioned in this article. ATTENTION PROSPECTIVE References 1. Panduri DG, Brozovi J, Susi M, Katanec D, Bego K, Kobler P. Assessing AUTHORS health-related quality of life outcomes after the surgical removal of a mandibular JIACD wants third molar. Coll Antropol. 2009 Jun; 33(2):437-447. to publish 2. Contar C, Oliveira P, Kanegusuku K, Berticelli R, Alanis L, Machado MA. your article! Complications in third molar removal: a retrospective study of 588 patients. Med Oral Pathol Oral Cir Bucal. 2009 Sep 21. Epub 2009 Sep 21. For complete details 3. Checchi L, Monaco G. Collana di chirurgia orale. In: Checchi L, Monaco regarding publication in G, eds. Terzi molari inclusi: Soluzioni terapeutiche. Vol. 2. Bologna: Edizioni Martina; 2001:25 JIACD, please refer 4. Zuniga JR. Management of third molar-related nerve injuries: observe or treat? to our author guidelines at Alpha Omegan. 2009 Jun; 102(2):79-84. 5. Dodson T, Pogrel A, et al. White Paper on Third Molar Data: AAOMS Surgical the following link: Update. AAOMS Surgical Update; 2008; 21 (1): 1-20. http://www.jiacd.com/ 6. Bonetti GA, Bendandi M, et al. Orthodontic Extraction: Riskless Extraction of Impacted Lower Third Molars Close to the Mandibular Canal . J Oral Maxillofac authorinfo/ Surg; 2007; 65: 2580-2586. author-guidelines.pdf 7. Blondeau F, Daniel NG. Extraction of impacted mandibular third molars: postoperative complications and their risk factors. J Can Dent Assoc 2007 May or email us at: 73(4): 325-330. [email protected] 8. Ozeç I, Hergüner Siso S, Ta demir U, Ezirganli S, Göktolga G. Prevalence and factors affecting the formation of second molar distal caries in a Turkish population. Int J Oral Maxillofac Surg. 2009 Aug 6. Epub 2009 Aug 6. 9. Ghaeminia H, Meijer GJ, Soehardi A, Borstlap WA, Mulder J, Bergé SJ. Position of the impacted third molar in relation to the mandibular canal. Diagnostic accuracy of cone beam computed tomography compared with panoramic radiography Int J Oral Maxillofac Surg. 2009 Sep; 38(9):964-71. Epub 2009 Jul 28. 10. Nakayama K, Nonoyama M, Takaki Y, Kaqawa T, Yuasa K, Izumi K, Ozeki S, Ikebe T. Assessment of the relationship between impacted mandibular third molars and inferior alveolar nerve with dental 3-Dimensional computed tomography. J Oral Maxillofac Surg 2009 Dec 67(12):2587-2591. 11. Schoen R, Suarez-Cunqueiro MM, Metzger MC, Schmelzeisen R. Osteomyelitis of the mandible following third molar surgery: a regrettable consequence in a healthy patient. Quintessence Int. 2009 May; 40(5):351- 354. 12. Clauser B, Barone R, Briccoli L, Baleani A. Complications in surgical removal of mandibular third molars. Minerva Stomatol. 2009 Jul- Aug;58(7-8):359-366. 13. Brauer HU. Unusual complications associated with third molar surgery: A systematic review Quintessence Int. 2009 Jul-Aug;40(7):565-572. 14. Monaco G, Tavernese L, Agostini R, Marchetti C. Evaluation of antibiotic prophylaxis in reducing postoperative infection after mandibular third molar extraction in young patients J Oral Maxillofac Surg. 2009 Jul; 67(7):1467- 1472. 15. Pogrel MA. Coronectomy to prevent damage to the inferior alveolar nerve. Alpha Omegan. 2009 Jun; 102(2):61-67. 16. Bonetti GA, Parenti SI, Checchi L. Orthodontic extraction of mandibular third molar to avoid nerve injury and promote periodontal healing.J Clin Periodontol 2008 Aug 35(8):719-723. 17. Checchi L, Alessendri Bonetti G, Pelliccioni GA. Removing high risk impacted third molars: a surgical–orthodontic approach. J Am Dent Assoc 1996 Aug 127(8):1214-1217. 18. Peng KY, Tseng YC, Shen EC, Chiu SC, Fu E, Huang YW. Mandibular second molar periodontal status after third molar extraction. J Periodontol 2001 Dec;72(12): 1647-1651. 19. Ferreira CE, Grossi SG, Novaes AB, Dunford RG, Feres –Filho EJ. Effect of mechanical treatment on healing after third molar extraction. Int J Periodontics Restorative Dent 1997 Jun; 17(3):250-259. 20. Karapataki S, Hugoson A, Falk H, Laurell L, Kugelberg CF. Healing following GTR treatment of intraboney defects distal to mandibular 2nd molars using resorbable and non-resorbable bariers. J Clin Periodontol 2000 May ;27(5): 333-340. 21. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J 1983 31(1): 3-9. 22. Wilcko MT, Wilcko WM, Pulver JJ, Bissada NF, Bouquot JE. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg. 2009 Oct; 67(10):2149-2159. 94 • Vol. 2, No. 7 • September 2010

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