Bisphosphonate Related Osteonecrosis of the Jaw

Optimal Site Preservation Bio-Oss® produced more favorable results than allogenic materials for the preservation of extraction sockets prior to dental implantation1 The long-term osteoconductive scaffold, Bio-Oss® induced more new bone deposition than allografts and exhibited increased osteoblastic activity. Rapid resorption of the allografts resulted in more fibrous connective tissue and less new bone than Bio-Oss®. 50 50 * * * 50 * * 40 * 40 * 40 45.9% 46.3% 30 * 30 * % new bone 30 34.1% % residual graft % fibrous tissue 20 23.6% 20 25.4% 20 10 17.2% 12.0% 10 12.0% 13.7% 10 0 Bio-Oss® Rocky Mtn Puros® 0 Bio-Oss® Rocky Mtn Puros® 0 Bio-Oss® Rocky Mtn Puros® Histograms showing the percentages of (left) new bone, (middle), residual graft particles, and (right) fibrous connective tissue in the biopsy specimens. *Significant difference (P < .05) T = 4.5 months; n = 20 To learn more, please visit us online at www.osteohealth.com or call 1-800-874-2334 References: 1Lee DW, Pi SH, Lee SK, Kim EC. Comparative Histomorphometric Analysis of Extraction Sockets Healing Implanted with Bovine Xenografts, Irradiated Cancellous Allografts, and Solvent-Dehydrated Allografts in Humans. Int J Oral Maxillofac Implants 2009; 24: 609-615. Bio-Oss® is a registered trademarks of Ed. Geistlich Söhne Ag Fur Chemische Industrie and is marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. Puros® is a registered trademark of Zimmer, Inc. ©2009 Luitpold Pharmaceuticals, Inc. OHD239 Iss. 9/2009

VOLUME 1, NO. 7 OCTOBER 2009 The Journal of Implant & Advanced Clinical Dentistry Bisphosphonate Related Osteonecrosis of the Jaw The BioDerm 2 Hours of CE Credit Technique

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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 13 Case of the Month Treatment Planning and Execution of Minimally Invasive Dentistry Michael Apa 21 JIACD Continuing Education Successful Management of a Severe Case of Bisphosphonate Related Osteonecrosis of the Jaw in a Multiple Myeloma Patient Cesar Luchetti, Sebastian Yantorno, Julian Barrales, Juan Napal, Jorge Milone, Alicia Kitrilakis 31 The Bio-Derm Ridge Plumping Technique for Pontic Site Development Nicholas Toscano, Dan Holtzclaw The Journal of Implant & Advanced Clinical Dentistry 3

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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 49 Minimally Invasive Antral Membrane Balloon Elevation to Treat Previous Sinus Augmentation Failure: A Case Report Ziv Mazor, Efraim Kfir 59 Comparison of Stress Patterns In and Around Orthodontic Micro-implants: A Finite Element Study S. Sakthish, Sridevi Padmanabhan, Arun Chithranjan 71 Dental 3D Imaging Centers Usage and Findings: Part II Anatomical Features of the Lingual Artery Alan A. Winter, Kouresh Yousefzadeh, Alan S. Pollack, Michael I. Stein, Frank J. Murphy, Christos Angelopoulos 77 Cultivating Your Online Dental Reputation with Blogs Shannon Mackey The Journal of Implant & Advanced Clinical Dentistry 5



The Journal of Implant & Advanced Clinical Dentistry Publisher Copyright © 2009 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD- Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest, constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article. the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA. or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry 7

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The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS A Minimally Invasive and SystematicEAdpiptororaiachl AtodSviinsuosrGyrBafotianrgd Tara Aghaloo, DDS, MD Richard Hughes, DDS George Priest, DMD Faizan Alawi, DDS Debby Hwang, DMD Giulio Rasperini, DDS Michael Apa, DDS Mian Iqbal, DMD, MS Michele Ravenel, DMD, MS Alan M. Atlas, DMD Tassos Irinakis, DDS, MSc Terry Rees, DDS Charles Babbush, DMD, MS James Jacobs, DMD Laurence Rifkin, DDS Thomas Balshi, DDS Ziad N. Jalbout, DDS Georgios E. Romanos, DDS, PhD Barry Bartee, DDS, MD John Johnson, DDS, MS Paul Rosen, DMD, MS Lorin Berland, DDS Sascha Jovanovic, DDS, MS Joel Rosenlicht, DMD Peter Bertrand, DDS John Kois, DMD, MSD Larry Rosenthal, DDS Michael Block, DMD Jack T Krauser, DMD Steven Roser, DMD, MD Chris Bonacci, DDS, MD Gregori Kurtzman, DDS Salvatore Ruggiero, DMD, MD Hugo Bonilla, DDS, MS Burton Langer, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Aldo Leopardi, DDS, MS Frank Setzer, DDS Ronald Brown, DDS, MS Shannon Mackey Maurizio Silvestri, DDS, MD Bobby Butler, DDS Miles Madison, DDS Dennis Smiler, DDS, MScD Donald Callan, DDS Carlo Maiorana, MD, DDS Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Jay Malmquist, DMD Muna Soltan, DDS Daniele Cardaropoli, DDS Louis Mandel, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Michael Martin, DDS, PhD Ahmad Soolari, DMD John Cavallaro, DDS Ziv Mazor, DMD Christian Stappert, DDS, PhD Stepehn Chu, DMD, MSD Dale Miles, DDS, MS Neil L. Starr, DDS David Clark, DDS Robert Miller, DDS Eric Stoopler, DMD Charles Cobb, DDS, PhD John Minichetti, DMD Scott Synnott, DMD Spyridon Condos, DDS Uwe Mohr, MDT Haim Tal, DMD, PhD Sally Cram, DDS Jaimee Morgan, DDS Gregory Tarantola, DDS Tomell DeBose, DDS Dwight Moss, DMD, MS Dennis Tarnow, DDS Massimo Del Fabbro, PhD Peter K. Moy, DMD Geza Terezhalmy, DDS, MA Douglas Deporter, DDS, PhD Mel Mupparapu, DMD Tiziano Testori, MD, DDS Alex Ehrlich, DDS, MS Ross Nash, DDS Michael Tischler, DDS Nicolas Elian, DDS Gregory Naylor, DDS Michael Toffler, DDS Paul Fugazzotto, DDS Marcel Noujeim, DDS, MS Tolga Tozum, DDS, PhD Scott Ganz, DMD Sammy Noumbissi, DDS, MS Leonardo Trombelli, DDS, PhD Arun K. Garg, DMD Arthur Novaes, DDS, MS Ilser Turkyilmaz, DDS, PhD David Guichet, DDS Andrew M. Orchin, DDS Dean Vafiadis, DDS Kenneth Hamlett, DDS Charles Orth, DDS Hom-Lay Wang, DDS, PhD Istvan Hargitai, DDS, MS Jacinthe Paquette, DDS Benjamin O. Watkins, III, DDS Michael Herndon, DDS Adriano Piattelli, MD, DDS Alan Winter, DDS Robert Horowitz, DDS Stan Presley, DDS Glenn Wolfinger, DDS Michael Huber, DDS Richard K. Yoon, DDS The Journal of Implant & Advanced Clinical Dentistry 9



Editorial Commentary A Great Meeting in Boston Nick and I just attended the 95th my bill and, of course, she had mixed my tab with Annual Meeting of the American the group that was sitting next to me. The waitress Academy of Periodontology (AAP) apologized and had the charges reversed…or in Boston and what a great trip it was. We so I thought. The $200 drink showed up on my arrived in Boston a few nights before the statement the next morning and it took me a few meeting started that is when the fun began. days to clear up that situation. What fun! The trip started off with a bang when my Aside from my phone being stolen and my iPhone was stolen at a restaurant downtown. I $200 drink, which was subsequently changed always had a fear about this happening, so I never to the correct price of $20 (still a bit pricey for kept any highly confidential information on the a single drink if you ask me), the actual meeting phone (thank goodness!). Within a few minutes was outstanding. The AAP put together a great of the phone disappearing, I sent a text message meeting with some top notch lecture topics. offering $100 for the safe return of the phone, but Growth factors and the treatment/prevention of alas, no response. I promptly reported the phone implant complications seemed to be one of the as being stolen, suspended all services to that major focuses of this meeting. particular phone, and changed all of my account passwords just to be safe. That was a wonderful As always, the corporate forums provided first night of the trip! some outstanding clinical lectures and a number of rooms were standing room only…until the The next day, Nick and I attended a marketing convention officials kicked people out of the room course offered by Dr. Paul Fugazzotto. Dr. for violating the fire code! When the rooms are Fugazzotto’s course was outstanding and I highly packed to overflowing, that is always a great sign. recommend it for anyone in private practice. He In addition to providing some informative lectures, was a gracious host and the information presented the corporate entities had some great deals in the was as good as gold! The food and wine were exhibition hall. pretty good as well! Next year’s AAP meeting is in the beautiful After attending Paul’s course, we went back state of Hawaii. Having lived in Hawaii for three to the hotel to meet and greet everyone as they years in the past, I am excited to go back! If next began to arrive for the meeting. It was nice seeing year’s meeting is as good as this year’s meeting, some old friends and even better making new it will be a great one. I will be sure to register as ones. With the night one theatrics of my stolen soon as I get a new phone. phone behind us, we had a drink in the hotel lobby prior to heading out for dinner. Upon finishing Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS my drink, I asked for my bill and was somewhat Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief surprised to see that I had been charged nearly $200. Hmm, I have had some good cocktails in my day, but I can’t remember one ever costing $200. I chatted with the waitress for a bit about The Journal of Implant & Advanced Clinical Dentistry 11

Kurtzman

Case of the Month Kurtzman Treatment Planning and Execution of Minimally Invasive Dentistry Michael Apa, DDS1 ABSTRACT CASE REPORT Conservation of tooth structure is essential in Figures 1-3 show the patient at initial presentation any patient. Multi-disciplinary treatment plan- with congenitally developed peg laterals, canted ning has allowed this to be a reality in con- midline, and a flared anterior segment due to a temporary dentistry. The case presented in thumb-sucking habit. In order to treat this case this article involves an 18 year old college conservatively, orthodontia was required. How- bound female who was unhappy with her ever, to satisfy the patientís goals of improving smile. Treatment planning that involved a com- her smile immediately, something had to be done bination of periodontics, orthodontics, and aesthetically prior to her leaving for college. As restorative dentistry allowed the patient to such, the four anterior teeth were minimally pre- be treated in a manner where she was happy pared for veneers, rolling in the teeth slightly. with her smile from the time of initial treat- Final plans were to finish this case with Invisalign® ment until delivery of her final restorations (Santa Clara, California, USA) and bring the upper anterior segment into the proper arch form. KEY WORDS: Orthodontics, periodontics, restorative dentistry, composite restorations, veneers 1. Private practice limited to prosthodontics, New York, NY USA The Journal of Implant & Advanced Clinical Dentistry 13

Apa In order to understand how much tooth struc- align® treatment. The patient now left for col- ture truly needed to be removed, a mock-up of the lege with a very aesthetic result, minimal tooth future position of the teeth was made and then structure removal, and clear orthodontics to fin- depth cut through an accurate set of provisionals. ish off bringing the anterior segment into the arch This allowed for planning of the proper amount of (figures 13-15). She went through 8 months tooth structure removal. For this case, anesthe- of orthodontic therapy and returned to the sia was not administered in order to make sure office where the occlusion and aesthetics were to tooth preparation remained in enamel. Topical checked. A lingual wire was bonded behind the anesthetic was applied to the gingival tissue for upper anterior teeth for retention (figure 16) and minor plasty on the zeniths of teeth 7, 8, and 10. the case was completed (figures 17-21). The spaces distal to the laterals were closed, which Figure 4 shows rolling in the centrals and confirmed that the anterior teeth were now in minor adjustments that were made to the gingiva proper position. The final color was chosen to with a diode laser. Now that the ìarch formî was be a half shade lighter than the original teeth to correct, the provisionals were fabricated. This give the patient a ìbleachedî yet natural aes- process is similar to what a laboratory does for thetic utilizing the chameleon effect of the arch. an additive/reductive wax-up, yet allows the cli- nician to utilize facial landmarks to be accurate CONCLUSION (figures 5-7). Prior to depth cutting, an alginate impression was taken for a stent to make final Being conservative will always allow for enhanced provisionals. At this point, the provisional res- bonding strength, less micro leakage, and lon- torations are depth cut (figure 8) according to ger lasting restorations. Also, using the under- desired porcelain thickness, keeping in mind ini- lying tooth for color will always result in a much tial color and desired color. Minimal tooth struc- more natural appearing restoration, which ture removal was needed in this case due to the should be the goal for both the aesthetic clini- light stump shade. Final margins and prepara- cian and patient. By treatment planning in a tion were performed, followed by smoothing of multi-disciplinary approach, goals of minimally all line angles (figure 9). At this point, an alginate invasive dentistry can be achieved with outstand- impression was filled with Luxatemp® (Zenith Den- ing transitional and final aesthetic results. tal, Englewood, New Jersey, USA) and checked to see if there was enough room for ceramic Disclosure (figures 10,11). Final impressions were taken, The author reports no conflicts of interest along with a bite registration, stump shade pho- with anything mentioned in this article. tos, and a counter impression. The provisionals were bonded in place and final shaping was done Correspondence along with the approval of the patient (figure 12). Dr. Michael Apa 30 East 76th Street, Suite 5B Four individual veneers were bonded to teeth New York, NY 10021 7-10, the bite was adjusted, and the patient was sent to the orthodonist to be fitted for Invis- 14 Vol. 1, No. 7 October 2009

Apa Figures 1-3 The Journal of Implant & Advanced Clinical Dentistry 15

Apa Figures 4-7 16 Vol. 1, No. 7 October 2009

Apa Figures 8-12 The Journal of Implant & Advanced Clinical Dentistry 17

Apa Figures 13-16 18 Vol. 1, No. 7 October 2009

KurtzmApana Figures 17-21 The Journal of Implant & Advanced Clinical Dentistry 19



JIACD Continuing Education Luchetti et al Successful Management of a Severe Case of Bisphosphonate Related Osteonecrosis of the Jaw in a Multiple Myeloma Patient Cesar Luchetti, DDS, MS1 2 3 6 4 5 Abstract Background: Bisphosphonate-related osteone- myeloma patient whose first signs of BRONJ crosis of the jaw (BRONJ) is a serious oral began in 2002 with the development of an complication of bisphosphonate treatment aggressive bilateral osteonecrosis of the man- involving the exposure of necrotic maxillary or dible. Successful management of this case is mandibular bone. BRONJ is associated with described with 17 months of follow up monitoring. pain, paresthesia, and oral dysfunction gen- erating an impairment of the quality of life. Conclusions: This case supports the concept that Treatment of this complication remains diffi- BRONJ may be successfully treated. The approach cult and the most useful action is prevention. described to treat this case, especially regarding sequestrum management, could minimize the sur- Case Report: This is a case report of a multiple gical corrections after the sequestrum is removed. KEY WORDS: Bisphosphonate necrosis, osteonecrosis, multiple myeloma 1. Associate Professor, Department of Implant Dentistry. National University of La Plata. (Universidad Nacional de La Plata). La Plata, Buenos Aires, Argentina. 2. Specialist in Haematology and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 3. Specialist in Infectology. La Plata, Buenos Aires, Argentina 4. Specialist in Internal Medicine and Staff of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 5. Specialist in Internal Medicine and Specialist in Haematology. Head of Oncohaematology and Transplants and Director of the Bone Marrow Transplant Unit. Italian Hospital of La Plata (Hospital Italiano de La Plata). La Plata, Buenos Aires, Argentina. 6. Head Professor, Department of Implant Dentistry and Department of Prosthodontics - National University of La Plata. (Universidad Nacional de La Plata) La Plata, Buenos Aires, Argentina This article provides 2 hours of continuing education credit. Please click here for details and additional information. The Journal of Implant & Advanced Clinical Dentistry 21

Learning Objectives Figure 1: Non-healing sockets after extractions in December 2002. After reading this article, the reader should be able to: bone, occurring in 1.8 to 12.8 % of the cases 1. Discuss Bisphosphonate Related Osteone- with intravenous bisphosphonates administration.7 crosis of the Jaw (BRONJ)and its causes. CASE DESCRIPTION 2. Understand how to diagnosis and manage A 48 year old white, male patient was referred to BRONJ the Department of Implant Dentistry at the National 3. Understand the surgical and University of La Plata. (Universidad Nacional de La Plata) in La Plata, Buenos Aires, Argentina in pharmocological management of BRONJ December 2005. The patient was undergoing treatment for multiple myeloma. The patient was INTRODUCTION diagnosed with multiple myeloma, IgG monoclo- nal band in proteinogram, in June 1996. Upon Bisphosphonates, a class of drugs that inhibit diagnosis of multiple myeloma, the patient was ini- bone resorption, were widely developed over the tially treated with four cycles of the “VAD proto- last four decades starting with the work of Herbert col” (vincristine, adriamycin and dexamethasone) Fleish, who published the first report in 1968.1 To and autologous bone marrow transplantation in date, the main use of the drug was for the pre- May 1997. Maintenance was accomplished with vention and treatment of osteoporosis and other interferon until 2000, and later thalidomide until bone metabolism diseases, based on their ability 2002. Concomitant treatments with bisphospho- to decrease bone turnover trough the inhibition nates were pamidronate from September 2001 to of osteoclast differentiation and a decrease in December 2001 and zoledronic acid from Janu- its activity and survival rate.2 Recently, bisphos- ary 2002 to December 2005. The patient expe- phonate use was extended to treat oncological rienced a relapse in 2006 and bortezomib was diseases which present bone affectation such used for 8 cycles. The patient has since experi- multiple myeloma and bone metastasis, in order to lower the skeletal effects. First studies are dated at the beginning of the nineties,3 being today a very important component of the therapeu- tic approach in these conditions.4 However, by the end of 2003, a new and a challenging entity developed as a complication in patients treated with bisphosphonates was described mainly associated with Pamidronate and Zoledronic Acid.5,6 Bisphosphonate-related osteonecro- sis of the jaw (BRONJ) is a serious oral compli- cation of bisphosphonate treatment involving the exposure of necrotic maxillary or mandibular 22 Vol. 1, No. 7 October 2009

Figure 2: Control radiograph in March 2003 showed no Figure 3: In September 2003, patient lost teeth 18, 20, improvements. and 29. Figure 4: Patient lost an additional tooth, number 31 in Figure 5: Control x-ray in December 2004 showed the March 2004 and boy sequestrums began to form. limits of the a ected bone. Figure 6: First contact with the patient in December 2005. Figure 7: Radiograph showing the status of the a ected Extensive bilateral bone exposure is noted. bone in December 2005. The Journal of Implant & Advanced Clinical Dentistry 23

Figure 8: Clinical situation in September 2006, without Figure 9: Radiograph taken in November 2006 showing a changes. progression of the a ected bone. Figure 10: Computer tomography scan showing the The patient was first seen in our department extension of the lesions. in December 2005 and presented with signifi- cant bilateral bone exposure in the mandible (fig- enced complete remission following this treatment. ures 6,7). According to the recommendations at In 2002, the patient had some routine den- the time, our approach was to try to maintain the exposed bone as clean as possible to prevent fur- tal extractions which never fully healed and ther infection. Our treatment consisted of long resulted in chronically exposed bone. Suspect- term antibiotics (Amoxicillin plus clavulanic acid, 1 ing myeloma dissemination to the mandible, the gr, twice a day and metronidazole 500 mg twice a oral surgeon at that time took a biopsy sample. day), local rinses with clorhexidine 0.12 % 3 times The condition now known as BRONJ was not yet a day, and rinses with 3% hydrogen peroxide once known at that time (figure 1). A few months later, a day. After nine months of this conservative treat- the condition became increasingly aggrivated, ment, the patient showed no improvement. Addi- with the consequent loss of more teeth and a tionally, the exposed bone in the right side of the progressive affectation to the bone (figures 2-5). mandible began to form a sequestrum and loosen (figures 8-10). At this time, the patient asked for a solution to his problem. We explained the risks and our approach based in the management of previous smaller cases. Following our discussions of the risk and benefits of treatment, the patient agreed to proceed. As such, our treatment pro- tocol for this patient was modified as follows. We started to manipulate the bony seques- trum by gently trying to loosen it three times a 24 Vol. 1, No. 7 October 2009

Figure 11: Clinical situation after removing the Figure 12: Sequestrum removed. sequestrum on the right side in December 2006. Figure 13: Histology showing necrotic bone, with empty Figure 14: Gram staining demonstrated Gram (+) bacillus. lacunaes and associated infected tissue. (H&E stain, (magni cation x 100) magni cation x 100) remaining bony spicules to get a smooth bone week. During each visit, we carefully irrigated and surface and facilitate healing (figures 11,12). cleansed the area apical to the sequestrum. To accomplish such, we used 5cc of clorhexidine The sequestrum was submitted for histo- 0.12% followed by 5cc of 3% hydrogen perox- logic examination which revealed necrotic bone ide. Detritus were eliminated by means of a hand with empty lacunaes and associated infected brush and finally, an additional two irrigations tissue. With gram staining, Gram (+) bacil- with clorhexidine and hydrogen peroxide were lus were identified (figures 13,14). Fifteen performed. After a couple of weeks the seques- days following surgery, the soft tissue heal- trum was loose enough to attempt removal. We ing looked acceptable and at one month, com- successfully removed the sequestrum with ron- plete healing of the surgical site was observed geurs and used rotary instruments to eliminate (figure 15). Having achieved this, we decided The Journal of Implant & Advanced Clinical Dentistry 25

Figure 15: Clinical situation one month after sequestrum Figure 18: Radiograph in July 2007. removal. to proceed in the same fashion on the left side. Figure 16: Removal of the rst part of the left sequestrum Bone sequestrum on the left side presented in February 2007. as two parts, first from the buccal and a few Figure 17: Clinical situation after removal of the remaining months later from the lingual (figures 16,17). part of the left sequestrum. After two months, the tissues at the surgical sites were stable. Radiographic examination did 26 Vol. 1, No. 7 October 2009 not reveal formation of additional bone seques- trum. We also performed a Serum C-terminal telopeptide (CTX) test according to the Marx pro- tocol8 and got a result of 130 pg/ml, compatible with a moderate risk (figure 18). We then fabri- cated and delivered a maxillary dental prosthe- sis to give the patient the possibility to return to normal function, both masticatory and aesthetics wise, after several years (figures 19-21). Sev- enteen months later, the previously affected tis- sues continue to appear stable (figure 22). DISCUSSION Bisphosphonate s associated osteonecrosis of the jaw was first described in late 2003 and early 2004.5,6 At this time, surgery was almost totally contraindicated in theses cases because of the probability of aggravating the condition. The usual recommendation was, and still applies, to main-

Figure 19: Removable prosthesis. Figure 20: Removable prosthesis. tain the exposed bone infection free and to have Figure 21: Removable prosthesis. in mind that the patient can live with some bone exposure without further problems.9,10 However, as Figure 22: Clinical situation in December 2008, showing we demonstrated in this case, the infection of the stability of the soft tissues. bone can worsen, no matter how great the effort to provide minimally invasive palliative treatment. Our thought is that once the lesion affects the cortical plate and the medullary bone becomes exposed, adequate cleansing of the area seems to be more difficult and the infection control requires extreme care, both home and professional. Clor- hexidine is the antiseptic of choice cited in most articles.9,10 We also like to use 3% hydrogen peroxide based on our experience in managing abscess lesions in soft tissues which are usually present in the limits of the exposed bone. Also, 3% hydrogen peroxide can help in cases where the exposed bone presents a rough surface in which anaerobic bacteria could grow. Micro- biological identification is important adjunct to aid infection management. Cultures must be made to search for aerobic and anaerobic bac- teria, and also for fungus. Fungus can be pres- ent as a result of many situations, with the most common being systemic immunity impairment The Journal of Implant & Advanced Clinical Dentistry 27

and the previous use of long term antibiotics. described to treat this case, especially regard- More recently, surgical approaches have ing sequestrum management, could minimize necessary surgical corrections upon removal of been described in order to achieve soft tissue the sequestrum. However, the resolution of this healing in certain cases. Common features of particular case does not ensure that every case these approaches are: 1) conservative resec- can be resolved in the same way or with the tion of the necrotic bone with attempts at obtain- same results, but shows us that there is a real ing a smooth surface; 2) use of platelet derived possibility to treat this pathology with success. growth factors; 3) tension free primary wound Each case must be evaluated individually and closue.11,12 We have used these approaches, primary approaches must always be conserva- especially with the use of platelet derived growth tive and focused on prevention. Additional stud- factor (PDGF), both for prevention in tooth extrac- ies on the development, diagnosis, prevention, tions in compromised patients and for treatment and management of BRONJ are warranted. of BRONJ. In cases where a bony sequestrum is present, it may be beneficial to loosen them in Disclosure steps rather than remove them in a single attempt. The authors report no conflicts of interest with anything mentioned in this article. With proper homecare involving the patient irri- Acknowledgements gating below the sequestrum, this conservative The author (Luchetti) would like to thank Dr. Cesar Migliorati, who was kind approach may lead to initial healing of the over- enough to share his opinion with him in Buenos Aires regarding this particular lying soft tissue, which could minimize surgi- case. The authors would also like to thank Dr. Gregori Kurtzman, Dr. Len cal corrections upon removal of the sequestrum. Tolstunov, and Dr. Douglas Martin for their assistance in the preparation of this manuscript. The serum C-terminal telopeptide (CTX) test8 References is currently recommended as a way to mea- 1. Fleisch H, Russell R, Bisaz S, Casey P, Muhlbauer R. The influence of sure the risks of development and progression of BRONJ. When used together with imaging, pyrophosphates analogues (diphosphonates) on the precipitation and clinical examination, and other complementary dissolution of calcium phosphate in vivo and in vitro. Calcif Tissue Res 1968; studies, CTX testing may prove to be a valu- 2(suppl.): 10-10a. able adjunct in the decision process for treat- 2. Fleisch H. Bisphosphonates: Mechanisms of action and clinical use. En: ing patients at risk for or currently affected by Bilezikian et al Principles of Bone Biology, Ed. Academic Press, 1996: 1037- BRONJ. The patient treated in this case report 1052. had moderate CTX levels and proceeded to 3. Merlini G, Parrinello G, Piccinini L, Crema F, Fiorentini ML, et al. Long-term heal without complication. Whether this heal- effects of parenteral dichloromethylene bisphosphonate (CL2MBP) on bone ing was a result of the CTX values or the treat- disease of myeloma patients treated with chemotherapy. Hematol Oncol 1990; ment rendered cannot be determined at this time. 8(1):23-30. 4. Body J. Bisphosphonates for malignancy-related bone disease: current status, CONCLUSIONS future developments. Support Care Cancer 2006; 14(5):408-418. 5. Marx R. Pamidronate (Aredia) and zoledronate (Zometa) induced avascular The latest literature, and also this case, sup- necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg 2003; ports the concept that BRONJ may be success- 61(9):1115-1117. fully treated in the short term. The approach 6. Ruggiero S, Mehrotra B, Rosenberg T, Engroff S. Osteonecrosis of the jaws associated with the use of bisphosphonates: A review of 63 cases. J Oral Maxillofac Surg 2004; 62(5):527-534. 7. Mehrotra B, Ruggiero S. Bisphosphonate complications including osteonecrosis of the jaw. Hematology Am Soc Hematol Educ Program 2006:356-360. 8. Marx R, Cillo J, Ulloa J. Oral bisphosphonate-induced osteonecrosis: Risk factors, prediction of risk using serum CTX testing, prevention, and treatment. J Oral Maxillofac Surg 2007; 65(12):2397-2410. 9. Marx R, Sawatari Y, Fortin M, Broumand V. Bisphosphonate-induced exposed bone (osteonecrosis/osteopetrosis) of the jaws: Risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg 2005; 63(11):1567-1575. 10. Migliorati C, Casiglia J, Epstein J, Jacobsen P, Siegel M, Woo S. Managing the care of patients with bisphosphonate-associated osteonecrosis: an American Academy of Oral Medicine position paper. J Am Dent Assoc 2005; 136(12):1658-1668. 11. Kademani D, Koka S, Lacy M, Rajkumar S. Primary surgical therapy for osteonecrosis of the jaw secondary to bisphosphonate therapy. Mayo Clin Proc 2006; 81(8):1100-1103. 12. Adornato M, Morcos I, Rozanski J. The treatment of bisphosphonate- associated osteonecrosis of the jaws with bone resection and autologous platelet-derived growth factors. J Am Dent Assoc 2007; 138(7):971-977. 28 Vol. 1, No. 7 October 2009

Luchetti et al 1. Bisphosphonates are a class of drugs 6. Bisphosphonate use was extended to that inhibit bone resorption. treat oncological diseases in order to a. True lower the skeletal effects. b. False a. True b. False 2. The main use of Bisphosphonates was for the prevention and treatment 7. The VAD Protocol includes the use of of osteoporosis and other bone Vincristine, Adriamycin and metabolism diseases, based on their Dexamethasone. ability to increase bone turnover a. True trough the activation of osteoclast b. False differentiation and a decrease in its activity and survival rate. 8. BRONJ was first described in what year? a. True a. 2000 b. False b. 1998 c. 2003 3. What percentage of BRONJ cases d. 2009 are associated with intravenous bisphosphonate administration? 9. BRONJ must be evaluated individually a. 2 - 10% and primary approaches must always be b. 1.8 - 12.8% conservative and focused on prevention. c. 12.8 - 20.3% a. True d. 0.001 - 0.002% b. False 4. What is the antiseptic of choice cited for 10. In cases where a bony sequestrum is treatment? present, it may be beneficial to loosen a. Saline them in steps rather than removing in a b. Listerine single attempt. c. Clorhexidine a. True b. False 5. Cultures must be made to search for aerobic bacteria, anaerobic bacteria, CLICK HERE TO TAKE THE QUIZ and fungus. a. True b. False The Journal of Implant & Advanced Clinical Dentistry 29

Toscano et al Does your bone grafting material measure up? Improvements in clinical and radiographic parameters in the GEM 21S® pivotal trial compare favorably with or exceed, documented outcomes for other regenerative therapies in studies examining defects with similar baseline characteristics.1,2,3,4 Radiographic Percent Bone Fill (BF%) Radiographic Linear Bone Growth (LBG) Clinical Attachment Level (CAL) Gain 60 3.0 4.0 57 3.7 40 2.6 3.0 2.0 2.7* Mean % BF 2.0 Mean LBG (mm) CAL Gain (mm) 0 20 1.0 1.1* GEM 21S® Enamel Matrix 14* Derivative (EMD) 0 0 GEM 21S® Enamel Matrix GEM 21S® Enamel Matrix Derivative (EMD) Derivative (EMD) *EMD results at 8 months, GEM 21S® results at 6 months To learn more, please visit us online at www.osteohealth.com or call 1-800-874-2334 View prescribing information: www.osteohealth.com/documents/52.pdf IMPORTANT SAFETY INFORMATION GEM 21S® Growth-factor Enhanced Matrix is intended for use by clinicians familiar with periodontal surgical grafting techniques. It should not be used in the presence of untreated acute infections or malignant neoplasm(s) at the surgical site, where intra-operative soft tissue coverage is not possible, where bone grafting is not advis- able or in patients with a known hypersensitivity to one of its components. It must not be injected systemically. The safety and effectiveness of GEM 21S® has not been established in other non-periodontal bony locations, in patients less than 18 years old, in pregnant or nursing women, in patients with frequent/excessive tobacco use (e.g. smoking more than one pack per day) and in patients with Class III furcations or with teeth exhibiting mobility greater than Grade II. In a 180 patient clinical trial, there were no serious adverse events related to GEM 21S®; adverse events that occurred were considered normal sequelae following any periodontal surgical procedure (swell- ing, pain). For full prescribing information, go to www.osteohealth.com or call 1-800-874-2334 and a copy will be sent to you. References: 1. Nevins M, Giannobile WV, McGuire MK, Mellonig JT, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE. Platelet Derived Growth Factor (rhPDGF-BB) Stimulates Bone Fill and Rate of Attachment Level Gain. Results of a Large Multicenter Randomized Controlled Trial. J Periodontol 2005; 76: 2205-2215. 2. Heijl L, Heden G, Svardstrom G, Ostgren. Enamel matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997; 24: 705-714. 3. Zetterstrom O, Andersson C, Driksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontol defects. J Clin Periodontol 1997; 24: 697-704. 4. See full prescribing infromation for more detail. Emdogain® is a registered trademark of BioVentures BV Corporation. ©COPYRIGHT Osteohealth Company 2008. All rights reserved. OHD235e Rev. 9/2009.

The Bio-Derm Ridge Plumping Toscano et al Technique for Pontic Site Development Nicholas Toscano, DDS, MS1 2 Abstract Background: Seibert Class III apicocoronal and Results: In all cases normal crestal hard and buccolingual alveolar ridge defects with associ- soft tissue architecture was restored, including ated gingival mucosal atrophy and absence of re-establishment of interdental papillae, through interdental papillae are common in edentulous simultaneous bone and soft tissue grafting with- areas within the anterior esthetic zone of the max- out resorting to secondary autogenous graft illa. Normal emergence profiles, critical to achiev- harvesting procedures. Definitive non-implant ing esthetic restorations, require restoration of supported fixed restorations with cleansable normal hard and soft tissue morphology, including and esthetic ovate pontics and normal emer- re-establishment of adjacent interdental papillae. gence profiles were achieved in each case. Methods: In this 30 patient consecutive case Conclusions: Thirty consecutive patients series, significant Seibert Class III defects were with significant Seibert Class III alveolar ridge simultaneously grafted with a slowly resorb- defects were successfully treated with simul- ing xenograft (Bio-Oss®) and an acellular dermal taneous bone (Bio-Oss® particulate) and soft matrix allograft (Puros Dermis®) in order to effect tissue grafting (Puros® Dermis Allograft) pro- both functional and esthetic improvements in the cedures. By avoiding autogenous hard and anterior maxilla without requiring secondary har- soft tissue grafts, the Bio-Derm Ridge Plump- vesting procedures. Fixed interim restorations with ing Technique eliminated the need for additional ovate pontics served as guides for the develop- invasive harvesting surgeries while allowing for ment of critically important interdental papillae. the completion of both bone and soft tissue aug- mentation procedures in a single surgical visit. KEY WORDS: Mucogingival surgery, bone graft, pontic, prosthetics 1. Private Practice, Washington DC, USA 2. Private Practice, Austin, TX, USA The Journal of Implant & Advanced Clinical Dentistry 31

Toscano et al INTRODUCTION often occur, including reduction or loss of kerati- nized marginal gingiva and disappearance of inter- In the esthetic zone of the maxilla a proper emer- dental papillae, both essential for esthetic dental gence profile, predicated on healthy normal reconstruction in the esthetic zone of the maxilla. marginal gingival tissues with intact interdental papillae, is critical to achieving esthetically pleas- Seibert, in an attempt to develop rational ther- ing traditional fixed and implant supported res- apeutic approaches to alveolar ridge deformities, torations. Adequate soft tissue morphology, classified three major types of ridge deformities.5 however, is dependent upon a stable, adequate Class I is a buccolingual loss of tissue with a nor- volume of underlying bone capable of serving as mal apicocoronal dimension. Class II is an apico- a viable, biologic foundation for overlying soft tis- coronal loss of tissue with normal buccolingual sues. Without the harmony afforded by a proper ridge width. Class III is a combination of bucco- balance of underlying bone and overlying soft tis- lingual and apicocoronal loss of tissue resulting in sue, esthetic restorations are not possible, espe- loss of both normal height and width and is the cially in the anterior maxilla. Frequently, however, most difficult class to successfully treat. Cor- alveolar bone loss disturbs that critical balance, rectly classifying the type of ridge deformity as a resulting in marginal tissue distortion, recession guide to effective surgical and restorative treat- and loss of esthetically crucial interdental papil- ment will help optimize the final restorative result. lae. Bone loss is common in the esthetic zone and can result from multiple precipitating events, Numerous procedures, including distrac- the most common following tooth extraction. Mul- tion osteogenesis, bone splitting, guided bone tiple studies have documented predictable 3 mm regeneration and autogenous onlay bone graft- to 4 mm of buccolingual and apicocoronal ridge ing provide surgeons with a wide range of resorption within 6 months after removal of max- alternative approaches to managing the bony illary anterior teeth. If left untreated up to 50% component of alveolar ridge deformity.6-11 Autog- buccolingual bone loss will occur after one year enous bone grafts have been considered the post tooth removal in the critical esthetic zone.1-3 “gold standard” for bone regenerative proce- dures.12-13 Autogenous bone harvesting, how- Buccal marginal bundle bone loss follow- ever, is both invasive and technically demanding. ing disruption of intact PDL fibers after tooth Moreover, autogenous grafted bone resorp- removal and prominent, thin buccal bone subject tion up to 40-50% has been demonstrated to critical blood supply loss following extraction, when autogenous grafts are used for treating are frequent causes of post-extraction bone loss horizontal and vertical alveolar ridge defects.14 within the maxillary esthetic zone.3-4 In addition, advanced periodontal disease, trauma, periapical Distraction osteogenesis, while an alter- infection and developmental defects commonly native approach to vertical ridge augmen- lead to bone loss and ridge deformities in areas tation, is technically demanding and often critical to esthetic restorations. As a conse- difficult for patients unable to tolerate intra-oral quence of such frequently encountered bone distraction devices.14-15 While suitable for Seib- loss, negative soft tissue morphologic changes ert Class II defects, distraction osteogenesis cannot treat the horizontal components of Seib- 32 Vol. 1, No. 7 October 2009

Toscano et al ert Class I and III alveolar ridge deformities. Class I defects, although they can be used to Guided bone regeneration (GBR) is used correct mild vertical height deficiencies as well. Connective tissue grafts provide good to excel- for bony ridge augmentation with or without lent color match with adjacent gingival tissues, osseointegrated implant placement.16-17 GBR, often resulting in increased amounts of kerati- with a barrier membrane in combination with bone nized tissue at the graft site.23-26 Free gingival full- grafts or bone graft substitutes, offers predict- thickness onlay grafts are used to correct Seibert ability in providing bone augmentation simultane- Class I, II and III ridge deficiencies, but often ously in both horizontal and vertical directions, pose esthetic problems with adjacent tissue.27 and is therefore appropriate for treating all three deformities within Seibert’s classification.18-20 Although widely used, soft tissue autografts Allografts, alloplasts and xenografts have all require an additional invasive surgical proce- been used in GBR procedures to correct alveo- dure to harvest the graft material, increasing lar ridge defects prior to restorative treatment. the potential for increased surgical morbidity. A finite amount of available autogenous tissue also Although critical to restorative success in the limits the amount of soft tissue grafting that can esthetic zone of the maxilla, regeneration of nor- be done at any one point in time. Furthermore, mal bony ridge architecture must also be asso- autograft shrinkage often demands further soft ciated with restoration of normal soft tissue tissue grafting, requiring additional harvesting anatomy, including recreation of missing inter- procedures, each with the potential for increased dental papillae. Insufficient volume of gingival postoperative pain, hemorrhage, or infection.25 soft tissue as well as poorly configured soft tis- sue architecture will mandate modifications in the In an attempt to avoid some of the problems design of fixed or removable prostheses to com- unique to soft tissue autografts, including the pensate for the deformity. Often such modifica- need for a second surgical procedure, clinicians tions result in overly large, ridge-lap pontics that have turned to acellular dermal matrix allografts fail to promote normal function, esthetics and as an alternative to autogenous soft tissue grafts. ready cleansibility.21 Current surgical methods to Originally developed for the treatment of full- correct soft tissue ridge deficiencies rely primar- thickness burn wounds, acellular dermal matrix is ily on autogenous soft tissue grafts or allograft an allograft obtained from human skin.28-29 Pro- acellular dermal matrices, either alone or in con- cessed so that the epidermal layer and all der- junction with bone regenerative procedures. mal cells are removed, the result is a graft matrix with normal type I collagen bundling architecture A variety of autogenous soft tissue graft types and an intact basement membrane. Removal of are available for correction of ridge deficiencies. all cells eliminates the possibility of viral survival Small to moderate Class I defects can be treated and transmission as well as the components nec- with the roll technique, utilizing a deepithelialized essary for graft rejection. Rather than healing by palatal connective tissue pedicle flap inserted granulation, acellular dermal matrix grafts serve within a properly prepared buccal pouch.22 Like- as conductive matrices, allowing cellular migra- wise, subepithelial connective tissue grafts are tion and neovascularization from the surrounding widely used for correction of primarily Seibert The Journal of Implant & Advanced Clinical Dentistry 33

Toscano et al Figure 1: Midline crestal and releasing incisions made Figure 2: Full-thickness mucoperiosteal aps allowed prior to ap re ection. complete access to all areas of the Seibert Class III defect. host bed to repopulate and replace the graft site. MATERIALS AND METHODS Although originally designed as an alterna- Study Population tive treatment for burn wounds, acellular der- Thirty consecutive patients with significant api- mal matrices have been used extensively in cocoronal and buccolingual alveolar hard and dentistry as alternatives to autogenous soft tis- soft tissue ridge deformities (Seibert Class III) sue grafts. Dental use has included manage- were included in this reported case series. The ment of gingival recession,30-37 increasing the patient population included 12 females and 18 zone of keratinized tissue around teeth and males between 19 to 58 years of age. Detailed implants,38-40 and preserving and/or increas- past medical and dental histories were obtained ing gingival thickness in edentulous areas.41-47 for each patient. All patients were treated by the authors as part of their clinical practice. The purpose of this thirty patient consecu- tive case series was to investigate the efficacy Clinical Evaluation of simultaneously grafting significant anterior Following a detailed clinical examination, pan- maxillary Seibert Class III alveolar ridge defects oramic and full-mouth periapical radiographs with a slowly resorbing xenograft particulate were obtained for each patient. All patients (Bio-Oss®, Osteohealth Company, Shirley, NY) presented with edentulous areas within the combined with an overlying acellular dermal maxillary esthetic zone that had been previ- matrix allograft (Puros® Dermis Allograft, Zim- ously restored with traditional, non-implant mer Dental Inc.) in order to restore both nor- supported fixed restorations. Entrance into mal osseous and soft tissue contours, including the study required Seibert Class III deficien- restoration of interdental papillae, in patients cies, including loss of interdental papillae. requiring traditional fixed prosthetic restorations. 34 Vol. 1, No. 7 October 2009

Toscano et al Figure 3: Bio-Oss® particulate graft material was carefully Figure 4: After being trimmed and saturated with sterile placed over the exposed buccal and palatal cortices as well saline, Puros® Dermis was positioned over the Bio-Oss® as the alveolar crest to allow bone regeneration to occur in graft in order to act as both a GBR barrier membrane and all areas of the ridge defect. conductive matrix for gingival soft tissue regeneration. Overview of the Surgical Procedure to act as a conductive matrix for gingival soft Prior to surgery, all patients received oral tissue regeneration to occur simultaneously hygiene instructions as well as full mouth scal- with underlying new bone formation (figure 4). ing and curettage. Detailed informed consents Importantly, the Puros® Dermis was placed fac- were obtained, indicating understanding of ing the periosteal surface of the mucoperiosteal the nature of the proposed surgical treatment. flap. The soft tissue flaps were then reposi- tioned and closed without tension via mul- Using a #15 scalpel, midline crestal inci- tiple interrupted 5.0 ePTFE sutures (figure 5). sions were made at each edentulous site. Mesial and distal vertical release incisions allowed A carefully prepared interim fixed restora- wide exposure of the maxillary buccal cortex tion with ovate shaped pontics was then placed (figure 1). Full-thickness buccal and palatal onto previously prepared abutment teeth (fig- mucoperiosteal flaps were reflected, exposing ure 6). In addition to satisfying both func- the entire extent of the alveolar ridge deformity tional and esthetic requirements, the interim (figure 2). Following thorough wetting with ster- restoration was used as a guide during soft ile saline, small particle size Bio-Oss® particu- tissue maturation for creation of a more natu- late graft material was carefully placed over the ral soft tissue profile, including the formation exposed buccal cortex as well as the over the of interdental papillae. Pleasing emergence alveolar crest and palatal cortex to allow bone profiles were thus created by guiding the mor- regeneration to occur in all areas of the ridge phology of the soft tissues with the interim defect (figure 3). Puros® Dermis Allograft was restoration during soft tissue regeneration. then trimmed to size, saturated with saline, and placed over the Bio-Oss® graft in order The Journal of Implant & Advanced Clinical Dentistry 35

Toscano et al Figure 5: Soft tissue aps were closed without tension via Figure 6: An interim restoration with ovate shaped pontics multiple interrupted 5.0 Gore-Tex sutures. served as a guide during soft tissue maturation for the development of interdental papillae. Figure 7: Seibert Class III defect demonstrates signi cant Figure 8: An occlusal view demonstrates severe bucco- apicocoronal bone loss. palatal narrowing in the esthetic zone of the maxilla. REVIEW OF Case #1 REPRESENTATIVE CASES The patient, a 37 year old male presented with a Seibert Class III anterior maxillary edentulous The following illustrate several representa- defect of 15 years duration (figures 7, 8). The tive cases that demonstrate both specific sur- patient’s current prosthodontist constructed a gical and prosthetic procedures as well as new interim fixed restoration to replace a pre- obtained results when correcting difficult to viously made and now clinically deficient fixed treat hard and soft tissue defects within the bridge. In order to compensate for significant esthetic zone of the maxilla with Bio-Oss® par- apicocoronal and buccolingual bone loss as well ticulate graft and Puros® Dermis Allograft. as for loss of interdental papillae, overly large 36 Vol. 1, No. 7 October 2009

Toscano et al Figure 9: Ridge lap pontics attempt to compensate for Figure 10: Additional view of ridge lap pontics from ridge de ciency of case 1. case 1. Figures 11: Flap re ection revealed signi cant bucco- Figure 12: Additional view of defect from case 1. palatal bone loss as well as the remnants of a residual cyst. ridge-lap pontics were placed in the edentulous Figure 13: Small particle size Bio-Oss® was carefully grafted area (figures 9, 10). At augmentation surgery, to cover all areas of the anterior maxillary defect site. well-released full thickness buccal and palatal flaps revealed severe alveolar ridge narrowing as well as a small residual cyst in the right lat- eral incisor region. When removed, the residual cyst resulted in an additional anatomic defect within the anterior maxillary ridge (figures 11, 12). In order to restore the anatomic integrity of the bony ridge to its normal dimensions, small par- The Journal of Implant & Advanced Clinical Dentistry 37

Toscano et al Figure 14: A double layer of Dermis allograft was placed Figure 15: Additional view of layered grafting technique. over the Bio-Oss® graft. conductive matrix for overlying soft tissue regen- Figure 16: A new xed interim restoration with ovate eration (figures 14, 15). The mucoperiosteal flaps shaped pontics, no longer over-sized, was temporarily were then closed primarily via multiple 5.0 ePTFE cemented into place. sutures. A new fixed interim restoration with ovate shaped pontics, no longer over-sized, was tempo- ticle size, slowly resorbing Bio-Oss® particulate rarily cemented into place (figure 16). During the graft material was carefully placed along both the ensuing healing period the interim restoration was entire exposed buccal cortex and alveolar ridge revised as needed in order to act as a guide during crest. Slight over-contouring with Bio-Oss® was soft tissue maturation for the development of criti- required in order to assure restoration of normal cally important interdental papillae (figures 17, 18). apicocoronal and buccolingual dimensions once healing was complete (figure 13). A double layer Case #2 of Puros® Dermis allograft was then placed over The second case is a 52 year old male with the Bio-Oss® graft, serving as both a Guided severe maxillary ridge atrophy in the maxillary Bone Regenerative barrier membrane and as a central incisor area secondary to long stand- ing tooth loss in this region (figure 19). In an attempt to compensate for both apicocoro- nal and bucco-palatal bone loss, the patient presented with oversized ridge lap pon- tics of both maxillary central incisors (figures 20-22). In addition to the patient’s Seibert’s Class III ridge defect, the patient also pre- sented with a deep anterior overbite second- ary to supreruption of the mandibular incisors, 38 Vol. 1, No. 7 October 2009

Toscano et al Figure 17: Case 1 interim restoration used for soft tissue Figure 18: Additional view of interim restoration with guidance. ovate pontics guiding soft tissue healing. loss of interdental papillae within the edentu- Figure 19: Severe apicocoronal and bucco-palatal lous space, periodontally compromised maxil- maxillary ridge atrophy seen in case 2. lary lateral incisor teeth, and multiple stained teeth throughout both arches (figure 21). patient’s dental problems, including correction of occlusal plane discrepancies with its deep Following reflection of full-thickness buccal overbite and supraeruption of the mandibular and palatal mucoperiosteal flaps, both maxillary incisors. The cast metallic framework for the lateral incisors were removed, exposing large final maxillary restoration dramatically illustrates fenestrated and dehiscence bony defects of the the increase in ridge width as well as creation buccal cortex, further exaggerating the alveo- of interdental papillae obtained by correcting lar ridge deformity (figure 23). As in Case #1, the patient’s severe Seibert’s Class III defect small particle size, Bio-Oss® particulate graft with simultaneous bone and soft tissue graft- material was carefully placed along both the ing (figure 29). No longer are ridge lap pontics entire exposed buccal cortex and alveolar ridge required. Rather proper placement of the fixed crest (figure 24). Puros® Dermis allograft was then placed over the Bio-Oss® graft and the flaps closed primarily with multiple interrupted ePTFE sutures (figures 25, 26). An interim restoration with ovate shaped pontics was temporarily cemented into place (figure 27). Over the next 4 months the interim restoration served as a guide for the formation of estheti- cally important interdental papillae (figure 28). In planning for the definitive restorative result, care was taken to address each of the The Journal of Implant & Advanced Clinical Dentistry 39

Toscano et al Figure 20: Oversized ridge lap pontics attempt to Figure 21: Note deep overbite associated with pre-op compensate for ridge de ciency of case 2. restorations of case 2. Figure 22: Occlusal view demonstrates severe ridge Figure 23: Removal of peridontally compromised lateral de ciency of case 2. incisors exposed signi cant fenestrated and dehiscence defects of the buccal cortex. restoration relative to normal anatomic emer- Case #3 gence profiles of all four maxillary incisor teeth Case #3 dramatically illustrates the potential of is now possible, satisfying the stringent esthetic simultaneous grafting with Bio-Oss® particulate requirements within the esthetic zone of the max- plus Puros® Dermis Allograft in the correction of illa. Improvement in both function and esthet- a severe dental Class III occlusal discrepancy. ics is dramatically evident in the final definitive The patient, a 24 year old male lost both maxil- restorations following correction of the patient’s lary central incisors secondary to trauma nine occlusal plane discrepancies (figures 30, 31). years prior to presenting for definitive restorative treatment. Trauma induced bone loss resulted 40 Vol. 1, No. 7 October 2009

Toscano et al Figure 24: Small particle size Bio-Oss® particulate graft Figure 25: Dermis allograft was placed over the Bio- material was placed along the exposed buccal cortex and Oss® graft, serving as a conductive matrix for soft tissue alveolar ridge crest. regeneration. Figure 26: Using 5.0 ePTFE sutures the mucoperiosteal Figure 27: An interim restoration with ovate shaped aps were closed without tension. pontics was temporarily cemented into place. in a severe Seibert Class III defect, resulting in served as a guide for the development of interden- a dental Class III occlusal relationship (figures tal papillae. An occlusal view of the fixed interim 32, 33). In order to compensate for the trauma restoration demonstrates the elimination of the induced functional and esthetic deformity, the abnormal “emergence profile” seen in the patient’s patient wore a removable appliance with an exag- removable appliance (figure 36). The traumati- gerated bucco-palatal flange (figures 34, 35). cally induced Class III occlusal relationship has been eliminated through simultaneous bone and Figures 1 through 6 describe the step-by-step soft tissue grafting, allowing proper positioning of corrective surgical procedures used in this case, the fixed restoration. Overly contoured, ridge lap including placement of an interim restoration that The Journal of Implant & Advanced Clinical Dentistry 41

Toscano et al Figure 28: Using the interim restoration as a guide, Figure 29: The cast metallic framework for the nal interdental papillae have been formed in order to allow for maxillary restoration demonstrates the increase in ridge excellent esthetics and proper emergence pro les of the width as well as creation of interdental papillae obtained de nitive xed restoration. by correcting the patient’s Seibert’s Class III defect with simultaneous bone and soft tissue grafting. Figure 30: Improvement in both function and esthetics is Figure 31: Note improved soft/hard tissue relationship evident following Bio-Derm ridge plumping and delivery of compared to gure 20. nal restorations. deficiencies were corrected through simultane- ous hard and soft tissue grafting (figures 38-40). pontics are unnecessary once the patient’s nor- mal anatomy was restored. Instead, esthetic and DISCUSSION readily cleansable ovate shaped pontics become the replacement restoration of choice (figure 37). Proper crestal gingival anatomy, including intact The final definitive fixed restoration demonstrates interdental papillae, are absolute prerequisites dramatic functional and esthetic improvements for natural appearing emergence profiles of once the patient’s hard and soft tissue ridge 42 Vol. 1, No. 7 October 2009

Toscano et al Figure 32: Case 3 pre-op pro le. Figure 33: Pre-op Siebert III ridge de ciency of case 3. Figure 34: Exaggerated bucco-palatal ange of patient’s Figure 35: Note exaggerated aring of incisors with old removable appliance. patient’s old removable appliance. Figure 36: An occlusal view of the xed interim restoration Figure 37: Correcting the patient’s anterior ridge demonstrates the elimination of the abnormal “emergence deformity allowed fabrication of readily cleansable, pro le” seen in the patient’s removable appliance. esthetic ovate shaped pontics. The Journal of Implant & Advanced Clinical Dentistry 43

Toscano et al Figure 38: Case 3 nal restorations. Figure 39: Note improvement of soft/hard tissue relationship after Bio-Derm augmentation. Figures 38-40: By eliminating the Class III dental malocclusion through correction of the anterior maxillary with thin buccal cortical bone, lead to significant alveolar defect, dramatic functional and esthetic bone resorption following tooth removal.3-4 Gin- improvements were possible in the nal de nitive xed gival recession, distortion, and loss of interdental restoration. papillae are the inevitable sequelae of bone loss in the anterior maxilla. Seibert Class I, II, and III traditional fixed or implant supported restora- defects are therefore commonly encountered in tions in the esthetic zone of the maxilla. With- the esthetic zone and must be adequately treated out normal soft tissue morphology, truly esthetic if esthetic fixed restorations are to be achieved. restorations cannot be achieved regardless of additional clinical effort. Adequate soft tissue A variety of clinical approaches have been architecture, however, is dependent upon a foun- used to restore normal soft tissue architecture.22-29 dation of anatomically stable and healthy alveo- Frequently, when non-implant supported fixed lar bone.48 In the critical esthetic zone, however, restorations are contemplated, autogenous or marginal buccal alveolar bundle bone, combined allograft soft tissue augmentation procedures are used without regard to the underlying bony mor- phology. While sometimes effective, multiple soft tissue grafting surgeries are often required before an adequate gingival profile can be achieved.25 At times the results from soft tissue grafting alone are inadequate to sustain long-term stable results, especially when attempting to reconstruct inter- dental papillae in the presence of significant under- lying apicocoronal and bucco-palatal bone loss. A more predictable approach to achieving esthetic and stable soft tissue marginal tissues 44 Vol. 1, No. 7 October 2009

Toscano et al in the anterior maxilla may be to correct both the Effective bone regeneration, while vitally impor- hard and soft tissue deficiencies present in most tant to esthetic success of dental restorations ridge defects. In the current 30 patient case within the esthetic zone, must also be associ- series, simultaneous grafting of both the under- ated with adequate overlying soft tissue thickness lying bone and the overlying soft tissue defects and architecture in order for true restorative suc- without the need of invasive harvesting proce- cess to be achieved. In each case within this 30 dures appeared to result in the natural emergence patient case series, apicocoronal and bucco-pal- profiles critical to esthetic fixed restorations. atal bone loss was also associated with gingival mucosal atrophy and absence of interdental papil- Critically important to restoring normal lae. Regeneration of normal crestal gingival thick- 3-dimensional ridge anatomy, especially when ness and restoration of interdental papillae were faced with significant buccal and crestal bone crucial elements required for successful definitive loss, is to consider the grafting requirements dental restoration in this critically esthetic area. needed for long term stability of the augmented ridge. In order to maintain stable bone volume As noted earlier, most attempts at soft tis- and architecture in the anterior maxilla, a slowly sue regeneration rely primarily on autogenous resorbing graft material with a low substitution grafts, especially subepithelial connective tis- rate is needed that can act as a long-term scaf- sue grafts from the palate.22-27 Although effec- fold for continuing bone formation.49-50 In addition, tive, such grafts require a second invasive surgery the graft material should be highly osteoconduc- and impose a limit to the amount of grafting avail- tive, with a highly porous particle structure and able at any one time. In addition, the potential a large inner surface area, both essential pre- for post-operative complications and morbidity requisites for effective bone graft substitutes.51 are always present.25 Therefore, in the current series an allogenic acellular dermal matrix was The bony ridge defects treated in this case chosen as an alternative to autogenous grafts. series were difficult to treat Seibert Class III defor- mities with significant apicocoronal and bucco- Puros® Dermis allograft served three pur- palatal bone loss. Successful resolution of these poses: 1) To serve as a resorbable barrier mem- defects required effective bone regeneration with brane, preventing unwanted fibroblastic cellular sustained, stable 3-dimensional bony architec- migration into the Bio-Oss® grafted site during the ture over time. Bio-Oss® bone mineral combines active Guided Bone Regenerative period; 2) To a complex, interconnected pore system condu- increase overall gingival thickness; and 3) To pro- cive for effective vascular and osteoblastic cellular vide sufficient soft tissue depth for the formation ingrowth with slow particle resorption, charac- of interdental papillae. Although generally placed teristics ideal for ongoing bone regeneration and directly onto a periosteal bed as a subsequent long term morphologic ridge stability.52-54 Bio- procedure following successful bone regenera- Oss® was therefore chosen as the graft material tion, in this particular series the acellular dermal of choice since it is likely to provide the necessary matrix was placed immediately over the Bio-Oss® bony support over time required by regenerated graft, simultaneously accomplishing both bone gingival soft tissues, including interdental papillae. grafting and soft tissue augmentation in a single The Journal of Implant & Advanced Clinical Dentistry 45

Toscano et al surgical visit. Vascular ingrowth from all areas of Disclosure the surrounding host bed, including the overly- The authors report no conflicts of interest with anything mentioned in this article. ing periosteum, appeared adequate for success- ful bone and soft tissue regeneration to occur. Acknowledgements Special thanks to Dr. Stuart Kay (Huntington, NY) for his help with the While hard and soft tissue grafting were organization and production of this manuscript. critically necessary procedures, proper devel- opment of interdental papillae through careful References fabrication and continued appropriate revision 1. Lekovic V, Camargo PM, Klokkevold PR, Weinlaender M, Kenney EB, of the fixed interim restoration cannot be over- stated. Meticulous use of properly shaped ovate Dimitrijevic B, Nedic M. Preservation of alveolar bone in extraction sockets pontics adjacent to regenerating gingival soft tis- using bioasorbable membranes. J Periodontol 1998 Sep;69(9):1044-49. sues allowed for the development of interdental papillae and natural appearing emergence pro- 2. Schropp L, Kostopoulos L, Wenzel A. Bone Healing and Soft Tissue Contour files, elements crucial to final restorative success. Changes Following Single-Tooth Extraction: A Clinical and Radiographic 12-month Prospective Study. Int J Periodontics Restorative Dent 2003 CONCLUSION Aug;23(4):313-323. Thirty consecutive patients with significant Seibert 3. Nevins M, Camelo C, DePaoli S, Friedland B, Schenk RK, Parma-Benfenati Class III alveolar ridge defects were successfully S, Simion S, Tinti C, Wagenberg B. A Study of the Fate of the Buccal Wall treated with simultaneous bone (Bio-Oss® par- of Extraction Sockets of Teeth with Prominent Roots. Int J Periodontics ticulate) and soft tissue grafting (Puros® Dermis Restorative Dent 2006;26:19-29. Allograft) procedures. The authors have coined this procedure the “Bio-Derm Ridge Plump- 4. Araujo M, Linder E, Wennstrom J, Lindhe J The Influence of Bio-Oss Collagen ing Technique for Pontic Site Development.” By on Healing of an Extraction Socket: An Experimental Study in the Dog. Int J avoiding autogenous hard and soft tissue grafts, Periodontics Restorative Dent 2008;28:123-135. the Bio-Derm Ridge Plumping Technique elimi- nates the need for additional invasive harvest- 5. Seibert JS, Reconstruction of Deformed, Partially Edentulous Ridges, Using ing surgeries while at the same time allowing for Full Thickness Onlay Grafts. Part I. Technique and Wound Healing. Compend the completion of both bone and soft tissue aug- Cont Educ Dent 1983;4:437-453. mentation procedures in a single surgical visit. 6. Simion, M., Trisi, P. & Piattelli, A. Vertical ridge augmentation using a Correspondence: membrane technique associated with osseointegrated implants. International Nicholas Toscano, DDS, MS Journal of Periodontics and Restorative Dentistry 1994;14: 496-511. Diplomate American Board of Periodontology Practice Limited to Periodontics and Implant 7. Nyman S. Bone regeneration using the priniciple of guided tissue Surgery regeneration. J Clin Periodontol 1991(18);494-498. 1140 19th Street, NW Suite 310 Washington, DC 20036 8. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion [email protected] technique: a five-year study. Int J Periodontics Restorative Dent. 1994 Oct;14(5):451-459. 10. Froum SJ, Rosenberg ES, Elian N, Tarnow D, Cho SC. Distraction osteogenesis for ridge augmentation: prevention and treatment of complications: thirty case reports. Int J Periodontics Restorative Dent. 2008 Aug;28(4):337-345. 11. McAllister BS, Haghighat K. Bone augmentation techniques: J Periodontol 2007;78:377-396. 12. Levin L, Nitzan D, Schwartz-Arad D. Success of dental implants placed in intraoral block bone grafts. J Periodontol 2007;78:18-21. 13. Cushing M. Autogenous red marrow grafts: potential for induction osteogenesis. J Periodontol 1969;40:492-497. 14. Sottostanti JS, Bierly JA. The storage of marrow and its relation to periodontal grafting procedures. J Periodontol 1975;46:162-170. 15. Wang JH, Waite DE, Steinhauser E. Ridge augmentation: An evaluation and follow-up report. J Oral Surg 1976;34:600-612. 16. Jensen OT, Laster Z. Preventing complications arising in alveolar distraction osteogenesis. J Oral maxillofac Surg. 2002;60(10):1217-8. 17. Becker W, Becker BE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case reports. Int. J Periodontics Restorative Dent. 1990;10(5):376-391. 18. Nyman S, Lang NP, Buser D, Bragger U. Bone regeneration adjacent to titanium dental implants using guided tissue regeneration: A report of two cases. Int J Oral Maxillofac Implants 1990;5(1):9-14. 19. Simion, M., Trisi, P. & Piattelli, A.Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int J Periodontics Restorative Dent 1994; 14: 496-511. 46 Vol. 1, No. 7 October 2009

Toscano et al 20. Nevins M, Mellonig J.T. Enhancement of the damaged edentulous ridge to receive 41. Schulman J. Clinical evaluation of an acellular dermal allograft for increasing the dental implants: A combination of allograft and the Gore-Tex membrane. Int J zone of attached gingival. Practical Periodontics Aesthet Dent 1996;8:201- Periodontics Restorative Dent 1992(12) 97-111. 208. 21. Nyman S. Bone regeneration using the priniciple of guided tissue regeneration. J 42. Luczyszyn SM, Papalexiou V, Novaes AB, Grisi MF, Louza SL, Taba M. Acellular Clin Periodontol 1991(18);494-498. Dermal Matrix and Hydroxyapatite in Prevention of Ridge Deformities after Tooth Extraction. Implant Dent 2005;14:176-184. 22. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199. 43. Fowler EB, Breault LG, Rebitski G. Ridge Preservation Utilizing an Acellular Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: part I. A Report 23. Scharf DR, Tarnow DP. Modified roll technique for localized alveolar ridge of 2 Cases. J Periodontol 2000;71:1353-1359. augmentation. Int J Periodontics Restorative Dent 1992;12:415-425. 44. Fowler EB, Breault LG, Rebitiski G. Ridge Preservation Utilizing an Acellular 24. Langer B, Calagna LJ. The subepithelial connective tissue graft. J Prosthet Dent Dermal Allograft and Demineralized Freeze-Dried Bone Allograft: Part II. 1980;42:363-367. Immediate Endosseous Implant Placement. J Periodontol 2000;71:1360-1364. 25. Langer B, Calagna LJ. The Subepithelial Connective Tissue Graft. A New 45. Batista EL, Batista FC, Novaes AB. Management of Soft Tissue Ridge Deformities Approach to the Enhancement of Anterior Cosmetics. Int J Periodont Restorative With Acellular Dermal Matrix. Clinical Approach and Outcome After 6 Months of Dent 1982;9(2):23-33. Treatment. J Periodontol 2001;72:265-273. 26. Allen EP, Gainza CS, Farthing GG, Newbold DA. Improved technique for localized 46. Fowler EB, Breault LG. Ridge Augmentation with a Folded Acellular Dermal ridge augmentation. A report of 21 cases. J Periodontol 1985;56:195-199. Matrix Allograft: A Case Report. J Contemp Dent Pract 2001;(2)3:31-40. 27. Orth C. A Modification of the Connective Tissue Graft Procedure for the 47. Breault LG, Lee SY, Mitchell NE. Fixed Prosthetics with a Connective Tissue Treatment of Type II and Type III Ridge Deformities. Int J Periodont Rest Dent and Alloplastic Bone Graft Ridge Aumentation: A Case Report. J Contemp Dent 1996;16:267-277. Pract 2004 November;(5)4:111-122. 28. Seibert JS. Reconstruction of deformed, partially edentulous ridges using full 48. Scarano A, Barros RM, Iezzi G, Piattelli A, Novaes AB. Acellular Dermal thickness onlay grafts. Part 1. Technique and wound healing. Compendium Matrix Graft for Gingival Augmentation: A Preliminary Clinical, Histologic, and Continuing Educ Dent 1983;4:437-451. Ultrastructural Evaluation. J Periodontol 2009;80:253-259. 29. Wainwright DJ. Use of an acellular allograft dermal matrix (Alloderm) in the 49. Grunder, U, Gracis S, et al. Influence of the 3-D Bone-to-Implant Relationship on management of full-thickness burns. Burns 1995;21:243-248. Esthetics. Int J Periodontics Restorative Dent 2005; 25:113-119. 30. Lattari V, Jones LM, Varcelotti JR, Latenser BA, Sherman HF, Barrette RR. The 50. Elian N, Ehrlich B, et al. Advanced Concepts in Implant Dentistry: Creating the use of a permanent dermal allograft in full-thickness burns of the hand and foot: a “Aesthetic Site Foundation”. Dent Clin N Am 2007;51:547-563. report of three cases. J Burn Care Rehabil 1997;18:147-155. 51. Traini T, Valentini P, et al. A Histologic and Histomorphometric Evaluation of 31. Richardson CR, Maynard JG. Acellular Dermal Graft: A Human Histologic Case Anorganic Bovine Bone Retrieved 9 Years After a Sinus Augmentation Procedure. Report. Int J Periodontics Restorative Dent 2002;22:21-29. J Periodontol 2007; 78:955-961. 32. Cummings LC, Kaldahl WB, Allen EP. Histologic Evaluation of Autogenous 52. Lee Yong-Moo, Shin Seung-Yun, et al. Bone Reaction to Bovine Hydroxyapatite Connective Tissue and Acellular Dermal Matrix Grafts in Humans. J Periodontol for Maxillary Sinus Floor Augmentation: Histologic Results in Humans. Int J 2005;76:178-186. Periodontics Restorative Dent 2006; 26:471-481. 33. Santos A, Goumenos G, Pascual A. Management of Gingival Recession by the 53. Orsini G, Traini T, Scarano A, Degidi M et al. Maxillary sinus augmentation with Use of an Acellular Dermal Graft Material. J Periodontol 2005;76:1982-1990. Bio-Oss particles: a light, scanning and transmission electron microscopy study in man. J Biomed Mater Res.B: Appl Biomater 2005;74(1):448-457. 34. Hirsch A, Goldstein M, Goultschin J, Boyan BD, Schwartz Z. A 2-Year Follow- Up of Root Coverage Using Subpedicle Acellular Dermal Matrix Allografts and 54. Piattelli M, Favero GA, Scarano A, et al. Bone reactions to anorganic bovine bone Subepithelial Connective Tissue Autografts. J Periodontol 2005;76:1323-1328. (Bio-Oss) used in sinus augmentation procedures: a histologic long-term report of 20 cases in humans. Int J Oral Maxillofac Implants 1999;14:835-840. 35. Mehlbauer MJ, Greenwell H. Complete Root Coverage at Multiple Sites Using an Acellular Dermal Matrix Allograft. Compendium 2005;26:727-733. 55. Sartori S, Silvestri M, Forni F, et al. Ten-year follow-up in a maxillary sinus augmentation using anorganic bovine bone (Bio-Oss). A case report with 36. Harris RJ. A Short-Term and Long-Term Comparison of Root Coverage With an histomorphometric evaluation. Clin Oral Implants Res 2003;14:369-372. Acellular Dermal Matrix and a Subepithelial Graft. J Periodontol 2004;75:734- 743. 37. Haim T, Moses O, Zohar R, Meir H, Nemcovsky C. Root Coverage of Advanced Gingival Recession: A Comparative Study Between Acellular Dermal Matrix Allograft and Subepithelial Connective Tissue Grafts. J Periodontol 2002;73:1405-1411. 38. Woodyard JG, Greenwell H, Hill M, Drisko C, Iasella JM, Scheetz J. The Clinical Effect of Acellular Dermal Matrix on Gingival Thickness and Root Coverage Compared to Coronally Positioned Flap Alone. J Periodontol 2004;75:44-56. 39. Harris RJ. Root coverage with a connective tissue with a partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodonotol 1998;69:1305-1311. 40. Cortes, ADQ, Maraatins AG, Nociti FH, Sallum AW, Casati MZ, Sallum EA. Coronally Positioned Flap With or Without Acellular Dermal Matrix Graft in the Treatment of Class I Gingival Recessions: A Randomized Controlled Clinical Study. J Periodontol 2004;75:1137-1144. The Journal of Implant & Advanced Clinical Dentistry 47