Vertical Augmentation with Piezoelectric Sandwich Technique

VOLUME 1, NO. 3 MAY 2009 The Journal of Implant & Advanced Clinical Dentistry Vertical Augmentation with Piezoelectric Sandwich Technique Treatment of Oral Lichen Planus

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The Journal of Implant & Advanced Clinical Dentistry 11 Prosthetic Case of the Month Table of Contents Customized Implant Abutment 41 Treatments and Treatment Outcomes in with Titanium Laser Welding Patients with Oral Lichen Planus Miguel A. Iglesia Abigail Soto, Celeste M. Abraham, Terry D. Rees 17 Piezoelectric Sandwich Vertical 55 Classi cation of Single Tooth Augmentation: A Series of Case Reports Edentulous Ridges with Augmentation Recommendations for Dental Dong-Seok Sohn, Won-Hyuk Lee,, Jeung-Uk Heo Implant Treatment 31 Modi ed Palatal Papilla Construction Flap Masana Suzuki. Yorimasa Ogata for Aesthetic Second Stage Implant Surgery GD Rachlin, MN Pratt, JF Koubi 63 Factors Driving Peri-implant Crestal Bone Loss - Literature Review and Discussion: Part 2 of 4 Mohammad Ketabi, Robert Pilliar, Douglas Deporter 73 Review of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) Gregory D. Naylor The Journal of Implant & Advanced Clinical Dentistry 3



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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 Michael Huber, DDS Stan Presley, DDS Faizan Alawi, DDS Richard Hughes, DDS George Priest, DMD Michael Apa, DDS Debby Hwang, DMD Giulio Rasperini, DDS Alan M. Atlas, DMD Anil Idiculla, DMD Michele Ravenel, DMD, MS Charles Babbush, DMD, MS Tassos Irinakis, DDS, MSc Terry Rees, DDS Thomas Balshi, DDS James Jacobs, DMD Laurence Rifkin, DDS Barry Bartee, DDS, MD Ziad N. Jalbout, DDS Paul Rosen, DMD, MS Lorin Berland, DDS John Johnson, 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 Joseph Kravitz, DDS, MS Salvatore Ruggiero, DMD, MD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Anthony Sclar, DMD Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS 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 Eric Stoopler, DMD David Clark, DDS Robert Miller, DDS Scott Synnott, DMD Charles Cobb, DDS, PhD John Minichetti, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Uwe Mohr, MDT Gregory Tarantola, DDS Sally Cram, DDS Jaimee Morgan, DDS Dennis Tarnow, DDS Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA Douglas Deporter, DDS, PhD Peter K. Moy, DMD Tiziano Testori, MD, DDS Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Michael Tischler, DDS Nicolas Elian, DDS Ross Nash, DDS Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Gregory Naylor, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD Marcel Noujeim, DDS, MS Ilser Turkyilmaz, DDS, PhD Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Dean Vafiadis, DDS David Guichet, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD Kenneth Hamlett, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Istvan Hargitai, DDS, MS Jacinthe Paquette, DDS Alan Winter, DDS Michael Herndon, DDS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Robert Horowitz, DDS Richard K. Yoon, DDS The Journal of Implant & Advanced Clinical Dentistry 7



Editorial Commentary Giving Dental Implants the “Mickey Mouse” Treatment For this year’s spring break, my family and I spent a week at the imagination mecca location? Are we using implant planning software Walt Disney World in Orlando, Florida. to simulate optimal fixture placement? Are we using traditional technology such as diagnostic Now, I have been to Walt Disney World about a wax-ups and jaw relation records? Are we using half dozen times before, but this trip was different. the most advanced technology of all…our peers During our stay, I picked up a copy of Walt in the form of consults and referrals? The time Disney’s biography and a book chronicling the to consult is before treatment begins, not after efforts of Disney “imagineers” in their design and problems arise. construction of the Magic Kingdom. I must say Finally, are we treatment planning with that I was thoroughly impressed by the content of attention to detail? Are we evaluating the gingival these texts and I now view the Walt Disney World tissue for thickness and margin location prior to complex with a newfound sense of awe and implant placement? Are we evaluating anticipated wonderment. The vision, foresight, and attention residual thickness of the buccal plate after to detail that went into the planning of this resort implant placement? Are we planning for papilla paradise are simply amazing. maintenance with interim restorations during the With a humbling respect for the men and healing phase? Although they may seem of minor women that devised this exquisite marvel of importance to some, little nuances such as these engineering and efficiency, I wondered if we could can be the determining factor as to whether an improve implant dentistry by employing some of implant case is a success or failure. the same practices that went into the planning of It is true that just about anyone can be trained Walt Disney World. to place a dental implant. Heck, if you operate a For starters, are we using vision in the field of dental drill and parallel a tooth, you can place a implant dentistry? To this, I would say “yes.” On dental implant. The question isn’t whether or not the manufacturing front, industry is continually you can place a dental implant, the question is if researching new and improved physical aspects you can think three steps ahead and anticipate of implant design such as surface modifications, what is needed for optimal implant restorability, thread pitch variations, abutment interface esthetics, and long term maintenance. To do connections, etc. On the surgical front, we so, one must have vision, foresight, and exacting are constantly developing new and improved attention to detail when planning and delivering techniques such as ridge splitting and application dental implant treatment. of growth factors to aid implant success. Concerning foresight, are we being thorough in our treatment planning of implant cases? To answer in the affirmative, we must consider whether we are using the vast array of technology currently at our disposal. Are we using cone beam computed tomography (CBCT) when there Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS are questions about bone morphology or nerve Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 9

Iglesia

Prosthetic Case of the Month Iglesia Customized Implant Abutment with Titanium Laser Welding Miguel A. Iglesia, DDS, MS1 Abstract Background: Customized dental implant abut- wax when necessary to provide for optimal res- ments provide the restoring dentist and lab- toration placement and maximum porcelain sup- oratory technician an opportunity to make port. This waxed structure was cast in grade-2 subtle changes to the final implant resto- titanium and laser welded to the abutment ration position. Such modifications assist at the apical joint prior to porcelain stacking. in the achievement of maximum aesthetics. Results: The final implant restoration achieved Methods: A customized dental implant abut- superior aesthetics while retaining maxi- ment was fabricated for replacement of a con- mum porcelain support. genitally missing maxil- lary lateral incisor. An Conclusion: Customized abutment designed for implant abutments with cementation was tight- titanium laser welding pro- ened in a working model, vide exceptional porcelain reducing it or adding support while still achiev- ing superior aesthetics. KEY WORDS: Dental implant abutment, dental implant, dental prosthetics 1. Private practice, Zaragoza, Spain The Journal of Implant & Advanced Clinical Dentistry 11

Iglesia Following orthodontic treatment, an 18-year Correspondence: old female patient presented with a con- Miguel A Iglesia, DDS MS genitally missing left maxillary lateral incisor Residencial Paraíso 1, esc B, 1ºC and requested a single fixed implant-supported 50008 ZARAGOZA restoration. The implant was placed during orth- Spain odontic treatment with a surgical template and Telephone: 34 976 233 448 osteotomes. Plasma rich in growth factors with [email protected] calcium sulphate was added to the buccal plate in order to achieve more bone volume. A provi- Disclosure sional restoration was screwed directly to the The author reports no conflicts of interest with anything mentioned in this article. implant after 4 months. When orthodontic space Acknowledgement closure was finished achieving an adequate The author mentions his gratitude to Pedro Lorente, DDS for the orthodontic mesio-distal width for the final restoration, the treatment depicted, and to Pedro Moreno CDT and Nuria Pérez CDT for their provisional restoration was modified in order to technical assistance. achieve aesthetics that closely mimicked that of the planned final restoration in regard to emer- gence profile, interdental contours, contact points, and gingival contour at the facial margin. After 4 months, these goals were achieved and a fixture-level impression was taken. A lat- eral incisor was waxed-up on the master cast and a facial/lingual index of the expected final resto- ration was created. An abutment designed for cementation was tightened in the working model, reducing it or adding wax when necessary to provide enough metal to support porcelain. A silicone index was utilized to verify that enough space for aesthetic porcelain was allowed. This waxed structure was cast in grade-2 titanium and laser welded to the abutment at the api- cal joint. After confirming clinically the precise and correct form of the customized metal abut- ment, special porcelain for titanium was applied. The final aesthetics of the restoration demon- strated improved integration, shape and shade. 12 Vol. 1, No. 1 May 2009

Iglesia The Journal of Implant & Advanced Clinical Dentistry 13

Iglesia 14 Vol. 1, No. 3 May 2009

Iglesia Products used for this case Biomet-3i ™ Osseotite MicroMiniplant Lifecore Biomedical Inc, Calmatrix calcium sulphate Biomet-3i ™ GingiHue abutment Orotig grade 2 titanium Orotig Titec 60L laser welder Orotig TiKron porcelain The Journal of Implant & Advanced Clinical Dentistry 15

WhoSohn et al says you can’t © 2009 Exactech, Inc. always get what you want? Having a reliable product from a dependable source means you can. Pericardium is an allograft barrier membrane that naturally occludes cells. It is easy to handle, flexible and adaptable while Pericardiumbeing tough and resilient. Pericardium is available in four convenient sizes and is supplied freeze- BIOLOGICAL MEMBRANE dried in individual packages, which can be stored at room temperature. It’s never been so easy to get what you want when you want it. Pericardium BIOLOGICAL MEMBRANE Pericardium is processed by RTI Biologics, Inc. and distributed by Exactech, Inc. www.exac.com/dental

Piezoelectric Sandwich Sohn et al Vertical Augmentation: A Series of Case Reports Dong-Seok Sohn1 2 3 Abstract Background: Variations of pedicled and inter- repositioned. Residual gaps between the positional bone grafts for dentistry have been mobilized bony segment and the basal bone in use for over 30 years. This case series were grafted with a variety of materials. reports on three cases in which a piezoelec- tric “sandwich” variation of the previously men- Results: Vertical gains of up to 6mm of new tioned grafting techniques was employed. bone were achieved with this technique. His- tologic analysis of bone core biopsy samples Methods: Three patients with significant from grafted sites demonstrated vital bone. alveolar ridge deficiencies were treated with piezoelectric sandwich augmentation. At Conclusions: The piezoelectric sandwich aug- edentulous sites requir- mentation technique pro- ing augmentation, a piezo- vides the ability to achieve electric surgery unit was significant gains in verti- used to create alveolar seg- cal bone without the need ments which were vertically for a secondary donor site. KEY WORDS: Alveolar ridge augmentation, dental implants, grafts, bone 1. Professor and Chair, Dept. of Dentistry and Oral and Maxillofacial Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea 2. Clinical instructor, Dept. of Dentistry and Oral and Maxillofacial Surgery, Daegu Catholic University Hospital, Daegu, Republic of Korea 3. Private Practice, Goodwill Dental Hospital, Pusan, Republic of Korea The Journal of Implant & Advanced Clinical Dentistry 17

Sohn et al INTRODUCTION Figure 1: Initial panoramic view showing severe mandibular vertical de ciencies. The atrophic alveolar ridge is a challenging site for dental implant placement and a variety of surgical the mandible and maxilla (figure 1). Under gen- techniques have been developed to reconstruct eral anesthesia, ridge augmentations of the man- such areas. Guided bone regeneration, alveolar dible and maxilla were performed on July 23, distraction osteogenesis, pedicled grafts, interpo- 2004. Sinus augmentation was performed in sition alveolar bone grafts, and onlay block grafting the pneumatized right maxillary sinus while inter- have been used to overcome bone deficiency.1-4 nal (crestal) elevation and simultaneous implant placement was accomplished in the left sinus. The “sandwich technique” with interposi- Titanium plate assisted horizontal ridge augmen- tional bone grafting is the vertical bone augmen- tation was performed to augment the severely tation procedure using a pedicled bony segment atrophic anterior maxilla. Titanium mesh (Jaeil moved crestally following osteotomies. In addi- Co, Seoul, Korea) assisted ridge augmentation tion to eliminating the need for a secondary sur- using allograft (OrthoBlast II®, IsoTis OrthoBilog- gical donor site, this technique preserves the ics Inc. Califonia, USA) was performed in the right lingual or palatal periosteum which maintains and left atrophic posterior mandible (figures 2, 3). vascular supply to the segmented bone. Accord- ingly, it leads to minimal resorption of the trans- After 2 weeks of healing, exposure of the tita- positioned bony segment and has led to gains nium mesh on the left side occurred secondary of up to 6mm in new vertical bone height. When to occlusion from the opposing premolars. The performing sandwich ostetomies, piezoelectric mesh was later removed and failure of the verti- surgery is recommended to preserve the lingual cal augmentation was revealed due to premature periosteum, soft tissue, and ancillary nerves. The exposure (figures 4, 5). After 4 months of heal- specialized piezoelectric surgical properties cut ing, sandwich augmentation using piezoelectric hard tissue while sparing soft tissue and, thus, is bone surgery (Piezosurgery®, Mectron, Genova, able to preserve the periosteal blood supply to Italy) was performed. Two vertical osteotomies segmented alveolar bone during osteotomies.5-8 and one apical horizontal osteotomy were per- This series of case reports evaluates the efficacy of vertical sandwich augmentation using piezo- electric bone surgery and interpositional allograft by means of radiographic and histologic analysis. CASE REPORTS Case Report 1 A 63 year old woman visited our department with the complaint of mobility of her upper and lower removable dentures. Plain panoramic and com- puted tomographic radiogram showed severe horizontal and vertical bony deficiencies in both 18 Vol. 1, No. 3 May 2009

Sohn et al Figure 2: Titanium mesh assisted ridge augmentation. Figure 4: Premature titanium mesh exposure. Figure 3: Postoperative panoramic view showing alveolar Figure 5: Panoramic view showing initial failure of vertical ridge augmentations. augmentation. formed until penetrating the lingual cortex of man- Figure 6: Sandwich osteotomies performed with dible (figure 6). Segmented bone was elevated vertically 6mm with an elevator and allograft (OrthoBlast II®) was compacted into the space between the elevated bony segment and basal bone (figure 7). The surgical site was then cov- ered with a resorbable membrane (Pericardium® Zimmer Dental Inc, Carlsbad, USA) (figure 8). Immediate postsurgical radiographs demonstrate the elevated bony segment (figure 9). The aug- mented ridge was exposed after 7 months of heal- ing and favorable bone density and volume was The Journal of Implant & Advanced Clinical Dentistry 19

Sohn et al Figure 7: Segmented alveolar bone was elevated 6mm Figure 10: After 7 months of healing, 2 implants were and gel conditioned allograft was grafted into the space placed in the augmented ridge. between segmented bone and basal bone. Figure 8: Resorbable membrane covers the graft. Figure 11: Panoramic view showing augmented ridge and implant placement in the left posterior mandible. Figure 9: Note vertical elevation of segmented bone in the Figure 12: Panoramic view of nal restoration. left posterior mandible. 20 Vol. 1, No. 3 May 2009

Sohn et al Figure 13: Figure 14 the right posterior mandible. observed. Two hydroxylapatite implants (TSV®, Zimmer Dental Inc, Carlsbad, USA) were placed Figure 15: Sandwich osteotomies were performed with and healing abutments were seated as a single stage technique (figures 10,11). Final prosthet- Figure 16: Segmented alveolar bone elevated 6mm and ics were delivered by the patient’s referring den- xed with microplate/microscrew. tist after 6 months of implant healing (figure 12). Stable bone height was demonstrated radio- graphically after 2 years in function (figure 13). Case Report 2 A 25 year old male visited our department with a chief complaint of mastication difficulty. Teeth 28-31 were missing and he expressed a desire for an implant supported prosthesis. Clinical and radiographic evaluation revealed atrophic alveolar bone in the right posterior mandible and extru- sion of opposing dentition (figure 14). To cor- rect extrusion of the opposing teeth, the patient was referred to the department of orthodontics before performing bone augmentation. A ves- tibular incision was made by diode laser (Lambda Scientifica SpA, Italy) and sandwich osteotomies were made with the piezoelectric device (Sur- gyBone®, Silfradent srl, Sofia, Italy) under local The Journal of Implant & Advanced Clinical Dentistry 21

Sohn et al Figure 17: Postoperative radiograph showing vertical Figure 20: Radiographic view after implant placement. elevation of segmented bone. Orthodontic implants were placed to correct the extrusion of opposing teeth. Figure 18: After six months of healing, four implants were Figure 21: placed into the augmented bone. Figure 19: Allograft and collagen membrane used to anesthesia with 2% lidocaine 1:100,000 epi- augment dehiscence defects around implants. nephrine (figure 15). The segmented alveolar bone was elevated up to 6mm high and fixed 22 Vol. 1, No. 3 May 2009 with microplate and microscrew (Jaeil Co. Seoul, Korea) (figure 16). The space between segmented bone and basal bone was grafted with mineral allograft (OrthoBlast II®) and cov- ered with collagen membrane (figure 17). After 6 months of uneventful healing, the microplate was removed and a bone biopsy was taken

Sohn et al Figure 22: Figure 24: implants. Figure 23: F ree gingival graft to augment keratinized Figure 25: Note stable marginal bone after fourteen gingiva. months in function. from the graft site to evaluate new bone forma- able vertical augmentation was observed (fig- tion. Four 4.3mm wide and 11mm high implants ure 22). At this time, a free gingival graft was (Endure implant, IMTEC Co, Ardmore, USA) performed to increase the amount of keratinized were placed (figure 18). Allograft (OrthoBlast gingiva around the implants (figure 23). After II®) was used to augment dehiscence defects 5 weeks of healing, a temporary prosthesis was around the implants and collagen membrane cemented onto the implants (figure 24). Deliv- was used to cover over the graft (figures 19, ery of the final prosthesis will be delayed until 20). The bone biopsy specimen showed active completion of orthodontic treatment. Stable new bone formation (figure 21). Implants were bone height was observed radiographically uncovered after four months healing and favor- after fourteen months in function (figure 25). The Journal of Implant & Advanced Clinical Dentistry 23

Sohn et al Figure 26: 4mm vertical defect in the anterior maxilla. Figure 28: Grafted gap between the elevated bone and basal bone after xation of elevated segment with microplate/microscrews. Figure 27: 6mm vertical elevation was achieved after Figure 29: Resorbable membrane was used to cover the piezoelectric sandwich osteotomies. graft. Case report 3 A vestibular incision was made to expose the A 48 year old male patient was referred to the labial surface of atrophic anterior maxilla. Two verti- Department of Oral and Maxillofacial Surgery at cal and one horizontal complete osteotomies were Catholic University Medical Center, Daegu, Korea created using a piezoelectric saw with minimal for reconstruction of an atrophic alveolar ridge in injury of the palatal periosteum. The newly seg- the anterior maxilla. The patient presented with sig- mented alveolar bone was then moved crestally to nificant vertical alveolar deficiency (figure 26) and the bone level of adjacent teeth. The segmented was treatment planned for a vertical ridge augmen- bone was secured with a microplate and screws tation with our piezoelectric sandwich technique. (Jaeil Co, Seoul, Korea) (figure 27). Final position- 24 Vol. 1, No. 3 May 2009

Sohn et al Figure 30: Note the favorable vertical augmentation after 5 months of healing. Figure 32: Figure 31: Figure 33: Grafting of exposed implant threads. in the graft site. able temporary prosthesis was delivered and mod- ing of the mobilized segment achieved 7mm of ified to avoid placing pressure on the healing graft. vertical gain. A mixture of allograft (Orthoclase® II) and Ca-P nano-coated xenograft (BioCera TM, After 5 months of uneventful healing, the Oscotec, Chunan, Korea) was condensed into the augmented ridge was reopened and the fixa- gap between mobilized bone and the basal bone tion hardware was removed (figures 30, 31). A (figure 28). A resorbable pericardium membrane biopsy specimen which was taken from the site was then utilized to cover the entire graft and the of the sandwiched bone graft showed favorable surgical site was sutured primarily with layered new bone formation (figure 32). Two conven- sutures. (figure 29). After site closure, a remov- tional implants (Scewplant implant, ImplantDi- The Journal of Implant & Advanced Clinical Dentistry 25

Sohn et al Figure 36: Removal of the mini-dental implant. Figure 34: Radiograph of implants and graft. Figure 37: implants after four months of healing. Figure 35: Immediate temporization using mini implant. rect Co, USA) and one provisional mini-implant 26 Vol. 1, No. 3 May 2009 (Mini-implant, Cowellmedi Co, Busan, Korea) were placed into the grafted site. Although sig- nificant vertical improvement of the augmented site was achieved, some exposure of the buc- cal implant threads remained. Bovine xenograft mixed with centrifuge concentrated growth fac- tors to accelerate bone formation was grafted as a first layer over the exposed implant threads and gel conditioned allograft was grafted on top of the first layer (figures 33, 34). Following pri-

Sohn et al mary closure, an immediate temporary fixed pros- of handling and showed extensive new bone thesis was cemented on the provisional mini- bone formation.14,15 OrthoBlast II® contains implant (figure 35). After an additional 4 months DBM, known for its ability to stimulate new healing, the provisional mini-implant was removed bone formation and cancellous bone which is (figure 36) and a temporary fixed prosthesis was known to provide an osteoconductive scaffold seated on the conventional implants (figure 37). for bone deposition and remodeling. Further- more, OrthoBlast II® incorporates DBM with a DISCUSSION reverse thermal poloxamer carrier. When dis- solved in water at low ambient temperatures, Many clinicians have modified and further devel- poloxamer is a fluid liquid. The retention and oped pedicled and interpositional bone grafts slow release of DBM and growth factors at the since the late 1970s.9-12 Harle first reported the surgical site could enhance osteoinduction.16,17 use of the visor osteotomy to augment the atro- The poloxamer is malleable at operating room phic mandible in 1975.9 He sectioned the man- temperatures, but hardens when placed in dible sagittally between the mental foramens the operative site. Therefore, the graft shows and the pedicled bone segment was fixed with minimal loss through irrigation and suction. wires in a lifted position. Peterson et al modi- fied Harle’s description of the visor in 1977.10 Sandwich osteotomy has been shown to Stoelinga et al reported on the combination of be less subject to resorption than that of onlay the visor osteotomy with the sandwich osteot- grafts by providing a greater vascular supply omy interpositional bone grafting of the eden- to the inlay graft.18 The sandwich technique tulous mandible in 1978.12 This study used is a simpler technique than distraction osteo- autogenous iliac crest corticocancellous grafts genesis, but is advocated only when the mag- placed in a subcortical position in the mandible. nitude of correction is small, in the order of 3 to 6 mm of vertical movement.19 Exceptional When grafting the space between elevated results of up to 10mm of vertical gain, how- bone segment and basal bone, various types of ever, have been demonstrated in the ante- bone graft may be utilized. Both the mineralized rior mandible with sandwich augmentation.20 allograft and the mineralized allograft mixed with bovine bone used in this report showed favor- Complications such as nerve damage may able new bone formation histologically after the occur as a result of the sandwich osteotomy healing. Sohn et al reported on the efficacy procedure. Egbert and colleagues reported of OrthoBlast II®, a synergistic combination of that the inferior alveolar nerve was located lin- demineralized bone matrix (DBM) and can- gually in many atrophic mandibles and there cellous bone in a reverse phase medium, and was insufficient space to make a sandwich Tutoplast® cancellous microchips with sand- osteotomy lingual to the foramen without dam- wich augmentation.13 This study reported an aging the nerve.21 Jensen noted that many average of 20.6% new bone formation after patients may have some transient paresthesia a short healing period. Other studies evaluat- post-surgically, the longest lasting six weeks ing putty or gel conditioned allograft note ease and that the paresthesia was likely related to The Journal of Implant & Advanced Clinical Dentistry 27

Sohn et al flap retraction of the mental nerve.3 Paresthe- CONCLUSION sia can occurred by nerve trauma during tis- sue distraction and osteotomy. In this study, a In this report, the sandwich technique with an piezoelectric device was used for osteotomy in interpositional mineralized allograft was a suc- order to reduce trauma to nerve and soft tissue. cessful procedure to augment vertical bony Piezoelectric surgery makes highly controlled defects in the atrophic mandible and maxilla osteotomies and reduces damage to soft tissue prior to the placement of implants. Piezoelectric and neurovascular bundle during osteotomy.5, 7-8, osteotomy offered highly controlled osteotomies 22 Nevertheless, temporary neurosensory distur- and preserved the lingual periosteum and soft bance did occur in one patient from this study. tissue during the procedure. Segmental bone segments demonstrated favorable bone regen- Previous studies have clearly demonstrated eration whether fixed or not, but fixation cases that fixation cases have shown less relapse showed less relapse of elevated alveolar bone of the elevated bone than non-ficxtion case.13 than non-fixation cases. Additional studies with Accordingly, fixation of the elevated alveo- long term follow up observation are warranted to lar bony segement with microplates is recom- further evaluate the efficacy of this technique. mended to prevent relapse of the elevated bone. Disclosure 9. Harle F. Visor osteotomy to increase the absolute 17. Cheung S, Westerheide K, Ziran B. Efficacy of The authors report no conflicts of interest with height of the atrophied mandible. J Maxillofac contained metaphyseal and periarticular defects anything mentioned in this paper. Surg 1975 Dec; 3: 257. treated with two different demineralized bone References matrix allografts, Int Orthop 2003; 27: 56-59. 1. Jensen OT, Greer RO Jr, Johnson L, Kassebaum 10. Peterson LJ, Slade E. Mandibular ridge augmentation by a modified visor osteotomy: a 18. Massimo P, Massimo R. Localized alveolar D. Vertical guided bone-graft augmentation preliminary report. J Oral Surg 1977; 35: 999- sandwich osteotomy for vertical augmentation of in a new canine mandibular model. Int J Oral 1004. the anterior maxilla. J Oral Maxillofac Surg 1999; Maxillofac Implants 1995 May-Jun; 10(3):335-44. 57: 1380-1382. 2. Jensen OT. Distraction osteogenesis and its use 11. Harle F. A follow up investigation of surgical with dental implants. Dent Implant. 1999 May; correction of the atrophied alveolar ridge with 19. Jensen OT, Kuhlke L, Bedard JF, White D. 10(5):33-36. visor osteotomy. J Maxillofac Surg 1979; 7: Alveolar segmental sandwich osteotomy for 3. Jensen OT. Alveolar segmental “Sandwich” 283-293. anterior maxillary vertical augmentation prior to osteotomies for posterior edentulous mandibular implant placement. J Oral Maxillofac Surg 2006; sites for dental implants. J Oral Maxillofac Surg 12. Stoelinga P, Tideman H, Beger J, de Koomen 64: 290-296. 2006; 64(3): 471-475. HA. Interpositional bone graft augmentation of 4. Misch CM. et al. Reconstruction of maxillary the atrophic mandible: A preliminary report. J 20. Moon JW, Choi BJ, Lee WH, An KM. Sohn DS. alveolar defects with mandibular symphysis grafts Oral Surg 1978; 36:30-2. Reconstruction of atrophic anterior mandible for dental implants; a preliminary procedural using piezoelectric sandwich osteotomy : A case report. Int J Oral Maxillofac Implants 1992; 7(3): 13. Sohn DS, Shin HI, Ahn MR, Lee JS. Piezoelectric report. Implant Dent; In press. 360-366. vertical bone augmentation using the 5. Vercellotti T. Technological characteristics and sandwich technique in an atrophic mandible 21. Egbert M, Stoelinga PJ, Blijdorp PA, de clinical indications of piezoelectric bone surgery. and histomorphometric analysis of mineral Koomen HA. The “Three-piece” osteotomy and Minerva Stomatol 2004; 53(5): 207-214. allografts: Case reports series. Int J Periodontics interpositional bone graft for augmentation of the 6. Sohn DS. Sinus bone graft using piezoelectric Restorative Dent; In press. atrophic mandible. J Oral and Maxillofac Surg surgery. J Oral & Maxillofacial Implantology 2003; 1986; 44: 680-687. 7(1): 48-55. 14. Callan DP, Salkeld SL, Scarborough N. 7. Sohn DS. Ahn MR, Lee WH, Lee JS. Piezoelectric Histologic analysis of implant sites after grafting 22. Eggers G, Klein J, Blank J, Hassfeld S. osteotomy for intraoral harvesting of block bone. with demineralized bone matrix putty and sheets. Piezosurgery: an ultrasound device for cutting Int J Periodontics Restorative Dent 2007; 27(2): Implant Dent 2000; 9(1): 36-44. bone and its use and limitations in maxillofacial 127-31. surgery, British J Oral and Maxillofac Surg 2004; 8. Sohn DS. Color atlas, Clinical applications of 15. Babbush CA. Histologic evaluation of human 42(5): 451-453. piezoelectric bone surgery, Koonja Publishing Co biopsies after dental augmentation with a 2008; 456-501. demineralized bone matrix putty. Implant Dent 2003; 4: 325-332. 16. Ziran B, Cheung S, Smith W, Westerheide K. Comparative Efficacy of 2 different demineralized bone matrix allografts in treating long-bone nonunions in heavy tobacco smokers, Am J Orthop 2005; 34(7): 329-332. 28 Vol. 1, No. 3 May 2009

Sohn et al

Rachlin et al Are you getting what you need from your current allograft implant provider? www.OraGraft.com LifeNet Health BIO-IMPLANTS DIVISON

Modi ed Palatal Papilla Rachlin et al Construction Flap for Aesthetic Second Stage Implant Surgery GD Rachlin, DDS1 2 JF Koubi, DDS3 Abstract Background: The aim Papilla Index Score (PIS) of this clinical case included: 1) Presence or series is to describe lack of the papillae at a surgical technique the time of the second to create “papillae” stage surgery; 2) Pres- around dental implants ence or lack of the papil- when they are missing lae at delivery of the final or when the initial hori- prosthetic restoration. zontal ridge covering the implant site is flat. Results: This surgi- cal technique allows to Methods: The described surgical technique uses obtain interdental-interimplant or interimplant tissue the thick palatal connective tissue to recreate the looking like papillae in area where they are missing. interdental papilla. 3 patients completed this case series. One presented with a single tooth replace- Conclusions: Primary used for single tooth ment while 2 other patients had two missing max- replacement, the technique is also predict- illary anterior teeth. Recorded data based on able in the cases of multiple teeth replacement. KEY WORDS: Dental implant, papilla, periodontal plastic surgery 1. Periodontist in private practice, Toulon, France 2. Periodontist in private practice, Toulon, France 3. Professor, Marseille University, Marseille, France The Journal of Implant & Advanced Clinical Dentistry 31

Rachlin et al INTRODUCTION Figure 1: Frontal view of the 1st case at the second stage surgery. Initially, implant treatment was a matter of func- tion.1,2 As time went on, aesthetics became Figure 2: Occlusal view of the case at the second stage equally important.3-5 In the anterior maxilla, the surgery. aesthetic component of implant treatment is often considered the most important criteria and to create the papillae, two “S-shaped” pal- for success.6 Many parameters are involved in atal incisions were developed and turned buc- achieving this success: the residual bone quan- cally (Figure 3). The cover screw was retrieved tity, the first stage surgery, the second stage and healing abutment placed. The two rotated surgery, and the final prosthetic restoration. palatal pieces of tissue were adjusted to fit around the healing abutment and secured The purpose of this case reports is to by two mattress sutures to the buccal flap describe a second stage surgical technique for which was apically positioned (Figures 4, 5). management of the interproximal soft tissue and Results create, when necessary, interdental papillae. Healing was uneventful and a provisional resto- The Papilla Index Score (PIS) used to measure papillae was originally described by Jemt.7 This technique can be used for single tooth replace- ment as well as for multiple teeth replacement. CASE 1: TECHNIQUE FOR A SINGLE IMPLANT A 42-year-old male patient was referred for implant surgery to replace a first right maxillary incisor which was extracted due to root fracture. The residual bone volume was adequate to place the implant in a desirable position without using regeneration techniques. After 6 months of fol- low up, the second stage surgery was planned. At that time, the clinical observation revealed a flat area between the 2 adjacent teeth and the mesial and distal PIS were 0 (Figures 1, 2). Surgical Procedure A sulcular incision was made from the distal to the mesial aspect of the adjacent teeth and then crossed the edentulous ridge so that the buccal part of the cover screw was uncovered when the flap was raised. To retrieve the cover screw 32 Vol. 1, No. 3 May 2009

Rachlin et al Figure 3: The buccal ap is open and the 2 S-shaped Figure 6: Frontal view of the provisional reconstruction. palatal incisions developed. Figure 4: The healing abutments positioning the 2 palatal Figure 7: Final Implant-supported reconstruction. Note pieces of tissue. good topography of the papillae. ration was rapidly made for patient convenience (Figure 6). Upon delivery of the final implant-sup- ported prosthesis, the mesial and distal papillae were classified as PIS 3 respectively (Figure 7). Figure 5: Mattress sutures are securing the buccal ap and the palatal pieces of tissue. The Journal of Implant & Advanced Clinical Dentistry 33

Rachlin et al CASE 2: TECHNIQUE FOR Surgical procedure ADJACENT IMPLANTS The same incision was made as in the first clinical case to uncover the buccal half of A 58-year-old female patient was referred for the cover screws (Figure 9). The mesial implant surgery to replace 2 Maxillary incisors “S-shaped” incisions were rotated to form papil- which were lost secondary to periodontal prob- lae between the teeth and the implants while lems. In spite of this, the residual bone volume the distal “S-shaped” incisions were sutured was enough to place the implants in a good posi- together, as in the double papilla technique, tion without regeneration techniques. After 6 and rotated between the two implants. The months follow up, the second stage surgery was flaps and the surgically created papillae were planned. At that time, the clinical observation secured by mattress sutures (Figures 10, 11). showed a relatively flat ridge and the PIS Mesial to the adjacent teeth and at the inter-implant site in the middle of the ridge were 0 (Figure 8). Figure 8: Frontal view of the 2nd case at the second stage Figure 10: Healing abutments with the palatal pieces of surgery. Note the at ridge at the surgical site. tissue in place. Figure 9: Buccal ap uncovering half of the cover screw. Figure 11: Notice the palatal tissue miming papillae between the healing abutments. 34 Vol. 1, No. 3 May 2009

Rachlin et al Results Healing was uneventful and, as in the first case, a provisional prosthesis was rap- idly placed (Figure 12). Upon delivery of the final implant-supported prosthesis, the papil- lae were respectively classified as PIS 3. Figure 13: Figure 12: Frontal view of the provisional restoration. Figure 14: The buccal ap is open and the 2 palatal Interdental papilla is present between the 2 teeth. S-shape pieces of tissue are prepared to be sutured altogether. CASE 3: TECHNIQUE FOR ADJACENT IMPLANTS ure 14), adapted to the healing abutments (Figure 15), and secured by mattress sutures. The buc- A 25 year-old female patient was referred for cal flap was apically positioned to give more thick- replacement of the two central maxillary inci- ness to the tissue around the implants (Figure 16). sors which were lost due to trauma many years ago. Upon referral presentation, she was wear- Results ing a partial denture and the bone volume was Healing was uneventful and the final prosthetic just enough to obtain a primary fixation of the reconstructions were made during the first month implants. To resolve the buccal depression, an following surgery. The PIS between the two adja- autogenous bone graft obtained with a coagulum cent implants was 3, whereas the PIS was 2 trap was placed without a membrane and the sur- between the implants and the teeth (Figure 17). gical area was gently closed with sutures. At the second stage surgery the PIS were 0 (Figure 13). Surgical procedure After the intra sulcular buccal incision, papillae were created from the palatal aspect using the previously described double papilla technique (Fig- The Journal of Implant & Advanced Clinical Dentistry 35

Rachlin et al DISCUSSION Figure 15: The 2 sutured pieces of tissue and healing This second stage surgical technique allowed abutments in place. aesthetic results with PIS generally higher than it was recorded pre-operatively (Table 1). The ability Figure 16: Occlusal view of the sutures. to regenerate or augment gingival tissue in a coro- nal direction is difficult to perform successfully,8 Figure 17: Frontal view of the interdental new Papilla. although some authors have reported that without reconstructive surgery there is interproximal tissue 36 Vol. 1, No. 3 May 2009 redevelopment after 1 to 3 years.9 Unfortunately, such long term results are unpredictable and are the impetus for a number of surgical techniques for papillae reconstruction. Previously published techniques for papillae reconstruction developed papillae-like formations using the buccal flap.10, 11 In the present surgical technique, the buccal flap was not split through its full thickness to create the mesial and the distal papillae. Papillary recon- struction tissue came from the thick palatal tissue to reduce aesthetic risks to the buccal tissue. An added benefit of this technique is peri-implant bone coverage with soft tissue during the healing phase. The papillae reconstructions presented in the 3 clinical cases of this paper were achieved no matter what the quality of the soft tissue pres- ent. It seemed more difficult to gain soft tissue and papilla-like formations between a tooth and an implant than between two implants (Table 1). It was important to keep in mind that the presence of the papillae is a function of the dis- tance between bone and crown contact point.12 CONCLUSION When flapless implant placement or single stage implant placement is not possible, the technique described in this paper allows: 1) preservation of buccal keratinized tissue during the second stage surgery; 2) creation of papillae-like tissue origi- nating from the palate to reduce the risk of buc-

Rachlin et al Table 1: P nº1 Mesial Pre-Op Distal Mesial Post-Op Distal P nº2 0 Inter Implant 0 3 Inter Implant 3 P nº3 0 0 3 3 0 - 0 2 - 2 0 3 0 3 cal tissue necrosis; 3) improved coverage of bone Figure 19: Buccal ap open (technique for 2 implants). surrounding the implant. This technique may be used for either single or multiple implants. Dia- grammatic depictions of the techniques described in this paper are provided in figures 18-25. Correspondence: GD Rachlin, DDS Phone: 04 94 92 21 11 e-mail: [email protected] Figure 18: Occlusal view of the incision (technique for 2 Figure 20: Palatal ap positioning before suturing implants). (technique for 2 implants). The Journal of Implant & Advanced Clinical Dentistry 37

Rachlin et al Figure 21: Occlusal view of the incision (technique for 1 implant). Figure 24: Palatal mesial and distal positioning (technique for 1 implant). Figure 22: Buccal ap open (technique for 1 implant). Figure 25: Papillae reconstructed before suturing (technique for 1 implant). Figure 23: Palatal mesial laps positioning (technique for 1 implant). Disclosure The authors report no conflicts of interest with anything mentioned in this article. 38 Vol. 1, No. 3 May 2009 Acknowledgement The authors would like to thank Dr Guy Mouren for the drawings he provided for this paper. References 1. Adell R, Erikson B, Lekholm U, Branemark P, Jemt T. Long term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990; 5(4): 347-359. 2. Albreksson T, Senerby L. State of the Art in oral implants. J Clin Periodontol 1990; 18: 474-481. 3. Laney W, Jemt T, Harris D, Henry P, Krogh P, et al. Osseointegrated implants for single tooth replacement: progress report from a multicenter prospective study after 3 years. Int J Oral Maxillofac Implants 1994; 9(1): 49-54. 4. Lazzara R. Managing the soft tissue margin: The key to implant esthetics. Pract Periodontics Aesthet Dent 1993; 5(5): 81-87. 5. Garber D. The esthetic dental implant: Letting restoration be the guide. J Am Dent Assoc 1995, 126(3): 319-325. 6. Reikie D. Restoring gingival harmony around single tooth implants. J Prosthet Dent 1995; 74(1): 47-50. 7. Nemcovsky C, Moses O, Artzi Z. Interproximal papillae reconstruction in maxillary implants. J Periodontol 2000; 71(2): 308-314. 8. Sullivan D, Kay H, Schwarz M, Gelb D. Esthetic problems in the anterior maxilla. Int J Oral Maxillofac Implants 1994; 9: 64-74. 9. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997; 17(4): 327-333. 10. Palacci P. Peri-implant soft tissue management: Papilla regeneration technique. In : Palacci P, Ericsson I, Engstrand P, Ranger B. eds. Optimal implant positioning and soft tissue management for the Branemark system. Chicago : Quintessence; 1995; 59-70. 11. Adriaenssens P, Hermans M, Ingber A et al. Palatal sliding stip flap soft tissue management to restore maxillary anterior esthetics at stage 2 surgery: A clinical report. Inter J Oral Maxillofac Implants 1999, 14 30-36. 12. Tarnow D, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of the bone on the presence or absence of the interproximal dental papilla. J. Periodontol 1992, 63: 995-996.

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Soto et al Preliminary List of Invited Speakers Dr Paulo Coelho, USA Dr Michael Pikos, USA Dr Matteo Danza, Italy Dr Paul Rosen, USA Dr Scott Ganz, USA Dr Philippe Russe, France Dr Robert Horowitz, USA Dr Maurice Salama, USA Dr Jack Krauser, USA Dr Marius Steigmann,Germany Dr Ziv Mazor, Israel Dr Tiziano Testori, Italy Prof Adriano Piattelli, Italy Dr Tomaso Vercellotti, Italy Secretariat Paragon Conventions 18 Avenue Louis-Casai, 1209 Geneva, Switzerland Tel: +41-(0)-22-5330-948, Fax: +41-(0)-22-5802-953 Email: [email protected]

Treatments and Treatment Soto et al Outcomes in Patients with Oral Lichen Planus Abigail Soto1 23 Abstract Background: The aim of this study was to review ment options. Other topical agents included retin- the clinical characteristics of biopsy proven oral oids, tacrolimus and pimecrolimus. Fluocinonide lichen planus (OLP), the therapeutic methods used gel was most often prescribed followed by clobeta- and treatment outcomes achieved in 100 individu- sol gel. Complete resolution occurred in 5 patients, als referred to a tertiary care center and followed complete resolution followed by recurrence in 10 for up to 4 and one-half years after diagnosis. patients, partial remission in 52 patients and no change in 4 patients. No clinical information was Methods: Retrospective data were collected available on the rest. Partial remission and complete from records of patients with biopsy proven OLP. resolution were achieved most often using topical Records were consecutively selected from indi- corticosteroids. Twenty-five percent of patients viduals who received diagnosis and treatment developed oral candidiasis in association with topi- for OLP between Jan 2004 and July 2008 in the cal therapy. Twelve percent of patients had concom- Stomatology Center, Baylor College of Dentistry. itant LP lesions on either skin, genitalia, or scalp. Collected data was recorded in a standardized table and included: Patient record number, location Conclusion: Topical corticosteroid therapy of OLP lesion(s), type of OLP, other oral mucosal is usually successful in achieving satisfactory diseases, concomitant lesions in other parts of the results in OLP patients who comply with rec- body, treatment(s) used, and treatment results. ommended treatment regimens and clinical follow-up. Some individuals using topical corti- Results: Reticular OLP lesions were most fre- costeroids intraorally develop secondary oral can- quently observed, usually occurring concomitantly didiasis and prophylactic antifungal therapy may with erosive lesions. Treatment most commonly be indicated. Finally, lack of patient compliance used was topical corticosteroids (89 times) often in is a deterrent to long-term treatment success. conjunction with palliative treatment or other treat- KEY WORDS: Lichen planus 1. Student Dentist, Baylor College of Dentistry, Texas A&M Health Science Center 2. Assistant Professor, Periodontics, Baylor College of Dentistry, Texas A&M Health Science Center 3. Director of Stomatology, Baylor College of Dentistry, Texas A&M Health Science Center The Journal of Implant & Advanced Clinical Dentistry 41

Soto et al INTRODUCTION Figure 1: Reticular pattern of oral lichen planus on dorsum of tongue. Oral Lichen Planus (OLP) is a chronic inflam- matory disease that affects the oral mucous Figure 2: Non-elevated, painless plaque-like oral lichen membranes and gingiva. The etiology of OLP is planus of lower labial mucosa. unknown, however it has been associated with several systemic diseases including hypertension, represent transition from the reticular to one of the diabetes mellitus, and hepatitis B, but no constant erosive forms (figure 3).10 Bullous OLP is rare; it relationship has been found.1 In some parts of the presents with vesicles or bullae that may range world (Italy, southern Europe, Japan, and other in size from 4mm to 2cm.10 The blisters may rup- countries) OLP is relatively strongly associated ture fairly quickly, leaving a painful atrophic or with chronic hepatitis C infection.2 There are also ulcerative lesion. The ulcerative form of OLP fea- well recognized oral lichenoid reactions that clini- tures painful, irregular and persistent ulcerations cally, histologically, and by direct immunofluores- (figure 4). On many occasions multiple forms of cence resemble idiopathic OLP. They result from OLP may be present simultaneously (figure 5). hypersensitivity to dental materials or initiated by exposure to a wide range of identified drugs most A variety of treatment modalities have been commonly, anti-malarials, non-steroidal anti-inflam- described for management of OLP. The most matory agents, or antihypertension mediciments.3,4 frequently used options are topical steroids, local- OLP is a relatively common disease, seen in about 2% of the general population.5 It may present in several forms as classified by Andrea- son. Among them are reticular, papular, plaque- like, atrophic, bullous, and ulcerative.6 The atrophic, ulcerative, and bullous forms feature tis- sue destruction and pain and are often grouped together as erosive lichen planus.7 Conversely the reticular, plaque-like, and papular forms may be asymptomatic.8 Reticular OLP is the most common clinical presentation. It is easily diag- nosed because it consists of raised, thin, white lines connected in arcuate patterns with a lace- work appearance against an erythematous back- ground (figure 1).9,10 These interconnected white lines are known as Wickham’s striae.9,10 Papular OLP presents as white painless papules without Wickham’s striae, while the plaque-like form is a white raised or flattened leukoplakia-like lesion (figure 2). Atrophic LP is erythematous and may 42 Vol. 1, No. 3 May 2009

Soto et al Figure 3: Atrophic (erythematous) lichen planus lesion of Figure 5: Combined ulcerative, atrophic and plaque-like right cheek mucosa. forms of OLP on dorsum of tongue. Figure 4: Ulcerative OLP lesion on right corner of mouth. cal corticosteroids such as triamcinolone, potent fluorinated steroids such as fluocinonide, and ized injectable steroids, and systemic steroids. superpotent halogenated steroids such as clo- Topicals range in potency and are available as betasol, betamethasone, or halobetasol.11-13 Other ointments, creams, gels, sprays, rinses, or other topical therapies that have been recommended forms.11-13 For example, there are midpotency topi- include, cyclosporine, Dapsone, griseofulvin, tac- rolimus, pimecrolimus, immunosupressants, immu- nomodulatory agents, or retinoids.11 It is probable that topical corticosteroids are most often pre- scribed to treat OLP. The drugs are relatively safe, although an observed side affect of topical steroid use has been development of secondary oral candidiasis.14,15 Therefore it is sometimes recommended that clinicians also prescribe an anti-fungal medicament when treating with topi- cal corticosteroids.15 Systemic corticosteroids such as Prednisone® are frequently prescribed when topical steroids have failed.11 Since sys- temic corticosteroids can have adverse side effects, they are usually prescribed at low doses and for short periods of time. Localized inject- The Journal of Implant & Advanced Clinical Dentistry 43

Soto et al Record # Location Other Oral Concomitant Treatment Results Type of OLP Diseases LP Lesions able steroids such as triamcinolone acetonide number of studies and case reports have indicated may be effective in managing localized erosive that individuals with OLP may be at slightly higher lesions.16 They too are administered in small risk of developing squamous cell carcinoma.18 dosages and for short periods of time so they will not cause an unwanted systemic response. The aim of the present study was to review therapeutic methods and treatment out- OLP can be associated with extra-oral con- comes achieved in a group of 100 individu- comitant lesions up to 15% of the time.17 Mucosal als with biopsy proven OLP patients who were lesions are found throughout the oral cavity and followed for up to 4 years after diagnosis. almost always have a bilateral symmetrical dis- tribution. Different forms of OLP may co-exist.9 METHODS When OLP is not displayed in its clinical reticular form, a histological confirmation may be needed Retrospective data were collected from patient to establish diagnosis and direct immunofluores- records of 100 individuals with OLP who were cence studies may provide additional diagnostic diagnosed and treated in the Stomatology Cen- information.7 A biopsy is also useful to identify ter, Department of Periodontics, Baylor College dysplasia or malignancies that may have lichenoid of Dentistry TAMHSC, Dallas, Texas. Involved features.8,9,11 Although the issue is controversial, a patients had previously granted permission to use data relative to their clinical visits and treatment 44 Vol. 1, No. 3 May 2009

Soto et al and no individuals were identified by name. Eli- RESULTS gibility was limited to those patients that did not display other types of chronic autoimmune dis- Chart 1: Includes the compiled data and types ease of the lining of the mouth. The 100 records of treatments used and their frequency of use. were consecutively selected from individuals who Therapies included topical, systemic, intra lesional had received diagnosis and treatment between corticosteroid injection, laser treatment, retinoids, Jan 1, 2004 and July 29, 2008. All patients had and other treatment options such as diet modifica- histopathologically confirmed OLP based on tion .i.e. cinnamon free or sodium benzoate free established histologic diagnostic criteria. The diets and changes in physician prescribed medi- oral examinations were performed by Periodon- cation with medical approval. The chart also dis- tics residents/faculty and recorded in a specially plays the number of times palliative treatments designed record used in the Stomatology Cen- were used (including changes in toothpaste and/ ter. After collection, the data was recorded in a or mouthrinses) in conjunction with the therapies standardized table (table 1). Information gath- listed above. The number of times other multiple ered from patient records included the follow- types of treatment were used simultaneously was ing: patient record number, location of the OLP also recorded. For example the simultaneous lesion(s), type of OLP found, other oral diseases use of a topical medication and an intra-lesional such as oral candidiasis, concomitant lesions of corticosteroid injection. Chart 2 shows the num- LP in other parts of the body, treatment(s) used, ber and types of topical agents that were used and results of the treatment. Therapeutic out- to treat OLP. These include Temovate®, Lidex®, comes were assessed by the following criteria: Diprolene®, Protopic®, Elidel®, Dexamethasone Elixir®, DesOwen® and their generic forms. Chart CR (complete resolution): Patient 3: Displays the type and number of times pallia- records showed no signs or symptoms tive treatment was used in conjunction with the of OLP lesions at follow up visits. main treatment for OLP. Chart 4: Shows the cli- PR (partial remission): Patient records nician determined treatment outcome. Graph showed a reduction in the symptoms 1 shows treatment used and drug used to treat and/or improvement in the lesions. the patient and reach a partial remission of OLP. NC (no change): Patient records showed no Graph 2 shows the number of cases determined improvement or worsening of the lesions. to have had complete resolution and the agents REC (recurrent): Patient records showed used to reach this outcome. In 35 patients no lesions that disappeared for a period of treatment results were available because the time but subsequently returned with same patient did not return for follow up. Attempts were intensity, higher intensity, or less inten- made to contact all 35 individuals to offer them the sity than the first lesions treated. opportunity to return for an oral evaluation, how- NI (no information available): Patient records ever not all were reached. Six patients agreed to did not show the results of treatment. return for evaluation, and ten of those contacted The information on the table was then declined the opportunity to return. These ten compiled into charts for comparison. patients reported their status over the telephone. The Journal of Implant & Advanced Clinical Dentistry 45

Soto et al 1% 1% 3%1% 2% 1% 5% 20% 30% 6% 39% 57% 28% 1% 2%2% Data representing the chart Data representing the chart 89 Temovate® (clobetasol propionate) 34 6 Lidex® (flucinonide) 64 Topical 4 Diprolene® Systemic Steroid (betamethasone dipropionate) 2 Intralesional Corticosteroid 2 Protopic Ointment® (tacrolimus) injection 65 Elidel cream® (pimecrolimus) 6 Laser treatment 13 Dexamethasone Elixir® 3 Simultaneous treatments used 45 DesOwen® (desonide) 1 Other (diet mod. & Rx change) 2 Palliative 2 Retinoids 3 Percent of times a particular topical medication was No Treatment prescribed in patients who received topical treatment. Data includes patients treated with more than one topical Percent of times the particular treatment was used in a medication. patient pool of 100. Nineteen patients were never reached. Graph 3 ment that was used for those particular patients. shows the telephonic patient reported treatment Twenty-five percent of patients developed outcome. Graphs 4-5 show more specifically the patient reported outcomes and the type of treat- oral candidiasis in association with topical therapy, and 3% of patients were treated pro- 46 Vol. 1, No. 3 May 2009

Soto et al 1% 4% 21% 54% 45% 11% 58% 6% Number of times palliative 30 Data representing the chart 52 treatment was prescribed 36 5 Partial remission Chlorhexidine 1 Complete remission 10 Biotene products Recurrent 19 Children’s toothpaste No information available No change seen 4 Palliative treatment was used 45 times. Data includes those Note: The numbers do not add to 100 because 10 who were treated with more than one. patients reported their treatment outcome over the telephone and was not determined by a clinician. phylactically with antifungals. Nystatin® was Treatment outcome in 100 patients. prescribed 75% of the time, Diflucan® 21% of the time, and Clotrimazole® 4% of the time. than one type of OLP was recorded as mixed (n=58) and not specified (n=4), Graph 6. Reticular OLP was the most commonly seen type (n=68). This was followed by the ulcer- DISCUSSION: ative form (n=39) and the erythematous/atro- phic form (n=39). The plaque like form (n=16) In this study 82 out of 100 patients were and the papular form (n=4) were less com- females with an average age of 54. 12% of mon and no patient presented with the bullous the patients reported concomitant LP lesions form. The number of patients that had more The Journal of Implant & Advanced Clinical Dentistry 47

Soto et al 50 31 Topical 9 Palliative 2 1 2 Laser Intralesional Systemic Diet/Rx modification These numbers are based on the 52 patients with clinician reported Partial Remission (PR). The numbers are based on all the treatments options. Some patients utilized more than one treatment method. Palliative treatment was never used alone to reach PR, it was always used in conjunction with another treatment method. 5 1 2 Topical Intralesional Palliative Five patients were reported by dental professionals to have complete resolution (CR) on follow-up examinations greater than 3 weeks from previous examination. The numbers are based on all treatment options. Some patients utilized more than one treatment method. Palliative treatment was never used alone to reach CR. on skin (n=26), genitalia (n=3), combination Additionally, prescription drug changes were also of skin and genitalia (n=3), and scalp (n=1). sometimes recommended and changed by the As defined in the exclusion criteria, none of patient’s physician. More than one treatment was the patients suffered from other chronic auto- used more than half the time, usually by combining immune diseases of the lining of the mouth. topical or systemic or intra-lesional injection with palliative or diet modifications. On three occa- The most common treatment used in this sions, patients did not receive any treatment as patient population was topical corticosteroid. It shown in Chart 1. These 3 patients did not return was frequently used in conjunction with a palliative after the initial appointment during which a biopsy treatment and, at times, with diet modification such was performed and diagnosis established. Chart as a cinnamon free or a sodium benzoate free diet. 48 Vol. 1, No. 3 May 2009