Journal of Implant and Advanced Clinical Dentistry October 2011

Volume 3, No. 6 October 2011 The Journal of Implant & Advanced Clinical DentistryStromalVascularFractionStem CellsImmediateMolar ImplantPlacement

OsteogenicsPick up Flash file from July/August issue page 2

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All-Natural, Bioactive ProductsDesigned to Stimulate the Healing Process DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1 Biopsy of Biopsy of • The signaling proteins (growth factors,DynaMatrix autogeneous glycoproteins, glycosaminoglycans) gingival graft communicate with the body to help treated site stimulate the natural healing process2 Accell is an all-natural concentration • Accell has nearly 5 times more BMPs of Bone Morphogenetic Proteins than DBM alone and each lot is validated (BMPs) and Growth Factors with for osteoinductive properties 3,4 Demineralized Bone Matrix (DBM) that directs and charges stem cells • Accell in delivered as an easy-to-handle to acclerate the body’s natural putty in a pre-filled syringe healing response. • Accell is the only allograft product that contains this powerful combination of DBM, BMPs and Growth Factors 1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543. 2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5. 3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract). 4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract). Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Burlington, MA 01803 USA Call: +1-781-328-3490 Call: 1-866-902-9272 / Fax: 1-866-903-9272 Fax: +1-781-328-3400 [email protected] www.keystonedental.com

The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 6 • October 2011 Table of Contents23 A Prospective Pilot Study on the Clinical Application of Stromal Vascular Fraction Stem Cells in the Treatment of Miller Class I and II Gingival Recession Defects Nicholas Toscano, Danny Holtzclaw, Steven Victor37 Immediate Molar Implant Placement: A Private Practice Clinical Investigation Alphonse Gargiulo, Thomas Manos, Mark Kolozenski, James Morrone, Alex Tzanos49 A Comparative Retrospective Follow Up of Patients Treated with Implants Either with a Blasted or Super Hydrophilic Surface with or without an Adjunctive GBR Procedure Thomas Zumstein, Nyree Divitini, Neil Meredith The Journal of Implant & Advanced Clinical Dentistry • 5

Treat small cspoancfiedsenwcithe Laser-Lok 3.0 placed in Radiograph shows proper esthetic zone. implant spacing in limited site. Image courtesy of Cary Shapoff, DDS Image courtesy of Michael Reddy, DDSIntroducing the Laser-Lok® 3.0 implantLaser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal boneon the implant collar1. Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array ofprosthetic options making it the perfect choice for high profile cases. • Two-piece 3mm design offers restorative flexibility in narrow spaces • Implant design is more than 20% stronger than competitor implant2 • 3mm threadform shown to be effective when immediately loaded3 • Laser-Lok microchannels create a physical connective tissue attachment (unlike Sharpey fibers) 4 For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010.2. Implant strength & fatigue testing done in accordance with ISO standard 14801.3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC.Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288.4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim.International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP10109 REV D SEP 2010

The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 6 • October 2011 Table of Contents61 H istological and Computed Tomography Analysis of Amnion Chorion Membrane in Guided Bone Regeneration in Socket Augmentation Steve Wallace, Charles Cobb75 S oft Tissue Esthetics in Implant Dentistry Strategies for Sucess: A Case Presentation Lanka Mahesh, Gregori Kurtzman87 I’m a doctor…why do I need a PR and Social Media Campaign? Rachel FIne, Andrea Smacicia The Journal of Implant & Advanced Clinical Dentistry • 7

Less pain for your patients.1 Less chair side time for you.1 IntroducIng Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits: For your patients...  Patients treated with Mucograft® require 5x less Ibuprofen than those treated with a connective tissue graft1  Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2 For you...  Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1  Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery Ask about our limited time, introductory special! Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. GeistlichSöhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 6 • October 2011Publisher Copyright © 2011 by SpecOps Media, LLC. All rightsSpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company SpecOps Media, LLC (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 9

DID YOU KNOW? Roxolid implants deliver more treatment options Roxolid is optimal for treatment of narrow interdental spaces. Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA

The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Robert Horowitz, DDS Giulio Rasperini, DDSFaizan Alawi, DDS Michael Huber, DDS Michele Ravenel, DMD, MSMichael Apa, DDS Richard Hughes, DDS Terry Rees, DDSAlan M. Atlas, DMD Mian Iqbal, DMD, MS Laurence Rifkin, DDSCharles Babbush, DMD, MS Tassos Irinakis, DDS, MSc Georgios E. Romanos, DDS, PhDThomas Balshi, DDS James Jacobs, DMD Paul Rosen, DMD, MSBarry Bartee, DDS, MD Ziad N. Jalbout, DDS Joel Rosenlicht, DMDLorin Berland, DDS John Johnson, DDS, MS Larry Rosenthal, DDSPeter Bertrand, DDS Sascha Jovanovic, DDS, MS Steven Roser, DMD, MDMichael Block, DMD John Kois, DMD, MSD Salvatore Ruggiero, DMD, MDChris Bonacci, DDS, MD Jack T Krauser, DMD Henry Salama, DMDHugo Bonilla, DDS, MS Gregori Kurtzman, DDS Maurice Salama, DMDGary F. Bouloux, MD, DDS Burton Langer, DMD Anthony Sclar, DMDRonald Brown, DDS, MS Aldo Leopardi, DDS, MS Frank Setzer, DDSBobby Butler, DDS Edward Lowe, DMD Maurizio Silvestri, DDS, MDDonald Callan, DDS Shannon Mackey Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Miles Madison, DDS Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Lanka Mahesh, BDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Michael Sonick, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Ahmad Soolari, DMDStepehn Chu, DMD, MSD Louis Mandel, DDS Neil L. Starr, DDSDavid Clark, DDS Michael Martin, DDS, PhD Eric Stoopler, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Scott Synnott, DMDSpyridon Condos, DDS Dale Miles, DDS, MS Haim Tal, DMD, PhDSally Cram, DDS Robert Miller, DDS Gregory Tarantola, DDSTomell DeBose, DDS John Minichetti, DMD Dennis Tarnow, DDSMassimo Del Fabbro, PhD Uwe Mohr, MDT Geza Terezhalmy, DDS, MADouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Tiziano Testori, MD, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Tischler, DDSNicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhDPaul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhDScott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhDDavid Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDSRonald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhDDavid Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSKenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDSIstvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDSMichael Herndon, DDS Michael Pikos, DDS Richard K. Yoon, DDS George Priest, DMD The Journal of Implant & Advanced Clinical Dentistry • 11



Editorial Commentary BarbieTM Doll DenistryThere has been a push in the media to represent people, especially women, in reality is that many of these authors and realistic terms. The recent Dove™ soap presenters are among the world’s top clinicians. They have immense amounts of experience andadvertising Campaign for Real Beauty, for often the gift of having hands of gold. Whenexample, showed women of all shapes and sizes the average provider is presented with thesein their television commercials. This shift in media results as being commonplace, it can havethinking, albeit minor to date, is in response the same detrimental effect that the modernto multiple reports noting that the media’s media’s portrayal of women is having.unrealistic portrayal of women has led to epidemic I can’t tell you how many times I have wantedpsychological issues for many females. In fact, to see some real world results from the averagecontemporary surveys have found that as little clinician presented at a meeting or portrayedas 2% of women currently consider themselves in an article. If not that, how about having some“beautiful.” Because the media has essentially of the top lecturers show some of their failures?told women that a Barbie™ doll figure is what they Everyone has cases that they want to hide in theshould have, eating disorders, low self-esteem, closet. The body is not like a car. When you fix it,and even suicide have ensued when women find it is not always going to turn out just the way youthat they cannot achieve this unattainable goal. planned. There is no shame in that, but modernOver the past twenty years, mass media’s dental literature’s portrayal of what is considereddepiction of women has gotten way out of hand. “the norm” does make people feel ashamed whenRecent reports indicate that modern female a case does not turn out perfectly. Our professionprofessional models currently weighs 23% less is doing exactly what the media is doing to womenthan the average woman and those models as and we need to put a stop to this.a whole weigh less than 95% of the general Every clinician has pearls of wisdom thatpopulation. When featured in magazines, they can share with one another. While somemost of these women are now photoshopped, providers produce results that others can neverairbrushed, and digitally altered to achieve the even hope to achieve, the average dentist doesever-so-perfect look. Add in the fact that these have the ability and the right to contributewomen have the world’s best hair stylists, make- to their profession. If these results are notup artists, and clothing designers and you make considered “perfect” in the eyes of some, theythe situation even worse. should take a moment to realistically look atWhen I was reading about this, it got me to the results of their cases. No one producesthinking about the way that dental literature and perfection every time...no one. ●the lecture circuit currently portrays dentistry…Perfection. When you see an article, everycase in the article is perfect. When you attenda lecture, every case presented is perfect. Ontop of that, the authors or presenters ofteninsinuate that these results are easily repeatable Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MSso long as you use a certain product. The Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 13

Letters to the Editors In response to Dr. Sammy Noumbissi’s article Author’s Response: Case of the Month: Restoration of Anterior Dear Dr. Kazemi, Ridge Deficiency with Block Allograft and After taking cognizance of your letter to the Dental Implants: A Visual Case Report in the July/August 2011 issue of JIACD, we editors of the Journal of Implant and Advanced received the following letter to the editor: Clinical Dentistry concerning the” case of the month” I submitted for publication and which From Dr. H. Ryan Kazemi of Bethesda, was published in the July/August issue, I am Maryland, USA: obliged to address your comments and claims on the matter. Hello, I read the article by Dr. Sammy Noumbissi First of all I would like to draw your attention in your July /August issue and I am most to the fact that from the outset of the Journal, disappointed for JIACD for publishing such the “case of the month” section of the Journal a report. There is no scientific rational, no is not one for referenced articles. This section references, and no techniques described was launched to provide a platform for clinical by the author. The Prosthetic rational and and photographic presentations of a case or treatment is very important in developing technique. implant sites and none of this was described. And the outcome is clearly poor. Had you been an attentive reader and After having researched the author, I found more thorough with your “research” you would that he is a general dentist who has taken a have grasped the fact that this feature of the year implant program. This is poor credentials Journal is about sharing a technique and/or the and I expect respected dental journals to ask outcome of a given clinical dental procedure. more questions about the authors and use Over a year ago I published a research article in better judgement before accepting them as this same publication and it was well referenced expert contributors. and certainly had a scientific rationale. If the purpose of this article was to fill up pages in your issue, you have succeeded. An astute reader would notice that this If it was to educate readers and help them journal deals with dental implantology and understand rational, techniques, and the advanced clinical dentistry. As such this journal implication to improve their patient care, then is not the sole province of oral surgeons and you have failed miserably. other specialists. The background of authors Best regards and educational levels are not necessarily the Dr. H. Ryan Kazemi basis for acceptance of articles or case of Oral & Maxillofacial Surgery month submissions. This Journal is unique in that it opens its columns to all practitioners,14 • Vol. 3, No. 6 • October 2011 general and specialists as long as their submissions and material is clinically relevant. Dr Kazemi you claim to have researched

my credentials and in referring to me you dare surgical and restorative end, I will also taketo say “This is poor credentials...” A simple this opportunity to congratulate Dr Dondregoogle search on your part would have yielded Simpson on the restorative work he providedbetter results. Your purported research (if any) for this patient. If you need further informationis erroneous at best. Your claims on both my to better understand this case, please ask andcredentials and the results achieved in this case I will gladly answer legitimate concerns andare full of false assertions and are slanderous in questions.nature. Sammy Noumbissi DDS MS Under such circumstances I have no choice Practice Limited to Oral Implantologybut to enlighten you here on my credentials. Silver Spring MarylandI attended and graduated from Loma LindaUniversity’s full-time three-year Graduate The Journal of Implant and Advanced ClinicalResidency Program in Implant Dentistry Dentistry (JIACD), its parent company Spec Opswith a Certificate in Implant Dentistry and a Media, LLC, and its employees do not support,Master’s Degree in Implant Surgery. Some endorse, nor offer any opinion on letters to theof the professors I trained under are/were editor. All letters written to the editors, in anythe pioneers of implant surgery and implant communication format, are left unedited and are theprosthodontics. Furthermore I am a published exact original content provided by the author of theauthor; my work is frequently quoted and listed letter. JIACD, its parent company, and employeesas a reference by well respected, established take no responsibility for the content of these letters.researchers and authors in the scientific dental All contents of letters to the editors are the opinionsimplantology community. of their authors and do not reflect the position of JIACD, its parent company, or its employees. By virtue of my training, I am fortunate tobelong to a very restricted group of practitionerswho are formally trained Dental Implantologists.I want to be clear however that this does notgive me the right to criticize, belittle or slanderother implantologists who have not followed thesame path. In closing Dr Kazemi, I will not tolerate anyfurther verbal or written misrepresentationsof my person or credentials by you. We bothpractice in geographically contiguous areasof Maryland and I am not surprised by suchcomments on your part. I stand by the case Ipublished, it was well executed both on the The Journal of Implant & Advanced Clinical Dentistry • 15

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Now BIOMET 3i Has An App For That!Continuing its quest to be the dental industry leader in new media innova- dental implant therapies and is designed for cli- tions, BIOMET 3i invites dental pro- nicians to utilize during patient consultations.fessionals worldwide to download the freeBIOMET 3i App for the iPad and iPhone, The BIOMET 3i Solutions App is freeAndroid and Blackberry smartphones. The and available to download and install directlyBIOMET 3i Solutions App was developed to from the BIOMET 3i Website at http://apps.add a level of convenience to the clinician’s biomet3i.com for the iPad and mobile ver-user experience and enhance the accessibil- sions are also available for most iPhone,ity of rich media educational resources for the Android and Blackberry smartphones.patient. The BIOMET 3i Solutions App con- The BIOMET 3i Solutions App will alsosists of two portals, one for the clinician and soon be released in Apple’s App Store.one for the patient. The Clinician Portal pro-vides immediate access to BIOMET 3i Product About BIOMET 3i BIOMET 3i, a division ofand Service Solutions for clinicians. Conve- Biomet, Inc., is a leading manufacturer of dentalnient libraries offer a wide variety of PDFs and implants, abutments and related products. Sincelinks to BIOMET 3i Social Media Sites, as well its inception in 1987, BIOMET 3i has been onas, up-to-date BIOMET 3i Educational Oppor- the forefront in developing, manufacturing andtunities, access to the Journal of Implant and distributing oral reconstructive products, includ-Reconstructive Dentistry and convenient online ing dental implant components and bone andordering. The Patient Portal is an interactive tissue regenerative materials. The company alsoversion of the BIOMET 3i Patient Education provides educational programs and seminars forBrochure with easy to understand animated dental professionals around the world. BIOMETinformation tailored to the patient. This infor- 3i is based in Palm Beach Gardens, Florida, withmation covers everything from the overall oral operations throughout North America, Latin Amer-environment and treatment options to various ica, Europe and Asia-Pacific. For more informa- tion about BIOMET 3i, please visit www.biomet3i. com or contact the company at (800) 342- 5454; outside the U.S. dial (561) 776-6700. ●18 • Vol. 3, No. 6 • October 2011

BIOMET 3i Introduces A New Parallel Walled ImplantDesigned To Assist In Achieving Better Primary StabilityToday, due to patient treatment expectations, Comments from clinicians who have used there are increasing demands on dental OSSEOTITE® 2 Parallel Walled Implants: implant designs and performance. BIOMET3i has answered these demands with the introduc- “In my opinion, the OSSEOTITE® 2tion of a new implant designed to help achieve pri- Certain® Implant can be a great help inmary stability and improved clinical success rates, achieving better primary stability in softthe new OSSEOTITE® 2 Parallel Walled Implant. bone.” — Dr. Michael Christgau,** Germany The new OSSEOTITE® 2 Parallel Walled “I found the implant provided higher pri-Implant is based on macrogeometric design mary stability, particularly in immediate place-enhancements of the legacy OSSEOTITE® ment scenarios!” — Dr. Tiziano Tealdo,** ItalyImplant and is designed for more Immediate Bone-to-Implant Contact (IBIC) for achieving better “The Implant provides a nice stable feeling. Iprimary stability. The new design has a longer par- believe it’s the best straight wall implant I haveallel walled section for more direct implant body ever placed.” — Dr. Pär-Olov Östman,** Sweden ●contact with the osteotomy walls. The shorter api-cal taper and cutting flutes provide more apicalstability, while the long and narrow thread profilefor the 5.0mm and 6.0mm implants generates ananchoring “bite-in-bone” engagement. This helpsto reduce the risk of excessive micromovementearly in the healing process. In addition, a clinicalevaluation indicates at least 98% success rates.* OSSEOTITE® 2 Parallel Walled Implants areavailable in 3.25, 4.0, 5.0 and 6.0mm configura-tions and are manufactured from biocompatiblecommercially pure titanium. To facilitate a transi-tion to the new design, existing OSSEOTITE®Parallel Walled Prosthetic Components, DrillingInstrumentation and Guidelines remain compatiblewith OSSEOTITE® 2 Implants with one excep-tion; tapping with new Dense Bone Taps for 5.0and 6.0mm OSSEOTITE® 2 Implants is required.*Data on file**These clinicians have a financial relationship with BIOMET 3i LLC resulting from speaking engagements, consultingengagements and other retained services. The Journal of Implant & Advanced Clinical Dentistry • 19

It’s Like a Magnetfor New BoneHEALOS® is an attractive choice for building new bone. © OraPharma, Inc. 2011 Rx only. Please refer to the package insert for further details. Distributed by: OraPharma, Inc. Manufactured by: DePuy Spine, Inc.HEALOS® Bone Graft Substitute for Dental Applications is intended to HEALOS® is a registered trademark of DePuy Spine, Inc.fill, augment, or reconstruct periodontal and/or bony defects in the HEA-178-10 3/11upper or lower jaw.• Excellent clinical handling properties• Provides an osteoconductive scaffold that supports cell adhesion• Biomimetic composition (70% collagen, 30% mineral) mimics immature bone to encourage new bone growth• 98% porosity allows material to soak up endogenous blood and draw in osteoprogenitor cells comprehensively within the material• Radiolucent so new bone is easily distinguished on a radiographHEALOS® is intended to fill, augment, or reconstruct periodontal and/or bonydefects of the upper or lower jaw. HEALOS® is a bone graft substitute that isresorbed and remodeled into new bone as part of the natural healing process.Order HEALOS® Bone Graft Substitute Today!Call a HEALOS® representative: 1-866-273-7846or visit us at www.healosfordental.com



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A Prospective Pilot Study on the Clinical ApplicatTiooscnano et al of Stromal Vascular Fraction Stem Cells in the Treatment of Miller Class I and II Gingival Recession DefectsNicholas Toscano DDS, MS1 • Danny Holtzclaw DDS, MS2 • Steven Victor MD3 AbstractRegenerative medicine is a rapidly expand- tion of dental tissues including bone and gingiva. ing set of innovative technologies that One such technique which has recently been restore function by enabling the body to used for such purposes is the use of adult mul-repair, replace, and regenerate damaged, aging or tipotent cells obtained from adipose tissue. Thediseased cells, tissues and organs. In the prac- aim of this prospective pilot study case series istice of surgical dentistry, a number of products to report use of the IntelliCell™ adipose process-and techniques have been introduced and used ing technique to obtain adult multipotent cellsover the past 20 years to stimulate regenera- for use in the treatment of gingival recession.KEY WORDS: Adipose multipotent cells, IntelliCell,™ gingival recession, gingival grafting 1. Private Practice limited to Periodontics and Dental Implants, Manhattan, New York, USA 2. Private Practice limited to Periodontics and Dental Implants, Austin, Texas, USA 3. Private Practice Dermatology, Manhattan, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 23

Toscano et al INTRODUCTION ity of existing blood vessels and faster healing. The IntelliCell™ technology process yieldsRegenerative medicine is a rapidly expand-ing set of innovative medical technologies SVF which is a functionally diverse cell popula-that restore function by enabling the body tion of cells that it is believed to be synergis-to repair, replace, and regenerate damaged, tic and able to communicate with other cellsaging or diseased cells, tissues and organs. in their local environment. The mechanism ofIn the practice of surgical dentistry, a num- action of the SVF is more than regenerative.ber of products and techniques have been The mixtures of cells in SVF have multiple func-introduced and used over the past 20 years tions that are highly integrated and may beto stimulate regeneration of dental tissues more potent then the adipose stem cells them-including bone and gingiva. One such tech- selves. The IntelliCell™ technology processnique which has recently been used for such yields autologous and homologous stromal vas-purposes is the use of adult multipotent cells cular fraction. Under FDA 361 published laws,obtained from adipose tissue. The aim of the cells produced must be autologous, mini-this prospective pilot study case series is to mally manipulated, used during the same pro-report use of the IntelliCell™ adipose process- cedure, and must be homologous. Once theing technique to obtain adult multipotent cells cells are returned to the doctor, and in this casefor use in the treatment of gingival recession. the periodontist, the cells can be used off label. In the case of the Intellicell™ technique, The SVF have the following regenerativeone can harvest 60 cc of adipose (fat) tissue cell function properties: Anti-inflammatory/from a patient’s stomach, hips or outer or inner Immunomodulation, Trophic Support Differen-thighs to produce a variety of growth factors for tiation, and Homing. The Anti-inflammatory/use in surgical dentistry. With this technique, Immunomodulation properties have been shownharvested adipose tissue is processed using to suppress mixed lymphocyte reactions andultrasonic cavitation to produce stromal vas- inhibit T cell proliferation induced by third cellcular fraction (SVF). The cellular composition type mitogenic factors. These cells have beenof the SVF ranges from adult stem cells (Mes- shown to be able to control lethal graft versusenchymal Stem Cells), pre-adipocytes, endo- host disease (GVHD) in mice after haploidenti-thelial cells, smooth muscle cells, pericytes, cal hematopoietic transplantation. The Trophicfibroblasts and growth factors. Typically, the Support of these cells have been demonstratedSVF also contains blood cells from the capil- to secrete a number of angiogenesis-relatedlaries supplying the fat cells. These include cytokines such as: Vascular endothelial growtherythrocytes, B and T cells, macrophages, factor (VEGF), Hepatocyte growth factormonocytes, mast cells, natural killer (NK) cells, (HGF), Basic fibroblast growth factor (bFGF),hematopoietic stem cells and endothelial pro- Granulocyte-macrophage colony stimulatinggenitor cells, to name a few. Hematopoietic factor (GM-CSF), and Transforming growthstem cells and endothelial progenitor cells factor – β (TGF-β). The differentiation qualityplay important roles in supporting the viabil- of these cells is due to the fact that they con-24 • Vol. 3, No. 6 • October 2011

Toscano et altain stems cells which studies demonstrate a ing cells detectable on the mouse femur.diverse plasticity, including differentiation into Apoptosis is defined as a programmedadipo-, osteo-, chondro-, myo-, cardiomyo-,endothelial, hepato-, neuro-, epithelial and cell death or “cell suicide”, an event that ishematopoietic lineages. In vivo experiments genetically controlled.  Under normal condi-and functional studies have demonstrated the tions, apoptosis determines the lifespan andregenerative capacity of IntelliCells  to repair coordinated removal of cells.  Unlike necro-damaged or diseased tissue via transplant sis, apoptotic cells are typically intact dur-engraftment and differentiation. Awad and col- ing their removal (phagocytosis).  Rehmanleagues1 reported significant improvements et al6 demonstrated anti-apoptosis inusing autologous MSC delivery in a rabbit acutely injured tissue denied critical blood-Achilles tendon repair model compared to cell- flow resulting in ischemia. Intellicels signifi-free collagen control rabbits. Nixon et al.2 dem- cantly reduced endothelial cell apoptosis.onstrated statistically significant improvementin histological repair of a collagenase induced Gingival recession, with well-known nega-injury in the superficial digital flexor tendonitis in tive sequelae, including cervical caries, dentinalhorses treated with IntelliCells harvested from root sensitivity, difficulty in allowing adequatefat. Cowan and colleagues3 demonstrated that plaque control, and esthetic deficiencies,IntelliCells heal a critical-size mouse calvarial demands effective surgical intervention withdefect in which there was increased bone for- minimum intra-operative and post-operativemation and mineralization compared to con- complications. In recent years, a number oftrols. Jeong et al.4 demonstrated in a rodent systematic reviews have examined clinical out-cerebral infarct model, that infracted rats admin- comes of various surgical approaches to reces-istered magnetically labeled IntelliCells adminis- sion defects, including the coronally advancedtered two weeks after the creation of an infarct flap (CAF) alone, CAF in combination with theexperienced restoration of locomotor function subepithelial connective tissue graft (CTG),compared to controls. Homing is an important guided tissue regeneration (GTR), enamel matrixfunction of IntelliCells™ which is the mechanism derivative (EMD), and acellular dermal matri-by where a cell migrates from one area of the ces (ADM).6-11 Although current alternatives tobody to a distant site. Homing is an important CTG + CAF appear effective when examiningfunction of IntelliCells™ and other progenitor specific clinical parameters, only CTG + CAFcells and one mechanism by which intravenous appears consistently effective in relation to allor parenteral administration of IntelliCells™ per- clinical efficacy endpoints, especially long-termmit cells to effectively target a specific area of maintenance of root coverage.12-26 Althoughpathology. Nilsson et al.5 demonstrated that such evidence based data has led many cli-labeled cells of bone lineage injected intra- nicians to view the CTG as the gold standardvenously into mice can engraft, form bone, treatment in reducing or eliminating gingivaland give rise to osteocytes and bone lin- recession, disadvantages such as the need for a distant donor site, increased morbidity asso- ciated with graft harvest, and limited amounts The Journal of Implant & Advanced Clinical Dentistry • 25

Toscano et alFigure 1: A mini liposuction is completed to harvest fat for Figure 2: The fat is harvested and prepared for processing.stem cell processing. val recession defects around teeth. Designed toFigure 3: The fat is processed via IntelliCell Biosciences support tissue ingrowth and regeneration, CM’stechnique. enhanced bilayer thickness facilitates surgical manipulation, provides support for mucosal cel-of available donor tissue have continued to lular migration and regeneration, and supportsstimulate the search for comparably effective, clot stabilization and subsequent soft and hardalternative therapies to autologous grafts.27,28 tissue ingrowth.29-34 A number of recently pub- lished prospective clinical trials investigating Recently, a 510(K)- FDA cleared xenogenic CM’s efficacy in treating both keratinized muco-porcine bilayer collagen matrix (CM) (Muco- sal deficiencies and gingival recession defectsgraft®, Osteohealth Company, Shirley, NY) com- suggest that CM may provide a viable alterna-posed of pure type I and III collagen obtained tive to autogenous soft tissue grafts as wellby standardized, controlled manufacturing pro- as to other currently favored approaches.32-35cesses without further cross-linking or chemical With the advancements of stem cell regenera-treatment has been cleared for multiple regen- tive medicine the authors decided to use SVFerative indications, including treatment of gingi- containing adult adipose stem cells and com- bine it with xenogenic porcine bilayer colla- gen matrix as a replacement for the traditional mucous membrance roof graft. The following consecutive case series study was designed to further investigate the use of SVF contain- ing adult adipose stem cells when combined with potential xenogenic porcine bilayer colla- gen matrix in the treatment of root recession.26 • Vol. 3, No. 6 • October 2011

Toscano et al Figure 5: After centrifugation to separate fat from cells and form pellet.Figure 4: Ultrasonic cavitation of adipose fat to Figure 6: Removing cellular pellet after centrifuging.manufacture stromal vascular fraction IntelliCellBioSciences technique. ment smoked up to 5 cigarettes per day. Many of the patients presented with multiple contigu- Materials and Methods ous gingival recession defects, although single defects were also included. Of the 8 cases,Subject Population 5 were treated in the maxilla and 3 in the mandible.Eight healthy patients, 7 female and 1 male, rang- In all treated defects, a minimum of 1 mm of mar-ing from 23 to 45 years of age with Miller Class ginal keratinized gingiva was present at initiationI or II gingival recession defects of > 3 mm, with of treatment. All patients were treated in a singlea mean defect depth of 3.79 mm, were included private practice office in Manhattan, New York.in this prospective consecutive case seriesstudy. The majority of patients were non-smokers,although a number of patients at the time of treat- The Journal of Implant & Advanced Clinical Dentistry • 27

Toscano et alFigure 7: The specimen is placed in a flow cytometer to Figure 8: Please note the cellular pellet at the bottom.measure cells. Figure 10: The stem cells are loaded into a syringe.Figure 9: The stem cells are ready for delivery into the Clinical Evaluationsurgical site. At the initial visit, the defect sites were exam- ined clinically, photographic documentation per-28 • Vol. 3, No. 6 • October 2011 formed, and defect measurements recorded. Following the initial baseline screening and surgery, all patients were followed for a mini- mum of 6 months. Radiographs were taken at baseline and at week 24. The following base- line clinical parameters were recorded for each consecutively treated patient: gingival reces- sion depth; height of keratinized tissue from

Toscano et alFigure 11: The preoperative Miller 2 recession prepped for Figure 12: Elevation of full thickness flap.incisions.Figure 13: Mucograft is injected with the stem cells and Figure 14: More stem cells are injected into the surgicalsutured in place. area prior to flap closure.the free gingival margin to the mucogingival gery until they were capable of demonstratingmargin; buccal and proximal probing pocket adequate supra-gingival plaque control.depths; and degree of gingival inflamma-tion. At six months post-surgery, photographic On the day of surgery, the patient under-documentation was again obtained as were went liposuction by a licensed physicianthe clinical parameters measured at baseline. and the fat which was obtained and was pro- cessed by the IntelliCell™ process (Figs. 1-10).Surgical Procedure This process consisted of taking 60cc of thePrior to surgery, all subjects received oral lipoaspirate which was subjected to ultrasonichygiene instructions, received full-mouth pro- cavitation as per the propertiery IntelliCell™phylaxis, and were not appointed for sur- BioScience protocol. The resulting product was filtered, washed and centrifugated to cre- The Journal of Implant & Advanced Clinical Dentistry • 29

Toscano et alFigure 15: Three months postoperative view with up to Figure 16: Case #2 presrugical view of maxillary Miller 2100 percent root coverage. recession.Figure 17: Case #2 surgical site with stem cells and Figure 18: Case #2 three months after surgery.Mucograft in place. full-thickness mucoperiosteal flap was reflectedate a pellet of stromal vascular fraction (SVF). apically to the mucogingival junction, followedThe SVF was withdrawn using a 20 cc syringe. by an apical partial thickness dissection (figureA sample of the SVF was then tested using 12) to eliminate muscle tension and to facili-a Millipore Guava flow cytometer to test for tate coronal repositioning of the flap. The rootcell count, viability, dead cells and debri. The surfaces were then planed and recontoured bypatients averaged 12 Million lived cells per odontoplasty in order to assure root confine-milliliter. A total of 3cc of SVF cells were pro- ment within the surrounding alveolar housing.vided to the periodontist from the physician. In addition to hand instrumentation, rotary fin- ishing burs or ultrasonics with diamond-coated At surgery, local anesthesia was adminis- inserts were used to perform the odontoplasty.tered and a reversed bevel intrasulcular incisionwithout vertical releasing incisions was made. A30 • Vol. 3, No. 6 • October 2011

Toscano et alFigure 19: Case #2 three months after surgery (secondary swab to the treated areas. Following this periodview). patients were instructed in a brushing technique that avoided apical directed toothbrush traumaThe root surfaces were then decontaminated to the surgerized segments. At six months afterwith tetracycline paste to eliminate the bacte- surgery, patients were re-evaluated accord-rial smear layer. The buccal portions of the ing to the aforementioned protocol (figure 15).interdental papillae were then de-epithelializedto create a connective tissue bed for subse- Resultsquent suturing of the coronally advanced flap.Mucograft® collagen matrix was then properly Patient Centered Resultssized, positioned to cover the exposed roots During the six-month follow-up period no sig-(figure 13), allowed to saturate with the fibro- nificant treatment related adverse eventsblast stems cells (figure 14) provided via the occurred. Immediate post-operative swell-liposuction, and sutured to the interdental papil- ing, inflammation and discomfort were mini-lae. (Figure 4) The fully mobile flap was then mal. For all treated areas the color, texturecoronally advanced with minimal to no tension and tissue thickness at month six appearedto the level of the CEJ and sutured with 5.0 indistinguishable from the adjacent anatomicvicryl suture to the de-epithelialized surfaces areas. Figures 16 – 19 depict one of theof the interdental papillae. Care was taken to eight patients of this prospective pilot study.avoid compression of the collagen matrix graft.Post suturing the fibroblast stem cell matrix Objective Clinical Resultswas injected into and around the surgical area. The mean root coverage gain at the end of six months was 3.00 mm, with a mean per- Patients were instructed not to brush the cent root coverage gain of 86.83%. Theteeth in the treated area but to use chlorhexi- mean residual recession depth was 0.79 mm.dine (0.2%) mouth rinse twice daily the first two 66% of the 8 patients experienced 100%weeks. During the next two weeks patients were root coverage. At the end of the 6-monthinstructed to apply chlorhexidine with a cotton follow-up period, a mean gain of 0.70 mm of marginal keratinized tissue was realized. Discussion McGuire in 2008 showed tissue-engineered graft bilayered cell therapy (BCT) containing fibroblast stem cells was safe and capable of generating de novo Keratinized tissue (KT) with- out the morbidity and potential clinical difficul- ties associated with donor-site surgery.34 The amount of KT generated with free gingival graft was greater than generated with BCT; however, The Journal of Implant & Advanced Clinical Dentistry • 31

Toscano et al24 of 25 test sites demonstrated an increase gival recession defects, further randomizedin KT at 6 months, with more than three-quar- controlled clinical trials with increased patientters of the sites yielding > or =2 mm bands of enrolment and follow-up times are needed.KT. In an attempt to reduce surgical morbidity Additionally, studies examining what the poten-secondary to graft harvest as well as to avoid tial effects of adding SVF for the use of perio-inherent autogenous tissue supply limitations, dontal regenerative therapies will be instructivealternatives to the CTG continue to be desired in clearly defining the range of clinical indica-goals in the treatment of gingival recession tions for the use of SVF in dental practice.●defects. The current case series, when exam-ined along side other recently published stud- Correspondence:ies, provides additional insight into the utility Nicholas Toscano DDS MSand efficacy of Stromal Vascular fraction (SVF) 45 West 54th Streetcontaining adult adipose stem cells the porcine Suite 1Ederived collagen matrix, Mucograft®, as an alter- New York, NY 10019native to the CTG and acellular dermal matrices [email protected] the treatment of gingival recession defects. In a recent 6 month prospective, rand-omized, split-mouth designed clinical trialMcGuire et al.34 compared Mucograft® to pala-tal CT grafts in the treatment of Miller Class Iand II recession defects. On multiple param-eters, including recession depth, percent rootcoverage, width of keratinized tissue, color andtexture of treatment sites, and subject estheticsatisfaction, Mucograft® and SVF proved a via-ble alternative to the CTG. When patient cen-tered outcomes were considered, Mucograft®and SVF were particularly attractive in eliminat-ing the need for an invasive harvesting proce-dure. The results of the current study comparefavourably to this randomized prospectivestudy, with comparable gains in mean root cov-erage gain and percent root coverage. It wasalso noted that these patients often reportedlittle to no pain or swelling post surgically. Although the current case series sug-gests Mucograft® with SVF may be a viableand advantageous alternative to treating gin-32 • Vol. 3, No. 6 • October 2011

Toscano et alDisclosure 12. H arris RJ. Root Coverage With Connective 23. Santos A, Goumenos G, Pascual A.Dr. Toscano has received financial compensation Tissue Grafts: An Evaluation of Short- and Long- Management of Gingival Recession by thefrom IntelliCell BioSciences, Inc. and serves as a Term Results. J Periodontol 2002;73:1054- Use of An Acellular Dermal Graft Material: Aconsultant to the company. Dr. Victor is President 1059.da Silva RC, Joly JC, de Lima AF, 12-Case Series. J Periodontol 2005;76:1982-and Chairmain of IntelliCell BioSciences, Inc. Tatakis DN. Root coverage using the coronally 1990. positioned flap with or without a subepithelialAcknowledgements connective tissue graft. J Periodontol 24. Mahajan A, Dixit J, Verma UP. A Patient-Stromal vascular cells manufactured by IntelliCell 2004;75:413-419. Centered Clinical Evaluation of AcellularBioSciences, Inc. at its New York tissue processing Dermal Matrix Graft in the Treatment ofcenter. Adipose harvesting courtesy of Dr. Steven 13. R ossberg M, Eickholz P, Raetake P, Ratka- Gingival Recession Defects. J PeriodontolVictor. Kruger P. Long-Term Results of Root Coverage 2007;78:2348-2355. with Connective Tissue in the EnvelopeReferences Technique: A Report of 20 Cases. Int J 25. Barker TS, Cueva MA, Hidalgo FR, Beach M,1. A wad HA, Butler DL, et al. Autologous PeriodonticsRestorative Dent 2008;28:19-27. Rossmann JA, Kerns DG, Crump TB, Schulman JD. A Comparative Study of Root Coverage mesenchymal stem cell-mediated repair of tendon. 14. Z ucchelli G, Clauser C, De Sanctis M, Using Two Different Acellular Dermal Matrix Tissue Eng 1999 Jun:5(3):267-77. Calandriello M. Mucogingival versus guided Products. J Periodontol 2010 online publication tissue regeneration procedures in the treatment prior to print.2. N ixon A, Dahlgren L. Adipose-Derived Pluripotent of deep recession type defects. J Periodontol Stem Cells for Tendon Repair. Submitted to 1998;69:138-145. 26. Griffin TJ, Cheung WS, Zavras AI, Damoulis Equine Vet J, 2006. PD. Postoperative complications following 15. M cGuire MK, Nunn M. Evaluation of human gingival augmentation procedures. J Periodontol3. C owan CM, Shi YY, Aalami OO, et al. Adipose- recession defects treated with coronally 2006;77:2070-2079. derived adult stromal cells heal critical-size advanced flaps and either enamel matrix mouse calvarial defects. Nat Biotechnol 2004 derivative or connective tissue. Part 1: 27. W essel JR, Tatakis DM. Patient outcomes May;22(5):560-7 Comparison of clinical parameters. J Periodontol following subepithelial connective tissue graft 2003;74:1110-1125. and free gingival graft procedures. J Periodontol4. J eong JH, Ki YW, Kim JY, Jan SH, Kim SH, Chang 2008;79:425-430. Y. Adipose Tissue Derived MSC Enhances Motor 16. A ichelmann-Reidy ME, Yukna RA, Evans Function in Rats with Cerebral InfARCtion. IFATS GH, Nasr HF, Mayer ET. Clinical evaluation 28. Herford AS, Boyne PJ. Evaluation of a Special 2005. Oral Presentation. of acellular allograft dermis for the treatment Collagen Implant Material as a Substitute for of human gingival recession. J Periodontol Free Mucosal or Skin Grafts in Oral Soft Tissue5. N ilsson, S.K. et al.1999. Cells capable of bone 2001;72:998-1005. Surgery. Unpublished report. production engraft from whole bone marrow transplants in nonablated mice. J. Exp. Med. 17. N ovaes AB, Grisi DC, Moina GO, Sergio LS, 29. FDA Premarket Notification, Review of 189:729-734. Taba M, Grisi F.M. Comparative 6-Month Clinical Mucograft and Acceptance of 510(K) Mucograft Study of a Subepithelial Connective Tissue Submission. May 23, 2008.6. R ehman J, Traktuev D, Li J, Merfeld-Clauss Graft and Acellular Dermal Matrix Graft for the S, Temm-Grove CJ, Bovenkerk JE, Pell CL, Treatment of Gingival Recession. J Periodontol 30. Mucograft FDA approved Package Insert. Johnstone BH, Considine RV, MARCh KL. 2001;72:1477-1484. Secretion of angiogenic and antiapoptotic factors 31. Herford AS, Akin L, Cicciu M, Maiorana C, by human adipose stromal cells. Circulation. 2004 18. P aolantonio M, Dolci M, Esposito P, D’Archivio Boyne PJ. Use of a Porcine Collagen Matrix as Mar 16;109(10):1292-8.  D, Lisanti L, De Luccio A, Perinetti G. an Alternative to Autogenous Tissue for Grafting Subpedicle Acellular Dermal Matrix Graft Oral Soft Tissue Defects. J Oral Maxillofac Surg7. R occuzzo M, Bunino M, Needleman I, Sanz and Autogenous Connective Tissue Graft 2010; 68:1463-1470. M. Periodontal plastic surgery for treatment of in the Treatment of Gingival Recessions: A localized gingival recessions: a systematic review. Comparative 1-Year Clinical Study. J Periodontol 32. Sanz M, Lorenzo JJ, Martin C, Orsini M. Clinical J Clin Periodontol 2002;29(Suppl. 3):178-194. 2002;73:1299-1307. evaluation of a new collagen matrix (Mucograft® prototype) to enhance the width of keratinized8. O ates T, Robinson M, Gunsolley JC. Surgical 19. T al H, Moses O, Zohar R, Meir H, Nemcovsky tissue in patients with fixed prosthetic Therapies for the Treatment of Gingival C. Root Coverage of Advanced Gingival restorations: a randomized clinical trial. J Clin Recession. A Systematic Review. Ann Periodontol Recession: A Comparative Study Between Periodontol 2009;36:868-876. 2003;8:303-320. Acellular Dermal Matrix Allograft and Subepithelial Connective Tissue Grafts. J 33. McGuire MK, Scheyer ET. Xenogeneic Collagen9. A cademy Report. Oral reconstructive and Periodontol 2002;73:1405-1411. Matrix With Coronally Advanced Flap Compared corrective considerations in periodontal therapy. J to Connective Tissue With Coronally Advanced Periodontol 2005;76:1588-1600 20. W oodyard JG, Greenwall H, Hill M, Drisko Flap for the Treatment of Dehiscence-Type C, Lasella JM, Scheetz J. The Clinical Effect Recesssion Defects. J Periodontol 2010;10. Cairo F, Pagliaro U, Nieri M. Treatment of of Acellular Dermal Matrix on Gingival 81:1108-1117. gingival recession with coronally advanced Thickness and Root Coverage Compared to flap procedures: a systematic review. J Clin Coronally Positioned Flap Alone. J Periodontol 34. McGuire MK, Scheyer ET, Nunn ME, Lavin PT.A Periodontol 2008;35:136-162. 2004;75:44-56. pilot study to evaluate a tissue- engineered bilayered cell therapy as an alternative to11. Chambrone L, Sukekava F, Araújo MG, 21. H arris RJ. A Short-Term and Long-Term tissue from the palate. J Periodontol. 2008 Pustiglioni FE, Chambrone LA, Lima LA. Root Comparison of Root Coverage With an Acellular Oct;79(10):1847-56. coverage procedures for the treatment of Dermal Matrix and a Subepithelial Graft. J localized recession-type defects. Cochrane Periodontol 2004;75:734-743. Database Syst Rev 2009;(Issue 2):CD007161 10.1002/14651858.CD007161.pub2. 22. G apski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: a meta-analysis. J Periodontol 2005;76(11)1814-1822. The Journal of Implant & Advanced Clinical Dentistry • 33

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Immediate Molar Implant Placement: Gargiulo et al A Private Practice Clinical Investigation Alphonse Gargiulo, DDS, MS1 • Thomas Manos, DDS, MS2 •Mark Kolozenski, DDS, MS3 • James Morrone, DDS3 • Alex Tzanos, DDS, MSD4 AbstractThe success rate of immediately placed male began and completed the study. Age of solid screw type implants into fresh patients ranged from 19 to 75 years, with a molar sockets was described in the mean age of 50.5 years. Ninety-seven solidpresent private practice clinical investiga- screw type implants were placed with 100%tion. Ninety-five patients, 42 female and 53 success rate over a 3 year range of treatment.KEY WORDS: Immediate dental implants, molars, extraction, bone graft, success rate 1. Former Director of Post Graduate Periodontics, Nova Southeastern University, Ft. Lauderdale, Florida. Private practice, Chicago, Illinois, USA.2. Former Clinical Assistant Professor, Loyola University of Chicago School of Dentistry, Maywood, Illinois. Private practice, Chicago, Illinois, USA. 3. Private practice, Chicago, Illinois, USA. 4. University of Illinois at Urbana-Champaign, Illinois, USA. The Journal of Implant & Advanced Clinical Dentistry • 37

Gargiulo et al Introduction study. Age of patients ranged from 19 to 75 years (mean age 50.5 years). Patients wereImmediate dental implant placement has not excluded due to chronic illnesses exceptbeen an acceptable procedure for at least in the case of uncontrolled diabetes. A dis-the past two decades.1-4 Commonly, immedi- tinction of smokers or nonsmokers was notate implants have been reserved for the single considered in this investigation. Patients onrooted anterior tooth and single or bi-rooted blood thinners were treated according to thepremolar tooth. Perhaps the most important most current guidelines7 in order not to placeaspect of any implant surgery in accordance the patient at any risk of bleeding. Acute orwith the successfulness5,6 of the procedure is chronic infections either periodontal or peri-implant stability and bone to implant contact apical were not excluded. Only when labial(BIC). Removal of molar teeth provides a chal- or lingual plates of bone were completelylenging and intriguing dilemma due to multiple resorbed due to the above types of infections,root morphology. In the case of extraction and these sites would be excluded from the study.immediate placement of dental implants pre-serving alveolar bone proper, particularly that of A total of 97 solid screw type implants werethe labial and lingual plates of bone is essen- inserted, either Straumann (Straumann USAtial in providing the optimal environment for LLC, 60 Minuteman Rd. Andover, Massachu-maximizing BIC and implant stability. Also, the setts, USA) or Blue Sky Bio (Blue Sky Bio, LLC,position of the final restoration must be con- 888 E. Belvidere Rd., Grayslake, Illinois, USA)sidered, in relation to intra and inter arch posi- brand. Each participant required a periapicaltion, occlusion, function and esthetics. Thus film, panoramic radiograph and computerizedminimal alveolar bone removal should be con- tomography scan as necessary. Panoramicsidered and attained to aid in the above factors radiographs were utilized to evaluate positionin order to provide an acceptable surgical site of maxillary sinus and mandibular canal. Atfor successful placement of the dental implant. the time of surgical extraction labial and lin-Finally, and perhaps most importantly when con- gual soft tissue flaps were avoided. Removal ofsidering immediate molar implant placement, a minimal amount of alveolar bone was alwaysremoval of the intra-alveolar septum or reduc- attempted to aid in maintaining maximum BIC.tion of this structure should be avoided to aid Thus, extraction was always done carefully within increasing BIC and allowing the attainment of the use of elevators to remove molar roots with-initial implant stability at the time of placement. out reducing intra-alveolar septum, interdental septum or labial or lingual boney plates. Care- Materials and Methods ful probing of the socket was utilized to evaluate socket integrity.8 Inflamed tissue was removedIn the present investigation, 95 patients were from the socket walls, but not intentionallytreated for at least a single molar tooth removal removed from periapical lesions, if present. Fol-and immediate implant placement of a single lowing complete removal of root structures andstage implant. More specifically, 42 female inflamed soft tissues, the socket was inspectedand 53 male patients began and completed the38 • Vol. 3, No. 6 • October 2011

Gargiulo et alFigure 1a: Pre-op radiograph. Figure 1b: Implant placement.Figure 1c: Final restoration. otic coverage for 5 days. Patients were advised to avoid chewing directly on the implant coverto find the most ideal position for implant place- screw with any hard food substance for a periodment, and occlusion with the opposing arch, of 2 weeks. Patients were seen on follow-up atwas also closely considered for implant position. 1, 4, 12, and 16 weeks post-implant placement.Following placement of the single stage implant As a general rule, implants underwent abut-and implant stability found to be favorable, the ment placement and final torquing of 35 Ncm,socket labial and lingual marginal tissue borders at 12 or 16 weeks post-implant placement.were sutured over the blood clot or, mineralizedbone was placed between the titanium implant Resultssurface and the interior walls of the socket. Ninety five total patients participated in the All patients were prescribed an analgesic, study with 42 female and 53 male patients.chlorhexidine 0.12% mouth rinse and antibi- Age of patients ranged from 19 to 75 years (mean age 50.5 years). Following a 3 year range of treatment in the present clinical inves- tigation, a survival rate of 100% was reported for all implants placed. Survival rate time range was 3–38 months post implant placement. Minimal post-operative discomfort and satisfac- tory wound healing was observed. Ceramic to metal full coverage restorations were placed at a minimum of 14 weeks post-implant place- ment by the restorative dentist. Five sam- ple cases are shown in figure series 1–5. The Journal of Implant & Advanced Clinical Dentistry • 39

Gargiulo et alFigure 2a: Pre-op radiograph. Figure 2b: Implant placement.Figure 2c: Final restoration. removal.10 Immediate placement benefits include, reduction in surgical procedures, pre- Discussion serving esthetics, conserving bone height and width and improving patient comfort, accep-In the present investigation immedi- tance and satisfaction.11-13 Furthermore, theate molar implant wound healing pro- healing capability of the fresh extraction sitegressed favorably. Implant survival rate, and implant surface characteristics provideranging from 3 to 38 months postimplant improved opportunity for osseointegration.14placement was 100%. None of the immediateimplants were immediately loaded in the In the case of immediate molar placementpresent investigation.9 The term immedi- into molar sites provide a larger challenge. Thisate implant placement refers to the place- challenge mainly involves site anatomy, occlu-ment of dental implants at the time of tooth sion and biomechanical issues. According to Atieh et al.15 the possibility of predictable out- comes with immediate molar sites is additionally compromised because of the larger extraction sockets, poor quality of bone particularly in the maxillary molar regions. In 2004, Ham- merle et al.4 suggests that implants should not be placed at the time of tooth extraction if the residual tooth socket morphology precludes attainment of primary stability. Further, the above authors advise against implant place- ment if the labial plate is completely resorbed, requiring augmentation and regeneration. In the40 • Vol. 3, No. 6 • October 2011

Gargiulo et alFigure 3a: Pre-op radiograph. Figure 3b: Implant placement.present investigation achieving primary stabil- Figure 3c: Final restoration.ity was paramount, regardless of presence ofinfection, suppuration or apical periodontitis, or of implants in chronically infected sites andinfection due to root fracture. Moreover, BIC found, that this is not contraindicated if appro-was attempted to be maximized through minimal priate procedures such as, antibiotic is pre-bone removal, thus aiding in implant stability. scribed, meticulous debridement and alveolar bone preparation prior to implant placement. In support of the above, a study involv- In support of the above study, Crespi et al.20ing immediate implant placement after tooth found in recent investigation of 30 patientsextraction with signs of chronic periapical infec- each receiving one immediate implant associ-tions, pain, periapical radiolucency, fistula and ated with a chronic periapical lesion did notsuppuration demonstrated significant bone demonstrate and increase rate of complica-regeneration with a high rate of success.16,17 tions, but showed favorable soft and hard tissueHypothetically, high success rates of imme-diate placed implants, whether in chronic oracute lesions may be explained by endodonticinfections, dominated by a variety of anaero-bic bacteria commonly found in the infectedtooth canals.18 Extraction of teeth associ-ated with periapical infections with propersocket degranulation leads to eradication ofmicroorganisms, which is beneficial in suc-cess rates of immediate implant placement insingle root or multiple root sockets.19 Novaeset al.14 studied immediate implant placement The Journal of Implant & Advanced Clinical Dentistry • 41

Gargiulo et alFigure 4a: Pre-op radiograph. Figure 4b: Implant placement.Figure 4c: Final restoration. results. The authors strongly support further studies to evaluate the clinical and histologi- cal results of immediate implant placement in molar sockets whether or not infection exists. Most definitely, stability and proper surgical placement of the dental implant is paramount. ●42 • Vol. 3, No. 6 • October 2011

Gargiulo et alFigure 5a: Pre-op clinical photo. Figure 5b: Extractions of teeth. Note bone preservation.Figure 5c: Immediate implant placement. Figure 5d: Three Weeks healing.Figure 5e: Pre-op radiograph. Figure 5f: Final restoration radiograph. The Journal of Implant & Advanced Clinical Dentistry • 43

Gargiulo et alAADDVVERETIRSETWISITHE Correspondence: Dr. Alphonse V. Gargiulo TODAY! 1960 Lincoln Park West Chicago, IL 60614 Reach more customers Tel: 773-327-3131 with the dental profession’s first Disclosure truly interactive The authors reported no conflicts of interest with this article. References paperless journal! 1. D eRouck T, Collys K, Cosyn J. Single tooth replacement in the anterior maxilla Using recolutionary online technology, by means of Immediate Implantation and provisionalization. A review. Int J Oral JIACD provides its readers with an Maxillofac Impl. 2008:25:897-904. 2. A cocella A, Bertolai R, Sacco R. Modified insertion Technique for immediate experience that is simply not available implant placement into fresh extraction socket in the first maxillary molar sites:with traditional hard copy paper journals. A 3-year prospective study. Impl Dent. 2010:19:220-224. 3. G runder U, Pollizi G, Goene R, et al.. A 3-year Prospective multicenter follow‐ WWW.JIACD.COM up report on immediate and delayed-immediate placement of implants. Int J Oral Maxillofac Impl. 1999: 14:210-216. 4. H ammerle C, Chen S, Wilson T. “Consensus Statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac. Impl. 2004: 19: 26-28. 5. B user D, von Arx T, Bruggenkate C. Basic principles with ITI implants. Clin Oral Impl Res. 2000:11:59-65. 6. B user D, Mericske-Stern R, Dula et al. Clinical experience with one-stage, non submerged titanium dental implants. Adv Dental Res. 1999:13:153-158. 7. G argiulo et al. 8. Magee G. Immediate single –tooth replacement, provisionalization. Impl Trib. 2010:5:1-7. 9. G aneles J, Rosenberg M, Holt R, Reichman L. Immediate loading of implants with fixed restorations in the completely edentulous mandible: Report of 27 patients from a private practice. Int J of Oral Maxillofac Impl. 2001:16:426- 430. 10. Lazzara, R. Immediate implant placement into Extraction sites: Surgical and restorative advantages. Int J Periodontics Restorative Dent. 1989:9:333-343 11.Crespi R, Cappare P, Gherlone, E. Fresh Socket implants in periapical infected sites in humans. 2010:81:378-383. 12. A nson, D. The changing treatment planning paradigm: Save the Tooth or Place and Implant. 2010. 30:506-5-17. 13. Lekholm U, Zarb G. Patient selection and preparation. In: Branemark, PI Zarb G, Albrektsson T. eds, Tissue integrated prostheses. Osseo-Integration in Clinical Dentistry. Chicago: Quintessence Publishing Co. 1995. 14. N ovaes A, Vidigal G, Novaes A, Grisi M, Polloni S, Rosa A. Immediate implants placed into infected Sites: A histomorphometric study. Int J Oral Maxillofac Impl. 1986:13:422-427. 15. Atieh M, Payne A, Duncan W, de Silva R, Cullinan M. Immediate placement or immediate restoration Loading of single implants for molar tooth Replacement: a Systematic Review. 2010:25:401-415. 16. S iegenthaler D, Jung R, Holderegger C, Ross M, Hammerle C. Replacement of teeth exhibiting Periapical pathology by immediate implants: A Prospective study, controlled clinical trial. Clin Oral Implant Res. 2007:18:727-737. 17. L indeboom J, Tjiook Y, Kroon F. Immediate placement of implants in periapical infected sites: A prospective randomized study in 50 patients. Oral Surg Oral Med Oral Path Oral Radiol Endod. 2006:101:705-710. 18. Peters L, Wesselink P, Winkelhoff, A. Combinations bacterial species in endodontic infections. Int Endod J. 2002:35:698-702. 19. S undqvist G. Associations between microbial species in dental root canal infections. Oral Microbiol Immunol. 1992:257-262. 20. C respi R, Cappare P, Gherlone E, Romanos G. Immediate versus delayed loading of dental Implants placed in fresh extraction sockets in the Aesthetic zone. 2008:23:753-758.44 • Vol. 3, No. 6 • October 2011

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