A Comparative Retrospective Follow Up of Zumstein et al Patients Treated with Implants Either with aBlasted or Super Hydrophilic Surface with or without an Adjunctive GBR ProcedureThomas Zumstein, DDS1 • Nyree Divitini2 • Neil Meredith, BDS, MSc, PhD3 AbstractBackground: The study aims to report Results: One ProActive implant failed (Cumu-the outcomes from a retrospective clini- lative Success Rate (CSR) 99.12%) duringcal study on a super hydrophilic implant and the follow up period compared to 8 implantscompare these results with those reported (CSR 95.6%) in the Bimodal reference groupon an implant with a blasted surface. after a comparative follow up period. A cumu- lative success rate of 100% for ProActiveMethods: The study group was comprised of implants compared with 98.2% for Bimodal50 consecutive patients treated with 155 Neoss implants was reported in cases without aProActive implants (Neoss Ltd, Harrogate UK) GBR procedure. In those cases where ain 57 treatment areas because of single tooth GBR procedure was performed in conjunc-loss or partial or total edentulism. Implants tion with implant surgery, ProActive implantswere placed in healed bone in 23 areas, while yielded a cumulative success rate of 98.46%in 34 areas a guided bone regeneration pro- compared with 94.4% for Bimodal implants.cedure was utilised in conjunction with implantplacement. The results were analysed in a life Conclusions: A clinically increased sur-table. A group of 50 patients previously treated vival rate was observed for implantswith 183 Neoss Bimodal implants (Neoss Ltd, having a super hydrophilic surface in com-Harrogate UK) in the same clinic under identi- parison to a control group of blasted sur-cal conditions served as the control group. face implants of the same design placed under the same clinical conditions.KEY WORDS: Dental implants, bone, remodeling, osseointegration, wettability, electrowetting 1. Private practice, Lucerne, Switzerland 2. Clinical Research Manager, Neoss Ltd, Harrogate, UK3. Director of Research, Neoss Ltd, Harrogate, UK and Professor of Prosthodontics, University of Queensland Dental School, Brisbane, Australia The Journal of Implant & Advanced Clinical Dentistry • 49
Zumstein et alFigure 1a: Technique of standard implant placement Figure 1b: Technique of standard implant placementprocedure without bone augmentation. procedure without bone augmentation. Introduction the hydrophilicity of a titanium implant surface.12-16 Super hydrophilicity may be considered to beThe use of osseointegrated endosseous dental a contact angle of less than 5 degrees.17 Suchimplants is now widely accepted as a proven and super hydrophilicity ensures the thorough wettingsuccessful treatment modality for the replacement of the implant surface by blood products and pro-of missing teeth.1,2 Such implants may be used teins at the moment the implant is placed, therebysingly or in partially or totally edentulous jaws.3 optimising the conditions for cellular adherenceSince their introduction some forty years ago, and attraction. The majority of implant surfacesboth the clinical techniques and implants them- that are currently available commercially may beselves have been continuously developed and considered to be hydrophobic having measuredrefined in order to optimise the success rate and contact angles greater than 50 degrees.17 Ansimplify and shorten clinical treatment procedures. exception to this is the Straumann SLActive sur-Surface modifications have played a major role in face which has a measured contact angle of 0this. A number of studies have demonstrated the degrees. Ensuring the optimal attachment ofbenefit of moderately increased roughness of a proteins and blood products to the titanium sur-titanium implant over that of a machined implant face is not solely related to mechanical topogra-surface.4-11 Modifications of surface topography phy. There is a complex relationship betweenmay enhance osseointegration in a number of the aspect ratio and the critical surface tensionways; by increasing mechanical surface area, by of an applied liquid to a roughened surface. Thisproviding the optimal topography for fibrous and aspect ratio is the relationship between the widthcellular attachments and by creating a bio-chem- of the peaks and the depths of the troughs on aically attractive surface to enhance and maximise roughened surface. Super hydrophilicity maybone formation. Recent studies on implant sur- be achieved in a number of ways. The Neossfaces have demonstrated the benefit of increasing50 • Vol. 3, No. 6 • October 2011
Zumstein et al Table 1: Distribution of ProActive implants in relation to position. Tooth # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total (Maxilla) 0 2 10 10 9 3 2 2 3 3 5 10 11 9 2 0 81 Tooth # 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Total (Mandible) 0 3 12 7 4 5 2 1 0 3 4 4 10 12 6 0 74ProActive implant is novel in using electrowet- (Neoss Ltd, Harrogate UK). Seven patientsting on a dielectric surface (EWOD), that makes were treated in both maxilla and mandible result-use of the combination of titanium, titanium oxide ing in 57 treatment areas (jaws). Intraoral andand an overlying ionic surface treatment. When panoramic radiographs as well as CT scanssuch a treated implant is placed in contact with were used for presurgical evaluations. Sevenblood or saline a very small electrical charge patients were totally edentulous (one partiallyoccurs on the surface of the implant which breaks edentulous in the other jaw), 24 patients weredown the surface tension of the applied liquid partially edentulous (3 in two areas and 1 withdrawing it into the implant surface porosities. a single tooth in the other jaw) and 19 were treated for single tooth loss (2 in both jaws). The Neoss Bimodal implant provides anopportunity to study the comparative benefits The patients were administered antibioticsof more traditional blasted implant surfaces or prior to surgery (Dalacin®C 300mg, Pfizer AG,the super hydrophilic surface produced with Zurich, Switzerland). Surgery was performedthe ProActive implant. The Bimodal and ProAc- under sterile conditions and local anaesthesiative implants have an identical geometry and are with Ultracain® DS Forte (Sanofi-Aventis, Geneva,manufactured from the same base titanium. The Switzerland). Crestal incisions were used andaim of this retrospective study was to report implant sites were prepared in accordance withon the experiences of Neoss ProActive sur- the guidelines given by the manufacturer for theface active implants for 50 consecutive patients appropriate implant diameter and length (Fig-treated in one private office and furthermore ure 1). Implants were inserted into position withto compare the relative performance of these a drill control unit. A total of 155 Neoss ProAc-implants to a Neoss Bimodal reference group. tive implants (Neoss Ltd, Harrogate UK) were placed; 81 in the maxilla and 74 in the mandible Materials and Methods (Table 1). Implant lengths and diameters are shown in Table 2 and 3. Bone quality and quan-Patients and Surgery tity, according to the Lekholm and Zarb index,18Fifty consecutive patients (21 males, 29 females, were registered and are shown in Tables 4 and 5.mean age 58 years) needing implant treat-ment were enrolled in the ProActive study. All In addition 34 of the treatment sites with 87fifty patients received Neoss ProActive implants implants underwent guided bone regeneration The Journal of Implant & Advanced Clinical Dentistry • 51
Zumstein et al Table 2: Placed and Failed ProActive Implants by Length Implant Placed Total Total Lost in Total Lost in Length Implants Lost GBR Patients Non-GBR Patients 7mm 5 0 0 0 9mm 49 1 1 0 11mm 56 0 0 0 13mm 44 0 0 0 15mm 1 0 0 0 17mm 0 0 0 0 Total 155 1 1 0 Table 3: Placed and Failed ProActive Implants by Diameter Implant Placed Total Total Lost in Total Lost in Diameter Implants Lost GBR Patients Non-GBR Patients 3.5mm 17 0 0 0 4.0mm 106 1 1 0 4.5mm 25 0 0 0 5.0mm 7 0 0 0 Total 155 1 1 0using BioOss™ and a resorbable BioGide™ mem- Healing abutments were connected afterbrane (Geistlich Pharma AG, Wolhusen, Switzer- a healing period of 3 to 6 months for 78land) simultaneously with implant placement19-21 implants. In 77 sites healing abutments were(Figure 2). This was due to insufficient bone width placed in conjunction with implant surgeryor remaining defects after extraction resulting in and in 28 of these a crown/bridge was fittedexposure of part of the implant after placement. within a few days for immediate/early function.52 • Vol. 3, No. 6 • October 2011
Zumstein et al Table 4: Placed and Failed ProActive Implants by Bone Quality Bone Placed Total Total Lost in Total Lost in Quality Implants Lost GBR Patients Non-GBR Patients 1 2 0 0 0 2 52 0 0 0 3 90 0 0 0 4 11 1 1 0 Total 155 1 1 0 Table 5: Placed and Failed ProActive Implants by Bone Quantity Bone Placed Total Total Lost in Total Lost in Quality Implants Lost GBR Patients Non-GBR Patients A 15 0 0 0 B 92 0 0 0 C 45 0 0 0 D 3 1 1 0 E 0 0 0 0 Total 155 1 1 0Prosthetics Follow Up The patients were scheduled for six monthly andFixture level impressions were taken for then annual check ups with clinical and radio- graphic examinations using intraoral or panoramicscrew-retained prosthodontics using radiographs. Marginal bone level measurements were performed by two examiners in all avail-NeoLink abutments (Neoss Ltd, Harro- able baseline and follow up intraoral radiographs using digitalised image software on a computer.gate UK). Gold-ceramic constructions The known diameter of the implant collar (4mmwere made in single and partial cases. Thecrowns and bridges were attached withgold screws using a preload of 32 Ncm. The Journal of Implant & Advanced Clinical Dentistry • 53
Zumstein et alFigure 2a: Immediate implant placement with guided Figure 2b: Bone graft placement for GBR.bone regeneration (GBR). gate, UK) were used as a control.1 Nine patientsFigure 2c: Barrier membrane application for GBR. had been treated for total edentulism (two in both jaws), 21 for partial edentulism (one in twofor 3.5/4mm implants and 4.5mm for 4.5mm areas) and 20 patients had been treated for sin-implants) was used as a reference for calibra- gle tooth loss and followed for at least 1 year.1tion of the measurements which were made fromthe top of the collar to the first bone contact and Resultsat the mesial and distal aspects of the implant. 48 ProActive patients have had their final crown/The mean value was calculated for each implant. bridge fitted, 35 patients have attended theReference Patient Group 6 month follow up visit and 13 patients haveA group of 50 patients (20 males, 30 females, attended the 12 month visit. No patients havemean age 57 years) treated by the same prac- been withdrawn from the study. One implanttitioner under identical conditions with 183 failure has been registered, giving a total CSRNeoss Bimodal implants (Neoss Ltd, Harro- of 99.12% (table 6). This failure occurred in the GBR group, no failures have been reported in the non-GBR group. The failure that occurred was a shorter length implant in soft bone (Type IV) (table 7). In spite of the fail- ure, all patients received and maintained a fixed crown or bridge during the follow up period. Discussion Comparative experiences between the Neoss Bimodal and ProActive implant systems from54 • Vol. 3, No. 6 • October 2011
Zumstein et alTable 6a: Lifetable Analysis for ProActive Implants (Total) Total - Proactive Surviving Implants Failed Implants CSR (%) 100% Implant placement – 151 0 Prosthesis delivery 99.12% 99.12% Prosthesis delivery – 6 months 113 1 6 months – 1 year 42 0 Table 6b: Lifetable Analysis for ProActive Implants (GBR group) GBR Group - Proactive Surviving Implants Failed Implants CSR (%) Implant placement – 85 0 100% Prosthesis delivery Prosthesis delivery – 6 months 65 1 98.46% 6 months – 1 year 33 0 98.46%Table 6c: Lifetable Analysis for ProActive Implants (Non-GBR group) Non-GBR Group - Proactive Surviving Implants Failed Implants CSR (%) Implant placement – 66 0 100% Prosthesis delivery Prosthesis delivery – 6 months 48 0 100% 6 months – 1 year 9 0 100%patients treated in one clinic are reported. Sur- relation with Zitzmann et al,19 a higher failurevival rate of 98.2% was achieved after 6 months rate was seen when implants were placed in ain routine cases with the Neoss Bimodal implant simultaneous guided bone regeneration proce-with no need for additional bone augmentation dure using bovine bone and a resorbable mem-procedures.1 This compared with a survival rate brane, as 7 out of 126 implants (CSR 94.4%)of 100% after 6 months with the Neoss ProAc- were lost for the Neoss Bimodal surface1tive implant under the same conditions. In cor- (table 8). This can be compared to 1 out of The Journal of Implant & Advanced Clinical Dentistry • 55
Zumstein et al Table 7: Details of Failed ProActive Implant Patient Position Length Diameter Bone GBR Time of Failure Number Quality & Prosthesis Quantity 6955 16 9 mm 4.0 mm 4 / D Yes 87 implants (CSR 98.46%) lost for the Neoss benefit when immediate loading and immediateProActive surface. This indicates that, for the replacement protocols are being considered.31same measured healing period, an active superhydrophilic surface may be of benefit in higher Conclusionsrisk cases and where augmentation is car-ried out. Marginal bone height measurements Within the limitations of the present ret-undertaken with the Neoss Bimodal implant rospective study, it is concluded that thefrom this same clinic have demonstrated 0.4mm Neoss Bimodal and ProActive implant sys-± 0.9mm bone loss after 5 years22 which tems results in good clinical outcomescompares well with that of other implant sys- in routine cases as evidenced by survivaltems.23-26 Two recent studies of Neoss implants rate. GBR procedures with short implantsreported a marginal bone loss of 0.6mm and soft bone seem to increase the risk ofafter 1 year of loading27 and 0.7mm after 18 implant failure. However, this may be ame-months of loading.28 Further investigations will liorated by the use of an advanced activebe carried out to assess marginal bone level surface such as that applied to createbone levels in a comparative manner for both super hydrophilicity and electrowetting. ●Bimodal and ProActive implants retrospectively.This is an especially interesting study as the only Correspondence:experimental variable is the different implant Dr. Thomas Zumsteinsurface. The clinical conditions, use of aug- zumstein dental clinic agmentation procedures, single operator variables Pfistergasse 3 CH-6003 Luzernand implant geometry remained constant. The Switzerlandalready high success rate of the Neoss Bimodal e-mail: [email protected] in both standard and augmented pro-cedures, as shown in this study and others,29,30may be further enhanced by the application ofthe ProActive surface, a super hydrophilic treat-ment. This also suggests that the applicationof such surface treatments may be of additional56 • Vol. 3, No. 6 • October 2011
Zumstein et al Table 8: Comparison of Cumulative SuccessRates for Neoss Bimodal1 and ProActive implants Total Cumulative Neoss Bimodal Neoss Proactive Success Rates Implants Implants Implant placement – 98.9% 100% Prosthesis delivery Prosthesis delivery – 1 year 95.6% 99.12% Total Cumulative Neoss Bimodal Neoss Proactive Success Rates - GBR Group Implants Implants 98.4% 100% Implant placement – Prosthesis delivery 94.4% 98.46% Prosthesis delivery – 1 year Total Cumulative Neoss Bimodal Neoss Proactive Success Rates - Non- GBR Group Implants Implants 100% 100% Implant placement – Prosthesis delivery 98.2% 100% Prosthesis delivery – 1 year The Journal of Implant & Advanced Clinical Dentistry • 57
Zumstein et alDisclosure 12. K lein MO, Bijelic A, Toyoshima T, Götz H, von 23. Piao CM, Lee JE, Koak JY et al. Marginal boneDr. Meredith and Nyree Divitini are employees of Koppenfels RL, Al-Nawas B, Duschner H. Long- loss around three different implant systems:Neoss LTD. term response of osteogenic cells on micron radiographic evaluation after 1 year. J Oral and submicron-scale-structured hydrophilic Rehabil 2009; 36:748–754.References titanium surfaces: sequence of cell proliferation1. Z umstein T, Billström C. A Retrospective Follow- and cell differentiation. Clin Oral Implants Res 24. Cooper LF, Ellner S, Moriarty J, et al. Three-year 2010; 21(6):642-9. evaluation of single-tooth implants restored 3 up of 50 consecutive patients treated with Neoss weeks after 1-stage surgery. Int J Oral Maxillofac Implants with or without an Adjunctive GBR- 13. V lacic-Zischke J, Hamlet SM, Friis T, Tonetti Implants 2009; 22:791–800. Procedure. Appl Osseointegration Res 2008; MS, Ivanovski S. The influence of surface 6:31-35. microroughness and hydrophilicity of titanium 25. Turkyilmaz I, Sennerby L, Tumer C, Yenigul on the up-regulation of TGFβ/BMP signalling in M, Avci M. Stability and marginal bone level2. E sposito M, Hirsch JM, Lekholm U, Thomsen osteoblasts. Biomaterials 2011; 32(3):665-71. measurements of unsplinted implants used for P. Biological factors contributing to failures mandibular overdentures: a 1-year randomized of osseointegrated oral implants. (I). Success 14. E lias CN, Oshida Y, Lima JH, Muller CA. prospective clinical study comparing early criteria and epidemiology. Eur J Oral Sci 1998; Relationship between surface properties and conventional loading protocols. Clin Oral 106:527–551. (roughness, wettability and morphology) of Implants Res 2006; 17:501–505. titanium and dental implant removal torque. J3. S ennerby L. Dental implants: matters of course Mech Behav Biomed Mater 2008; 1(3):234-42. 26. Turkyilmaz I. A 3-year prospective clinical and and controversies. Periodontol 2000 2008; radiologic analysis of early loaded maxillary 47:9–14. 15. W all I, Donos N, Carlqvist K, Jones F, Brett P. dental implants supporting single-tooth crowns. Modified titanium surfaces promote accelerated Int J Prosthodont 2006; 19:389–390.4. T abassum A, Walboomers F, Wolke JG, Meijer GJ, osteogenic differentiation of mesenchymal Jansen JA. The Influence of Surface Roughness stromal cells in vitro. Bone 2009; 45(1):17-26. 27. S ennerby L, Andersson P, Verrocchi D, Viinamäki on the Displacement of Osteogenic Bone R. One-Year Outcomes of Neoss Bimodal Particles during Placement of Titanium Screw- 16. S chwarz F, Wieland M, Schwartz Z, Zhao G, Implants. A Prospective Clinical, Radiographic, Type Implants. Clin Implant Dent Relat Res 2009; Rupp F, Geis-Gerstorfer J, Schedle A, Broggini and RFA Study. Clin Imp Dent Relat Res 2010; [Epub ahead of print] N, Bornstein MM, Buser D, Ferguson SJ, [Epub ahead of print]. Becker J, Boyan BD, Cochran DL. Potential5. S ennerby L, Gottlow J, Engman F, Meredith of chemically modified hydrophilic surface 28. Bogaerde LV, Pedretti G, Senerby L, Meredith N. Histological and Biomechanical Aspects characteristics to support tissue integration of N. Immediate/Early Function of Neoss Implants of Surface Topography and Geometry of titanium dental implants. J Biomed Mater Res B Placed in Maxillas and Posterior Mandibles: An Neoss Implants. A Study in Rabbits. Appl Appl Biomater 2009; 88(2):544-57. 18-Month Prospective Case Series Study. Clin Osseointegration Res 2008; 6:18-22 Imp Dent Relat Res 2010; 1(Suppl.1):83-94. 17. M eredith N. The significance of wettability and6. R amaglia L, Postiglione L, Di Spigna G, Capece hydrophilicity on the osseointegration of dental 29. Pagliani L, Sennerby L, Anderson P, Verrocchi G, Salzano S, Rossi G. Sandblasted-acid-etched implant surfaces. 2011; In press. D, Meredith N. Insertion torque measurements titanium surface influences in vitro the biological during placement of Neoss implants. Appl behavior of SaOS-2 human osteoblast-like cells. 18. L ekholm U, Zarb GA. ‘Patient selection Osseointegration Res 2008; 6:36–38. Dent Mater J 2011; 30(2):183-92. and preparation’ in:Brånemark P-I, Zarb GA, Albrektsson T ( eds). Tissueintegrated 30. Dahlin C, Widmark G, Bergkvist G, Fürst7. A lbrektsson T, Wennerberg A. Oral implant prostheses: osseointegration in clinical dentistry. B, Widbom T, Kashin H. One-Year Results surfaces: Part 1 – review focusing on topographic Chicago: Quintessence; 1985; 199–209. of a Clinical and Radiological Prospective and chemical properties of different surfaces and Multicentre Study on Neoss Dental Implants. in vivo responses to them. Int J Prosthodont 2004; 19. Z itzmann NU, Schärer P, Marinello CP. Long- Clin Implant Dent Relat Res 2011; [Epub ahead 17:536–543. termresults of implants treated with guided bone of print]. regeneration: a 5-year prospective study. Int J8. B user D, Schenk RK, Steinemann S, Fiorellini Oral Maxillofac Implants 2001; 16:355–366. 31. Rosen P, Meredith N, Reynolds M. Case Reports JP, Fox CH, Stich H. Influence of surface Describing the “Bump”: A New Phenomenon in characteristics on bone integration of titanium 20. D ahlin C, Lekholm U, Linde A. Membrane- Implant Healing. J Implant Adv Clin Dent 2010; implants. A histomorphometric study in miniature induced bone augmentation at titanium implants. 2(9):27-37. pigs. J Biomed Mater Res 1991; 25:889–902. A report on ten fixtures followed from 1 to 3 years after loading. Int J Periodontics Restorative9. W ennerberg A. On surface roughness and Dent 1991; 11:273–281. implant incorporation. Thesis 1996; Gothenburg University. 21. B eni-GI, Jung RE, Siegenthaler DW, Hämmerle CH. Clinical and radiographic comparison10. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, of implants in regenerated or native bone: Wennerberg A. Histologic evaluation of the bone 5-year results. Clin Oral Implants Res 2009; integration of TiO(2) blasted and turned titanium 20:507–513. microimplants in humans. Clin Oral Implants Res 2001; 12:128–134. 22. Z umstein T, Billström C, Sennerby L. A 4- to 5-Year Retrospective Clinical & Radiographic11. Burgos PM, Rasmusson L, Meirelles L, Study of Neoss Implants Placed with or without Sennerby L. Early bone tissue responses to GBR Procedures. Clin Implant Dent Relat Res turned and oxidized implants in the rabbit tibia. 2010; [Epub ahead of print]. Clin Implant Dent Relat Res 2008; 10:181–190.58 • Vol. 3, No. 6 • October 2011
performance in more applications.case study 1 OraGraft®Mineralized Cortical ParticulateMissing maxillary Following treatment with a reinforced membrane and Facial view of case implant placement complete lateral incisor oraGraft® mineralized cortical particulate (occlusal view) prior to implant placementcase study 2 OraGraft®Ilium Strip Block & OraGraft®Mineralized Cortical ParticulateSeverely atrophic Placement of oraGraft® oraGraft® mineralized cortical Completed case following maxillary ridge ilium strip Block with fixation crews particulate implant placement Case study photos courtesy of Dr. Dan Holtzclaw and Dr. nicholas Toscano. • Structural Bio-implants • Particulates • Soft Tissue/Membranes To learn more about OraGraft, contact a RLifeNet Health representative at (888) 847-7831. www.OraGraft.com
Histological and Computed Tomography AnalysWisallace et al of Amnion Chorion Membrane in Guided Bone Regeneration in Socket AugmentationSteve Wallace, DDS, MS1 • Charles Cobb, DDS, PhD2AbstractBackground: Tooth extraction often results in phine. The cores fixed in 10% buffered for-the loss of height and width of alveolar bone malin and demineralized in EDTA/HCL andin untreated socket sites. Subsequent reduc- processed for light microscopy using hema-tion in the height and width of alveolar bone can toxylin and eosin staining. The slides werecompromise the placement of implants. Numer- analyzed for histophometry to determine per-ous non-resorbable and resorbable membranes centage of host and new bone (NB), residualhave been successfully utilized for guided bone graft material (GM), and connective tissue (CT).regeneration (GBR). Placental tissue is consid-ered immunoprivileged, possesses anti-inflam- Results: All patients exhibited excellent earlymatory and antibacterial properties, and provides healing. Histomorphometric analysis of thea protein enriched matrix to facilitate cell migra- cores obtained at an average of 13 weekstion. The purpose of this case series was to revealed excellent bone regeneration attachedevaluate the use of allograft amnion chorion to and surrounding residual allograft material.membrane (ACM) for use in (GBR) over extrac- There was no evidence of ACM or inflammatorytions grafted with freeze-dried allograft bone cell infiltrate. The average NB = 54.5%, GM =(FDBA) in preparation of implant placement. 20.9%, and CT = 24.7%. The density of grafted sockets averaged 844 Hounsfield units (HU).Methods: Seven otherwise healthy non-smokers with a single tooth deemed unsal- Conclusions: The high percentage of vitalvageable were enrolled in the study. Sockets bone and bone density suggests that the usewere debrided, grafted with freeze dried of ACM to cover extraction sockets in GBR inbone allograft and covered with ACM. At preparation for implant placement is effective8-17 weeks, computed tomography scans within the limits of this case series, and due toand radiographs were taken. A biopsy was its physical and biologic attributes, may pro-obtained with a 2.0 mm internal diameter tre- vide for early bone and soft tissue maturation.KEY WORDS: Site preservation, bone graft, amnion-chorion, dental implant1. Private practice, Wilmington, North Carolina, USA. Professor and Director, Division of Periodontics and Interim Chair, Department of Stomatology, Medical University of South Carolina, Charleston, South Carolina, USA 2. Professor Emeritus, University of Missouri-Kansas City, Kansas City, Missouri, USA The Journal of Implant & Advanced Clinical Dentistry • 61
Wallace et al INTRODUCTION dental surgery. The use of allograft placental tis- sue possess many beneficial attributes not foundThe successful outcome of implant therapy is with traditional xenograft and alloplast barrierrestoratively driven, and dependent on correct membranes; placental allograft tissue consideredthree-dimensional positioning within bone. Ridge immunoprivileged, possesses anti-inflammatoryresorption horizontally and vertically along with and anti-bacterial properties, and provides a pro-soft tissue changes following extraction of teeth, tein enriched matrix to facilitate cell migration.12is well documented and directly affects our abil-ity to correctly position implants. Healing bone The placental allografts membrane productsin extraction sites does not regenerate coronal are sourced from the amniotic sac. This part ofto the horizontal level of the bone crest or to the the placenta encloses and protects the develop-level of the adjacent teeth resulting in incomplete ing fetus through term. Amnion tissue, the innerfill of the grafted socket.1,2 Ungrafted extraction layer of the amniotic sac, contains collagen typessites have been shown to lose 40-60% of bone III, IV, V, and laminin.13 Chorion, the outer layervolume after 12 months.3 Immediate implant of the amniotic sac, contains collagen types I, III,placement does not prevent the loss of bone and IV, V, VI, and laminin.14 Laminins are the majormay affect osseointegration of the implant.4,5 Bone class of basement membrane proteins that haveloss is progressive without intervention; treatment multiple biological functions, including promo-to augment extraction sites is important to prevent tion of cell adhesion, migration, and differentia-resorption of alveolar bone before implant place- tion of phenotypes.15 The basement membranement.6 Clinicians often use guided bone regen- of amnion tissue closely mimics the basementeration (GBR) to facilitate new bone formation. membrane of human oral mucosa and contains aGBR involves filling the bony void with a particu- high concentration of laminin-5.16 The presencelate bone graft and placing a barrier membrane of Laminin-5 is of particular importance due toover the grafted area. The membrane’s role is its high affinity for adhesion of gingival epitheliato provide isolation of the clot, and the grafted cells.17 Amnion has been shown to contain cyto-area, from migration of gingival epithelial cells and kines including fibroblast growth factor, epidermalfibroblasts from the lamina propria. This allows growth factors, platelet derived growth factor, andfor population of the protected space by osteo- transforming growth factor beta.18,19,20 Amnionprogenitor cells which differentiate into bone and chorion tissue is derived from trophoblasts.producing osteoblasts. Over the past 20 years, These cells possess characteristics of stem cellsnumerous non-resorbable and resorbable mem- with multipotent differentiation ability that can gen-branes have been successfully utilized for GBR erate cell development into all three germ layers.21in socket augmentation in preparation for dental Trophoblasts only exhibit major histocompatibilityimplants.7,8,9,10,11 Recently, allograft placental tis- complex (MHC) Class II antigens. They do notsue based membranes have become available for possess MHC Class I antigens which are pres-use in applications throughout the body, includ- ent in all caderivic allografts and are responsibleing use as an anti-adhesion barrier, ocular recon- for rapid rejection of non-processed allografts.22struction, treatment of chronic wounds and in Amnion tissue contains glycoproteins and tissue62 • Vol. 3, No. 6 • October 2011
Wallace et alFigure 1: ACM comes dehydrated and is placed over Figure 2: Preoperative radiograph of tooth #19 deemedgrafted sockets without pre-hydration. unsalvageable.inhibitor of metalloproteinases-1 which inhibits efficacy and the quality of the bone formed whendegradation of the extracellular matrix and miti- using ACM for GBR in extraction sockets graftedgates inflammation.23,24 Amnion possesses immu- with FDBA in preparation for implant placement.nosuppressive properties, as demonstrated by itsability to suppress the proliferation of splenocytes; MATERIALS AND METHODSa mixture of lymphoid and mononuclear cells,monocytes, and macrophages.25 Fresh amnion in Subject Populationrabbit gingival wounds reduced the presence of Seven patients in a private practice were includedpolymorphonuclear cells and promoted greater with a single tooth deemed unsalvageable duenew blood vessel formation and denser collagen to recurrent caries, endodontic complications,fibrils compared to untreated sites.26 Another trauma or other factors. Patients were enrolledstudy demonstrated homogenous frozen amnion in this study from March 2010 to January 2011,used to treat oral mucositis in rats prevented and the study was conducted in accordance withbacterial colonization, reduced inflammation, and the Helsinki Declaration of 1975, as revised inallowed for complete wound closure compared 2000. Exclusion criteria included patients whoto controls.27 These two studies histologically were heavy smokers, exhibited bruxism symptoms,demonstrate that the use of amnion accelerates had untreated periodontal disease, were preg-healing, reduces inflammation, and acts as a bac- nant, and patients with a history of alcohol or drugterial barrier. Amnion chorion membrane (ACM) dependence, or other general medical conditionsused in this study was introduced in 2010 to the that would affect soft tissue or bone healing e.g.,dental community, but there is currently minimal osteoporosis, hyperparathyroidism, autoimmunedocumentation on its use.28,29,30 The purpose diseases, chemotherapeutic or immunosuppres-of this case series was to determine the clinical sive agents, steroids, bisphosphonates or similar type drugs. Following explanation of treatment The Journal of Implant & Advanced Clinical Dentistry • 63
Wallace et alFigure 3: The socket is debrided of soft tissue remnants. Figure 4: Upon placement ACM initially turns translucent as it hydrates and adapts over the grafted socket.recommendations and options for treatment,oral and written informed consent was obtained. can Association of Tissue Banks (AATB). These safety measures include testing for serologicalMembrane Preparation infectious diseases such as human immuno-In the production of the ACM used in this study, deficiency virus (HIV) type 1 and 2 antibodies,the tissue is procured from mothers who donate human T-lymphotropic virus (HTLV) type 1 andtheir placenta during elective caesarian sec- 2 antibodies, Hepatitis C antibody, Hepatitis Btion surgery. All donated tissue followed strict surface antigen, Hepatitis B core total antibody,guidelines for procurement, processing, and dis- serological test for Syphilis, HIV type 1 nucleictribution, as set forth by the United States Food acid test, and Hepatitis C virus nucleic acidand Drug Administration (FDA) and the Ameri- test. Upon collection of the placental tissue, the amnion and chorion tissues are carefully sepa-64 • Vol. 3, No. 6 • October 2011
Wallace et alFigure 5: Primary closure was obtained with a continuous Figure 6: At one week the treatment site was markedmattress technique. excellent early healing and minimal inflammation.rated and the amnion is cleansed prior to pro- maintain the desired level of conscious seda-cessing. The allograft is dehydrated, packaged, tion. A prophylactic antibiotic (amoxicillin) wasand terminally sterilized (SAL 10-6) (Figure 1). delivered intravenously during surgery. Two per- cent (2%) lidocaine with 1:100,000 epineph-Surgical Protocol rine was used for block and local anesthesia.All surgeries were done with monitored intrave-nous sedation using an automatic pulse oxim- Atraumatic tooth extraction of molar teetheter displaying heart rate, electrocardiogram, deemed unsalvageable (Figure 2) was performedoxygen saturation and blood pressure. Seda- after sectioning off crowns and separating rootstion was initiated with intravenous injection of using fissure burs, periotomes and elevators. Allmedications that were titrated to induce and socket sites treated had intact buccal and lin- gual walls. The sockets were debrided of epi- The Journal of Implant & Advanced Clinical Dentistry • 65
Wallace et alFigure 7: Two week postoperative radiograph shows Figure 8: Postoperative radiograph of the implant placedstability of the bone graft. A 10 mm copper wire was at eight weeks. Density = 800 HU.attached to x-ray sensor for dimensional comparison.Figure 9: Collage consisting of two overlapping low thelial remnants (Figure 3). The site was graftedmagnification views of the trephine core biopsy obtained with a mixture of cortical and cancellous particu-at 12 weeks post-grafting. Computerized measurement of late FDBA, particle size 600 to 1250 micronssurface areas determined composition to be: 52% host and (MinerOss™, BioHorizons, Birmingham, Alabama,new bone, 9% residual graft material, and 39% connective USA). Graft material was placed with light com-tissue (50x of original magnification). pression into the socket sites and added incre- mentally until the socket was slightly over filled.66 • Vol. 3, No. 6 • October 2011
Wallace et alFigure 10: View of thick mature trabecular bone (TB) Figure 11: High magnification view of bone graft (BG)surrounding graft material. Bone graft (BG) material is with newly forming bone at the surface (arrows). Note thedifferentiated from host and/or new bone by the presence presence of a cluster of three large multinucleated giantof vacant lacunae, reversal lines (arrows) of characteristic cells at lower left corner of photo (thick arrows) (400x ofdark purple staining (x200 of original magnification). original magnification).The grafted socket was covered with ACM (BioX- Figure 12: High magnification view of thick trabecularclude™, Snoasis Medical, Denver, CO) that was bone consisting of a melding together of bone graftcut to extend 3 to 5 mm past the socket periph- material (BG) and host and/or newly formed bone (NB)ery on the buccal and lingual. Upon placement, separated by distinct reversal lines (arrows) (400x ofACM quickly hydrated and closely adapted over original magnification).the particulate bone graft, and buccal and lingualbony walls (Figure 4). No sutures were used tosecure ACM into place. Flaps were released withreflection into the vestibule facially and scoringof the periosteum with a 15-c blade; Iris scissorswere inserted into the cuts and tissue spreadingwas done to maximize flap release. For mandib-ular teeth, the lingual flap was extended at leastone tooth mesial and distal to the surgery site anddown to a depth of 15 mm. This was continueduntil passive flap release with complete closureover the socket was achieved. The flaps wereapproximated fully and sutured with 4-0 polypro-pylene sutures (Figure 5). Routine post-operativeinstructions were given. Analgesic (Vicoprofen) The Journal of Implant & Advanced Clinical Dentistry • 67
Wallace et alTable 1: Breakout of Histological and Computed Tomography Results for Each Patient Patient Tooth Length New Graft Connective Hounsfield (weeks) Bone Material Tissue Units 43% 22% 800 8 53% 35% 28% 930 1 19 12 54% 19% 22% 749 12 52% 24% 39% 915 2 6 13 59% 9% 24% 875 14 57% 18% 24% 753 3 5 16 64% 18% 14% 888 17 42% 23% 19% 657 4 19 13 16% 5 15 6 30 7 14 Average and antibiotic (amoxicillin 500 mg t.i.d. for 5 days) 3 mm in height were placed to initiate thedrugs were prescribed. Patients returned for soft tissue emergence profile development.one week to evaluate healing (Figure 6). At thetwo-week post-surgical evaluation the sutures Histological Analysiswere removed and the patient was instructed Trephine cores were obtained from the graftedto resume conventional home care (Figure 7). defects, fixed in 10% buffered formalin and shipped to the University of Missouri Kansas CityCore Biopsies and Computed for histological processing. Extraction of the min-Tomography Scans eralized graft from the trephine yielded fragmentedComputed tomography scans (V.I.P., BioHori- specimens that were demineralized in EDTA/HCLzons, Birmingham, Alabama, USA) were taken and processed for light microscopy using hema-prior to surgery to evaluate the bone graft den- toxylin and eosin staining. Circular cross sec-sity, and to determine optimal implant posi- tions of 5-6 mm thickness, from three randomlytioning. At between 8-17 weeks (average of selected specimens, were analyzed for histophom-13 weeks) a bone biopsy was obtained with etry to determine percentage surface area of newa 2.0 mm internal diameter trephine. Implants bone (NB), residual graft material (RM) and con-(RBT Laser-Lok, BioHorizons, Birmingham, nective tissue (CT). Histomorphometric measure-AL.) were subsequently placed at 50 Ncm ments were accomplished by light microscopytorque. All implants placed showed primary coupled to a computer using Optimas 6.5 Imagestability on placement and healing abutments Analysis Software, (Optimas Corp, Bothell, WA).68 • Vol. 3, No. 6 • October 2011
Wallace et alTable 2: Review of Results Reported in other Histological Socket Augmentation Studies Study Timeframe Number Graft Barrier Host/New Graft Connective of sites Material Membrane Bone Material Tissue Fotek et al.7 16 10 FDBA ADM 28% 14% 58% (2009) weeks 10 FDBA PTFE 33% 15% 53% Friedman et al.8 28 14 ABM RCM 42% 44% 14% (2002) weeks 13 ABM ePTFE 39% 46% 15% Smuckler et al.9 30+ 10 DFDBA ePTFE 56% 6% 38% (1999) weeks Wang et al.10 20-24 7 FDBA CT 69% 15% 53% (2008) weeks Wood et al.11 18-20 16 DFDBA CT 38% 9% 43% (2011) weeks 16 FDBA CT 25% 25% 50% Current case 8-17 7 FDBA ACM 54% 21% 25% series weeks FDBA = freeze-dried bone allograft, DFDBA = demineralized FDBA, ABM = anorganic bone mineral ADM = acellular dermal matrix, PTFE = polytetrafluoroethylene, ePTFE = expanded polytetrafluoroethylene CT = collagen tape, RCM = resorbable collagen membrane, and ACM = amnion chorion membraneProsthetic Protocol stability when seated in grafted sites at 50Implants were allowed to osseointegrate for nCM (Figure 8). There were no complicationsfour months before proceeding to the restor- of implants lost during the observation period.ative phase. All implants were restored with asingle cement-retained crown. Post-restorative The density of cores averaged 844 Houn-evaluations were done after crown cementa- sfield units (HU). Histomorphometric analysistion and then scheduled for yearly probing revealed excellent bone regeneration attacheddepth and radiographic evaluations thereafter. to and surrounding residual allograft mate- rial (Figures 9-12). There was no evidence of RESULTS ACM or inflammatory cell infiltrate. The average NB = 54.4%, GM = 20.9%, and CT = 24.7%.In all cases, soft tissue healing was rapid anduneventful in all cases treated. None of the DISCUSSIONsites exhibited membrane exposure and no lossof grafted bone occurred. All implants showed Preparing extraction sites for implant placement is challenging in several respects. Extraction sites The Journal of Implant & Advanced Clinical Dentistry • 69
Wallace et alnot treated can lose bone width and height 25% new bone at 18-20 weeks using RCMrapidly, thus causing difficulties with implant (Table 2). Of interest were the results of Trom-placement in desired positions.31 The facial belli et al.35 who reported in an undisturbedsupporting bone must be approximately 1.8 socket site 32-36% woven bone formation 6mm in thickness to ensure long term stability.32 months after tooth extraction. These studiesSoft tissue must be regained and supported indicate the effectiveness of ridge preserva-by bone regeneration over a socket site to pro- tion surgery using mineralized allograft bone tovide the desired emergence profile, especially promote new bone formation. Allowing graftedin maxillary anterior sites.33 Grafting extraction sites longer time to mature may not be benefi-sites with particulate mineralized freeze-dried cial, as Beck et al. showed similar amounts ofallograft bone and barrier membrane place- new bone growth in sockets grafted with min-ment is widely used to promote alveolar repair.34 eralized bone at 3 months and 6 months.36 The density of bone was estimated to be D3 Our focus in this case series was to docu- according to Misch et al. based on the resis-ment the quality of bone when using ACM as tance felt with trephines and osteotomy drills.37a barrier membrane for guided bone regenera- Although this was not recorded as part of thistion over grafted extraction sockets. Trephine study, the height and width of extraction sitebiopsies and computed tomography scans were bony components appeared to be maintained.done to gauge the degree of bone maturationat an early average re-entry point of 13 weeks. Exposure of membranes in guided boneDensity measured in HU averaged 844. This regeneration can compromise the healing pro-reading was taken with proprietary software cess.38,39 For this reason, adequate flap releaseand was consistent with resistance observed for primary closure is an important factor inwith trephine and osteotomy drills. All sites in prevention of incision line opening, allowingthis study displayed robust new bone forma- bone grafts to heal without infection or tissuetion. Our results showed an average of NB = in-growth.40 Soft tissue growth progresses at54%, GM = 21%, and CT = 25% (Table 1). the rate of 0.5-1.0 mm per day and can takeThese results compare favorably with those of 7-10 days to granulate in, leaving the exposedFotek et al. which reported 28% and 33% new membrane in contact with bacteria and salivarybone at 16 weeks using polytetrafluoroethyl- enzymes41. The anti-inflammatory propertiesene and acellular dermal matrix, Friedman et of ACM may decrease the risk of dehiscence;al.8 which reported 44% and 39% new bone inflammation following GBR has been shown toat 28 weeks using resorbable collagen mem- increase the probability of membrane exposure.42brane (RCM) and expanded polytetrafluoroeth- Holtzclaw et al.29 recently demonstrated the suc-ylene (e-PTFE), Smukler et al.9 which reported cessful use of ACM when left exposed to thean average of 56% new bone at 30 weeks oral environment in site preservation, suggest-using e-PTFE, Wang et al.10 which reported ing primary closure may not be necessary. The69% new bone at 20-24 weeks using RCM, author noted early healing was marked by mini-and Wood et al.11 which reported 38% and mal inflammation and rapid epithelial migration70 • Vol. 3, No. 6 • October 2011
Wallace et alover exposed portions of the ACM; histologic CONCLUSIONanalysis of a core taken from one case obtainedat 12 weeks revealed NB = 46%, GM = 21%, The high percentage of vital bone and bone den-and CT = 33%. This compares favorably with sity at an average of 13 weeks, suggests withinresults from this case series. The inherent bio- the limits of this case series, the use of ACMlogical properties of ACM may better enable it to cover extraction sockets in GBR in prepara-to maintain barrier function and promote wound tion for implant placement is effective, and dueclosure when exposed to the oral environment. to its physical and biologic attributes, may pro- vide for early bone and soft tissue maturation. ● The physical nature of ACM is unique. Itmust be kept dry until time of placement. ACM Correspondence:can be placed upward or downward and Steve Wallace, DDS, MHSclosely adapts and adheres to underlying sur- 2525 Delaney Avenuefaces as it hydrates. Due to the relatively thin Wilmington, NC 28403nature of ACM (≈300 μm) and its self adher- (910) 620-6760 (office)ent qualities, excess membrane can be folded (910) 620-6760 (mobile)onto itself without consequence. However, (910) 343-9512 (fax)these same benefits limit its use to a graft con- [email protected] tainment function and cannot be expected toprovide primary stability for the bone graft. Charles Cobb, DDS, PhD, UMKC School of Dentistry The unique biological and physical attri- 650 E. 25th Streetbutes provided by ACM may have played a role Kansas City, MO 64108in the early maintenance of bone graft and rapid (816) 235-2147(office)maturation reported in this case series. Furtherinvestigation on the clinical utility of ACM foruse as a barrier membrane in GBR is warranted.ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] The Journal of Implant & Advanced Clinical Dentistry • 71
Wallace et alDisclosure 14. Niknejad H, Peirovi H, Jorjani M, Ahmadiani 30. R osen P. Comprehensive PeriodontalThis research was supported in part by Snoasis A, Ghanavi J, Seifalian M. Properties of the Regenerative Care: Combination TherapyMedical. Dr. Wallace has a financial interest in amniotic membrane for potential use in tissue Involving Bone Allograft, a Biologic, a Barrier,Snoasis Medical and serves on Snoasis Medical’s engineering. Euro Cells & Mat 2008; 15 :88-89. and a Subepithelial Connective Tissue Graft toClinical Advisory Board. Correct Hard- and Soft-Tissue Deformities. Clin 15. Tunggal P, Smyth N, Paulsson M, Ott C. Laminins: Adv Perio 2011; 1(2): 154-159.References structure and genetic regulation. Microscopy1. Werbitt MJ, Goldberg PV. Immediate implantation. Res Technique 2000; 51: 214-227. 31. S chropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes Preservation of bone volume and osseous 16. T akashima S, Yasuo M, Sanzen N, Sekiguchi K, following single-tooth extraction: A clinical and regeneration. J Periodonal 1991; 10(2): 157-166. Okabe M, Yoshida T, et al. Characterization of radiographic 12-month prospective study. Int J laminin isoforms in human amnion. Tissue & Cell Perio Rest Dent 2003; 23: 313-3232. Pollizi G, Grunder U, Goene R, et al. Immediate 2008; 40: 75-81. and delayed implant placement into extraction 32. S pray J, Black C, Morris H, Ochi S. The Influence sockets: a 5 year report. Clin Implant Dent Relat 17. Pakkala T, Virtanen I, Oksanen J, Jones C, Hormia of Bone Thickness on Facial Marginal Bone Res 2000; 2(2): 93-99. M. Function of laminins and laminin-binding Response: Stage 1 Placement Through Stage 2 integrins in gingival epithelial cell adhesion. J Uncovering. Ann Periodontol 2000; 5: 119-128.3. Schropp L, Wenzel A, Kostopoulos L, Karring T. Periodontal 2002; 73(7): 709-719. Bone healing and soft tissue contour changes 33. B user D, Martin W, Belser U. Optimizing following single-tooth extraction: A clinical and 18. R odriguez-Ares M, Lopez-Valladares M, Tourino esthetics for implant restorations in the anterior radiographic 12-month prospective study. Int J R, Vieites B, Gude F, et al. Effect of lyophilization maxilla: Anatomic and surgical considerations. Perio Rest Dent 2003; 23: 313-323 on human amniotic membrane. Acta Ophthalmol Int J Oral Maxillofac Implants 2004; 19(suppl): 2009; 87: 396-403. 43-61.4. Araujo M, Sukekava F, Wennnstrom J, Lindhe J. Ridge alterations following implant placement in 19. Lim L, Riau A, Poh R, Tan T, Bauerman R, Mehta 34 F iorellini J, Nevins M. Local ridge augmentation/ fresh extraction sockets: An experimental study in J. Effect of dispase denudation on amniotic preservation. A systematic review. Ann the dog. J Clin Periodontol 2005; 32: 645-652. membrane. Mol Vis 2009; 15: 1962-1970. Periodontol 2003; 8: 321-327.5. Botticelli D, Berglundh T, Lindhe J. Hard-tissue 20. Koizumi N, Inatomi T, Sotozono C, Fullwood 35.Trombelli L, Farina R, Marzola A, Bozzi L, alterations following immediate implant placement N, Quantock A, Kinoshita S. Growth factor Liljenberg B, Linde J. Modeling and remodeling at extraction sites. J Clin Periodontol 2004; 31: mRNA and protein in preserved human amniotic of human extraction sockets. J Clin Periodontol 820-828. membrane. Curr Eye Res 2000; 20: 173-177. 2008; 35: 630-639.6. Iasella JM, Greenwell H, Miller RL, et al. Ridge 21. T oda A, Okabe M, Yoshida T, Nikaido T. The 36. Beck TM, Mealey BL. Histologic analysis preservation with freeze-dried bone allograft and Potential of Amniotic Membrane/Amnion-Derived of healing after tooth extraction with ridge a collagen membrane compared to extraction Cells for Regeneration of Various Tissues. J preservation using mineralized human bone alone for implant site development: A clinical and Pharmacol Sci 2007; 105: 215-228. allograft. J Periodontol 2010; 81: 1765-1772. histologic study in humans. J Periodontol 2003; 74: 990-999. 22. A agard-Tillery K M, Silver R, Dalton. J Immunology 37. Misch C. Divisions of available bone in implant of normal pregnancy. Semin Fetal Neonatal Med. dentistry. Int J Oral Implantol 1990; 7(1):9-17.7. Fotek P D, Neiva R F, Wang H L. Comparison 2006; 11(5): 279-95. of dermal matrix and polytetrafluoroethylene 38. Zubillaga G, Von Hagen S, Simon I, Deasy J. membrane for socket bone augmentation: A 23. K oh W, Shin J, Oh Y, Kim K, Ko H, Hwang M, Changes in alveolar bone height and width clinical and histologic study. J Periodontal 2009; et al. The expression of TIMPs in cyro-preserved following post-extraction ridge augmentation 80(5): 776-85. and freeze dried amniotic membrane. Curr Eye using fixed bioabsorbable membrane and Res 2007; 32: 611-616. demineralized freeze-dried bone osteoinductive8. Friedman A, Strietzel F P, Maretzki B, Pitaru graft. J Periodontal 2003; 74(7): 965-975. S, Bernimoulin J P. Histological assessment of 24. Hao Y, Ma H, Hwang G, Kim S, Zhang augmented jaw bone utilizing a new collagen F. Identification of Antiangiogenic and 39. Simon M, Baldoni M, Rossi P, Zaffe D. A barrier membrane compared to a standard Antiinflammatory Proteins in Human Amniotic comparative study of the effectiveness of e-PTFE barrier membrane to protect a granular bone Membrane. Cornea 2000; 19(3): 348-352. membranes with and without early exposure substitute material. Clin Oral Implants Res during the healing period. Int J Perio & Rest Dent 2002; 13(6): 587-94. 25. Park CY, Kohanim S, Zhu L, Gehlbach PL, Chuck 1994; 14(2): 167-180. RS. Immunosuppressive Property of Dried9. Smukler H, Landi L, Setayesh R. Human Amniotic Membrane. Ophthalmic Res 40. L ekovic V, Kenney E, Winlender M. A bone Histomorphometric evaluation of extraction 2009; 41: 112–113. regenerative approach to alveolar ridge sockets and deficient alveolar ridges treated with maintenance following tooth extraction. Report allograft and barrier membrane: A pilot study. Int 26. Rinastiti M, Harijadi, Santoso A, Sosroseno W. of 10 cases. J Periodontol 1997; 68: 563-570. J Oral Maxillofac Implants 1999; 14(3): 407-416. Histological evaluation of rabbit gingival wound healing transplanted with human amniotic 41. Engler W. Healing following simple gingivectomy.10. Wang H, Tsao Y. Histologic evaluation of socket membrane. Int J Oral Maxillofac Surg 2006; 35: A tritiated thymidine radioautographic study. J augmentation with mineralized human allograft. 247–251. Periodontol 1966; 37: 298-308. Int J Perio Rest Dent 2008; 28: 231-237. 27. Vilela-Goulart G, Teixeira S, Rangle C, Niccoli- 42. Simion M, Baldoni M, Rossi P, Zaffe D. A11. Wood R, Mealey B. Histological comparison Filho W, Gomes M. Homogenous amniotic comparative study of the effectiveness of e-PTFE of healing following tooth extraction with ridge membrane as a biological dressing for oral membranes with and without early exposure preservation using mineralized vs. demineralized mucositis in rats: Histomorphometric analysis. during the healing period. Int J Perio Rest Dent freeze dried bone allograft. J Periodontal 2011; Arch Bio 2008; 35: 1163-1171. 1994; 14(2): 167-180. accepted for publication July 12. 28. Wallace S. Radiographic and histomorphometric12. Chen E, Tofe A. A literature review of the safety analysis of amniotic allograft tissue in ridge and biocompatibility of amnion tissue. J Implant preservation: a case report. J Implant Adv Clin Adv Clin Dent 2010; 2(3): 67-75. Dent 2010; 2(6): 49-55.13. Hodde J. Naturally occurring scaffolds for soft 29. Holtzclaw D, Toscano N. BioXclude placental tissue repair and regeneration. Tiss Eng 2002; allograft tissue membrane used in combination 8(2): 295-308. with bone allograft for site preservation. J Implant Adv Clin Dent 2011; 3(3): 35-50.72 • Vol. 3, No. 6 • October 2011
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Soft Tissue Esthetics in Implant Dentistry Mahesh et al Strategies for Sucess: A Case PresentationLanka Mahesh, BDS1 • Gregori Kurtzman, DDS, DICOI2 AbstractEchoing the relationship between the peri- esthetic rehabilitation is concerned, it is governed odontal tissues and a natural tooth, the by multiple patient and surgical factors defining supporting tissues of an osseointegrated the esthetic risk in the anterior region (estheticimplant must be organized not only to anchor zone). The aim of this paper is to discuss mul-the implant in the bone, but also to provide func- tiple factors which must be considered for opti-tional and esthetic dental rehabilitation. Where mal soft tissue esthetics in implant dentistry.KEY WORDS: Dental implant, esthetics, bone graft, gingival graft, treatment planning 1. Private Practice, New Delhi, India 2. Private Practice, Silver Spring, Maryland, USA The Journal of Implant & Advanced Clinical Dentistry • 75
Mahesh et al Introduction Figure 1: Determining dental midline.Echoing the relationship between the periodontal maxillary and mandibular dental midlines are coinci-tissues and a natural tooth, the supporting tissues dent with or parallel to the facial midline (Figure 1).of an osseointegrated implant must be organizednot only to anchor the implant in the bone, but also Height of the Lip Line Upon Smilingto provide functional and esthetic dental rehabili- High lip line patients often display their maxillarytation. Where esthetic rehabilitation is concerned, anterior teeth as well as significant portion of sup-it is governed by multiple patient and surgical porting soft tissues (Figure 2a). The esthetic riskfactors defining the esthetic risk in the anterior of these patients is greatly increased, mostly asso-region (esthetic zone). The aim is to rehabilitatesmile esthetics which is decided to a great extentby the soft tissue esthetics in implant dentistry. PATIENT EVALUATIONFacial and Dental SymmetryNasal midline, upper lip philtrum and chin midlineare evaluated for coincidence with facial midline.After evaluation of the facial midline, dental symme-try is checked by determining whether the papillabetween the maxillary central incisors as well as Table 1: Diagnostic Factors for Esthetic Risk● Patient treatment expectations.● Patient smoking habits.● Height of the lip line on smiling.● Gingival biotype in the treatment area.● Shape of the missing or surrounding teeth.● Infection at the implant site and bone level at adjacent teeth.● Restorative status of the teeth adjacent to the edentulous teeth.● Character of the edentulous space.● Width of the hard and soft tissues in the edentulous space.● Height of the hard and soft tissues in the edentulous space.76 • Vol. 3, No. 6 • October 2011
Mahesh et alFigure 2a: High lip line. Figure 2b: Medium lip line.Figure 2c: Low lip line. Figure 3 Incisal plane.ciated with gingival tissue display. It can be diffi- Tooth Proportioncult to develop healthy, symmetric and contoured Central incisors dominate the smile with width-soft tissues and any failures will be readily visible. length ratio of 75% to 80%. Central incisors wider than the lateral incisors and lateral incisors wider Medium lip line patients display most of their than the canine from a frontal view is a pleasinganterior maxillary teeth and very little periodon- tooth-tooth relationship. Medial tipping of the lateraltal structures (Figure 2b). Here esthetic risk incisors from central to canine enhances esthetics.is increased associated with tooth size, color,shape, texture as well as shape and appear- Gingival Outlineance of the incisal and gingival embrasures. Two esthetically pleasing outline patterns are: The low lip line patients display a predomi- ● Sinuous pattern: Occurs when lateral incisornance of mandibular teeth or an equal mix of gingival margin is just coronal to the neighbor-maxillary and mandibular teeth (Figure 2c). ing central incisor and canine unilaterallyHere esthetic risk is reduced as the lips effec- (Figure 5).tively mask the outcomes associated with theappearance of the gingival tissues, tooth propor- The Journal of Implant & Advanced Clinical Dentistry • 77tions and the apical aspects of the restoration.
Mahesh et alFigure 4: Tooth ratios. Figure 5: Sinous pattern.Figure 6: Straight pattern. Figure 7a: Thick gingival biotype.● S traight pattern: Gingival margin of central Medium Gingiva Biotype (Figure 7b) incisors, lateral incisors are of same level ● More challenging in the long term. unilaterally (Figure 6). ● Esthetic risk is increased. ● T hey exhibit characteristics of both thick as● Combination pattern: Both patterns can exist on either side of the midline. well as thin gingiva biotype.Gingival Biotype Thin Gingiva Biotype (Figure 7c)Thick Gingiva Biotype (Figure 7a) ● Excellent esthetic single tooth restorations.● Low risk. ● Periodontal health and bone crest of adja-● Thick gingiva resistant to recession.● Masks the colour of the implants and any cent teeth have to be kept in consideration. ● Increased esthetic risk of recession. subgingival metallic components. ● Special surgical considerations.● F avors long term stability of esthetic peri-implant tissue.● They are more prone to post surgical scarring.78 • Vol. 3, No. 6 • October 2011
Mahesh et alFigure 7b: Medium gingival biotype. Figure 7c: Thin gingival biotype.Figure 8: Hard and soft tissue deficiency. Figure 9: Potential implant sites with different potential bone scenarios.Hard and soft tissue defectsWhen horizontal and vertical hard and soft tissues Infection at the Implant Site and Bone Leveldeficiencies exist (Figure 8), appropriate augmenta- of Adjacent Teethtion procedures are carried out. Vertical bone defi- Local infections (periodontal lesions, endodon-ciencies pose a greater challenge. To optimize soft tic lesions, post traumatic lesions, foreign bod-tissuevolume,completeorpartialcoveringoftheheal- ies) reduce the quantity and quality of hard anding cap/implant is recommended in anterior maxilla. soft tissues at potential implant sites (Figure 9).Shape of the missing and adjacent teeth Probability of black triangles increases● Influence the risk associated with implant- with greater crestal bone loss due to local infections on adjacent roots. supported restorations.● Square teeth reduce the risk. SURGICAL CONSIDERATIONS● T riangular shaped tooth associated with peri- Flap design odontal defects and loss of interdental Curvilinear flap (Figure 10a) papilla increases risk (black triangles). ● It is a buccal flap approach. The Journal of Implant & Advanced Clinical Dentistry • 79
Mahesh et alFigure 10a: Curvilinear Flap. Figure 10b: Peninsula Flap.Figure 10c: Crestal Flap. Figure 11: Bone scalloping.● Indications include visualization of buccal anat- Crestal flap (Figure 10c) omy and hard and soft tissue augmentation. ● C reated with a crestal incision located approxi-Peninsula flap (Figure 10b) mately 2-3 mm toward the palatal aspect.● Follows a U shaped path over the area where ● Avoids the formation of scar tissue in the the implant restoration will emerge. middle crestal area .● A llows visualization of palatal, lingual, and ● Ensures sufficient visualization of the facial flap buccal bone crests without the need of . buccal flap elevation.● U seful for submerged, non submerged, Tissue Punch semi-submerged approaches. ● Preserves excess soft tissue volume on the facial aspect. ● A vailable in a variety of diameters to accom- modate different sizes of implants. ● Less traumatic.80 • Vol. 3, No. 6 • October 2011
Mahesh et alFigure 12a: Mesiodistal. Figure 12b: Orofacial.Figure 12c: Coronal-apical. ● Orofacial dimension: Implant shoulder should be in the comfort zone. Comfort zone mea-Bone Scalloping (Figure 11) sures about 1.5-2 mm in width (Figure 12b).● F acilitates an easier and more precise ● C orono-apical dimension: Comfort zone is a preparation of the implant bed. narrow band (yellow colored) of about 1 mm● Smoothens the alveolar crest and imitates apical to the CEJ of the contra lateral tooth (Figure 12c). its natural shape.● N o bone should be removed in the proximal Surgical template Facilitates correct three dimensional implant place- areas of the adjacent tooth as it is important for ment during surgery. Cervical end of the template the support and maintenance of the papilla. indicates the desired future soft tissue margin.Implant Positioning● M esiodistal dimention: Danger zone (enclosed PROSTHETIC CONSIDERATIONS in red boundary) is located next to the adjacent root surface and is about 1-1.5 mm wide. ● Essex retainer: It is used in immediate post (Figure 12a). operative period. Its fabrication requires the restorative team to obtain impressions to create a master cast as well as shade selection prior to surgery procedure. ● R esin bonded: It provides superior function, esthetics and also protects the underlying surgical site. It can also be designed to main- tain the scalloped soft tissue architecture. The Journal of Implant & Advanced Clinical Dentistry • 81
Mahesh et al● P artial denture: It is easily fabricated and CONCLUSION simple to fit. Care must be taken to prevent the gingival portion of the interim partial denture When implant therapy is contemplated for an from contacting an exposed healing abutment. area of esthetic concern, the pre-treatment evaluation must include a complete functional● Custom tooth form healing abutment: and esthetic dento-periodontal evaluation not Closely approximates cross sectional anatomy only focusing on the area of planned implant of the lost tooth or the planned replacement at restoration but also taking into consideration the gingival level. It enhances esthetic soft tis- the overall result. In essence, the presence of sue contours, which yields superior soft tissue positive and negative elements affecting the results. It is a practical approach for early initia- outcome should be evaluated and a systemic tion of prosthetic guided soft tissue healing. quantification of the same should be done. ●● Anatomic healing abutments: Beneficial when a tooth with an unusual size or shape is being replaced in an area of esthetic con- cern. Important consideration is to avoid introducing excessive labial over contouring which can result in soft tissue recession. ATTENTIONPROSPECTIVE AUTHORS JIACD wants to publish your article!For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] • Vol. 3, No. 6 • October 2011
Mahesh et al● Figure 13 ● Figure 14● Figure 15 ● Figure 16 Figure 13: Pre-operative view. The Journal of Implant & Advanced Clinical Dentistry • 83 Figure 14: Implant placement. Figure 15: Harvesting palatal graft. Figure 16: Placement of graft.
Mahesh et al ● Figure 18● Figure 17 ● Figure 20● Figure 19 Correspondence: Dr. Lanka Mahesh Figure 17: G raft secured with 3-0 PTFE S-382, Panshila Park • New Delhi, India sutures. Email: [email protected] Figure 18: G ingival cuff at 4 months Disclosure exhibiting excellent peri implant Dr Lanka Mahesh lectures for Biohorizons implant systems whose products are soft tissue. mentioned in this article. References Figure 19: Retracted view. 1. C hiche G. Pinault A. artistic and scientific principles applied to esthetic Figure 20: Final smile, CZAR, (zirconia crown). dentistry. In: Chiche G, Pinault A(als). Esthetics of anterior fixed84 • Vol. 3, No. 6 • October 2011 prosthodontics. Chicago: Quintessence, 1994: 13-32 2. M orley J. smile design- specific considerations. J Calif Dent Assoc. 1997;25:633-637 3. L evin El. Dental esthetics and the golden proportion. J Prosthet Dent 1978;40: 244-252. 4. S clar Anthony. Soft tissue and esthetic considerations in implant therapy. Quintessence, 2003;2:13-43 5. ITI Treatment guide,VOL1, Implant Therapy in the Esthetic Zone,Single Tooth Replacements:Quintessence,2007
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Wilcko et alI’m a doctor…why do I need a PR and Social Media Campaign?Many dental and medical professionals shy from publicity and social media ● Your reputation among peers is because they mistakenly believe they enhanced. Your peers comprise the com- munity you belong to and there is impor-don’t warrant the attention, they are often too tant wisdom in the old axiom thathumble to invest in PR or feel they don’t have encourages one to remember their roots.the time to be active on social media platformslike Twitter and Facebook, and they believe ● A proactive PR and Social Media team is likethey can’t afford it. The reality is that the pub- a security blanket. When times are tough andlic is hungry for credible information that can competition is stiffer than ever, the relationshiphelp them lead healthier lives and in today’s you build between your brand and the public isultra competitive mar- essential for longevity and continued growth.ket, dental and medicalspecialists simply can’t ● Priceless appearances in all facets of theafford not to invest in media and on platforms like Twitter main-marketing themselves. tain your brand’s relevance as the seasons,Combining Public and the times, change. Demonstrating yourRelations and Social brand’s stability through consistent mediaMedia is the most effec- appearances and tweets will let your patienttive way to increase base know you are in it for the long haul.awareness of yourpractice among key, ● Instant connectivity to your patients pro-targeted audiences: media and influencers, vides a public two-way conversation. You knowprofessional peers, existing patients, poten- your net promoter patients - the ones who telltial new patients, and widespread consum- everyone how much they love you? Twitterers who rely on experts like yourselves to help gives them an effective platform to put yourguide their decision making in a time when name- and immediate contact information- outthey largely feel neglected by the medical field. there regularly. They will continuously shareThat’s why in today’s marketplace there are your content with their large circle of friends.huge benefits to effectively leveraging publicrelations and social media to generate valu- ● Rather than relying on a stagnant websiteable buzz around your practice. To name a few: with infrequent updates, Twitter provides you a launching spot to share all of your press cover-● “Buzz” about your company is gener- age and media placements at the moment theyated. A well-planned PR and social media hit the stands. Plus, adding links to your tweetscampaign increases the recognition of a increases their relevance in Google rankings-brand and gets people talking about it. whether or not anyone even clicks through them. The Journal of Implant & Advanced Clinical Dentistry • 87
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