Journal of Implant and Advanced Clinical Dentistry September 2014

Volume 6, No. 6 September 2014 The Journal of Implant & Advanced Clinical DentistryMaxillaryAnteriorImmediateImplants Periosteal Pedicle Graft

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The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 6 • September 2014Table of Contents5 A nterior Maxillary Extraction, 27 P eriosteal Pedicle Graft: Immediate Implant Placement, An invigorate for root and Provisionalization with coverage procedures Two Years Follow-up: A Case Report Major (Dr) B Harshavardhana, M. Bajali, Azz. Abdulgani, M. Abu-Hussein Major (Dr) Reenesh Mechery13 R eview of Platform Switching 37 C omparative Evaluation of and a New Concept Proposed Remineralization Potential of for Tissue Recession & Dental Different Materials on Enamel Implant Exposure Lesion: An In Vitro Study Dr. Peter Chien, Dr. Rita Hung, Dr. Amanpreet Singh, Dr. Neeraj Mahajan Dr. Zizhong Wu The Journal of Implant & Advanced Clinical Dentistry • 1

The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 6 • September 2014Publisher Copyright © 2014 by LC Publications. All rightsLC Publications 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 • [email protected] 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 LC Publications (hereinafterJIACD staff 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 LC Publications, Las Vegas, Nevada, USA.or by calling 1-888-923-0002.2 • Vol. 6, No. 6 • September 2014

The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Co-Editor in Chief Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS Nick Huang, MD Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDSMichael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MSThomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMDJohn Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDSLeon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMDStepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMDDavid Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhDCharles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDSSpyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDSSally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MATomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDSMassimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDSDouglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhDAlex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhDNicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhDPaul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDSDavid Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhDRonald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSDavid Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDSKenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDSIstvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 3

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Anterior Maxillary Extraction, Immediate ImplanWt ilcko et al Placement, and Provisionalization with Two Years Follow-up: A Case Report M. Bajali, DDS,PhD1 • Azz. Abdulgani, DDS, PhD1 M. Abu-Hussein, DDS, MScD, MSC, DPD1 AbstractBackground: This case report describes Results: The atraumatic operating tech-extraction of a fractured right maxillary cen- nique and the immediate insertion of thetral incisor tooth, followed by immediate place- Implant resulted in the preservation ofment of a dental implant in the prepared socket the hard and soft tissues at the extrac-and temporization by a bonded restoration. tion site. The patient exhibited no clini- cal or radiologic complications through twoMaterials and Methods: The tooth was years of clinical monitoring after loading.extracted with minimal hard and soft tissuetrauma and without flap reflection. The socket Conclusion: The dental implant and provi-was prepared to the required depth and a sional restoration provided the patient withStraumman Implant was inserted. An impres- immediate esthetics, function, comfort andsion was made 4 months after implant inser- most importantly preservation of tissues.tion, and a definitive restoration was placed.KEY WORDS: Implant, Immediate placement, Temporization. 1. Faculty of Dentistry, Al-Quds University, Jerusalem The Journal of Implant & Advanced Clinical Dentistry • 5

Bajali et al INTRODUCTION speaking, these benefits include reduction of morbidity, reduction of alveolar bone resorp-Endosseous dental implant therapy is rapidly tion Controlled clinical studies have demon-becoming the prosthetic standard of care for strated an average of 4.4mm of horizontal anda vast array of clinical applications, however, 1.2mm of vertical bone resorption six monthsdespite the high success rate of endosse- after tooth extraction,1,2 preservation of gin-ous implant therapy, it has yet to achieve wide gival tissues, preservation of the papilla in thepublic acceptance and utilization.1 Endos- esthetic zone, and reduction of treatment costseous implant therapy in the mandible (para- and time.1-5 With the extraction socket as asymphyseal mandible) has repeatedly been guide, the surgeon can also more easily deter-reported at a success rate of 95% or better, mine the appropriate parallelism and alignmentyet public utilization of endosseous implant relative to the adjacent and opposing residualtherapy has not exceeded 5%. The most fre- dentition. To maximize the advantage of thesequently cited reasons for underutilization of benefits and to minimize implant failure, caseendosseous implant therapy are that treat- selection must be based on sound clinical andment cost is perceived to be too high and research criteria. Immediate placement andtreatment takes too long (Branemark’s origi- provisionalization for single tooth replacementnal treatment protocols required up to a year allows for minimal disruption of the marginalor more to complete treatment). An obvi- soft tissues, providing immediate prostheticous area of focus has been to decrease the support for the peri-implant tissues throughamount of time necessary to complete implant the use of a carefully crafted provisional res-therapy. Approaches to achieve this goal have toration. Primary implantation is fundamentallydominated clinical research and practice: indicated for replacing teeth with pathologiesdelayed/immediate implant loading, improv- not amenable to treatment, such as caries oring implant surface technology (promotion of fractures. Immediate implants are also indi-quicker healing and better osseointegration), cated simultaneous to the removal of impactedand immediate placement of an endosseous canines.5,6 Immediate implantation can be car-implant after extraction of a natural tooth.1 In ried out on extracting teeth with chronic api-this paper a case presentation supporting the cal lesions which are not likely to improve withlast of these three approaches will be shown. endodontic treatment and apical surgery.7 The definition for an immediate endosse- The surgical requirements for immediateous implant is extraction of a natural tooth implantation include extraction with the leastfollowed by immediate placement of an endos- trauma possible, preservation of the extrac-seous dental implant. Immediate implants have tion socket walls and thorough alveolar curet-become widely accepted despite controversial tage to eliminate all pathological material.beginnings and the available literature consis- Primary stability is an essential requirement,tently cites high levels of success (ranging from and is achieved with an implant exceeding94-100% on average), immediate implants pro- the alveolar apex by 3-5 mm, or by placing anvide clinically recognizable benefits. Broadly6 • Vol. 6, No. 6 • September 2014

Bajali et alFigure 1: Pre-surgical photograph of tooth #11 (FDI). Figure 2: Pre-surgical photograph of tooth #11 (FDI) while in occlusion.Figure 3: Surgical extraction of tooth #11 (FDI) Figure 4: Extracted tooth #11 (FDI).implant of greater diameter than the remnant with labial bony dehiscence or fenestrationalveolus. Esthetic emergence in the anterior defects; Insufficient bone apically to ensurezone is achieved by 1-3 mm sub-crest implan- primary stability of the implant; Systemic fac-tation. The existence of an acute periapical tors that may impair healing (e.g. smoking);inflammatory process constitutes an absolute Large bulbous root morphology, Interproximalcontraindication to immediate implantation.8,9 bone loss (aesthetic zone), active periodontitis. In the case of socket-implant diameter dis-crepancies in excess of 5 mm, which wouldleave most of the implant without bone con-tact, prior bone regeneration and delayedimplantation may be considered.10 Avoid teethwith large or acute periapical infection; Teeth The Journal of Implant & Advanced Clinical Dentistry • 7

Bajali et alFigure 5: Surgical guide for dental implant placement. Figure 6: Placement of dental implant.Figure 7: Placement of provisional crown. Figure 8: Placement of provisional crown (alternate view). CASE REPORTA 45-year-old male patient presented with ahistory of trauma and crown fracture at thecervical area of tooth FDI 11 (figs. 1-2) andrequested an immediate solution. Clinical andradiological evaluation revealed adequatealveolar bone, absence of periapical pathol-ogy but fracture line was below the crest ofalveolar bone and was limited to the tooth. So,it was decided to extract and place endos-seous implant immediately and place a pro-visional restoration to avail the benefits like8 • Vol. 6, No. 6 • September 2014

Bajali et alFigure 9: Bone graft placement. Figure 10: Guided bone regeneration membrane placement.Figure 11: Surgical suture closure. Figure 12: Clinical result at 2 years.preservation of bone and emergence profile. tooth fragment was slowly luxated and pulled After administering appropriate antibiotic out of the socket using the file (figs. 3, 4).and analgesic, induction of local anesthesia The sockets were debrided with curetteswas carried out using xylocaine 2% with adren- and a dental implant was planned (Straummanaline1;200,000. As preservation of alveolar 4.1x 14mm). The drilling sequence was carriedbone is key to success of immediate implants, out (fig. 5) and after checking for primary stabil-extraction of tooth has to be atraumatic, so ity (fig. 6), which was achieved by advancing theusing periotomes and small periosteal eleva- implant into the bone beyond the apex of thetors the fragment was luxated without exces- socket, a provisional crown was attached to thesive enlargement of the socket, and using implant (figs. 7, 8). Xenograft was then packedan innovative method where endodontic between the implant and labial socket wall andfile was used to engage the canal wall and covered with a guided bone regeneration barrier The Journal of Implant & Advanced Clinical Dentistry • 9

Bajali et alFigure 13: Smile 2 years after restoration. Figure 14: Radiograph at 2 years.(figs 9, 10). Interrupted sutures were placed to cal time, a single local anesthetic injection,close the flap (fig. 11). A radiograph was taken a flapless procedure and immediate place-to see the implant placement and was found to ment of the implants. From the patient’s pointbe satisfactory. Post operative instructions were of view, the immediate incorporation of a fixedgiven to the patient, and was asked to report implant supported provisional restoration isafter 1 week. The sutures were removed after 7 very acceptable and even requested. With thedays and the patient received temporary acrylic clinical procedure described here, both dentistcrown bonded to the adjacent teeth with fibre- and patient can evaluate the aesthetics of thereinforced composite on the same day. The restoration. Soft-tissue support is enhancedpatient was recalled after four months for the and achievement of the desired result is facili-prosthetic procedures and was given porce- tated. With initial implant stability, proper tissuelain fused to metal crown over the implant. He management and correct use of the availablewas recalled for prophylaxis and follow up every implant components, a predictable aestheticthree months. The clinical and radiographic result can be produced. On the other hand,appearances at six months and after one year occlusal control, oral hygiene and a regularshow good aesthetic result and acceptableosseointegration of the implant (figs. 12-14). DISCUSSIONImplant placement subsequent to tooth extrac-tion in conjunction with the use of provisionalrestorations in the anterior maxillary region iscertainly challenging for the dental practitio-ner. However, this treatment modality offersseveral advantages, including reduced clini-10 • Vol. 6, No. 6 • September 2014

Bajali et alrecall program should be considered prerequi- Correspondence:sites for maintaining a long-lasting restoration. Dr. M. Abu-Hussein [email protected] Single-tooth implants have shown highsuccess rates in both the anterior and the Disclosure:posterior regions of the maxilla and the man- The authors report no conflicts of interest with anything mentioned within thisdible.1–4 Immediate post-extraction implant article.placement has been done since the earlyyears of the clinical application of implants References:with very good clinical outcomes.5–8 Deci- 1. W agenberg BD, Ginsburg TR. Immediate implant placement on removal ofsive factors for immediate implant placementare lack of infection in the periodontal tissues the natural tooth: retrospective analysis of 1,081 implants. Compendium ofand an intact tooth socket. Immediate incor- Continuing EducDent 22:399-404; 2001poration of a temporary restoration has beenpresented in the literature with encouraging 2. Cooper LF, Rahman A, Moriarty J, et al. Immediate mandibular rehabilitationresults.7–14 Although clinical experiences have with endosseous implants: simultaneous extraction, implant placement, andadvocated this clinical technique for many loading. Int JOralMaxillofac Implants 17:517-25; 2002years, more extended long term clinical stud-ies are necessary to prove the efficacy of the 3. D ouglass GL, Merin RL. The immediate dental implant. J California Dentmethod and establish a stable clinical protocol. Assoc30:362-5; 2002; CONCLUSION 4. Gelb DA. Immediate implant surgery: ten-year clinical overview. Compendium of Cont Educ Dent 20:1185- 92; 1999This case report describes a technique to pre-serve and augment anterior aesthetics by 5. Cornelini R, Scarano A, Covani U, Petrone G, Piattelli A. Immediate one-stagecombining atraumatic teeth extraction, hard postextraction implant: a human clinical and histologic case report. Int J Oraland soft tissue augmentation, immediate pro- Maxillofac Implants15:432-7; 2000visionalization and using the platform switch-ing concept to preserve the buccaI plate. The 6. Calvo JL, Muñoz EJ. Implantes inmediatos oseointegrados como reemplazogingivaI tissue surrounding the implants has a caninos superiores retenidos. Evaluación a 3 años. Rev Europea Odontoe-remained stable with no recession two years stomatol 6:313-20; 1999following final crowns placement (fig. 14). Theimplant therapy must fulfill both functional and 7. C oppel A, Prados JC, Coppel J. Implantes post-extracción: Situación actual.esthetic requirements to be considered a pri- Gaceta Dental Sept. 120:80-6.; 2001mary treatment modality. Aiming to reduce theprocess of alveolar bone resorption and treat- 8. Zabalegui I, García M. En Gutiérrez JL, García M, eds. Integración de la im-ment time, the immediate placement of endos- plantología en la práctica odontológica. Madrid: Ergon. p. 127-36; 2002seous implants into extraction sockets achievedhigh success rate of between 94-100%, 9. N ovaes-Junior AB, Novaes AB. Soft tissue management for primary closure incompared to the delayed placement. ● guided bone regeneration: surgical technique and case report. Int J Oral Maxil- lofac Implants12:84-7; 1997 10. N ovaes-Junior AB, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J Oral Maxillofac Implants10:609-13; 1995 11. C oppel A, Prados JC, Coppel J. Implantes post-extracción: Situación actual. Gaceta Dental Sept.120:80-6; 2001 12. S trub JR, Kohal RJ, Klaus G, Ferraresso F. The reimplant system for immedi- ate implant placement. J Esthet Dent 9:187-96;1997 The Journal of Implant & Advanced Clinical Dentistry • 11

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Review of Platform Switching and a Wilcko et al New Concept Proposed for TissueRecession & Dental Implant ExposureDr. Peter Chien1 • Dr. Rita Hung2 • Dr. Zizhong Wu3 AbstractIn the mid-1990’s, a fortuitous experience feature. Unfortunately, a Platform Switch does realized by utilizing a small diameter abut- not resolve problems related to tissue reces- ment with a larger diameter dental implant sion, dental implant exposure, and deficiencyestablished a “switch” in platform diameter in vertical bone height due to lack of flexibilitybetween the abutment and the endosseous for clinicians to change the crown margin loca-dental implant. This relocation of platform-to- tion. The purpose of this article is to reviewabutment diameter, referred to as a Platform clinical benefits of the Platform Switch as wellSwitch, has been found to reduce marginal loss as to provide additional perspective on theof crestal bone, provides better implant stress macrostructure design problems that accountdistribution, and offers favorable results in bio- for the remaining clinical issues such as tissuelogical width. Certainly, there are numerous recession and implant exposure that have yetclinical advantages to dental implant systems to be solved. A new concept with respect towith a Platform Switch macrostructual design a reduction of platform diameter is introduced.KEY WORDS: Dental implants, platform switching, micro-gap, gingival recession, implant design 1. Los Angeles, California, USA 2. Mesa, Arizona, USA3. Director and Chief Surgeon for the People’s Liberty Army – 88th Hospital The Journal of Implant & Advanced Clinical Dentistry • 13

Chien et alFigure 1: Dental implant with a platform switch designfeature - showcasing a reduction in abutment diameter. INTRODUCTION Figure 2: Small gap resides between the abutment and the dental implant adjoining interface.Contributing factors that lead to minor oradvanced recession of hard and soft tissue OVERVIEW OF PLATFORMwill invariably result in the failure of an endos- SWITCHINGseous implant placement. Generally, facial/buccal plates resorb 1.5 mm- 2 mm1,2 within There are specific benefits of a Platform Switchthe first year after surgery which means that, design that include an enhanced preventionin combination with subsequent bone loss, in micro gap infiltrations, reduced tissue expo-it may result in implant thread exposure and sure/recession, and an advantage against dentalsubsequent implant failure.3,4 An expecta- implant exposure. These are contributing factorstion of 0.1 mm - 0.2 mm of bone resorp- that serve to significantly reduce resorption oftion will apply to each subsequent year.5,6 crestal bone.9,10 Platform Switch is the concept of utilizing a smaller diameter abutment in relation Lazzara and Porter were the first to develop to the interfacing surface of the implant platforman ideology of shifting an implant-abutment diameter.11,12 Post-restorative biologic processjunction towards a centralized location to con- resulting in the loss of crestal bone height isfine the inflammatory cell infiltrations within a altered when the outer edge of the implant-90-degree region which reduces the loss of abutment interface is horizontally repositionedmarginal bone loss.7 By relocating the inter- inward.13 Platform Switch offers the additionalfacing region between abutment and implant benefit of maintaining biological width and offerssurface area toward a central axis, the micro better stress distribution to a myriad of clinicalgap is relocated away from the contacting sur-face of the crestal bone.8 This design limitsconcentrations of infiltration zone (Figure 1).14 • Vol. 6, No. 6 • September 2014

Chien et alapplications.14 Additionally, a decrease in crestal Figure 3: Dimension for biological width. Implant is placedbone loss ensures a greater chance of success at an equal-crestal level.for the duration of a placed implant in alveolarbone when using the Platform Switch design.15-17 nificant loss in crestal bone.24 Furthermore, theCanullo et al., stated that Platform Switch on cervical portion of endosseous implants typicallymarginal bone level was discovered to be “dose- exhibits a degree of bone resorption. However,dependent”, meaning a greater platform-abutment in the case of a Platform Switch, a saucerizationmismatch resulted in the least marginal bone loss. (in surgical applications) creates an evacuationIt was concluded the degree of abutment-to- of tissue to form a shallow shelving depressionimplant interface may significantly change the out- to facilitate drainage.25 Confining and drain-come of peri-implant marginal bone remodeling.18 ing areas established serve to prevent exces- sive bone resorption. This design is particularly BENEFITS OF A critical for achieving good results in maxillary PLATFORM SWITCH aesthetic zones. It also ensures an enhanced sta- bility for dental implants within alveolar bone.26,27Micro GapAt the time of implant insertion, surfaces of an Biological Widthimplant and adjoining components are unpol- In order to obtain a satisfactory esthetic andluted and uninhabited by indigenous microbi- functional result of an implant placement, theota.19 When utilizing a two-piece implant system, preservation of crestal bone around endosseousa microscopic gap resides between the con- implants and maintenance of the gingival papillatacting surfaces of the implant and the abut- is imperative.28-30 Numerous factors includingment (Figure 2).20 Although surface contact is excessive occlusal stress can cause bone resorp-established between both components (implant tion or even failure of dental implant–bone inter-and abutment), infiltration of bacteria is gener- face. However, an absence of stress could alsoally unavoidable.21 Numerous clinical issues result in atrophy or even bone loss.31,32 Not onlymay result from colonization of bacteria within a does a Platform Switch design confine bacte-“micro gap.” They include soft tissue inflamma-tion/migration and a potential shift in the innateapical reestablishment of a biologic width. Colo-nization of bacteria or microbial will ultimately leadto resorption of crestal bone.22 A deterioration ofhard tissue will often resorb crestal bone to thefirst thread of an endosseous dental implant andinvariably lead to implant failure.23 The degreeof inflammation in peri-implant tissues is lessaround one-piece dental implants because of thelack of micro gap when compared to two-pieceimplants with a micro gap which results in a sig- The Journal of Implant & Advanced Clinical Dentistry • 15

Chien et alrial infiltration, but it also provides a better result cal advantage of shifting the stress concentrationin maintaining aesthetic and structural integrity of area away from the cervical bone-implant interface,gingival tissue.33 Junctional epithelium and con- resulting in less post-loading bone resorption.47nective tissue adjacent to the tooth, referring tothe area between the deepest point of the gingi- Maeda et al. in a 3D finite element analy-val sulcus and the alveolar bone crest, is known sis, found the biomechanical advantagesas the biologic width (Figure 3).34 When fabri- of platform switching. They noted that thiscating dental restorations, this distance is impor- design feature shifts the stress concentra-tant to consider because they must respect the tion away from the bone-implant interface,natural architecture of the gingival attachment if however these forces then increased in theharmful consequences are to be avoided.35 The abutment or the abutment screw as well.48biologic width is patient specific and may varyfrom 0.75-4.3 mm.36 Becker et al., could not dif- Remaining Clinical Issuesferentiate the Platform Switch and the control Implant exposure and tissue recession generallygroups statistically in an animal study and found arises out of issues of infection and rough implantthat Platform Switch could prevent apical down- surfaces at the neck area of the dental implant.49-52growth of the barrier epithelium in 28 days.37,38 Features of Platform Switch serve to solve many clinical implications, but more is needed to Since a Platform Switch macrostructure helps ensure an improved clinical result. The Platformprevent crestal bone resorption as well as an api- Switch design offers a beneficial result with a relo-cal recession of the gingival sulcus and junctional cation of micro gap bacteria colonization, a moreepithelium, it can be concluded that Platform effective preservation/maintenance of a biologi-Switch may help to maintain biological width and cal width and an improved distribution of stressprevent excessive tissue recession which can lead to cortical bone. However, issues with respect toto a higher probability of implant success.39-42 soft tissue recession and implant thread exposure (Figures 4a, 4b) are still not completely resolved. Cappiello et al. offered a clinical and radio- Furthermore, dental implants with a Platformgraphic prospective study in a control group that Switch design feature offer limited clinical benefitsshowed a reduction in bone resorption to 0.95 with respect to patients that may have deficiencymm compared to 1.67 mm of a control group. in vertical bone height and horizontal bone width.The Platform Switch design was responsiblefor the resulting benefit of limited bone loss.43 SOFT TISSUE RECESSION AND IMPLANT EXPOSUREBetter Stress DistributionPlatform Switch allows for bone remodel- Infectioning around an implant, enhancing the ability for A major contributor for progressive tissue reces-maintenance of the bone crest with a reduc- sion is the presence of an infection, eithertion in stress in the cervical region of the dental within an extraction zone or bacteria infiltrationimplant.44-46 Maeda et al. suggested that the plat- from an exposed implant thread or micro gap.53form-switching configuration has the biomechani- Due to design parameters, Platform Switch16 • Vol. 6, No. 6 • September 2014

Chien et alFigure 4a: Radiograph of resorption of alveolar boneleading to implant thread exposure.Figures 4b,c,d: Radiographs of dental implants resulting in Figure 4bcrestal bone loss.Figure 4c Figure 4d The Journal of Implant & Advanced Clinical Dentistry • 17

Chien et alFigure 5a: When there is a deficiency in horizontal bone Figure 5b: When there is a deficiency in vertical bonewidth, the thin buccal plate may result in implant exposure. height, a dental implant placed at bone level can cause damage to inferior alveolar nerve.endosseous implants require bone-level place-ment to ensure that the implant platform will vated by a patient with occlusal overload, whichnot exceed an equal-crestal position in verti- further damages crestal bone (Figure 5a).60cal height.54,55 This bone-level placement of theimplant platform prohibitively affects the limited Deficiency in Bone Heightability to drain and abate accumulations of bac- When limitations in mandibular alveolar boneteria and is not able to compensate for the typi- height exist, placing an implant at bone level maycal post-extraction bone resorption. When the cause damage to the inferior alveolar nerve. If suchrough surface area of dental implant threads a deficiency of vertical height prohibits an ability toare inevitably exposed, it tends to accumulate place an implant at bone level, you cannot sink the25 times more plaque than on smooth surfaces.56 platform. Furthermore, exposure of thread surface of a dental implant is unavoidable. This will proveDeficiency in Bone Width to be an automatic failure if the necessary boneAnother clinical issue to consider is when the height is not available (Figure 5b).61 Regardingalveolar crest is thin, establishing any crestal clinical cases with implant thread exposure orbone loss with subsequent accumulation of bac- advanced tissue recession, the current designsteria on implant surfaces will lead to second- of most dental implant systems do not allow cli-ary peri-implantitis and more bone deterioration. nicians to change crown margin location and toDuring dental implant site preparation, a surgical accommodate crestal bone loss or tissue reces-application of tapping may result in buccal/facial sion. In these clinical cases, dentists will have todehiscence and fenestration. This can aggravate remove the dental implants or to graft the areasa resorption of thin alveolar crest.57-59 Further- involved, which may involve more complications.more, this condition could potentially be aggra- Therefore, a new dental implant design is needed to solve these problems in a convenient manner.18 • Vol. 6, No. 6 • September 2014

Chien et alFigure 6: Conceptual design of a Platform Reduction(Slope and Steps Implant design). A NEW CONCEPT OF Figure 7: Cervical slope of Platform Reduction allows PROPOSED PLATFORM dental implant to be placed within narrow ridges and preserves thin buccal or lingual plate. REDUCTION DESIGN positioned narrow ridge after surgical toothThe concept of Platform Reduction refers to a extraction.62,63 This establishment of marginalreduction in implant platform diameter in rela- bone loss is commonly associated with buc-tion to the widest area on an implant body. cal dehiscence and fenestrations.64-66 Accord-This reduction in diameter of platform creates a ing to Rodríguez-Ciurana et al., 1-2 mm ofslope or steps, which start from the widest por- crestal bone is required to maintain the integ-tion of dental implant (it locates a couple of mil- rity of tissue to avoid tissue recession.67 Inlimeters apical to the platform) to the platform order to limit the effect of this marginal bonesurface of a dental implant (Figure 6). The loss, the intent of a dental implant macrostruc-design benefits for clinical implications may tual design concept should strive to replicateinclude a potential solution regarding thin buc- the natural biological contour of the alveolarcal-lingual plates, a solution to tissue reces- ridge, preserving the maximum amount of bone.sion, and ability to place implants with minimum Since Platform Reduction design does notvertical bone height. It offers an option to require tapping and it may allow slight underchange crown margin locations in case of preparation of implant site during implant sur-dental implant exposure or tissue recession. gery, thereby preserving more thin crestal bone facially and lingually (Figures 7, 8a, 8b).Thin Buccal Plate – Alveolar CrestAlveolar bone tends to exhibit a pattern ofbone resorption both in vertical and horizon-tal dimension which results in a more lingually The Journal of Implant & Advanced Clinical Dentistry • 19

Chien et alFigures 8a,b: Platform Reduction dental implant was placed in narrow ridge to preserve thin buccal or lingual plate.Solving Issues with Tissue Exposure prevent unnecessary tissue recession whileBased on our clinical experience, Platform accommodating the natural biological con-Reduction may also provide the added ben- tour of an alveolar ridge. This possible ben-efit of a “tenting” effect where the surround- efit will require further clinical investigation.ing gingiva would rest along the slope of theimplant head providing gingival contact along Reducing Negative Effect of Micro Gapthe coronal section of an endosseous implant. The one-piece dental implant design does notThis outcome may result in a reduction in api- have micro gap. Therefore, there is no hori-cal migration of the biological width, with zontal bacteria infiltration.68 With a Platformrespect to the gingival sulcus and junctional Reduction design, there may be another poten-epithelium, providing a better aesthetic and tial benefit of placing an implant more coro-healthy result. For this concept, the slope (or nally, which may allow for intra-oral drainagesteps) of the Platform Reduction may serve to coronally of bacteria infiltration. This design20 • Vol. 6, No. 6 • September 2014

Chien et alFigure 9: Platform reduction allows for a reduced effect implant thread exposure. Then, how should aof micro gap vir a direct coronal drainage of bacteria dentist or oral surgeon proceed? Therefore, it isinfiltration. important to design a dental implant that may be placed supragingivally, subgingivally or equalmay drastically prohibit colonization of bacte- crestally which means there are more optionsria infiltrates horizontally which usually leads to for dentists to position dental implants accord-bone resorption to the first thread (Figure 9).69 ing to pre-existing alveolar bone deficiencies in vertical height to avoid nerve injury. In otherChange Margin Locations words, the platform design of a dental implantOnce a dental implant is placed and a crown is with a Platform Reduction may provide sur-affixed to an abutment, in a two-piece implant geons an advantage of flexibility to compensatesystem, it is difficult to properly accommodate for minimum available bone height to preventproblems related to bone resorption and tissue nerve injury by allowing the platform of dentalrecession. If a patient is afflicted with issues, implant to be placed supragingivally or supra-such as periodontal disease, deterioration of crestally (Figure 10). In addition, reduction ofalveolar bone, or other clinical issues, then an implant platform diameter along a slope orthese factors may invariably lead to subsequent steps also provides an advantage of maximum flexibility for restorative dentists to perform pros- thetic correction. In other words, a restorative dentist can assign multiple crown margin loca- tions according to soft tissue level to achieve aesthetic and functional demand (Figure 11). CONCLUSION After systemic review of Platform Switch design, we found that it is an effective option to reduce marginal bone loss, provide better implant stress distribution and offer favorable results in maintaining biological width. How- ever, a Platform Switch leaves many unsolved problems to many clinical issues. Progressions in technological advancement of dental implant systems will invariably continue. The proposed concept of a reduction in platform diameter may offer numerous clinical benefits to maintain the integrity of gingival tissue and crestal bone. A dental implant with a Platform Reduction macrostructure may be the viable solution to The Journal of Implant & Advanced Clinical Dentistry • 21

Chien et alFigure 10: Placement of dental implant platform at different levels to avoid inferior alveolar nerve damageFigure 11: Platform reduction design would allow the dentist to sit crown margins at different steps to prevent injury to theinferior alveolar nerve.22 • Vol. 6, No. 6 • September 2014

Chien et alaccommodate for tissue recession and implant AADDVVERETIRSETWISITHEexposure because it can provide the addedbenefit of crown margin relocation without TODAY!requiring dental implant replacement. Since thecoronal portion of dental implant body is angled Reach more customerstoward a central axis, it follows the biological with the dentalcontour (thinner at coronal portion) of the alveo- profession’s firstlar ridge. The Platform Reduction architecture truly interactivemay help to preserve a thin buccal plate andprevent crestal bone loss. This should provide paperless journal!additional room for maintaining alveolar bone,building thicker soft tissue and maintaining the Using recolutionary online technology,tissue structure. However, more clinical studies JIACD provides its readers with anare needed to prove the proposed benefits. ● experience that is simply not available Correspondence: with traditional hard copy paper journals. Dr. Peter Chien 725 S Bixel St. #654B Los Angeles, CA 90017 Phone: 951-660-4442 Email: [email protected] WWW.JIACD.COM The Journal of Implant & Advanced Clinical Dentistry • 23

Chien et alDisclosure 12. Rodríguez-Ciurana X, et al. The effect of 23. H ermann JS, Cochran DL, Nummikoski PV,The authors of this article report no conflicts of interimplant distance on the height of the Buser D. Crestal bone changes around titaniuminterest. interimplant bone crest when using platform- implants. A readiographic evaluation of unloadedReferences switched implants. Int J Perio Rest Dent nonsubmerged an submerged implants in the1. A lbrektsson, T., Zarb, G., Worthington, P. & 2009;29:141–151. canine mandible. J Periodontol 1997;68:1117- 1130¬ Erikson, A.R. (1986) The long-term efficiency 13. Maeda Y, Horisaka M, Yagi K. Biomedical of currently used dental implants: a review and rationale for a single implant-retained mandibular 24. H ermann JS, Buser D, Schenk RK, Schoolfield proposed criteria of success. International Journal overdenture: An in vitro study. Clin Oral Implant JD, Cochran DL. Biological Width around one- of Oral & Maxillofacial Implants I: 1-25 Res 2008; 19:271-5 and two- piece titanium implants. A histometric2. S mith DE, Zarb GA. Criteria for success of evaluation of unloaded nonsubmerged and osseointegrated endosseous implants. J Prosthet 14. Vela-Nebot X, et al. Benefits of an implant submerged implant in the canine mandible. Clin Dent. 1989;62:567-72. [PubMed: 2691661] platform modification technique to reduce Oral Impl. Res, 2001;559-5713. B user Weber HP, Lang NP. Tissue integration crestal bone resorption. Implant Dent of non-submerged implants. 1-year results of a 2006;15:313–320 25. C appiello M, Luongo , Di Iorio D, Bugea C, prospective study with 100 ITI hollow-cylinder and Cocchetto R, Celletti R. Evaluation of peri- hollow-screw implants. Clin Oral Implants Res. 15. Hurzeler M, Fickl S, Zuhr O, Wachtel HC. implant bone loss around platform –switched 1990;1:33-40. [PubMed] Peri-implant bone level around implants with implants. Int J Periodontics Restorative Dent.4. Adell, R., Lekholm, U., Rockler, B. & Branemark, platform switched abutments: Preliminary data 2008;28:347-55 P.I. (1981) A 15-year study of osseointegrated from a perspective study. J Oral Maxillofac implants in the treatment of the edentulous jaw. Surg. 2007;65(7 Suppl 1):33-9. [PubMed: 26. A lbrektsson T, Branemark Pl, Hansson HA, International Journal of Oral Surgery 10:387-416 17586347] Lindstrom J. Osseointegrated titanium implant:5. A dell, R., Lekholm, U., Rockler, B., Branemark, requirements for ensureing a long-lasting, direct P.I. Lindhe, J., Eriksson, B. & Sbordone, L. (1986) 16. Baumgarten H, Cocchetto R, testori T, Meltzer bone to implant anchorage in man. Acta Orthop Marginal tissue reactions at osseointegrated A, Porter S. A new implant design for crestal Scand. 1981;52(2):155-70 titanium fixtures (I). A 3-year longitudinal bone preservation: Initial observations and case prospective study. International Journal of Oral report. Pract Proced Asthet Dent. 2005;17:735- 27. A lbrektsson T, Zarb G, Worthington P, Erisson and maxillofacial Surgery 15: 39-52 40. [PubMed: 16506616] RA. The longterm efficacy of currently used6. H eydenrijk K, Meijer HJ, van der Reijden dental implants: a review and proposed criteria WA, Raghoebar GM, Vissink A, Stegenga 17. C alvo Guirado JL, Ortiz Ruiz AJ, Gomez of success. Int J Oral Maxillofac Implants. B. Microbiota around root-form endosseous Moreno G, Lopez Mari L, Bravo Gonzalez LA 1986;1(1):11-25 implantsL A review of the literature. Int J Oral Immediate loading and immediate restoration Maxillofac Imlpants 2002;17:829-838 in 105 expanded-platform implantsvia the Diem 28. S orensen JA. A standardized method for7. L azzara RJ, Porter SS. Platform switching System after a 16-month follow-up period. Med determination of crown margin fidelity. J Prosthet A New concept in implant dentistry for Oral Patol Oral Cir Bucal. 2008;13:E576-81. Dent 1990;64:18–24. controlling postrestorative crestal bone [PubMed: 18758403] levels. Int J Periodontics Restorative Dent. 29. H ermann JS, Schoolfield JD, Nummikoski 2006;26:9-17[PubMed] 18. Canullo L, Fedele GR, Ianneloo G, Jepson S. PV, Buser D, Schenk, Cochran DL. Crestal8. H ermann JSSJ, Buser D, Schenk RK, Cochran Platform switching and marginal bone-level bone changes around titanium implants: DL. Influence of the size of the microgap on alterations: The result of a randomized-controlled A methodology study comparing linear crestal bone changes around titanium implants: trial. Clin Oral Implants Res 2010;21:115-121 radiographic with histometric measurments. Int J A histometric evaluation of unloaded non- oral Maxillofac Implants. 2001;16:475-85[PubM submerged implants in the canine mandible. J Clin 19. Quirynen, M. Van der Mei, H.C., Bollen, C.M.L., ed:111515994] Periodontal. 2001;72:1372-83 Schotte, A., Marechal, M., Doornbusch, G.I.9. Calvo Guirado JL. Saez Yuguero MR, Pardo Naert, I., Busscher, H.J. & van Steenberghe, 30. N evins, M; Skurow, HM. The intracrevicular Zamora G, Munoz Barrio E. Immediate D. (1993) An in vitro study of the influence restorative margin, the biologic width, and the provisionalization on a new implant design for of surface roughness of implants on the maintenance of the gingival margin. Int J Perio esthetic restoration and preserving crestal microbiology of supra- and sub- gingival plaque. Rest D 1984;3:31–49. bone. Implant dent. 2007;16:155-64. [PubMed: Journal of Dental Res earch 72:I304-I309 17563506] 31. G ottlieb, B. Der Epithelansatz am Zahne.10. D egidi M, Iezzi G, Scarano A, Piattelli A. 20. King GN, Hermann JS, Schoolfield JD, Buser Deutsche Monatsschrift für Zahnheilkunde D, Cochran DL. Influence of the size of the 5:142-147 Immediately loaded titanium implant with a microgap on crestal bone levels in non- tissue-stabilizing/maintaining design (‘beyond submerged dental implants: A radiographic 32. B ecker J, Ferrari D, Herten M, Kirsch A, Schaer platform switch’) retrieved from man after 4 study in the canine mandible. J Periodontol A, Schwarz F. Influence of platform switching weeks: A histological and histomorphometrical 2002;73:1111–1117 on crestal bone changes at non-submerged evaluation. A case report. Clin Oral Maxillofac titanium implants: A histomorphometrical study Surg. 2008;19:276-82 [PubMed: 18081870] 21. King GN, Hermann JS, Schoolfield JD, Buser in dogs. J Clin Periodontal. 2007;34:1089-9611. G ardner DM. Platform switching as a means to D, Cochran DL. Influence of the size of the [PubMed: 17953691] achieving implant esthetics. NY State Dent J. microgap on crestal bone levels in non- 2005;71:34-7. [PubMed: 16013682] submerged dental implants: A radiographic 33. B ecker J, Frerrari D, Mihatovic I, Sahm N, Schaer study in the canine mandible. J Periodontol A, Schwarz F, Stability of crestal bone level 2002;73:1111–1117 at platform-switched non-submerged titanium implants: A histomorphometrical study in dogs. 22. Quirynen M, Bollen CM, Eyssen H, van J Cin Periodontol. 2009;36:532-9.[PubMed: Steenberghe D. Microbial penetration along 19508252] the implant components of the Branemark system. An in vitro study. Clin Oral Implants Res 34. C arranza’s Clinical Periodontology, 9th Ed. W.B. 1994;5:239-244 Saunders, 2002, page 23.24 • Vol. 6, No. 6 • September 2014

Chien et al35. C ochran DL, Hermann JS, Schenk RK, 48. Papaspyridakos, P.; Mokti, M.; Chen, C. J.; 59. J ohnson K. A study of the dimensional changes Higginbottom FL, Buser D. Biologic width Benic, G. I.; Gallucci, G. O.; Chronopoulos, V. occurring in the maxilla following tooth around titanium implants. A histometric (2013). “Implant and Prosthodontic Survival extraction. Aust Dent J. 1969;14:241-244 analysis of the implant-gingival junction around Rates with Implant Fixed Complete Dental unloaded and loaded nonsubmerged implants Prostheses in the Edentulous Mandible after at 60. Hermann JS, Schoolfield JD, Nummikoski PV, in the canine mandible. J Clin Periodontal. Least 5 Years: A Systematic Review”. Clinical Buser D, Schenk RK, Cochran DL, Crestal 1997;68:186-98 Implant Dentistry and Related Research: n/a. Bone changes around titanium implants: doi:10.1111/cid.12036 . PMID 23311617. A methodological study comparing linear36. T arnow D. Elian N, Fletcher P, Froum S, Magner radiographic with histometric measurements. A, Cho SC, et al. Vertical distance from the crest 49. Berglundh, T.; Persson, L.; Klinge, B. (2002). “A of bone to the height of the interproximal papilla systematic review of the incidence of biological 61. N evins M, Camelo, De Paoli S, et al. A study of between adjacent implants. J. Periodontol. and technical complications in implant dentistry the fate of the buccal wall of extraction sockets 2003;74:1785-8. [PubMed: 14974820] reported in prospective longitudinal studies of at of teeth with prominent roots. Int J Periodontics least 5 years”. Journal of clinical periodontology. Restorative Dent. 2006;26:19-2937. T arnow DP, Cho SC, Wallace SS. The effect 29 Suppl 3: 197–212; discussion 232–3. of inter-implant distance on the height of doi:10.1034/j.1600-051X.29.s3.12.x . PMID 62. F iorellini JP, Howell TH, Cochran D. et al. inter-impant bone crest. J Clin Periodontol. 12787220. Randomized study evaluating recombinant 2000;71:546-9. human bone morphogenetic protein -2 for 50. Pjetursson, B. E.; Thoma, D.; Jung, R.; Zwahlen, extraction socket augmentation. J Periodontol.38. C appiello M, Luongo , Di Iorio D, Bugea C, M.; Zembic, A. (2012). “A systematic review of 2005;76:605-613 Cocchetto R, Celletti R. Evaluation of peri- the survival and complication rates of implant- implant bone loss around platform –switched supported fixed dental prostheses (FDPs) after 63. [BB] Cardaropoli G, Araujo M, Lindhe J. implants. Int J Periodontics Restorative Dent. a mean observation period of at least 5 years”. Dynamics of bone tissue formation in tooth 2008;28:347-55 Clinical Oral Implants Research 23: 22–38. extraction sites. An experimental study in dogs. J doi:10.1111/j.1600-0501.2012.02546.x . Clin Periodontal. 2003;30:809-81839. Manz MC. Factors associated with radiographic PMID 23062125. vertical bone loss around implants placed in a 64. Araujo MG, Lindhe J. Dimensional ridge clinical study. Ann Periodontol 2000;5:137–51. 51. B ozini, T.; Petridis, H.; Garefis, K.; Garefis, alterations following tooth extraction. An P. (2011). “A meta-analysis of prosthodontic experimental study in the dog. J. Clin40. S pray JR, Black CG, Morris HF, Ochi S. complication rates of implant-supported fixed Periodontal. 2005;32:212-218 The influence of bone thickness on facial dental prostheses in edentulous patients after marginal bone response: stage 1 placement an observation period of at least 5 years”. 65. J ohnson K. A study of the dimensional changes through stage 2 uncovering. Ann Periodontol The International journal of oral & maxillofacial in the maxilla after tooth extraction. Part 1: 2000;5:119–28. implants26 (2): 304–318. PMID 21483883. Normal healing. Aust Dent J. 1963;8:428-434 4541. B ratu EA, Tandlich M, Shapira L. A rough 66. J ohnson K. A study of the dimensional changes surface implant neck with microthreads 52. A dell R, Lekholm U, Rockler B. A 5 year occurring in the maxilla following tooth reduces the amount of marginal bone loss: a study of osseointegrated implants in the extraction. Aust Dent J. 1969;14:241-244 prospective clinical study. Clin Oral Implants treatment of edentulous jaw. Int Oral Surg Res 2009;20:827–32. 1981;10:387-416 67. R odríguez-Ciurana X, et al. The effect of interimplant distance on the height of the42. S chrotenboer J, Tsao YP, Kinariwala V, Wang 53. Ruggeri A, Franchi M, Marini N Trial P, Piattelli interimplant bone crest when using platform- HL. Effect of microthreads and platform A. Supracrestal circular collagen fiber network switched implants. Int J Perio Rest Dent switching on crestal bone stress levels: a finite around non submerged titanium implants. Clin 2009;29:141–151. element analysis. J Periodontol 2008;79:2166– Oral Impl Res 1992;3:169-75 72. 68. H ermann JS, Cochran DL, Nummikoski PV, 54. Finne K. Rompen E, Toljanic J. Clinical evaluation Buser D. Crestal bone changes around titanium43. C anullo L, Fedele GR, Iannello G, Jepsen S. of a prospective multicenter study on 1- piece implants. A readiographic evaluation of unloaded Platform switching and marginal bone-level implants: Part 1: Marginal bone level evaluation nonsubmerged an submerged implants in the alterations: the results of a randomized- after 1 year of follow up. Int J Oral Maxillofac canine mandible. J Periodontol 1997;68:1117- controlled trial. Clin. Oral Impl. Res. 21, 2010; Implants 1130¬ 115–121. 55. Quirynen M, Vogels R, Peeters W, van 69. T arnow DP, Cho SC, Wallace SS. The44. Gardner DM. Platform switching as a means to Steenberghe D, Naert I, Haffajee A. Dynamics effect of inter-implant distance on the height achieving implant esthetics. N Y State Dent J of initial subgingival colonization of ‘pristine’ of inter-implant bone crest. J Periodontol 2005;71:34–7. peri-implant pockets. Clin Oral Implants Res 2000;71(4):546-9 2006;17:25-3745. L azzara RJ, Porter SS. Platform switching: a new concept in implant dentistry for controlling 56. Steflik de, Mckinney RV, Koth DL. Ultrastructural post restorative crestal bone levels. Int J Peri- (TEM) observations of the gingival response to odontics Restorative Dent 2006;26:9–17. the single crystal sapphire endosteal implant. J Dent. Res 1982;61:23146. Maeda Y, Miura J, Taki I, Sogo M. Biomechanical analysis on platform switching: is there any 57. A raujo MG, Lindhe J. Dimensional ridge biomechanical rationale? Clin Oral Implants Res alterations following tooth extraction. An 2007;18:581–4. experimental study in the dog. J. Clin Periodontal. 2005;32:212-21847. W agenberg B, Froum SJ. Prospective study of 94 platform-switched implants observed from 58. Johnson K. A study of the dimensional changes 1992 to 2006. Int J Periodontics Restorative in the maxilla after tooth extraction. Part 1: Dent 2010;30:9–17. Normal healing. Aust Dent J. 1963;8:428-434 The Journal of Implant & Advanced Clinical Dentistry • 25

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Periosteal Pedicle Graft: Wilcko et alAn invigorate for root coverage proceduresMajor (Dr) B Harshavardhana1 • Major (Dr) Reenesh Mechery1 AbstractBackground: Various periodontal surgical pro- cal parameters were measured presur-cedures have evolved over time for obtaining gically, 3 and 6 months postsurgically.complete root coverage of gingival recessiondefects. A latest addition to these procedures Results: There was a reduction in the recessionis Mahajan’s periosteal pedicle graft which uses depth, probing depth and clinical attachmenta pedicled autogenous periosteum for root cov- loss. There was an improvement in the width oferage. The aim of this study was to evaluate keratinised gingival. On an average 85% of rootthe effectiveness of periosteal pedicle graft in coverage was achieved at the end of 6 months.treating Millers Class I and II isolated defects. Conclusion: Periosteal pedicle graft isMethods: Ten isolated Millers Class I/ effective in achieving root coverage in iso-II recession defects were treated using lated Millers Class I and II recession defectsperiosteal pedicle graft (PPG). The clini-KEY WORDS: Gingival recession, gingival grafting, pedicle graft, root coverage 1. Department of Dental Surgery, AFMC, Mathura, India The Journal of Implant & Advanced Clinical Dentistry • 27

Harshavardhana et alFigure 1: Pictorial representation of periosteal pedicle Figure 2: Isolated gingival recession on tooth FDI #13graft (PPG) procedure. before surgery. INTRODUCTION gery procedures is to obtain an optimal aes- thetic appearance with complete root coverageGingival recession is defined as the displace- and blending of the mucosa and/or gingiva.ment of the gingival marginal tissue apical to Although the predictability of the various sur-the cement enamel junction (CEJ).1 In most of gical treatment modalities varies, almost com-the cases, patients with gingival recession gen- plete coverage can be anticipated in Millerserally have complaints regarding aesthetics, Class I and Class II defects, while coveragedentin hypersensitivity, or inability to perform expected in Millers Class III and IV defects isproper oral hygiene procedures. In addition, if much less. Over the years, clinicians are con-the exposure of root cementum and/or dentin tinually seeking new procedures which areto the oral environment due to recession is not less morbid and more predictable for root cov-addressed it can lead to root caries and other erage. One such new procedure for reces-problems such as abrasions and chemical ero- sion coverage as patented by Mahajan is thesion. Predisposing factors for gingival reces- utilisation of the periosteal pedicle graft (PPG)sion are a thin gingival biotype, prominence of technique (Figure 1).4 PPG is a GTR basedteeth, and patients with obsessive oral hygiene. treatment which avails the osteogenic poten-Miller, based on anatomical considerations, has tial of the periosteum due to its highly vascu-classified the recession defects into 4 types.2 lar nature, presence of fibroblasts, osteoblasts and stem cells.5 But the query that arises is Over time, various periodontal surgical pro-cedures have evolved for treating recessiondefects such as rotational and advanced gin-gival flaps, free gingival or connective tissuegrafts, and guided tissue regeneration (GTR).3The main goal of these periodontal plastic sur-28 • Vol. 6, No. 6 • September 2014

Harshavardhana et alFigure 3a: Combination flap is raised. Figure 3b: Pedicled periosteum is elevated.weather PPG is really effective in covering was the presence of isolated Millers Class I or IIrecession defects as other procedures men- recession defects (Figure 2) in the labial aspecttioned above. To concoct this contention the of either maxillary or mandibular anterior toothfollowing study was conducted to evaluate the which was vital and did not have any periapi-effectiveness of using PPG in treatment of iso- cal pathology. Patients with any systemic con-lated Millers Class I and II recession defects. dition which would influence the course of periodontal disease or treatment, who were MATERIAL AND METHODS smokers/tobacco consumers, who had orth- odontic appliances, who had previously under-Subject Selection gone surgery for recession coverage of theTen patients (7 males and 3 females) between defect, and pregnant or lactating women werethe ages of 20 to 45 years attending the outpa- excluded from the study. All subjects were ver-tient department of Department of Dental Sur- bally informed and written informed consentgery, AFMC were randomly selected for the was obtained for their participation in the study.study. The criterion for inclusion into the study The Journal of Implant & Advanced Clinical Dentistry • 29

Harshavardhana et alFigure 4a: Rotated periosteum is stabilized. Figure 4b: Coronally advanced flap sutured.Pre-surgical Evaluation which was the distance between cementoe-Proper case history was recorded for all the namel junction to the apical most margin ofpatients. Routine hematological and urine the gingiva, Clinical attachment level (CAL) ininvestigations were performed. Intraoral peri- which the PD was added to the RD, Width ofapical radiographs of the concerned tooth keratinized gingival (KG) which was the dis-were recorded. Phase I therapy was insti- tance measured between the mucogingivaltuted to all the patients and after the mainte- junction to the apical most margin of gingiva.nance phase they were taken up for surgery.The clinical parameters measured before the Surgical Proceduresurgery (baseline), 3 months and 6 months One month after the initiation of Phase I ther-after the surgery with the help of a UNC-15 apy, the patients were seen for root coverageprobe were: Probing depth (PD) which was surgical procedures utilizing the PPG tech-the distance the probe penetrated the depth nique. The clinical parameters were recordedof the gingival sulcus, Recession depth (RD) presurgically for the concerned tooth. The facial30 • Vol. 6, No. 6 • September 2014

Harshavardhana et alFigure 5: Post-Op 6 months result of root coverage using ing at the terminal ends of the horizontal inci-periosteal pedicle graft. sions which extended beyond the mucogingival junction. A full thickness mucoperiosteal flapskin all around the oral cavity was scrubbed was raised about 2 mm apical to the osseouswith 7.5% povidone iodine solution and the crest (Figure 3a). Tension was created by pull-intra oral surgical site was painted with 5% ing the flap bucally and incision was contin-povidone iodine solution. The surgical site was ued through the periosteum to create a partiallocally anaesthetised using 2% Lignocaine with thickness flap. The overall raised flap was a1:80,000 adrenaline. After profound anaesthe- combination of both full thickness and a par-sia was achieved, an intrasulcular incision was tial thickness flap. Two vertical incisions weremade with No. 11 Bard Parker surgical blade made in the periosteum starting 2 mm apical toin the tooth with recession. Two horizontal inci- the point from where the partial thickness inci-sions were made perpendicular to the adjacent sion was performed. The vertical incisions wereinterdental papillae, slightly coronal to CEJ pre- then be joined by a single horizontal incision onserving the gingival margin of the neighbouring the apical most part of periosteum. The perios-teeth. Two vertical incisions were given start- teum was then raised with a periosteal eleva- tor starting from the horizontal incision (Figure 3b). Care was taken not to detach the perios- teum at the coronal portion. Root planning was thoroughly done and depapillation was done on adjacent papilla. The pedicled periosteum obtained was then rotated to cover the reces- sion defect and secured using and 5-0 absorb- able suture (Figure 4a). The flap was then coronally advanced over the recession defect and secured using 3-0 non absorbable sutures (Figure 4b). Periodontal pack and post-oper- ative instructions were given to the patients. Patients were prescribed antibiotics, analge- sics and were instructed for oral rinsing with 0.2% chlorhexidine mouth wash twice daily. Both the sutures and pack were removed one week later. Patients were recalled and assessed postoperatively every 30 days for six months. At the end of 3 and 6 months all the clinical parameters were recorded again (Figure 5). The pre and post-surgical parameters recorded were tabulated and presented as mean The Journal of Implant & Advanced Clinical Dentistry • 31

Harshavardhana et alTable 1: Statistical Comparison of Clinical Parameters using ANOVA. Recession Probing Clinical Keratinized Clinical Parameters depth depth attachement level gingiva width (Mean +/-SD) (Mean +/-SD) (Mean +/-SD) (Mean +/-SD) Baseline (Presurgical) 3.4 +/-0.51mm 2.7 +/-1.03 5.3 +/-1.86 2.3 +/-1.90 3 months 0.3 +/-0.35mm 1.1 +/-0.45 1.5 +/-0.52 5.6 +/-1.70 6 months 0.5 +/-0.55mm 1.4 +/-0.56 1.8 +/-0.92 5.4 +/-1.4 Intergroup comparison 0.001 0.001 0.001 0.001 ‘P’ value+/- standard deviation. The statistical analy- and slightly increased to 0.5 +/- 0.55 mm insis was done by setting the ‘P’ value at 0.05. 6 months, with slight variations for measure- ments at the other time intervals (Table 1). RESULTS When the results were expressed as a per- centage of root coverage, the amount obtainedTen patients (mean age: 32.2 +/- 9.0 years) was 91.2% in 3 months and reduced to 85.6%with isolated Miller’s Class I or II recession in 6 months. The mean PD which was 2.7 +/-defects were enrolled into the study. All the 1.03 mm at baseline was 1.1 +/- 0.45 mm and10 patients (7 males & 3 females) completed 1.4 +/- 0.56 mm in 3 and 6 months respec-the study. The data set was complete with tively. The mean CAL was 5.3 +/- 1.86 mm atno missing data. Six patients had defects baseline and improved to 1.5 +/- 0.52 mm inin the maxillary arch and 4 had defects in the 3 months and finally to 1.8 +/- 0.92 mm in 6mandibular arch and all were in the ante- months. The mean KW which was measured atrior region. Of the 10 defects 4 were local- 2.3 +/- 1.90 mm at baseline increased to 5.6ized to canine, 4 were localized to central +/- 1.70 mm in 3 months and slightly reducedincisor and 2 were localized to lateral incisor. to 5.4 +/- 1.4 mm in 6 months (Table 1). All the patients showed significant post- The intergroup comparison using ANOVAsurgical improvement in recession coverage was done at different stages and for all thewhen compared with baseline. The mean RD clinical parameters. This showed that the inter-decreased significantly from 3.4 +/- 0.7 mm group comparisons for all were highly signifi-at baseline to 0.3 +/- 0.35 mm in 3 months32 • Vol. 6, No. 6 • September 2014

Harshavardhana et alTable 2: Inter Group Comparison using Student’s T-test. Baseline v/s Baseline v/s 3 months v/s Inter group 3 months 6 months 6 months comparison ‘P’ value ‘P’ value ‘P’ value 0.001 0.002 0.240 Recession depth (Mean +/-SD) 0.015 0.012 0.140 Probing depth 0.001 0.002 0.160 (Mean +/-SD) 0.001 0.002 0.140 Clinical attachment level (Mean +/-SD) Keratinized gingiva width (Mean +/-SD)cant (< 0.05) (Table 1). The student’s t-test epithelial connective tissue grafts (SCTG)when applied revealed that the ‘P’ value was which is considered the gold standard.6,7 Butsignificant (<0.05) in baseline & 3 months and it does have shortcomings like secondary sur-baseline & 6 months for all the clinical parame- gical site and limited quantity of graft. Maha-ters except for the PD in which the values were jan was the first to use this PPG for recessionnot significant (>0.05) [Table 2]. The compari- coverage and achieve complete root coverage.son between 3 and 6 months for all the clini- Only very few case reports and particularlycal parameters were not significant (Table 2). one study is are available about PPG.4,8 The pedicled periosteum which is a latest addition DISCUSSION comprises of at least two layers, an inner cellu- lar or cambium layer and an outer fibrous layer.The aim of the current study evaluated the The inner layer contains numerous osteoblastseffectiveness of PPG in coverage of Miller’s and osteoprogenitor cells and the outer layer isClass I and II recession defects. Various tech- composed of dense collagen fibers, fibroblastsniques over the years have been used to obtain and their progenitor cells.9 Hence the regen-root coverage in patients with gingival reces- erative potential of the periosteum is immense.sion defects.3 Some structured reviews have Since the periosteum is rich in vascular plexusrevealed a superior root coverage in Miller it makes a predictable and viable graft over anClass I and II recession defects with the sub- The Journal of Implant & Advanced Clinical Dentistry • 33

Harshavardhana et alavascular root surface. Studies have been con- ies by Trombelli et al and Muller et al whereinducted using periosteum as a barrier membrane the PD increased post surgically.14,15 Ourfor the treatment of periodontal defects.10,11 PD results were in par with study by Harris.16 The PD did not alter much as the etiological As PPG is fairly a new technique for reces- The mean CAL drastically improved from 5.3sion coverage, we decided to do a pilot study of +/- 1.86 mm at baseline to 1.8 +/- 0.92 mmjust 10 cases to visualize its potential in achiev- post surgically. This result is in par with stud-ing root coverage. We decided for studying only ies by Mahajan and Jepsen et al.8,17 But stud-isolated defects since mostly the principal rea- ies by Zucchelli et al. and Harris have provedson for isolated defects are faulty tooth brush- otherwise in which the gain in CAL in not thating and hence the bone loss associated will much.16,18 As expected like in studies by Jep-be minimal, which becomes a crucial factor in sen et al and Harris, the mean KW improvedensuring the success of the surgical procedure. to around 5.4 mm postsurgically from pre-sur-Selection of cases becomes an important crite- gical 2.8 mm.16,17 The healing in all the casesrion here as a patient with a thin biotype gingiva was uneventful. No necrosis of the graft wasor a malposed tooth is not a suitable candi- observed postoperatively in any of our cases.date for PPG. Either the gingiva has to be aug- This characteristic advantage is because of themented or the malposition corrected before root pedicle attachment to the bone and the coro-coverage. In our study almost complete root nally positioning of the flap over the graft ensur-coverage was achievable in most of the cases. ing good protection of the graft. In two casesThe mean RD reduced from 3.4 +/- 0.7 mm to the gingival contour obtained after six months0.5 +/- 0.55 mm at the end of six months giv- was bulkier than normal. This may be attribut-ing us around 85% root coverage. This result able to the excessive thickness of the perios-is in comparison to a PPG study by Mahajan, teum harvested which was more than actuallyslightly higher than SCTG study by Ricci et required. So it becomes evident that the thick-al and lower than an SCTG study by Rachlin ness of the graft harvested is a very importantet al.8,12,13 Even though the average root cov- criterion for success. The overall advantageserage was around 85% in two of the cases of this technique are: Presence of periosteumthe root coverage obtained was just around adjacent to the defect and in sufficient quan-72 %. This partial coverage achieved may be tity avoiding two surgical sites resulting in lessbecause of the non-compliance of the patient surgical trauma, postoperative complicationstowards proper oral hygiene protocols as and better patient satisfaction. More than oneadvised by our team. Since the results of PPG adjacent recession defects may be addressedis in par with that of SCTG, it definitely has an in a single surgery using this technique.upper hand over the disadvantages of the later. CONCLUSION The mean PD pre and post surgically whencompared even though was not statistically sig- The PPG technique opens a new vista innificant but slight improvement of about 1 mm the techniques used for root coverage. Thewas seen. This result does not match with stud-34 • Vol. 6, No. 6 • September 2014

Harshavardhana et alPPG technique requires certain prerequisites should be undertaken in a larger scale in ordersuch as good surgical dexterity on the part of to use it on regular basis for root coverage. ●the operator, especially during the lifting upof the periosteum which is firmly adherent to Correspondence:the underlying bone. Any long term compli- Major (Dr) B Harshavardhana,cations with the PPG technique are yet to be 1 CDU,assessed. Histological studies revealing the Mathura - 281001.exact type of healing as well as randomized Phone : +918954502006controlled trials comparing the results of this E-mail: [email protected] with already established techniquesDisclosure 8. Mahajan A, Bharadwaj A, Mahajan P. Compari- 14. Trombelli L, Scabbia A, Tatakis DN, CaluraThe authors report no conflicts of interest with son of periosteal pedicle graft and subepithe- G. Subpedicle connective tissue graft versusanything mentioned in this article. lial connective tissue graft for the treatment guided tissue regeneration with bioabsorbable of gingival recession defects. Aust Dent J membrane in the treatment of human gingivalReferences 2012;57(1):51-7. recession defects. J Periodontol 1998;1. A merican Academy of Periodontology. Glossary 69:1271-7. 9. Brook AL. The periosteum: its function reas- of periodontal terms. 3rd edn. Chicago: Ameri- sessed. Clinical Orthopaedics and Related 15. Muller HP, Stahl M, Eger T. Root coverage can Academy of Periodontology, 1992. Research 1984;189:300–7. employing an envelope technique or guided tissue regeneration with a bioabsorbable2. M iller PD. A classification of marginal tissue 10. Lekovic V, Kenney EB, Carranza FA, Marti- membrane. J Periodontol 1999;70:743-51. recession. Int J Periodontics Restorative Dent gnoni M. The use of autogenous periosteal 1985;5:8-13. grafts as barriers for the treatment of Class 16. Harris RJ. A comparison of 2 root coverage II furcation involvements in lower molars. J techniques: guided tissue regeneration with3. A merican Academy of Periodontology. Acad- Periodontol 1991;62(12):775–80. bioabsorbable matrix style membrane versus emy Report. Oral reconstructive and correc- a connective tissue graft combined with coro- tive procedures used in periodontal therapy. J 11. Kwan SK, Lekovic V, Camargo PM. The use nally positioned pedicle graft without vertical Periodontol 2005;76:1588–1600. of autogenous periosteal grafts as barriers for incisions. Results of a series of consecutive the treatment of intrabony defects in humans. cases. J Periodontol 1998;69:1426-34.4. M ahajan A. Periosteal pedicle graft for the J Periodontol 1998;69:1203–19. treatment of gingival recession defects: a novel 17. J epsen K, Heinz B, Halben JH, Jepsen S. technique. Australian Dental Journal 2009; 54: 12. Ricci G, Silestri M, Tinti C, Rasperini G. A Treatment of gingival recession with titanium 250–254. clinical/statistical comparison between the reinforced barrier membranes versus connective subpedicle connective tissue graft method tissue grafts. J Periodontol 1998;69:383-91.5. M ahajan A. Periosteum: A highly underrated and the guided tissue regeneration technique tool in dentistry. Int Journl of Dent 2012; 2: 1-5. in root coverage. Int J Periodontics Restor- 18. Zucchelli G, Clauser C, de Sanctis M, Ca- ative Dent 1996;16:539-45. landriello M. Mucogingival versus guided tis-6. R occuzzo M, Bunino M, Needleman I, Sanz M. sue regeneration procedures in the treatment Periodontal plastic surgery of localized gingival 13. Rachlin G, Koubi G, Dejou J, Franquin JC. The of deep recession type defects. J Periodontol recessions: A systematic review. J Clin Peri- use of a resorbable membrane in mucogin- 1998;69:138-45. odontol 2002;29(Suppl.3):178-94. gival surgery. Case series. J Periodontol 1996;67:621-6.7. O ates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival reces- sion. A systematic review. Ann Periodontol 2003;8:303-20. The Journal of Implant & Advanced Clinical Dentistry • 35

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Comparative Evaluation of Remineralization Singh et al Potential of Different Materials on Enamel Lesion: An In Vitro StudyDr. Amanpreet Singh1 • Dr. Neeraj Mahajan2 AbstractObjective: The aim of this study was to assess calcium phosphate (CPP-ACP), and combinationand compare the ability of Tooth Mousse (CPP- of casein phosphopeptide - amorphous calciumACP containing toothpaste), Tooth Mousse phosphate and fluoride (CPP-ACPF). A cariesPlus (CPP-ACP/ fluoride 900 ppm contain- progression test (pH cycling) was carried outing toothpaste) and Novamin (calcium sodium and surface microhardness was measured again.phosphosilicate containing toothpaste) to Cross-sectional microhardness (CSMH) was eval-remineralize early enamel lesion in vitro. uated to assess any subsurface remineralization.Materials and Methods: In this study, twenty Results: Combination of casein phosphopep-intact caries free extracted human premolars were tide - amorphous calcium phosphate and fluoridecollected. The coronal part of each tooth was sec- (CPP-ACPF) has better remineralizing propertiestioned into four parts. The surface microhardness as compared to the other remineralizing agents.(SMH) was measured using Vickers microhard-ness (VHN) testing machine before as well as after Conclusion: CPP-ACP paste significantly rem-demineralization. Artificial enamel carious lesions ineralized the artificial enamel lesion in vitro.were created on each enamel specimen by sus- The surface hardness increases with applica-pending them in demineralization solution. Enamel tion of CPP-ACPF, CPP-ACP and Novaminspecimens were then subjected to different rem- separately on induced demineralized enamelineralization products i.e. calcium sodium phos- in vitro. The surface hardness increase is maxi-phosilicate, casein phosphopeptide -amorphous mum in CPP-ACPF and least in control group.KEY WORDS: CPP-ACP; Demineralization; Novamin.; Remineralization1. Senior Lecturer, B.J.S. Dental College, Ludhiana, Punjab, India 2. Professor & Head, GNDDC, Sunam, Punjab, India The Journal of Implant & Advanced Clinical Dentistry • 37

Singh et alFigure 1: Graphical Representation of Division of Number of samples. INTRODUCTION vides the benefit of having both calcium and phosphate ions close to each other in an amor-Despite worldwide improvements in the oral phous phase. The beneficial effect obtainedhealth, dental caries is still a major oral health with CPP-ACP is associated with ability toproblem in most industrialized countries, affect- localize calcium and phosphate in the dentaling 60-90% of school children and the vast plaque in the proximity of the tooth, thus mak-majority of adults. Dental caries is a pathologi- ing it available when needed. In the presencecal condition that results from an imbalance in of an acid environment, such as after eating,the physiological process of remineralization/ when pH of the mouth decreases, the caseindemineralization of the dental structure. Differ- phosphopeptide proteins release amorphousent preventive therapies have been studied to calcium and phosphate, creating a supersatu-enhance remineralization, decrease demineraliza- rated state of calcium and phosphate around thetion and therefore, arrest the active caries lesions. tooth. Novamin: the active ingredient is a cal-Fluoride is recognized as a remineralizing agent. cium sodium phosphosilicate that reacts when Amorphous calcium phosphate (ACP) pro-38 • Vol. 6, No. 6 • Septemer 2014

Singh et alFigure 2: Graphical Representation of mean surface microhardness scores after remineralizaion.exposed to aqueous media, thus providing cal- the centre. Then the prepared samples werecium and phosphate ions to the applied surface. subjected to Vickers microhardness test to evaluate surface microhardness. After testing MATERIALS & METHODS the surface microhardness, the samples were subjected to the process of demineralization.Twenty extracted premolars free of caries, werecleaned of any surface debris &stored in nor- Caries Lesion Formationmal saline. The coronal part sectioned bucco- Carious lesions representing preliminary stagelingually and mesio-distally into four sections. of subsurface enamel demineralization wereCustom made cylindrical molds were made then produced by suspending four sections ofeach enamel specimen with enamel surface each tooth into glass tubes containing 50 mlexposed was embedded on the top of partially of demineralization solution, for 72 hours, inset acrylic resin mold, nail varnish was applied an incubator at a temperature of 35oC.5 Afteraround the exposed enamel surface leaving a induction of enamel lesions, all the speci-window of 3mm × 3mm of enamel exposed at The Journal of Implant & Advanced Clinical Dentistry • 39

Singh et alFigure 3: Graphical Representation of mean subsurface microhardness scores after remineralization.mens were evaluated for surface microhard- Section 4- this served as the control groupness. Later, these samples were subjected to where no surface treatment was performed.the process of remineralization and ph cycling. pH CyclingExperimental Procedure A pH cycling regimen included surface treat-Section 1- a generous layer of Calcium Sodium ment, alternative demineralization (three hours)Phosphosilicate agent was applied with applica- and remineralization (21 hours) for five consecu-tor brush and left undisturbed for 20 minutes. tive days. For demineralization phase, the demin-Section 2- a generous layer of CPP-ACP eralization solution used for induction of enamelagent was applied with applicator brush lesion was used and for remineralization phase,and left undisturbed for 20 minutes. synthetic saliva preparation was carried out. AfterSection 3- a generous layer of CPP-ACPF pH cycling again Vickers microhardness numberagent was applied with applicator brush was assessed for all the specimens under 100gand left undisturbed for 20 minutes. load for 20 seconds and data was recorded.40 • Vol. 6, No. 6 • Septemer 2014

Singh et alFigure 4: Mean subsurface microhardness after ● Surface Microhardness of Enamel afterremineralization Demineralization: The mean hardness of enamel after demineralization in Group 1, 2, 3Cross Sectional Microhardness and 4 was 162.75 VHN.Each specimen was longitudinally sectioned ● Surface Microhardness values after Rem-into two halves through center of the window. ineralization: Group 1 shows the mean surfaceAll the sections were evaluated for the mea- microhardness score of 194.90 VHN. In Groupsurement of cross sectional microhardness. 2, a mean value of 203.70 VHN, while Group 3 had a mean value of 275.25 VHN. GroupSurface Microhardness Recovery 4 had a mean value of 167.60 VHN. ANOVAPercentage test results showed that there is statistically% SMHR = Treated Enamel (VHN) – highly significant difference between the meanDemineralizaed Enamel DE (VHN) × 100 scores of 4 different groups contained in theInitial Enamel TE (VHN) – Demineralized study (P <0.001). So, among the microhard-Enamel DE (VHN) ness values obtained, the values of Group 3 were statistically highly significant when com- The data thus obtained was col- pared to Group 1, Group 2 and Group 4.lected and analyzed statistically. Cross Sectional Microhardness (Subsurface) RESULTS Each specimen was longitudinally sectioned into two halves through center of the window. A row● Surface Hardness of Sound Enamel: of five indentations was made at approximatelyThe mean hardness value of sound enamel 100 microns below the enamel surface and micro-is 307.70 VHN. hardnesss was measured. The subsurface hard- ness in Group 1 had a mean value of 152.05 VHN , Group 2 had a mean value of 152.45 VHN, Group 3 had a mean value of 154.15 VHN and Group 4 had a mean value of 149.20 VHN. Inter-Group Comparison of Cross Sectional Microhardness The samples of group 1 and group 2 does not show any significant difference among the rem- ineralization scores (p = .982) The test shows no significant difference (P =.217) in reminer- alization values among the samples of Group 1 and Group 3 . On comparing the samples of Group 1 and Group 4 significant difference The Journal of Implant & Advanced Clinical Dentistry • 41

Singh et al Table 1: Surface Microhardness Scores of Sound Enamel Sample No. Group 1 Group 2 Group 3 Group 4 1 254 254 254 254 2 260 260 260 260 3 262 262 262 262 4 271 271 271 271 5 278 278 278 278 6 275 275 275 275 7 306 306 306 306 8 310 310 310 310 9 302 302 302 302 10 290 290 290 290 11 285 285 285 285 12 315 315 315 315 13 316 316 316 316 14 325 325 325 325 15 340 340 340 340 16 350 350 350 350 17 355 355 355 355 18 360 360 360 360 19 330 330 330 330 20 370 370 370 37042 • Vol. 6, No. 6 • Septemer 2014

Singh et al Table 2: Mean microhardness scores after remineralization Standard Standard N Mean Deviation Error Surface Hardness Group 1 20 194.90 24.881 5.563 Group 2 20 203.70 29.727 6.647 Group 3 20 275.25 38.214 8.545 Group 4 20 167.60 31.398 7.021among remineralization score has been observed and Fluoride. Fluorides have been proved to be(p = .048 )Group 3, Group 2 , Group 1 shows successful in preventing tooth demineralization instatistically significant difference than Group 4 . smooth surface areas. Schemethorn et al. 1999 stated that, although saliva is a natural source of% Recovery all these mineral ions, the absence of fluoride andThe % Recovery in Group 1 had a mean value relatively less amount of calcium phosphate ionsof 21.05% For Group 2 mean value obtained available to replace the lost ions from the toothis 26.95% ,in Group 3 had a mean value of makes it, a poor medium for the remineralization69.30% While Group 4 showed the mean process. These ions can be supplemented invalue of 2.84% .ANOVA test results showed different ways like through mouth rinses, topicalthat there is statistically highly significant dif- application, dentifrices etc. The dissolving cal-ference between the mean scores of 4 differ- cium ions and phosphate ions form various cal-ent groups contained in the study (P < 0.001). cium phosphate salts that either diffuse to the exterior or provide an environment that facilitates DISCUSSION the repair of the faulty crystallites beneath the sur- face of enamel facilitating remineralization. Min-In the present field of Preventive Dentistry, a eral loss or demineralization proceeds as long asnumber of dental materials used for the pre- sufficient acid is available. As more enamel dis-vention of dental diseases are available. The solves, concentration of the calcium and phos-main approaches available for the prevention phate ion increases. As calcium and phosphateof dental caries at present include, plaque con- ions diffuse outwards, remineralization at the sur-trol, systemic and topical fluorides, pit and fis- face becomes more and more likely. This leads tosure sealants and caries vaccines which are the the formation of an apparently intact enamel sur-area being subjected to in depth research work. face layer about 20-40 microns where the mineral content is higher than the body of the lesion. Enriching the mineral content of the tooth bymeans of continued supply of Calcium, Phosphate The Journal of Implant & Advanced Clinical Dentistry • 43

Singh et al Table 3: Subsurface Microhardness After Remineralization Group 3 Group 1 Group 2 Tooth Mousse Group 4 Sample No. Novamin Tooth Mousse Control Plus 1 149 148 150 148 2 148 148 148 148 3 150 150 153 148 4 152 153 155 149 5 153 151 156 149 6 152 152 152 150 7 151 152 154 149 8 152 153 154 148 9 158 159 160 152 10 159 158 159 152 11 159 159 161 153 12 155 153 158 151 13 149 150 152 150 14 149 152 153 147 15 148 151 152 148 16 142 148 149 143 17 152 155 156 149 18 159 151 152 151 19 153 154 155 150 20 151 152 154 14944 • Vol. 6, No. 6 • Septemer 2014

Singh et al Table 4: Mean Subsurface Microhardness After Remineralization Standard Standard N Mean Devaition Error Minimum Maximum 1 20 21.05 13.652 3.053 1 44 2 20 26.95 14.088 3.1502 2 55 Recovery 3 20 69.30 21.106 4.720 10 87 4 20 2.84 2.124 .475 1 8 In the present study, 80 sectioned samples calcium and phosphate species increase thepremolars were kept in the demineralization activities of Ca 2+ and PO4 3- , thereby increas-solution (CaCl2, NaH2 PO4, Lactic acid and ing the degree of saturation with respect toFluoride) for 72 hours at 37° C which created hydroxyapatite. The formation of hydroxyapa-a subsurface demineralization of approximately tite in the lesion would lead to the generation150 microns width with an intact surface simu- of acid and phosphate, which would diffuse outlating an early enamel lesion. The surface micro of the lesion along a concentration gradient. Byhardness values for each group of the enamel stabilizing calcium phosphate in a metastablespecimens were decreased to 162-183 at solution, the CPP facilitates high concentra-the end of 72 hours of demineralization which tions of calcium and phosphate ions, which canis in accordance with the study conducted by then diffuse into the enamel subsurface lesion.Maupome et al 1999. The samples were then The CPP will also maintain high activities of thesubjected to pH cycling using three different free calcium and phosphate ions during remin-materials. The period for demineralization in the eralization through the reservoir of the boundpH cycling phase is for three hours, which was ACP. By being in dynamic equilibrium with freeto stimulate the duration of demineralization calcium and phosphate ions, the bound ACPthat occurs in the oral cavity. The test materi- will maintain the concentrations of the speciesals were applied on enamel blocks to simulate involved in diffusion into the lesion. Furthermore,the normal recommended daily oral prophylaxis. dissociation of the CPP-bound ACP will be facilitated by the acid generated during enamel The remineralization process involves dif- remineralization. This would explain why CPP-fusion of calcium and phosphate ions through supported, metastable calcium phosphate solu-the protein/water-filled pores of the carious sur- tions are such efficient remineralizing solutions,face enamel into the body of the enamel lesion. as they would consume the acid generated dur-Once in the body of the enamel lesion, these The Journal of Implant & Advanced Clinical Dentistry • 45

Singh et aling enamel lesion remineralization by generating dance with study done by N Srinivasan et al,21more calcium and phosphate ions, thus main- who showed the remineralization effect oftaining their high concentration gradients into the CPP–ACP with 900 ppm of fluoride to be supe-lesion. CPP-ACP localizes ACP on the tooth rior to that of CPP– ACP alone. It is likely that asurface, and buffers the free calcium and phos- combination of CPP–ACP and fluoride resultedphate ion activities, helping to maintain a state in co-localization of calcium and phosphateof supersaturation with respect to the enamel ions with fluoride ions at the enamel surface,by suppressing demineralization and enhanc- presumably as CPP–ACFP nanocomplexes..ing remineralization. The CPP has a substantialability to stabilize calcium phosphate in solution. Of all 21 remineralizing products used by F. Cai et al. in their study, only Tooth Mousse CPP can stabilize over 100 times more Plus containing casein phosphopeptide (CPP),calcium phosphate than is normally possible exhibited high levels of water soluble calcium,in aqueous solution at neutral or alkaline pH phosphate and fluoride ions. These high lev-before spontaneous precipitation occurs. CPP- els of water-soluble ions were attributed toACPF has, in addition, fluoride. Studies have the presence of the CPP in CPP-ACP (Recal-shown that remineralization of small lesions dent). These high levels of water-solublewith low-dose fluoride therapy is more effi- calcium, phosphate and fluoride ions are con-cient. The fluoride ions are adsorbed onto the sistent with the recent clinical trials of Toothsurface of enamel crystals, inhibiting dissolu- Mousse and CPP-ACP / fluoride toothpastestion and increasing remineralization. The soft- showing enhanced remineralization of cariesened surface lesions remineralize faster and lesions. There is no increase in microhardnessmore completely than subsurface lesions. With at the enamel subsurface, which is accordancethe use of low fluoride concentration as is pres- with the study done by S Lata et al.9 There isent in CPP-ACPF (0.2% or 900 ppm of NaF), no remineralization at subsurface level and allthere is a complex localization of free calcium the treatment groups failed to remineralize thephosphate and fluoride ion activities, which subsurface lesion in depth. Nevertheless, fluo-helps in maintaining a state of super-saturation ride, fluoride + ACP-CPP and to a lesser extentby suppressing demineralization. Thus CPP- ACP-CPP can remineralize the surface lesion.ACPF (Tooth Mousse Plus) is an excellent local There was no increase in CSMH at the subsur-slow-delivery system to treat the white spot face level and the values suggested that, thatlesion. Novamin deposits fine particles onto the none of the surface treatment agents coulddentin or enamel surface and a series of reac- penetrate the demineralized enamel at the sub-tions occurs over time that results in the forma- surface level. The reason could be; fluoride ionstion of a crystalline, hydroxycarbonate apatite and ACP-CPP were not able to penetrate the(HCA) layer. This HCA layer is chemically and subsurface enamel area, the in vitro set up isstructurally similar to natural enamel and den- not exactly mimicking the in vivo conditionstin and is more resistant to acid challenges. occurring in the mouth and duration of the experimental set up (eight days) is too short. The results of present study are in accor-46 • Vol. 6, No. 6 • Septemer 2014

Singh et al CONCLUSION Correspondence: Dr. Amanpreet SinghCPP-ACP paste significantly remineral- B.J.S Dental College • Sector 39ized the artificial enamel lesion in vitro. Urban Estate • Ludhaina • Punjab, India Phone: 09872630013 The surface hardness increases with appli- Email: [email protected] of CPP-ACPF, CPP-ACP and novaminseparately on induced demineralized enamel invitro. The surface hardness increase is maxi-mum in CPP-ACPF and least in control group. ●Disclosure 10. Lee YE, Baek HJ, Choi YH, Jeong SH, Park ;19. Shen P, Cai F, Nowicki A, Vincent J,The authors report no conflict of interest with any- YD, Song KB. Comparison of remineralization Reynolds EC. Remineralization of Enamelthing mentioned in this article. effect of three topical fluoride regimens Subsurface Lesions by Sugar-free Chewing on enamel initial caries lesions, Journal of Gum Containing Casein Phosphopeptide-References dentistry ,2010,38,166-171. Amorphous Calcium Phosphate. J Dent Res1. A brahahams LJ, Yonese M, Higuchi WI, Fox JL, 2001 80: 2066 11. Litkowski LJ, Quinlan K, Pandya A. In situ Charbeneau GT. In vivo Remineralization Using comparison of surfaces by optical profilometry, 20. Spooner PJ, Kanaya Y, Fox JL, Higuchi WI. a Sustained Topical Fluoride Delivery System. Journnal dental research,2007. Novel topical fluoride delivered system for J Dent Res March 1980 Vol. 59 No. 3 583-87 remineralization of dental enamel: optimization 12. Moezizadeh M, Moayedi S. Anticariogenic studies International Journal of Pharnrareutics,2. A guilar EDB, Goldstein JW, Lockwood effect of amorphous calcium phosphate 1983:15;177- 184 SA. Fluoride varnishes: a review of their stabilized by casein phosphopeptide : a clinical use, cariostatic mechanism, efficacy review article. Research journal of biological 21. Srinivasan N, Kavitha M, Loganathan SC. and safety. Journal of American Dental sciences 4 (1): 132-136, 2009 Comparison of the remineralization potential Association,2000,131,589-596. of CPP-ACP with 900ppm fluoride on eroded 13. Nakashima S, Yoshie M, Sano H, Bahar A. human enamel:an in situ study, Archives of3. A laudin SS, Fontana M. Evaluation of novamin Effect of a test dentifrice containing nano oral biology,2010, 55, 541-544. as an adjunct to fluoride for caries lesion -sized calcium carbonate on remineralization remineralization. of enamel lesions in- vitro, Journal of oral 22. Sudjalim TR, Woods MG, Manton DJ. science vol.51,no.1,2009,69-77. Prevention of white spot lesions in orthodontic4. A zarpazhooh A, Limeback H, Clinical efficacy practice: a contemporary review, Australian of casein derivatives j am dent assoc 14. Prabhakar AR, Arali V, Comparison of the dental journal,2006,51(4),284-289. 2008;139;915-924 Remineralizing Effects of Sodium Fluoride and Bioactive Glass Using Bioerodible Gel 23. Tay FR, Pashley DH. Biomimetic5. B iberach ER. GC Tooth Mousse: effective Systems. JODDD, Vol. 3, No. 4 Autumn 2009 remineralization of resin bonded acid etched protection against caries and hypersensitivity. dentine, 2009,88, 719-724. 15. Reynolds EC, Cai F, Shen P, Walker GD.6. B urwell AK, Litkowski LJ, Greenspan DC, Retention in plaque and remineralization of 24. Tencate JM, Featherstone JDB, Mechanistic Calcium sodium phosphosilicate (novamin) : enamel lesion by varios forms of calcium in aspects of the interactions between Fluoride remineralization potential, Advances in dental a mouth rinse or sugar free chewing gum, and Dental enamel,Critical reviews in Oral research,2009,21,35-39. Journal of dental research, 2003,82, 2006- biology and Medicine,1991,2,283-296. 2011.7. F eatherstone JDB, Behrman JM, Bell JE. 25. Wang X, Megert B, Hellwig E, Neuhaus Effect of whole saliva components on enamel 16. Reynolds EC. Anticariogenic phosphopeptide. KW, Lussi A. Preventing erosion with novel demineralization in –vitro. Critical reviews in oral United states patent. agents. J Dent. 2011 39(2):163-70. biology and medicine,1993,4(3/4),357-362. 17. R eynolds EC. Remineralization of 26. Wei SHY, Kaqueler JC, Massler M.8. J ones RS, Fried D. Remineralization of enamel Enamel Subsurface Lesions by Casein Remineralization of carious dentine, journal of caries can decrease optical reflectivity, Journal Phosphopeptide-stabilized Calcium Phosphate dental research, 1968, 10.11, 381-391. of dental research, 2006, 85, 804-808. Solutions. J DENT RES 1997 76: 1587 27. Z hang L, Xuedong Z, Cui F, Wei L, Chemical9. L ata S, Varghesei NO, Varghesei JM. 18. Rooij JFD, Nancollas GH. The formation and and crystallographic study of remineralized Remineralization potential of fluoride and remineralization of artificial white spot lesions surface on initial caries enamel treated with galla amorphous calcium phosphate-casein : a constant composition approach,,Journal of chinensis. 2009,31,236-245. phosphopeptide on enamel lesions: in vitro dental research, 1984,63,864-867. comparative evaluation, 2010, 13. The Journal of Implant & Advanced Clinical Dentistry • 47