Journal of Implant and Advanced Clinical Dentistry June 2014

Volume 6, No. 3 June 2014 The Journal of Implant & Advanced Clinical DentistrySmile Makeover with All Ceramic Crowns Zygomatic Dental Implants

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The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 3 • June 2014 Table of Contents13 F rom Maxilla to Zygoma: A Review on Zygomatic Implants Dr. D.R. Prithviraj, Dr. Richa Vashisht, Dr. Harleen Kaur Bhalla21 L ateral Sinus Augmentation: A Safer Technique Dr. Gregori Kurtzman, Dr. Douglas F. Dompkowski The Journal of Implant & Advanced Clinical Dentistry • 3

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The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 3 • June 2014 Table of Contents33 Loading of Two Implants in the Mandible and Final Restoration with a Locator: A Case Report and Review Dr. A. Abdulgani, Dr. M. Bajali, Dr. M. Abu-Hussein43 S mile Makeover with all Ceramic Crowns and Biologic Shaping Dr. Arshad Hasan53 O ccurrence Regions and Sites of Peri-implant Inflammation with Bone Resorption in Japanese Partially-Edentulous Patients Motohiro Munakata, Noriko Tachikawa, Katsuichiro Maruo, Aoi Sakuyama, Yoko Yamaguchi, Shohei Kasugai The Journal of Implant & Advanced Clinical Dentistry • 5



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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 • 11

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From Maxilla to Zygoma: Wilcko et alA Review on Zygomatic ImplantsDr. D.R. Prithviraj1 • Dr. Richa Vashisht2 • Dr. Harleen Kaur Bhalla3AbstractBackground: Patients with moderate to severe Results: Based on the current literature review,atrophy challenge the surgeon to discover alter- zygomatic implants show excellent survival ratesnative ways to use existing bone or resort to ( > 90% ) and a low incidence of complications.augmenting the patient with autogenous oralloplastic bone materials. The objective was Conclusions: With proper case selection, cor-to review the published literature to evalu- rect indication, and knowledge of the surgi-ate treatment success with zygomatic implants cal technique, the use of zygomatic implantsin patients with atrophic posterior maxilla. associated with standard implants offers advantages in the rehabilitation of severelyMethods: MEDLINE/PubMed searches resorbed maxillae, especially in areas withwere conducted using the terms atrophic inadequate bone quality and volume, with-maxilla, zygomatic implant, zygomatic bone, out needing an additional bone graftinggrafts, maxillary sinus, as well as combina- surgery, thereby shortening or avoiding hos-tions of these and related terms. The few arti- pital stay and reducing surgical morbidity.cles judged to be relevant were reviewed.KEY WORDS: Zygomatic dental implants, maxilla, maxillary sinus 1. Dean Cum Director, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore2. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore3. Post Graduate Student, Dept. of Prosthodontics Govt. Dental College and Research Institute, Bangalore Victoria Hospital Campus, Fort, Bangalore The Journal of Implant & Advanced Clinical Dentistry • 13

Prithviraj et al INTRODUCTION: (Fig. 1). Anatomical Buttresses of the midface: 1) Frontomaxillary buttress; 2) Fronto-Dental implants are now commonly used for zygomatic buttress; 3) Pterygomaxillary buttress.replacing missing teeth in various clinical situ-ations. Dental implants are surgically inserted ANATOMY OFin the jawbones. Unfortunately, restrictions ZYGOMATIC BONEhave appeared in the use of oral implants.One of them is the lack of sufficient bone vol- The zygoma bone can be compared to a pyra-ume, especially in the posterior maxilla.[1] mid, offering an interesting anatomy for the insertion of implants. In 1993, Aparicio et During the last 3 decades, several surgical al. mentioned the possibility of inserting den-procedures have been developed to increase tal implants in the zygomatic bone.[3] In 1997,local bone volume in deficient anatomical Weischer et al. cited the use of the zygomaregions, including total/segmental bone onlays, as a support structure in the rehabilitation ofLe Forte1 osteotomy with interpositional bone patients subjected to maxillectomies.[4] Follow-grafts, and grafting of the maxillary sinus with ing Branemark’s description, Uchida et al. inautogenous bone and/or bone substitute.[2] 2001, measured the maxilla and zygoma in 12 cadavers, observing that the apex of a 3.75 These techniques pose a series of inconve- mm-diameter implant requires a zygoma of atniences, such as the need for multiple surgical least 5.75 mm in thickness. With respect tointerventions, the use of extraoral bone donor implant placement, they advised that an angu-sites (e.g., iliac crest or skull) - with the morbid- lation of 43.8º or less increases the risk ofity involved in surgery of these zones - and the perforating the infratemporal fossa or the lat-long duration during which patients remain with- eral area of the maxilla; if the angulation isout rehabilitation during the graft consolidation more vertical, 50.6º or more, this increasesand healing interval. These factors complicate the risk of perforating the orbital floor.[5]patient acceptance of the restorative treatmentand limit the number of procedures carried out. Nkenke et al. used computed tomography and histomorphometry to examine 30 human In order to overcome such limitations, dif- zygoma, the study revealed that the zygomaticferent therapeutic alternatives have been pro- bone consists of trabecular bone, an unfavor-posed, such as, implants placed in specific able parameter for implant placement; however,anatomical areas like the pterygoid region, the success of implants placed in the zygomaticthe tuber or the zygoma. Any of these proce- bone was achieved by the implant crossing fourdures requires considerable surgical exper- portions of cortical bone.[6] Kato et al. investi-tise and has its own advantages, limits, gated the internal structure of the edentuloussurgical risks and complications involving bio- zygomatic bone in cadavers using micro-com-logical and financial costs. The placement of puted tomography, finding that the presenceimplants in the zygomatic bone as an alterna- of wider and thicker trabeculae at the apicaltive to maxillary reconstruction with autoge- end of the fixture promotes initial fixation.[7]nous bone grafts has been considered a viableoption in the rehabilitation of atrophic maxillae14 • Vol. 6, No. 3 • June 2014

Prithviraj et alFigure 1: Anatomical Buttresses of the midface. Figure 2: Radiologic aspect of a patient restored with two1) Frontomaxillary buttress; 2) Frontozygomatic buttress; zygomatic implants.3) Pterygomaxillary buttress. oramic radiographs, which generally depict the DESCRIPTION OF THE size and configuration of the maxillary sinuses, ZYGOMATIC IMPLANT the height of the residual ridge, and the posi- tion of the nasal floor. The body of the zygomaThe zygomatic implants are self-tapping can usually be visualized.[9] However, OPGscrews in c.p. titanium with a well-defined can give distorted information and therefore,machined surface. They are available in eight the examination of choice is the spiral or heli-different lengths ranging from 30 to 52.5 mm. coid computed tomography (CT) scan, whichThey present a unique 450 angulated head makes two- and three-dimensional imaging pos-to compensate for the angulation between sible with axial cuts every 2 mm parallel to thethe zygoma and the maxilla. The portion that palatal arch and conventional tomography withengages the zygoma has a diameter of 4.0 frontal tomograms perpendicular to the hardmm, and the portion that engages the resid- palate every 3-4 mm. The CT scan also gives theual maxillary alveolar process a diameter of opportunity to visualize the health of the maxilla4.5 mm (Fig. 2).[8,9] Radiologic aspect of a and the sinus. Sinusitis, polyps or any sinusalpatient restored with two zygomatic implants. pathology can be excluded. The density, length and volume of the zygoma can be evaluated PRESURGICAL EVALUATION and special templates for inserting the zygo- matic implants can be constructed on stereo-Clinical examination is not sufficient for this lithographic models to facilitate the orientationevaluation and radiologic assessment has to beconsidered. Bedrossian et al. in their study onzygomatic and premaxillary implants used pan- The Journal of Implant & Advanced Clinical Dentistry • 15

Prithviraj et alFigure 3: (Right): Trans-zygomatic implantation following an intrasinusal path. (Left): The extrasinus technique. Note theimplant emergence above the alveolar crest at first molar level, with a more vertical angulation.of the zygomatic implants during the surgery have varied the technique slightly. Stella andwith minimal errors in angulation and position. Wagner described a variant of the technique[10] Vrielinck et al., presented a planning system (Sinus Slot Technique) in which the implant isfor zygomatic implant insertion based on pre- positioned through the sinus via a narrow slot,operative CT imaging; they calculated the posi- following the contour of the malar bone andtion of the implants and fabricated a surgical introducing the implant in the zygomatic pro-guide. Using this system they obtained a suc- cess. In this way, the need for fenestration ofcess rate of 92% in 29 patients with zygomatic the maxillary sinus is avoided, and the implantimplants (two implants did not reach the zygo- is caused to emerge over the alveolar crest atmatic arch when using this surgical guide).[11] first molar level, with a more vertical angula- tion.[13] Penarrocha et al.[12] published in 2007 PROCEDURE a series of 21 cases with the “Slot technique” with a 100% survival rate, but the Schneide-The original procedure, defined by Brane- rian membrane was perforated in all cases,mark in 1998, consisted of the insertion of a even though the incidence of sinus pathology35-55 mm-long implant anchored in the zygo- was low (two cases).[14] (Fig 3.) Right - Trans-matic bone following an intra-sinusal trajec- zygomatic implantation following an intrasinusaltory.[12] Since this description, many authors16 • Vol. 6, No. 3 • June 2014

Prithviraj et al Table 1: Success Rate of Zygomatic Implants No. of Study/ No. of Zygomatic Follow- Success Year Patients Implants up Rate Complication Sinusitis, loosening of the zygomatic implant gold screws Aparicio 6- in nine patients, fracture of one gold screw as well as the et al., 69 131 months 99% prosthesis in one patient. 200617 5 years Bedrossian 14 28 12 100% et al., 200618 months Penarrocha 21 40 29 100% Ecchymosis et al., 200714 months Davo et al,. 42 81 12-42 100% Oroantral fistula and sinsusitis 200819 months was found in one patient Pi-Urgell 54 101 1-72 96% Sinusitis et al. , 200820 months Balshi et al., 56 110 9 months- 96% 200921 5 years Aparicio et al., 25 47 2-5 years 100% 201022 Malevez et al., 20 80 6-40 96% 201023 months Miglioranca 75 150 12 98.7% Two zygomatic implants et al. , 201124 months (1.33%) failed and were removed Davo et al., 42 81 5 years 98.5% One zygomatic impant was lost. 201325path; Left - The extrasinus technique. Note the MULTIPLE ZYGOMATICimplant emergence above the alveolar crest at IMPLANTSfirst molar level, with a more vertical angulation. The use of multiple zygomatic implants (i.e. two to three in each side) was suggested by The Journal of Implant & Advanced Clinical Dentistry • 17

Prithviraj et alBothur et al.[15] In a recent study, Duarte et al. grafting procedures, the technique is lessused four zygomatic implants and no premax- invasive and complicated and has a lowerillary conventional implants in the prosthetic risk of morbidity because of the fact that har-rehabilitation of 12 patients with edentulous vesting of bone graft is usually not needed.and severely resorbed maxillas. A fixed bridge Based on the current literature review, zygo-of a gold framework and acrylic teeth was fab- matic implants show excellent survival ratesricated and delivered shortly after implant sur- ( > 90 %) and a low incidence of complica-gery. The patients were evaluated after 6 and tions, so this should be considered a valid30 months when the bridges were removed for and safe treatment option when dealing withindividual testing of implant stability. One zygo- patients with advanced maxillary atrophy. ●matic implant was found to be loose at the 6-month follow-up and another one was found to Correspondence:be loose at the 30-month check-up. Thus, the Dr. Richa Vashishtoverall survival rate was 95.8% after 30 months Post Graduate Studentof follow-up. No severe complications relating Dept. of Prosthodonticsto the sinus or the soft tissues were reported.[16] Govt. Dental College and Research Institute Bangalore COMPLICATIONS Victoria Hospital Campus Fort Bangalore 560002The reported complications associated with +918050606896zygomatic implants include postoperative sinus- [email protected], oroantral fistula formation, periorbital andsubconjunctival hematoma or edema, lip lacera-tions, pain, facial edema, temporary paresthe-sia, epistaxis, gingival inflammation, and orbitalpenetration/injury. Postoperative concernsregarding difficulty with speech articulationand hygiene caused by the palatal emergenceof the zygomatic implant and its effect on theprosthesis suprastructure have been reported. CONCLUSIONThe zygomatic implant is an alternative proce-dure to bone augmentation, maxillary sinus liftand to bone grafts in patients with posterioratrophic maxillae. The zygomatic implant tech-nique should be regarded as a major surgi-cal procedure and proper training is of courseneeded. However, in comparison with bone18 • Vol. 6, No. 3 • March 2014

Prithviraj et alDisclosure 10. V an Steenberghe D, Malevez C, Van 17. Aparicio  C, Ouazzani W, Garcia R, ArevaloThe authors report no conflicts of interest with any- Cleynenbreugel J, Bou Serhal C, Dhoore E, X, Muela R, Fortes V. A prospective clinicalthing mentioned in this article. Schutyser F, Suetens P, Jacobs R. Accuracy study on titanium implants in the zygomatic arch of drilling guides for the transfer from 3-D CT for prosthetic rehabilitation of the atrophicReferences based planning to placement of zygomatic edentulous maxilla with a follow-up of 61. Kuabara MR, Ferreira EJ, Gulinelli JL, Paz implants in human cadavers. Clin Oral Implants months to 5 years. Clin Implant Dent Relat Res 2003: 14: 131–136. Res. 2006;8:114-22. LG. Rehabilitation with zygomatic implants: a treatment option for the atrophic edentulous 11. Vrielinck L, Politis C, Schepers S, Pauwels 18. B edrossian  E, Rangert B, Stumpel L, Indresano maxilla--9-year follow-up.Quintessence Int. 2010 M, Naert I. Image-based planning and clinical T. Immediate function with the zygomatic implant: ;41:9-12. validation of the zygoma and pterygoid implant a graftless solution for the patient with mild placement in patients with severe bone atrophy to advanced atrophy of the maxilla. Int J Oral2. R aghoebar GM, Timmenga NM, Reintsema using customized drill guides. Preliminary results Maxillofac Implants. 2006;21:937-42. H, Stegenga B, Vissink A. Maxillary bone from a prospective clinical follow-up study. Int J grafting for insertion of endosseous implants: Oral Maxillofac Surg 2003;32:7-14. 19. Davo R, Malevez C, Rojas J, Rodriguez J, Regolf results after 12-124 months. Clin Oral Implants J. Clinical outcome of 42 patients treated with Res. 2001;12:279-86. 12. Branemark P-I. Surgery and fixture installation. 81 immediately loaded zygomatic implants: a Zygomaticus fixture clinical procedures (ed 12- to 42-month retrospective study. Eur J Oral3. Aparicio C, Branemark P-I, Keller EE, Olive J. 1). Goteborg, Sweden: Nobel Biocare AB; Implantol. 2008;1:141-50. Reconstruction of the premaxila with autogenous 1998. p. 1. iliac bone in combination with osseointegrated. Int 20. P i Urgell J, Revilla Gutierrez V, Gay Escoda CG. J Oral maxillofac Implants 1993;8:61-7. 13. Stella J, Warner M. Sinus slot technique for Rehabilitation of atrophic maxilla: a review of simplification and improved orientation of 101 zygomatic implants. Med Oral Patol Oral Cir4. W eischer T, Schettler D, Mohr C. Titanium zygomaticus dental implants: a technical note. Bucal. 2008;13:363-70. implants in the zygoma as retaining elements after Int J Oral Maxillofac Implants 2000;15:889-93. hemimaxillectomy. Int J Oral Maxillofac Implants 21. B alshi SF, Wolfinger GJ, Balshi TJ. A 1997;12:211-4. 14. P enarrocha M, Garcı´a B, Martı E, Boronat retrospective analysis of 110 zygomatic implants A. Rehabilitation of severely atrophic maxillae in a single-stage immediate loading protocol. Int5. U chida Y, Goto M, Katsuki T, Akiyoshi T. with fixed implant-supported prostheses using J Oral Maxillofac Implants. 2009;24:335-41. Measurement of the maxilla and zygoma as an aid zygomatic implants placed using the sinus in installing zygomatic implants. J Oral Maxillofac slot technique: clinical report on a series of 21 22. Aparicio C, Ouazzani W, Aparicio A, Fortes Surg 2001;59:1193-8. patients. Int J Oral Maxillofac Implants 2007: 22: V, Muela R, Pascual A, Codesal M, Barluenga 645–650. N, Franch M. Immediate/Early loading6. Nkenke E, Hahn M, Lell M, Wiltfang J, of zygomatic implants: clinical experiences after Schultze-Mosgau S, Stech B, et al. Anatomic 15. Bothur S, Jonsson G, Sandahl L. Modified 2 to 5 years of follow-up. Clin Implant Dent Relat site evaluation of the zygomatic bone for technique using multiple zygomatic implants in Res. 2010;12:77-82. dental implant placement. Clin Oral Impl Res reconstruction of the atrophic maxilla: a technical 2003;14:72-9. note. Int J Oral Maxillofac Implants 2003: 18: 23. S tievenart M, Malevez C. Rehabilitation of 902–904. totally atrophied maxilla by means of four7. Kato Y, Kizu Y, Tonogi M, Ide Y, Yamane G. Internal zygomatic implants and fixed prosthesis: a structure of zygomatic bone related to zygomatic 16. Duarte LR, Filho HN, Francischone CE, Peredo 6-40-month follow-up. Int J Oral Maxillofac fixture. J Oral Maxillofac Surg 2005;63:1325-9. LG, Branemark PI. The establishment of a Surg. 2010;39:358-63. protocol for the total rehabilitation of atrophic8. M alevez C, Daelemans P, Adriaenssens P, maxillae employing four zygomatic fixtures in an 24. Miglioranca RM, Coppede A, Dias Rezende Durdu F. Use of zygomatic implants to deal with immediate loading system – a 30- month clinical RC, de Mayo T. Restoration of the edentulous resorbed posterior maxillae. Periodontol 2000. and radiographic follow-up. Clin Implant Dent maxilla using extrasinus zygomatic implants 2003;33:82-89. Relat Res 2007: 9: 186–196 combined with anterior conventionalimplants: a retrospective study. Int J Oral Maxillofac9. B edrossian E, Stumpel L III, Beckely ML, Implants. 2011;26:665-72. Indresano T. The zygomatic implant: preliminary data on treatment of severely resorbed maxillae. 25. Davo R, Malevez C, Pons O. Immediately loaded A clinical report. Int J Orai Maxiiiofac Implants. zygomatic implants:a 5-year prospective study. 2002;17:861-865. Eur J Oral Implantol. 2013;6:39-47. The Journal of Implant & Advanced Clinical Dentistry • 19



Lateral Sinus Augmentation: Wilcko et al A Safer TechniqueDr. Gregori Kurtzman1 • Dr. Douglas F. Dompkowski2 AbstractThe lateral sinus augmentation approach surgical units. These approaches had potential can be challenging as tearing of the sinus for membrane damage (burs in a high speed) membrane often necessitates abandon- or were very slow (peizo). A recently intro-ing the procedure and re-entry at a later date duced drilling kit allows for safe lateral accessafter the membrane has healed. Previous tech- to the sinus with reduced risk of perforationniques involved use of diamonds or carbides of the Schneiderian membrane. This casein a high speed hand piece or the use of peizo- report demonstrates use of this new drilling kit.KEY WORDS: Dental implants, sinus augmentation, Schneiderian membrane, bone graft 1. Private practice, Silver Springs, Maryland, USA 2. Private practice, Bethesda, Maryland, USA The Journal of Implant & Advanced Clinical Dentistry • 21

Kurtzman et alFigure 1: Lateral Approach Sinus Kit (LASK). ate an osteotomy and subsequent in-fracturing of the sinus floor while elevating the Schneiderian Introduction membrane. Following manipulation, the space created in the sinus is augmented with variousThe posterior maxilla presents with a common bone particulate graft materials increasing theproblem clinically following tooth extraction volume of bone available for implant placement.or crestal bone loss resulting in loss of osse-ous height sufficient to place implants. Resorp- Various studies have reported that when 5 mmtive patterns in some patients along with sinus of residual alveolar bone is present, simultane-enlargement result in minimal bone that can ous implant placement can be preformed achiev-accommodate implant placement. Maxillary sinus ing adequate primary stability.6, 8, 9 But, when lessaugmentation over the past 18 years with various than 5 mm of residual alveolar bone height isbone graft materials has become routine treat- available, a delayed 2-stage approach has beenment. Numerous studies have reported highly recommended.10, 11 The most common complica-successful implant survival rates when placed tion of the lateral sinus elevation approach is typi-into the augmented sinus.1-3 Transalveolar sinus cally tearing of the Schneiderian membrane whichfloor elevation also referred to as subantrial aug- could allow for bacterial contamination or loosementation, was first described by Tatum4 and particles to gain access to the sinus cavity. A saferlater modified by Summers.5-7 This technique uti-lized a series of osteotomes with a mallet to cre-22 • Vol. 6, No. 3 • June 2014

Kurtzman et alFigure 2a: CBCT radiograph pretreatment demonstrating Figure 2b: CBCT radiograph pretreatment demonstratinginsufficient osseous height for implant placement without insufficient osseous height for implant placement withoutsinus augmentation in the molar region. sinus augmentation in the molar region.lateral window approach sinus augmentation pro- are run at 1,200 to 1,500 RPM with irrigation incedure will be discussed using specialized safe an implant surgical handpiece. Metal depth con-cutting end drills with vertical stoppers for osse- trol stoppers are provided that fit on the Domeous window formation and subsequent membrane drills limiting depth of penetration (0.5, 1.0, 1.5,elevation (Lateral Approach Sinus Kit, HIOSSEN). 2.0, 2.5 and 3.0 mm) and are used sequen- tially to safely expose the sinus membrane. MATERIAL AND METHODS The Core drill, also available in 5.0 and 7.0 mmThe Lateral Approach Sinus Kit (LAS-Kit) (HIOS- diameter differs from the Dome drill in that the cen-SEN) provides “Dome” drills, “Core” drills, metal ter does not cut, with bone removal resulting in astoppers, side wall drill and a bone separator core of bone being left over the sinus. This boneytool (Figure 1). The Dome drill is a unique osse- lid may be elevated with the sinus membrane stillous drill allowing removal of the lateral wall of attached becoming the new “roof” to the sinusthe maxillary sinus while collecting autogenous with osseous augmentation being placed below it.bone to be added to the material to be placed This particular drill follows the same design of theinto the sinus. Macro and micro cutting blades CAS Kit (crestal augmentation sinus) drills andprovide excellent cutting of the lateral wall with- is utilized at 1,200-1,500 RPM. The metal drillout tearing of the sinus membrane. These Dome stoppers also fit these drills allowing controlleddrills available in both 5.0 and 7.0mm diameter sequential depth preparation. The Bone Separator tool is utilized to separate the osseous core cre- ated with the Core drill if removal is desired and is based on the practitioners preferred technique. The Side Wall drill, may be used to enlarge the osseous window created by the Dome The Journal of Implant & Advanced Clinical Dentistry • 23

Kurtzman et alFigure 3: Buccal concavity evident as a result of long Figure 4: A trapezoidal shaped flap was created with astanding loss of the first molar compromising the width of scalpel with the crestal incision placed to the palatal aspectthe site. of the ridge.Figure 5: Lateral aspect of the maxillary posterior Figure 6: Dome drill with 0.5mm stopper placed on thefollowing elevation of a full thickness flap. surgical hand piece.drill if desired. The tip of this drill is smooth and drills in this kit, irrigation is used during its use.designed to safely push the sinus membraneaway from the cutting portion of the drill, which Case Reportstarts 1mm from the safe end. Osseous cut-ting is performed at 1,500 RPM using the side A male aged 32, presented with the desireof the rotating drill to enlarge the osseous win- for implant placement in the posterior maxil-dow. The CAS Kit metal drill stoppers may be lary right quadrant which had been missing theplaced on this drill to limit accidental penetration first molar for an extended period of time. Thetoo far into the sinus and tearing of the mem- result of long term loss of the tooth resultedbrane during this drills use. As with the other in drifting of the second molar into the space which was corrected orthodontically prior to24 • Vol. 6, No. 3 • June 2014

Kurtzman et alFigure 7: Lateral sinus approached initiated with the Figure 8: The initial Dome drill created an outline into theDome drill and a 0.5mm drill stopper. bony wall.Figure 9: Lateral sinus approached continued with the Figure 10: Bone is collected from the Dome drill to beDome drill and a 1.0mm drill stopper. utilized to augment the graft to be placed.implant surgery. Radiographically, enlargement a crestal lingual incision was made with verti-of the maxillary sinus was noted with insufficient cal releasing incisions at the mesial and distalheight in the molar region for implant placement aspect of the site and a full thickness flap was(Figure 2). Resorption was noted compromis- elevated, leaving the attached gingiva undis-ing the width of the ridge at the buccal leading turbed on the adjacent teeth (Figure 4). Eleva-to a mild concavity (Figure 3). Sinus augmen- tion of the flap extended superiorly to exposetation was discussed to assist in achieving the lateral wall of the maxillary sinus up tothe patients desired treatment goal of implant the inferior aspect of the zygoma (Figure 5).placement and restoration with a fixed crown. A 5mm wide Dome drill was placed onto Following administration of local anesthetic, the surgical handpiece with a 0.5mm drill stop- The Journal of Implant & Advanced Clinical Dentistry • 25

Kurtzman et alFigure 11: Following each Dome drill the site is examined Figure 12: Lateral sinus approached continued with thefor identification of the underlaying membrane which will Dome drill and a 1.5mm drill stopper.appear darker as bone is removed over it.Figure 13: Lateral sinus approached continued with the Figure 14: Lateral wall of the maxillary sinus followingDome drill and a 2.0mm drill stopper. sequential use of the Dome drill with increasing stopper depth demonstrating no damage to the sinus membrane after bone removal.per (Figure 6). This would allow initiation of the radiographically (Figure 7). This is done to ensurewindow without the possibility of excessive pen- that the window created has elevated the mem-etration and subsequent damage to the sinus brane circumferentially. When maximum depthmembrane. The initial Dome drill is placed onto has been achieved with the 0.5mm drill stopperthe surgical handpiece with the selected drill stop. present, the drill stopper is changed to a 1.0mmThe Dome drill with stopper was placed on the lat- stopper and drilling is continued (Figure 8). Theeral sinus wall at a height more superior then the drill stopper is sequentially increased checkingcurrent height of the available bone as measured for membrane exposure. Lateral drilling continues26 • Vol. 6, No. 3 • June 2014

Kurtzman et alFigure 15: A curette is utilized to separate the sinus Figure 16: Lateral window completed demonstrating themembrane from the bone of the maxillary sinus, elevating intact sinus membrane following use of the Dome drillsit superiorly from the inferior floor to the medial wall. and stoppers.Figure 17: A collagen membrane is placed into the sinus Figure 18: Osseous graft material was mixed with theover the elevated membrane to help confine the graft to be patients donor bone collected from the Dome drills and isplaced should a micro tear be present in the elevated sinus gently packed into the sinus.membrane.stepping up to the next drill stop (Figure 9). Bone to show clinically at the window (Figure 11).collected on the Dome drills is removed from the Final window creation is made with thedrill and placed into a sterile dish to be added tothe graft to be placed, adding the host’s osteo- Dome drill, in this particular case with a 2.5mmpotential cells to the graft (Figure 10). As bone drill stopper (Figure 13). Some patients mayis removed over the sinus membrane, the area require deeper drilling which is dependant onchanges in color from the light color of the bone thickness of the lateral maxillary sinus wall. The(ivory) to darker gray as the dark sinus begins intact sinus membrane is noted with no bone over the membrane at the window that has been The Journal of Implant & Advanced Clinical Dentistry • 27

Kurtzman et alFigure 19: The elevated sinus area has been completely Figure 20: Implant placement following osseous graftpacked with osseous graft material. healing demonstrating the new sinus height achieved.Figure 21: A resorbable membrane was placed over the the medial wall of the sinus so that fills a volumeboney sinus window to limit soft tissue ingrowth into the great enough that the implant when placed will begraft during the healing phase. surrounded by bone. Failure to elevate the medial aspect may result in the implant when placedcreated on the lateral wall (Figure 14). Addi- having no osseous contact which may decreasetional, host bone is collected from the Dome drill. clinical success following loading. Additionally, the authors advise elevation to a greater height Sinus curettes are utilized to start the sinus then the implant length to be placed when amembrane elevation at the inferior aspect, teasing delayed fixture placement is to be performed. Thisthe membrane from the osseous wall of the sinus will allow for possible graft settling during heal-interiorly (Figure 15). Following elevation of the ing that may yield less height then was planned.membrane, the membrane should be intact andfree of visible tears that may prevent graft distribu- An absorbable extracellular membranetion within the sinus during initial healing (Figure (Dynamatrix, Keystone Dental, Burlington, MA)16). It is important that the elevation also include is inserted into the sinus to act as protec- tion containing the graft material and thicken the sinus membrane sealing any micro tears that might be present (Figure 17). The resor- able membrane is cut to size and placed into the sinus dry using the patients blood in the site to wet it as its placed. Once wetted with blood the resorable membrane becomes sticky gluing itself to the sinus membrane.28 • Vol. 6, No. 3 • June 2014

Kurtzman et alFigure 22: The flap was repositioned and closed with ahorizontal mattress and interrupted sutures. Figure 23: I mplant following 8 months healing and exposure to place a healing abutment demonstrating blending of the grafted sinus with the surrounding native bone.Figure 24a: CBCT demonstrating new volume of bone Figure 24b: CBCT demonstrating new volume of boneachieved following sinus augmentation and implant achieved following sinus augmentation and implantplacement which is ready for restoration of the implant. placement which is ready for restoration of the implant. Regenform Cortical Cancellous Bone Chips(Exatech, Gainsville, FL) and Sureoss, a freeze-dried cortical allograft (Hiossen, Philadelphia,PA) in a 50:50 ratio in a sterile dappen dishand mixed with the autogenous bone collectedfrom the Dome drill. The osseous graft mixturewas carried to the oral cavity and introducedinto the elevated sinus and gently condensedwith a large plugger, pushing the mixture to themedial wall and filling in a lateral direction until The Journal of Implant & Advanced Clinical Dentistry • 29

Kurtzman et althe entire cavity was filled (Figure 18). The pro- been placed into the sinus, integration of thecess was repeated in the cavity anterior to the implant and seating of the healing abutmentsepta. Sufficient osseous graft was placed till on the fixture (Figure 23). A CBCT was takenthe sinus was augmented to be flush with the to check the graft and implant integration andouter aspect of the lateral sinus wall at the the implant is ready to be restored (Figure 24).window that had been created (Figure 19). Conclusion Following sinus grafting the site was pre-pared and an implant (4.5 x 10mm, ETIII, Hios- Emphasis has moved to the use of a crestalsen, Philadelphia, PA) was placed and the site. approach to sinus elevation when additionalA low profile cover screw was used to allow pri- osseous height is required for implant place-mary closure of the flap. The radiograph shows ment. This approach works well when atinitial graft placement and the elevation achiev- least 5mm of osseous height is present foring a site that can accommodate implant place- immediate implant placement. Yet, whenment at this surgical appointment (Figure 20). less bone height is present, a lateral window approach may be the preferred technique to A long term resorbable membrane (Dyna- increase crestal height and geometric vol-matrix) was cut to extend beyond the outline of ume so that implant fixtures may be placed.the lateral window and placed over the osseousgraft that had been placed into the sinus (Fig- The lateral sinus augmentation approachure 21). The flap was repositioned and initially can be challenging as tearing of the sinusclosed with a horizontal mattress suture using membrane often necessitates abandoning thea 5-0 Cytoplast suture material, (Osteogenics procedure and re-entry at a later date afterBiomedical, Inc., Lubbock, TX) to achieve pri- the membrane has healed. Previous tech-mary closure of the flap without tension then niques involved use of diamonds or carbidesthe crest was closed with interrupted sutures in a highspeed handpiece or the use of peizo(Figure 22). This suture serves to resist soft surgical units. These approaches had poten-tissue tension that may result due to inflamma- tial for membrane damage (burs in a high-tion and the resulting swelling following surgery. speed) or were very slow (peizo). The LAS Kit,Additional sutures are placed to close the inci- from Hiossen utilizes special designed drillssion line using a simple interrupted technique. that greatly minimize tearing of the membrane and improve the safety of the procedure. ● The patient returned 8 months followingimplant placement. Soft tissue in the site on Correspondence:the lateral aspect demonstrated no inflam-mation and incision lines were not discern- Dr. Gregori Kurtzmanable on the gingiva. The implant was exposedusing a disposable tissue punch and the cover 3801 International Drive, Suite 102screw was replaced by a healing abutment.A radiograph was taken to check and verify Silver Spring, MD 20906the organization of the osseous graft that had 301-598-350030 • Vol. 6, No. 3 • June 2014

Kurtzman et alDisclosure The Journal of Implant & Advanced Clinical DentistryThe authors report no conflicts of interest with anything mentioned in this article. ATTENTIONReferences PROSPECTIVE1. B lomqvist JE, Alberius P, Isaksson S. Two maxillary sinus reconstruction with AUTHORS endosseous implants: A prospective study. Int J Oral Maxillofac implants 1998; 13:758-766. JIACD wants to publish2. V alentini P, Abensur DJ. Maxillary sinus grafting with anor-ganic bovine bone: A your article! clinical report of long-term results. Int J Oral Maxillofac Implants 2003; 18:556- 560.3. T ong DC, Drangsholt M, Beirne OR. A review of survival rates for implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral Maxillofac Implants 1998; 13:175-1824. Tatum OH Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986; 30:207-2295. Rosen PS, Summers R, Mellado Jr, et al. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac implants 1999; 14:853-8586. S ummers RB. A new concept in maxillary implant surgery: the osteotome technique. Compend Contin Educ Dent 1994; 15:152-1627. Summers RB. The osteotome technique: part 3- less invasive methods of elevating the sinus floor. Compend Contin Educ Dent 1994: 15:698-7108. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: a systemic review and meta-analysis. J periodontal 2005; 76:1237-12519. Toffler M. Osteotome- mediated sinus floor elevation: a clinical report. Int J Oral Maxillofac implants 2004; 19:266-7310. Peleg M, Mazor Z, Chaushu G, Garg AK. Sinus floor augmentation with simultaneous implant placement in the severely atrophic maxilla. J Periodontal 1998; 69:1397-140311. P eleg M, Mazor Z, Garg AK. Augmentation grafting of the maxillary sinus and simultaneous implant placement in patients with 3 to 5 mm of residual alveolar bone height. Int J Oral Maxillofac implants 1999; 14:549-556 For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/ authorinfo/ author-guidelines.pdf or email us at: [email protected] The Journal of Implant & Advanced Clinical Dentistry • 31

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Loading of Two Implants in the Wilcko et alMandible and Final Restoration with a Locator:A Case Report and ReviewDr. A. Abdulgani1 • Dr. M. Bajali2 • Dr. M. Abu-Hussein3 AbstractSuccessful treatment with the two-implant will not be determined by the selection made. overdenture has been documented with This is due primarily to the anatomy and den- multiple implant designs (ie. hexago- sity of the bone in the anterior mandible. Thenal, Morse taper, internal connection) and many aim of this case report is to demonstrate theimplant systems. Clinicians may select implants concept of immediate functional loading in thefor retention of the two-implant overdenture mandible using unsplinted implants to supportaccording to personal experience and prefer- a locator attachment supported overdenture.ence with confidence that treatment successKEY WORDS: Dental implants, denture, locator attachments, overdenture 1. Assist.Professor, Al Quds University, Jerusalem, Palestine 2. Assistant Professor, Al Quds University, Jerusalem, Palestine 3. Visiting Professor, Napoli university, Italy and University of Athens, Greece The Journal of Implant & Advanced Clinical Dentistry • 33

Abdulgani et al Introduction sity trabecular bone. Sennerby et al.11 com- pared implants placed in rabbit cortical versusDental implants are prosthetic devices, made cancellous bone and established that corti-of alloplastic materials that are inserted into the cal bone has a higher modulus of elasticity, isoral cavity to provide retention and support to harder to deform and provides greater resis-removable and fixed dental prostheses.1,2 The tance to motion. Hence, Class I and Class IIconcept of using implants to replace teeth is bone would facilitate higher primary stabilityage old. In fact, in ancient history thousands ofyears ago, ivory teeth were used as implants in The original protocol for loading, asEgyptian mummies. However, the era of mod- described by Branemark, involved waiting forern dental implantology began much later, in three months (for mandible) to six months (forthe 1940’s, with the discovery of screw type maxilla) after implant placement. Such a delayedimplants by Formiggini et al.3,4 The introduc- loading protocol was aimed at allowing undis-tion of the concept and the biology of osseoin- turbed healing and complete osseointegra-tegration, by Branemark et al.5 added another tion before implants could be loaded. For amilestone in the history of dental implantol- long time it was assumed that premature load-ogy. Over the years, this field has signifi- ing would limit peri-implant osteogenesis andcantly evolved and emerged as an extensively induce fibrous tissue formation.7,12 Schnitmanused treatment modality for oral rehabilitation. et al. introduced the concept of immediate loading, which has been described as attach- The first clinical outcome of surgical pro- ment of the prostheses within twenty-fourcedure is the primary stability of the implant. hours to one week after implant placement.13,14Primary stability is rigid fixation and lack of Some of the advantages of immediate load-micro motion of the implant into the bone cav- ing are shortened treatment time and earlyity.1,6,7 Absence of stability can lead to exces- functional, physiological and psychologicalsive mobility and cause fibrous tissue formation rehabilitation of the patient. In addition, therearound the implants inhibiting osseointegra- have been some claims made about a biologiction.7,9 Primary stability depends on the surgi- advantage in the form of enhanced osteoblas-cal technique, implant design and the implant togenesis with immediate loading. An in-vivosite.9,10 Bone tissue is arranged in two macro study by Qi et al. evaluated the response ofarchitectural forms, trabecular or cancellous mesenchymal stem cells to mechanical strainand cortical or compact. Leckholm and Zarb and their consequent gene expression pat-(1985) have classified bone types in the oral terns.15 Their results suggested that mechani-cavity, depending on the relative proportions cal strain might act as a stimulator to induceof cancellous and cortical bone: A) Class I: differentiation of stem cells into osteoblasts.15predominantly cortical; B) Class II: thick layer Indeed, cyclic tensile strain has been shownof compact bone surrounding a dense cancel- to increase osteoprotegrin synthesis andlous core; C) Class III: thin layer of compact decrease soluble receptor activator of nuclearbone surrounding a cancellous core; D) Class factor kappa-B ligand (RANKL), thus favoringIV: very thin compact layer around a low den-34 • Vol. 6, No. 3 • June 2014

Abdulgani et albone formation.16 This theory was tested in an index).23,24 The long-term efficacy of implant-rabbit model by Duyck et al. who concluded supported overdentures has been establishedthat mechanical loading stimulated bone for- in many retrospective and longitudinal trials.25-27mation and led to a higher bone fraction.17,18 Implant overdentures are used in conjunc-Treatment of Complete Edentulism with tion with attachments and there are manyImplant Overdentures different attachments provided by a largeAn overdenture is defined as any dental pros- number of manufacturers around the world.thesis that covers and rests on one or more The attachments currently available can beremaining natural teeth, the roots of natural broadly divided into two major categories: A)teeth, and /or dental implants.2 The concept Splinted / Bar Attachments (Dolder bar andof overdentures is age old. Ledger as early as Hader bar are examples of splinted attach-1856, suggested utilizing natural teeth to sta- ments); B) Non-splinted / Solitary / Studbilize removable prostheses and after a whole Attachments (Ball attachments, magnetscentury Miller introduced the concept of tooth and locators exemplify solitary attachments).retained overdentures.19 The downside ofthese prostheses was frequent failure of abut- Loading of Implant Overdenturesments caused by periodontal disease, peri- A fairly recent systematic review by Gallucciapical lesions, caries and fracture of teeth.20 et al (2009), presented the strength of evi- dence available for different loading protocols The introduction of osseointegrated implants (conventional, early and immediate loading) inand implant-retained prostheses led to a para- completely edentulous patients. Their searchdigm shift for the management of edentulism. led to a conclusion that the highest level ofThis is true especially for mandibular edentu- scientific and clinical validation was avail-lism, where the problem of advanced alveo- able for conventional loading with mandibu-lar resorption and difficulty in providing stable, lar overdentures. However, immediate loadingretentive and functionally comfortable prosthe- of mandibular dentures was clinically wellses seemed to represent a major challenge.21 documented but not scientifically validated.28 A number of randomized controlled tri- Clinical documentation of immediate load-als have demonstrated increased patient ing can be exemplified by various prospectivesatisfaction and reduced negative impact trials that have been conducted using this pro-on quality of life with implant retained over- tocol for mandibular dentures. For example, adentures as opposed to conventional den- longitudinal study with 3-8 years of follow up bytures in the mandible.22 Other studies have Chiapasco et al.33 looked at success and sur-reported an improvement in chewing abil- vival of immediately loaded implants supportingity, bite force and in serum nutritional and a mandibular overdenture. Four implants wereanthropometric parameters (such as skin placed per patient, connected by a splintedfold thickness, waist hip ratio and body mass bar attachment. A cumulative success rate of The Journal of Implant & Advanced Clinical Dentistry • 35

Abdulgani et al88.2% and survival rate of 96.1% was seen trial by Meijer et al (2009), among many oth-after a mean follow up period of 62 months. ers, have shown that there is no difference inThe authors concluded that, for about 3 years the clinical and radiographic performance ofafter immediately loading the implants, the suc- two or four implants supporting a mandibularcess and survival were the same as that docu- overdenture.27,28 Hence, having establishedmented for delayed loading. However, with a that immediately loaded four implants support-longer follow up it became evident that immedi- ing a mandibular overdentures are comparableately loaded implants had a moderate decrease to delayed loaded implants, it would be inter-in success rate.29 Similar results were reported esting to see if these results can be replicatedby Kronstrom et al.30 wherein he advised cau- when two implants were used in conjunctiontion in using immediate loading due to a low with unsplinted attachments such as locators.survival rate of 81.8% at 1 year follow up. Case Report Other investigators have, however, reportedhigher rates of success and survival using A 58-year-old female patient without any medicalan immediate loading protocol. A cohort contra-indications for implant therapy presentedstudy by Gatti et al.31 has shown a cumula- with an ill-fitting, lower complete denture thattive survival rate of 100% and minimal bone she had been wearing for four years. The clini-level changes (0.5–0.9 mm) around immedi- cal and radiographic findings revealed slight toately loaded implants. Alfadda et al.32 used moderate mandibular ridge resorption with anhistorical controls with delayed loading in a ill-fitting lower denture (Figs. 1, 2). The patientprospective cohort study and compared it to was given the option of placing two implantsimmediate loading. At 5 years, they found iden- to support her existing lower denture. Thetical success, survival, satisfaction and impact treatment plan was accepted and included anon quality of life between the two groups. immediate functional loading by using a locator attachment-supported mandibular overdenture. Randomized clinical controlled trials (RCT)are considered as the most reliable (Level I) At the surgical appointment, following theform of validation in the hierarchy of scien- administration of local anesthetic, a mid-crestaltific evidence, essentially because they reduce incision was performed and a full-thicknessspurious causality and bias. In order to prove flap was reflected. In addition, osteotomiesthe efficacy and safety of an immediate load- were prepared in type II bone. Bone taps wereing protocol Chiapasco et al.33 performed a used to countersink the sites, after which twoRCT comparing an immediate and a delayed ITI Tapered implants (ITI 3.3X14-mm) wereprotocol for four splinted implants supporting placed with the hand piece and hand ratchet.a mandibular overdenture. They found no dif- The implants were torqued to 35 N (Figs. 3, 4).ference in cumulative survival rate, bone loss, Immediately after implant surgery (Fig. 5), theclinical and radiographic parameters at 2 years mandibular denture was seated in the patient’sbetween the two groups. A review paper by mouth and adjusted to provide clearance inGallucci et al (2009) and a 10 years clinical the area of the locators (Fig. 6). Two locators36 • Vol. 6, No. 3 • June 2014

Abdulgani et alFigure 1: Mandible at the time of implant placement with Figure. 2: Pre-op panoramic radiograph.moderate bone resorption.Figure 3: Guiding pins at the time of implant placement. Figure 4: Two tapered implants at placement.(4 mm in length) were torqued to 30 N (Figs. implant-supported overdenture was to be left7, 8). Following the suture of the flap with4-0 in place for 48 hours. Two days later, she wasvicryl, the processing rings were placed over seen for a follow-up visit and the healing pro-the locators and were picked up directly in the cess was uneventful. The black processingmouth using hard self-curing acrylic (Rebase II, rings were switched to blue rings ten weeksTokuyama; Fig. 7). The patient was given post- after placement. After six months, the patientoperative instructions, including the use of 0.12 returned for another follow-up visit and both% chlorhexidine gluconate three times a day. locators were torqued to 30 N again. It was determined that both implants had achieved full She was furthermore prescribed 500 mg of integration. Currently, the patient is on a six-amoxicillin (to be taken every six hours for seven month recall to ensure the proper maintenancedays). The patient was then informed that the The Journal of Implant & Advanced Clinical Dentistry • 37

Abdulgani et alFigure 5: Panoramic radiograph immediately after implant Figure 6: The processing rings were picked up directly inplacement. the mouth.Figure 7: Occlusal view of the locators two weeks post- Figure 8: Buccal view of the locators two weeks post-implant placement. implant placement.Figure 9: Buccal view of the overdenture in place. Figure 10: Final smile.38 • Vol. 6, No. 3 • June 2014

Abdulgani et alof the implants and the prosthesis (Figs. 9, 10). AADDVVERETIRSETWISITHEThe last maintenance visit was 24 months post-placement and all implants have maintained TODAY!healthy soft tissue and a stable bone level. Reach more customers Conclusion with the dental profession’s firstWithin the limits of this interim report, immedi- truly interactiveate loading of two implants supporting a loca-tor retained mandibular overdenture seems paperless journal!to be a suitable treatment option. The mar-ginal bone level changes around immediately Using recolutionary online technology,loaded implants are comparable to those seen JIACD provides its readers with anaround implants loaded with a torque do noteffect peri-implant bone loss. Implant sur- experience that is simply not availablevival of immediately loaded implants maybe with traditional hard copy paper journals.lower than those loaded with a delayed pro-tocol, but this needs to be confirmed in futureinvestigations with a larger sample size. ● Correspondence: Dr. Abu-Hussein Muhamad 123 Argus Street 10441 Athens Greece [email protected] WWW.JIACD.COM The Journal of Implant & Advanced Clinical Dentistry • 39

Abdulgani et alDisclosure 19. Miller PA: COMPLETE DENTURES SUPPORTED BY NATURAL TEETH. TexThe authors report no conflicts of interest with anything mentioned in this article. Dent J 1965, 83:4-8.References 20. Fenlon MR: Periodontal disease, periapical lesions and caries were, in that1. Meyer U, Joos U, Mythili J, Stamm T, Hohoff A, Fillies T, Stratmann U, Wiesmann order, the causes of overdenture abutment loss. J Evid Based DentPract 2005, 5(2):94-95. HP: Ultrastructural characterization of the implant/bone interface of immediately loaded dental implants. Biomaterials 2004, 25(10):1959-1967. 21. F eine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ, Gizani S, Head T, Lund JP, MacEntee M, Mericske-Stern R et al: The McGill consensus statement2. . The glossary of prosthodontic terms. J Prosthet Dent 2005, 94(1):10-92. on overdentures. Mandibular two-implant overdentures as first choice standard of care for edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral3. 1 5. Kibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system Maxillofac Implants 2002, 17(4):601-602. for an endosteal tooth implant: I. Critical assessment of previous designs. Oral Implantol 1975, 6(2):172-192. 22. Thomason JM, Lund JP, Chehade A, Feine JS: Patient satisfaction with mandibular implant overdentures and conventional dentures 6 months after4. K ibrick M, Munir ZA, Lash H, Fox SS: The development of a materials system for delivery. Int J Prosthodont 2003, 16(5):467-473. an endosteal tooth implant. II. In vitro and in vivo evaluations of a new composite- material design. J Oral Implantol 1977, 7(1):106-123. 23. Morais JA, Heydecke G, Pawliuk J, Lund JP, Feine JS: The effects of mandibular two-implant overdentures on nutrition in elderly edentulous individuals. J Dent5. B ranemark PI, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson A: Intra- Res 2003, 82(1):53-58. osseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 1969, 3(2):81-100. 24. B akke M, Holm B, Gotfredsen K: Masticatory function and patient satisfaction with implant-supported mandibular overdentures: a prospective 5-year study. Int6. A dell R, Lekholm U, Rockler B, Branemark PI: A 15-year study of J Prosthodont 2002, 15(6):575-581. osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981, 10(6):387-416. 25. Vercruyssen M, Marcelis K, Coucke W, Naert I, Quirynen M: Long-term, retrospective evaluation (implant and patient-centred outcome) of the two-7. Marco F, Milena F, Gianluca G, Vittoria O: Peri-implant osteogenesis in health and implants-supported overdenture in the mandible. Part 1: survival rate. Clin Oral osteoporosis. Micron 2005, 36(7-8):630-644. Implants Res 2010, 21(4):357-365.8. Soballe K, Hansen ES, H BR, Jorgensen PH, Bunger C: Tissue ingrowth 26. A ttard NJ, Zarb GA: Long-term treatment outcomes in edentulous patients into titanium and hydroxyapatite-coated implants during stable and unstable with implant overdentures: the Toronto study. Int J Prosthodont 2004, mechanical conditions. J Orthop Res 1992, 10(2):285-299. 17(4):425-433.9. S evimay M, Turhan F, Kilicarslan MA, Eskitascioglu G: Three dimensional finite 27. M eijer HJ, Raghoebar GM, Batenburg RH, Visser A, Vissink A: Mandibular element analysis of the effect of different bone quality on stress distribution in an overdentures supported by two or four endosseousimplants: a 10-year clinical implant-supported crown. JProsthet Dent 2005, 93(3):227-234. trial. Clin Oral Implants Res 2009,20(7):722-728.10. Buchter A, Kleinheinz J, Joos U, Meyer U: [Primary implant stability with different 28. Marzola R, Scotti R, Fazi G, Schincaglia GP: Immediate loading of two implants bone surgery techniques. An in vitro study of the mandible of the minipig]. Mund supporting a ball attachment-retained mandibular overdenture: a prospective Kiefer Gesichtschir 2003, 7(6):351-355. clinical study. Clin Implant Dent Relat Res2007, 9(3):136-143.11. S ennerby L, Thomsen P, Ericson LE: A morphometric and biomechanic 29. C hiapasco M, Gatti C: Implant-retained mandibular overdentures with comparison of titanium implants inserted in rabbit cortical and cancellous bone. immediate loading: a 3- to 8-year prospective study on 328 implants. Clin Int J Oral Maxillofac Implants 1992, 7(1):62-71. Implant Dent Relat Res 2003, 5(1):29-38.12. Albrektsson T: Direct bone anchorage of dental implants. J Prosthet Dent 1983, 30. Kronstrom M, Davis B, Loney R, Gerrow J, Hollender L: A prospective 50(2):255-261. randomized study on the immediate loading of mandibular overdentures supported by one or two implants: a 12-month follow-up report. Int J Oral13. Esposito M, Grusovin MG, Willings M, Coulthard P, Worthington HV: The Maxillofac Implants 2010, 25(1):181-188. effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral 31. G atti C, Chiapasco M: Immediate loading of Branemark implants: a 24-month Maxillofac Implants 2007, 22(6):893-904. follow-up of a comparative prospective pilot study between mandibular overdentures supported by Conical transmucosal and standard MK II implants.14. S chnitman PA, Wohrle PS, Rubenstein JE: Immediate fixed interim prostheses Clin Implant Dent Relat Res 2002, 4(4):190-199. supported by two-stage threaded implants: methodology and results. J Oral Implantol 1990, 16(2):96-105. 32. A lfadda SA, Attard NJ, David LA: Five-year clinical results of immediately loaded dental implants using mandibular overdentures. Int J Prosthodont 2009,15. Qi MC, Zou SJ, Han LC, Zhou HX, Hu J: Expression of bone-related genes in 22(4):368-373. bone marrow MSCs after cyclic mechanica strain: implications for distraction osteogenesis. Int J Oral Sci 2009, 1(3):143-150. 33. C hiapasco M, Abati S, Romeo E, Vogel G: Implant-retained mandibular overdentures with Branemark System MKII implants: a prospective comparative16.Kusumi A, Sakaki H, Kusumi T, Oda M, Narita K, Nakagawa H, Kubota K, Satoh study between delayed and immediate loading. Int J Oral Maxillofac Implants H, Kimura H: Regulation of synthesis of osteoprotegerin and soluble receptor 2001, 16(4):537-546. activator of nuclear factor-kappaB ligand in normal human osteoblasts via the p38 mitogen-activated protein kinase pathway by the application of cyclic tensile strain. J Bone Miner Metab 2005, 23(5):373-381.17. Duyck J, Slaets E, Sasaguri K, Vandamme K, Naert I: Effect of intermittent loading and surface roughness on peri-implant bone formation in a bone chamber model. J Clin Periodontol 2007, 34(11):998-1006.18. Vandamme K, Naert I, Vander Sloten J, Puers R, Duyck J: Effect of implant surface roughness and loading on peri-implant bone formation. J Periodontol 2008, 79(1):150-157.40 • Vol. 6, No. 2 • June 2014

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Smile Makeover with all HasanCeramic Crowns and Biologic ShapingDr. Arshad Hasan1AbstractBackground: Smile makeover with the use of tory. All endodontics treatment was repeatedAll Ceramic restorations is a proven and well and crowns were removed. After reshapingaccepted modality. When there is a violation of the abutments, temporary restorations werebiological width in such cases, soft and hard provided and incrementally adjusted whichtissues might be trimmed to achieve a healthy allowed the soft tissues to heal and regainfoundation and ideal proportions. Recent publi- their shape. Minimal gingivoplasty was requiredcations suggest a more conservative approach on teeth no 11 and 21. A healing period wasto address this situation, namely the Biologic followed by the final preparations and place-Shaping. A case of biologic width impingement ment of 6 all ceramic (Empress 2) crowns.is presented here in which the need for crownlengthening was substantially reduced due to Results: The concept of biologic shap-application of principals of biologic shaping. ing allowed to complete the case with mini- mal surgical intervention and resulted inMethods: A female patient, 24 years old pre- an extremely happy and satisfied patient.sented with unsightly crowns on teeth no. 13 to33(FDI). Clinically, the porcelain fused to metal Conclusions: Biologic shaping is a con-crowns had overhanging and impinging margins, servative option to treat cases with bio-improper proportions and a very monochromatic logic width impingement and can beartificial appearance. The teeth were also end- successfully used in the aesthetic zone.odontically treated which was also unsatisfac-KEY WORDS: Biological width, Biologic shaping, All ceramic restorations, IPS Empress 2, Bleaching, Smile makeover, Golden proportions, Endodontic retreatment1. Associate Professor and Head of Operative Dentistry, Dow Dental College, Dow University of Health Sciences, Baba-e-Urdu Road, Karachi Pakistan The Journal of Implant & Advanced Clinical Dentistry • 43

HasanFigure 1: Pre-operative view. Figure 2: Pre-operative view. Introduction ary intention is encouraged. A provisional restoration with 1mm clearance from gingivalBiologic width violation is treated convention- margin is placed over the teeth and left thereally by either surgical crown lengthening or orth- for 3 months. Once the gingival apparatus hasodontic extrusion.1 Former procedure requires healed, permanent restorations are providedthe operator to remove significant hard and with margins just coronal to this newly estab-soft tissues, so that a 3mm zone is established lished gingiva.3 The case presented here wasfrom the margin of restoration to the crestal treated by the author without the knowledge ofbone as described by Gargiulo.2 This results these principals at the time of treatment. How-in significant and often un-necessary removal ever, the ideology was similar i.e. to allow gin-of soft and hard tissues to achieve the objec- gival tissues to heal and regain their originaltive. It also doesn’t allow for individual varia- dimensions before provision of permanent resto-tion of biologic width to exist as it forces a rations rather than surgical crown lengthening.3mm rule to every tooth.3 Biologic shapingwas recently introduced by Melker which allowsindividual variation in biologic width to existand significantly reduces the need for soft andhard tissue removal.4 In the first appointmenta buccal partial thickness and palatal full thick-ness flap is raised, root surfaces are renderedclean of irregularities, existing restorative mar-gins and calculus. A series of diamonds fromcoarse to extra-fine are used to give a smoothroot surface. This is followed by apically repo-sitioned flap closure and healing by second-44 • Vol. 6, No. 3 • June 2014

HasanFigure 3: Assessment of teeth proportions.Figure 4: Endodontic retreatments. Figure 5: Putty stent for temporization. Case Report chromatic and had overhanging and impinging margins. The soft tissues adjacent to these res-A 24 year old medically healthy female presented torations were edematous and bled on prob-to the Department of Operative Dentistry, Ham- ing (Figure 1). There was an asymmetry ofdard University Dental Hospital in April 2009. papilla between teeth 7-10. An adequate bandHer chief complaint was poor aesthetics of front of attached gingiva was present. Radiographicsix maxillary teeth. Clinically there were six indi- evaluation revealed inadequate endodontic treat-vidual porcelain fused to metal crowns pres- ment of all restored teeth (Figure 2). A diagnosisent on teeth no 6, 7, 8, 9, 10, and 11 (FDI tooth of biologic width impingement was made basednumbering system). The crowns were mono- The Journal of Implant & Advanced Clinical Dentistry • 45

HasanFigure 6: Extensive damage to soft tissues revealed. Figure 7: Initial preps and cleaning of debris.Figure 8: Fabrication of temporary restoration using the Figure 9: Adjustment of contours of temporaryputty stent. restoration.on clinical findings and probing depths. Further 3M ESPE, Seefeld Germany) of existing restora-digital smile analysis revealed that teeth 8 and tions was made (Figure 5). The existing crowns9 had improper width to length ratio and were were removed by cutting a groove through theshorter than the smile arc (Figure 3). The treat- facial surface and twisting with a plastic instru-ment plan included retreatment of inadequate ment. Once removed the damage to the soft tis-endodontics, tooth reshaping, long term provision- sues was evident (Figure 6). A soft tissue flapalization, reassessment of aesthetic proportions was not raised as the author was not aware ofand delivery of final all ceramic (IPS EMPRESS the principals of biologic shaping at that time.2, Ivoclar Vivadent, Liechtenstein) restorations. However, a plan was made to allow the soft tis- sues to heal, recoil and regain its natural dimen- The endodontic retreatments were performed sions without dictating any dimensions. Thethrough the existing crowns to facilitate place- teeth were lightly prepared with a chamfer burment of rubber dam (Figure 4). Once endodon- to remove the debris (Figure 7). The putty stenttics was complete, a putty stent (Express STD,46 • Vol. 6, No. 3 • June 2014

HasanFigure 10: 1 week healing after temporization. Figure 11: Biologic shaping, gradual relief of temporary restoration to allow the soft tissues to regain health.was used to fabricate a provisional using an autopolymerizing resin (Protemp, 3M ESPE, Seefeld Figure 12: Non-vital bleaching to lighten discolored teethGermany) (Figure 8). The margins of the provi- no. 9 and 10.sional restoration were kept short of the gingi-val margins to facilitate healing (Figure 9). The val margins to correct a level, as determined by theresults were immediately evident at 1 week recall post provisionalization aesthetic evaluation (Fig-as there was excellent tissue healing (Figure 10). ure 14). Once this surgical site healed, the cor-The margins of provisional were further modi- onal structure of teeth 9 and 10 were reinforcedfied over a period of 3 appointments and papilla with fiber posts (Rebuilda Post, Voco Germany).between teeth 8 and 9 was allowed to become The posts were luted with a self-adhesive resinsymmetrical with its counterpart (Figure 11). Dur- (Breeze, Pentron Clinical Technologies, Walling-ing these appointments teeth 9 and 10 werealso bleached since they exhibited discoloration(Figure 12). A classic walking bleach techniquewas used here with a mixture of sodium perborate(Nanchang Dental Bright Technology, China) andhydrogen peroxide (Hydrogen Peroxide Solution,Karachi Pharmaceutical Laboratories, Karachi). After the completion of bleaching and softtissue healing, the dimensions were once againassessed. Teeth 8 and 9 were found to haveimproper width to length ratio (Figure 13). Thisevaluation showed that both central incisors couldbe lengthened incisally and cervically. The teethwere probed to reveal an adequate sulcus depth,a gingivectomy was performed to bring the gingi- The Journal of Implant & Advanced Clinical Dentistry • 47

HasanFigure 13: Final assessment of proportions after biologic Figure 14: Aesthetic crown lengthening, 1 week post-shaping. operative healing.ford, Connecticut, USA)(Figure 15). Core build- Figure 15: Fiber posts placed in teeth no 9 and 10.ups were performed with a fiber reinforced dualcure core buildup resin (Buildit FR, Pentron Clini- a light curing unit (Elipar Freelight, 3M ESPE,cal Technologies, Wallingford, Connecticut, USA). Seefeld Germany), excess removed and patient was dismissed with home care instructions. The teeth were now ready for final prepara-tions. The finish line was at the level of gingival The patient returned on a follow up visitmargin in teeth 8 and 9, however it was subgin- 2 months later (Figure 19). The gingival tis-gival in rest of teeth (Figure 16). An impressionwas recorded with an addition silicon material ina stock tray. The impression of opposing archwas recorded with alginate in a stock tray. Biteregistration paste was used to register the centricocclusion. Shade A1 was selected for body ofcrowns and A2 for the gingival third. Slight inci-sal translucency was requested since patient wasstill young. The case was then sent to lab for fab-rication of All Ceramic crowns (IPS EMPRESS2, Ivoclar Vivadent, Liechtenstein). The case wasreceived from the lab 2 weeks later (Figure 17).It was first tried in and was found to be adequatewith respect to occlusion, margins, contact,emergence profile and aesthetics. The restora-tions were luted with dual cure luting resin of A1shade (RelyX Unicem, 3M ESPE, Seefeld, Ger-many) (Figure 18). The cement was cured with48 • Vol. 6, No. 3 • June 2014

HasanFigure 16: Final teeth preparations for All ceramic crowns. Figure 17: All ceramic IPS Empress 2 crowns on cast, (Ceramist, Mohammad Ali Khan, Khan Dental Laboratories, Karahi).Figure 18: Front and side profile after final cementation. sues exhibited excellent health. There was complete papilla fill in all embrasures. How- ever a slight swelling in interdental papilla was noticed between teeth 7 and 8. Since there was no bleeding on probing and probing depths were within normal limits, no further action was taken. Also the gingiva on tooth 9 had grown over the crown margin and altered the width to length ratio. The patient returned on a sec- ond follow-up a year later and presented a simi- lar healthy gingival tissue except between teeth 7 and 8 (Figure 19). The patient was extremely satisfied with the results, while operator was concerned about the slight gingival swelling. Discussion Health, function and aesthetics are the three most important aspects of Aesthetics Dentistry which must be addressed to obtain exceptional results. The Journal of Implant & Advanced Clinical Dentistry • 49

HasanFigure 19: 2 month and 1 year recall. Figure 20: Before and after.While health and function can exist indepen- (IPS EMPRESS 2, Ivoclar Vivadent, Liechten-dently, aesthetics cannot be achieved unless the stein) after ensuring adequate healing of soft tis-former two are obtained.5 Aesthetic cases with sues. However two undesirable events occurredbiologic width violation are most challenging to on follow up. The interdental papilla betweentreat, since there is not only an unhealthy soft tis- teeth number 7 and 8 exhibited slight swelling butsue response, tooth to tooth proportions are also did not bled on probing. Also the gingiva on toothusually incorrect. Traditionally, these cases have 9 had grown over the crown margin and alteredbeen treated with surgical crown lengthening the width to length ratio. Both the events werealone. Major disadvantage of crown lengthening not expected. However, the patient was not both-procedure is the need to remove bone and gin- ered about either and no further action was taken.giva, sometimes unnecessarily to fulfill biologicalobjectives. Another shortcoming is that it brings Conclusionthe narrower part of root more coronally and thisresults in compromised emergence profile, tri- Biologic shaping is a conservative option to treatangular gingivae and possible black triangles.1 cases with biologic width impingement and can be successfully used in the aesthetic zone. ● Biologic shaping was introduced by Melkerto address the shortcomings of surgical crown Correspondence:lengthening. The benefits of this procedure have Dr. Arshad Hasanbeen explained by Melker.4 The author was Dow Dental College, Dow University of Healthnot aware of this technique since the case was Sciencestreated in 2009 and hence could not apply all Baba-e-Urdu Road, Karachi Pakistanthe principals of this novel concept. We cleaned Phone Office: 009221-99215754 ext 324the tooth surface and provided a long term provi- Cell No. 0092321-2437304sional with margins short of gingiva as proposed Email: [email protected] Melker.3 Definitive restorations were placed50 • Vol. 6, No. 3 • June 2014