Restoring the Severely Atrophic Maxilla

VOLUME 1, NO. 2 APRIL 2009 The Journal of Implant & Advanced Clinical Dentistry Restoring the Severely Atrophic Maxilla Implant Induced Sublingual Hematoma







The Journal of Implant & Advanced Clinical Dentistry Table of Contents 11 No Bone SolutionTM Computer Guided 41 Life Threatening Sublingual Hematoma Implant Surgery Protocol for Formation Following Placement of Prosthodontic Rehabilitation of the Two Mandibular Implants: A Case Report Severely Atrophic Maxilla Michael Tame, David McNeil, Richard Parkin Thomas J. Balshi, Glenn J. Wolfinger, John J. Thaler II, James R. Bowers, Stephen F. Balshi 47 The Agony and Ecstasy of Buying Cone Beam Technology Part II: The Agony Dale A. Miles 19 Factors Driving Peri-implant Crestal Bone 57 4% Articaine Use in United States and Loss - Literature Review and Discussion: Canadian Dental Schools Part 1 of 4 Matthew R. Byarlay Mohammad Ketabi, Robert Pilliar, Douglas Deporter 63 The E ects of Periodontal Therapy 31 Sinus/Alveolar Crest Tenting Technique: on Helicobacter pylori Clearance in A Case Report with Histology and Gastritis Patients: A Pilot Study 40-Month Clinical Follow-up N. Shumaker, A. Soolari, A. Gentry, H. Liu, A. Dubois Alan A. Winter, Alan S. Pollack, Ronald B. Odrich The Journal of Implant & Advanced Clinical Dentistry 3

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The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS A Minimally Invasive and SystematicEAdpiptororaiachl AtodSviinsuosrGyrBafotianrgd Tara Aghaloo, DDS, MD Robert Horowitz, DDS George Priest, DMD Faizan Alawi, DDS Michael Huber, DDS Giulio Rasperini, DDS Michael Apa, DDS Richard Hughes, DDS Michele Ravenel, DMD, MS Alan M. Atlas, DMD Debby Hwang, DMD Terry Rees, DDS Charles Babbush, DMD, MS Anil Idiculla, DMD Laurence Rifkin, DDS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Paul Rosen, DMD, MS Barry Bartee, DDS, MD James Jacobs, DMD Joel Rosenlicht, DMD Lorin Berland, DDS Ziad N. Jalbout, DDS Larry Rosenthal, DDS Peter Bertrand, DDS John Johnson, DDS, MS Steven Roser, DMD, MD Michael Block, DMD John Kois, DMD, MSD Salvatore Ruggiero, DMD, MD Chris Bonacci, DDS, MD Joseph Kravitz, DDS, MS Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Maurizio Silvestri, DDS, MD Ronald Brown, DDS, MS Burton Langer, DMD Dennis Smiler, DDS, MScD Bobby Butler, DDS Aldo Leopardi, DDS, MS Muna Soltan, DDS Donald Callan, DDS Carlo Maiorana, MD, DDS Michael Sonick, DMD Nicholas Caplanis, DMD, MS Louis Mandel, DDS Ahmad Soolari, DMD Daniele Cardaropoli, DDS Michael Martin, DDS, PhD Christian Stappert, DDS, PhD Giuseppe Cardaropoli DDS, PhD Ziv Mazor, DMD Eric Stoopler, DMD John Cavallaro, DDS Dale Miles, DDS, MS Scott Synnott, DMD Stepehn Chu, DMD, MSD Robert Miller, DDS Haim Tal, DMD, PhD David Clark, DDS John Minichetti, DMD Gregory Tarantola, DDS Charles Cobb, DDS, PhD Jaimee Morgan, DDS Dennis Tarnow, DDS Spyridon Condos, DDS Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Peter K. Moy, DMD Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Mel Mupparapu, DMD Michael Tischler, DDS Alex Ehrlich, DDS, MS Ross Nash, DDS Tolga Tozum, DDS, PhD Nicolas Elian, DDS Gregory Naylor, DDS Leonardo Trombelli, DDS, PhD Paul Fugazzotto, DDS Marcel Noujeim, DDS, MS Ilser Turkyilmaz, DDS, PhD Scott Ganz, DMD Sammy Noumbissi, DDS, MS Dean Vafiadis, DDS Arun K. Garg, DMD Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Alan Winter, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Glenn Wolfinger, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Richard K. Yoon, DDS Michael Herndon, DDS Stan Presley, DDS The Journal of Implant & Advanced Clinical Dentistry 7

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Editorial Commentary Daddy, what is a newspaper? Ihave two young daughters that simply love to read. Between the two of them, I would ven- edge. While this is true for products and tech- ture to say that they have at least three hun- niques, I cannot say the same for our profession’s view of dental literature. I cannot even begin to dred books. They must have received this gene tell you how many times Nick and I receive puzzled from their mother because I personally do not read looks when we tell our colleagues that JIACD is a much for pleasure. Considering the fact that I am paperless journal. For some reason, many in our constantly reading countless numbers of den- industry cling to the antiquated notion that dental tal articles, the last thing I want to do in my spare literature must be printed to be worthwhile. time is read. Online dental publishing allows for options A few days ago, my youngest daughter was that simply cannot be replicated in print issues. reading a book called If You Lived 100 Years Embedded hyperlinks, flash animation, video, Ago (McGovern A. Scholastic, New York 1999). audio, and a virtually unlimited number of pho- This wonderful book describes what life was like tographs are just a few of the benefits of online at the dawn of the twentieth century in terms that publication. Couple these features with no sub- a child can understand. Roughhewn cobble- scription fees and instantaneous worldwide stone streets, horse drawn carriages, iceboxes, access, and you have a combination that benefits and dime stores are just a few of the many now our entire profession as a whole. defunct items discussed in this book. One addi- Mark my words, within a few years, all den- tional item that may soon be added to this list is tal journals will offer online versions, while many the printed newspaper. will follow the lead of JIACD and eliminate their Over the past year, dozens of newspapers in print versions entirely. Most will say this change the United States have either closed their doors is their way of “going green”, but the bottom line or eliminated their print editions in favor of online is that this change will be based on economics. publication. In fact, just yesterday, The Seat- Newspapers, the bastion of printed journalism, are tle Post-Intelligencer published its last print edi- already succumbing to this pressure and dental tion after 146 years of operation. Can you believe journals are sure to follow. this? In the classic perception of Americana, the Do not be afraid of change; embrace it! The newspaper was considered a rock of Gibraltar, benefits of online dental literature will far outweigh an institution that could not fail. Heck, Clark Kent the ability to hold a collection of printed words in (a.k.a Superman), the most invincible of all super- your hand. heroes, even worked at a newspaper! All good things must come to an end, so they say, and the printed newspaper seems well on its way to antique status. Dentistry is an industry that has never seemed to fear change. New products and techniques are being constantly introduced, and our thirst for con- Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS tinuing education keeps most of us on the cutting Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 9

Balshi et al

Case of the Month Balshi et al No Bone SolutionTM Computer Guided Implant Surgery Protocol for Prosthodontic Rehabilitation of the Severely Atrophic Maxilla Thomas J. Balshi, DDS, FACP1 1 1 1 2 Abstract Background: Prosthodontic rehabilitation of the mark System® Zygoma implants. The patient severely atrophic maxilla presents significant chal- received an immediate fixed screw retained provi- lenges to the restoring dental team. Inadequate sional prosthesis on the day of surgery and was bone quantity often necessitates time depen- restored with a final prosthesis 5 months later. dent augmentation procedures that consider- ably delay delivery of the final dental prostheses. Results: Surgical treatment and implant This case report demonstrates a newly developed delivery utilizing the No Bone SolutionTM pro- specialized computer guided dental implant sur- tocol were uneventful. The patient’s maxil- gery protocol for prosthetic rehabilitation of the lary prosthetic rehabilitation has been without severely atrophic maxilla: the No Bone Solution.TM complication for 3 years following surgery. Methods: A 67 year old Indian male with a some- Conclusion: The No Bone SolutionTM com- what compromised medical history and severely puter guided implant surgery protocol pro- atrophic maxilla presented for rehabilitation with vides a restorative option for patients with dental implants. The patient was treated with severely atrophic maxillary bone. This pro- the No Bone SolutionTM protocol for delivery of tocol does not require bone augmentation 5 standard Brånemark implants and 4 Bråne- and significantly reduces total treatment time. KEY WORDS: Dental implants, zygoma, maxilla, cone beam computed tomography, CAD/CAM, osseointegration 1. Pi Dental Center, Fort Washington, PA, USA. 2. CM Ceramics, Mahwah, NJ, USA The Journal of Implant & Advanced Clinical Dentistry 11

Balshi et al CASE REPORT surgery for placement of five traditional Brånemark implants and freehand placement of four zygomatic Long-term success of osseointegrated implants implants to support an interim all acrylic screw- depends on the length of the implants used and retained fixed prosthesis. After 12 weeks of heal- the quality and quantity of bone surrounding ing and osseointegration, the fixed screw retained these implants. As surgical and prosthetic tech- titanium and ceramic prosthesis was fabricated. niques have evolved, the success rate for rou- tine implant treatment has improved and implant Computer Plan prosthodontics has become the standard of care. A virtual plan of the intended surgery was com- pleted using the Nobel Biocare Procera soft- A 67 year-old retired surgeon was referred ware. Computer data was transmitted to a to the Pi Dental Implant Center by his periodon- rapid prototype machine for production of the tist and restorative dentist in April 2007 with a surgical template. Using this template, a mas- prior diagnosis of “no bone in the maxilla.” This ter cast was constructed and articulated. The patient’s desire for treatment included “fixed screw retained provisional prosthesis was then teeth” with improved oral function and esthetics. constructed prior to dental implant surgery. Some of his medical conditions were potentially detrimental to the long-term prognosis of com- Surgical Protocol plex dental treatment, but not insurmountable. Blood was drawn prior to surgery, transferred to The patient was diagnosed with diabetes, emphy- the Harvest cell separator unit and Platelet Rich sema, high blood pressure and dry mouth syn- Plasma was prepared. General anesthesia was drome. To further complicate matters, he smoked then administered and the patient was fully draped two packs of cigarettes a day and admitted to an using the standard sterile protocol. Local anes- intense parafunctional bruxing and clenching habit. thesia was also used for hemostasis. Following the guided portion of the surgery, which assists in Initial Clinical and Radiographic Assessment the placement of 5 Brånemark implants, the surgi- After a thorough oral examination, which cal template was removed. A crestal incision and included evaluation of the existing prosthet- vertical releasing incisions were made bilaterally ics, articulated diagnostic casts, panorex and full thickness flaps were elevated to the level radiograph, lateral cephalometric radiograph of the superior aspect of the zygomatic bone. The and preoperative clinical photographs, the transantral osteotomies, using graduated diam- following treatment plan was developed eter drills, were completed to permit the apex of using the No Bone Solution™ protocol. the implants to penetrate through the lateral sur- face of the zygoma. A total of four Brånemark Treatment Plan System® Zygoma implants were installed—two in (1) Removal of the non-integrated “mini” implants each zygoma. Finally, using the Teeth In A Day® in the area of teeth 14 and 15. (2) Fabrication of conversion protocol, the previously constructed a new maxillary denture that incorporated radio- prosthesis was installed on the standard Bråne- graphic markers to be used in conjunction with an i-Cat cone beam scan. (3) NobelGuide™ guided 12 Vol. 1, No. 2 April 2009

Balshi et al mark implants and then connected intraorally Correspondence: to the zygomatic implants. The prosthesis was Dr. Thomas J. Balshi then removed, adjusted, polished and reinstalled. 467 Pennsylvania Avenue, Suite 201 Fort Washington, PA 19034 USA The Final Prosthesis TEL: 215-643-5881 Osseointegration, under immediate loading con- FAX: 215-643-1149 ditions is paramount to the success of this pros- [email protected] thesis. Research on immediate loading has shown that after eight weeks, osseointegration Disclosure: should be mature to allow for a predictable out- The authors of this article disclose that they have come. Due to this patient’s numerous medical agreements and/or financial arrangements with conditions, the final impression was taken after the Pi Dental Center and Nobel Biocare®. a 12-week healing time. He was restored using Acknowledgement CM Ceramics technology produced in Mahwah, The Pi team gratefully thanks two dedicated dental spe- New Jersey. The final prosthesis for the maxilla cialists, Dr. Russell Morgan, Restorative Dentist and Dr. consisted of a CAD/CAM robotically milled titanium Gregory Felthousen, Periodontist (both of Salisbury, MD) for frame with individual zirconium ceramic crowns extraordinary “insights” in their encouragement and genuine using the Nobel Biocare Procera Technology. concern for the patient illustrated in this issue. Likewise, we also acknowledge numerous colleagues who have pro- CONCLUSION vided similar guidance to clinically “hopeless” patients. Lab Support: Patients with extreme maxillary atrophy generally Stephen F. Balshi, MBE suffer with ill-fitting removable prostheses that CM Ceramics, LLC chronically irritate the mucosa and insult what lit- tle underlying bone remains. For patients with no The Journal of Implant & Advanced Clinical Dentistry 13 remaining alveolar bone, the No Bone Solution™ protocol demonstrated in this article is an ideal treatment that avoids major bone grafting and the long associated healing and treatment time. The No Bone Solution™ potentially shortens treat- ment time to only 3 visits over a 3-month period. It also provides patients with little or no bone with a non-removable solid set of teeth in just one day. No Bone Solution™ is a special treatment protocol developed at the Pi Dental Center. It combines unique computer guided implant sur- gery with precision screw retained fixed prost- hodontic rehabilitation of the severely atrophic maxilla. The protocol eliminates the need for inva- sive bone grafting and extensive procedures

Balshi et al INITIAL PRESENTATION 14 Vol. 1, No. 2 April 2009

Balshi et al PRE-SURGICAL PLANNING The Journal of Implant & Advanced Clinical Dentistry 15

Balshi et al FINAL PROSTHESES 16 Vol. 1, No. 2 April 2009

Balshi et al POST-SURGICAL RESTORATION The Journal of Implant & Advanced Clinical Dentistry 17

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Factors Driving Peri-implant Ketabi et al Crestal Bone Loss - Literature Review and Discussion: Part 1 of 4 Mohammad Ketabi, DDS, MDS1 2 3 Abstract Many factors contribute to the cumulative in English language refereed journals for the crestal bone loss seen around endosseous decade preceding May 2008 and attempted dental implants. This can create confusion for to identify the major factors associated with the practicing clinician and lead to undesirable peri-implant bone loss. Part one of this article outcomes. In this four part review series, we series examines surgical and anatomical factors have searched the literature for papers published associated with peri-implant crestal bone loss. KEY WORDS: Crestal bone loss, dental implants, causative factors 1. Dean, Professor and Chairman, Department of Periodontology, Faculty of Dentistry, Islamic Azad University (Khorasgan Branch), Arghavanieh, Isfahan, Iran 2. Professor Emeritus, Faculty of Dentistry & Center for Biomaterials, University of Toronto 3. Professor, Discipline of Periodontology and Oral Reconstructive Center, Faculty of Dentistry, University of Toronto The Journal of Implant & Advanced Clinical Dentistry 19

Ketabi et al INTRODUCTION loss. The generally accepted upper limit of crestal bone loss used to define implant success is less The use of osseointegrated dental implants as a than 0.2mm per annum after year one1 with the foundation for prosthetic replacement of miss- majority of implants showing undetectable radio- ing teeth has become routine clinical practice. graphic changes thereafter.2-7 However, many fac- Advances in radiographic imaging techniques, sur- tors, both biological and biomechanical, will have gical and prosthetic procedures and implant design a cumulative impact on the final amount of bone and surface features have evolved to the point loss seen. It is important for clinicians to under- that implant dentistry now offers highly predict- stand all of these factors in addition to their rela- able treatment outcomes for cognizant clinicians. tive contributions and interactions. A summary of contributing factors to be addressed in this review An important parameter in assessing long- paper is provided in Table 1 and their proposed term success or failure of a dental implant is the extent of its cumulative peri-implant crestal bone Flap Design Genetic Pro le Level of Geometry Early Load Facial Cortical Microgap Length and Overload Oral Hygiene Platform-Switching Bone Smoking & Width DIsuse Thickness Alchohol Implant-Tooth Neck Design Atrophy Bone Quality Consumption or Inter-Implant History & Type Surface Single vs of Periodontitis Distance Roughness 2-Stage Implant Diabetes Placement Early Exposure of Cover Screw Quantity of Keratinized Tissue 20 Vol. 1, No. 2 March 2009

Ketabi et al interactions are depicted schematically in Figure using submerged or non-submerged technique, 1. These factors include: i) surgical and anatomi- early unintentional exposure of originally sub- cal considerations such as mucoperiosteal flap merged implant cover screws by mucosal dehis- design, thickness of facial and lingual/palatal corti- cence and, amount of peri-implant keratinized cal plate of bone remaining after osteotomy prepa- tissue; ii) patient risk factors such as medical and ration, bone quality, whether the implant is placed pharmacological status, habits including cigarette The Journal of Implant & Advanced Clinical Dentistry 21

Ketabi et al smoking, poor oral hygiene and possibly excessive ences were selected on the basis of their titles alcohol consumption, mucosal abnormalities such and abstracts. As the final selection method, full as erosive lichen planus, susceptibility to and pre- texts of publications identified as possibly relevant vious history of periodontitis, type of oral microflora were reviewed for more detailed evaluation. Pub- present, presence and type of periodontitis (i.e. lications reviewed included experimental animal chronic vs aggressive); iii) biologic width related studies, prospective and retrospective human clini- factors such as level of the micro-gap, platform- cal studies, a few case reports and relevant review switching and implant-tooth or implant-implant papers. Because of the limited numbers of avail- distance; iv) implant design features including able studies for some factors and their heterogene- geometry, surface texture, length and diameter; ity, focusing on a specific pre-defined question to and v) biomechanical factors including early vs be answered by a systematic review was not feasi- delayed loading, disuse atrophy of crestal bone ble and therefore no meta-analysis was attempted. or over-loading related to prosthetic design (e.g. whether the prosthesis is removable or fixed, and if DISCUSSION fixed whether cement- or screw-retained) quality of prosthetic work (e.g. with or without a well-equili- A number of surgical and anatomical factors brated occlusion), habits such as bruxism, loosen- may contribute to peri-implant crestal bone loss. ing of prosthetic retention screws and, repeated The most common factors associated with such removal and re-insertion of implant restorations. loss include: In this review, an attempt has been made to iden- tify relative contributions and interactions of key Flap Design factors driving crestal bone loss with the pur- Ramfjord and Costich8 reported long ago that, pose of helping practicing clinicians to plan and whenever a mucoperiosteal flap is reflected about conduct successful implant treatments resulting a tooth, some crestal bone resorption is inevitable. in predictable long-term crestal bone equilibrium. Similarly, elevating a flap to place a dental implant will lead to crestal bone loss and, evidence exists MATERIALS AND METHODS to suggest that there is a direct relationship between size of mucoperiosteal flap and resulting A literature search of papers published in ref- post-surgical bone loss. The least amount of post- ereed journals in the English language for the surgical bone loss is likely to result with flapless decade preceding May 2008 was performed placement of dental implants. Flapless implant by computer using the National Library of Medi- placement has been made possible by the innova- cine (http://www.ncbi.nlm.hih.gov/PubMed) and tive approach of using CT scan radiographic data SCOPUS Cochrane Oral Health Group data- to design and fabricate what are purported by bases. Search strategy included a specific the manufacturers to be highly accurate surgical series of terms and key words. The reference templates. However, recent research with “com- lists of identified publications, relevant textbooks puter-assisted virtual treatment” has indicated that and professional workshops also were scanned. complications are higher and thus, this method As the first selection method, relevant refer- 22 Vol. 1, No. 2 April 2009

Ketabi et al must still be regarded to be in an exploratory Figure 2: Example of peri-implant crestal bone loss. phase and for highly experienced clinicians.9,10 ized crestal incisions and soft tissue reflection Jeong et al11 compared bone loss with or to the area immediately above intended implant without the use of flaps in dogs. Threaded den- sites and, repositioning and suturing of the mini- tal implants were inserted in previously edentu- flap margins after implant insertion. The majority lated dog posterior mandible sites. Control sites of implants showed bone loss within the range 0 had implants placed after elevation of full muco- - 0.4 mm, but 9 implants in the flap group showed periosteal flaps, while test sites had their implants > 1.2mm bone loss as compared to no implants placed without flap elevation by accessing bone with this level of loss in the mini-flap group. Also, through 5mm diameter circumferential incisions of interest is the fact that 5 implants in the flap and, removal of the resulting gingival plugs. After group failed, as opposed to none in the flapless 8 weeks site healing, crestal bone loss was quan- group. However, the latter observation should be tified using micro-computerized tomography and, tempered by the fact that all 71 patients managed showed statistically significant differences with with full flaps were completed before the mini-flap crestal bone loss at flapless sites being on aver- group was treated. As such, there may have been age 1 mm less. Becker et al12 also studied this a surgical learning curve biasing the earlier results. issue in dogs but, reported no statistically signifi- cant differences using more traditional histological Gomez-Roman14 reported differences in radio- evaluation of retrieved specimens after 12 weeks graphic measurements of inter-proximal crestal of site healing. Nevertheless, Becker reported the bone loss occurring after placement of 21 single- same magnitude of difference in buccal vertical tooth implants in 21 patients using either a widely bone loss (1mm less for flapless) as Jeong. Inter- mobilized (that included contiguous papillae) or a estingly, Becker et al also found that the flapless limited flap design (not involving papillae). Inter- approach increased the odds of implant failure by proximal crestal bone loss was significantly less 42%, perhaps because they did not have the ben- following the use of the limited flap design. At efit of pre-operative CT imaging in their experiment. the time of prosthetic restoration the mean dif- Human clinical data comparing crestal bone loss following flapless versus full flap sur- gery would not appear to have been available in the published literature at the time of prepa- ration of the present review. However, Jeong et al13 reported no statistically significant differ- ences (0.20 mm for mini-flap vs 0.26 mm for flap; P > .05) in crestal bone loss with mini-flaps (142 implants / 58 patients) as opposed to con- ventional full thickness flaps (144 implants / 71 patients) 3 to 4 months after implant placement surgery. The mini-flap procedure involved local- The Journal of Implant & Advanced Clinical Dentistry 23

Ketabi et al ference in bone loss between the two groups non-damaged sites at the time of implant uncov- was 0.49mm (P= 0.03) and this difference was ering, regardless of the type of augmentation pro- even greater one year later (0.83mm; P= 0.006). cedure used at the time of implant placement. Facial Alveolar Bone Thickness Bone quality The main blood supply for facial alveolar bone Manz21 conducted a prospective human study is supplied by vessels in the overlying mucope- to quantify marginal bone loss around implants riosteum15 and is greatly affected by elevating a placed in sites of differing bone density using mucoperiosteal flap to facilitate placement of a the classification of Lekholm.22 Peri-implant dental implant. Spray et al16 studied changes in bone loss in the interval from implant insertion to the height of facial bone from the time of sub- implant uncovering was similar for all bone quali- merged implant placement using a full-thickness ties (Types I to IV). However, 6 months after pros- flap until implant uncovering (3-4 months in mandi- thesis delivery, varying levels of post-load bone ble, 6-8 months in maxilla). Results were classified loss were observed with the least amount for according to original residual facial bone thick- Type I bone (0.68 mm) and the most (1.44 mm) ness after osteotomy preparation. Measurements for Type IV bone. This correlation between mar- were collected for more than 3,000 implants. ginal bone loss and initial bone density was later After osteotomy preparation, direct measurements verified by other investigators who reported that of residual facial bone thickness were made using bone loss around implants placed in the maxilla calipers at a point approximately 0.5mm below the (less dense bone) was greater than that occur- facial crest. Vertical facial bone height was mea- ring around implants placed in the mandible.23-28 sured in relation to the top of each implant with a periodontal probe. Results indicated that as Single versus 2-Stage Implant Placement residual facial bone thickness approached 1.8 to Whether a single or 2-stage implant placement 2mm, loss in vertical bone height decreased sig- protocol is followed will impact crestal bone loss nificantly. Similar findings were made by Qahash since the 2-stage approach may include a second et al17 as part of an investigation of facial bone mucoperiosteal flap elevation with attendant bone healing in dogs. This would suggest that if resid- resorption. To minimize this effect, if at all possible, ual facial bone thickness is less than 2mm and/or tissue punches or circumscribed incisions with a if dehiscences or fenestrations of facial bone have scalpel blade are used to expose cover screws of occurred during osteotomy preparation, consider- integrated implants. One-stage implants also will ation should be given to augmenting facial bone be exposed to much earlier loading, whether inten- thickness with a grafting procedure.18,19 It should tional or not. This may have a beneficial or detri- be noted, however, that in the case of immedi- mental impact on crestal bone levels depending ate implant placement (maxillary anterior or pre- on the magnitude of the resulting bone strains and molar sites)20, whenever facial cortical bone was any associated early implant micro-movements. damaged (e.g. dehiscence), significantly (P= Single stage implants may be one or two piece in 0.005) greater resorption was seen compared to design and this too will impact crestal bone loss. 24 Vol. 1, No. 2 April 2009

Ketabi et al Early Exposure of Cover Screw able perforations (Class I), bone loss was signifi- Following submerged implant placement, per- cantly less than for perforations where the cover foration of the overlying mucosa and prema- screw was quite visible (Classes II, III, IV). For ture exposure of an implant cover screw can the 115 early exposed implants assessed, 10 result where mucosal tissues fail to achieve pri- showed greater than 2mm bone loss, 3 implants mary wound closure, are too thin to avoid dehis- showed 3 to 4mm bone loss, and one implant cence, or have been somehow traumatized (e.g. showed 5mm of bone loss. In Class II and III pressure from a transitional prosthesis). Toljianic exposures, there was more bone loss associ- et al29 reported that patients with prematurely ated with the facial aspect of the implants and exposed cover screws suffered 3.9 times greater not visible in radiographs. Like Yoo32, Tal sug- likelihood of bone loss with HA-coated (rough- gested that prematurely and partially exposed surfaced30) press-fit cylinder implants than non- implants should be fully uncovered as soon exposed ones. This influence of early exposure as possible after the perforation is observed. was confirmed in a study with baboons by Sev- erson et al31 using machine-turned (minimally In a recent retrospective study, Van Assche rough30) threaded implants. Spontaneous early et al34 reported interesting data on three different exposure was more common in the mandible and scenarios in a group of 60 particle-blasted (moder- led to greater bone loss than implants that had not ately rough30) threaded implants. Twenty implants suffered early exposure. For example, on facial (condition A) were placed using a 2-stage pro- aspects, a highly significant (P= 0.0003) differ- cedure with their healing caps intentionally left ence of 1mm of bone loss was seen. In another exposed, 20 implants (condition B) were placed animal study, Yoo et al32 assessed the effect of with a 2-stage procedure and submerged for a early partial exposure of particle-blasted (moder- healing time of 3 to 6 months, and 20 implants ately rough30) implants placed in dog mandible. (condition C) were placed following a 1-stage pro- For half of the implants, the cover screw was left cedure. Mean bone loss values in the 3 conditions partially exposed while the remaining implants after initial site healing were 1.96mm, 0.01mm and were converted to promote non-submerged heal- 0.14mm for conditions A, B and C respectively. ing by the immediate addition of healing abut- The investigators again concluded that early expo- ments. Using micro-computed tomography, sure of 2-stage moderately rough implants resulted significantly greater crestal bone loss was seen at in significant early bone destruction. This was 8 weeks for the partially exposed implants. The possibly because of inevitable early contamina- investigators suggested that when early partial tion of the microgap by periodontal pathogens.35,36 exposure of submerged implants occurs, healing abutments should be added as soon as is feasible. Quantity of Keratinized Tissue Whether the width and/or thickness of peri-implant Tal et al33 discovered a correlation between the keratinized tissue have an influence on crestal degree of cover screw exposure and associated bone loss has not been adequately investigated. bone loss in humans with TPS-coated (rough30; Apse et al37 reported that the absence of kerati- Steri-Oss®) threaded implants. For barely detect- nized tissue around Branemark-Type® implants The Journal of Implant & Advanced Clinical Dentistry 25

Ketabi et al (machine-turned, minimally rough surface finish30) of keratinized mucosa and alveolar bone loss appeared to have no impact on long-term health around dental implants with a variety of surface of affected implants, however, a correlation with finishes (machine-turned, acid-washed, particle- crestal bone loss was not sought. Wennstrom et blasted/acid-washed, TPS-coated). However, al,38 on the other hand, reported that peri-implant as critiqued by Bouri et al,41 Chung et al did not tissues around Branemark-Type® implants had adjust for other important variables like smok- a greater tendency to be inflamed if there was ing, plaque index and implant surface roughness. 2mm of keratinized tissue present. The investi- gators speculated that sites with minimal kerati- Berglundh and Lindhe43 investigated the issue nized tissue might be more susceptible to plaque of peri-implant mucosal thickness on crestal accumulation. The results of Warrer et al39 lend bone loss in an experimental model in dogs. At support to this idea. These investigators used a test sites at the time of implant (machine-turned) ligature-induced gingivitis model in monkeys and placement, thickness of peri-implant mucosa reported that rough implants (TPS-coated hollow was surgically reduced (to 2mm) while, at con- cylinder implants) with a keratinized tissue cover- trol sites, no mucosal alteration was done. The ing were less susceptible to soft tissue recession results, assessed at the time of uncovering of and bone loss than those without keratinized tis- healed implants suggested that as part of bio- sue. Block et al40 found that a lack of peri-implant logic width accommodation at test sites, crestal keratinized tissue had a significant impact on fail- bone loss occurred to allow for re-establish- ure of HA-coated (i.e. rough30) press-fit cylindri- ment of lost thickness of peri-implant connective cal implants in humans, reporting that HA-coated tissue. This factor was also found to be a pos- implants with no keratinized tissue had a 10x sible contributor to peri-implant bone loss in the greater risk of failure than implants with keratinized study in humans by Bouri et al,41 where mid-facial tissue. These results and those of Warrer et al39 mucosa at sites with < 2mm of keratinized tissue suggest that the effect of keratinized tissue could width were also significantly thinner. Adequate vary between implant designs and, in particular, keratinized tissue may be more important around between different implant surface characteristics. implants than natural teeth for several reasons: supracrestal collagen fibers are oriented in parallel Bouri et al,41 in a cross-sectional study of rather than perpendicular configuration adjacent 200 implants (implant type not specified) in 76 to trans-mucosal surfaces of implants44 provid- patients, reported significantly greater crestal ing less resistance to local trauma and microbial bone loss in sites where the width of mid-facial penetration; and, peri-implant mucosa may have a keratinized mucosa was < 2mm as compared to reduced capacity to regenerate itself due to com- 2mm. This relationship remained significant even promised number of cells and poor vascularity.45 after taking into account time since implant place- ment, smoking, thickness of keratinized tissue, Summary of Surgical and and plaque index using multivariate linear regres- Anatomical Factors sion analysis. In contrast, Chung et al42 reported no association between width (< 2mm vs 2mm) Following implant placement surgery, crestal bone loss is likely to be less with a mini-flap or 26 Vol. 1, No. 2 April 2009

Ketabi et al flapless surgery than with a traditional widely exposed submerged implants should be done as reflected mucoperiosteal flap, primarily because soon as feasible after the exposure to minimize of the extent of temporary interruption of the prin- potential bone loss. Finally, while some contro- ciple blood supply to facial bone. Further, thick- versy remains, it has been argued that a mini- ness ( 2mm is recommended) and integrity mum width ( 2mm) and thickness of keratinized (absence of fenestrations and/or dehiscences) tissue is needed to minimize marginal bone loss of facial bone remaining after osteotomy prepara- around dental implants, after accounting for other tion can impact the extent of post-surgical crestal possible driving factors such as smoking and bone loss. Concerning bone quality, peri-implant plaque index. The importance of keratinized tis- crestal bone loss has been reported to be least in sue in minimizing crestal bone loss may differ with Type I and greatest in Type IV bone, which coin- implant type (e.g. implant surface roughness). cides with the general observation of greater crestal bone loss around maxillary than mandibu- Correspondence: lar implants. Early partial exposure of implants Douglas Deporter, DDS, PhD placed using submerged technique is a risk fac- [email protected] tor for bone loss especially on facial surfaces of moderately rough or rough implants. Accord- ingly, connection of a healing abutment at partially This is part 1 of a 4 part review series. Parts 2, 3 and 4 will appear in future issues of JIACD. The Journal of Implant & Advanced Clinical Dentistry 27

Ketabi et al Disclosure J Clin Periodont 1994; 21: 189-193. 31. Severson S, Vernino A, Caudill R, Holt R, The authors report no conflicts of interest with 16. Spray J, Black C, Morris H, Ochi, S. The Church C, Davis A. Effect of early exposure on anything mentioned within this article. the integration of dental implants in the baboon: References influence of bone thickness on facial marginal Part 1- Clinical findings at uncovering. Int J Perio 1. Albrektsson T, Zarb G, Worthington P, Eriksson bone response: Stage 1 placement through Rest Dent 2000;20:161-71. stage 2 uncovering. Ann Periodont 2000; 5: A. The long-term efficiently of currently used 119-128. 32. Yoo J, Choi B, Li J, Kim H, Ko C, Xuan F, Jeong dental implants : A review and proposed criteria of 17. Qahash M, Susin C, Polimeni G, Hall J, Wikesjo S. Influence of premature exposure of implants success. Int J Oral Maxillofac Impl 1986; 1 : 11-25. U. Bone healing dynamics at buccal peri-implant on early crestal bone loss: An experimental 2. Bower R, Radny N, Wall C, Henry P. Clinical sites. Clin Oral Impl Res 2008; 19: 166-172. study in dogs. Oral Surg Oral Med Oral Pathol and microscopic findings in edentulous patients 18. Jovanovic SA, Spiekermann H, Richter El. Bone Oral Radiol Endod 2008;105:702-706. 3 years after incorporation of osseointegrated regeneration around titanium dental implants in implant supported bridgework. J Clin dehisced defect sites: a clinical study. Int J Oral 33. Tal H, Artzi Z, Moses O., Nemcovsky C, Periodont 1989; 16: 580-587. Maxillofac Impl. 1992;7: 233-245. Kozlovsky A. Spontaneous early exposure of 3. Lekholm U, Adell R, Lindhe J, Branemark P-I, 19. Garg AK. Augmentation and grafting for maxillary submerged endosseous implants resulting in Eriksson B, Rockler B, Lindvall A, Yoneyama T. alveolar ridges. In: Bone. Biology, Harvesting, crestal bone loss: A clinical evaluation between Marginal tissue reactions at osseointegrated Grafting for Dental Implants. Rationale and stage I and stage II surgery. Int J Oral Maxillofac titanium fixtures. II. A cross-sectional retrospective Clinical Applications. 2004. Quintessence Publ., Impl 2001;16: 514–521. study. Int J Oral Maxillofac Surg 1986; 15: 53-61. Carol Stream,IL., chapter 9: 213-240. 4. Cox J, Zarb G. The longitudinal clinical efficacy of 20. Chen S, Darby I, Adams G, Reynolds E. A 34. Van Assche N, Collaert B, Coucke W, Quirynen osseointegrated implants: A 3-year report. Int J prospective clinical study of bone augmentation M. Correlation between early perforation Oral Maxillofac Impl 1987; 2: 91-100. techniques at immediate implants. Clin Oral Impl of cover screws and marginal bone loss: 5. Kline R, Hoar J, Beck G, Hazen R, Resnik R, Res 2005; 16: 176-84. A retrospective study. J Clin Periodont Crawford E. A prospective multicenter clinical 21. Manz MC. Radiographic assessment of 2008;35:76-79. investigation of a bone quality-based dental peri-implant vertical bone loss: DICRG implant system. Implant Dent 2002;11: 224-234. Interim Report no. 9. J Oral Maxillofac Surg. 35. Barboza E, Caula A, Carvalho W. Crestal 6. Pham A, Fiorellini J, Paquette D, Williams R, 1997;55:62-71. bone loss around submerged and exposed Weber H. Longitudinal radiographic study of 22. Lekholm U, Zarb G. Patient selection and unloaded dental implants: A radiographic and crestal bone levels adjacent to non-submerged preparation. In: Tissue-Integrated Prostheses. microbiological descriptive study. Impl Dent dental implants. J Oral Impl 1994;10: 26–34. Osseointegration in Clinical Dentistry. 2002; 11: 162-169. 7. Naert I, Koutsikakis G, Quirynen M, Duyck J, van Branemark P-I, Zarb G, and Albrektsson T, eds. Steenberghe D, Jacobs R. Biologic outcome of Quintessence Publ., Chicago, 1985, pp 199- 36. Quirynen M, Vogels R, Peeters W, van implant-supported restorations in the treatment 209. Steenberghe D, Naert I, Haffajee A. Dynamics of partial edentulism. Part 2 : A longitudinal 23. Adell R, Lekholm U, Rockler B, Branemark P-I. A of initial subgingival colonization of ‘pristine’ radiographic evaluation. Clin Oral Impl Res 2002 ; 15-year study of osseointegrated implants in the peri-implant pockets. Clin Oral Impl Res 2006; 13 : 390-395. treatment of the edentulous jaw. Int J Oral Surg 17: 25-37. 8. Ramfjord S, Costich E. Healing after exposure of 1981; 6: 387-416. periosteum on the alveolar process. J Periodont. 24. Jemt T, Lekholm U. Oral implant treatment in 37. Apse P, Zarb G, Schmitt A, Lewis D. The 1986; 39: 199-207. posterior partially edentulous jaws: A 5-year longitudinal effectiveness of osseointegrated 9. Komiyama A, Klinge B, Hultin M. Treatment follow-up report. Int J Oral Maxillofac Impl 1993; dental implants. The Toronto Study: Peri-implant outcome of immediately loaded implants installed 8: 635-640. mucosal response. Int J Perio Rest Dent 1991; in edentulous jaws following computer-assisted 25. Naert I, Duyck J, Hosny M, Jacobs R, Quirynen 11: 94-111. virtual treatment planning and flap-less surgery. M, van Steenberghe D. Evaluation of factors Clin Oral Impl Res 2008; 19: 677-685. influencing the marginal bone stability around 38 Wennstrom J, Bengazi F, Lekholm U. The 10. Van de Velde T, Glor F, De Bruyn H. A model implants in the treatment of partial edentulism. influence of the masticatory mucosa on the peri- Clin Impl Dent Rel Res 2001; 3: 30-38. implant soft tissue condition. Clin Oral Impl Res study on flap-less implant placement by clinicians 26. Karoussis I, Salvi G, Heitz-Mayfield L, Bragger 1994; 5: 1-8. with a different experience level in implant U, Hammerle C, Lang N. Long-term implant dentistry. Clin Oral Impl Res 2008; 19: 66-72. prognosis in patients with and without a history 39. Warrer K, Buser D, Lang N, Karring T. Plaque- 11. Jeong S-M, Choi B-H, Li J, Kim H-S, Ko C-Y, of chronic periodontitis: a 10-year prospective induced peri-implantitis in the presence or Jung J-H, Lee H-J, Lee S-H, Engelke W. Flap- cohort study of the ITI Dental Implant System. absence of keratinized mucosa. An experimental less implant surgery: An experimental study. Oral Clin Oral Impl Res 2003; 14: 329–339. study in monkeys. Clin Oral Impl Res 1995; 6: Surg Oral Med Oral Pathol Oral Radiol Endod 27. Wennström J, Zurdo J, Karlsson S, Ekestubbe 131-138. 2007; 104: 24-28. A, Gröndahl K, Lindhe J. Bone level change at 12. Becker W, Wikesjo U, Sennerby L, Qahash M, implant-supported fixed partial dentures with 40 Block M, Gardiner D, Kent J, Misiek D, Finger Hujoel P, Goldstein M, Turkyilmaz I. Histologic and without cantilever extension after 5 years in I, Guerra L. Hydroxyapatite-coated cylindrical evaluation of implants following flap-less and function. J Clin Periodont 2004; 31:1077-1083. implants in the posterior mandible: 10-year flapped surgery: A study in canines. J Periodont 28. Schwartz-Arad D, Kidron N, Dolev E. A long-term observations. Int J Oral Maxillofac Impl 1996; 11: 2006; 77: 1717-1722. study of implants supporting overdentures as a 626-633. 13. Jeong S-M, Choi B-H, Li J, Ahn K-M, Lee S-H, model for implant success. J Periodont 2005;76: Xuan F. Bone healing around implants following 1431-1435. 41. Bouri A, Bissada N, Al-Zahrani MS, Faddoul F, flap and mini-flap surgeries: A radiographic 29. Toljianic J, Banakis M, Willes L, Graham L. Nouneh I. Width of keratinized gingiva and the evaluation between stage I and stage II surgery. Soft tissue exposure of endosseous implants health status of the supporting tissues around Oral Surg Oral Med Oral Pathol Oral Radiol between stage I and stage II surgery as a dental implants. Int J Oral Maxillofac Impl 2008; Endod. 2008; 105: 293-296. potential indicator of early crestal bone loss. Int J 23: 323-326. 14. Gomez-Roman G. Influence of flap design Oral Maxillofac Impl 1999;14:436-41. on peri-implant interproximal crestal bone 30. Albrektsson T, Wennerberg A. Oral implant 42. Chung D, Oh T, Shotwell J, Misch C, Wang loss around single-tooth implants. Int J Oral surfaces: Part I: Review focusing on topographic H. Significance of keratinized mucosa in Maxillofac Impl 2001; 16: 61-67. and chemical properties of different surfaces maintenance of dental implants with different 15. Berglundh T, Lindhe J, Jonsson K, Ericsson I. and in vivo responses to them. Int J Prosthodont surfaces. J Periodont 2006; 77: 1410-1420. The topography of the vascular systems in the 2004; 17: 536-543. periodontal and peri-implant tissues in the dog. 43. Berglundh T, Lindhe J. Dimension of the peri- implant mucosa. Biological width revisited. J Clin Periodont 1996; 23: 971-973 44. Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. The peri-implant hard and soft tissues at different implant systems: A comparative study in the dog. Clin Oral Impl Res 1996; 7: 212-219. 45. Lindhe, J., Berglundh, T. The interface between the mucosa and the implant. Periodontology 2000. 1998;17:47-54. 28 Vol. 1, No. 2 April 2009

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Winter et al

Sinus/Alveolar Crest Tenting Technique: Winter et al A Case Report with Histology and 40-Month Clinical Follow-up Alan A. Winter, DDS1 1 1 Abstract Background: Pneumatized maxillary sinuses in used to remove a core of bone from the surgical the posterior maxilla often require augmentation site during implant restoration and was examined to permit dental implant placement. A number of with low power H&E analysis. Additional radio- techniques have been developed to accomplish graphic follow up was performed 40 months fol- such augmentation with most requiring use of lowing implant activation autografts, allografts, xenografts, or a combination thereof. This case report reviews the Sinus/Alveo- Results: The surgical procedure was accom- lar Crest Tenting (S.A.C.T.) technique that uses a plished uneventfully and the patient was func- crestal approach to raise the sinus membrane in a tionally restored with dental implant restorations. severely atrophic (2mm) posterior maxilla without Microscopic analysis of the trephine bone core grafts or tissue barriers. revealed broad trabeculae of viable bone and asso- ciated loose vascular fibrous connective tissue. Methods: A 74 year-old Caucasian male was referred for implant placement in the maxillary left Conclusion: A case report with histology is pre- posterior sextant in the area of teeth 13, 14, and sented that describes the S.A.C.T. technique 15. The left maxillary sinus was severely pneu- with a 40-month follow-up after activation of the matized with only 2mm of residual vertical bone implants. This case illustrates the inherent heal- remaining. A total of 3 dental implants were deliv- ing potential of the residual alveolar bone and sup- ered, with 2 utilizing the S.A.C.T. technique. One ports the potential for osteogenesis from the sinus year following implant placement, a trephine was membrane and periosteum. KEY WORDS: atrophic maxillary ridge, dental implants, sinus graft, S.A.C.T. technique 1. Private practice, Park Avenue Periodontal Associates, P.C., 532 Park Avenue, New York, N.Y. 10021 The Journal of Implant & Advanced Clinical Dentistry 31

Winter et al BACKGROUND infracture the sinus floor and raise the membrane without graft material. This technique, the Local- Pneumatized maxillary sinuses in the posterior ized Management of the Sinus Floor (L.M.S.F.), maxilla often require augmentation to permit den- utilized osteotomes that extended beyond the tal implant placement. After Tatum1 and then sinus floor that demonstrated a success rate of Boyne and James2 first described techniques 97.5% in atrophic ridges with > 7mm of bone. to gain access to the maxillary sinus, a variety of graft materials have been successfully used to Winter et al20 reported on the use of the increase bone volume for dental implant place- L.M.S.F. technique to treat 34 consecutive ment. These techniques include the use of autog- patients with atrophic ridges of < 4mm height of enous bone grafts,3-6 allografts,7-9 and xenografts bone. Fifty-eight implants were placed in ridges such as bovine bone.10-12 Tatum approached that averaged 2.87mm in height with a 91% the sinus via a crestal window while Boyne and success rate after twenty-two months. They James employed a lateral window approach. concluded that implants may be placed in the posterior maxilla when there is < 4mm of bone Other techniques have subsequently been under the sinus without the need for bone grafts. described to augment atrophic bone under the maxillary sinus. Summers13-15 used a trephine to The Sinus/Alveolar Crest Tenting (S.A.C.T.) core-out the osteotomy site, stopping at or just technique21 evolved as an offshoot of the LMSF shy of the sinus floor. Osteotomes were used to treat edentulous segments with minimal bone to pack graft material to displace and raise the under the maxillary sinus floor. This technique sinus membrane. In this technique, osteotomes combined the crestal window approach first did not extend beyond the sinus floor. In a multi- described by Tatum1 with the principles underlying center study, Rosen et al16 demonstrated the high the L.M.S.F. technique described by Bruschi, Scip- success rate of the Summers technique when ioni, and Calesini.19 In the S.A.C.T. technique, a the atrophic ridge was > 5mm. Davarpanah et rectangular window is created along the atrophic al17 demonstrated the benefits of the Summers alveolar crest following partial thickness dissec- technique when the width of the alveolar ridge tion of soft tissues to preserve periosteal vascular was > 8mm and the height was > 5mm. Fugaz- supply to the bony ridge. This window is elevated zotto18 described a variation of this technique and raised through careful dissection of the Sch- that utilized a trephined bone core to raise the neiderian membrane. Dental implants are inserted sinus membrane. Fugazzotto used an osteot- so that the bony plate is lifted without placing ten- ome to advance the freed core so that addi- sion on the Schneiderian membrane which drapes tional graft material could be pushed into the over it in a tent-like manner. Ultimately, what was site. As a group, these papers demonstrated once the alveolar crest rests atop the implants; no a high success rate when elevating the sinus grafts are used to fill the surgically created gaps membrane with simultaneous implant placement between the implants and the displaced mem- when > 5mm bone is present under the sinus.16 brane. Collagen sponges are placed to main- tain the blood clot as secondary intention healing In contrast to the Summers technique, Bruschi, commences. Support for the implants is gained Scipioni, and Calesini19 used osteotomes to 32 Vol. 1, No. 2 April 2009

Winter et al by making the width of the rectangular box narrow Figure 1: Maxillary left presurgical radiograph. Note enough that the residual buccal and palatal walls atrophic bone under sinus. of bone firmly grip the implants in a stable posi- tion. This can be altered to a staged approach if Figure 2: CT scan demonstrating nal implant sites. Icons primary stability of implants cannot be obtained. are proportionate to presurgical bone levels. Interestingly, Lundgren et al recently described The patient was referred for a dental com- a maxillary sinus augmentation technique with- puted tomography (CT) scan (SimPlant®, out graft material in ten patients with an aver- Columbia Scientific/Materialise, Inc., Mary- age of 7mm of residual crestal bone.22 Access land) that revealed bilateral atrophic ridges to the sinus was created through a conven- with 2mm of residual bone under the left tional lateral window approach. Dental implants sinus in the area of #14 and #15 (Figure 2). were inserted at the time of surgery. While blood filled the surgically created compartment A 6.5mm x 10mm Frialit-2 implant (Friadent NA, between the sinus floor and the membrane, no Dentsply, York, PA) was inserted in the #13 site graft material was used. Lundgren used reso- in the conventional manner using graduated burs. nance frequency analysis, radiographs, and clini- After this was completed, the S.A.C.T. technique cal examination to conclude (without histology) was used to insert implants in the #’s 14 and that new bone formed around the implants and that this was a predictable technique. In con- trast, many investigators have performed histo- logical examinations of implants placed in the subantral area in conjunction with graft materials.23-30 This case report illustrates the S.A.C.T. tech- nique and presents histology of new bone that formed without using graft material in an area of the maxillary sinus above an atrophic maxillary site. Case Report A 74 year-old Caucasian male was referred for implant placement in the maxillary left poste- rior sextant in the area of teeth #’s 13, 14, and 15 (Figure 1). Tooth #13 had fractured and was deemed non-restorable. The patient’s medical history was notable for adult-onset diabetes, heart disease, mitral valve prolapse, hypothyroidism, and arthritis. His medications included: Furo- semide, Synthroid, Vasotec, Inderal, Aspirin, Pravachol, Atenolol, Cardura, and Norvasc. The Journal of Implant & Advanced Clinical Dentistry 33

Winter et al Figure 3: Rectangular outline of crestal bony incision. 15 area. The S.A.C.T. technique was employed to gain access to the Schneiderian membrane Figure 4: Diagrammatic view elevating alveolar crest through a rectangular window made at the alveo- with osteotome. Buccal bone is removed for enhanced lar crest (Figure 3). The alveolar crest was ele- visualization. vated and the membrane sufficiently released to displace the alveolar crest into the sinus (Figure Figure 5: Initial implant placement. No grafting material 4) until the implants could be inserted without used. tearing the membrane. Prior to implant insertion, the patient’s nares were pinched and the patient 34 Vol. 1, No. 2 April 2009 asked to blow gently to insure that the sinus mem- brane was still intact. Next, the implants were gently tapped to place using a surgical mallet. It was critical to make the rectangular window approximately 2mm smaller than the width of the implants so the implants were stabilized by the residual buccal and palatal residual bony crests. With the implants in place, the bony window (alveolar crest) now rested on the apical ends of the implants (Figure 5). Once the implants were secure, a layer of resorbable collagen tape was placed over the implant heads. Periosteal sutures were used to apically position the flap without any attempt to gain primary closure. Post-operative instructions were the same as for sinus graft pro- cedures. Healing was uneventful. The patient returned approximately 6 months later to remove residual tissues about the heads of the implants. It should be noted that the implant heads were partially exposed during the entire healing period. New bone appeared to have formed between and above the two distal implants on the maxil- lary left (Figures 6 and 7). With the patient’s permission, a trephine was used to remove a sample of bone from an area where the sinus floor had been raised for microscopic analy- sis. A 3mm x 7mm bone core was removed from between the apices of the two posterior maxillary left implants (Figures 8 and 9). After the core

Winter et al Figure 7: Stage-2 uncovering revealing new bone formation. Figure 6: Six month postsurgical radiograph taken at Stage-2 uncovering. Figure 8: Bone core removed. Figure 9. Bone core measures 7mm. Figure 10: Placement of healing abutments. The Journal of Implant & Advanced Clinical Dentistry 35

Winter et al Figure 11A: Low power photomicrograph of trephine core. Figure 11B: High power photomicrograph of trephine Note viable bone. (Hematolin and eosin stain, original core. Note viable bone. (Hematolin and eosin stain, magni cation 10X). original magni cation 40X). Figure 12 A: Buccal view of nal prosthesis 40 months Figure 12B: Palatal view of nal prosthesis 40 months after insertion. after insertion. was secured, healing abutments were placed window from the alveolar crest was raised and (Figure 10). All implants were clinically stable. left to rest after implant insertion (Figure 13). Histological examination revealed broad trabe- DISCUSSION culae of viable bone and associated loose vascular fibrous connective tissue. No significant inflamma- Two commonly accepted techniques have tory component was noted (Figures 11A and 11B). evolved to increase the bone volume of verti- cally atrophic ridges under the maxillary sinus. Custom abutments were fabricated The first and most widely described technique and ceramo-metal crowns fabricated (Fig- uses graft material under the sinus membrane ures 12A and 12B). A post-operative radio- with access gained through a lateral window graph taken 39 months following stage-2 technique.2,23,31-33 This approach often requires surgery demonstrated thickened bone apical two surgeries for implant placement, but may be to the implants. This is where the rectangular 36 Vol. 1, No. 2 April 2009

Winter et al Figure 13: Radiograph 40 months after stage-2 This case report describes the S.A.C.T. tech- uncovering. nique plus immediate implant placement with approximately 2mm of residual ridge height. No accomplished in a single surgery under certain bone grafts or membranes were used for this pro- circumstances. Kahnberg34 and Tawil35 analyzed cedure. Histological examination of the trephine the benefits of performing the sinus lift with simul- core revealed newly formed bone. Additionally, taneous implant placement. They concluded that radiographic examination revealed bone along- predictable success was achieved when there side and above the apical ends of the implants was > 5mm of residual bone beneath the sinus. 40 months after the implants were uncovered. Blomqvist36 suggested that a 2-stage approach To date, the patient has functioned with the final would be more suitable for optimum prosthetic prosthesis for 89 months without complication. results. Peleg37 suggested that implants can be placed simultaneously when sinus grafts CONCLUSION are performed with as little as 2mm of residual crestal bone and achieve predictable results. A case report with histology is presented that describes the S.A.C.T. technique with a Alternative techniques to augment deficient 40-month radiographic follow-up after activa- bone in the posterior maxilla use osteotomes tion of the implants. This case illustrates the through the alveolar crest instead of through a lat- inherent healing potential of the residual alveolar eral window.13-18 While some techniques utilized bone and supports the potential for osteogen- graft material and others did not, studies using esis from the sinus membrane and periosteum osteotomes to raise the sinus floor conclude that predictable results can be achieved when >5mm Correspondence: of residual atrophic bone is present. In contrast, Dr. Alan A. Winter Winter et al 20 demonstrated predictable results Park Avenue Periodontal Associates, P.C. using an osteotome technique in 53 of 58 cases 532 Park Avenue with an average residual bone height of 2.87mm. New York, NY 10021 212-838-0940 Email: [email protected] The Journal of Implant & Advanced Clinical Dentistry 37

Winter et al Disclosure 13. Summers RB. A new concept in maxillary 27. Moy PK, Lundgren S, Holmes RE. Maxillary The authors report no conflicts of interest with implant surgery: the osteotome technique. sinus augmentation: histomorphometric anything mentioned in this artricle. Compendium 1994; 15:698-708. analysis of graft materials for sinus floor augmentation. J Oral Maxillofac Surg 1993; Acknowledgments 14. Summers RB. The osteotome technique: Part 51:857-862. Thank you to Dr. George Hribar for performing the 2 – The ridge expansion osteotomy (REO) prosthetics and providing Figures 12A and B. procedure. Compendium 1994; 15:422-436. 28. Smiler DG, Holmes RE. Sinus lift procedure Thank you to Dr. John E. Fantasia, Chief of the using porous hydroxyapatite: a preliminary Division of Oral Pathology at Long Island Jewish 15. Summers RB. The osteotome technique: Part report. J Oral Implantol 1987; 13:239-253. Medical Center, New Hyde Park, NY, who 3 – Less invasive methods of elevating the prepared the photomicrographs and performed the sinus floor. Compendium 1994; 15:698-708. 29. Hürzeler MB, Quinones CR, Kirsch A, et al. histological examination. Maxillary sinus augmentation using different 16. Rosen PS, Summers R, Mellado JR, Salkin LM, grafting materials and dental implants in References: Shanaman RH, Marks MH, Fugazzotto PA. The monkeys. Part III. Evaluation of autogenous 1. Tatum, OH Jr. Maxillary and sinus implant bone-added osteotome sinus floor elevation bone combined with porous hydroxyapatite. technique: multicenter retrospective report of Clin Oral Implants Res 1997; 8:401-411. reconstructions. Dent Clin North Am 1986; consecutively treated patients. Int J Oral and 30:207-229. Maxillofac Implants 1999; 14:853-858. 30. Quinones CR, Hürzeler MB, Schupach P, 2. Boyne P, James R.: Grafting of the maxillary floor Arnold DR, Strub, Caffesse RG. Maxillary with autogenous marrow and bone. J Oral Surg 17. Davarpanah M, Martinez H, Tecucianu J-F, sinus augmentation using different grafting 1980; 38:613-616. Hage G, Lazzara R. The modified osteotome materials and dental implants in monkeys. 3. Wood RM, Moore DL. Grafting of the maxillary technique. Int J Perio & Res Dent 2001; Part IV. Evaluation of hydroxyapatite-coated sinus with intraorally harvested autogenous bone 21:599607. implants. Clin Oral Implants Res 1997; 8:497- prior to implant placement. Int J Oral Maxillofac 505. Implants 1988; 3:209-214. 18. Fugazzotto PA. Immediate implant placement 4. Daelemans P, Hermanns M, Godet F, Malevez, C. following modified trephine/osteotome 31. Wood RM, Moore DL. Grafting of the maxillary Autologous bone graft to augment the maxillary approach: success rates of 116 implants to sinus with intraoral harvested autogenous bone sinus in conjunction with immediate endosseous 4 years in function. Int J Oral and Maxillofac prior to implant placement. Int J Oral and Max implants: a retrospective study up to 5 years. Int Implants 2002; 17:113-120. Impl 1988; 3:209-214. J Perio & Rest Dent 1997; 17:27-39. 5. Blomqvist JE, Alberius P, Isaksson S. 19. Bruschi GB, Scipioni A, Calesini G, Bruschi 32. Kent J, Block M. Simultaneous maxillary Retrospective analysis of one-stage maxillary E. Localized management of sinus floor with sinus floor bone grafting and placement sinus augmentation with endosseous implants. simultaneous implant placement: a clinical of hydroxyapatite-coated implants. J Oral Int J Oral Maxillofac Implants 1996; 11:512-521. report. Int J Oral and Maxillofac Implants 1998; Maxillofac Surg 1989; 47:238-242. 6. Miyajima H. Experimental study on the healing 13:219-226. processes after the immediate reconstruction 33. Jensen OT, Simonsen EK, Sindet-Pedersen of maxillary bone defect – fresh autogenous 20. Winter AA, Pollack AS, Odrich RB. Placement S. Reconstruction of the severely resorbed iliac bone graft. Ou-dagaku-Shigakushi 1990; of implants in the severely atrophic posterior maxilla with bone grafting and osseointegrated 17:168-182. maxilla using Localized Management of the implants: a preliminary report. J Oral Maxillofac 7. Small SA, Zinner ID, Panno FV, Shapiro HJ, Stein Sinus Floor: a preliminary study. Int J Oral and Surg 1990; 50:15-418. JI. Augmenting the maxillary sinus for implants. Maxillofac Implants 2002; 17:687-695. Report of 27 patients. Int J Oral Maxillofac 34. Jensen OT, Greer R. Immediate placement of Implants 1993; 8:523-528. 21. Winter AA, Pollack AS, Odrich RB. Sinus/ osseointegrating implants into the maxillary 8. Tidwell JK, Blijdorp PA, Stoelinga PJ, Brouns JB, Alveolar Crest Tenting (SACT): a new sinus augmented with mineralized cancellous Hinderks F. Composite grafting of the maxillary technique for implant placement in atrophic allograft and Gore-Tex: second-stage surgical sinus for placement of endosteal implants. A maxillary ridges without bone grafts or and histological findings. In: Laney WR, preliminary report of 48 patients. Int J Oral membranes. Int J Perio & Rest Dent Tolman DE (eds). Tissue Integration in Oral, Maxillofac Surgery 1992; 21:204-209. 2003;23:557-565. Orthopedic & Maxillofacial Reconstruction. 9. Hirsch J-M, Ericsson I. Maxillary sinus Chicago: Quintessence, 1992:321-333. augmentation using mandibular bone grafts and 22. Lundgren S, Andersson S, Gualini F, Sennerby simultaneous installation of implants. A surgical L. Bone reformation with sinus membrane 35. Kahnberg K-E, Ekestubbe A, Gröndahl K, technique. Clin Oral Impl Res 1991; 2:91-96. elevation: a new surgical technique for maxillary Nilsson P, Hirsch J-M. Sinus lifting procedure. 10. Piatelli M, Favero GA, Scarano A, Orsini G, sinus floor augmentation. Clin Imp Dent and I. One-stage surgery with bone transplant and Related Res 2004; 6:165-173. implants. Clin Oral Impl Res 2001; 12:479-487. Piatelli A: Bone reactions to anorganic bovine bone (Bio-Oss) used in Sinus Augmentation 23. Proussaefs P, Lozada J. Histologic evaluation 36. Tawil G, Mawla M. Sinus floor elevation using a Procedures: A histologic long-term report of of a 9-year-old hydroxyapatite-coated cylindric bovine bone mineral (Bio-Oss) with or without 20 cases in humans. Int. J. Oral & Maxillofacial implant placed in conjunction with a subantral concomitant use of a bilayered collagen barrier Implants. 1999; 14: 835-840. augmentation procedure: a case report. Int J (Bio-Gide): a clinical report of immediate and 11. Hallman, M, Nordin T: Sinus floor Oral and Maxillofac Implants 2001; 16:737- delayed implant placement. Int J Oral and augmentation with bovine hydroxyapatite 741. Maxillofac Implants 2001; 16:713-721. mixed with fibrin glue and later placement of nonsubmerged implants: a retrospective 24. Wallace S, Froum S, Tarnow D. Histologic 37. Blomqvist JE, Alberius P, Isaksson S. study in 50 patients. Int. J. Oral & Maxillofacial evaluation of sinus elevation procedure: a Retrospective analysis of one-stage maxillary Implants. 2004; 19: 22-227. clinical report. Int J Perio and Rest Dent 1996; sinus augmentations with endosseous implants. 12. Ewers R, Goriwoda W, Schopper C, Moser D, 16:47-51. Int J Oral Maxillofac Implants 1996; 11:512- Spassova E: Histologic findings at augmented 521. bone areas supplied with two different bone 25. Rosenlicht JL, Tarnow DP. Human histologic substitute materials combined with sinus floor evidence of functionally loaded hydroxyapatite- 38. Peleg M, Mazor Z, Chaushu G, Garg AK: lifting. Clin Oral Impl Res 2004; 15:96-100. coated implants placed simultaneously with Sinus Floor Augmentation with Simultaneous sinus augmentation: a case report 2.5 years Implant Placement in the Severely Atrophic post-placement. J Oral Implantol 1999; 25:7- Maxilla. J Perio 1998; 69: 1397-1403. 10. 26. Wheeler SL, Holmes RE, Calhoun CJ. Six- year clinical and histologic study of sinus-lift grafts. Int J Oral and Maxillofac Implants 1996; 11:26-34. 38 Vol. 1, No. 2 April 2009

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

Life Threatening Sublingual Tame et al Hematoma Formation Following Placement of 1 Two Mandibular Implants: A Case Report Michael Tame, BDS, MFDS1 1 Abstract A 68 year old male patient underwent surgery to an Oral and Maxillofacial surgery unit where to place two mandibular implants at a dental emergency immediate airway management was surgery. Ninety minutes later the patient devel- performed. The patient subsequently required oped a rapidly expanding sublingual haematoma intubation, surgical drainage of the haema- which was causing a significant life threaten- toma, and admission to the Intensive Care Unit. ing airway obstruction. The patient was referred KEY WORDS: Hematoma, dental implant, mandible 1. The Royal Gwent Hospital, Department of Oral and Maxillofacial Surgery, Newport, United Kingdom The Journal of Implant & Advanced Clinical Dentistry 41

Tame et al CASE REPORT to the Oral and Maxillofacial surgery department at the local Hospital immediately (a journey of The patient, a 68 year old male presented to 20 minutes) where the patient was assessed by the dental surgery complaining of an inabil- the Oral and Maxillofacial surgery team. He pre- ity to wear his lower denture. He had no sig- sented with massive bilateral sublingual swell- nificant medical history other than a penicillin ing which had elevated his tongue against his allergy. He was treatment planned for two palate and posterior oropharynx. Gross bilat- mandibular implant fixtures which, following eral, submandibular swelling was also apparent. osseointegration, would help to restore him The combination of these swellings was caus- with an implant retained lower overdenture. ing an airway obstruction (Figures 1 and 2). The implant surgery was performed by two The patient was given high flow oxygen via experienced oral surgeons, under sterile con- face mask and intravenous (IV) access was ditions within the dental surgery. Anaesthesia established immediately. Basic observations was obtained with bilateral mental nerve blocks were carried out, which showed normal oxy- and lingual infiltrations using 12 millilitres (mls) gen saturations but an increased respiratory of 2% lignocaine with 1:80,000 adrenaline local rate. The on-call anaesthetist was contacted anaesthetic. A crestal incision was made from and the patient was taken straight to theatre. the lower left 1st premolar to right 1st premolar Consent was taken for a possible tracheostomy area. A buccal flap was raised, mental nerves and drainage of the haematoma. In view of the were visualised and protected. A lingual flap gross anterior neck swelling the patient under- was also raised 15mm subcrestally protect- went a trial, awake fibro-optic nasal intubation ing soft tissue from any potential perforation by which was successful. It was noted that he was the implant drill. Standard drilling sequences a grade 4 intubation (defined as the most dif- were followed and two 3.5mm diameter, 15mm ficult, in which the epiglottis cannot be seen).1 long Astra (Astra Tech AB, Molndal, Sweden) implants were placed in the lower left and lower An incision in the midline of the floor of right canine area. They were noted to be in a mouth was made, releasing over 100 mls of good position and angulation with excellent pri- blood and clot tracking posteriorly beneath mary stability. The wound was closed with 3-0 the ventral tongue to the anterior wall of the Vicryl sutures and haemostasis was achieved oropharynx. The area was explored but no (At no point during the surgery was there any bleeding vessel was found. A corrugated silas- significant bleeding). The patient was dis- tic drain was inserted and the patient was given charged home with Paracetamol, Ibuprofen, 16 milligrams (mg) IV Dexamethasone, 1.5 Metronidazole and Chlorhexidine mouthwash. grams Cefuroxime and 500mg of Metronidazole. After 90 minutes the surgeon received a The patient was transferred, paralysed and phone call from the patient’s daughter, con- ventilated to the intensive care unit (ITU) for cerned about swelling occurring in the floor of observation. After 36 hours in ITU and fol- the patient’s mouth as well as difficulty breath- lowing endoscopic examination to assess ing. The daughter was told to take the patient tongue oedema and feasibility of extubation, he 42 Vol. 1, No. 2 April 2009

Tame et al Figure 1: Sublingual haematoma formation. Figure 2: Nasotracheal intubation to treat compromised airway. returned to theatre. The drain was removed and hospitalisation, 12 were intubated and five he was subsequently extubated. Following this needed a tracheostomy. No fatalities have been he was moved to the oral and maxillofacial sur- recorded, but in all cases only appropriate and gery ward for a further 48 hours, an orthopan- rapid airway management prevented catastrophe. tomogram and lateral cephalometric radiograph showed the implants in a good position axially. Cases of haematoma following other oral sur- The patient was investigated for an underlying gical procedures including extractions, osteoto- coagulopathy but screening results were normal mies and floor of mouth biopsies have previously and the patient was discharged home on oral been reported.2,3 The most likely cause pos- Metronidazole and Chlorhexidine mouthwash. tulated in these cases is perforation of the lin- gual cortex and damage to one of the branches After four days, continuing resolution of the of the sublingual or facial arteries or vein.4,5 haematoma was noted and subsequent review Cadaver studies have shown accessory foram- uneventful, with no residual sequelae. The patient ina above or below the genial tubercles in the planned to continue treatment to provide an entire lingual cortex of the mandible in between implant retained overdenture at the dental surgery. 72%4and 89%6 of skulls. Through these foram- ina, the incisive arteries, (branches of the infe- DISCUSSION rior alveolar artery) form a dense anastomosing plexus with the sublingual branch of the lingual Incidence of such a gross floor of mouth swelling artery and the submental artery (a branch of following mandibular implant placement is thank- the facial artery). Surgeons should be aware fully very rare. Literature review revealed very few of their presence as a potential source of hae- cases of sublingual haematoma formation follow- morrhage when placing implants. Preparation ing implant placement. All previous cases required The Journal of Implant & Advanced Clinical Dentistry 43

Tame et al support. of the implant site at the wrong angulation may flap designed to protect such a rare occur- perforate the lingual cortex and possibly rupture rence. However a small lingual perforation can- these vessels. Trauma to lingual soft tissue and not be ruled out even with direct inspection of muscles such as stripping the lingual mucosa the lingual cortex and careful instrumentation. may cause similar damage to these vessels. Early recognition and treatment of acute sub- The patient claimed that the swelling lingual haematoma is vital. If a practitioner finds occurred in the space of 5 minutes, approxi- themselves in this scenario the key is to remain mately 90 minutes following the end of sur- calm and follow basic life support (BLS). (As gery. This is most likely to be due to rebound demonstrated in the Resus Council UK 2005 vasodilation of an injured blood vessel when guidelines for basic and advanced life support).7 the vasoconstrictor (adrenaline) within the local anaesthetic solution wore off. A haemorrhage Airway management is the immediate priority of such a vessel is likely to cause a dissecting in a case such as this. An anaesthetist was imme- sublingual, submandibular and submental hae- diately contacted to assess and treat the patient. matoma3 (as in this case, Figure 2). It is unclear as to how or why a vessel was traumatised here During this same time, the patient was given as the lingual flap enabled direct visualisation high flow oxygen to maintain oxygen saturation of the lingual plate and soft tissue protection and pulse oximetry and blood pressure monitor- during the drilling sequence and implant place- ing measured his respiratory and cardiovascular ment. One can speculate that a vessel may status. IV access was established immediately have been traumatised on infiltrating lingually in case the patient was to develop a cardio- with local anaesthetic or by raising the lingual respiratory embarrassment and his peripheral circulation shut down. This would make can- nulation difficult and thus, delay the administra- 44 Vol. 1, No. 2 April 2009

Tame et al tion of appropriate drugs and fluid replacement. of haematoma via incision or wide gauge needle, Following anaesthetic assessment, defini- this could however worsen the situation as a draining haematoma will have less of a tendency tive airway management (via an awake fibro- to tamponade bleeding and we think it would be optic nasal intubation) by the anaesthetist prudent to ensure secured airway as the priority. was carried out as a life saving measure. It is obviously easier to deal with such a patient in CONCLUSION a hospital environment with emergency staff and facilities at your disposal, but if this patient A life threatening sublingual haematoma is had re-attended the dental surgery the situa- something most dental practitioners will never tion would have been even more dangerous. see. However, clinicians placing mandibular implants should be aware of its rapid develop- Any clinician who is placing mandibu- ment as a potential risk of surgery and be well lar implants should be aware of all poten- versed in the early recognition and immediate tial sequelae and be confident that they management of what can be a life threatening can deal with the situation, should it arise, scenario. A clinician who follows basic emer- it would be wise to follow the Resus Coun- gency management correctly will give their cil (UK) Guidelines7 as depicted in figure 3. patient the optimum chance for recovery with- out potentially catastrophic consequences. In adjunct to these guidelines it would be good practice to sit the patient up as they Correspondence: will find it easier to maintain their airway with Michael Tame, BDS, MFDS their upper body and head leaning forward. A Phone: +447919363455, +441633238519 nasal airway could also be inserted to keep Email: [email protected] the airway patent prior to the anaesthetist achieving a definitive airway. During this time it is obviously important to try to keep the patient calm, providing words of reassurance. Some clinicians suggest immediate drainage Disclosure 3. Kalpidis C D, Setayesh R M. 5. Niamtu J III. Near-fatal airway The authors report no conflicts of Hemorrhaging associated with obstruction after routine implant interest with anything mentioned in this endosseous implant placement in placement. Oral Surg Oral Med Oral article. the anterior mandible: a review of the Pathol Oral Radiol Endod 2001; 92: References literature. J Periodontol 2004; 75: 597-600. 1. Cormack RS, Lehane J. Difficult 631–645. 6. Shiller WR, Wisewell OB, Lingual intubation in obstetrics. Anaesthesia 4. Nagar M, Bhardwaj R, Prakesh R. foramina of the mandible. Anat Rec 1984; 39: 1105-11. Accessory lingual foramen adult 1954; 119: 387-90. 2. Isaacson TJ. Sublingual hematoma Indian mandibles. J Anatomical Soc formation during immediate India 2001; 50(1): 13-24. 7. Resuscitation Council (UK) placement of mandibular Guidelines 2005. Available at endosseous implants. J Am Dent http://www.resus.org.uk. Accessed Assoc 2004; 135: 168-171. February 25, 2009. The Journal of Implant & Advanced Clinical Dentistry 45

Miles

The Agony and Miles Ecstasy of Buying Cone Beam Technology Part II: The Agony Dale A. Miles, DDS, MS1 Abstract Background: This is the sec- Results: CBCT scan vol- ond article in a two part series umes, CBCT scan information, that presents additional deci- range of interest (ROI), field sion considerations when pur- of view (FOV), multifunction- chasing a cone beam computed ality, and potential liabilities tomography (CBCT) machine are discussed by the author. for use in dental practice. Conclusion: When con- Methods: The author, a Diplo- sidering the acquisition mate of the American Board of of a CBCT machine, one Oral and Maxillofacial Radiology, should evaluate a number draws upon his personal experience from interpret- of factors to make an informed purchase. Fail- ing over 3,700 CBCT scans to provide general and ure to consider these factors may result in technical information on a number of CBCT systems. a dissatisfied buyer and potential liabilities. KEY WORDS: Cone beam computed tomography, digital radiography, radiographic image enhancemnet 1. Arizona School of Dentistry and Oral Health; Private Practice Fountain Hills, AZ, USA The Journal of Implant & Advanced Clinical Dentistry 47

Miles INTRODUCTION tifunctional, that is, one that can deliver a cone beam data set or volume, even if only 8cm x 8cm, In part one of this two part article series, “The and still retain the panoramic and cephalometric Ecstasy,” I presented introductory information capability, then a machine like the Planmeca Pro- on cone beam computed tomography (CBCT) Max (Roselle, IL), the eWoo Picasso (Va-tech, machines, the wide array of applications made Seoul, Korea) or Morita Veraviewepocs3D (Kyoto, possible by the incredible variety of image out- Japan) could be advantageous. Initially, Planmeca put choices, and some decision consider- was the only multifunctional machine and currently ations for helping you decide which cone beam remains the only “upgradeable” x-ray machine on device might best suit your practice. In the sec- its existing platform. In addition to its panoramic ond installment of this series, I will provide you and cephalometric capabilities, the ProMax CBVT with additional “decision points” to consider 3D machine can also perform bitewing and peria- when selecting the appropriate machine or ser- pical-like projections as well as selectable tomo- vice for your practice and some of the reali- graphic views of the TMJ and sinus regions. This ties of adopting this technology related to: 1) is because of its unique technology: SCARA – The amount of information in each scan volume; Selectively Compliant Articulating Robotic Arm. 2) The types of information in each scan; 3) The This SCARA technology (figure 2), coupled with potential liability accompanying your purchase. a C-arm mounted on the top of the machine, is a patented “one-of-a-kind” device in the dental Scan Volume Decisions x-ray industry. The description of this technology Initially, there was a marketing competition is beyond the scope of this article, but its con- between companies that sold cone beam cept is what allows for all of the following, mak- machines, with each making claims about the ing this machine the most “multi-functional”: 1. value of “large volume” machine advantages True panoramic (not reconstructed from soft- over “small volume” machines and vice versa. ware); 2. True cephalometric image; 3. Tomo- Some claims, I feel, are valid, and some are not. graphic views (TMJ, sinus and implant if desired); 4: Bite-wing views (large enough to see all peri- If you are an orthodontist and need to make apices and at about 6 lp/mm); 5: Orthagonal measurements for various orthodontic analyses, panoramic view to see interproximal bone levels. you may require a large volume CBCT machine. Certainly, if the CBCT machine volume is 4cm x This concept of “multifunctionality” can be 4cm or less, for example, a small volume machine confusing with some claiming you can replace all would not suffice if you do not have a cephalomet- dental imaging with cone beam technology. As in ric unit in addition to your cone beam machine. medicine, dentists need to preserve several types You would have to select a machine like the Imag- of imaging modalities and choices to assist their ing Sciences i-CAT (Hatfield, PA) or similar large diagnostic tasks. Medicine certainly does not use Field of View (FOV) machine to capture your or expect one radiographic imaging modality to Region of Interest (ROI). Figure 1 shows some cover all diagnostic tasks. Accordingly, the medi- image areas captured by a “large” FOV machine. cal profession uses plain radiographic images, However, if you had a machine that was mul- 48 Vol. 1, No. 2 April 2009