Heat Induction Analysis from Piezoelectric Bone Surgery

VOLUME 2, NO. 8 OCTOBER 2010 The Journal of Implant & Advanced Clinical Dentistry Heat Induction Analysis from Piezoelectric Bone Surgery Dynamic Positive Pressure Sinus Augmentation Technique

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 8 • OCTOBER 2010 Table of Contents 17 Case of the Month Adjacent Implants Replacing Maxillary Central Incisors: The Keys for Success Miquel Iglesia 29 The Dynamic Positive Pressure Sinus Augmentation Technique: A Description of the Technique Carlos A. S. Pires, Michael H. Morgan, Luis F. S. Pires 37 Analyses of Heating Induced by Piezoultrasonic Devices During Bone Surgery Marie Grace Poblete-Michel, Eric Tuffreau, Jean-François Michel The Journal of Implant & Advanced Clinical Dentistry • 5



The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 8 • OCTOBER 2010 Table of Contents 55 Clinical Evaluation of Flapless Free Hand Immediate Implant Placement in Fresh Extraction Sockets Amr Zahran, Mahmoud El-Refai, Tamer Amir, Mohamed Fouda 67 Use of Plateform Implants as an Alternative to Complex Grafting in the Posterior Arch Gregori M. Kurtzman, Edgar Montalvo Avila ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] The Journal of Implant & Advanced Clinical Dentistry • 7



The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 8 • OCTOBER 2010 Publisher Copyright © 2010 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD- Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest, constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article. the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA. or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 9

Platform Ø 6.0 mm & length 6.5 mm for SPI®ELEMENT implants Advantages at a glance ELEMENT implants are now available in platform Ø 6.0 mm. Additionally, an implant length of 6.5 mm ELEMENT platform Ø 6.0 mm is perfectly suited has been added for ELEMENT platforms Ø 4.0 mm, for large molar restorations 4.5 mm, 5.0 mm and the new platform Ø 6.0 mm. Identical surgical and restorative procedures as existing platform sizes For further information and availability, contact your ELEMENT length 6.5 mm is ideal for cases with Thommen Medical country representative office. limited vertical bone height or difficult nerve anatomy Bone augmentation procedures may be simplified or eliminated to improve predictability and reduce treatment time. SWISS PRECISION AND INNOVATION. www.thommenmedical.com

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 Editorial Advisory Board Tara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Michael Huber, DDS Terry Rees, DDS Michael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDS Daniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMD John Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDS Stepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMD David Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMD Charles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDS Sally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDS Tomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Alex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDS Nicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhD David Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDS Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDS Ronald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 11



Wilcko et al Need More Space? BIOMET 3i O ers A Solution BIOMET 3i’s Low Profile Abutment is now available - a solution designed to provide clinicians with more space for screw-retained restorations in clinical areas of limited interarch distance. Screw- retained abutments provide clearer access to, and retrievability of, single and multiple-unit implant restorations. In addition, certain patient situations may require the benefits of screw- retained restorations such as full mouth recon- struction and immediate loading techniques. The new BIOMET 3i Low Profile Abutment is designed for: Screw-Retained Restorations in Areas of Limited Interarch Distance Immediate Or Traditional Loading Procedures The Low Profile Abutment Offers: tional programs and seminars for dental profes- One Restorative Platform for Ease of Use sionals around the world. BIOMET 3i is based A Contoured Emergence Profile Providing in Palm Beach Gardens, Florida, with opera- Easier Placement in Subcrestal and Flapless tions throughout North America, Latin America, Surgery Europe and Asia-Pacific. For more information about BIOMET 3i, please visit www.biomet3i. When you require more space, keep a low pro- com or contact the company at (800) 342- file with one of the lowest restorative profiles on 5454; outside the U.S. dial (561) 776-6700. the market today, the BIOMET 3i Low Profile Abutment. About BIOMET 3i BIOMET 3i, a division of Biomet, Inc., is a leading manufac- turer of dental implants, abutments and related products. Since its inception in 1987, BIOMET 3i has been on the forefront in developing, manufacturing and distributing oral recon- structive products, including dental implant components and bone and tissue regenerative materials. The company also provides educa- The Journal of Implant & Advanced Clinical Dentistry • 13

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Case of the Month Iglesia Adjacent Implants Replacing Maxillary Central Incisors: The Keys for Success Miquel Iglesia, DDS, NS1 Abstract Background: One of the most challenging tissue reconstruction, and gingival sculpturing. scenarios in dental implantology is the resto- ration of two adjacent central maxillary inci- Results: The end result met our sors. In such cases, a meticulous diagnosis, objectives of a natural smile show- evaluation, and preoperative planning are ing ideal soft tissue architecture. necessary to achieve an esthetic outcome. Conclusion: To achieve optimal final out- Methods: A 37 year-old patient pre- comes in challenging situations such sented with two missing maxillary cen- as adjacent dental implants for replace- tral incisors lost due to trauma. Multiple ment of maxillary central incisors, meticu- surgeries were used for implant placement, soft lous preoperative planning is paramount. KEY WORDS: Dental Implants, maxilla, incisors, porcelain, treatment planning 1. Private practice, Zaragosa, Spain The Journal of Implant & Advanced Clinical Dentistry • 17

Iglesia One of the most challenging scenarios of future recession (figs. 13-15). The provi- in dental implantology is the restora- sional restoration must be modified in consecu- tion of two adjacent central maxillary tive appointments in order to achieve esthetics incisors. In such cases, a meticulous diagno- that closely mimic that of the planned final res- sis, evaluation, and preoperative planning are toration in regards to emergence profile, inter- necessary to achieve an esthetic outcome. The dental contours, contact points, and gingival final objective is to have two natural appear- contour of the facial margins (figs. 16-20). ing central incisors, for which are needed the following: two osseointegrated implants After an additional 4 months these goals in the correct position, an adequate soft tis- were achieved and the final restorations were sue framework, and esthetic restorations. developed. A customized CAD-CAM zirconium screw-retained framework was fabricated and A 37 year-old patient presented with two porcelain covered (figs. 21-24), copying the missing maxillary central incisors lost due to provisional restoration anatomy and profile. The trauma 25 years ago (figs. 1-3). There was no definitive implant-supported fixed partial denture relevant point in the clinical history, and after achieved our objective of a natural smile show- careful clinical and radiographic evaluation, ing ideal soft tissue architecture (figs. 25-27). implant restorations were planned. An atrau- matic incisionless surgery was accomplished Products used in this case: with conservative low-speed preparation of Biomet-3i™ Full-Osseotite NT implant the bone. A surgical template was utilized to Alloderm® Regenerative Tissue Matrix achieve correct three-dimensional positioning of NobelProcera™ Implant Bridge Zirconia the implants, leaving as much quantity of bone between them as possible (fig. 4). Adjunc- Correspondence: tive soft tissue grafting during implant surgery Miguel A Iglesia, DDS MS was performed in order to increase the thick- Residencial Paraíso 1, esc B, 1ºC ness of the buccal tissues (fig. 5). Note soft 50008 ZARAGOZA tissue volume after 14 days post-op (figs. 6-8) Spain Telephone: 34 976 233 448 After 4 months the second-stage sur- [email protected] gery was performed and additional soft tissue augmentation was performed using the roll- Disclosure: technique (figs. 9,10). A screw-retained pro- The author reports no conflicts of interest with anything mentioned in this article. visional restoration was then developed (figs. 11,12). It is important to design the provisional Acknowledgements: with a concave subgingival profile to support The author wants to recognize the artistry of the ceramist Alicia Tomé (CDT) the soft tissues without pressure. This stabi- lizes the facial tissue and decreases chances 18 • Vol. 2, No. 8 • October 2010

Iglesia Figures 1-3 The Journal of Implant & Advanced Clinical Dentistry • 19

Iglesia Figures 4-8 20 • Vol. 2, No. 8 • October 2010

Iglesia Figures 9-12 The Journal of Implant & Advanced Clinical Dentistry • 21

Iglesia Figures 13-15 22 • Vol. 2, No. 8 • October 2010

Iglesia Figures 16-20 The Journal of Implant & Advanced Clinical Dentistry • 23

Iglesia Figures 21-24 24 • Vol. 2, No. 8 • October 2010

Iglesia Figures 25-27 The Journal of Implant & Advanced Clinical Dentistry • 25

R

Treat small spaces with confidence Laser-Lok 3.0 placed in Radiograph shows proper esthetic zone. implant spacing in limited site. Image courtesy of Cary Shapoff, DDS Image courtesy of Michael Reddy, DDS Introducing the Laser-Lok® 3.0 implant Laser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal bone on the implant collar1. Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array of prosthetic options making it the perfect choice for high profile cases. • Two-piece 3mm design offers restorative flexibility in narrow spaces • Implant design is more than 20% stronger than competitor implant2 • 3mm threadform shown to be effective when immediately loaded3 • Laser-Lok microchannels create a physical connective tissue attachment (unlike Sharpey fibers) 4 For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com 1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010. 2. Implant strength & fatigue testing done in accordance with ISO standard 14801. 3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC. Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288. 4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim. International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP10109 REV D SEP 2010

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The Dynamic Positive Pressure Pires et al Sinus Augmentation Technique: A Description of the Technique Carlos A. S. Pires, DMD, MSD1 • Michael H. Morgan, DDS, MS2 Luis F. S. Pires, DMD, MSD3 Abstract The sinus floor elevation, or sinus lift pro- Schneiderian membrane to a horizontal posi- cedure, is an internal augmentation of tion forming the new sinus bottom. The space the maxillary sinus, which is intended to underneath this lifted window and sinus mucosa increase the vertical bony dimension in the lateral is filled with graft material. The aim of this article maxilla in order to make the placement of dental is to describe a newly developed technique for implants in posterior maxilla possible. The oper- sinus floor augmentation – the Dynamic Posi- ation was conceived and introduced by Tatum tive Pressure technique – aiming minimal inva- at the Birmingham Alabama Implant Meeting of sive and atraumatic procedure and less surgical 1976. This technique has been modified through time. With this modified sinus augmentation tech- the years. The classic sinus lift operation con- nique, the risk for sinus membrane perforation sists of the preparation of a top hinge door (win- and time consumption is decreased and there is dow) in the lateral maxillary sinus wall. This door reduced trauma to the patient reducing the inflam- is luxated inward and upward together with the matory reaction and post-operative discomfort. KEY WORDS: Maxillary sinus, sinus lift, bone graft, dental implants 1. Private Practice – Limited to Oral Implants and Periodontics – Independence, OH, USA 2. Private Practice – Limited to Oral Implants and Periodontics – Independence, OH, USA 3. Resident at Case Western Reserve University, Department of Periodontics, Cleveland, OH, USA The Journal of Implant & Advanced Clinical Dentistry • 29

Pires et al INTRODUCTION graft material to flow from the delivery syringe and spread into the graft site. The DynaBlast™ The introduction of the sinus lift, also known allows for gentle and consistent Dynamic as the subantral bone augmentation or sinus Positive Pressure, lifting the membrane and floor augmentation procedure, has had a sig- symmetrically distributing the graft material. nificant impact on the placement of den- Additionally, the shape of the delivery syringe tal implants in the posterior maxilla. The is critical. The tapered barrel allows for tight original technique was described by Tatum, adaptation to the bony margins of the window but the first publication on this surgical tech- and prevents backflow of the graft material. nique was however by Boyne & James in 19801, followed by Tatum himself in 1986.2 The aim of this article is to describe a newly developed technique for sinus floor This technique has been modified through augmentation aiming minimal invasive and the years. The classic sinus lift opera- atraumatic procedure and less surgical time, tion consists of the preparation of a hinged the Dynamic Positive Pressure Technique. window in the lateral wall of the maxillary sinus. Following elevation of the Schneide- TECHNIQUE DESCRIPTION AND rian membrane, the window is mobilized CASE PRESENTATION medially and superiorly (inward and upward) and bone graft material utilized to fill the The technique is described as follows: void. Variations of the technique have been 1. Pre-operatory radiographic evalation – described, including the use of balloons to assist in the lifting of the sinus membrane.3 computer tomography recommended (Figures 1a, 1b). Although successful, the techniques 2. Adequate local anesthesia. require large flaps for access, risk perfora- 3. Incision design: small, semi-lunar incision, tion of the sinus membrane, and in the case full thickness flap (Figure 2). of the balloon technique and osteotomes, an 4. Preparation of the osseous window increase in instrumentation. The Dynamic (4-5 mm diameter) – just superior to the floor of Positive Pressure technique is a significant the maxillary sinus (egg-shaped modification of the procedure that has the fol- carbide bur or piezo-surgery) (Figure 3). lowing advantages: 1) Minimally invasive; 2) 5. Slight elevation of the membrane (Figure 4). Reduced surgical time; 3) Minimal instrumen- 6. Positioning of the syringe barrel in tation; 4) Minimal post-operative recovery the window (Figure 5). time; 5) Minimal post-surgical complications. 7. Slight pressure on the plunger. 8. Gentle, consistent pressure to inject 2-4 cc The technique takes advantage of of graft material (varies according to anatomy DynaBlast™ (Keystone Dental, Burlington, MA, and number of implants planned) (Figure 6). United States) – a bone graft material made 9. Optional membrane placement at the of demineralized bone matrix putty paste with osteotomy window. cancellous bone with a reverse phase medium. 10. Closure of the mucoperiosteal flap. The gel-like nature of this material allows for the 30 • Vol. 2, No. 8 • October 2010

Pires et al Figure 1a: Presurgical sagittal CBCT evaluation of the Figure 2: Full thickness ap with minimal surgical trauma. surgical site (4 mm of alveolar ridge height). Figure 1b: Presurgical coronal CBCT evaluation of the Figure 3: Osteotomy of the lateral window (note the small surgical site (4 mm of alveolar ridge height). size). DISCUSSION Because of the graft consistency and method of delivery of this material, the membrane is softly elevated with minimal compression and reduces the risk of perforation. Radiographic images confirm retention of the graft material following surgery and implant placement (Figures 7a, 7b). The Journal of Implant & Advanced Clinical Dentistry • 31

Pires et al Figure 4: Slight elevation of the edges of the Schniederian Figure 5: The lateral window dimension is compatible with membrane. the size of the tip of the delivery syringe. Veri cation of the seal, adding DynaBlast™. for the patient. Outlay for instrumentation is minimal. The DynaBlast™ material is safe, sta- ble, and delivered in a manner that reduces time and the need for large surgical access. Figure 6: Grafting completed . Collagen membrane on the Correspondence: lateral window optional. Carlos A. S. Pires, DMD, MSD 6505 Rockside Road, #310 CONCLUSION Independence, OH 44131, USA Telephone: (216) 642-9111 The Dynamic Positive Pressure Technique FAX: (216) 642-8801 offers many advantages over traditional meth- e-mail: [email protected] ods of augmenting the maxillary sinus. The minimally invasive technique allows for a more Disclosure: efficient procedure for the surgeon, less intra- The authors report no conflicts of interest with anything mentioned in this article. operative and post-operative complications, References and a greatly improved post-operative course 1. Boyne P, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Maxillofac Surg 1980; 17:113-116. 2. Tatum OH. Maxillary and sinus implant reconstruction. Dent Clin N Am 1986; 30: 207-229. 3. Soltan M, Smiler DG. Antral membrane balloon elevation. J Oral Implantol 2005; 31: 85-90. 32 • Vol. 2, No. 8 • October 2010

Pires et al Figure 7a: Immediate postsurgical sagittal CBCT The Journal of Implant & Advanced Clinical Dentistry evaluation of the surgical site. ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! Figure 7b: Immediate postsurgical coronal CBCT For complete details evaluation of the surgical site. Note 10 mm of total vertical regarding publication in gain of the augmented sinus oor (2.0 cc of graft material used). 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 • 33





Poblete-Michel et al 100,000 Lux!

Analyses of Heating Induced by PiezoultrPaosbolentei-cMichel et al Devices During Bone Surgery Marie Grace Poblete-Michel, DMD, MS1 • Eric Tu reau, DDS2 Jean-François Michel, DDS, PhD3 Abstract Managing the periodontal bone environ- using two powerful piezoultrasonic devices: ment is a continuous challenge for the the Piezosurgery™ (Mectron®, Italy), the Piezo- periodontist. The health, esthetic and tome™ (Satelec®, France) and a conventional function of the periodontal tissues depend on drill. These were then compared and assessed the integrity of the alveolar bone. Various sur- by infrared thermography in order to determine gical techniques and protocols requiring bone the heating of bone produced during sectioning. surgery are available to treat bone loss caused by periodontal disease, extractions, infections or Analyses of the bone temperatures at the accidents. Most of these techniques are within end of a Piezosurgery™ incision shows variable the context of achieving osteointegrated endo- heating, 10°C compared to the Piezotome™. osseous implants. With the recent develop- The Piezotome™ gives stable average values ments in ultrasonic-assisted osteotomes, new at 40°C with a maximum of 45.3°C. We have surgical protocols are proposed. This paper shown that heating produced by the two devices presents a pilot research on the heating induced is acceptable and closely related to the quan- by this technique during the in vitro sectioning tity of irrigation, which must be at least 30ml/ of animal cortical bone. The incisions were done min. However, comparison of two devices has shown that large variations could be observed. KEY WORDS: Piezoelectric surgery, piezoultrasonic, bone, heat generation, irrigation 1. Clinical supervisor, CHU General Hospital, Dental Department, Dijon, France 2. Post-graduate, Faculty of Dentistry, University of Rennes I, Rennes, France 3. Former Chair, Department of Periodontology, Faculty of Dentistry, University of Rennes I, Rennes, France The Journal of Implant & Advanced Clinical Dentistry • 37

Poblete-Michel et al BACKGROUND (2005).13,14,15 According to Giraud et al (1991), two reasons limit the use of this instrumentation: The health, esthetic and function of the periodon- its nonspecificity and the risk of heating.16 Schlee tal tissues depend on the integrity of the alveolar (2005) insisted on the primary importance of irri- bone. Various surgical techniques and protocols gation during the intervention without mentioning requiring bone surgery are available to treat bone the quality of irrigant to be used.17 Certain authors loss caused by periodontal disease, extractions, spoke of an excessive increase in temperature;15 infections or accidents.1 Most of these techniques however, inspite of this inadequacy, ultrasonic are within the context of achieving osteointegrated instrumentation seems to include interesting endo-osseous implants, thus it must respect tools for performing cortical bone harvesting.18 the recommended protocols such as those pro- posed in periodontology and implant dentistry Technically, ultrasonic-assisted osteotomes where bone surgery is either a subtractive type appear to be similar to ultrasonic devices already (resection) or an additive type (reconstruction).2 used in our daily dental practice. They are com- Amongst these procedures, two bone surgi- posed of a handpiece, a tip screwed into the hand- cal techniques seem to allow successful recon- piece, an alternative current (AC) generator of struction in cases of insufficient bone volume: average frequency, a power control and an adjust- 1) bone grafts3,4 and 2) guided bone regeneration able external irrigation device. Four parameters (GBR) associated with or without bone grafts.5 make ultrasonic scalers different from conventional scalers: 1) frequencies of the generator, 2) mass, Nowadays, ultrasounds in medecine are used 3) shape and 4) hardness of the tips.19 However, for diagnostic and therapeutic means.6,7 The ther- ultrasonic-assisted instrumentation produces an apeutic applications of the mechanical effects of elevation in the temperature.16,20 The tempera- sound waves (eg, shock waves, cavitation) are ture is a physical phenomenon that is a mani- used for the destruction of calculi, while the ther- festation of kinetic energy. It is produced by the mal effects such as absorption are used for the displacement of the extremity of the tip. This fac- ablation of tumors. With the recent developments tor alone compromises the quality of bone healing. in ultrasonic-assisted osteotomes, new surgical protocols are proposed.8,9,10 The term piezosurgery In this study, two piezoultrasonic saw tips and applies to devices that cut tissues by employing a conventional bur were compared to determine the piezoelectric effect to generate ultrasounds. bone heating induced by these instruments dur- As a result of continues studies, this technique ing in vitro sectioning of samples of animal corti- is relatively new and is in constant development. cal bone. The incisions were then assessed using infrared thermography. The aim of this study is Historically, Catuna (1953) was the first to to answer the following questions: 1) what is the describe the sectioning effects of ultrasonic temperature elevation produced by the two pow- devices on hard tissues.11 Stübinger et al (2005) erful piezoultrasonic devices and their specific insisted that piezoelectric instruments have known tips?; 2) is this temperature elevation comparable a new impetus since the 1990s.12 The technol- to that produced by conventional rotary instru- ogy was then adapted and perfectionned by Ver- ments?; 3) what amount of irrigation output allows celloti (2004), Siervo et al (2004) and Boioli et al 38 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al heating compatible with the biology of bone? Figure 1: Thermographic camera and mounted sample during the experiment. MATERIALS AND METHODS adjusted to 35 ml/min as recommended by the Two powerful devices with piezoelectric technol- fabricant. For the second experiment, the irrigation ogy were used for this study: 1) Piezosurgery™ was analysed from 5 to 50 ml/mn. The animal corti- (Mectron®, Italy) with a frequency between 22 to cal bone samples used were the closest possible 29.5 kHz, power of 2.8 to 16W, oscillating between to human mandibular cortical bone (ie, veal bone 20 to 200µ and 2) the Piezotome™ (Satelec®, for Experiment I and ewe bone for Experiment II). France) device with a frequency between 28 to The thickness of the sample for Experiment I was 4 36kHz, power of 0.1 to 20W, oscillating between mm and for Experiment II, 3 mm. This sample was 4 to 200µ. A comparison was done between mounted on a glass support that was transparent two piezoultrasonic saw tips and a rotary instru- to infrared in order to interpose glass between ment: the BS1 saw tip used in mode 1 (Satelec®, the camera and the internal surface of the corti- France), the OT7 saw tip used in mode « bone cal bone. Since infrared rays absorbed by water quality 1 » (Mectron®, Italy) and a E0123 (Maille- cannot be detected, this type of mounting avoided fer®, France) round tungsten carbide bur, mounted the irrigation to flow between the camera and the on a WI-75 EIKM™ surgical handpiece (W&H®, cortical bone. The handpiece was held firmly with- France) attached to an ImplantMed™ implantology out excessive pressure given that a very strong micromotor (W&H®, France ) at 40,000 trs/min. pressure will only limit the movement of the tip thus creating heating that leads to its complete block- Our in vitro study analysed the heating induced age.17,21 A rapid back and forth movement is there- by these instruments while in contact with the tis- fore recommended.21,22 The incision was done on sues of an animal cortical bone during incision. In the external surface of the cortical bone. During the protocol, we used a thermographic camera the sectioning, the thermally affected zone was that allows putting into effect the infrared ther- observed through the internal surface. The cam- mography principle (Figure 1). According to the era registered the surface temperature at the level French Association for Standardization (Associa- of the internal cortical bone and provided mea- tion Française de Normalisation, AFNOR), this technique allows to obtain the thermal image of the zone observed in an infrared spectral domain. Experiemental Phases (2) 1) Experiment I studied heating induced during the useoftwopiezoultrasonicsawtipsandaconventional round bur for sectioning the animal cortical bone. 2) Experiment II studied the effect of the quanti- tative variation of the irrigating solution on heat- ing for the two powerful piezoultrasonic devices. For the first experiment, the irrigation was The Journal of Implant & Advanced Clinical Dentistry • 39

Poblete-Michel et al Figure 2b: Incision of the veal cortical bone using an OT7 saw tip in Experiment I. Figure 2a: Incision of the veal cortical bone using a BS1 Figure 2c: Perforation of the veal cortical bone using the saw tip in Experiment I. round bur in Experiment I. surements every two seconds. The final phase of The length of the incision determined each sectioning (ie, the moment when we approach the step until the perforation of the internal sur- internal surface of the cortical bone) is the most face of the cortical bone, where the limits of critical moment for the thermal values. It took into the measurements are no longer possible account the sum of the last ten temperature results due to the absorption of the infrared by water. known as the oddments. It was observed that once the irrigant comes in contact with the glass, the measurements were no longer possible. A single calibrated examiner performed the experiments. The power and irrigation (ie, physiologic saline solution at room temperature) of the machines were adjusted as recommended. Each measure- ment was done throughout the incision of the cor- tical bone at a length of 15 mm, during 1 mn ± 5 seconds for the saw tips (Figures 2a & 2b) and during the perforation with a round bur (Figure 2c). 40 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al Figure 4a: Piezoultrasonic saw tips (BS1 & OT7) and round bur (RB) used in Experiment 1. Figure 3: Example of a thermographic measurement Figure 4b: View of the external surface of the veal cortical registration. bone at the end of Experiment I showing incisons done with a BS1 saw tip (n° 1,3,5,10); with a OT7 saw tip (n° 2,4,9) The teeth of the saw tips were impacted into and perforations using a round bur (n°6,7,8). the samples with a back and forth motion over the entire length of the incision line using moder- was used. A summary of the results is found ate pressure. By these to and fro translations, the on the measurement registrations (Figure 3). instrument only works during traction. This com- plete translation also occurs with horizontal and RESULTS vertical micromovements avoiding the instrument to be blocked thus allows better sectioning of the In Experiment I, we carried out a series of num- bone.19 The goal of the operator is to perform bered tests from 1 to 10 on veal bone using incisions that is similar in duration and form. The a standard irrigation of 35ml/min (Figure 4a): data were collected in the thermographic report. 1. Four incisions were made with the BS1 saw tip; Between two points on the same image, a variation 2. Three incisions were made with the OT7 in temperature of about 0.1 to 30°C was observed. saw tip; To analyse the observations, a ThermaCAMTM 3. Three perforations were made using a classic Reporter 2000 Pro software (FLIR®, Sweden) 2 mm round bur (Figure 4b). The Journal of Implant & Advanced Clinical Dentistry • 41

Poblete-Michel et al Table 1: Temperatures Observed After Sectioning with BS1 and OT7 Saw Tips Measurement Mean Value Mean End Value (10) Incision 3/BS1 38.39 38.89 Incision 5/BS1 31.78 38.61 Incision 1/BS1 32.81 38.12 Incision 4/OT7 47.59 73.38 Incision 9/OT7 36.23 49.15 Incision 2/OT7 40.93 56.34 Mean BS1 32.93 38.54 Mean OT7 41.59 59.62 Figure 5: View of the external surface of the ewe cortical We noted six incision tests: three with a BS1 bone at the end of Experiment II under variable but and three with an OT7 of which the oscillating dura- controlled irrigation outputs (n°1 low irrigation, n°5 high tions were between 52 and 55 seconds. A com- irrigation). parative work was then possible. The sum of the results is reported in Table 1. Two of the drillings with a round bur were useful (n° 7 and 8) which allowed us to show maximum temperatures of 35 °C and 45 °C during an incision of 10 seconds. In Experiment II, we performed a series of ten tests on a sample ewe cortical bone under vari- able but controlled irrigation outputs (Figure 5): 1. Five incisions were made with the BS1 saw tip at mode 1 2. Five incisions were made with the OT7 saw tip at bone quality 1 mode. The measurement of the irrigation flow was done during 2 minutes. The observation of bone samples showed that on the exter- nal surface of the cortical bone, the precise and rectilinear incisions measured 15 mm for Experiment I and 13 mm for Experiment II. 42 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al Figure 6: Thermal observations during the use of a BS1 Figure 7: Thermal observations during the use of an OT7 saw tip. saw tip. We can observe several irregular impacts of ses of the results show a progressive increase in the saw’s teeth at the edge of these incisions. the temperature. The peak temperature was reg- istered several seconds before the perforation At the internal surface, the impact of the saw’s of the cortical bone between 10 to 12 seconds. teeth was not visible. The slice is perfectly smooth, regular and seems to be lightly straighter at the The use of the Piezosurgery™ provoked heating edges of the incision. The length of the incisions superior to that of the Piezotome™. This heating is more significant and variable between 12 to 16 is apparent as soon as half of the incision time is mm for Experiment I compared with much smaller reached. Its peak at the end of the incision seems and more homogeneous incisions between 4 to 6 to be superior to the peak of the Piezotome™. mm in Experiment II. The width of the incisions was less than a millimeter for both BS1 and OT7 tips. The analyses of the average temperatures at the end of the incision for the Piezosurgery™, show vari- Thermal observations showed that for Experi- able heating and at least 10°C difference compared ment I, twenty-nine measurements were collected to the Piezotome™. The latter gives stable mean val- for each incision, thus allowing us to establish a ues at 40°C (Figure 8) with a maximum of 45.3°C. curve for each (Figures 6 & 7). We used the sum We have observed that 40°C corresponds to the of the last ten temperature oddments for each inci- average set out by the use of a bur. The temperature sion in order to emphasize this interesting phase curves are smooth at the start of the incision then of the temperature recordings. Considering the present peaks in the second part of the incision. given protocol, the camera measures the surface temperature close to the internal surface of the cor- This second part of the curve shows sig- tical bone. No comparisons were made between nificant differences between the two devices. the use of a traditional bur and the piezoultra- sonic saw tips. For the two devices, the analy- They are numerous and less elevated for the Piezotome™ and rare but more pronounced for the Piezosurgery™ (Table 1). We also The Journal of Implant & Advanced Clinical Dentistry • 43

Poblete-Michel et al Table 2: Incision test results according to irrigation output PiezotomeTM (Satelec®, France) 1 23 4 5 Mode 1/BS1 tip Incision 16 20 30 40 50 Recommended irrigation output (ml/mn) 11 20.5 30 40 50 31 35 35 27 38 Measured irrigation output (ml/mn) 75 41 48 57 37 Time of incision (seconds) 5 4 Maximum Temperature (°C) 47 30 PiezosurgeyTM (Mectron®, Italy) 12 3 4 41 Bone Quality 1/OT7 tip Incision 01 2 3 Recommended irrigation output (ml/mn) 5 15 27 41 Measured irrigation output (ml/mn) 30 30 32 22 Time of incision (seconds) 100 120 46 41 Maximum Temperature (°C) observed maximum temperatures of 124.3°C, shows similar heating when the irrigation is supe- 82°C and 79.7°C for the three OT7 incisions. rior to 30 ml/min (Figure 9). For the two devices, we observed that the temperature curves were lev- For Experiment II, we performed identical inci- eled out with the increase in the irrigation output. It sions under varying irrigation outputs. The Piezo- is clear that the quantity of irrigation supplied has tome™ and Piezosurgery™ devices were used side an effect on the heating at the end of the incision. by side in order to compare both devices. The results were obtained when varying the quantity The effect is very clear for the Piezosurgery™ of irrigation by controlling the validity of the irrig- device. We obtained a mean of 32.6°C without ant output recommended by the manufacturers peaks starting from 27 ml/min. However, differences (Tables 2, 3a, and 3b). The temperature curve between the devices were observed with irrigation comparing the two devices show the same char- output between 30 to 50 ml/min. The Piezotome™ acteristics as that obtained in the Experiment device showed an increase in heating with an aver- I. The observation confirms the capacity of the age of 3.3°C (ie, peaks from 57°C and 48°C). Only Piezosurgery™ device to generate more heat- the peak of 57°C alone created a significant contrast ing than the Piezotome™ device at the end of the of 16°C compared to the Piezosurgery™ device. incision. The study of the comparative diagram of mean temperatures at the end of the incision Note that this incision was the fastest and only carried out in 27 seconds. At a minimum irriga- 44 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al Table 3a: Observed temperatures during Experiment II using a BS1 saw tip Irrigation Test BS1 Tip Mean Value of Tests (°C) Mean End Value (°C) BS1 Irrigation 1 42.2 52.5 BS1 Irrigation 2 35.6 37.8 BS1 Irrigation 3 35.9 40.6 BS1 Irrigation 4 36.0 43.4 BS1 Irrigation 5 32.2 34.0 Mean Temperature Value (°C) 36.4 41.7 Table 3b: Observed temperatures during Experiment II using a OT7 saw tip Irrigation Test OT7 Tip Mean Value of Tests (°C) Mean End Value (°C) OT7 Irrigation 1 49.9 71.5 OT7 Irrigation 2 49.6 68.9 OT7 Irrigation 3 32.5 38.5 OT7 Irrigation 4 32.7 36.8 OT7 Irrigation 5 32.7 34.9 Mean Temperature Value (°C) 39.5 50.1 tion of 30 ml/min between 20°C to 30°C, the duced the general hypothesis and the model retained Piezosurgery™ induces considerable heating that for the following study. The second and third parts reached mean oddment values superior to the compared heating induced by the piezoultrasonic Piezotome™ device. The maximum temperature saw tips. Finally, the fourth part tackles the ques- reached 100°C and 120°C. The two devices tions related to the variations in the irrigation output. generated significant heating but this can eas- ily be controlled with the Piezotome™. The study The purpose of this study was to detect possi- of the diagram comparing the mean tempera- ble differences between the elevated temperatures ture oddments reveals these results (Figure 10). produced by the different devices. We were only interested in the findings prior to the temperature For the statistical analysis, the first part intro- peaks. The heating phenomenon was modeled The Journal of Implant & Advanced Clinical Dentistry • 45

Poblete-Michel et al Figure 8: Comparative thermal observations between the Figure 9: Comparative diagram of mean temperatures at BS1 and the OT7 tips. the end of the incisions using a BS1 and an OT7 saw tip. Figure 10: Diagram comparing the mean temperature that assumes that the Gaussian noise is identi- oddments. cally distributed particularly in the same variance. For this we used the modified least squares.23 by the formula: and . The coefficients that interested us were and We conducted a linear regression on our data , which gave us slopes of regression lines where the first coefficient was twice smaller then observed any eventual difference that could then the second. These figures clearly confirmed that the BS1 saw tip heats less than the OT7. be statistically significant between the estimated Figures 11 and 12 graphically represent the parameters of regression. However, graphical two linear regressions represented as the green and blue lines. As well as the evolution of temper- representations of data show an increase in the ature increases for all three readings of each tip. variance of noise (ie, deviation from the curve) Another way to study heating was to apply randomized experiments using the Bootstrap depending on the temperature. It is not possible method.24 This method consists of creating new sample values from samples that we already to use the classical theory of linear regression have. In our case, it is possible to simulate new temperature curves drawing randomly each time temperature increases among the augmenta- tions observed. By multiplying these simulations, we obtain an approximation of the law of temper- ature distribution at a time from which it is possible to apply statistical experiments. In our 46 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al Figure 11: Linear regression lines showing the readings Figure 12: Linear regression lines showing the readings for the BS1 saw tip. for the OT7 saw tip. case, we used two distinct experiments. The first The second experiment compares the aver- experiment equalizes the laws of distribution in the temperature increases between the two pow- age temperatures between the two devices. The erful piezoultrasonic devices. Thus, we came up with the following hypotheses: First, for each hypotheses are as follows: First, the average law between and , the temperature increases of and are of the same law of prob- of probability of and are ability. Second, there is a juncture in between identical. Second, the average law of probabil- and . As the temperature increases, and did not have the same law of probability. ity of and are distinct. Remember that an experiment is accepted if The first twenty-five temperature increases the first hypothesis is not refused (ie, non-sig- nificant experiment) otherwise it is rejected (ie, for each result are always considered in pri- significant experiment). In addition, there is a probability to reject the experiment by assuming ority. This time there is no significant differ- that the first hypothese is true. This level is gen- erally fixed at 5%. Finally, the critical level of an ence between the methods of heating during experiment is considered so that the results are overturned. When one considers the top twenty- the incisions with the BS1 and OT7 saw tips five temperature increases for each result, the BS1 saw tip shows the least heating compared (p>0.05) and the critical level is at 5.8%. to the OT7 (p<0.05) with a critical level of 3.8%. It is possible to apply the different methods previously mentioned above for the measure- ments concerning the different irrigation outputs. However, having a single temperature curve for each irrigation level and for each device prevented us from performing another parallel experiment. Consequently, we experimented on the following: 1) the different incisions that can be performed under irrigation for each device and 2) between the devices under their different irrigation levels. The Journal of Implant & Advanced Clinical Dentistry • 47

Poblete-Michel et al Table 4a: Statistical results of the experiments using the di erent irrigation outputs BS1 saw tip Irrigation 1 Irrigation 2 Irrigation 3 Irrigation 4 Irrigation 5 Irrigation output 16ml/mn 20ml/mn 30ml/mn 40ml/mn 50ml/mn Irrigation 1 NS (13.8%) NS (32.8%) NS (23.1%) NS (16.0%) Irrigation 2 X NS (21.3%) NS (27.8%) NS (91.0%) Irrigation 3 X NS (99.0%) NS (22.1%) Irrigation 4 X NS (25.1%) Irrigation 5 X X Table 4b: Statistical results of the experiments using the di erent irrigation outputs OT7 saw tip Irrigation 1 Irrigation 2 Irrigation 3 Irrigation 4 Irrigation 5 Irrigation output 5ml/mn 15ml/mn 27ml/mn 41ml/mn 47ml/mn Irrigation 1 X NS (73.4%) S (2.2%) S (2.5%) S (0.6%) Irrigation 2 S (3.7%) S (3.0%) S (0.5%) Irrigation 3 X NS (53.3%) NS (39.7%) Irrigation 4 X NS (77.8%) Irrigation 5 X X In each experiment, data were taken between DISCUSSION the initial time and the first moment when one of the two curves reached its maximum. The results Schlee (2005), Boioli et al. (2005) insisted on the are summarized in Tables 4a and 4b. Finally, the primary importance of irrigation during bone sur- results of randomized experiments are relevant gical interventions to avoid excessive increase in despite the low number of measurements. A temperature, however, the quantity of irrigation out- dozen temperature readings for each device put to be used was not mentioned.17,25 In 1991, and each level of irrigation output are needed Giraud et al. proposed to study heating in order to improve the results of these experiments. to validate the use of such instrumentation.16 For Stübinger et al (2005), it is important to know whether thermal alterations exist in the soft and 48 • Vol. 2, No. 8 • October 2010