Heat Induction Analysis from Piezoelectric Bone Surgery

Poblete-Michel et al hard tissues.12 While Gruber et al (2005) thought devices: the Piezosurgery™ with the OT7 tip, the that it is necessary to estimate temperature Piezotome™ with the BS1 tip and the SurgySonic™ changes in the cortical bone during osteotomies.20 with the ES007 tip (American Dental DevicesÒ, USA). The movement was horizontal at 6.5 mm with We conducted the comparison of heat pro- a pression of 3N, an irrigation of 55 ml/min using duced by the Piezosurgery™ and Piezotome™ physiologic serum for an incisal depth of 2.5 mm. during the incisions of animal cortical bone The temperature was measured with an aide of a without trying to make a significant approxi- type 04 thermocouple positioned at 3 mm under mation with the traditional drilling device. The the incision zone of the tip. The heating was not results obtained with the round bur served as a statistically different between the ES007 and OT7 guide and helped to assess the respective time tips, but statistically lesser for the BS1 tip. The sec- needed to carry out the programmed intervention. tioning performance was equivalent for both OT7 and BS1 tips but statistically different and lesser In our experiment, heating became signifi- for the ES007 tip.26 In 2009, the same authors re- cant in half the time of the incision. Given the evaluated and compared the bone cutting perfor- mode of measurement, it is clear that the inter- mance and intraosseous temperature development nal surface of the cortical bone does not show of the same devices using the same technique of an increase in temperature at the beginning of analysis. They concluded that the Piezotome™ and the incision. It is normal to observe the increase the Piezosurgery™ (Mectron®, Italy) showed a sig- in temperature while the sectioning instrument nificantly higher cutting performance than the Sur- descends into the incision. The rapid return to gySonic™. While The Piezotome™ produced the a temperature close to the starting temperature, smallest increase in intraosseous temperature.27 plus a dozen degrees Celsius was observed. The consequences of heating are important Accordingly, the second time of the incision was for the surrounding tissues. Horton et al (1975 the exploited phase. During this phase, the Piezo- & 1981) histologically compared bone healing surgery™ induced heating that was clearly superior in dogs after bone resection using three types to the Piezotome™. More than an average of 20°C of instruments: a classical CavitronTM (Dentsply, for Experiment I and <10°C for Experiment II. It USA), a bone chisel and a bur mounted on a hand- was also observed that the immediate return to the piece.8,28 The authors showed at three then at initial temperature increased ten times. The peak seven days a more advance and organized bone temperature of 124.3°C in our measurements with formation in bone defects made with both a bone the Piezosurgery™ can be explained either by the chisel and an ultrasonic device compared to the lack of irrigation during the incision due the posi- bur. They concluded that ultrasonic and manual tion of the tip on the concavity of the cortical bone instruments revealed little difference in healing turned downward or by the abnormal heating of the and that irrigation is necessary to avoid excessive tip during the incision. A peak of 120°C was also heating that may adversely affect the cell viability. obtained during an incision under minimum irrigation. Chiriac et al (2005) have studied cell differen- Harder et al (2007)26 analysed and compared tiation and viability of bone samples made by the the effectiveness of the incision and the intraosse- ous temperature elevation by using three ultrasonic The Journal of Implant & Advanced Clinical Dentistry • 49

Poblete-Michel et al Piezosurgery™ and a bur.29 The bone chips were tion perfectly pays its role, it must not be forgotten analyzed to determine their viability by measuring that these piezoelectric devices naturally generate the alkaline phosphatase activity and differentiation heat. Our results also demonstrate that the Piezo- by immunochemical quantification of osteocalcin. tome™ better controls heating and irrigation out- The results showed that there was no significant put. It may be observed that aside from 73.7°C difference on cell proliferation and differentiation of and 57.8°C measured during Experiment II under osteoblasts between the two types of samples. Ver- minimum irrigation, the Piezotome™ never induced celloti et al (2004) compared by histomorphometry temperature measurements superior to 57°C. the healing of bone resections in dogs made with the Piezosurgery™, a tungsten carbide bur and a Other parameters that must be taken into diamond-coated bur.13 The results demonstrated a consideration would be the manner of incision, difference on the 14th day. The sites treated with quality and initial temperature of the irrigating the diamond-coated and carbide bur lost bone solution, operator’s technique, use and quality of while those treated with the piezoultrasonic device the saw tips, adjustment and maintenance of the showed bone gain. These results were confirmed machine’s parameters and finally, the bone qual- on the 56th day after the surgery, the difference ity. However, taking in consideration all these pre- being statistically significant. Berengo et al (2006) cise factors is not the subject of this study but also mentioned the superiority of the manual and must not be neglected. Additional studies must piezoelectric instruments over classical rotary be performed to better understand and improve instruments on the cellular vitality of the samples.30 ultrasonic-assisted instrumentation to enhance its usage and to limit heating, especially during There was no significant difference between osteotomies of solid and dense bony structures. the two devices when used with abundant irri- gation in Experiment II. However, the compari- CONCLUSIONS son is not possible between Experiment I and II. Through infrared thermography, we measured The appearance of temperature peaks and the heating induced by powerful piezoultrasonic rapid return to a lower temperature after reaching devices during the incision of sample animal cor- the peak or at the end of the incision must be ana- tical bone. The results during the second time of lyzed. The abundance of the irrigating solution is incision show important variations between the indispensable. Its circulation and replenishment are experimented devices. The mean temperatures at certainly related to the continuous movement dur- the oddments obtained using the Piezosurgery™ ing the incision. The manner of sectioning facilitated is superior at an average of 10 to 20°C com- the regularity in the curve of the results obtained in pared to that obtained using the Piezotome™. In Experiment II. At the end of the incision, cooling Experiment II, which studied the influence of irri- can be explained by the efficient action of the liquid gation on heating, showed that a minimum irri- on the thinnest part of the remaining cortical bone. gation output of 30 ml/min is recommended. We observed during the experiment that a mini- The use of piezoultrasonic saw tips seems mum irrigating output of 30 ml/min must be used to induce heating comparable to osteotomies to maintain heating below 57°C. Even if the irriga- performed with a traditional bur when the inci- 50 • Vol. 2, No. 8 • October 2010

Poblete-Michel et al sion is improperly performed and the irrigation is Disclosure inferoir to 30 ml/min. However in this study, we The authors report that financial assistance for equipment used in this study was showed that the proper use of these tips could provided by Acteon. significantly change previous notions on heating. References 1. Goldman H.M, Cohen D.W. The infra-bony pocket : classification and Nowadays, the popularity of implant dentistry brings us to reflect on newer and advanced tech- treatment. J Periodontol 1958; 29:272-291. niques to improve the bone support in simple 2. Mattout P, Mattout C. Les thérapeutiques parodontales et implantaires. Paris, and more complex cases. In the past 10 years, bone surgical techniques have greatly evolved France: Quintessence; 2003: 495. and the piezosurgery technique brings con- 3. Misch. C.M, Misch C, Resnir R.R, Ismail Y.H. Reconstruction of maxillary crete answers to these delicate surgical proto- cols. It brings about new advantages such as alveolar defects with mandibular symphysis grafts for dental implants: selective, precise and secure sectioning action. preliminary procedural report. Int J Oral Maxillof ac Impl 1992; 3(7): 360-366. 4. Khoury F, Happe A. The 3 dimensional reconstruction of the alveolar crest with Certain authors showed that the use of mandibular bone block graft: a clinical study. Int J Oral Maxillofac Implants these techniques has advantages on bone heal- 2004; 19: 765-766. ing.9,16,20,31 Histologically, the tissue response is 5. Buser D, Dula K, Belser U, Hort H.P, Berthold H. Localized ridge augmentation better and makes postsurgical conditions more using guided bone regeneration.l. Surgical procedure in the maxilla. Int J favorable than the conventional techniques. Periodontics Restorative Dent 1993; 13(1): 29-45. The histological data has not yet given a clear 6. Sun D, Zhou Z.Y, Liu Y.H, Shen W. Development and application of ultrasonic explanation and many questions are still to be systems. IEEE Trans Biomed Eng 1997; 44(6): 462-70. answered about the influence of ultrasounds on 7. Gagnot G, Poblete M.G. Du bon usage des ultrasons : la maîtrise des the periodontal tissues as well as on hemostasis. vibrations. Revue d’odonto-stomatologie 2004; 33 : 85-95. 8. Horton J.E, Tarpley T.M, Jacoway J.R. Clinical applications of ultrasonic In normal operating conditions, the Piezo- instrumentation in surgical removal of bone. Oral Surg Oral Med Oral Path tome™ allowed better control of irrigation tem- 1981; 51(3): 236-241. perature below the level of potential bone cellular 9. Vercelloti T, Kim D.M, Wada K, Fiorellini J. Réponse osseuse après résection necrosis. However, there are still other elements piézo-chirugicale. Int J Periodontics Restorative Dent 2005; 25 (6): 543-548. to consider (eg, effects on distant tissues, the 10. Michel J-F, Poblete-Michel M.G, Hourdin S. Utilisation des ultrasons de form of tips) that have to be investigated before completely validating this type of osteotomy. puissance en chirurgie parodontale et implantaire. Objectif Paro 2007; 13–17. 11. Catuna M.C, Sonic energy. A possible dental application. Primary report of an Correspondence: Poblete-Michel Marie Grace ultrasonic cutting method. Ann Dent 1953; 12: 256-260. Address: L’Abbaye 2 bis Place Saint Melaine 12. Stübinger S, Kuttenberger T. Intraoral piezosurgery: Preliminary Results of a 35000 Rennes, France Telephone: +33 2 99 63 33 33 new technique. J Oral Maxillofac Surg 2005, 63:1283-1287. Fax: +33 2 99 27 53 81 13. Vercellotti T. Technological characteristics and clinical indications of Email: [email protected] piezoelectric bone surgery. Minerva Stomatol 2004; 53: 207-214. 14. Siervo S, Ruggli-Milic S, Radici M, Siervo P, Jager K. La piézochirurgie intra- orale. Rev Mens Suisse Odontostomatol 2004; 114(4): 365-77. 15. Boioli L.T, Vercellotti T, Tecucianu J.F. La chirurgie piézoélectrique une alternative aux techniques classiques de chirurgie osseuse. Inf dent 2004; 86(41): 2887-2893. 16. Giraud J.Y, Villemin S, Darmana R, Cahuzac J.P, Autefage A, Morucci J.P. Bone slitting. Clin Phys Physiol Mens 1991; 12(1):1-19. 17. Schlee M. Ultraschallallgestützte Chirurgie-Grundlagen und Möglichkeiten. Deutscher Ärzte-verlag Köln 2005; 21(1): 48-59. 18. Leclercq P, Dohan D. De l’intérêt du bistouri ultrasonore en implantologie : technologie, applications cliniques. Première partie : technologie. Implantodontie 2004; 30: 1-7. 19. Poblete-Michel M.G., Michel J.F. Clinical Success in Bone Surgery with Ultrasonic Devices. Paris, France: Quintessence; 2009: 28-29. 20. Gruber R.M, Kramer F-J, Merten H-A, Schliephake H. Ultrasonic surgery – an alternative way in orthognathic surgery of the mandible. Int J Oral Maxillofac Surg 2005; 34: 590-593. 21. Robiony M, Polini F, Costa F, Vercellotti T, Politi M. Piezoelectric bone slitting in multipiece maxillary qsteotomies. Int J Oral Maxillofac Surg 2004; 62: 759- 761. 22. Eggers G, Klein J, Blank J, Hassefeld S. Piezosurgery : an ultrasound system for slitting bone and its use and limitations in maxillofacial surgery. Br J Oral Maxillofac Surg 2004; 42(5): 451-453. 23. Huet S, Jolivet E, Messéan A. La régression non-linéaire, méthodes et applications en biologie. Paris, France: Institut national de la recherché agronomique (INRA); 1992: 256. 24. Efron B, Tibshirani R. J. An Introduction to the Bootstrap. New York: Chapman and Hall ; 1993. 25. Boioli L.T, Vercellotti T, Tecucianu J.F. La chirurgie piézoélectrique une alternative aux techniques classiques de chirurgie osseuse. Inf dent 2004; 86(41): 2887-2893. 26. Harder S, Wolfart K, Ludwig K, Möller R, Steiner M, Kern M. Bone slitting performance of ultrasonic systems and associated temperature development. J Dent Res 2007; 86: 2914. 27. Harder S, Wolfart S, Mehl C, Kern M. Performance of ultrasonic devices for bone surgery and associated intraosseous temperature development. Int J Oral Maxillofac Implants 2009; 24(3): 484-90. 28. Horton J.E, Tarpley T.M, Wood L.D. The healing of surgical defects in alveolar bone produced with ultrasonic instrumentation, chisel, and rotary bur. Oral Surg Oral Med Oral Patho Oral Radiol 1975; 39(4): 536-546. 29. Chiriac G, Herten M, Rothamel D, Becker J. Autogeneous bone chips : influence of a new piezoelectric system (Piezosurgery™) on chip morphology, cell viability and differenciation. J Clin Periodontol 2005; 3: 994-999. 30. Berengo M, Bacci C, Sartori M, Perini A, Della Barbera M, Valente M. Histomorphometric evaluation of bone grafts harvested by different methods. Minerva Stomatol 2006; 55(4): 189-198. 31. Kotrikova B, Wirtz R, Kremrien R, Blank J, Eggers G, Samiotis A, Mühling J. Piezosurgery, a new safe technique in cranial osteoplasty? Int J Oral Maxillofac Surg 2006; 35: 461-65. The Journal of Implant & Advanced Clinical Dentistry • 51

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Clinical Evaluation of Flapless Free Hand Zahran et al Immediate Implant Placement in Fresh Extraction Sockets Amr Zahran, BDS, MDS, PhD1 • Mahmoud El-Refai, BDS, MDS, PhD2 Tamer Amir BDS3 • Mohamed Fouda, BDS4 Abstract Background: The procedure of the flapless free Results: The overall survival rate was 100% and hand, implant placement in fresh extraction socket the overall mean bone loss was 0.59mm (SD in conjunction with immediate loading has many ±0.33; range 0.03-1.28mm) and 0.70mm (SD challenges and needs documentation. This paper is ±0.35; range 0.06-1.04mm) after 6 months and a retrospective study for documentation of the pro- 12 months respectively. The average Periotest cedure using a new design of one-piece implants. M values were -2.35 (SD ±0.99; range -0.5 to -4.7) as measured immediately after implant Methods: Sixty two tapered one-piece implants placement, while the values were -2.72 were placed in 62 patients (27 males and 35 (SD ±0.70; range -1.8 to -3.8) and -3.18 females with a mean age of 44.3 years) imme- (SD ±0.83; range -1.9 to -4.9) after 6 diately after extraction of a single anterior tooth months and 12 months respectively. or premolar. All the implants were placed using the free hand flapless technique and immedi- Conclusion: The flapless, free hand imme- ately restored with a provisional acrylic resin res- diate post-extraction implant placement and toration. The patients were evaluated at 6- and loading using tapered one-piece implants 12-month intervals. Clinical criteria were survival is a highly successful treatment modal- rate, Periotest M values and crestal bone level. ity and the prognosis depends on proper treatment planning and case selection. KEY WORDS: Dental implants, immediate implant, extraction 1. Professor, Department of Periodontology, Cairo University, Cairo, Egypt 2. Chairman, Department of Periodontology, Cairo University, Cairo, Egypt 3. Researcher, Department of Periodontology, Cairo University, Cairo, Egypt 4. Researcher, Department of Periodontology, Cairo University, Cairo, Egypt The Journal of Implant & Advanced Clinical Dentistry • 55

Zahran et al INTRODUCTION According to recent researches, we have three options of implant loading: Conventional The original protocol, as described by Brane- staged loading protocol in which the implant is mark and colleagues, required a two-stage loaded after insertion by 3-8 months,20 immedi- surgical protocol: the surgical placement and ate loading protocol involves the loading of the surgical uncovering of an implant. They sug- implants immediately after insertion or within gested a healing period of 3-6 months after a week after placement,21-23 while early load- tooth extraction to allow for bone filling and ing protocol allows the implant to be loaded contouring before implant placement.1,2 Inves- after insertion by 1 week to 2 months.24,25 tigations showed that significant bone volume changes of the alveolar process take place fol- The combination of immediate post- lowing tooth extraction.3,4 Schropp et al 2003 extraction placement with immediate load- reported a 50% reduction in bucco-lingual ing of dental implants has the advantage of width of the extraction socket over a period of shortening the treatment time and increas- twelve months with two thirds of the reduction ing case acceptance and reported to be safe taking place during the first three months and a in terms of survival rates and esthetics.24,26,27 reduction of crestal bone level ranging from 0.7 to 1.5 mm after four to six months.5 Thus, imme- Although most of the literature describes diate post extraction implant placement into the need initially to raise a flap for implant fresh extraction sockets is considered a pre- placement, many studies have demonstrated dictable and accepted procedure of preserving that flap reflection often results in gingival the alveolar dimensions, with its consequences recession and bone resorption around natural of better crown-implant ratio, improved soft tis- teeth.28 When soft tissue flaps are reflected sue esthetics and favorable inter-arch relation- for implant placement, blood supply from the ship.6-10 Immediate implant placement has also soft tissue to the bone (supraperiosteal blood been reported to have the advantage of reduc- supply) is removed, thus leaving poorly vascu- ing the treatment time required and the reduc- larized cortical bone, prompting bone resorption tion of the number of surgical interventions.11-13 during the initial healing phase.29 To minimize Many implantologists are very trustful of 2-stage the possibility of postoperative peri-implant tis- implant placement procedures as they are sue loss and to overcome the challenge of soft unaware of the successful concept of immedi- tissue management during or after surgery, ate loading which began more than 40 years the concept of flapless implant surgery has ago.14 With the evolution of implant design been introduced and clinically applied to both regarding the development of improved surface delayed and immediate loading cases.9,13,30-32 treatments and thread designs which has the purpose of achieving better primary stability and However, some prerequisites for the flap- osseointegration, immediate loading became less implant surgery have been reported; these more popular and many authors have reported include sufficient bone width and height since a high success rate with this technique.15-19 direct visualization of bone is limited, adequate keratinized soft tissue in order to be estheti- cally pleasing, an absence of significant tis- 56 • Vol. 2, No. 8 • October 2010

Zahran et al Figure 1: Periotest M values over time. the cortex using under-sized drilling, followed by slow and gradual insertion of the implant sue undercuts to prevent tissue dehiscence or into the socket. Each turn will smoothly dis- fenestration, and finally the correct angula- place the bone, thereby improving the bone tion of the implant drills for fear of perforating quality by condensing the bone. The self-tap- the cortical plates especially the buccal aspect ping design together with the buttress thread resulting in dehiscence or fenestration.10,33 design enables the clinician to place the implant into an under-sized osteotomy, making the sur- The new Maxi Z one-piece implants have gery less traumatic, and also contributes to tapered macro- design with tapered-end and achieving high initial stability which is essen- mimic the shape of the natural single rooted tial for the success of immediate placement tooth. The tapered shape of the implant and immediate loading of dental implants.13 allows for nearly complete fill of the extraction socket space, leaving the minimal peri-implant MATERIALS AND METHODS bony defect or space between the wall of the socket and the body of the implant (jump- Patients ing distance). This implant system allows for A total of 62 patients, including 27 males and simultaneous expansion and compression of the bone by creating a small opening through The Journal of Implant & Advanced Clinical Dentistry • 57

Zahran et al Figure 2: Preoperative clinical picture. Figure 3: Immediate postextraction implant placement. 35 females, were consecutively included in this cal radiographs and cone beam volumet- study between September 2007 and October ric tomography (CBVT) whenever indicated. 2008. The average age at the time of implant placement was 44.3 years (range 24-79 years). Implants The patients were required to be in good gen- Sixty two Maxi Z one-piece implants (Osteo- eral health, and had no condition that might Care™ Implant System, London, United Kingdom) jeopardize the outcome of the treatment. All were used in this study. The Maxi Z one-piece patients had a single anterior tooth or premo- implant has a tapered design with tapered- lar indicated for extraction due to root frac- end which allows for bone compression dur- tures, endodontic failure, non restorable crown ing insertion through under-sized osteotomy. fracture and periodontal disease. The patients Also it has a unique “buttress” thread design were thoroughly informed of the immediate that allows for maximum bone to implant con- loading protocol and of all the risks associated tact, resulting in the achievement of high initial with this type of procedure. They all gave their stability in poor quality bone. This implant has full informed consent. The treatment planning grit-blasted and acid etched surface treatment. for the patients included extraction of the hope- less teeth and the immediate placement of one- Surgical Protocol piece implants of proper diameter and length All implant surgeries were performed under and followed by delivery of acrylic resin provi- local anesthesia. All the extractions were done sional restorations immediately after placement. atraumatically and no flaps were designed before or after teeth extraction. Presence of Pre-Surgical Evaluation intact buccal plate of bone was considered cru- Pre-surgical evaluation was carried out cial for the immediate post-extraction implant with panoramic radiographs, periapi- placement procedure. The integrity of buc- 58 • Vol. 2, No. 8 • October 2010

Zahran et al Figure 4: The provisional acrylic crown. Figure 6: The nal ceramo-metal restoration. Figure 5: Immediate postoperative periapical radiograph. was used at the center of the apex of the socket which was used as a guide to make the ini- cal plate of bone was assessed by an osteot- tial osteotomy and extended 3-5 mm beyond omy probe through the extraction socket. Any the socket level. According to the bone den- socket with buccal dehiscence or fenestration sity beyond the socket level, another 2 sequen- was excluded from the study. Flapless, free- tial wider drills (2.2 and 2.75mm) were used in handed implant surgery was used for all the oste- cases with hard bone to facilitate easier inser- otomy preparations and implant placements. tion of the implant without exerting undue pres- Osteotomy Preparation sure on the bone. All the drilling procedures were The profile pilot drill with a diameter of 1.3mm done under copious irrigation using saline to pre- vent heat generation and damage of the bone. Implant Placement After choosing the proper implant diameter and length to occlude the extraction socket space without leaving a peri-implant defect (jump- ing gap) of more than 1.5mm, the implant was removed from its protective pouch and manually placed with its tapered tip to engage the open- ing of the under-sized osteotomy through the extraction socket. Then the hex driver and the ratchet wrench were used to complete the seat- ing of the implant. The first thread of the implant was placed 3mm below the crestal bone of the The Journal of Implant & Advanced Clinical Dentistry • 59

Zahran et al Figure 7: 12 months postoperative periapical radiograph. ratory or by the dentist chair-side. The provisional acrylic resin crown was then temporarily cemented socket as confirmed by the periapical radiograph. to the prepared abutment of the implant. The pro- visional crown was carefully adjusted out of direct Implant Stability occlusal contacts (non functional occlusion). Attaining primary stability of over 30 Ncm was considered crucial with all the placed implants in Final Restorations the extraction sockets to allow for the immediate After a healing period of 6 months, the acrylic loading protocol. Primary stability of the implants resin provisional crowns were removed, and was evaluated by the torque wrench. The implant replaced by definitive ceramo-metal restorations. stability was checked also by the Periotest M (Medizinntechnik Gulden, Bensheim, Germany). Follow-up The patients were evaluated at 6 and 12months Abutment Preparation intervals. The following criteria were applied High speed diamond or carbide burs were to evaluate the implant success: Implant used to adjust the angulation and height of the success was calculated according to the abutment, if necessary. The abutment prepa- following parameters: absence of mobil- ration was done under a copious stream ity, absence of painful symptoms or par- of water irrigation to prevent overheating. esthesia, absence of radiolucency during radiographic evaluation, and absence of pro- Immediate Loading gressive marginal bone loss (bone resorption Once the abutment preparation and impression in measurement areas not greater than 1mm, taking were completed, the provisional acrylic during the first year of implant positioning).34 resin restoration was fabricated either in the labo- Radiographic evaluation of the crestal bone was evaluated with conventional and digital radiographs taken immediately after implant placement and after 6 and 12 months of the follow-up period. Conventional radio- graphs were photographed with a digital cam- era. Each radiograph was calibrated using the known length of the implants. The lower corner of the collar was used as a reference point for measurements at the mesial and dis- tal side of the implant. Measurements were done using the UTHSCSA image tool version 3.0 (developed in the Department of Dental Diagnostic Science at The University of Texas Health Science Center, San Antonio, Texas). 60 • Vol. 2, No.. 8 • October 2010

Zahran et al The Periotest-M was used to evalu- the implants were -2.35 (SD ±0.99; range -0.5 ate the clinical stability. Periotest M values to -4.7) as measured immediately after implant (PT) of (0 to -8) were considered the ideal placement, while the values were -2.72 (SD values that denote successful osseointe- ±0.70; range -1.8 to -3.8) and -3.18 (SD ±0.83; gration. The measurements were repeated range -1.9 to -4.9) after 6 months and 12 months at the 6 and 12 months follow-up period. respectively. There was a statistically significant decrease in the mean Periotest M values after 6 Statistical Analysis months, after 12 months and through the follow-up Data were presented as minimum, maximum, period (6 months-12 months) (P 0.05) (figure 1). means, standard deviation (SD) and standard error (SE) values. Paired t-test was used to study DISCUSSION the changes by time in each variable. The sig- nificance level was set at P 0.05. Statistical The flapless, free hand implant placement in analysis was performed with SPSS 16.0® (Statis- fresh extraction socket in conjunction with tical Package for Scientific Studies) for Windows. immediate loading is relatively a new tech- nique. This technique is increasingly gaining RESULTS popularity as an attractive advantage for both patients and clinicians alike. Today, quick deliv- Complete soft tissue healing was gener- ery of implant-supported restorations imme- ally uneventful in all patients and showed diately after extraction can be considered the no postoperative inconveniences during the standard of care in case of a missing tooth or study period. Twenty one patients experi- missing teeth. Many clinicians, however, are enced no postoperative pain, 32 patients had unaware that the concept of immediate loading mild pain, 8 patients had moderate pain and by using titanium one-piece implants as well as one patient experienced severe pain. The sur- flapless surgery is actually not new and began geon scored 7 patients as having slight edema. in the early sixties of the last century.14,35,36 The patients in general, reported the minimal need for analgesics. The provisional acrylic For a long period of time, the success doc- resin crowns became loose in three patients umented for Brånemark’s protocol convinced and were carefully re-cemented the same day. clinicians that this was the only acceptable protocol. Recently, the evolution of the sci- All the 62 one-piece implants were suc- ence of Dental Implantology yielded techno- cessfully osseointegrated as revealed by clini- logical breakthroughs of the macro and the cal and radiographic examinations. Implant micro-design of the dental implants, includ- survival rate of 100% was attested. The over- ing improved implant shape, thread patterns all mean marginal bone loss was 0.59mm and surface treatments that have demonstra- (SD ±0.33; range 0.03-1.28mm) and bly fostered greater primary stability and faster 0.70mm (SD ±0.35; range 0.06-1.04mm) osseointegration. These modern implants were after 6 months and 12 months respectively. designed for the immediate loading procedures and were applied to rehabilitate the partially eden- The average Periotest M values (PT) for all The Journal of Implant & Advanced Clinical Dentistry • 61

Zahran et al tulous patients with high predictability.17 In parallel for bone augmentation materials unnecessary.38,39 with the recent technical advances of the implant In this study, the flapless immediate post- designs, the better understanding of biology had led to shifting towards the minimally invasive or extraction implant placement cannot be the atraumatic flapless surgical procedures.9,29,35 considered as a “blind” surgical technique The appropriate patient selection, single-stage as the integrity of the socket and the buc- surgery, immediate loading, and flapless site prep- cal plate of bone could be checked eas- aration are dependable treatment approaches ily by probing and could even be visualized that offer favorable long-term prognosis.28,33 through the socket opening. Thorough knowl- edge of clinical anatomical structures around On the other hand, some clinical reports eval- the implant site and sound surgical skills uated the success of immediately loaded den- are needed for the validation of the flapless tal implants that were placed in fresh extraction technique in order to become more popu- sites versus healed bony sites and demonstrated lar for single-stage implant procedures. controversial results,20,37 others considered the flapless implant placement as a “blind” surgical Primary implant stability and lack of micro- procedure and care must be taken when using movement are considered two of the main fac- this technique. Some academicians are against tors necessary for the achievement of predictably the flapless implant concept as well as the imme- high success rates for osseointegrated oral diate loading procedures as literature still lacks implants.20 The authors of the present study sufficient documentation for their credibility to reported a strong correlation between implant be implemented in routine clinical practice.33 successes and the initial stability of the implants ( > 30 Ncm) which was achieved by under-sized It was reported that immediately loaded osteotomy preparation followed by placement of implants may be at a greater risk of fail- the new implant with tapered macro-design and ure than conventionally loaded ones.15 The buttress threads. In this study, the initial stabil- authors of the present study decreased ity of the implants was not tested only by the the risk of failure with immediately loaded torque wrench but the Periotest M was used implants, by using various “clinical tricks”, as well. All the implants had Periotest M val- such as under-sized osteotomy preparation ues below zero at the time of immediate place- of the implant site to achieve high primary ment and all the implants were successfully stability, with the use of non-occluding pro- osseointegrated and gave better significant visional crowns during the healing period. Periotest M values over the follow-up period. The tapered design of the new implant The first thread of the implants used in this with its tapered-end conforms to the shape of study was placed 3mm below the crestal bone the socket and the extracted root that allowed level of the extraction sockets and this could be for filling of most of the socket space leav- the reason for the minimal crestal bone resorp- ing from 0-1.5mm of a jumping gap (circum- tion that occurred during the 12 month follow-up ferential defect) that increased the initial period of this study. Other studies recommended stability of the implants and rendered the need placement of the implants with their platforms 62 • Vol. 2, No. 8 • October 2010

Zahran et al below the level of the socket by 1-2mm.11,40 high degree of primary fixation seems to be one of the prerequisites for success of the procedure. CONCLUSION Correspondence: The flapless, free hand implant placement in fresh Prof. Amr Zahran extraction socket in conjunction with immediate 10 Al-Nakhil St. loading is a successful technique when proper Mohandseen, Cairo, Egypt case selection as well as proper choice of implant E-mail: [email protected] design is applied. This study showed a 100% Tel: 002-0123 101977 clinical success of the new design one-piece implants when placed in well selected patients. A Disclosure 14. Tramonte S. A further report on intra-osseous 26. Cooper L, Rahman A, Moriarty J, Chaffee N, The authors report no conflicts of interest with implants with improved drive screws. The Sacco D : Immediate Mandibular Rehabilitation anything mentioned in this article. Journal of Implant and Transplant surgery. 1965; with Endosseous Implants: Simultaneous References 11: 35-37. Extraction, Implant Placement, and Loading, Int J 1. Branemark PI. Osseointegrated implants in the Oral Maxillofac Implants. 2002;17:517–525. 15. Gapski R, Wang HL, Mascarenhas P, treatment of the edentulous jaw: experience Mascarenhas P, Lang NP. Critical review of 27. Crespi R, Capparè P, Gherlone E, Romanos G. from a 10 year period; Scand J of Plastic and immediate implant loading. Clin Oral Implants Immediate Occlusal Loading of Implants Placed Reconstructive Surgery. 1977; 16: 1-13. Res. 2003; 14:515- 527. in Fresh Sockets After Tooth Extraction, Int J Oral 2. Adell R, Lekholm U, Rockler B, Branemark P-I. Maxillofac Implants. 2007;22:955–962. A 15-year study of osseointegrated implants in 16. Lorenzoni M, Pertl C, Zhang K, Wimmer G, the treatment of the edentulous jaw. Int J Oral Wegscheider WA. Immediate loading of single- 28. Oh TJ, Shotwell J, Billy E, Byun HY, Wang HL. Surgery. 1981; 10: 387–416. tooth implants in the anterior maxilla. Preliminary Flapless implant surgery in the esthetic region: 3. Denissen HW, Kalk W, Veldhuis HA, van Waas results after one year. Clin Oral Implants Res. Advantages and precautions. Int J Periodontics MA. Anatomic consideration for preventive 2003; 14:180–187. Restorative Dent. 2007; 27(1): 27 -33. implantation. Int J Oral Maxillofacial Implants. 82:191–196, 1993. 17. Testori T, Del Fabbro M, Galli F, Francetti L, 29. Campelo LD, Camara JR. Flapless implant 4. Araujo M, Lindhe J. Ridge alterations following Weinstein R. Immediate occlusal loading the surgery: a 10-year clinical retrospective analysis. tooth extraction with and without flap elevation: same day after implant placement: Comparison Int J Oral Maxillofac Implants. 2002; 17(2): an experimental study in the dog. Clin. Oral Impl. of 2 different time frames in totally edentulous 271-6. Res. 2009; 20: 545–549. lower jaws. J Oral Implantol. 2004; 30:307- 313. 5. Schropp L, Wenzel A., Kostopoulos L, Karring T. 30. Hahn J. Single-stage, immediate loading, and Bone healing and soft tissue contours following 18. Tsirlis AT. Clinical evaluation of immediate loaded flapless surgery. J Oral J Oral Implantol. 2000; single tooth extraction: A clinical and radiographic upper anterior single implants. Implant Dent. 26(3): 193-198. twelve month prospective study; Int J Periodontic 2005; 14:94–103. Restorative Dent. 2003; 23(4):313-323. 31. Flanagan D; Flapless dental implant placement; 6. Schulte W, Kleineikenscheidt H, Linder K, 19. Wang HL, Ormianer Z, Palti A, Perel ML, Trisi J Oral Implantology. 2007; 33:75-84. Schareyka R. The Tübingen immediate implant in P, Sammartino G. Consensus conference clinical studies; Dutch Zahnarztl Zeitschr.1978; on immediate loading: The single tooth and 32. Chen ST, Darby BI, Reynolds EC, Clement J; 33:348–359. partial edentulous areas. Implant Dent. 2006; Immediate postextraction implant placement 7. Rosenquist B, Grenthe B. Immediate placement of 15:324–333. without flap elevation; J Periodont 2009; 163- implants into extraction sockets: implant survival. 172 Int J Oral Maxillofac Implants. 1996; 11:205–209. 20. Esposito M, Grusovin, M, Willings M, Coulthard 8. Sclar A; The importance of site preservation. P, Worthington H. The effectiveness of 33. Van de Velde T, Glor F, De Bruyn H. A model In: Sclar A, ed. Soft tissue and esthetic immediate, early, and conventional loading of study on flapless implant placement by clinicians considerations in implant therapy. Chicago, III: dental implants: A cochrane systematic review with a different experience level in implant Quintescence publishing Co. 2003; 76-79 of randomized controlled clinical trials. Int J Oral surgery. Clin. Oral Impl. Res. 2008; 66–72. 9. Oh TJ, Shotwell JL, Billy EJ, Wang HL. Effect of Maxillofac Implants. 2007; 22:893–904. flapless implant surgery on soft tissue profile: a 34. Albrektsson T, Zarb G, Worthington P, Eriksson randomized controlled clinical trial. J Periodontol. 21. Cavicchia F, Bravi F. Case reports offer a AR. The long-term efficacy of currently used 2006; 77:874–882. challenge to treatment strategies for immediate dental implants: a review and proposed criteria 10. Lee DH, Choi BH, Jeong SM, Xuan F, Kim HR. implants. Int J Periodontics & Restorative Dent. for success. Int J Oral Maxillofac Implants.1986; 1999; 19:66-81. 1:11–25. Effects of Flapless Implant Surgery on Soft Tissue Profiles: A Prospective Clinical Study. 22. Glauser R, Ree A, Lundgren A, Gottlow J, 35. Linkow LI, Miller RJ. Immediate loading of Clinical Implant Dentistry and Related Research. Hammerle C, Scharer P. Immediate occlusal endosseous implants is not new. 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Clin Implant Dent Relat Res. 13. Zahran A. Clinical evaluation of OsteoCare™ 5(2): 89-93. (Published on line) 2009. Midi one-piece implants for immediate loading. Implant Dentistry Today. 2008; 2(3): 26-33. 24. De Bruyn H, Collaert B. Early loading of 38. Botticelli D, Berglundh T, Buser D, Lindhe J. machined-surface Branemark implants in The jumping distance revisited. An experimental completely edentulous mandibles: healed bone studyin the dog. Clinical Oral Implants Research. versus fresh extraction sites. Clin Implant Dent 2003; 14: 35-42. Relat Res. 2002; 4(3): 136-142. 39. Botticelli D, Berglundh T, Lindhe J: Hard- 25. Attard NJ, Zarb GA. Immediate and early implant tissue alterations following immediate implant loading protocols: A literature review of clinical placement in extraction sites. J Clin Periodontol studies. J Prosthet Dent. 2005; 94:242–248. 2004; 31:820-828. 40. Becker W. Immediate implant placement: treatment planning and surgical steps for successful outcomes. 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Kurtzman et al Use of Plateform Implants as an Alternative to Complex Grafting in the Posterior Arch Gregori M. Kurtzman, DDS, MAGD, DICOI1 Edgar Montalvo Avila, DDS, MD, MSD2 Abstract Plateform implants, also referred to as ment. Additionally, they also have increase treat- blade implants, have been in use for 40 ment costs and may place implant treatment out years but have been used less in recent of the realm of possibility for some patients. The years in favor of grafting procedures. Graft- aim of this article is to demonstrate that plateform ing procedures are used to increase the osse- implants are still a viable option for patients with ous base for placement of root form implants severely atrophied ridges who cannot have or do and lengthen the time required to complete treat- not want to have osseous grafting procedures. KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft 1. Private practice, Silver Springs, Maryland, USA 2. Private practice, Alicante, Spain The Journal of Implant & Advanced Clinical Dentistry • 67

Kurtzman et al Figure 1: Atrophy of the ridges is noted in both the maxilla Figure 2: Wax setup shown on the articulator. and mandible. INTRODUCTION was addressed by introduction of two stage plateform implants that could be placed and Plateform implants, also referred to as blade allowed to fully osseointegrate before being implants, have been in use for 40 years. loaded. Linkow was granted a patent for the These implants have been used less fre- submerged plateform implant in May 1972. quently in recent years with the development of more predictable bone grafting procedures. Over the past 40 years since that time, the These complex bone grafting procedures to literature has documented the use and suc- increase the osseous base and allow place- cess of this implant modality.2 Proussaefs and ment of root form implants lengthens the time Lozada reported in 2002 on two immediately required to complete treatment and puts loaded plateform implants retrieved from the patients through additional surgery. Addition- posterior maxilla of two different patients after ally, they also have higher associated treat- 13 and 21 years of function. 3 Additionally, ment fee’s and may place implant treatment Linkow and Cappuccilli, in separate published out of the realm of possibility for some patients. papers, documented patients successfully treated with plateform implants with some hav- The first plateform implants were intro- ing treatment histories of up to 28 years.4-6 His- duced in 1967 by Dr. Leonard Linkow and he tological data has shown that osseointegration was granted a patent in September 1969.1 can be maintained at the interface between Early plateform implants were single stage the immediate loaded plateform implant and immediate load fixtures. These often resulted surrounding bone over a long period of up to in a fiberous integration and were a point of 20 years.7 This suggests that plateform den- concern as root form implants became more tal implants have the potential to achieve and common method of implant treatment. This 68 • Vol. 2, No. 8 • October 2010

Kurtzman et al Figure 3: Paralleling pins shown upon the anterior Figure 4: A crestal cut is made at the ridge crest with a Star*Lock root form implants. 700xl carbide ssure bur. maintain osseointegration over the long term. rior to the retromolar pad and continuing along This article will discuss use of plateform the crestal midline to the opposite retromolar pad. No vertical releasing incisions were uti- implants in the posterior when there is suf- lized. A periosteal elevator was next utilized to ficient osseous height, but there is a lack of reflect a full thickness flap to expose the crestal width for placement of root form implants. bone. Using a surgical stent based upon the wax try-in of the denture, pilot holes were made CASE REPORT into the mandibular symphysis. Subsequent preparation of the osteotomies was accom- A 68 year old female presented with a severely plished using sequential drills in a latch end atrophied maxilla and mandible. Both arches surgical unit. Final osteotomy size was 3.3 x presented with loss of ridge width in the pos- 14mm. A Star*Lock threaded root form implant terior but adequate height (figure 1). Treatment (Park Dental Research, NY) matching the oste- options were discussed with the patient and otomy size was inserted to depth. Paralleling the treatment plan developed would treat both pins were utilized to assist in aligning the root arches with implant supported bar overdentures. form implants (figure 3). A 700xl carbide bur in a highspeed handpeice using profuse irrigation Upper and lower dentures were setup in wax was used to create a cut at the crests midline in and verified intraorally for proper vertical dimen- the posterior where the plateform implant was sion of occlusion, lip support and phonetics to be placed. Depth was then prepared using (figure 2). At the initial surgical appointment, the same bur checking with a depth gauge local anesthetic (4% Articaine with 1:100,000 as the osteotomy was completed (figure 4). epinephrine) was administered as blocks and infiltration in both arches. An incision was made with a #15 scalpel blade starting ante- The Journal of Implant & Advanced Clinical Dentistry • 69

Kurtzman et al Figure 5: Double headed Startanius plateform implant Figure 6: Placement instrument being used to tap the being placed into the cut made through the crest in the plateform implant to the desired depth. posterior mandible. Figure 7: Antirotaitonal connector shown on the Star*Lock Figure 8: Startanius plateform implants shown bilaterally implant at the midline and healing screws placed on the in the posterior mandible with four Star*Lock root form implants in the mandibular right. implants in the symphasis prior to ap closure. A Startanius two stage plateform dou- ders be placed slightly below the crestal ridge ble headed implant (Park Dental Research, so that bone will encompass the entire implant NY) that was selected based on the available except for the necks of the heads which will bone height in the posterior was inserted into be slightly supracrestal (figure 7). The Star- the osteotomy (figure 5) and an instrument tanius blade is provided with 0 curvature was utilized to tap the implant to depth (fig- to the plateform portion, but may be modi- ure 6). It is important that the implants shoul- fied by gentle bending using titanium pliers 70 • Vol. 2, No. 8 • October 2010

Kurtzman et al Figure 9: Impression heads placed upon the Startanius Figure 10: Analogs placed into the master impressions of plateform and Star*Lock root form implants after the maxillary and mandibular arches. uncovering following implant healing. Figure 11: Maxillary and mandibular overdenture bars Figure 12: Finished maxillary and mandibular shown intraorally. overdentures with Dolder metal clips. to accommodate any curvature of the arch. implant bilaterally in the posterior maxilla. The Healing screws are placed upon each of patients dentures were relieved over each implant so that pressure was not placed on the implants and the soft tissue was closed the cover screws during the healing phase with a sutures. (figure 7 and 8) The steps and a soft liner was placed in the dentures. outlined were repeated in the maxilla with four Star*Lock root forms being placed in Following a healing period of six months, the premaxilla and a Startanius plateform all implants were uncovered using a scal- The Journal of Implant & Advanced Clinical Dentistry • 71

Kurtzman et al Figure 13: Panoramic radiograph showing the completed Figure 14: Completed maxillary and mandibular dentures. bar overdentures upon the integrated implants in the maxilla and mandible. teeth were placed into the stent and placed on each model to permit the bar to be fabri- pel to expose the healing screws. Healing cated to fall within the confines of the estab- screws were removed and closed tray impres- lished dentures. It was decided that the bars sion abutments were placed on each implant would be cemented to four of the implants in (figure 9) and a full arch impression was taken each arch and screw retained to the remain- using an addition reaction silicone, Provil- ing four implants (the bar would be both screw novo (Heraeus Kulzer, Armonk, NY). After and cement retained). UCLA type heads setting of the impression material, the impres- were placed onto each implant analog on sion abutments were removed and the healing the model and plastic bar stock was attached screws were reinserted. Analogs were placed between the heads using Duralay resin (Den- onto each of the impression abutments (figure tal Manufacturing Comp, Worth, IL). The bars 10) and each was inserted into the impres- were then cast in chrome cobalt and finished. sion. A master model was then fabricated. The models with bars upon them were dupli- The lab retrofitted the wax up of the den- cated and a cast partial denture framework ture to each of the master models mounted was fabricated and cast from chrome cobalt to on the articulator. The bars were returned strengthen the overdenture and prevent fracture for intraoral try-in to verify passive fit (fig- during usage. Metal Dolder clips (Attachments ure 11). The retrofitted wax-up of the den- International, San Mateo, CA) where placed on tures was tried in over the bars and occlusion the finished bar on the original models, with clips was verified. The case was then returned to in the anterior and bilateral posterior. The bars the lab for processing of the over-dentures. were blocked out between the inferior aspect of A silicone stent was made of each arch on the master model. Wax was removed and the 72 • Vol. 2, No. 8 • October 2010

Kurtzman et al the bar and the model to prevent acrylic entrap- Correspondence: ment during processing. The cast reinforcement Gregori M. Kurtzman, DDS framework was seated over the overdenture bar 3801 International Drive, Suite 102 and waxed to the cast. The stent was used to wax Silver Spring, MD 20906 the denture teeth to the framework and occlusion 301-598-3500 was verified on the articulator. The models were 301-598-9046 (Fax) flasked and packed with a heat curable denture [email protected] acrylic and processed and finished (figure 12). Disclosure The overdenture bars and finished dentures The author reports no conflict of interest with any reported in this article. were returned for insertion. The cementable abutment heads were inserted in the implants. Acknowledgment Ketac-Cem glass ionomer luting cement (3M/ Surgical and prosthetic treatment for the case illustrated were performed by Dr. ESPE, St. Paul, MN) was mixed and placed Edgar Montalvo Avila. into the bar at those locations. The bars were seated, fixation screws were inserted at the other References: implant locations, and the cement allowed to 1. Linkow LI. Implant Dentistry Today, A multidisciplinary approach. Piccin, Padua, set. Excess cement was removed with a scaler. A panoramic radiograph was taken to verify Italy. 1990, Vol. 1, p35-40. seating of the over-denture bars and removal 2. Shen TC. The use of different implant modalities in the atrophied ridge. J Oral of excess cement (figure 13). The finished den- tures were inserted, retention with the Dolder Implantol 1999;25(2):109-113. clips was verified, and occlusion checked and 3. Proussaefs P, Lozada J. Evaluation of two vitallium blade-form implants adjusted. The patient was returned to func- tion and lip support was achieved (figure 14). retrieved after 13 to 21 years of function: a clinical report. J Prosthet Dent 2002;87(4):412-415. CONCLUSION: 4. Linkow LI, Giauque F, Ghalili R, Ghalili M. Levels of osseointegration of blade-/ plate-form implants. J Oral Implantol 1995;21(1):23-34. Plateform implants are often overlooked as an 5. Linkow LI, Donath K, Lemons JE. Retrieval analyses of a blade implant after alternative to extensive grafting procedures when 231 months of clinical function. Implant Dent 1992;1(1):37-43. adequate osseous height is available but resorp- 6. Cappuccilli M, Conte M, Praiss ST. Placement and post-mortem retrieval tion has resulted in deficient ridge width. Two of a 28-year-old implant: a clinical and histologic report. J Am Dent Assoc stage plateform implants permit the implant to 2004;135(3):324-329. be placed and left unloaded to allow osseoin- 7. Di Stefano D, Iezzi G, Scarano A, Perrotti V, Piattelli A. Immediately loaded tegration as is achieved with root form implants. blade implant retrieved from a after a 20-year loading period: a histologic and With multiple articles showing long term func- histomorphometric case report. J Oral Implantol 2006;32(4):171-176. tion, plateform implants should be considered as a possible alternative when adequate ridge width does not exist and the patient cannot or will not tolerate ridge widening procedures. The Journal of Implant & Advanced Clinical Dentistry • 73



Preliminary List of Invited Speakers Dr Eduardo Anitua, Spain Dr Ziv Mazor, Israel Dr R. Cancedda, Italy Dr Eitan Mijiritsky, Israel Dr Joseph Choukroun, France Dr Robert Miller, USA Dr Paulo Coelho, USA Dr Stefano Pagnutti, Italy Dr Danilo Di Stefano, Italy Dr G. Papaccio, Italy Dr Matteo Danza, Italy Dr Gabriele Edoardo Pecora, Italy Dr Marco Degidi, Italy Prof Adriano Piatelli, Italy Dr Stefano Fanali, Italy Dr Roberto Pistilli, Italy Dr Pietro Felice, Italy Dr Lorenzo Ravera, Italy Dr Massimo Frosecchi, Italy Dr U. Ripamonti, South Africa Dr Scott Ganz, USA Dr Paul Rosen, USA Dr Dan Holtzclaw, USA Dr Philippe Russe, France Dr Robert Horowitz, USA Dr Gilberto Sammartino, Italy Dr Michelle Jacotti, Italy Dr Marius Steigmann, Germany Dr Adi Lorean, Israel Dr Tiziano Testori, Italy Dr Jack Krauser, USA Dr Nicholas Toscano , USA Dr Carlo Mangano, 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]