Journal of Implant and Advanced Clinical Dentistry December 2012

Volume 3, No. 7 December 2012 The Journal of Implant & Advanced Clinical DentistryAtraumatic Extractionof Multi-Rooted Teeth Site Preservation with Bioactive Calcium-Phosphosilicate Grafts

Less pain for your patients.1 Less chair side time for you.1 IntroducIng Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits: For your patients...  Patients treated with Mucograft® require 5x less Ibuprofen than those treated with a connective tissue graft1  Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2 For you...  Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1  Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery Ask about our limited time, introductory special! Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. GeistlichSöhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

tri-cam Surgically compatible with NobelBiocare™ NobelReplace® Familiar Confidence. The infinity System allows you to place our implants with the familiar confidence you get from your existing system. Sensible Compatibility. each infinity implant only Designed to work with your existing implant system, you have the flexibility to use your existing surgical drills, drivers, and prosthetics to place and restore the implant. Endless Opportunities. You will notice one difference with the infinity Implant...pricing. We are committed to delivering a compatible implant at pricing that creates significant opportunities for both you and your patients.internal hex Give us a call today to experience infinity! Surgically compatible with Zimmer® Tapered Screw-Vent® ALL NEW FROMacesurgical.com 1.800.441.3100ExpandablE bOnE GraFtinG COmpOSitENuOssXC™ the latest development in natural bone substitutes: Expanded NuOssXC™ Sinus• Supports bone growth in periodontal and oral maxillofacial defects.• Is a composite grafting material comprised of mineralized de-proteinated bovine granules Compressed and purified type I bovine collagen. NuOssXC™ Socket• When placed into a bleeding site, the material expands to a predetermined size and shape.• Available in sinus form and socket form, which is supplied pre-loaded in a delivery syringe. Features and Benefits:• Expanding composite material allows for placement in a compressed form with self-expansion to fill the entire defect upon hydration.• Simple implantation technique.• Composite nature of the material enhances graft stability and minimizes particulate migration.• Optimizes spacing between particulate to allow for bone ingrowth .Expansion time:Immediately upon contact with blood source or by hydration with sterile saline after implantation. ACE Surgical Supply Co., Inc • 1034 Pearl Street, Brockton, MANobelBiocare™ and NobelReplace® are trademarks of Nobel Biocare Services AG. • Zimmer® and Tapered Screw-Vent® are registered trademarks of of Zimmer Dental, USA

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, DDSIntroducing the Laser-Lok® 3.0 implantLaser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal boneon the implant collar1. Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array ofprosthetic 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.com1. 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

OsteogenicsPick up Flash file from October issue page 1

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The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 7 • December 2011 Table of Contents21 H istologic and Clinical Evaluation of a Bioactive Calcium-Phosphosilicate Bone Graft Material in Post-Extraction Alveolar Sockets Aron Gonshor, Lanka Mahesh, Stephen A. Saroff, Frederic P.C. Joachim, Jacques A. Charon35 R eimplantation of Failed Implants: Three Cases of an Unusual Procedure with Five Year Follow Up Francisco Mesa, Ricardo Muñoz-Martínez, Pablo Galindo-Moreno47 A traumatic Extraction of Multi-Rooted Teeth Utilizing the Powertome® Automated Periotome: A Case Series Dan Holtzclaw, Nicholas Toscano, Jason White The Journal of Implant & Advanced Clinical Dentistry • 5

DID YOU KNOW? Roxolid implants deliver more treatment options Roxolid is optimal for treatment of narrow interdental spaces. Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA

The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 7 • December 2011 Table of Contents59 Complication of Inferior Alveolar Canal Perforation During Immediate Implant Placement into a Fresh Mandibular Molar Socket Dr. Loong T. Yong69 M anagement of Bilateral Severe Gingival Recessions in a HIV Positive Individual with Lateral Sliding Flaps Shaziya A. Haque, Shilpa Kolhatkar, Crystal McIntosh, Monish Bhola, James R. Winkler79 D ental Implants in Children and Adolescents: A Literature Review Dr. Nivedita Mankani, Dr. Ramesh Chowdhary, Dr. Brajesh A Patil, Dr. Nagaraj, Dr. Poornima Madalli The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 7 • December 2011Publisher Copyright © 2011 by SpecOps Media, LLC. All rightsSpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company SpecOps Media, LLC (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 9

Compatibility Innovation Value Shipping World Wide ❘Bio TCP - $58/1cc Beta-Tricalcium Phosphate – available in .25 to 1mm and 1mm to 2mm X Cube Surgical Motor with Handpiece - $1,990.00 Including 20:1 handpiece, foot control pedal, internal spray nozzle, tube holder, tube clamp, Y-connector and irrigation tube❘Bio SuturesAll Sutures 60cm length, 12/boxPolypropylene - $50.00 ❘Bio One Stage ❘Bio Internal Hex ❘Bio TrilobePGA Fast Resorb - $40.00PGA - $30.00 Straumann Zimmer NobelNylon - $20 Compatible Compatible CompatibleSilk - $15 Order online at www.blueskybio.comBlue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affiliated with Nobel Biocare, StraumannAG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of NobelBiocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental.*activFluor® surface has a modified topography for bone apposition on the implant surface without additional chemical activity.**U.S. and Canada. Minimum purchase requirement for some countries.

The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Robert Horowitz, DDS Giulio Rasperini, DDSFaizan Alawi, DDS Michael Huber, DDS Michele Ravenel, DMD, MSMichael Apa, DDS Richard Hughes, DDS Terry Rees, DDSAlan M. Atlas, DMD Mian Iqbal, DMD, MS Laurence Rifkin, DDSCharles Babbush, DMD, MS Tassos Irinakis, DDS, MSc Georgios E. Romanos, DDS, PhDThomas Balshi, DDS James Jacobs, DMD Paul Rosen, DMD, MSBarry Bartee, DDS, MD Ziad N. Jalbout, DDS Joel Rosenlicht, DMDLorin Berland, DDS John Johnson, DDS, MS Larry Rosenthal, DDSPeter Bertrand, DDS Sascha Jovanovic, DDS, MS Steven Roser, DMD, MDMichael Block, DMD John Kois, DMD, MSD Salvatore Ruggiero, DMD, MDChris Bonacci, DDS, MD Jack T Krauser, DMD Henry Salama, DMDHugo Bonilla, DDS, MS Gregori Kurtzman, DDS Maurice Salama, DMDGary F. Bouloux, MD, DDS Burton Langer, DMD Anthony Sclar, DMDRonald Brown, DDS, MS Aldo Leopardi, DDS, MS Frank Setzer, DDSBobby Butler, DDS Edward Lowe, DMD Maurizio Silvestri, DDS, MDDonald Callan, DDS Shannon Mackey Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Miles Madison, DDS Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Lanka Mahesh, BDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Michael Sonick, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Ahmad Soolari, DMDStepehn Chu, DMD, MSD Louis Mandel, DDS Neil L. Starr, DDSDavid Clark, DDS Michael Martin, DDS, PhD Eric Stoopler, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Scott Synnott, DMDSpyridon Condos, DDS Dale Miles, DDS, MS Haim Tal, DMD, PhDSally Cram, DDS Robert Miller, DDS Gregory Tarantola, DDSTomell DeBose, DDS John Minichetti, DMD Dennis Tarnow, DDSMassimo Del Fabbro, PhD Uwe Mohr, MDT Geza Terezhalmy, DDS, MADouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Tiziano Testori, MD, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Tischler, DDSNicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhDPaul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhDScott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhDDavid Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDSRonald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhDDavid Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSKenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDSIstvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDSMichael Herndon, DDS Michael Pikos, DDS Richard K. Yoon, DDS George Priest, DMD The Journal of Implant & Advanced Clinical Dentistry • 11

It’s Like a Magnetfor New BoneHEALOS® is an attractive choice for building new bone. © OraPharma, Inc. 2011 Rx only. Please refer to the package insert for further details. Distributed by: OraPharma, Inc. Manufactured by: DePuy Spine, Inc.HEALOS® Bone Graft Substitute for Dental Applications is intended to HEALOS® is a registered trademark of DePuy Spine, Inc.fill, augment, or reconstruct periodontal and/or bony defects in the HEA-178-10 3/11upper or lower jaw.• Excellent clinical handling properties• Provides an osteoconductive scaffold that supports cell adhesion• Biomimetic composition (70% collagen, 30% mineral) mimics immature bone to encourage new bone growth• 98% porosity allows material to soak up endogenous blood and draw in osteoprogenitor cells comprehensively within the material• Radiolucent so new bone is easily distinguished on a radiographHEALOS® is intended to fill, augment, or reconstruct periodontal and/or bonydefects of the upper or lower jaw. HEALOS® is a bone graft substitute that isresorbed and remodeled into new bone as part of the natural healing process.Order HEALOS® Bone Graft Substitute Today!Call a HEALOS® representative: 1-866-273-7846or visit us at www.healosfordental.com

Editorial Commentary*Offer Valid While Supplies LastIf you live in the United States and pay close attention to advertising, whether it is in a something as innocuous as removal of an ingrown magazine, radio, internet, billboard, etc., you toenail, and it is easy to see why patients in the United States have a much easier time gettingwill notice that you see many advertisements medical treatment than dental treatment. If dentalfor dentists. These advertisements are all over insurance paid for treatment comparably tothe place…in your mailbox, on the subway, medical insurance, the level of dental treatment inheck, they even pop-up on your Facebook™ the United States would skyrocket.page! Why is it that dentists must advertise This is why we see so much dental advertisinglike a car dealership? (Loud booming voice) in the US, especially for dental implant or surgicalSunday, Sunday, SUNDAY!!! Come down to treatment. The out of pocket expenses are simply tooJim’s Dental Wonderland and get an exam, high and dental treatment becomes discretionaryxrays, AND FREE BLEACHING FOR LIFE in many cases. We must advertise to attract theall for the ridiculously low price of $19.95!!! patients that can afford the out of pocket costs.(Loud music to close the commercial) This is also a reason why I think dentists in the USCome on, seriously? We are professionals get little respect in comparison to physicians. If wehere. Why do we feel the need to hawk our were “real doctors” like physicians, we would actservices like street peddlers? Do you see cardiac like physicians and not advertise.surgeons advertising (Loud booming voice) “This If medical insurance was as bad as dentalmonth Dr. Jones is offering coronary artery bypass insurance, we would see a lot more medicalsurgery for only $995! (small, fast speaking advertising, not to mention a lot of very sickvoice…offer valid while supplies last, anesthesia, people roaming the streets. People simply couldmonitoring, and hospital stay not included). No, not afford the out of pocket expenses for mostwe do not see anything like this. Why is this so? medical treatment in the US without huge medicalMy best guess is insurance. insurance payouts. $200,000 for an open heartIn the United States, there is a huge disparity surgical procedures with all of the trimmings? Nobetween medical and dental insurance. To be problem…your medical insurance will pay for it.frank, dental insurance in the United States is $4,000 for a tooth extraction, bone graft, dentaldownright pathetic. US dental insurance policies implant, and crown? Whoa, whoa, whoa therehave teeny tiny monetary caps. By the time most fella…we (dental insurance) are not going to paypatients get one procedure done, especially if you for all of that! We will cover $1,000. You are onare talking about an implant related procedure, your own for the rest. ●they have used up their dental benefits for theyear. Unfortunately, once patients hit their cap,they must pay for the remainder of their treatmentout of pocket. This is why many patients put offdental treatment. There are simply too muchout of pocket costs. Compare this to medical Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MSinsurance which will pay thousands of dollars for Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 13

GUIDOR® Bioresorbable Matrix BarrierBarrier function is maintained for 6 weeks after surgery and gradually degrades until the matrix is fully absorbed in 6 to 12 months. 15.00mmIndications 20.00mmThe use of GUIDOR to aid in bone regeneration and augmentation should be limited to defects and concavities within skeletalcontours and to defects/situations where moderate increase of bone volume beyond the skeletal contours is desirable. In all cases,appropriate space making support should be used.ContraindicationsGUIDOR is contraindicated in those situations where general periodontal surgery should not be performed. Currently there are noknown additional contraindications to the use of GUIDOR.For Excellent predictability and ease of use in GBR SPrecautions 5090GUIDOR is not intended for use in cases other than those described under indications and has not been clinically tested in patients P3 - 15mm x 20mm Matrix Barrierwith extra large defects, for extensive bone augmentation, or for use in the treatment of failing implants.GUIDOR has not been clinically tested in pregnant women or in immunocompromised patients (patients with diabetes, HIV,undergoing chemotherapy or irradiation).Adverse ReactionsPossible complications following any oral surgery include thermal sensitivity, ap sloughing, some loss of crestal bone height, abscessformation, infection, pain, and complications associated with the use of anesthesia; the patient may experience minor discomfort fora few days. 12 GUIDOR® has a double layered matrix with two uniquely perforated layers: The two layers are separated by inner spacers (1) to form an interspace (2) into which tissues can grow. SPECIAL PROMOTION! A $90.00Buy 3 P3s get 1 P3 FREE!* Value *This o er ends 1/31/11ORDER TODAY! 1-877-GUIDOR1 (1-877-484-3671)www.GUIDOR.com ©2010 Sunstar Americas, Inc. GDR10038 10272010 V1

All-Natural, Bioactive ProductsDesigned to Stimulate the Healing Process DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1 Biopsy of Biopsy of • The signaling proteins (growth factors,DynaMatrix autogeneous glycoproteins, glycosaminoglycans) gingival graft communicate with the body to help treated site stimulate the natural healing process2 Accell is an all-natural concentration • Accell has nearly 5 times more BMPs of Bone Morphogenetic Proteins than DBM alone and each lot is validated (BMPs) and Growth Factors with for osteoinductive properties 3,4 Demineralized Bone Matrix (DBM) that directs and charges stem cells • Accell in delivered as an easy-to-handle to acclerate the body’s natural putty in a pre-filled syringe healing response. • Accell is the only allograft product that contains this powerful combination of DBM, BMPs and Growth Factors 1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543. 2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5. 3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract). 4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract). Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Burlington, MA 01803 USA Call: +1-781-328-3490 Call: 1-866-902-9272 / Fax: 1-866-903-9272 Fax: +1-781-328-3400 [email protected] www.keystonedental.com

PIEZOTOME2 and IMPLANT CENTER2 All the benefits of the PIEZOTOME2...PLUS...- Three times more power than PIEZOTOME1! - I-Surge Implant Motor (Contra-Angles not included) (60 watts vs 18 watts of output power in the handpiece) - Compatible with all electric contra-angles (any ratio) Procedures are faster than ever, giving you a clean and effortless cut - Highest torque of any micro-motor on the market - Widest speed range on the market- NEWTRON LED and PIEZOTOME2 LED Handpieces output 100,000 LUX!- Extremely precise irrigation flow to avoid any risk of bone necrosis- Selective cut: respect of soft tissue (nerves, membranes, arteries)- Less traumatic treatment: reduces bone loss and less bleeding- 1st EVER Autoclavable LED Surgical Ultrasonic Handpieces- Giant user-friendly 5.7\" color touch-control screen- Ultra-sharp, robust and resistant tips (30+ Surgical & 80+ Conventional)Autoclavable LED's Progressive Pedal Controlled PowerACTEON Nwowrtwh.uAsm.aecTrteiecloa-n.(g81r0o20u4)pG2.ca8oi9tmh6e3.r6E7D-.rmivFaeail,x:S-iun(if8toe5@61u)4s20.2a2cMt4eo7ou2nn6gtroLuaupr.ecol,mNJ 08054

TrPIyarmTapllhlaeelnAPt!riWCahlmIlaaslerldyAecnShtgiaee?bviilintgy To Learn More About The New Parallel Walled Implant Click Here Immediate Primary Bone-To- Stability Implant Contact Confidence Clinical OptionsINTRODUCING IMPLANTS More Surface Area For New Design Features For Greater Immediate A Tighter Osteotomy Fit To Assist With AchievingBone-To-Implant Contact Primary StabilityHigher Insertional Torque For Increased Lateral Threads Confident Placement For “Bite-In-Bone” Engagement, Expanding Clinical OptionsProviding Clinicians One Solution At A Time With IMPLANTS Join Us Follow Us Watch Us To Achieve Primary Stability WithOSSEOTITE is a registered trademark and Providing Solutions – One Patient At A Time and design are trademarks of IMPLANTS, Contact Your LocalBIOMET 3i LLC. BIOMET 3i and design are trademarks and BIOMET is a registered trademark of BIOMET, Inc.©2011 BIOMET 3i LLC. All rights reserved. Sales Representative Today! In the USA: 1-888-800-8045, Outside The USA: +1-561-776-6700 Or Visit Us Online At www.biomet3i.com

Institute for Implant & Reconstructive Dentistry (IIRD™)Opens to Serve Dental Professionals Worldwide State-of-the-Art Facility and Leading-Edge Technology Enable Oral Health-Care Providers to Learn and Share Latest Advances in Implant, Regenerative, and Digital DentistryDental professionals worldwide can hone less of their experience level, dental profession- their skills, learn about the latest tech- als will be able to fine-tune their skills, build their niques, and share information – online confidence with the latest dental technologyor on location – through the new Institute for and, perhaps, be challenged by new perspec-Implant and Reconstructive Dentistry (IIRD™). The tives on patient care. All this can lead to growingstate-of-the-art facility opened on November 16, their practices and enhancing patient outcomes.”2011 at the South Florida campus of BIOMET3i, a global leader in dental implants, abutments, The IIRD™ is the culmination of the vision ofand regenerative oral health-care products. BIOMET 3i co-founder Richard J. Lazzara, DMD, MScD, who passionately believes education, Education and knowledge sharing of evi- evidence-based research, and leading-edge den-dence-based dentistry using leading-edge tech- tal techniques are essential to providing the bestnology is at the heart of IIRD.™. World-renowned dental solutions and care to patients. Dr. Laz-leaders in the fields of implant and reconstructive zara is one of many world-class dental profes-dentistry comprise the faculty and guest-speaker sionals who will serve as faculty of the Institute.panel. The facility is equipped with state-of-the- Subject matter ranging from treatment planning,art dental and educational technology to maxi- advances in digital dentistry, implant dentistrymize experiential learning through live surgeries, innovations, implant restoration, CT-guided sur-tele-surgeries, hands-on training, educational gery and advanced diagnostics and complexprograms, lectures, and information sharing. TheIIRD™ also will conduct on-line educational pro-grams, including lecture series, university partner-ship programs, and industry events and meetings. “The Institute for Implant and Reconstruc-tive Dentistry is designed to serve dental pro-fessionals as a trusted educational partner.However, we go beyond providing continuingeducation courses,” explains Anthony Single-ton, BIOMET 3i Global Director, the Institute forImplant and Reconstructive Dentistry. “Regard-18 • Vol. 3, No. 7 • December 2011

case management provide a comprehensive developing, manufacturing and distributing oraleducation continuum for varying levels of dental reconstructive products, including dental implantspecialists and clinicians, allied staff and dental components and bone and tissue regenerativelaboratory technicians. Programs are continuously materials. The company also provides educa-added and can be found by visiting www.iird.com. tional programs and seminars for dental profes- sionals around the world. BIOMET 3i is based In addition to information about course offer- in Palm Beach Gardens, Florida, with opera-ings and online registration, the IIRD™ web- tions throughout North America, Latin America,site allows visitors to take a virtual tour of Europe and Asia-Pacific. For more informationthe facility. Insightful articles and research, about BIOMET 3i, please visit www.biomet3i.videos and interviews are also included on com or contact the company at (800) 342-the website, along with links to the Jour- 5454; outside the U.S. dial (561) 776-6700.nal of Implant & Reconstructive Dentistry®(JIRD®), the official publication of the IIRD™. For media inquiries, please contact Sha- ron S. Bournes, Global Director Of Advertis- For more information about ing, PR And Communications for BIOMET 3i. ●IIRD™, please visit www.iird.com. The Institute for Implant and Recon-structive Dentistry is a training and edu-cation facility of BIOMET 3i, LLC.About BIOMET 3iBIOMET 3i, a division of Biomet, Inc., is a lead-ing manufacturer of dental implants, abutmentsand related products. Since its inception in1987, BIOMET 3i has been on the forefront in The Journal of Implant & Advanced Clinical Dentistry • 19

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Histologic and Clinical Evaluation of a Gonshor et alBioactive Calcium-Phosphosilicate Bone Graft Material in Post-Extraction Alveolar Sockets Aron Gonshor, PhD, DDS1 • Lanka Mahesh, BDS, MBA, MS2Stephen A. Saroff, DDS, MSD3 • Frederic P.C. Joachim, DDS, MSc4 Jacques A. Charon, DDS, MSc5 AbstractBackground: Long-term success of dental Results: At 5-6 months post grafting thereimplants has been demonstrated when placed was bone regeneration showing both normalsimultaneously with or after a socket grafting clinical attributes and radiographic trabecu-procedure. Although optimal bone formation can lar appearance. Histomorphometric analysisbe from 6 to 9 months or longer with grafting revealed average vital bone content of 48.2%materials other than autogenous bone, utiliza- ± 6.8 to residual graft content of 2.4% ± 1.4tion of bone allograft eliminates patient morbid- for the 22 sockets in the study, at an aver-ity through elimination of autograft harvest sites. age healing period of 5.4 months ± 1.5.Methods: This study evaluated bone forma- Conclusions: The high percentage of vitaltion following grafting of 22 post-extraction bone content, after a relatively short healingalveolar sockets with bioactive calcium phos- phase, suggests that CPS Putty can be a reli-phosilicate putty (CPS Putty) graft material. able choice for osseous regeneration in cases of crest preservation and implant related surgeries.KEY WORDS: Site preservation, bone graft, allograft, extraction, dental implants 1. Lecturer, Faculty of Dentistry, McGill University, Montreal, Quebec, Canada. 2. Private Practice, New Delhi, India. 3. Periodontal Private Practice, Richmond, Virginia, USA. 4. Periodontal Private Practice, Lille, France. 5. Periodontal Private Practice, Lille, France. The Journal of Implant & Advanced Clinical Dentistry • 21

Gonshor et al INTRODUCTION phorous. This product has evolved and is now being marketed as a pre-mixed, moldable mate-Extractions occur primarily as a result of periodon- rial called NovaBone Dental Putty® (US Bioma-tal disease, caries or trauma. Caries is endemic terials Corp., Alachua, Fla.) consisting of fourand a leading cause of tooth loss in the US pop- components: two bioactive phase componentsulation. Periodontal disease is responsible for - a 55% standard calcium phosphosilicate (CPS)30-35% of extractions in people over 40 years of particulate, and a 14% CPS smaller particulateage.1 Clinically it is important to replace missing - as well as a12% polyethylene glycol additiveteeth with the most suitable option for the patient, phase and a19% glycerin binder phase. In den-so that ridge and site preservation at the time of tistry this latter putty form of calcium phospho-extraction is critical to long term success, irrespec- silicate is designed for osseous regeneration oftive of the procedure used for tooth replacement.2 periodontal bone defects, filling of alveolar sock- ets, sinuses and augmentation of alveolar ridges. Autogenous bone has been considered the“gold standard” for filling bony defects, especially The purpose of this study was to clinically,large defects resulting from cysts and tumors, radiographically and histotologically evaluatealveolar resorption, and periodontal bony defects, CPS Putty when used as a bone graft mate-all of which leave insufficient bone for the place- rial in human alveolar post-extraction sockets.ment of implants. The cancellous portion is usuallyused and it is rich in mesenchymal cells, which are MATERIALS AND METHODSgenerally involved in osteogenesis. However, clini-cal situations, such as the size of the bony defect, Materialabsence of enough donor tissue, or the need Bioactivity is initiated immediately upon implan-for a second intervention, may preclude its use. tation. The smaller CPS particles release cal- cium and phosphorous ions into the area, the The ongoing development of biomaterials has binder material gets absorbed over a period ofimproved the characteristics and properties of a week exposing the larger CPS particulatespotential synthetic bony substitutes.3 The chal- to blood. Breaking the silicon-oxygen bondslenge has been to assess the interface between releases silicic acid, which forms a negativelythe biomaterial and the host.4 Alloplastic bioac- charged gel at the particle surface. In severaltive graft substitutes are a potential advance in hours calcium phosphate is produced in thesolving this issue. A bioactive material is defined gel, which then crystallizes into a new surfaceas one that will create a biological response that apatite layer. Bioactivity begins in this surfacewill prevent a fibrous repair at the interface, but layer when collagen, glycoproteins and muco-rather lead to a bony union of the material and polysaccharides from the surrounding bone arethe host tissue.5 Bioactive glass ceramics have incorporated into the apatite layer. This helpsdemonstrated such biocompatibility and direct to produce a direct chemical bond with thecontact with bone.6 The first bioactive material host bone. In vivo, the graft substitute bonds towas reported in 1971.7 It was a four-component connective tissues and to bone.8 The apatiteoxide mixture, consisting of 45% silica dioxide, layer helps in the stimulation of osteoprogeni-24.5% sodium, 24.5% calcium and 6% phos-22 • Vol. 3, No. 7 • December 2011

Gonshor et altor cells to produce transforming growth factor, being careful not to touch the material with surgi-by the release of silicon from the surface.3,9-12 cal gloves, or to impact the material too tightly. The volume of putty material used varied from 0.5ccMethods to 1.0cc. No membranes were placed. MucosalThere were 22 patients (14 males and 8 females), and periosteal releasing incisions were created tobetween the ages of 25 and 79 (mean of 51), allow for tension-free primary closure, using 3-0 orrequiring tooth extraction. The surgical proce- 4-0 plain gut or chromic sutures. No pre or post-dures were performed only in private offices. operative antibiotics were administered, and allPatients were screened, and all provided written patients were placed on Chlorhexidine oral rinseand oral consent. They were enrolled from Octo- post-operatively. Pre and immediate post-opera-ber 2008 to August 2010, and the study was tive radiographs were taken. Patients were thenconducted in accordance with the Helsinki Dec- followed clinically and radiographically at timelaration of 1975, as revised in 2000. The case- intervals of 1 week, 2-3 weeks, 6-8 weeks andselection criteria included the absence of acute 3-4 months. At the latter visit there was a discus-periodontal or odontogenic disease; women sion as to subsequent implant placement, whichwho were not pregnant nor intended to become took place within the 3-6 month period. A num-pregnant during the study period; no history of ber of patients decided against implant therapy.cancer or human immunodeficiency virus; nountreated periodontal disease, including peri- Core Biopsiesapical disease; and the absence of any medical In this study, on the day appointed for implantcondition or therapeutic regimen that alters soft surgery, prior to the implant placement, a tre-and/or hard tissue healing (i.e., osteoporosis, phine bur with a 2.7-mm internal diameter (3.5hyperparathyroidism, autoimmune diseases, che- mm external diameter) was used to obtain amotherapeutic or immunosuppressive agents, bone core from the center of the regeneratedsteroids, bisphosphonates, or similar type drugs). socket. The cores were left within the trephine and placed in 10% neutral buffered formalin for All cases in this study were tooth extractions fixation. Decalcified specimens were preparedwith immediate socket grafting. The teeth chosen in 14 of the 22 cases that opted for subsequentfor removal had little if any periodontal involve- implant placement. Undecalcified preparationsment. They were for the most part fractured teeth. were performed in the remainder (8 cases),Care was taken to remove the teeth atraumati- with subsequent histomorphometric analysis.cally, so as to preserve the surrounding bone. Inall cases the sockets had 4 or 5 wall defects. Any Histologic Preparationsocket with a significant bone dehiscence was Undecalcified histologies were performed byexcluded from the study. After extraction the sock- the Division of Anatomic Pathology, Universityets were debrided and any inflammatory granula- of Connecticut, Framington, Connecticut, USA.tion tissue removed, also ensuring that there was Specimens were fixed in formalin prior to decal-suitable residual bleeding. The sockets were then cification. A stronger decalcification solution wasfilled with the CPS Putty material (Figures 1a, 1b), The Journal of Implant & Advanced Clinical Dentistry • 23

Gonshor et alFigure 1a: Calcium phosphosilicate bioactive bone inmoldable putty form. Figure 1b: Calcium phosphosilicate bioactive bone in syringe injectable paste.used for dense bone cores (eg. Mandible). A high never exceeded 40ºC, then cut and ground.13,14speed bone decalcifier-Decal Stat, [hydrochloric Specimens were prepared in an apico-coronalacid], (Decal Chemical Corp.) was used for decal- direction (parallel to the long axis) and were cut tocification of samples. The slides were stained with a thickness of 150 µm on a cutting/grinding sys-modified Hemotoxylin/Eosin and histologic analy- tem (EXAKT Technologies, Oklahoma City, OK,sis was performed. All histologic preparations for USA). The cores were polished to a thicknesshistomorphometrics were performed by the Divi- of 45-65 µm with a series of polishing sandpapersion of Pathology, University of Minnesota, Minne- disks from 800 to 2,400 grit, using a microgrind-apolis, Minnesota, USA. Upon receipt, specimens ing system, followed by a final polish with 0.3 µmwere dehydrated with a graded series of alcohols alumina polishing paste. The slides were stainedfor 9 days. Following dehydration, the specimens with Stevenel’s blue and Van Gieson’s picrowere infiltrated with a light-curing embedding resin fuchsin and coverslipped for histologic analy-(Technovit 7200 VLC, Kulzer, Wehrheim, Ger- sis using brightfield and polarized microscopy.many). Following 20 days of infiltration with con-stant shaking at normal atmospheric pressure, the Histomorphometryspecimens were embedded and polymerized by Following non-decalcified histologic prepara-450 nm light; the temperature of the specimens tion, the cores were evaluated histomorpho-24 • Vol. 3, No. 7 • December 2011

Gonshor et alFigure 2A: Pre-surgical view of maxillary right first Figure 2B: Pre-surgical radiograph of maxillary rightpremolar with buccal fistula. first premolar demonstrating periapical lesion and root fracture.Figure 3: Placement of CPS Putty into #5 alveolus. Notethe loss of buccal plate. metrically. The cores were digitized at the same magnification using a microscope (Zeiss Axiolab, Carl Zeiss MicroImaging, Thornwood, NY, USA) and a digital camera (Nikon Coolpix 4500. Nikon, Melville, NY, USA). Histomorpho- metric measurements were completed using a combination of programs (Adobe Photoshop, Adobe Systems, San Jose, CA, USA; NIH Image, National Institutes of Health, Bethesda, MD, USA). Parameters evaluated were the total area of the core, percentage of new bone for- mation, and percentage of residual graft mate- rial. The remainder of the area was considered soft tissue or void. The primary slide evaluated for each specimen was from the most central region of the obtained core. No comparison was made between the apical and coronal sections. The Journal of Implant & Advanced Clinical Dentistry • 25

Gonshor et alFigure 4A: Occlusal view of regenerated alveolar crest Figure 4B: Normal trabecular appearance of thewith CPS Putty replaced by new bone, including the area of regenerated alveolus.buccal bone loss.Figure 5: Occlusal view of implant osteotomy, showing Figure 6: High magnification histological viewrobust vascularity. RESULTS 5.4) post graft period all sockets demonstrated dense bone fill, with no visual evidence of resid-The study consisted of 22 alveolar sockets ual graft material. Clinically, there was no signifi-in all. 17 sockets were in the maxilla, with 11 cant difference noted in the “tactile feel” whenin the anterior, cuspid-to-cuspid region and 6 drilling into treated sites as compared to adja-in the posterior, premolar-molar region. In the cent non-treated sites, with bleeding in the graftmandible the remaining 5 sockets were in the site osteotomies showing clear evidence of vas-molar region only. At the 5-6 month (average26 • Vol. 3, No. 7 • December 2011

Gonshor et alFigure 7: New crown on tooth #5, showing the elimination Figure 8: Radiograph of the implant #5. Note normal boneof the pre-treatment gingival recession. trabeculation pattern.Figure 9a: Undecalcified cores at 5.5 months (100x Figure 9b: Undecalcified cores at 5.5 months (200xmagnification). Red-stained tissue is mineralized, newly magnification). Red-stained tissue is mineralized, newlyregenerated bone with visible cell nuclei. Residual graft regenerated bone with visible cell nuclei. Residual graftmaterial can be seen. material can be seen.cular ingrowth. Radiographs demonstrated very fistula in the buccal mucosa of the upper rightsubstantial bone fill in the sockets. The trabecu- first premolar (Figure 2a). Radiographic evalua-lar pattern in the regenerated areas appeared tion revealed a periapical lesion, secondary to avery similar to the adjacent (native) bone. root fracture (Figure 2b). After evaluation, the decision was made to extract the tooth, with A representative case is that of a 74 year old the view to eventual implant placement. Thefemale, in stable health, who presented with a The Journal of Implant & Advanced Clinical Dentistry • 27

Gonshor et altooth was extracted atraumatically, at which DISCUSSIONtime it was determined that the quality of bonewas insufficient for immediate implant place- The results of the present study show that inment, due to a significant loss of buccal plate. post-extraction alveolar sockets, CPS PuttyThe alveolus was curetted and CPS Putty was graft material is able to achieve bone regen-placed (Figure 3). The patient was recalled 4 eration results that are favorable for the place-months post graft for evaluation, and a decision ment of subsequent osseointegrated implants.was made to place an implant at that time. After In addition, by eliminating the need for sec-raising a full thickness flap at the crest of the ond site donor harvesting and the resultingridge it was noted that the CPS Putty had been increased risk of morbidity, the use of this syn-replaced by regenerated bone that had a normal thetic graft substitute becomes very appealing.clinical and radiographic appearance (Figures4a, 4b). The quality of the regenerated bone Historically the function of biomaterialswas excellent with healthy natural bleeding and has been to replace damaged and missing tis-a completely regenerated buccal plate, which sues.7,16 Compositions such as 45S5 Bio-permitted normal implant placement (Figure 5). glass, having the highest bioactivity rate, allowA core was taken prior to implant placement. A for rapid trabecular bone regeneration with anrepresentative high magnification sample of the architecture, volume and bio-mechanical bonedecalcified Hematoxylin-Eosin sections shows quality that matches the original bone in thatsubstantial portions of vascularized dense vital region.17 The multi-stage mechanisms andbone, interspersed with a normal connective kinetics of surface reactions of CPS and bonetissue matrix (Figure 6). The final prosthetic have been extensively covered.18,19 What isresult showed a normal clinical crown form with clear is that the surface reactions take placehealthy peri-implant tissue (Figure 7), as well as within a short, 2-4 day time frame,20 with attach-a normal trabecular bone appearance (Figure 8). ment of stem cells and the subsequent pro- liferation and differentiation of osteoblasts Figures 9a and 9b shows representative rapidly occurring on the surface of the bioac-histologic images of an undecalcified core, tive material.21,22 Moreover, Xynos et al wereat increasing magnifications, taken from the able to show that modulation of the osteoblastbone graft site of a separate case. Histomor- cell cycle is achieved by the controlled releasephometric evaluation of all the undecalcified of ionic dissolution products from CPS parti-cores revealed an average vital bone con- cles.21 In particular, the ionic dissolution prod-tent of 48.2% ± 6.8 (standard deviation). As ucts of biologically active Silicon and Calciuma comparison, autogenous trabecular bone released from these bioactive glasses stimu-volumes, which can vary widely, have a range late the genes that control osteoblast differ-from under 20% to 40%.15 A residual graft entiation, as well as proliferation. Gene arraycontent of 2.4% ± 1.4 was found for the cal- analyses confirmed that after several hours ofcium-phosphosilicate bone graft, following exposure of human primary osteoblasts to thea healing time of 5.4 months ± 1.5 months. soluble chemical extracts from CPS particles, several gene families were up-regulated or28 • Vol. 3, No. 7 • December 2011

Gonshor et alactivated: Genes that encode for nuclear tran- be attributed to various factors, including thescription factors and growth factors, especially disease and patient population variations, theIGF-II.21 Among the differentially expressed types and depths of the defects, the baselinegenes were those involve with cell cycle regu- clinical conditions, or the evaluation methodslation, differentiation and proliferation, as well used.37 CPS particles have been used in a lim-cell adhesion and bone mineralization.20,23,24 ited number of sinus augmentation studies. In aThese studies all point to a capability pos- histomorphometric study comparing augmenta-sessed by CPS particles to stimulate differen- tion with 100% autogenous iliac crest bone totiation toward a cell lineage with therapeutic a composite graft, consisting of 80-90% CPSpotential in tissue engineering. In addition there particles and 10-20% autogenous iliac bone, itis evidence that these particles possess a tran- was found that the composite graft acceleratedsient antimicrobial activity,25 most probably healing time to about 6 months, compared todue to a direct and indirect pH-related effect.26 12 months for the autogenous graft alone.38 In a recent comparative histomorphometric study Human clinical studies and reports of bioac- by Galindo-Moreno et al.39 bone core biopsiestive glasses use have dealt, for the most part, with were taken 6 months after sinus grafting withrepair of periodontal and alveolar ridge defects, either a bovine hydroxylapatite (HA) or CPS par-with more limited studies in orthopedics and other ticles. No bone loss was observed radiographi-areas of the head and neck.10,11,27-31 Lovelace et cally or clinically in both groups. Histological.32 showed that freeze-dried bone allograft analysis revealed that both grafts had a highgave similar pocket depth reduction in moderate biocompatibility. In the bovine HA- containingand deep periodontal osseous defects when group, minimal xenogenic graft absorption wascompared with CPS particles. Other authors noted. In contrast, the CPS group samples pre-who have treated infra-bony defects with CPS sented a high absorption rate with some remain-particles have shown similar results, with attach- ing particles imbedded in new normal bone.ment gains of 2.7 to 3.0 mm and 2.8 mm andreductions in pocket probing depth of 3.7 to In the present study tissue regeneration4.4 mm,33,34 with preoperative probing depth at after graft placement occurred without compli-7.9 to 8.1 mm. Significant improvement in prob- cations. Most significantly, there was a very highing depths has also been reported when CPS level of bone formation within the implantedparticles were used in the treatment of class material. This was evidenced by new bone for-II furcation defects.3 These results have not mation, including mature trabecular bone withbeen uniform. Other authors have found only osteocytes in lacuna, as well as marrow for-a slight, non statistically significant, improve- mation within the new bone structure. Thement in infra-bony defects treated with CPS degree of trabecular bone formation betweenparticles in comparison with those of controls the implant particles was consistent with thetreated with open debridement only.35,36 The previously reported histologic results in animalreasons for the discrepancies between similar models after a similar time frame.30,40 In thesetrials in the literature remain speculative but may studies new bone formed around all particles, The Journal of Implant & Advanced Clinical Dentistry • 29

Gonshor et alAADDVVERETIRSETWISITHE with a progressive thickening of the bone layer as the particles decreased in size. The histo- TODAY! logic findings of this study indicate that the graft material followed the same pattern of Reach more customers bone formation as seen in other human and ani- with the dental mal studies. A high degree of neovasculariza- profession’s first tion was seen within the grafted area, which is truly interactive crucial for the support of new bone formation. There was no evidence of reduction of the over- paperless journal! all size of the graft material and newly formed bone, although longer study duration would be Using recolutionary online technology, necessary to demonstrate no long-term resorp- JIACD provides its readers with an tion. In addition there was no evidence, either clinically or histologically, of any significant experience that is simply not available inflammatory reaction surrounding the graftwith traditional hard copy paper journals. material, suggesting good tissue compatibility. CONCLUSION The high percentage of vital bone con- tent, after a relatively short healing phase, suggests that bioactive calcium phospho- silicate putty can be a reliable choice for osseous regeneration in cases of crest pres- ervation and implant related surgeries. ● Correspondence: Dr Aron Gonshor, 4980 Glencairn Avenue, Montreal, Quebec, Canada, H3W 2B2. FAX: 514 486 7010 Email: [email protected] WWW.JIACD.COM30 • Vol. 3, No. 7 • December 2011

Gonshor et alACKNOWLEDGMENTS 11. C ancian DC, Hochuli-Vieira E, Marcantonio 27. A mato MM, Blaydon SM, Scribbick Jr FW,NovaBone Products (Manufacturer of the bone RA, Garcia JIR. Utilization of autogenous bone, Belden CJ, Shore JW, Neuhaus RW, et al. Usegraft material used in this study) provided partial bioactive glasses, and calcium phosphate of bioglass for orbital volume augmentationresearch support for this project. The authors cement in surgical mandibular bone defects in enophthalmos: a rabbit model (oryctolagusgratefully acknowledge the assistance of Dr. in Cebus apella monkeys. Int J Oral Maxillofac cuniculus). Ophthal Plast Reconstr SurgMichael Rohrer, director, Hard Tissue Research Implants 2004;19:73-79. 2003;19:455-465.Laboratory and Oral Pathology Laboratories,University of Minnesota School of Dentistry, for 12. W ilson J, Pigott GH, Schoen FJ, Hench LL. 28. Conejero JA, Lee JA, Ascherman JA. Cranialthe preparation of the specimens, the histologic Toxicology and biocompatibility of bioglasses. J defect reconstruction in an experimentaldata used for histomorphometric analysis, and the Biomed Mater Res 1981;15:805-817. model using different mixtures of bioglassassistance of Dr. Easwar Natarajan at the University and autologous bone. J Craniofac Surgof Connecticut Health Center, Oral Pathology 13. D onath K, Breuner G. A method for the study of 2007;18:1290-1295.Diagnostic Service, Farmington, CT, for the undecalcified bones and teeth with attached softpreparation of the decalcified specimens. tissues. J Oral Pathol 1982;11:318-326. 29. TeÛfilo JM, Brentegani LG, Lamano-Carvalho TL. Bone healing in osteoporotic female ratsDisclosure 14. R ohrer MD, Schubert CC. The cutting- following intra-alveolar grafting of bioactiveNovaBone Products (Manufacturer of the bone graft grinding technique for histologic preparation glass. Arch Oral Biol 2004;49:755-762.material used in this study) provided partial research of undecalcified bone and bone-anchoredsupport for this project. implants:: Improvements in instrumentation 30. Leatherman BD, Dornhoffer JL. Bioactive glass and procedures. Oral Surg Oral Med Oral Path ceramic particles as an alternative for mastoidREFERENCES 1992;74:73-78. obliteration: results in an animal model. Otol1. K linge B, Hultin M, Berglundh T. Peri-implantitis. Neurotol 2002;23:657-660. 15. W atzek G, Ulm C, Haas R. Anatomic and Dental Clin North Am 2005;49:661-676. Physiologic Fundamentals of Sinus Floor 31. Wilson J, Clark AE, Hall M, Hench LL. Tissue2. L ekovic V, Kenney E, Weinlaender M, Han T, Augmentation. In: The Sinus Bone Graft. Jensen response to Bioglass endosseous ridge O, ed. Chicago: Quintessance, 1992:35-37. maintenance implants. J Oral Implantol Klokkeveld P, Nedic M. A bone regeneration 1993;19:295-302. approach to alveolar ridge maintenance following 16. 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Reimplantation of Failed Implants: Mesa et alThree Cases of an Unusual Procedure with Five Year Follow UpFrancisco Mesa, MD, PhD1 • Ricardo Muñoz-Martínez, DDS, PhD2 Pablo Galindo-Moreno, DDS, PhD3 AbstractTwo approaches to the early (preload) years to date. Neither the implants nor the screw- osseointegration failure of a dental implant retained fixed prostheses have shown any clinical have been described: placement of a or radiological sign that casts doubt on the suc-new implant after a period of wound-healing, or cess of the reimplantation. It is not our intentionthe immediate insertion of a larger implant. We to describe a new protocol for cases of implantpresent the first report of immediate reimplan- failure, but rather to report the successful out-tation at the same site using the same implants, come of an unusual approach, using two distinctperformed in three patients with three differ- implant systems, which was adopted in responseent implant brands, which have survived for five to the specific requirements of our patients.KEY WORDS: Dental implant, failure, reimplantation, replacement, osseointegration 1. Department of Periodontics, School of Dentistry, University of Granada, Spain 2. Private Practice in Periodontology and Oral Implants, Granada, Spain3. Associate Professor, Oral Surgery and Implant Dentistry Department, University of Granada, Spain The Journal of Implant & Advanced Clinical Dentistry • 35

Mesa et alFigure 1: Case 1. Diagnostic panoramic X-ray. Teeth 3 and Figure 2: Case 1. Initial implant placement.4 require replacement. INTRODUCTION implants after applying expanders due to the narrowness of the crest. OsteotomesThere are currently two approaches to implant were used to achieve a slight atraumaticreplacement. One is to wait until the implant sinus floor elevation (Figure 2), leaving thebed is fully healed, a period ranging from the heads of the implants exposed (semi-sub-8 weeks recommended for some systems to merged technique). An adequate primary sta-the 4-5 months or longer proposed by some bility was obtained (Periotest® value of -2).authors.1 The other approach is immediatereimplantation using a larger implant.2 We After 8 weeks, the manufacturer’s recom-report three cases of immediate reimplan- mended osseointegration period, the peri-tation of the same implant at the same site implant tissue had a good appearance, withwhich have now survived for 3 years. After no mobility or discomfort and with a metal-loading with a screw-retained fixed prosthe- lic sound on percussion. Periapical radio-sis, clinical and radiological follow-up exami- graphs showed no mesiodistal radiolucencynations confirmed the successful outcomes. in either implant, and transfers were attached to take impressions. When the transfers wereCase 1 removed, the implant in position 3 unscrewedA 58 year old female, non-smoker, with no in a pain-free manner (Figure 3). The patientclinical findings or history of interest, was refused our proposal to wait for 8 weeks untilreferred for replacement of teeth 3 and 4. the empty socket was healed before plac-Figure 1 shows the panoramic radiograph ing a new implant. She also refused surgerytaken at the first visit. Tooth 4 was replaced for placement of a wider implant. We there-with a 3.3 x 12mm implant and tooth 3 with fore decided upon the immediate utilization ofa 3.8 x 10mm implant, using Klockner© SK2 the same implant after confirming the absence36 • Vol. 3, No. 7 • December 2011

Mesa et al Figure 4: Case 1. Reimplantation of implant #3 (2 mm deeper).Figure 3 : Case 1. Intraoral clinical photo at the time ofinitial implant failure.of clinical or radiological signs of infection. Figure 5: Case 1. Radiological image of completed After anesthetizing the patient and scraping prosthesis.the socket with a Lucas-type surgical curette to Figure 6: Case 1. Clinical image at 36-month follow up.eliminate soft tissue, the implant was washedwith physiological saline and reimplanted,screwing it into the same surgical bed withno drilling. It was introduced a further 2 mminto the maxillary sinus (Figure 4), achieving agood primary stability (Periotest® value of -1).3Examination at 8 weeks showed clinical andradiological signs of osseointegration. Impres-sions were then taken, the corresponding metaltest and bisque try-in were performed, and thedefinitive prosthesis was placed (Figure 5).Three years later, the implant and prosthesisshow no clinical or radiological signs that castdoubt on the successful outcome (Figure 6). The Journal of Implant & Advanced Clinical Dentistry • 37

Mesa et alFigure 7: Case 2. Diagnostic panoramic X-ray. Teeth 3 and Figure 8: Case 2. Initial insertion of implant (position 19).19 require replacement.Figure 9: Case 2. Same implant re-implanted at Figure 10: Case 2. Radiological image of completedimpression-taking. prosthesis.Case 2 implant in position 19 explanted in a pain-freeA 67 year old female, non-smoker, with no clini- manner, with no suppuration or clinical signs ofcal findings or history of interest was referred for inflammation. The socket was curetted and thereplacement of teeth 3 and 19. Figure 7 depicts same implant was cleaned with physiologicalthe initial panoramic radiograph. The teeth were saline solution for 2-3 minutes and replaced inreplaced with Osteoplus Iridium® implants the same bed, obtaining good primary stability(3.8x12 mm). Implants were clinically and radio- with a Periotest® value of -1 (Figure 9). Crownslogically assessed monthly (Figure 8). At three were fitted at three months, and both implantsmonths (initiation of prosthetic phase), the have remained problem free to date (Figure 10).38 • Vol. 3, No. 7 • December 2011

Mesa et alFigure 11: Case 3. Diagnostic radiological image. Tooth 9 Figure 12: Case 3. Initial placement of implantrequires replacement. (position 9).Case 3 ted, and the same implant was cleaned withA 32 year old female, non-smoker, with no physiological saline solution and placed in theclinical history of interest was referred for same bed, obtaining a good primary stabil-replacement of tooth 9. Figure 11 shows the ity (Ostell® 57) (Figure 13). At 3 months, theinitial radiograph. Tooth 9 was replaced with implant was satisfactorily loaded (Figure 14).a 3.8x14 mm Osteoplus Iridium® implant.Figure 12 shows the implant in position 9 DISCUSSIONafter its original placement. At one month,this implant explanted in a pain-free manner. We do not know the cause of the originalSince there were no clinical signs of gingival implant failure in these cases. The recom-inflammation and there was no wider implant mended surgical procedure was meticulouslyavailable at that time, the socket was curet- followed, there were no clinical or radiologi- cal signs of infection, and the gingiva showed The Journal of Implant & Advanced Clinical Dentistry • 39

Mesa et alFigure 13: Case 3. Same implant (position 9) re- Figure 14: Case 3. Radiographic image at five year followimplanted. up.no signs of inflammation/infection after implant tion in our patients, we decided to replace theremoval. Moreover, in the first two cases, there same implant immediately, minimizing poten-was no radiographic evidence of alteration to the tial bone resorption at the site.5 The sameimplant-bone interface at transfer attachment. approach was adopted in the third patient because a wider implant was not available The first two patients were offered the two from the manufacturer in question at that time.standard treatment options but refused toaccept any waiting period or undergo any fur- Grossmann and Levin described a survivalther surgery for placement of a wider implant. rate of 71% for single implants placed in sitesMardinger et al. found that the main reasons of previously failed implants after a mean wait-given by patients for refusing reimplanta- ing period of around 5 months,1 and a three- totion were the additional costs (27%), fear of four-fold higher proportion of lost fixtures hasadditional pain (17.7%), and fear of a sec- been reported in comparison to non-affectedond failure (16.2%).4 Faced by this situa- first-time implant sites.6 According to Evian and40 • Vol. 3, No. 7 • December 2011

Mesa et alCutler,2 a wound-healing period is not manda- Although biological tests were not applied,tory after implant failure as long as three prereq- no clinical or radiological signs of infectionuisites are met: 1) a correct preparation of the were observed in these patients, allowing thebed to eliminate invasive soft tissue; 2) use of same implant to be reutilized in the same beda new implant with a larger diameter than the after appropriate treatment, as in the avulsionoriginal and; 3) adequate available bone for of natural teeth. Besides washing the implantthe procedure. Only the second criterion was with saline solution, manual curettage was per-not met in our cases, although primary stabil- formed to eliminate granulation tissue, leav-ity was obtained in the first case by insert- ing a bleeding surface at the explanted site.1ing the coronal part a further 2 mm, providingbicortical support and having a similar effect The novelty of this report is that an imme-as placing a larger implant (Figure 5). Accord- diate reimplantation was performed aftering to the literature, when substantial infection implant failure using the same implant, obtain-is associated with an explanted implant, the ing outcomes that remain stable after 5 years.clinician may have to postpone implant place- It is not our intention to describe a new pro-ment to permit resolution of the infection. This tocol for cases of implant failure but rather towas not the case with the present patients. report the successful outcome of an unusual approach, using two distinct implant systems It was reported that cleaned implants rein- (Klockner® and Osteoplus Iridium®). Weserted into dog mandible achieved integration adopted this strategy in extremis becauseand obtained the same amount of bone-to- there was no pain or clinical signs of inflam-implant contact as did a new implant.7 Another mation and because of the specific demandsanimal study found that plaque-contaminated of our patients and the prospect of a delayrough implant surfaces can re-osseointegrate in placing a new implant (freely offered byafter cleaning with different substances, includ- implant companies). Further studies are war-ing citric acid (30 s), 10% hydrogen peroxide ranted to test the possibility that implants can(1 min), or physiological saline (1 min). The be re-inserted when there are no clinical orauthors concluded that any biological debris radiological signs of infection, avoiding thethat might not have been removed by their need for a waiting period or further surgery. ●cleaning methods did not appear to significantlyalter the osseointegration pattern.8 Among Correspondence:methods for cleaning contaminated implant Dr. Francisco Mesasurfaces, Parlar et al. found that in situ spray- Facultad de Odontología. Univ. De Granadaing with saline solution for 3 minutes gave the Campus de Cartuja S/N 18071, Granada,most favorable outcomes.9 These results can- Spainnot be extrapolated to humans, but they support Tel +34 958240654our decision to washing the failed implants with Fax +34 958240908saline before their reimplantation, which may E-mail: [email protected] contributed to the successful outcomes. The Journal of Implant & Advanced Clinical Dentistry • 41

Mesa et alAADDVVERETIRSETWISITHE Disclosure This investigation was supported in part by Research Group #CTS-583 (Junta de TODAY! Andalucía, Spain). Reach more customers References with the dental 1. G rossmann Y, Levin L. Success and survival of single dental implants placed in profession’s first truly interactive sites of previously failed implants. J Periodontol 2007; 78:1670-1674. paperless journal! 2. Evian CI & Cutler SA. Direct replacement of failed CP titanium implants with larger-diameter, HA-coated Ti-6Al-4V implants: report of five cases. Int J Oral Using recolutionary online technology, Maxillofac Implants 1995; 10: 736-743. JIACD provides its readers with an 3. N oguerol B, Muñoz R, Mesa F, de Dios Luna J, O’Valle F. Early implant failure. experience that is simply not available Prognostic capacity of Periotest: retrospective study of a large sample. Clinwith traditional hard copy paper journals. Oral Implants Res 2006; 17:459-464. 4. Mardinger O, Oubaid S, Manor Y, Nissan J, Chaushu G. Factors affecting the decision to replace failed implants. A retrospective study. J Periodontol 2008; 79: 2262-2266. 5. C ovani U, Barone A, Cornelini R, Crespi R. Clinical outcome of implants placed immediately after implant removal. J Periodontol 2006; 77:722-727 6. W agenberg, B. & Froum, S.J. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004. Int J Oral Maxillofac Implants 2006; 21: 71–80. 7. Kolonidis SG, Renvert S, Hämmerle CHF, Lang NP, Harris D, Claffey N. Osseointegration on implant surfaces previously contaminated with plaque. An experimental study in the dog. Clin Oral Implants Res 2003; 14; 373–380. 8. A lhag M, Renvert S, Polyzois I, Claffey N. Reosseointegration on rough implant surfaces previously coated with bacterial biofilm: an experimental study in the dog. Clin Oral Implants Res 2008; 19; 182–187. 9.Parlar A, Bosshardt DD, Çetiner D, Schafroth D, Ünsal B, Haytaç¸ C, Lang NP. Effects of decontamination and implant surface characteristics on re- osseointegration following treatment of peri-implantitis. Clin Oral Implants Res 2009; 20, 391–399. WWW.JIACD.COM42 • Vol. 3, No. 7 • December 2011

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Atraumatic Extraction of Multi-Rooted Teeth Wilcko et alUtilizing the Powertome® Automated Periotome: A Case Series Dan Holtzclaw, DDS, MS1 • Nicholas Toscano, DDS, MS2 Jason White, DDS3 AbstractSince their introduction nearly fifty years the term “atraumatic extraction.” In this proce- ago dental implants have revolution- dure, atraumatic refers to inducing as little dam- ized dentistry, changing the way we age as possible to the surrounding bone and aapproach everything from dentures to single number of instruments have been introduced tounit crowns. One treatment that has changed achieve this goal. Use of very small 15c scal-considerably with the progression of dental pel blades, periotomes, and piezoelectric surgi-implants is the extraction of teeth. Contem- cal units have been documented for atraumaticporary dental implant treatment recommends tooth removal. Recently, an automated versionat least 1.0 to 1.5mm of bone surround all of the periotome has been introduced. Theaspects of the fixture. To achieve such a goal, aim of this paper is to demonstrate how thepreservation of existing bone is essential dur- automated periotome is used as an adjuncting tooth removal. This concept has ushered for atraumatic extraction of multi-rooted teeth.KEY WORDS: Atraumatic tooth extraction, Powertome, automated periotome, dental implants 1. Private practice limited to periodontics and dental implants. Austin, Texas, USA. 2. Private practice limited to periodontics and dental implants. New York, New York, USA. 3. Private practice. Lubbock, Texas, USA. The Journal of Implant & Advanced Clinical Dentistry • 47

Holtzclaw et alFigure 1: Use of 15c scalpel blade for extraction. Figure 2: Powertome™ automated periotome. Introduction Use of very small 15c scalpel blades (figure 1), periotomes, and piezoelectric surgical unitsSince their introduction nearly fifty years ago have been documented for atraumatic toothdental implants have revolutionized dentistry, removal.4,5 The concept of atraumatic toothchanging the way we approach everything from removal is simple: remove a tooth with as littledentures to single unit crowns. One treat- damage as possible to the surrounding alveo-ment that has changed considerably with the lar bone. Although this sounds easy, the exe-progression of dental implants is the extrac- cution of atraumatic tooth removal is anothertion of teeth. In the past, tooth removal was story, especially when comparing removaloften approached with the mindset of get- of single rooted teeth to multi-rooted teeth.ting the tooth out of the mouth as fast as pos-sible with little to no thought given to the Recently, an evolution of the periotome wascondition of the surrounding bone. In fact, introduced to speed atraumatic tooth extrac-many older texts advocated bone removal or tion. Unlike traditional periotomes whichfracture to facilitate easier tooth extraction.1 require a surgical mallet to advance the thin blade down the periodontal ligament (PDL), Contemporary dental implant treatment rec- the Powertome® (Westport Medical, Salem,ommends that at least 1.0 to 1.5mm of bone Or. USA) employs a proprietary foot-pedalsurround all aspects of the fixture.2 3 To achieve activated handpiece for this purpose (figuresuch a goal, preservation of existing bone is 2). The aim of this report is to document andessential during tooth removal. This concept demonstrate the use of the Powertome® forhas ushered the term “atraumatic extraction.” atraumatic removal of multi-rooted molar teeth.In this procedure, atraumatic refers to induc-ing as little damage as possible to the sur- Single Rooted Teethrounding bone and a number of instrumentshave been introduced to achieve this goal. Single rooted teeth include incisors, canines,48 • Vol. 3, No. 7 • December 2011