Journal of Implant and Advanced Clinical Dentistry December- January 2007

Volume 3, No. 1 December/January 2011 The Journal of Implant & Advanced Clinical DentistrySinus Perforation Treatment & Classifications Dr. Paul Fuggazzotto on the Role of Guided Tissue Regneration in Modern Practice

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The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 1 • December/January 2011 Table of Contents19 S inus Perforation: Treatment and Classifications Leon Chen, Jennifer Cha, Hsin-Chen Chen, Hong Liang Lin33 T he Role of Guided Tissue Regenerative Therapy in Today’s Clinical Practice Paul A. Fugazzotto49 O utcomes of Implant Treatment in Patients with Aggressive Periodontitis and Multiple Maxillary External Root Resorption: Review and Five Year Follow-up Francisco Mesa, Pablo Galindo-Moreno, Ricardo Muñoz, Luis A. Perez, Hom-Lay Wang The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 1 • December/January 2011 Table of Contents59 G uided Bone Regeneration Using a Rapidly Formed Absorbable Polymer Barrier: A Case Series Report Paul S. Rosen, Mark A. Reynolds75 Immediate Loading of Dental Implants with Provisional Restorations and Soft Tissue Manipulation for Achieving Optimal Esthetics: A Case Report Sudhindra Kulkarni, Srinath Thakur, Sampath Kumar83 O ral Bisphosphonate and Dental Implants: A Review and Update Manpreet S Walia, Saryu Arora, Bhawana Singal The Journal of Implant & Advanced Clinical Dentistry • 7



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The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 1 • January/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 • 11

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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 Michele Ravenel, DMD, MSFaizan Alawi, DDS Michael Huber, DDS Terry Rees, DDSMichael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MSThomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDDonald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDNicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDSDaniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMDGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDSStepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMDDavid Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhDSpyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDSSally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDSTomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MAMassimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDSDouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, 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 George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 13

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Letters to the Editors JIACD has been a great addition for and a camaraderie building experience with your dentists to learn about the latest in peers.  Additionally, you can receive feedback techniques and interdisciplinary care. from readers in over 80 countries in as quickly as The thing that has impressed me the most 3 to 6 months following submission.  TRY IT! about this journal is that the information Dr. Tom Wilcko, Erie, Pennsylvania, USA is online, easy to access, and the quality of the photos and case presentations is JIACD brings to all aspects of dentistry some amazing. things that are lacking with other journals.  Dr. Paul Rosen, Philadelphia, The articles are timely, relate to all aspects of Pennsylvania, USA dentistry, and are relevant to all readers.  As a researcher and clinician, I appreciate theI really appreciate JIACD because it’s a timeliness of getting my articles publishedfundamental tool for both practitioner and AND reading the current research performedresearcher in the field of Periodontology and by others in the field.  This is what dentistrydental implant continuing education. What I has needed for a long time to help us all moveprefer most is the reliability, the friendly use, and forward more quickly to deliver the best, latest,the extremely high quality of the images and the state-of-the-art care to our patients.interesting topics.  Clinicians and scientists can Dr. Robert Horowitz, Scarsdale, New York, USAfind clear clinical suggestions and solutions tonew and old problems for daily practice. My complements on what you haveDr. Giulio Rasperini, Italy accomplished with this online publication.  Content has been superb.  What a serviceJIACD is a very informative and educational to implantology.online journal. Each issue educates with cutting Dr. Gary Henkel, Horsham, Pennsylvania, USAedge clinical technology. The best advantagesof JIACD are unlimited openness to clinicians After reading several informative, well writtenall over the world. I highly recommend dental articles by highly respected educators andclinicians to become subscribers of JIACD. clinicians I was inspired to submit my own articleDr. Dong-Seok Sohn, Republic of Korea to JIACD. The editorial process was speedy and painless and the reviewers made some veryThe internet is now the medium of choice helpful suggestions actually improving my originalfor the timely distribution and collection of submission. I intend to continue writing for theknowledge.  The editors and reviewers of journal as I am anxious to be a part of this superbJIACD understand the concept of “timely”.   The online educational process.JIACD review process is thorough but streamlined Dr. Michael Toffler, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 15

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Chen et alSinus Perforation: Treatment and Classifications Leon Chen, DMS, MS1 • Jennifer Cha, DMS, MS2 Hsin-Chen Chen, MD3 • Hong Liang Lin, MD4 AbstractBackground: Tooth loss in the posterior area also introduce two medical terms, sinus cav-of the maxilla will result in the atrophying of ity space (SCS), and sinus membrane spacebone along the alveolar ridge over time. This (SMS). It is very important to distinguishcan make implant placement in the sinus area between these two spaces in this article asimpossible without first re-establishing suf- they both occupy the same sinus area and areficient bone height. The traditional answer distinguished by the existence of a perforation.to this problem is the lateral window sinus lift. Conclusions: This article presents a new iden-Methods: In this article, we present a sys- tification method and treatment planning guidetem of classifications and reparations of the for sinus membrane perforations. We havesinus membrane perforations while performing attempted to account for all sizes and types ofsinus augmentation from the crestal approach. sinus membrane perforations and to create aThe classification consists of 5 classes of method for treatment that is both simple to per-varying perforation severity, each with corre- form and will minimize further complications.sponding management techniques. We willKEY WORDS: Maxillary sinus, bone graft, sinus augmentation, complication, repair 1. CEO and Co-Founder of the Dental Implant Institute, Las Vegas, Nevada2. President and Co-Founder of the Dental Implant Institute, Las Vegas, Nevada 3. Private Practice limited to otolaryngology, Chang-Hwa City, Taiwan 4. Private Practice limited to otolaryngology, Yonghe City, Taiwan The Journal of Implant & Advanced Clinical Dentistry • 19

Chen et al Introduction brane perforations from a crestal approach. Whether preexisting, or created during theThe advent of crestal approached based sinuslift methods have produced methods to perform procedure itself, a sinus perforation can causea sinus lift procedure with fewer complications, short and long term complications5,8,9 andless trauma, and a shorter healing time than the should be dealt with immediately. By classify-traditional lateral window.1-10 There are currently ing the perforations we provide a simple set ofonly two  principle techniques of penetrating the rules to follow when performing these proce-crestal bone in order  to reach the sinus mem- dures. These procedures allow the clinician tobrane. The first involves cracking the bone, better quickly identify and execute the proper techniqueknown as the osteotome technique.6 The second necessary to promote the healing of the sinusincludes drilling through the bone, which is known membrane and the overall health of the patient.as hydraulic sinus condensing technique.2 Oncethrough the bone, there are many modifications Classification of sinusthat have been developed for actually dissecting membrane perforationsthe sinus membrane in order to create sinus mem-brane space (SMS). These methods use a variety The classification of membrane perforationsof tools and materials such as: bone,2 sinus eleva- will be made primarily by size and degree oftors,11 balloon,14 collagen,4 sinus condensers,2 and separation of the soft and hard tissues. Perfo-sinus curettes.5 Two important terms are intro- rations will be separated into 5 classes, eachduced in this paper. The aforementioned SMS with their own severity and course of action.refers to the space between the sinus membraneand its underlying bone. This space can only be Class 1 Perforation – Utilize Graftingcreated by elevating the Schneiderian membrane Materialaway from the underlying bone. The sinus cav- A class 1 perforation is less than 2mm in diam-ity space (SCS) is that space which can only be eter. A membrane perforation into the SCSreached by perforating the Schneiderian mem- of less than 2mm is not typically cause for con-brane. Under normal circumstances, this space cern8,9 and will not usually require any specialis fully surrounded by intact sinus membrane.  treatment. Simply continue the bone graft and implant placement exercising extreme care not Sinus membrane perforation is a poten- to enlarge the perforation. The act of elevatingtial obstacle that must be avoided or managed the sinus membrane will naturally cause the per-while performing any type of sinus augmenta- forated membrane to fold over itself, causing thetion procedure, whether through crestal or lat- membrane to close and heal. The perforationeral access. Few papers have been published should heal on its own with no repercussions.on lateral sinus membrane perforation and theircorresponding repair techniques.4,8 These tech- Class 2 Perforation – Sinus Membraneniques have been tested and clinically proven Folding Techniquesuccessful. This report, however, will show a If the membrane perforation is larger than 2mmmethod of classifying and repairing sinus mem- but less than 5mm, you may consider per-20 • Vol. 3, No. 1 • December/January 2011

Chen et alFigure 1a: Dissecting sinus membrane away from Figure 1b: Condensing bone into the SMS after the sinusunderlying bone in a Class 2 membrane perforation. membrane has folded itself close in a Class 2 membrane perforation.Figure 1c: Multiple clinical photographs depicting closure of a Class 2 membrane perforation utilizing the Sinus MembraneFolding Technique.forming the Sinus Membrane Folding Tech- ing the sinus membrane and can be seennique. This technique can be immediately more in patients with a very thin mucosa.10performed when the space is discovered andthe clinician will not need to postpone the Gently dissect approximately 5 to 10 mmbone grafting or placement of implants. This of membrane from around the edges of thetype of perforation is most commonly cre- bone. Once this has been accomplished, foldated during a traumatic extraction or while lift- the membrane in on itself while gently elevat- ing the membrane. After folding the mem- The Journal of Implant & Advanced Clinical Dentistry • 21

Chen et alFigure 2a: Primarily healed Class 3 membrane perforation Figure 2b: Split thickness incision allowing theprior to grafting. Note that a soft tissue plug closes the granulation tissue plug to remain fused to the sinusoro-antral communication. membrane.Figure 2c: Bone condensation into the SMS utilizing Figure 2d: Dental implant delivery into repaired/graftedthe granulation tissue plug to close the Class 3 sinus Class 3 sinus membrane perforation.membrane perforation.22 • Vol. 3, No. 1 • December/January 2011

Chen et al Table 1: Definition of SCS and SMS Sinus Cavity Space Can only be reached Must remain Naturally occuring (SCS) through a perforation a cavity from birth in the sinus membrane Created by dissecting Sinus Membrane Cannot exist in an Can be the sinus membrane Space (SMS) area where a filled in from the bone sinus membrane perforation exists brane and gently elevating, place your bone a minimum of 3 weeks. This will allow gingivalgrafting material inside the SMS. Using bone tissue to grow in the area of the perforationgrafting material to compact the membrane and granulation tissue to form in the osteotomy.will adequately seal the perforation, allowingyou to continue normally with the implant pro- Once this tissue has fully healed, you cancedure. Demonstration of Class 2 sinus per- then reopen the site and make a split thick-foration and repair is shown in figures 1a-1c. ness incision in order to create a flap with the gingival tissue and expose both the oste-Class 3 Perforation – Delayed Membrane otomy and the granulation tissue plug. OverSandwich Technique the course of 3 weeks the sinus membraneA class 3 perforation will consist of a complete or gingival connective tissue will have had atear (greater than 5mm) of the sinus membrane chance to repair and attach to the granula-occurring during a surgical procedure caus- tion tissue. The newly formed granulated pluging the SCS to be fully exposed. In a class will have fully compartmentalized the SCS and3 situation, you will not be able to locate the SMS. Using a condenser, elevate the sinusSMS. The patient will not be eligible for a sinus membrane/gingival connective tissue gentlylift procedure until the gingival tissue is fully using bone graft material (in effect, this “sand-formed. As the membrane is already perforated wiches” the bone between the connective tis-beyond repair, you should not sequential drill sue.) You are now able to place an implant inthe osteotomy. Instead, utilize the final drill size the SMS. Demonstration of Class 3 sinus per-to efficiently complete the osteotomy through foration and repair is shown in figures 2a-2d.to the SCS. While apparently counter-intuitive,this will create a uniform osteotomy, which will Class 4 Perforation - Split Thickness Sinusallow for predictable healing results and a safer “Membrane Sandwich” Techniquere-entry into the SMS once the osteotomy has While class 1, 2, and 3, perforations are typi-healed. Close the site and allow it to heal for cally encountered and repaired during the sur- gical procedure, class 4 and 5 perforations The Journal of Implant & Advanced Clinical Dentistry • 23

Chen et alFigure 3a: Intra-surgical photograph of Class 4 sinus Figure 3b: Intra-surgical photograph of Class 4 sinusmembrane perforation prior to treatment. membrane perforation after treatment.Figure 3c: Radiograph of Class 4 sinus membrane Figure 3d: Radiograph of Class 4 sinus membraneperforation prior to treatment. perforation after treatment.will be encountered after the perforation has require the “Membrane Sandwich Technique”.occurred and typically has attempted to heal. This technique is identical to the “DelayedThese perforations are usually created during Membrane Sandwich Technique” with one dif-extraction complications, or multiple failed sinus ference. Instead of making a final osteotomylift attempts. A class 4 perforation will show and waiting for it to heal, we are using the sitebony antra-oral communication, with only the as it has naturally healed. This is basically thesoft tissue intact. This type of perforation will delayed technique without the delay, and again24 • Vol. 3, No. 1 • December/January 2011

Chen et al Table 2: Perforation Size, Classification, and Repair Technique Class 1 Class 2 Class 3 Class 4 C lass 5 Perforation Perforation Perforation Perforation Perforation Size < 2mm 2 - 5mm Complete Bony oro-antral Complete communication. tear communication, Soft and hard soft tissue intact tissues are separated Repair Continue Sinus Delayed Split thickness Invagination membrane membrane sinus membrane technique Technique with bone sandwich folding technique sandwich grafting technique technique is only suitable in those cases where the patient there is complete antra-oral communicationhas had a perforated sinus membrane pres- ranging in size from a pinhole, to several cen-ent long enough for tissue to grow into the timeters in diameter. In every class 5 perfora-tooth socket or osteotomy. Make a split thick- tion, the gingival tissue will have grown intoness incision, and create a gingival connective the opening which will prevent the bone ortissue flap, exposing the healed tissue inside. sinus from naturally closing the wound. InUse a condenser; elevate the gingival connec- order to repair this type of a perforation wetive tissue flap. Use the connective tissue flap need to use the “Invagination Technique.”as if it were the sinus membrane itself. Gently“sandwich” bone grafting material between the Start by making an incision in the gingivaltwo gingival connective tissue flaps to create tissue about 2 mm around the opening. Gen-a new SMS. Demonstration of Class 3 sinus tly remove the gingival tissue from the bone,perforation and repair is shown in figures 3a-3d. and elevate the sinus membrane within the cavity. Due to the antra-oral communication,Class 5 Perforation - Invagination Technique the sinus membrane will now have extra tis-A class 5 perforation usually results from sue attached to it in the form of gingival tis-severe extraction complications or multiple sue that will have flapped from the bone. It isperforations resulting from repeated attempts important to be very gentle while working withto perform a sinus lift when both the bone this gingival tissue. Fold the gingival connectiveand the gingival tissue fail to heal properly. tissue together and secure with a resorbableThis perforation is classified by the fact that suture on the extra gingival tissue. By sutur- ing the gingival tissue together, the SCS and The Journal of Implant & Advanced Clinical Dentistry • 25

Chen et alFigure 4a: Class 5 sinus membrane perforation. Figure 4b: Split thickness dissection of gingival tissue surrounding Class 5 sinus membrane perforation. Note that the gingival tissue remains attached to the Schneiderian membrane at the perimeter of the perforation.Figure 4c: Initial elevation of sinus membrane/gingival Figure 4d: Once the sinus membrane/gingival tissuestissue in the Class 5 sinus membrane perforation repair. have been fully elevated away from the underlying bone, the gingival tissue ring surrounding the perimeter of the Class 5 sinus membrane perforation is sutured together to separate the SMS from the SCS.26 • Vol. 3, No. 1 • December/January 2011

Chen et alFigure 4e: Continued elevation of the repaired sinus Figure 4f: Initial bone condensation into the SMSmembrane creates a larger SMS. following repair of the Class 5 sinus membrane perforation.Figure 4g: A buccal flap is advanced to close the crestal SMS will separate into two separate spaces.access to the repaired/grafted Class 5 sinus membrane Compact the new SMS with bone graftingperforation. material and vertically translate the existing gingival tissue over the site for primary clo- sure.17 After allowing this area to heal for 3 months, the site will be ideal for implant place- ment. Demonstration of Class 5 sinus per- foration and repair is shown in figures 4a-4o. Discussion In order to successfully treat a patient, it is important to be prepared to handle any situ- ation that may arise. The sinus membrane can create many variables in the placement of implants in the maxillary posterior. While mem- brane perforations are rarer and much easier to repair from a crestal approach than a lat- eral approach,3,6 they are still a reality. Mem- brane perforations can also be created during The Journal of Implant & Advanced Clinical Dentistry • 27

Chen et alFigure 4h: Intra-surgical photograph of Class 5 sinus Figure 4i: Demonstration of split thickness incisionmembrane perforation. around perimeter of Class 5 sinus membrane perforation (corresponds to figure 4b).Figure 4j: Intra-surgical photograph of initial elevation Figure 4k: Intra-surgical photograph showing the gingivalof sinus membrane/gingival tissue in the Class 5 sinus tissue ring surrounding the perimeter of the Class 5 sinusmembrane perforation repair (corresponds to figure 4c). membrane perforation being sutured together to separate the SMS from the SCS (corresponds to figure 4d).extraction or implant placement. Therefore, themembrane could have been perforated months type will increase your overall success rateor even years before it is discovered. Know- and give you more confidence to perform anding how to handle perforations of any size and repair sinus lift procedures in patients regard- less of membrane health or bone height.28 • Vol. 3, No. 1 • December/January 2011

Chen et al Figure 4m: Intra-surgical photograph of buccal flap being advanced to close the crestal access to the repaired/grafted Class 5 sinus membrane perforation (corresponds to figure 4g).Figure 4l: Intra-surgical photograph of initial bonecondensation into the SMS following repair of the Class 5sinus membrane perforation (corresponds to figure 4f).Figure 4n: Pre-surgical CBCT of Class 5 sinus membrane Figure 4o: Post-surgical CBCT of Class 5 sinus membraneperforation prior to repair. perforation after repair. The Journal of Implant & Advanced Clinical Dentistry • 29

Chen et al One thing to note with the Invagination DisclosureTechnique is that the gingival epithelium, that The authors report no conflicts of interest with anything mentioned in this article.at one time was in the oral cavity, will foldin and become part of the membrane facing Referencesthe SCS. The gingival connective tissue will 1: F errigno N, Laureti M, Fanali S. Dental implant placement in conjunction withthen be in the SMS. This will make sure thatthe sinus cavity is completely covered with osteotom sinus floor elevation: a 12-year life-table analysis from a prospectiveepithelial tissue, while the non-epithelial con- study on 588 ITI implants. Clin Oral Implants Res 2006; 17(2):194-205.nective tissue will be facing the graft material. 2: C hen, Leon, & Cha, Jennifer. An 8-Year Retrospective Study: 1,100 Patients While more research and long term follow- Receiving 1,557 Implants using the Minimally Invasive Hydraulic Sinusup studies need to be performed, the goal Condensing Technique. Innovations in Periodontics 2005; 76(3):482-491.of these techniques is that clinicians usingthis guide will be able to repair any sinus 3: H ernández-Alfaro F, Torradeflot MM, Marti C. Prevalence and management ofmembrane perforation that they encounter. Schneidarian membrane perforations during sinus-lift procedures. Clin Oral Implants Res 2008; 19(1): 91-98. Conclusions 4: P ikos MA. Maxillary sinus membrane repair: update on technique for large andThis article presents a new identification complete perforations. Implant Dent 2008; 17(1):24-31.method and treatment planning guide for sinusmembrane perforations. We have attempted to 5: M isch CE. The maxillary sinus lift and sinus graft surgery. In: Misch CE, ed.account for all sizes and types of sinus mem- Contemporary Implant Dentistry. Chicago, IL:Mosby;1999:469-495.brane perforation, and to create a methodfor treatment that is both simple to perform 6: S ummers, RB. The osteotome technique: part 3. Less invasive methods ofand will minimize further complications. ● elevating the sinus floor. Compendium Cont Educat Dent 1994. 15(6):698- 708. Correspondence: Dr. Chen 7: C hanavaz, M. Maxillary sinus: anatomy, physiology, surgery, and bone grafting Dental Implant Institute related to implantology - eleven years of surgical experience (1979-1990). J 6170 W Desert Inn Rd. Oral Implantology 1990; 16(3):199-209. Las Vegas, Nevada, USA 89146 Phone: (702) 220-5000 8: F ugazzotto P, Vlassis J. A Simplified Classification and Repair System for Sinus Fax: (702) 247-4014 Membrane Perforations. Innovations in Periodontics 2003; 73(10): 1534- E-mail: [email protected] 1542. 9: A imetti M, Romognoli R, Ricci G, Massei G. Maxillary sinus elevation: the effect of macrolacerations and microlacerations of the sinus membrane as determined by endoscopy. Int J Periodontics and Rest Dent 2001; 21(6):581- 589. 10: N kenke E, Schlegel A, Schultze-Mosgau S, Neukam FW, Wiltfang J. The endoscopically controlled osteotome sinus floor elevation: a preliminary prospective study. Int J Oral Maxillofac Implants 2002; 17(4):557-566. 11: T atum, O.H. Jr., Maxillary and sinus implant reconstruction, Dental Clinics of North America 1986; 30:207-229. 12: W ood RM, Moore DL. Grafting of the maxillary sinus floor with intraorally harvested autogenous bone prior to implant placement. Int J Oral Maxillofac Implants 1988; 3: 209-214. 13: Z inner I, Small S. Sinus lift graft: using the maxillary sinuses to support implants. J Am Dent Assoc 1996; 127:51-57. 14: S oltan, Muna, Smiler, Dennis G. Antral Membrane Balloon Elevation. J Oral Implantology 2005; 31(2):85-90. 15: W allace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian membrane perforation rate during sinus elevation using piezosurgery: clinical results of 100 consecutive cases. Int J Periodontics Rest Dent 2007; 27(5):413-419. 16: T atum OH, Maxillary sinus grafting for endosseous implants. Presented at the annual meeting of the Alabama Implant Study Group. Birmingham Alabama, April 1977. 17: Chen L, Cha J, Chih-Hsiang H. A Three-Point-Translation Technique for Root Coverage With 4 Year Follow-up. Dentistry Today 2002; 21(10):112-115.30 • Vol. 3, No. 1 • December/January 2011

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The Role of Guided Tissue Regenerative Fugazzotto Therapy in Today’s Clinical PracticePaul A. Fugazzotto, DDS1 AbstractGuided tissue regeneration (GTR) was tory capacity of these cells renders such a introduced into clinical practice in the consideration moot. As a result of appropriate United States in the mid-1980’s, and membrane selection and placement, the pluriquickly became an important component of the potential mesenchymal cells in the perivascularclinical periodontists’ therapeutic armamentarium. tissues of the periodontal ligament migrate over the previously diseased root surface, effecting GTR is conceptually based upon the selec- regeneration of damaged periodontal attach-tive repopulation of a previously diseased root ment apparatus. Such regeneration is char-surfaces by specific cell types. GTR utilizes an acterized by the formation of new cementumocclusive membrane, which is placed to cre- and Sharpey fiber insertion into the cementum.ate space for regeneration and to prevent in-growth of cells from the overlying epithelium When utilized appropriately, GTR therapyor the connective tissue corium. While the yields highly predictable therapeutic results,cells in the marrow spaces of the supporting when treating both periodontally involved fur-osseous structures facing the defect and root cations and infrabony defects. The aim of thissurface could theoretically repopulate the dis- article is to provide a timely update on the roleeased root surface, the relatively slow migra- of GTR therapy in today’s clinical practice. KEY WORDS: Guided tissue regeneration, bone graft, periodontal disease, review1. Private practice limited to periodontics and dental implants, Milton, Massachusetts, USA The Journal of Implant & Advanced Clinical Dentistry • 33

Fugazzotto BACKGROUND of Class II and III furcation involvements, and long term stability,5 such a treatment approach isBased upon the pioneering work of Nyman, Got- dependent on strict diagnostic and case selec-tlow, Karring, and Lindhe1-4 guided tissue regen- tion criteria, is technically demanding, and entailseration (GTR) was introduced into clinical practice a significantly greater expense to the patientin the United States in the mid-1980’s, and quickly than the aforementioned regenerative efforts.became an important component of the clini-cal periodontists’ therapeutic armamentarium. GTR therapy was initially viewed as a “magic bullet” which would allow the clinician to eas- GTR is conceptually based upon the selec- ily attain reattachment and closure of periodon-tive repopulation of a previously diseased root tally involved furcations and eliminate infrabonysurfaces by specific cell types. GTR utilizes an defects, in all clinical situations. Such expecta-occlusive membrane, which is placed to create tions were unreasonable. Unfortunately, as GTRspace for regeneration and to prevent in-growth therapy “failed” repeatedly, the same cliniciansof cells from the overlying epithelium or the con- who were proponents of its indiscriminate usenective tissue corium. While the cells in the mar- condemned GTR treatment as a short term solu-row spaces of the supporting osseous structures tion at best, and often as an outright failure offacing the defect and root surface could theoreti- therapy. Such an assessment was not accurate.cally repopulate the diseased root surface, the Utilized appropriately, GTR therapy yields highlyrelatively slow migratory capacity of these cells predictable therapeutic results, when treating bothrenders such a consideration moot. As a result periodontally involved furcations and infrabonyof appropriate membrane selection and place- defects. The vast majority of failures whenment, the pluri potential mesenchymal cells in the employing GTR therapy may be directly attributedperivascular tissues of the periodontal ligament to inappropriate diagnosis, poor case selection,migrate over the previously diseased root sur- errors in technical execution, or all of the above.face, effecting regeneration of damaged periodon-tal attachment apparatus. Such regeneration is FAILURES IN DIAGNOSIScharacterized by the formation of new cementumand Sharpey fiber insertion into the cementum. Unfortunately, no standardized classification sys- tem exists for considering periodontally involved Numerous animal studies have demonstrated furcations. Any diagnostic system employedhistologic reattachment to previously diseased must be easy to utilize, reproducible, and provideroot surfaces following the use of an occlusive information which is directly applicable to treat-membrane to effect regeneration.1,2 Clinical stud- ment selection. When considering mandibularies have consistently demonstrated the attain- furcation involvements, the following furcationment of superior results following treatment of classification system has proven highly useful:Class II furcation involvements and/or infrabonydefects with GTR, as opposed to the use of Horizontal Furcation Involvementsnon-surgical or open flap debridement thera- Class I: Entrance into the furcation extends lesspies. While root resective techniques have dem- than half of the horizontal dimension of the tooth.onstrated a high level of efficacy in the treatment34 • Vol. 3, No. 1 • December/January 2011

FugazzottoClass II: Entrance into the furcation treated, maxillary molars present unique diag-extends greater than half of the horizon- nostic and therapeutic challenges when con-tal dimension of the tooth, but less than sidering guided tissue regenerative therapies.the full horizontal dimension of the tooth. A Class II buccal furcation involvement whichClass III: Entrance into the furcation does not extend either mesially or distally into theextends along the complete horizontal dimen- internal aspects of the mesial and distal furcationssion of the tooth, connecting both the buc- of the tooth being considered, may be treatedcal and the lingual furcation entrances. more predictably with regenerative therapy than a Class II buccal furcation involvement which doesVertical Furcation Involvements along extend into the mesial and/or distal furcationsA: Loss of attachment apparatus com- of the tooth internally, for reasons which will dis-less than 25% of the vertical tooth. cussed below. As such, the following degreesponent of the furcation of the of furcation involvement must also be considered when assessing a maxillary molar for GTR therapy:B: Loss of attachment appara-tus along more than 25% of the verti- i: The horizontal dimension of the internal fur-cal component but less than 50% of the cation involvement between the other twovertical component of the furcation of the tooth. roots extends less than 25% of the hori- zontal dimension of the tooth in this area.C: Loss of attachment apparatus alongmore than 50% of the vertical com- ii: Entrance into the furcation between the otherponent of the furcation of the tooth. two roots extends greater than 25% the horizon- tal dimension of the tooth, but less than the full The vertical component of furcation involve- horizontal dimension of the tooth, in this area.ment has significant ramifications in the treatmentof Class II furcations. However, this vertical com- iii: Entrance into the furcation between theponent plays no role in the treatment of Class I fur- other two roots extends along the completecations, unless the vertical furcation involvement horizontal dimension of the tooth in this area.extends to such a degree as to render attainmentof appropriate osseous morphologies impossible, Any extension of the vertical dimen-or reaches the apices of the tooth in question. In sion of the furcation involvement betweensuch situations, molar extraction must be effected. the two other roots of greater than 25% is problematic, as will be discussed.Additional Considerations for MaxillaryFurcation Involvements Cemento Enamel ProjectionsDue to the presence of three roots, and thus Cemento enamel projections or enamel pearlsadditional potential furcation involvements to be in the furcation area prevent the establishment of true attachment to the root surface, as con- The Journal of Implant & Advanced Clinical Dentistry • 35

Fugazzottonective tissue will not insert into enamel. These Root Morphologycemento enamel projections thus represent a In order to employ GTR therapy effectively, itpotential “funnel” for bacteria into the entrance is imperative that periodontal ligament pluriof the furcation, as the only barrier to such pen- potential mesenchymal cells (PMC) be avail-etration is an overlying junctional epithelial able for migration and differentiation over theadhesion. Junctional epithelial adhesion has previously diseased root surface. As such,demonstrated significantly greater vulnerability to if a tooth presents with a Class II furcationdetachment in the presence of plaque than con- involvement, fusion of the roots apical to thenective tissue attachment. Cemento enamel furcation involvement, and no bone verticallyprojections should be classified as follows: between the furcation defect and the point of root fusion, it is unreasonable to expect GTRA: Previously called a Class I cemento therapy to be successful. The paucity of avail-enamel projection (CEP), this CEP extends able PMCs for use is an absolute contraindica-less than half the distance from the “nor- tion to employing a GTR therapeutic approach.mal” CEP to the entrance to the furcation. Interproximal Bone LevelsB: This CEP, formally classified as The presence of interproximal bone at a levelClass II, extends greater than half the dis- coronal to that of the furcation entrance is oftance from the “normal” position of paramount importance when considering GTRthe CEJ to the furcation entrance, but therapy. Once again, the clinician must realis-does not reach the furcation entrance. tically assess the reservoir of available PMCs for use, and the expected behavior of theseC: This CEP, formally classified as cells. GTR therapy must occur within strictlyClass III, extends from the “normal” CEJ proscribed temporal limits. A nonresorbablearea to the entrance of the furcation. membrane must be removed approximately six weeks post-operatively due to the overlying tis- Class A cemento enamel projections are of no sue response. Resorbable membranes employedclinical significance in development of treatment during GTR therapy lose their structural integ-algorithms. Class B cemento enamel projec- rity and effectiveness approximately six weekstions are only of clinical significance if the patient after insertion. It is unreasonable to believe thatpresents with a root trunk short enough to result appropriate cell migration will occur in the allottedin the Class B cemento enamel projection being time to effect root surface repopulation if thesewithin 1mm of the furcation entrance. Such prox- cells are a significant distance from the site to beimity does not allow enough vertical dimensions treated, and if the cells must be expected to per-for development of adequate connective tissue form aerial acrobatics to access the treated area.attachment coronal to the furcation entrance.Class C CEPs must always be eliminated, as Tooth Mobilitythey represent a potential furcation involvement. An effort must be made to determine whether the36 • Vol. 3, No. 1 • December/January 2011

FugazzottoFigure 1: A patient presents with a deep infrabony defect Figure 2: Following utilization of DFDBA and a coveringbetween the maxillary cuspid and lateral incisor. Guidor membrane, significant regeneration is noted eight months post-operative. Probing depths are less than 3mm.encountered mobility is increasing or increased. If GTR therapy is to be contemplated aroundIncreasing mobility is a sign of an unstable situa- a tooth demonstrating increasing mobility, thetion and may be a result of primary or secondary etiologic agents responsible for this increasingocclusal trauma. Such mobility must be appropri- mobility must be determined, and the problemsately addressed, whether it be through occlusal appropriately managed, prior to initiation of surgi-equilibration, reconstructive therapy, splinting, cal intervention. When GTR therapy is plannedtooth extraction, or a combination of the above. for a tooth which demonstrates increased mobil-Increased mobility is not pathologic. Rather, such ity, the tooth should be splinted to adjacent teeth,mobility may be noted due to loss of periodon- through either extra coronal or intra coronal meanstal support, or other factors. If no surgical inter- depending upon the overall treatment plan, priorvention is anticipated and teeth demonstrate an to initiation of surgical treatment. There is noincreased, but not an increasing, mobility, these doubt that periodontal regenerative therapy dem-teeth need not undergo other types of therapy. onstrates a significantly higher degree of success The Journal of Implant & Advanced Clinical Dentistry • 37

Fugazzottowhen performed around stable teeth, as com- access for professional and patient plaque con-pared to their mobile counterparts. The endodon- trol efforts. Such therapies are merely a meanstic, restorative, periodontal and occlusal state of by which to slow down progression of the dis-the tooth to be treated must also be considered. ease process in periodontally involved furcations.In addition, the importance of the tooth to the over- The literature underscores the inadequacy ofall treatment plan must be assessed presurgically. therapies aimed at “maintenance” of periodontal health in periodontally involved furcations, with- As has been discussed in detail elsewhere,6 out elimination of the aforementioned furcationall surgical therapy must be grounded in com- involvement. Becker et al.7 in a longitudinal studyprehensive diagnosis and development of a of patients who refused active periodontal ther-definitive interdisciplinary treatment plan. No apy but remained under continued maintenancesurgical intervention should be undertaken care, tooth loss for non furcated teeth of 7.2% inunless these prerequisites have been met. The the maxilla and 11.7% in the maxilla. Maxillary fur-steps involved in performing such diagnosis cated teeth were lost at a rate of 11.6%. Man-and treatment planning have been well eluci- dibular furcated teeth were lost at a rate of 9.4%.dated elsewhere and will not be discussed here. Goldman et al.8 assessed tooth loss in 211 As the understanding of the prerequisites patients treated in a private periodontal prac-for performance of successful GTR therapy tice through root planing, curettage, and openhave evolved, the diagnostic criteria employed flap debridement, and maintained for fifteenhave likewise advanced. These criteria are to thirty years on a consistent recall sched-grounded in the basic tenants of GTR therapy: ule. Furcation involvements were not elimi- nated. The overall rate of tooth loss was 13.4%.● T horough debridement of the previously Maxillary and mandibular teeth with furca- diseased root surface. tion involvements were lost at a rate of 30.7% and 24.2% respectively, a significantly higher● Exclusion of undesirable cell populations incidence of loss than non-furcated teeth. from the root surface to be treated through the use of an occlusive membrane. McFall9 reporting upon tooth loss in one hundred treated patients with periodontal dis-● Provision of adequate space between the ease, maintained for fifteen years or longer occlusive membrane and the root surface to following active therapy, demonstrated loss allow ingress of the desired regenerative cells. of maxillary and mandibular teeth with fur- cation involvements at rates of 22.3% and DEBRIDEMENT 14.7%, respectively. Similar findings have been consistently reported in the literature.10-12The difficulties faced when attempting to debridea periodontally involved furcation have been A study by Fleisher et al.13 underscores thewell established. Attempts at “maintenance” of difficulty in performing appropriate debride-involved furcations center around debridement of ment of a periodontally involved furcation. Fiftya closed or surgical nature, or tunneling to provide molars were treated through closed curet-38 • Vol. 3, No. 1 • December/January 2011

FugazzottoFigure 3: A patient presents with a severe infrabony defect Figure 4: Following extra coronal splinting, placement ofon the mesial aspect of the maxillary left central incisor, DFDBA, and utilization of a covering Guidor membraneand a Class II+ mobility of the tooth. sutured around the tooth being treated, marked bone regeneration is noted six months after treatment. No probing depths are present in excess of 3mm.tage or open flap debridement. The teeth oughly debrided. A challenge becomes effectingwere extracted and stained to assess the effi- such debridement in these areas. Following flapcacy of intrafurcal root debridement. 32% of reflection and defect debridement with curettesthe tooth surfaces facing the involved furca- and ultrasonic instruments, higher magnifica-tions stained positive for plaque and/or calculus. tion is highly advantageous to ensure that the root surfaces have been planed as thoroughly In order to maximize long-term prognosis, as possible. A super fine diamond bur is thenthe furcation must be eliminated, thus providing utilized on all root surfaces against which regen-the patient with a milieu amenable to appropri- erative therapy will be performed. When treat-ate plaque control efforts. Prior to contemplating ing mandibular molars, a small diamond shapedGTR therapy in a periodontally involved furca- bur is utilized on the internal aspect of the mesialtion, it is crucial that the root surfaces are thor- The Journal of Implant & Advanced Clinical Dentistry • 39

Fugazzottoroot, due to the fluted nature of this root. The II ii or a maxillary Class II iii furcation involvement.root surfaces are next treated with EDTA, to Treatment of Class III maxillary and mandibu-remove bacterial remnants and effect decalci-fication of the outer aspect of the root surface. lar furcation involvements is highly predictable. Regenerative therapy always fails in such areas. The ability or inability to debride a givenroot surface is an absolute indication or con- INFRABONY DEFECTStraindication to the performance of GTR ther-apy in the area. When faced with a maxillary Defect Morphologymolar which demonstrates a Class II buccal Infrabony defects may be classified as one wall,furcation involvement which extends internally two wall, three wall, or a combination of thebetween the other roots of the tooth in ques- above as previously described in the literature.tion to a degree of ii or iii, effective root debride- This classification system is well established andment is not predictable, and GTR is not indicated. widely utilized. The greater the number of osse- ous walls surrounding the periodontal infrabony When GTR therapy was first introduced as defect to be treated, the more predictable regen-clinical modality, it was touted as the ideal ther- erative therapy will be. This fact has been attrib-apy to be performed when the clinician encoun- uted to a number of considerations, including thetered a Class II furcation involvement or a two greater percentage of PMCs which surround theor three wall infrabony defect. Diagnostic cri- defect and are available to contribute to heal-teria were rapidly modified to state that maxil- ing; the ability to better place particulate graftlary and mandibular buccal Class II furcation materials into a contained defect and have theminvolvements could be more predictably treated remain where desired to help effect clot stabiliza-with GTR therapy than mesial or distal maxil- tion and prevent clot shrinkage; and the role thelary Class II furcation involvements. The reasons greater number of osseous walls plays in help-cited for this fact were both the greater avail- ing to prevent soft tissue collapse into the defect.ability of surrounding periodontal ligament cellswhen treating buccal furcation involvements Debridementthan their mesial and distal counterparts, and the The most daunting challenge a clinician facesability to more easily debride the region. How- when treating deep infrabony defects is thoroughever, such diagnostic criteria proved inadequate. debridement of both the root surface and the base of the defect. Such debridement is accom- All Class II maxillary buccal furcation involve- plished through the use of hand and ultrasonicments are not equal with regard to predictability instrumentation, followed by utilization of a thinfollowing GTR therapy. As already mentioned, super fine diamond to ensure debridement of theif the furcation involvement in question extends most apical extent of the previously diseased rootinternally between the other two roots of the tooth, surface, in the narrowest and otherwise inacces-appropriate debridement cannot be affected. sible aspect of the infrabony defect. Once again,Therefore, all other components being equal, a the root is treated with EDTA to remove bacterialmaxillary Class II i furcation involvement is more remnants and effect decalcification of the outeramenable to GTR therapy than a maxillary Class40 • Vol. 3, No. 1 • December/January 2011

FugazzottoFigure 5: A significant osseous defect is present between Figure 6: Following elimination of the furcation throughthe maxillary right first molar and second bicuspid. odontoplasty, placement of DFDBA, and utilization of aA Class I mesial furcation involvement is present on the covering Guidor membrane sutured around the maxillarymaxillary first molar. right first molar, bone regeneration has been effected. The area probes less than 3mm clinically.aspect of the root surface. All other consider- lium. The incision is carried to osseous crest.ations which have been previously discussed,including interproximal bone height, mobility, Releasing Incisionsetc apply when contemplating GTR therapy in Mesial and distal releasing incisions are placedthe treatment of periodontal infrabony defects. in such a manner as to ensure that the most mesial incision is placed on the distal aspect of Flap Design the interproximal papilla, and the most distal inci- sion is placed on the mesial aspect of the inter-Specific flap designs must be employed to help proximal papilla. The scalpel blade is angled soattain soft tissue coverage of both the defect and as to create a beveled incision which will blendregenerative materials which have been placed. into the body of the papilla. A common techni-Such flap closure must be tension free, so as cal error is to place the most mesial releasingto maintain soft tissue coverage over the area. incision on the mesial aspect of the papilla and/ or the most distal releasing incision on the dis-Initial Incision tal aspect of the interproximal papilla. In such aEither a subsulcular buccal incision is situation, the vertical releasing incision must beemployed which extends at least one tooth beveled into thinner buccal radicular soft tissues,mesial and distal of the tooth to be crown rather than the thicker interproximal papilla. Thelengthened. A 15 blade is angled in such net result will be more post operative scarringa manner as to remove the sulcular epithe- The Journal of Implant & Advanced Clinical Dentistry • 41

Fugazzottoand greater evidence of the incision upon healing. tissue margin, a greater extent of palatal soft tis-Vertical releasing incisions must be of adequate sue repocketing, and a compromised outcomeextension to allow repositioning of the buccal to the crown lengthening surgery. Soft tissuesmucoperiosteal flap at the desired level following do not heal at sharp angles. Failure to manageosseous resective therapy, as will be discussed. soft tissue morphologies during surgery has sig- nificant, undesirable post healing ramifications. The buccal flap is now reflected in a full thick-ness manner beyond both the mucogingival If flap mobility is not adequate to ensure pas-junction and the level the defect to be treated. sive primary closure over the membranes whichReflection of the most apical few millimeters of have been placed, the vertical release incisionsthe buccal mucoperiosteal flap is carried out in and flap reflection are extended until passivitya split thickness manner, utilizing a 15 blade. is attained. This coverage of the membrane by soft tissues significantly enhances the final treat- Even if a distal wedge procedure is to be ment outcome. Following defect debridement, ifperformed, the aforementioned releasing inci- the infrabony defect to be treated is not activelysions are placed on the mesial and distal bleeding, decortication of the defect walls shouldaspects of the buccal and palatal flaps. Such be accomplished, utilizing a Piezo surgical tipan approach allows positioning of the buccal or a #2 round carbide bur. Such decorticationflap independent of the final soft tissue posi- helps maximize the influx of blood and pluri poten-tion of the buccal distal wedge flap, as well as tial mesenchymal cells into the area, and signifi-providing greater access and visualization for cantly contributes to the final therapeutic result.management of the disto buccal and disto pala-tal line angles of the terminal tooth in the arch. Membrane Selection The palatal flap is thinned, utilizing a tissue An appropriate membrane should dem-forceps or a 1-2 pickup, to its most apical extent. onstrate the following characteristics:This “internal wedge” of tissue is scored at itsbase with a 15 blade or Goldman-Fox 7 gingivec- ● Configurations which can be well adapted totomy knife. The separated internal wedge of soft the defect to be treated.tissue is removed. If concomitant mucogingivaltherapy is required on the buccal aspects of the ● Ease of clinical manipulation.teeth being treated, the internal distal wedge tis- ● T he ability to be trimmed and reshapedsue will be employed as a connective tissue graftbeneath a buccal flap. The purpose of thinning without shredding.the palatal flap is to ensure an even thickness of ● Sufficient body and memory to maintain thepalatal tissues upon suturing. Such thinning of thepalatal flap helps ensure that a soft tissue “ledge” established morphology during placementwill not be created on the palatal aspects of the and suturing.treated teeth. If a soft tissue “ledge” did result ● The ability to be easily sutured around thefollowing therapy, subsequent healing would lead tooth in question.to a more coronal final position of the palatal soft ● The presence of a thicker occlusive por- tion which will be placed against the tooth, coronal to the defect to be treated.42 • Vol. 3, No. 1 • December/January 2011

FugazzottoFigure 7: Flap reflection and defect debridement reveal a Figure 8: The defect and diseased root surface havesevere two wall osseous defect on the distal aspect of the been thoroughly debrided, DFDBA has been placed, andmandibular left first molar. a Guidor membrane has been trimmed appropriately and sutured around the first molar. The mucoperiosteal flaps● T he ability to maintain structural integrity will now be sutured in such a manner as to provide passive for six to eight weeks, thus affording pluri soft tissue coverage of the regenerative materials which potential cells the time necessary to repopu- have been placed. late the previously diseased root surface. site. The literature has conclusively demon-● A predictable time table of loss of occlu- strated the ability to effect regeneration and sive ability, and further degradation. reattachment to a previously diseased root surface through appropriate use of Guidor● A degradation process which does not membranes.14-19 In addition, the time of degra- cause inflammation at the healing site. dation and the chemical pathways found dur- A membrane composed of a blend of poly- ing degradation are well established and well suited to the clinical problems to be treated.lactic acid and citric acid ester, in a design ofmulti perforated layers (Guidor) is currently A variety of membranes have been intro-the only product available which fulfills all duced which tout simplicity due to their “easeof these requirements. The aforementioned of handling” and the fact that “no suturing ofmatrix design helps stabilize the wound site the membrane around the tooth is necessary.”and effects early integration with the gin- While such claims abound, no evidence basedgival connective tissues. The presence of data is available to substantiate them. One ofa thicker occlusal collar effectively prohib- the basic tenants of GTR therapy is utilizationits epithelial downgrowth into the healing of an occlusive membrane to ensure selected repopulation of the previously diseased site. Such cell occlusion can only be guaranteed The Journal of Implant & Advanced Clinical Dentistry • 43

Fugazzottothrough tight adaptation and suturing of the odontoplasty is highly predictable and may beocclusive membrane to the tooth surface. To carried out without a prosthetic commitment.expect a membrane which has been placedwithout suturing to remain exactly where the Unfortunately, Class II furcation involve-clinician desires throughout the course of heal- ments cannot be eliminated through odon-ing, and to thus perform the occlusal function toplasty, as such tooth recontouring wouldso vital to successful GTR results, is misguided result in a tooth morphology which was deeplyat best. The additional advantage offered by “notched” and not conducive to plaque con-the Guidor membrane is the fact that the suture, trol efforts. When treating a Class II furca-made of similar material, is an integral part of the tion involvement, ondontoplasty is performedmembrane, greatly aiding the suturing process. to the horizontal depth which would be appro- priate for elimination of a Class I horizon- Odontoplasty in tal furcation involvement. The appropriate Furcation Areas Guidor membrane is then trimmed, positioned and sutured over the area. Passive soft tis-Class I furcation involvements can always be sue coverage of the membrane is attained,eliminated through odontoplasty. However, if and the mucoperiosteal flaps are sutured.the Class I furcation involvement has a verticalcomponent which extends to such an extent Utilization of odontoplasty in conjunctionthat positive osseous architecture may not be with GTR therapy significantly enhances treat-developed, the problems in this region can- ment outcomes by lessening the horizontalnot be resolved through ondontoplasty. Such dimension of the furcation involvement, anddevelopments are rare when treating Class I thus the distance which PMCs must travel fromfurcation involvements. The roof of the furca- the interradicular bone to the outer aspect oftion is recontoured to eliminate the cul-de-sac the furcation involvement. Because GTR ther-which traps plaque, and the newly established apy has severe temporal restrictions of six totooth contours are carried onto the radicu- eight weeks, with regard to either removal oflar surfaces of the tooth to create a continu- a nonresorbable membrane or degradation onous, smooth morphology conducive to patient a resorbable membrane, reduction of the hori-plaque control efforts. Osseous resection with zontal component of the furcation by 50% orapically positioned flaps is performed at the more positively affects treatment outcomes.same time, in the conventional manner. Theresult of treatment is elimination of both deeper Particulate Graftpocket depths (defined as > 3mm) and Class I Materialsfurcation involvements. Coincident to odonto-plasty is the elimination of any cemento enamel The size and morphology of the defect which isprojections which are encountered, enhanc- being treated will help determine whether or noting the formation of an appropriate attachment particulate graft materials are placed beneathapparatus to protect the furcal entrance. Such the membrane prior to membrane suturing. Prior to the advent of predictable implant recon- structive therapy, GTR therapy was performed44 • Vol. 3, No. 1 • December/January 2011

Fugazzottoaround teeth which exhibited large one and two that deeper probing depths beyond 3-4mmwalled defects, resulting in a lower predictabil- are more difficult to maintain, and moreity of therapy than desired. In these situations, prone to subsequent periodontal breakdown.significant amounts of particulate graft materialwere placed beneath the membrane, to help Successful periodontal therapy, whetherstabilize the forming blood clot, and to add sup- it be resective or regenerative in nature,port to the membrane. Such treatment is no lon- or a combination of both, yields a postger warranted. When faced with such a severely therapeutic result of no horizontal furca-compromised tooth, extraction and concomitant tion involvement and no probing depthsregenerative therapy, in anticipation of even- in excess of 3mm, assuming patient com-tual implant placement and restoration, is indi- pliance both with the selected course ofcated. Nevertheless, particulate graft materials therapy and post operative plaque control.are still placed in situations where combinationosseous defects are encountered, which dem- Conclusionsonstrate one or two wall bony components. Thepurposes of these graft materials are to better Guided tissue regeneration therapy is highlystabilize the initial blood clot and thus enhance predictable, assuming appropriate diagno-healing, and to help ensure that adequate sis and rigorous case selection are carriedspace remains beneath the covering membrane out. While many teeth which were previouslyfor ingress of the desired regenerative cells. treated through GTR therapy in an attempt at maintenance are now extracted and replaced Definitions of Success with implant supported prosthetics, GTR therapy should still play a significant roleThe goal of GTR therapy in furcation areas as a component of the conscientious clini-is the elimination of furcation involvements. cian’s therapeutic armamentarium. FailureAs such, successful GTR therapy results in to utilize this treatment modality will resultno horizontal probing depths into the furca- in the loss of teeth which otherwise couldtion. “Resolution” of a furcation defect to be saved in a highly predictable, and lesssuch an extent that a residual horizontal prob- financially taxing, manner for the patient. ●ing of 2-3mm remains, is unsuccessful ther-apy. Such a residual furcation involvement will Correspondence:continue to break down periodontally. Should Dr. Paul A. Fugazzottothis treatment result be encountered, second 25 High Streetstage ondontoplasty must be carried out to Milton, MA 02186eliminate the residual furcation involvement. United States of America 617-696-7257 Vertical probing depths in access of 3mm [email protected] the entrance to a furcation previouslytreated with GTR therapy are also unaccept-able. The literature has established the fact The Journal of Implant & Advanced Clinical Dentistry • 45

Fugazzotto The Journal of Implant & Advanced Clinical Dentistry Disclosure The author reports no conflicts of interest with anything mentioned in this article. ATTENTIONPROSPECTIVE References 1. N yman S, Gottlow J, Karring T, et al: The regenerative potential of the AUTHORS periodontal ligament. An experimental study in the monkey. J Clin Periodontol JIACD wants 1982; 9:257-265. to publish your article! 2. G ottlow J, Nyman S, Karring T, et al: New attachment formation as the result of controlled tissue regeneration. J Clin Periodontol 1984; 11:494-503. For complete details regarding publication in 3. N yman S, Lindhe J, Karring T, et al: New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982; 9:290-296. JIACD, please refer to our author guidelines at 4. G ottlow J, Nyman S, Lindhe J, et al: New attachment formation in the human periodontium by guided tissue regeneration. Case reports. J Clin Periodontol the following link: 1986; 13:604-616. http://www.jiacd.com/ 5. F ugazzotto P.A. A comparison of the success of root resected molars and authorinfo/ molar position implants in function in a private practice: Results up to 15-plus author-guidelines.pdf years. J Periodont 2001; 72:1113-1123 or email us at: 6. F ugazzotto PA. Implant and Regenerative Therapy in Dentistry: A Guide to [email protected] Decision Making. Iowa: Wiley-Blackwell, 2009. 7. B ecker W, Becker BE, Berg L, et al: New attachment after treatment with root isolation procedures. Report for treated Class III and Class II furcations and vertical osseous defects. Int J Periodontics Restorative Dent 1998; 8:8-23. 8. G oldman MJ, Ross IF, Goteiner D: Effect of periodontal therapy on patients maintained for 15 years or longer. A retrospective study. J Periodontol 1986; 57: 347-353. 9. M cFall WT: Tooth loss in 100 treated patients with periodontal disease – a long-term study. J Periodontol 1982; 53: 539-549. 10. Wood WR, Greco GW, McFall WT Jr: Tooth loss in patients with moderate periodontitis after treatment and long-term maintenance. J Periodontol 1989; 516-520. 11. Hirschfeld L, Wasserman B: A long-term study of tooth loss in 600 treated periodontal patients. J Periodontol 1978; 49: 225-237. 12. W ang HL, Burgett FG, Shyr Y, et al: The influence of molar furcation involvement and mobility of future clinical periodontal attachment loss. J Periodontol 1994; 65: 25-29. 13. F leicher HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD. Scaling and root planning efficacy in multi-rooted teeth. J Periodontol 1989:60: 402-409. 14. F alk H, laurel L, Ravald N, Teiwik A, Persson R. Guided tissue regeneration of 203 consecutively treated intrabony defects using a bioabsorbable matrix barrier: Clinical and radiographic findings. J Periodontol 1997; 68: 571-581. 15. Hugoson A, Ravald N, Fornell J, Johard G, Teiwik A, Gottlow J. Treatment of class II furcation involvements in humans with bioresorbable and nonresorbable guided tissue regeneration barriers. A randomized multi-center study. J Periodontol 1995; 66: 624-634. 16. L undgren D, Mathisen T, Gottlow J. The development of a bioresorbable barrier for guided tissue regeneration. J Swed Dent Assoc 1994; 86: 741- 756. 17. G ottlow J, Laurell L, Teiwik A, Genon P. Guided tissue regeneration using a bioresorbable matrix barrier. Pract Periodontics Aesthetic Dent 1994; 6: 71- 80. 18. Gottlow J, Laurell L, Lundgren D, MAthisen T, Nyman S, Rylander H, Bogentoft C. Periodontal tissue response to a new bioresorbable guided tissue regeneration device: A longitudinal study in monkeys. Int J Periodontics Restorative Dent 1994; 14: 437-449. 19. Gottlow J, Guided tissue regeneration using bioresorbable and nonresorbable devices: Initial healing and long-term results. J Periodontol 1993; 64: 1157-1165.46 • Vol. 3, No. 1 • December/January 2011



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