Journal of Implant and Advanced Clinical Dentistry December- January 2007

Outcomes of Implant Treatment in Patients Mesa et alwith Aggressive Periodontitis and MultipleMaxillary External Root Resorption: Review and Five Year Follow-upFrancisco Mesa1 • Pablo Galindo-Moreno2 • Ricardo Muñoz1 Luis A. Perez3 • Hom-Lay Wang4 AbstractBackground: Generalized external root resorp- five implants (from  three different commer-tion (ERR), only the upper jaw, on permanent cial systems) placed in sites of previousteeth is a rare finding. The treatment of mul- external root resorption, showing a 100% suc-tiple ERR depends on the symptoms, extent, cessful outcome at 5 years. The role of periodon-and severity of the root resorption. Implant tal disease in multiple ERR was also reviewed.placement in patients with a history of mul-tiple ERR has not been previously docu- Conclusions: Our cases are the first in all themented, and its predictability remains unknown. literature indicating that implant therapy may be a useful approach in patients with this disease.Results: We present two cases of multi- Nevertheless, well-controlled prospective lon-ple ERR in the maxilla with aggressive peri- gitudinal studies are required to establish theodontitis that were successfully treated with effects of resorption on implant osseointegration. KEY WORDS: Dental implants, root resorption, aggressive periodontitis 1. Department of Periodontics, School of Dentistry, University of Granada, Spain 2. Department of Oral Surgery, School of Dentistry, University of Granada, Spain 3. Private Practice, Periodontics and Dental Implants, Flint, Michigan, USA4. Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA The Journal of Implant & Advanced Clinical Dentistry • 49

Mesa et alFigure 1A: Severe ERR of upper right 2nd molar and 2nd Figure 1B: Generalized moderate-to-severe bone loss andpremolar. ERR on all maxillary teeth except for the upper left 2nd molar. INTRODUCTION Bakland’s etiologic classification for root resorption4 is one of the most frequently cited.Root resorption (RR) can occur internally at the Etiologies associated with RR include infection,pulp chamber and/or root canal or externally at trauma, avulsion, luxation, orthodontic tooth move-the cervical or apical portion of the root surface.1 ment, excessive occlusal forces, and a variety ofInjury and stimulation have been related to play systemic conditions such as hyperparathyroidism,a role on its occurrence.2,3 Multiple RR on per- Paget’s disease, and Papillon Lefevre syndrome.manent teeth is a rare event.4 External RR (ERR) Periodontitis may expose root cementum to theis a remodeling process with multiple differ- periodontal pocket and inflamed PDL, which couldent etiologies. One of the most common etiolo- produce transient cementum resorption.4,10,11gies is damage to or pressure of the periodontal Crespo et al. and Rodriguez-Pato showed apicalligament (PDL), which may induce a chemotactic cementum resorption in periodontal disease thateffect on cytokines. This in turn stimulates the involved teeth with no history of orthodontic move-reaction of inflammatory-related multinucleated ment or external trauma.11,12 However, it remainscells such as osteoclasts and odontoclasts. An controversial whether inflammation per se is anincrease in the activity of these cells may lead etiologic factor for multiple ERR at the apical level.to resorption of cementum and dentin.1 Thetooth structure occasionally becomes part of The presence of multiple ERR has beenthe osseous system that is undergoing remodel- reported by several authors.13-16, 39-54 Multipleing, causing ankylosis of the root.1,5 Various fac- ERR in permanent teeth without periodontaltors can trigger this response,1,6,7,8.9 categorized involvement was first described by Balanger &as physiologic, systemic, local or idiopathic. Coke.13 Since then, only a few isolated case50 • Vol. 3, No. 1 • December/January 2011

Mesa et alFigure 1C: Panoramic radiograph at 2 year follow-up. Figure 1D: Panoramic radiograph at 5 year follow-up.reports have been published,14-20 including history of orthodontic treatment, occlusal inter-patients with multiple resorption in combina- ferences, or facial trauma. Radiographic exami-tion with periodontitis. With this background, nation revealed generalized moderate-to-severethe purpose of this study was to examine the bone loss and generalized ERR on all maxillaryetiologic factors that may contribute to ERR teeth except for the upper left 2nd molar (Figs.and determine the correct periodontal manage- 1A, 1B). Hematological and biochemical find-ment of these conditions, reporting the treatment ings were in normal ranges, and there was noof two ERR patients, including the placement medical or family history of interest. The patientof dental implants, and the outcome at 5 years. was diagnosed with generalized aggressive peri- odontitis23 in combination with multiple ERR. CASE REPORTS The upper right 2nd molar, upper right andCASE A left central incisors, and lower left central inci-A 37 year-old Caucasian male was referred for sor were extracted. The hygienic phase con-evaluation. He was a smoker of 40 cigarettes per sisted of behavioral modification (smokingday with the following: poor oral hygiene (OH), cessation counseling and OH instructions) andpresence of supra- and sub-gingival calculus, full-mouth scaling and root planing. The surgi-generalized (100%) gingival bleeding on probing cal phase involved osseous surgery on the man-(BOP),21 grade 3 mobility22 and suppuration of dibular quadrants. After a three-month interval,upper right 2nd molar, upper right and left central dental implants were placed on upper right 1stincisors, and lower left central incisor, with prob- molar, upper right central incisor, upper left cen-ing depths ranging from 4 to 7mm. He had no tral incisor, and lower left central incisor. The The Journal of Implant & Advanced Clinical Dentistry • 51

Mesa et alpatient has quit smoking and is undergoing a Figure 2A: Severe ERR with avulsion of upper right central3x/yr supportive periodontal treatment regimen. incisor. Panoramic radiography at 2 and 5 year fol- placed at the initial appointment, using the avulsedlow-up visits (Figs. 1C, 1D) revealed no pro- crown as a temporary restoration (Fig. 2B) untilgression of the resorptions but showed minimal restoration with a metal-porcelain crown at 3attachment levels for upper right 1st premo- months. The hygienic phase consisted of behav-lar, upper right lateral incisor, and upper left ioral modification (smoking cessation counselingcanine. There were no signs/symptoms of and oral hygiene instruction) and full mouth scal-active periodontal disease (pain, BOP, mobility ing and root planing. To manage his periodontaland increasing attachment loss) or progression condition, the patient quit smoking, his faulty res-of root resorptions during the 5 year follow-up torations were replaced, and he is undergoing aperiod. However, grade 1 mobility22 of the upper 3x/year supportive periodontal treatment regimen.right lateral incisor was detected at 5 years. At the 5 year follow-up, a panoramicCASE B radiograph revealed no progression of theA 36-yr-old Caucasian male presented with avul- resorptions, with implant osseointegrationsion of the upper right central incisor after minor and no residual bone loss (Fig. 2C). Prob-facial trauma (Fig. 2A). He was a smoker of 20 ing depths were reduced to ≤ 3mm, exceptcigarettes per day with the following: poor OH; for a depth of 5mm at the upper left 2nd pre-presence of generalized supra- and sub-gingival molar, and there were no signs or symp-calculus; BOP (100%) 21; grade 0 mobility22 toms of active periodontal disease (i.e., pain,and localized suppuration in lower left canine, BOP, mobility, or increased attachment loss).lower left lateral incisor, lower right canine, andlower right 1st and 2nd premolars, with prob-ing pocket depths ranging from 3 to 5mm. Hehad no history of orthodontic treatment orocclusal interferences. Several faulty restora-tions were observed. Radiographic evaluationrevealed generalized mild-to-moderate bone lossand severe ERR in all maxillary teeth except forthe upper right 2nd molar. There was no medi-cal or family history of interest. The patient wasdiagnosed with avulsion of upper right cen-tral incisor and generalized aggressive peri-odontitis23 in combination with multiple ERR. Clinical evaluation of the avulsed tooth (upperright central incisor) showed complete resorptionof the root (Fig. 2A). An immediate implant was52 • Vol. 3, No. 1 • December/January 2011

Mesa et alFigure2B: Immediate implant. The avulsed crown was used Figure2C: Panoramic radiograph at 5 year follow-up.as a temporary restoration. produced by a decrease in the pH value may DISCUSSION enhance osteoclastic activity, and hydroxyapatite becomes more soluble when pH reaches 3 andThe literature was reviewed by searching the 4.5,25 favoring resorption. Numerous systemicWeb of Knowledge, PubMed, and Scopus data- factors such as parathormone (PTH), 1, 25-dihy-bases, using “root resorption” and “multiple” droxyvitamin D3 (Vitamin D), and calcitonin, haveor “permanent teeth” as key words, with post- also been found to regulate osteoclastic activ-orthodontic root resorption as the only exclusion ity. Cytokines, such as interleukins (specificallycriterion. Although ERR associated with orth- IL-1, IL-6, and IL-11), prostaglandin E2, and tumorodontic pressure due to biological and mechani- necrosis factor (TNF)-α are local factors that havecal factors is frequently observed in isolated been shown to stimulate osteoclastic activity byteeth,24 it is uncommon in a generalized form,4 affecting the balance of RANKL (Receptor Acti-especially in non-orthodontic cases. Therefore, vator for Nuclear Factor κ B Ligand) and osteo-we had to rule out various local and systemic fac- protegerin.27 All of these factors are influencedtors before inflammation could be established by the inflammatory cells present in periodontitisas the main cause in our cases of multiple RR. (macrophages, neutrophils, and lymphocytes). Both of our patients presented with general- Odontoclasts have been related toized aggressive periodontitis,23 showing inflam- deciduous tooth and internal root resorp-mation of the periodontium. This is a common tions, while cementoclasts have been asso-cause of multiple external root resorption, which is ciated with external tooth resorption.28induced by localized inflammatory reaction. Sev-eral pathogenic mechanisms have been proposed In published reports of ERR in periodontallyfor the induction of root resorption by periodon- involved teeth with no history of orthodontic treat-tal inflammation.25-27 Thus, an acidic environment The Journal of Implant & Advanced Clinical Dentistry • 53

Mesa et alment and/or trauma, the resorption ranged from parison to the mandible, which may facilitate41% to 98% and increased proportionally with the rapid spread of the inflammatory process.the severity of periodontitis.11,12,29 The apical third Smoking can also have a local effect on thewas the predominant site for resorption, involving periodontium; it weakens the immune responsecementum and dentin. It has been hypothesized and reduces the gingival blood flow, num-that the cellular cementum on the apical third ber of circulating cells, and oxygen levels,may be more easily resorbed due to its organic thereby affecting the attachment, prolifera-components and less mineralized structure.30 tion, and chemotaxis of periodontal cells.34-36 More recently, peripheral sensory neural The treatment of multiple ERR depends onsystems have also been associated with the the symptoms, extent, and severity of the rootdevelopment of acute and chronic inflamma- resorption. Implant placement in patients withtory processes through the local release of neu- a history of multiple ERR has not been previ-ropeptides.31 In vitro and in vivo studies showed ously documented, and its predictability remainsthat the neuropeptide substance P (SP) stimu- unknown.37, 38 The present report shows that alates the production of cytokines such as IL-1β, stable outcome can be achieved at 5 yrs afterIL-6, and TNF-α in human dental pulp fibro- implantation in sites of tooth loss due to ERR.blasts.31,32 This may play an important role in rootresorption in the presence of orthodontic move- CONCLUSIONSment. In addition, the loss of PDL fibers dimin-ishes the capacity of the tooth to sustain vertical Five implants (from 3 three different commer-and lateral occlusal loads, potentially triggering cial systems) placed in sites of previous ERRPDL inflammation and tooth mobility. It is well show a 100% successful outcome at 5 yrs,documented that moderate-to-severe attach- indicating that implant therapy may be a usefulment loss may produce pathologic tooth migra- approach in patients with this disease. Never-tion,33 which may also be responsible for the root theless, well-controlled prospective longitudinalresorption noted in the setting of periodontitis. studies are required to establish the effects of resorption on implant osseointegration. ● The radiography studies in the presentpatients revealed apico-coronal resorption with Correspondence:progressive shortening of the root length, affect- Dr. Francisco Mesaing all maxillary teeth to some degree. Once Facultad de Odontología. Univ. De Granadathe periodontal disease was treated and con- Campus de Cartuja S/N 18071, Granada,trolled, RR was no longer observed, support- Spaining our diagnoses of inflammatory-related ERR. Tel +34 958240654 Fax +34 958240908 To our best knowledge, asymmetric ERR E-mail: [email protected] only maxillary teeth has not been pre-viously reported. Multiple ERR may be morecommon in the maxilla because of its greaterblood supply and lesser bone density in com-54 • Vol. 3, No. 1 • December/January 2011

Mesa et alDisclosure 19. P ankhurst CL, Eley BM, Moniz C. Multiple 36. Baig MR, Rajan M. Effects of smoking on theThe authors do not have any financial interests, idiopathic external root resorption. A case outcome of implant treatment: a literature review.either directly or indirectly, in the products listed in report. Oral Surg Oral Med Oral Pathol 1988; Indian J Dent Res 2007; 18:190-195.the study. 65:754-756. 37. Ong CT, Ivanovski S, Needleman IG, Retzepi M,References 20. Y usof WZ, Ghazali MN. Multiple external root et al. Systematic review of implant outcomes in1. N e RF, Witherspoon DE, Gutmann JL. Tooth resorption. J Am Dent Assoc 1989; 118:453- treated periodontitis subjects. J Clin Periodontol 455. 2008; 35:438-462. resorption. Quintesence Int 1999; 30:9-25. 21. A inamo J, Bay I Problems and proposal for 38. Marx RE, Garg AK. Bone structure, metabolism,2. T ronstad L. Root Resorption: Etiology, terminology recording gingivitis and plaque. Dent J 1975; and physiology: its impact on dental and clinical manifestations. Endod Dent Traumatol 25: 229-235. implantology. Implant Dent 1998; 7:267-276. 1988; 4:241-252. 22. O ´Leary TJ. Indices for measurement of tooth 39. Mueller E, Rony HR. Laboratory studies of an3. T rope M. Root resorption of dental and traumatic mobility in clinical studies. J Periodontol Res unusual resorption. J Am Dent Assoc 1930; origin: classification based on etiology. Pract 1974; 9: 94-105. 17:326-333. Periodont Aesthet Dent 1998; 10:515-522. 23. A rmitage GC. Development of a classification 40. Carr HG. Multiple idiopathic resorption of teeth.4. B akland LK. Root resorption. Dent Clin North system for periodontal diseases and conditions. Br Dent J 1958;105:455-456 Am 1992; 36:491-507. Ann Periodontol 1999; 4:1-6. 41. Pinska E, Jarzynka W. Spontaneous of the roots5. L öe H, Waerhaug J. Experimental replantation of 24. A buabara A. 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External cervical differentiation by local factors. Bone 1995; 17: root resorption following bleaching. J Endod 87-91. 44. Cowie P, Wright BA. Multiple idiopathic root 1986; 12: 414-418 resorption. J Can Dent Assoc 1981;47:111- 27. Taubmann MA, Kawai T. Involvement of T- 112.9. F uss Z, Tsesis I, Lin S. Root resorption – Lymphocytes in periodontal disease and in direct diagnosis, classification and treatment choices and indirect induction of bone resorption. Crit 45. Brooks JK. Multiple idiopathic apical external based on stimulation factors. Dent Traumatol Rev Oral Biol Med 2001; 12:125-135. root resorption. Gen Dent 1986;34:385-386. 2003; 19:175-182. 28. B erglundh T, Thilander B, Sagne S. Tissue 46. Saravia ME, Meyer Ml. Multiple idiopathic root10. H arvey J, Zander H. Root surface resorption of characteristics of root resorption areas in resorption in monozygotic twins: case report. periodontally disease teeth. Oral Surg Oral Med transplanted maxillary canines. Acta Odontol Pediatr Dent 1989;11:76-78. Oral Pathol 1959; 12:1439-1443. Scand 1997; 55:206-211. 47. L ydiatt DD, Hollins RR, Peterson G. Multiple11. Rodriguez-Pato RB. Root resorption in chronic 29. L opez NJ, Gioux C, Canales ML. Histological idiopathic root resorption: diagnostic periodontitis: a morphometrical study. J differences between teeth with adult considerations. Oral Surg Oral Med Oral Pathol Periodontol 2004;75:1027-1032. periodontitis and prepuberal periodontitis. J Oral Radiol Endod 1989;67:208-210. Periodontol 1990; 61:87-94.12. C respo Abelleira AC, Rodríguez Cobos MA, 48. Moody GH, Muir KF. Multiple idiopathic root Fuentes Boquete IM, Castaño Oreja MT, Jorge 30. B osshardt DD, Schroeder HE. How repair resorption: a case report and discussion of Barreiro FJ, Rodríguez Pato RB. Morphological cementum becomes attached to the resorbed pathogenesis. J Clin Periodontol 1991;18:577- study of root surfaces in teeth with adult roots of human permanent teeth. Acta Anat 580. periodontitis. J Periodontol 1999; 70:1283- 1994; 150:253-266. 1291. 49. Counts Al, Widlak RA. Generalized idiopathic 31. Y amaguchi M, Kojima T, Kanekawa M, Aihara N, external root resorption. J Clin Ortho13. B elanger GK, Coke JM. Idiopathic external root Nogimura A, Kasai K. Neuropeptides stimulate 1993;27:511-513. resorption of the entire permanent dentition: production of interleukin-1 beta, interleukin-6, report of a case. J Dent Child 1985; 52:359- and tumor necrosis factor-alpha in human dental 50. Di Domizio P, Orsisni G, Scarano A, Piattelli A. 363. pulp cells. Inflamm Res 2004; 53:199-204. Idiopathic root resorption: report of a case. J Endod 2000;26:299-300.14. C holia SS, Wilson PH, Makdissi J. Multiple 32. Y amaguchi M, Ozawa Y, Mishima H, Aihara idiopathic external apical root resorption: report N, Kojima T, Kasai K. Substance P increases 51. Schatzle M, Tanner SD, Basshardt DD. of four cases. Dentomaxillofac Radiol 2005; production of proinflammatory cytokines Progressive, generalized, apical idiopathic root 34:240-246. and formation of osteoclasts in dental pulp resorption and hypercementosis. J Periodontol fibroblasts in patients with severe orthodontic 2005;76:2002-2011.15. Postlethwaite KR, Hamilton M. Multiple root resorption. Am J Orthod Dentofacial Orthop idiopathic external root resorption. Oral Surg 2008; 133:690-698. 52. Iwamatsu-Kobayashi Y, Satoh-Kuriwada S, Oral Med Oral Pathol 1989; 68:640-643. Yamamoto T, et al. A case of multiple idiopathic 33. B runsvold MA. Pathologic tooth migration. J external root resorption: A 6-year follow-up16. R ivera EM, Walton RE. Extensive idiopathic Periodontol 2005; 76: 859-866. study. Oral Surg Oral Med Oral Pathol Oral apical root resorption. A case report. Oral Surg Radiol Endod 2005;100:772-779. Oral Med Oral Pathol 1994; 78:673-677. 34. P orter SR, Scully C. Periodontal aspects of systemic disease: classification. In: Lang 53. Moazami F, Karami B. Multiple idiopathic apical17. Llena MC, Amengual J, Corner L. Idiopathic NP, KarringT, eds. Proceedings of the 1st root resorption: a case report. Int Endod J external root associated to Hypercalciuria (in European Workshop on Periodontology. Berlin: 2007;40:573-578. Spanish). Med Oral 2002; 7:192-197. Quintessence Books; 1994:375-414. 54. Gupta T, Prakash V. Bilateral extensive idiopathic18. S ogur E, Sogur HD, Baksi Akdeniz BG, Sen 35. A h MKB, Johnson GK, Kaldahl WB, Patil apical root resorption in supraerupted maxillary BH. Idiopathic root resorption of the entire KD, Kalkwarf KL. The effect of smoking on molars: a case report. Oral Surg Oral Med Oral permanent dentition: systematic review and the response to periodontal therapy. J. Clin Pathol Oral Radiol Endod 2008;106:44-47. report of a case. Dent Traumatol 2008; 24:443- Periodontol 1994; 21:91-97. 448. The Journal of Implant & Advanced Clinical Dentistry • 55

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Guided Bone Regeneration Using a Rapidly Rosen et al Formed Absorbable Polymer Barrier: A Case Series ReportPaul S. Rosen, DMD, MS1 • Mark A. Reynolds, DDS, PhD2 AbstractBackground: Guided bone regeneration (GBR) one where the barrier is formed in situ and theusing a nonabsorbable barrier has provided other where the barrier is rapidly formed at chair-clinicians with the ability to place implants in side prior to its placement. Second stage sur-sites that are compromised by insufficient bone geries were performed at 6 months (range 3.5including those where teeth have been immedi- to 8.5 months) post-placement. Biopsy mate-ately extracted. GBR efforts originally involved rial from 7 sites was obtained while exposinga barrier of expanded polytetrafluoroethylene the implant for healing abutment connection.(ePTFE) used alone or in conjunction with abone replacement graft. Today, resorbable bar- Results: An overall success rate of 93.8% wasriers have gained much favor with this treatment. achieved. Histologic evaluations revealed the formation of viable bone, frequently in closeMethods: This report presents a case series amalgamation with residual graft particles.of 17 patients with 32 osseous defects whowere consecutively treated with guided bone Conclusion: These results suggest that aregeneration (GBR). An absorbable polymer poly(DL-lactide) polymer can be used as abarrier of poly(DL-lactide) was used in conjunc- physical barrier with a composite bone replace-tion with a composite graft of freeze-dried bone ment graft to achieve successful GBR results.allograft (FDBA)/ demineralized freeze-dried bone The compilation of case information is ongo-allograft (DFDBA) mixed in a ratio of 1:1. Two ing to determine whether similar results willtechniques of barrier formation were assessed; be found in a larger number of patients.KEY WORDS: Bone graft, dental implants, barriers, guided bone regeneration, GBR1. Clinical Associate Professor, Department of Periodontics, Baltimore College of Dental Surgery University of Maryland, Baltimore, MD 2. Professor, Chairman and Postgraduate Director, Department of Periodontics, Baltimore College of Dental Surgery, University of Maryland, Baltimore, MD The Journal of Implant & Advanced Clinical Dentistry • 59

Rosen et al Introduction Figure 1A: Placement of a 4 mm wide implant into maxillary right canine area leaves a dehiscence defect inGuided Bone Regeneration (GBR) has the coronal 1/3 of the implant due to optimal prostheticexpanded the placement of dental implants to positioning.sites that were not a part of the original implantprotocol. GBR has expanded the predict- bone replacement graft, resulting in successfulable treatment options for clinicians to meet clinical outcomes.47,48 Since the polymer doespatients’ aesthetic and masticatory needs. not significantly degrade until 5-6 months,46 the same benefits of clot stability, space main- The principles of GBR date back close to tenance, and tissue exclusion might also be50 years.2-4 Early experimental studies5-8, clini- gained in GBR procedures with implants.cal studies9-15 and case reports16-42 demon-strated successful outcomes for GBR at a wide The purpose of this case series report isvariety of osseous defects thereby facilitating to present consecutive clinical experiencesimplant placements. The original GBR reports with a poly(DL-lactide) polymer (ATRISORB®)discussed the successful use of expanded used either in an in situ technique or an extra-po|ytetrafluroethylene (e-PTFE) (GoreTex®, W.L. oral (rapid polymerization) technique with aGore), a non-absorbable barrier, either alone9- composite bone replacement graft for GBR15,18-20,23,26,29,34,37-40 or in combination with a bone around implants. Implant sites requiring ostec-replacement graft21,22,24,25,27,30-33,37,41 Subsequent tomy for exposure of the fixture permitted his-evidence suggests that an absorbable barrier of tologic evaluation of the new bone formation.polylactic acid/polyglycolic acid (PLA/PGA) usedover autogenous bone can be as effective as the Materials & Methodssame treatment with e-PTFE, the gold standard,for dehiscence/fenestrations around implants.43 Seventeen consecutively treated patients (12 male and 5 female) with an average age of 51.4 An absorbable barrier has been developed (range 32-81) years had a total of 32 acid-etchedwhere a polymer of poly(DL-lactide) is dissolved implant fixtures (Osseotite®, Biomet/3i, Palmin a carrier of N-methyl-2-pyrrolidone (NMP)(ATRISORB®, Tolmar Inc., Fort Collins, Colo-rado), which upon contact with water or otheraqueous solution, forms a barrier of firm con-sistency. Originally, a partially set barrier wasformed at chairside that could be trimmed to thedimensions of a periodontal defect.44,45 Onceplaced, the polymer completely solidified insitu forming an absorbable barrier for GTR.46 A regenerative technique for periodontaldefects has been described where this poly(DL-lactide) polymer was flowed in situ to form acustom fitting barrier directly over composite60 • Vol. 3, No. 1 • December/January 2011

Rosen et alFigure 1B: Composite osseous graft of DFDBA/FDBA in a Figure 1C: A rapidly formed barrier has been made atratio of 1:1 is placed over the implant. chairside and is placed over the composite graft, implant and defect.Figure 1D: Re-entry at 4.5 months shows the barrier is still Figure 1E: Dense connective tissue and hard bone tissuepresent. revealed after removal of the barrier.Beach Gardens, FL) (Restore®, Noble Biocare, were taken throughout the implant and GBR pro-Yorba Linda, CA) inserted in combination with a cedures and clinical measurements were madeGBR procedure. The implant surgeries were con- of the osseous defects treated. All measure-ducted utilizing standard protocols of the respec- ments were done from the most coronal aspecttive implant systems, notwithstanding the GBR of the implant collar to the base of the defect.procedure. All implant placements were done in With the exception of one 3-wall lesion whichthe absence of pre-tapping the site. Photographs required no graft, all defects received a com- The Journal of Implant & Advanced Clinical Dentistry • 61

Rosen et alFigure 2A: Teeth 5 and 6 were extracted in this 59-year Figure 2B: DFDBA/FDBA composite osseous graft is placedold female due to vertical root fracture with immediate at both implants.implant placements. The implant at site 6 is 5 mm wideand has a narrow 3-wall defect at its palatal aspect and acombined dehiscence-3 wall defect at its facial aspect.Figure 2C: The poly(DL-lactide) polymer barrier has been Figure 2C: Stage II surgery at 5.5 months reveals hardapplied using an in situ technique. Sterile water from tissue formation.the handpiece has initiated its formation which can bedetected by opacification of the surface.posite graft of demineralized freeze-dried bone a 1:1 ratio. Both graft materials were obtainedallograft (DFDBA) (particle size 250-710 microm- from a tissue bank that has demonstrated induc-eters) mixed with freeze-dried bone allograft tivity for its DFDBA material (LifeNet Health, Vir-(FDBA) (particle size 250-710 micrometers) in ginia Beach, VA).49.50 The graft was re-hydrated62 • Vol. 3, No. 1 • December/January 2011

Rosen et alFigure 2E: Removal of the newly formed bone was Figure 2F: Photomicrograph at 10X power revealsnecessary for abutment connection. amalgamation of new bone with residual graft particles.with sterile saline prior to its placement around seconds in order to drive of the NMP. Care wasthe implants and the defect was filled incremen- taken to press the forming barrier against thetally using light pressure. An in situ (FreeFlow™) sides of the dampen dish to begin barrier forma-method of barrier placement was used for the first tion. Corn suture pliers (Hu-Friedy, Chicago, IL)14 implants. The polymer was expressed from were used to remove the polymer barrier fromthe dose pack through an 18 gauge, 1-inch long the dappen dish to trim it to an appropriate sizecannula. The barrier was formed by applying ster- with suture scissors. If necessary, the barrier wasile saline from the implant handpiece and its for- handled with gloves to facilitate trimming. The bar-mation was determined by surface opacification rier was then placed at the graft site with 2-3mmbeing visible. Any portion of the composite graft overlapping the adjacent osseous structure. Ifnot covered with the initial application received additional barrier was needed, the same processadditional polymer to fill any voids or gaps. The was repeated with the new piece overlapping thenext 17 implant sites received a rapidly formed prior barrier with the two coalescing together.chairside application of the barrier. Five-ten dropsof polymer were placed from the dose pack into The endpoint of flap management was pas-a sterile glass dappen dish. Sterile saline was sive primary closure, which was achieved by usingadded in a ratio of two drops for every five drops releasing incisions that extended well beyond theof polymer. A 7A wax spatula (Hu-Friedy, Chi- mucogingival junction and into the buccal turncago, IL) introduced the saline throughout the of the vestibule. Partial thickness dissection inpolymer and rapid mixing was performed for 8-10 the apical portion of the facial flaps allowed the flaps to be passively drawn together. A mono- The Journal of Implant & Advanced Clinical Dentistry • 63

Rosen et alfilament suture was used of either an absorb- for a total of 21 days. Patients were instructedable, Monocryl (Ethicon, Sommerville, NJ), or a to use a 0.12% chlorhexidine rinse 2 times pernon-absorbable material, e-PTEE (W.L. Gore & day for the first 30 days or during the entireAssociates, Flagstaff, AZ), for flap adaptation. healing period if the barrier became exposed. The antibiotic regimen was 2g of amoxicillin Flaps were reflected at the second stage sur-at the time of implant surgery followed by 500mg gery to place healing abutments at which time3 times per day for 10 days. The regimen was fol- the success or failure of the GBR procedurelowed by doxycycline 100mg taking 2 capsules was assessed. Clinical photographs were usedon the first day and then 1 capsule per day for to determine results of treatment. Complete suc-13 days. Two patients were allergic to amoxicil- cess, partial success, and failure were based onlin and were placed on the doxycycline regimen the definitions offered by Mellonig & Triplett.3064 • Vol. 3, No. 1 • December/January 2011

Rosen et alComplete success was defined as coverage of Resultsall threads or exposed implant surfaces with boneor with bone and dense, firm connective tissue. The osseous defects treated included 19 dehis- cence/fenestration defects, 10 extraction sites Partial success was deemed as incomplete and 3 thin buccal alveolar housings. Repre-coverage of most threads or exposed implant sentative clinical cases and outcomes are illus-surfaces with a maximum of two threads or trated in Figures 1-3. Second stage surgeries2mm of implant surface left uncovered by bone and evaluations were performed between 3.5or by bone and dense, firm connective tissue. and 8.5 months (6.0 months average). Table lFailure was defined as no coverage by bone summarizes the outcomes of the GBR proce-or by bone and dense, firm connective tissue dure by defect type. Extraction sites and thinbeyond two threads or 2mm of implant surface. buccal alveolar housings responded favorably The Journal of Implant & Advanced Clinical Dentistry • 65

Rosen et alto both techniques with complete success at A summary of the outcome data for each100% and 90%, respectively. Dehiscence/fen- technique, categorizing by defect type (Tablesestration defects had a complete success rate lll & lV), suggests that both methods wereof 78.9% with an overall success rate of 94.7%. effective for extraction sites and thin buc- cal bone. The in situ method (Table lll) was Table ll summarizes outcomes by tech- not as successful at treating dehiscence/nique. Both the in situ and rapidly formed fenestration defects with complete and par-chairside techniques had an overall suc- tial success totaling only 88.9%. The rapidlycess rate of 93.8%. The in situ method formed chairside method, however, was suc-had a 73.3% complete success rate which cessful in achieving a positive regenerativeappeared related to its reduced performance result for all three types of defects except forfor dehiscence/fenestration defects (Table lll).66 • Vol. 3, No. 1 • December/January 2011

Rosen et alone extraction site where the barrier became Fragmentation of the barrier resulted in its pre-prematurely exposed, leading to 4 threads mature loss. The barriers were otherwise wellexposed at the second stage surgery (Table lV). tolerated by the tissue with no sites demonstrat- ing untoward granulation reactions or infection. Premature loss of the barrier occurred atthree implant sites approximately 4 weeks fol- The histologic evaluation of biopsy speci-lowing clinical exposure. One of these sites mens revealed the presence of viable bone andresulted in a regenerative failure, as discussed residual grab particles. Islands of viable bonepreviously, though the implant was integrated. were frequently observed in close amalgamationPremature loss of the barrier at 2 implant sites with graft particles. Notably absent in all speci-was observed 3 weeks post-placement sec- mens was evidence of an inflammatory reaction.ondary to physical forces during mastication. The Journal of Implant & Advanced Clinical Dentistry • 67

Rosen et al Discussion mation. Consistent with this possibility, an absorbable barrier of PLA/PGA was previ-The clinical outcomes of this case series are ously associated with reduced regenerativeconsistent with the results of studies9,13,43 and outcomes, compared to e-PTFE due to col-case reports21,22,26,33 describing the applica- lapse of the barrier.51 In these case reportstion of nonabsorbable and absorbable barriers the GBR procedure incorporated a compos-in GBR therapy. Nevertheless, comparisons ite graft of DFDBA/FDBA in a 1:1 ratio, whichacross studies remain difficult because of previously has been shown to support suc-differences in the variety of bone defects cessful regenerative outcomes.21 The concepttreated, temporal sequencing of implant and of mixing these two graft materials capitalizesGBR surgeries and surgical outcome mea- on combining the potential osteoinductive/sures. Given the concern for the preserva- osteoconductive capabilities of DFDBA49,50tion of aesthetics, the Mellonig & Triplett30 with the osteocondudive and spacemak-outcome criteria was chosen to evaluate the ing advantages of FDBA.21 Allograft materialsGBR results. Removal of any dense con- used in this case series were obtained fromnective tissue present might have compro- the same tissue bank, which routinely verifiesmised any newly regenerated bone, which the osteoconductive potential of its processedcould have impacted on the soft tissue height. DFDBA in the athymic mouse model.49,50 GBR therapy using the in situ and rapidly Histologic evaluation of the new boneformed chairside techniques for barrier forma- formation was possible at 7 sites, wheretion was highly effective for extraction sites ostectomy had been required to expose theand thin buccal bone defects. In contrast, the implant for placement of the healing abut-in situ method demonstrated a lowered overall ment. In all histologic specimens, viable bonesuccess rate of 88.9% for dehiscence/fenes- was observed in the absence of an inflamma-tration defects with complete success at only tory infiltrate. New bone formation was fre-55.6% in these cases to date. The reason for quently in close amalgamation with residualthe lower success rate may be related to sam- graft particles. These histologic findings areple size and/or the inability to control the flow consistent with previous reports following theof the polymer over large areas, especially in use of DFDBA in regenerative therapy.52,53the posterior maxilla. Unseen voids and gaps inthe in situ formed barrier could permit epithe- There are a number of advantages to a liquidlial and/or connective tissue down-growth and polymer barrier. Previous reports demonstratedloss of graft material, thereby diminishing the the clinical benefits of the poly(DL-lactide) bar-regenerative outcome. Barrier formation using rier, which can be formed in a chairside kit44,45the rapidly formed chairside technique reduces or in situ47,48 for GTR procedures. This casethe likelihood of developing gaps or voids. series documents and confirms the successful application of the poly(DL-lactide) barrier with A bone replacement graft was used in com- bone replacement grafts in GBR proceduresbination with the polymer barrier, in part, to involving dental implants.55 This dual capacityavoid barrier deformation prior to its final for-68 • Vol. 3, No. 1 • December/January 2011

Rosen et alfor GBR and GTR use simplifies the clinician’s tion and potentially affect the final regenerativeinventory of barriers since the material can be outcome.56 The regenerative consequences offlowed or trimmed to a variety of clinical situa- barrier exposure and loss are related to the mat-tions. The barrier can be rapidly formed (8-10 urational stage of the wound healing process.second) avoiding the cumbersome 4-5 minutewait that was part of the original chairside kit The results of this consecutive case seriesinstructions. The in situ method may further pre- suggest that a poly9DL-lactide) polymer canvent bacterial contamination of the barrier since be used as a physical barrier with a com-it is not handled which may add to its intrinsic posite bone replacement graft to achieveantimicrobial property.54 The polymer system successful GBR results with implants. Thepermits repairs or modification of the barrier if compilation of case information is ongo-it is inaccurately cut or trimmed since additional ing to determine whether similar results willmaterial can be added to the existing barrier be found in a larger series of patients. ●with the two coalescing. The barrier’s final con-sistency is hard and rigid adding to its space Correspondence:maintenance capabilities. It takes approxi- Paul S. Rosen, DMD, MSmately 5-6 months for significant degradation of 907 Floral Vale Boulevardthe barrier to begin and since it is completely Yardley, PA 1906absorbed by twelve months, there is less con-cern that remaining barrier could affect the site. Disclosure The author reports no conflicts of interest with anything mentioned in this article. There are also some limitations to this bar- Referencesrier. The final consistency of the material is 1. B ranemark P-I, Hansson B, Adell R, Breine U, Lindstrom J, Hallen 0, Ohmanhard and firm making it susceptible to fractureand premature loss in the presence of untow- A.Osseointegrated implants in the treatment of the edentulous jaw: Experienceard occlusal forces. Although this occurred from a l0-year period. Scand J Plast Reconstr Surg 1977,.1 1(Suppl.16):1-132.in one patient at two implant sites, the clinical 2. M urray G, Holden R, Roachleu W. Experimental and clinical study ofoutcome was still favorable. In the presence new growth of bone in a cavity. Am J Surg 1957;96:385-387.of large defects, premature loss of the barrier 3. L inghorne WJ. The sequence of events in osteogenesis as stud-might substantially compromise the regenera- ied in polyethylene tubes. Ann NY Acad Sci 1960;85:445-460.tive outcome. A second concern is that expo- 4. M elcher AH, Dwyer CJ. Protection of the blood clot in the healing of cir-sure of the poly(DL-lactide) barrier may also cumscribed bone defects. J Bone Joint Surg (Br) 1962;48:424-430.lead to premature loss. Early exposure of the 5. D ahlin C, Sennerby L, Lekholm U, Linde A, Nyman S. Generation of newbarrier occurred at two patients’ implant sites bone around titanium implants using a membrane technique: An experi-at 7 days after placement. While the barrier mental study in rabbits. Int J Oral Maxillofac Implants 1989;4:19-25.remained intact at both for approximately 4-5 6. S eibert J, Nyman S. Localized ridge augmentation in dogs. A pilot studyweeks, one of the sites had a failed regenerative using membranes and hydroxyapatite. J Periodontol 1990;61:157-165.outcome. Exposure of nonabsorbable barriers, 7. B ecker W, Becker BE, Handlesman M, Celletti R, Ochsenbeinwhich remain intact, permit bacterial coloniza- C, Hardwick R, et al. Bone formation at dehisced dental implant sites treated with implant augmentation material: A pilot study in dogs. Int J Periodontics Restorative Dent 1990;10:93-101. 8. B ecker W, Becker B, Handlesman M, Ochsenbein C, Albrekts- son T. Guided tissue regeneration for implants placed into extrac- tion sockets. A study in dogs. J Periodontol 1991;62:703-709. 9. D ahlin C, Andersson L, Linde A. Bone augmentation at fenes- trated implants by an osteopromotive membrane technique. A con- trolled clinical study. Clin Oral Implants Res 1991;2:159-165. 10. Becker W, Dahlin C, Becker BE, Lekholm U, van Steenburghe D, Higuchi K, Kultje C. The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: A prospec- tive multicenter study. Int J Oral Maxillofac Implants 1994;9:31-40. Continued on page XX The Journal of Implant & Advanced Clinical Dentistry • 69

Rosen et al11. Jovanovic SA, Spiekermann H, Richter EJ. Bone 26. B user D, Hirt H-P, Dula K, Berthold H. 42. A shman A. An immediate truth root replace- regeneration around titanium dental implants GBR-technique/implant dentistry. Schweiz ment: an implant cylinder and synthetic bone in dehisced defect sites: A clinics study. Int J Monatsschr Zahnmed 1992;102:1491-1501. combination. J Oral Implant 1990;16:28-38. Oral Maxillofac Implants 1992;7:233-245. 27. Buser D, Dula K, Belser UC, Hirt H-P, Ber- 43. S imion M, Misitano U, Gionso L, Salvato A.12. Simion M, Baldoni M, Rossi P, Zaffe D. Com- thold H. Localized ridge augmentation using Treatment of dehiscences and fenestrations parative study of the effectiveness of GTAM guided bone regeneration. 11. Surgical around dental implants using resorbable and membranes with and without early exposure procedure in the mandible. Int J Periodon- nonresorbable membranes associated with during the healing period. Int J Periodon- tics Restorative Dent 1995;15:11-29. bone autografts: a comparative study. Int J tics Restorative Dent 1993;13:167-180. Oral Maxillofac Implants 1997;12:159-167. 28. C allan DP, Rohrer MD. Use of bovine-derived13. D ahlin C, Lekholm U, Becker W, Becker BE, hydroxyapatite in the treatment of edentulous 44. P olson AM, Southard GL, Dunn RD, Polson Higuchi K, Callens A, van Steenberghe D. ridge defects: A human clinical and histological AP, Billen JR, Laster LL. Initial study of guided Treatment of fenestration and dehiscence case report. J Periodontol 1993;64:575-582. tissue regeneration in Class II furcation defects bone defects around oral implants using after use of a biodegradable barrier. Int J Peri- the guided tissue regeneration technique: 29. Dahlin C, Lekholm U, Linde A. Mem- odontics Restorative Dent 1995;15:43-55. A prospective multicenter study. Int J Oral brane induced bone augmentation at Maxillofac Implants 1995;10:312-318. titanium implants. Int J Periodontics 45. Polson AM, Garrett S: Stoller NH, et at. Guided Restorative Dent 1991’,1 1:273-282. tissue regeneration in human furcation defects14. Dahlin C, Andersson L, Linde A. Bone augmen- after using a biodegradable barrier: A multicenter tation at fenestrated implants by an osteopromo- 30. M ellonig JT, Triplett RG. Guided tissue regenera- feasibility study. J Periodontal 1995;66:377-385. tive membrane technique. A controlled clinical tion and endosseous dental implants. Int J Peri- study. Clin Oral Implant Res 1991;2:159-165. odontics Restorative Dent 1993;13:109-119. 46. Coontz, BA, Whitman SL, O’Donnell M, Polson AM, Bogle G, Garrett S, et al. Biodegradation15. Andersson B, Odman P, Widmark G, Waas 31. N evins M, Mellonig J. Enhancement of the and biocompatibility of a guided tissue regenera- A. Anterior tooth replacement with implants damaged edentulous ridge to receive den- tion barrier formed from a liquid polymer mate- in patients with a narrow alveolar ridge form. tal implants: A combination of allograft and rial. J Biomed Mater Res 1998;42: 303-311. A clinical study using guided tissue regenera- the GORE-TEX membrane. Int J Periodon- tion. Clin Oral Impl Res 1993;4:90-98. tics Restorative Dent 1992;12:96-111. 47. R osen PS, Reynolds MA, Bowers GM. A tech- nique report on the in situ application of Atrisorb®16. B lock M, Kent J. Placement of endosseous 32. N evins M, Mellonig JT. The advantages of as a barrier for combination therapy. Int J Peri- implants into tooth extraction sites. J Oral localized ridge augmentation prior to implant odontics Restorative Dent 1998;18:249-255. Maxillofac Surg 1991;49:1269-1272. placement: A staged event. Int J Periodon- tics Restorative Dent 1994;14:96-111. 48. R osen PS, Reynolds MA. Polymer-assisted17. Y ukna R. Clinical comparison of hydroxyap- regenerative therapy: Case reports of 22 atite-coated titanium dental implants placed 33. Rominger JW, Triplett RG. Re use of consecutively treated periodontal defects in fresh extraction sockets and healed guided tissue regeneration to improve with a novel combined surgical approach. sites. J Periodontol 1991;62:468-472. implant osseointegration. J Oral Maxil- J Periodontol 1999;70:554-561. lofac Surg 1994;52:106-112.18. Augthun M, Yildirim M, Spiekermann H, 49. S chwartz Z, Mellonig JT, Carnes DL Jr., De Biesterfeld S. Healing of bone defects 34. S imion M, Baldoni M, Zaffe D. Jawbone enlarge- La Fontaine J, Cochran DL, Dean DD, Boyan in combination with immediate implants ment using immediate implant placement BD. Ability of commercial demineralized using the membrane technique. Int J Oral associated with a split-crest technique and freeze-dried bone allograft to indue new bone Maxillofac Implant 1995;10:421-428. guided tissue regeneration. 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Oral Maxillofac Implants 1991;6:127-135. implants. lnt J Periodontics Restorative Guided bone regeneration using resorbable Dent 1994;14:497-512. and nonabsorbable membranes: A com-21. S hanaman RH. A retrospective study parative histological study in humans. Int J of 237 sites treated consecutively with 37. Gelb DA. Immediate implant surgery: three-year Oral Maxillofac Implant 1996;11:735-742. guided tissue regeneration. Int J Periodon- retrospective evaluation of 50 consecutive cases. tics Restorative Dent 1994;14:31-40. Int J Oral Maxillofac Implant 1993;8:388-399. 52. S imion M, Trisi P, Piattelli A. GBR with an e-PTFE membrane associated with22. Fugazzotto PA, Shanaman R, Manos T, Shect- 38. B ecker W, Becker B. Guided tissue regen- DFDBA: histologic and histochemi- man R. Guided bone regeneration around eration for implants placed into extraction cal analysis in a human implant retrieved titanium implants: Report of the treatment of sockets and for implant dehiscence: surgical after 4 years of loading. Int J Periodontics 1503 sites with clinical re-entries. Int J Peri- techniques and case report. Int J Periodon- Restorative Dent 1996;16:338-347. odontics Restorative Dent 1997;17:293-299. tics Restorative Dent 1990;10:376-391. 53. R eynolds MA, Bowers GM. Fate of demineral-23. Becker W, Becker BE, McGuire MK. Local- 39. T olman D, Keller E. Endosseous implant ized freeze-dried bone allograft in human intra- ized ridge augmentation using absorbable placement immediately following dental bony defect. J Periodontol 1996;67:150-157. pins and e-PTFE barrier membranes: A new extraction and alveoloplasty: preliminary surgical technique. Case reports. Int J Peri- report with 6-year follow-up. Int J Oral 54. Botz M, Ronhold CH, Godowski KC, Dunn RD, odontics Restorative Dent 1994;14:49-61. Maxillofac Implant 1991;6:24-28. Southard GL. Intrinsic antimicrobial properties of a bioabsorbable GTR barrier. J Dent Res24. B user D, Dula K, Belser U, Hid H-P, Ber- 40. W ilson T Jr. Guided tissue regeneration around 1997;76(Spec. Issue):435(Abstr. 3375). thold H. Localized ridge augmentation dental implants in immediate and recent extrac- using guided bone regeneration. I. Surgical tion sites: initial observations. lnt J Periodon- 55. R osen PS, Reynolds MA. Guided bone regen- procedure in the maxilla. Int J Periodon- tics Restorative Dent 1992;12:185-193. eration for dehiscence and fenestration defects tics Restorative Dent 1993;13:29-45. on implants using an absorbable polymer 41. W atzek G, Haider R, Mensdorff-Puilly N, barrier. J Periodontol 2001;72:250-256.25. B user D, Bragger U, Lang NP, Nyman S. Haas R. Immediate and delayed implanta- Regeneration and enlargement of jaw- tion for complete restoration of the jaw 56. Nowzari H, Slots J. Microbiologic and clinical bone using guided tissue regeneration. following extraction of all residual teeth: study of polytetrafluoroethylene membranes Clin Oral Implant Res 1990;1:22-32. A retrospective study comparing different for guided bone regeneration around implants. types of serial immediate implantation. Int J Int J Oral Maxillofac Implant 1995;10:67-73. Oral Maxillofac Implant 1995;10:561-567.70 • Vol. 3, No. 1 • December/January 2011



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Immediate Loading of Dental Implants with Provisional Restorations and Soft TissueManipulation for Achieving Optimal Esthetics: A Case ReportSudhindra Kulkarni1 • Srinath Thakur1 • Sampath Kumar2 AbstractThe restoration of anterior maxilla in an provides the clinician with an option to rehabili- esthetically acceptable way is probably the tate the anterior maxilla with immediate provisional most challenging of all clinical scenarios. restorations thus enhancing patients’ comfort.Ideal implant positioning as well as proper soft The following case report is of a patient who wastissue management is the key to achieve opti- treated with immediate provisional restorationsmal esthetic result. Immediate loading of dental and soft tissue contouring was carried out toimplants is now an accepted clinical reality and achieve harmonious hard and soft tissue esthetics. KEY WORDS: Dental implants, Immediate load, Provisionalization, Esthetics 1. Faculty, Department of Periodontics and Implantology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India2. Faculty, Department of Prosthodontics and Implantology, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India The Journal of Implant & Advanced Clinical Dentistry • 75

Kulkarni et alFigure: 1: Pre-Operative intraoral photograph. Figure 2: Pre-operative radiograph. Introduction conventional delayed loading of the implants.5 The increased esthetic demands of the patientIn the current scenario of implant practice, ourpatients desire immediate and esthetically pleas- make it important to not only have the implantsing results. At the time when the concept of placed in an ideal location and loaded immedi-osseointegration and the basic principles for ately, but also achieve soft tissue contours thatimplantology were being laid down by Brane- result in a natural appearing emergence profiles.mark,1 the main goal of therapy was to provide This is more critical in those patients who dis-fixed and more stable replacements; esthetics play gingival margins of the maxillary anteriorand immediate replacement were not considered. teeth during facial expression. Achieving proper emergence profiles is not only esthetic but also To overcome the 2nd stage surgery and promotes optimal plaque control and gingivalavoid resulting trauma for the patient along with health.6,7 Many techniques have been suggestedreduced surgery time for the surgeon, a non sub- in the literature for soft tissue management.9-12merged approach or also known as one-stageimplant placement was carried out and reported The following report is of a case wheresuccessful osseointegration.2,3 This approach implants were loaded immediately with temporaryfurther lead to development of immediate load- restorations which were later replaced with provi-ing of the implants either at the time of implant sional restorations to achieve harmonious soft tis-placement or within a short period of time. Tar- sue contours and esthetically pleasing outcomes.now et al. reported a success rate of 96% over aperiod of 5 years for implants immediately loaded Case Reportwith fixed prosthesis in 10 completely edentu-lous cases.4 A recent review by Jokstad and Carr A 56 year old female patient reported to thereported that over a 1-10 year period there is no Department of Oral Implantology, SDM Col-significant difference between immediate and lege of Dental Sciences and Hospital, Dharwad, Karnataka, India with a chief complaint of miss-76 • Vol. 3, No. 1 • December/January 2011

Kulkarni et alFigure 3: Implant placed in the maxillary anterior. Figure 4: Immediate provisional restorations.ing teeth in the maxillary anterior area and the final restorations after a period of six months.right maxillary/mandibular posterior areas of thejaw. Three years prior, the teeth were extracted Treatmentdue to endodontic complications and a remov-able partial denture was fabricated that replaced A prefabricated post was inserted into theher anterior teeth. She desired a replacement tooth #7 and core build-up was done. Thewhich was fixed and also esthetically pleasing. acrylic crown on was removed and an acrylic prosthesis extending from #’s 7-11 was fabri- Clinical and Radiographic examination (fig- cated on the cast which would then be used asures 1 and 2) revealed multiple missing teeth. a guide during the surgery and later modifiedTeeth numbers 7, 11, 14, and 32 were end- to act as an immediate temporary restoration.odontically treated, #11 had an acrylic tempo-rary crown, #’s 5 and 6 had connected crowns It was decided to place the posterior implantswhich supported cantilever prosthesis for tooth first followed by the anterior implants. A full thick-#4. The gingiva appeared healthy on all the ness mucoperiosteal flap was elevated in the max-remaining teeth, though #29 displayed some illary posterior area. Sequential drilling was carriedamount of bone loss and gingival recession. out and two implants of 3.5 mm and 5.0mm diam- eter of 12mm and 9mm in length were placed in The patient was informed about the treat- the #’s 2 and 3 areas respectively (Maestro, Bio-ment plan which involved post and core res- horizons Dental Implants, Birmingham, AL, USA).toration on #7 and placement of one implantper missing teeth in both the arches. The max- A 4.0mm diameter and 12mm in lengthillary anterior implants were to be loaded with implant was placed at site #8 and 3.5x12mmimmediate provisional restorations; where implants were placed at sites 9 and 10. It wasas the posterior implants would be left sub- noted that the implant in site #9 was not in amerged. All the implants would receive the favorable position, so it was decided to cover it with a cover screw and leave it submerged (fig- The Journal of Implant & Advanced Clinical Dentistry • 77

Kulkarni et alFigure 5: Soft Tissue contouring. Figure 6: Final set of provisional restorations.Figure 7: Final restorations. Figure 8: Radiograph of the final restorations.ure 3.). The abutments were kept on the implants site #30 and a conventional 3.5x12mm implantat sites #8 and 10 and the flaps were approxi- was placed at site #31. All implants had goodmated and closed with 3-0 resorbable sutures. primary stability. The flaps were then approxi- mated and closed with 3-0 resorbable sutures. In the areas of teeth 30/31, it was noted thatthe mesio-distal space was inadequate for place- The acrylic temporary was modified andment of two conventional implants. To create the relined at the conclusion of the surgery so asspace it was suggested to the patient to extract to fit the natural as well as the implant abut-third molar in the quadrant which would then help ments extending and was cemented within creating the necessary space, but the patient luting cement (IRM, Dentsply) (figure 4).refused to have the tooth removed. A 3.0x12mmsingle stage implant (Biohorizons, Maximus Den- Post-operatively, the patient was prescribedtal Implant, Birmingham, AL, USA) was placed at amoxicillin 500mg tid and ibuprofen 400mg. Home care instructions were given and 10 days78 • Vol. 3, No. 1 • December/January 2011

Kulkarni et alFigure 9: Two year post-operative photo (Frontal view). Figure 11: Two year post operative radiographFigure 10: Two year post operative radiograph (maxilla). (mandible). later the sutures were removed. The patient was recalled after 90 days after the implant place- ment and evaluated. It was noticed that the soft tissues had healed well around the implants, but the soft tissue contours were not pleasing. The temporary acrylic restorations were removed, gingival contouring was accomplished around the implants as well as the adjacent natural teeth to improve soft tissue contours and emer- gence profiles (figure 5). Impressions were then made and heat polymerized acrylic provisional restorations were fabricated to match with the newly created soft tissue contours. (figure 6) Three months later the patient reported for her final restorations. Second stage pro- cedures were carried out to uncover the implants in the posterior maxilla and man- dible. Fifteen days later the final impressions were made and final restorations were fabri- cated and cemented (figures 7,8). The patient expressed satisfaction with the new final res- torations. At the two year follow-up period we could note stable hard and soft tissue mar- gins and the screw access hole completely The Journal of Implant & Advanced Clinical Dentistry • 79

Kulkarni et alcovered by the soft tissue (figures 9-11). ment of a “ball on a stick” restoration.19 Bain and Weisgold20 state that most healing abut- Discussion ments and transfer copings are round and do not simulate the normal cross section of ante-The advantages of one stage and imme- rior teeth, resulting in an unnatural sulcular formdiate loading of the implants with tempo- around implant abutments. The provisionalrary restorations in the maxillary anterior restoration must therefore flow from a roundarea cannot be overstated. In the current shape into a crown shape to develop a natural-case only the implants in the maxillary ante- looking replacement. In this case the immediaterior were immediately loaded with tem- temporary restorations that were placed on theporary restorations primarily for esthetic day of the surgery were not aiding in creatingreasons. The implants in the posterior areas the desired soft tissue contours. After a periodof the jaws were submerged to be exposed of initial healing, the gingival tissues around6 months later for conventional loading. the implants and the adjacent natural teeth were contoured and we replaced the immedi- Immediate loading of implants aids in splint- ate temporary restorations with heat polymer-ing the implants together which enhances load ized acrylic resin provisional restorations thatdistribution over a wide area. While replac- adapted to newly created form. This methoding the anterior teeth, immediate temporiza- planed the provisional restoration emergencetion offers the benefits of enhanced function profile so that the developed shape may alsoand stability during the healing period. The be repeated for the definitive prosthesis.19patients need not wear a removable pros- This approach of immediate loading followedthesis, which in turn has a strong psychologi- by soft tissue contouring for the anterior res-cal impact and increases the acceptance of torations and a conventional approach for theimplant treatment.5 With success rates of posterior implant restorations aided in achiev-95 - 100% survival over 3-5 years13-16 which ing optimal esthetics as desired by the patient.is similar to conventionally loaded implantsand better bone-implant contact for imme- Over a period of 1 year follow-up, thediate loaded implants,17,18 immediate load- bone levels were maintained and none of theing may be well suited for the anterior maxilla. implants were lost. Misch and Degidi reported a bone loss of approximately 0.07mm from Even though there is ample support in the final prosthesis delivery to 1 year radiographicliterature for immediate loading of implants evaluation.16 They also reported mean cumu-even in the posterior areas, in the current case lative bone gain after 1 year or more aroundwe decided to load the posterior implants in a some of those implants in their study and attrib-conventional way after a period of 6 months. uted it to the implant design, which permitted a bone turnover rate less than 5m/d which cor- The demand for esthetics around any form responds to the rate of lamellar bone remodel-of restorations is paramount, whether it is ing and a success rate of 100% over 5 years.21around natural teeth or around implants. Aproper emergence profile should be consid-ered in 3 dimensions to avoid the develop-80 • Vol. 3, No. 1 • December/January 2011

Kulkarni et al Conclusion Disclosure The authors report no conflicts of interest with anything mentioned in this article.Immediate loading of implants along Referenceswith soft tissue contouring supported 1. B ranemark PI, Hansson BO, Adell R.Osseointegrated implants in the treatmentby heat polymerized provisional restora-tions helps in creating optimal emergence of the edentulous jaws. Experience from a ten year period. Scand J plastprofiles which can be later maintained Reconsttr Surg Suppl 1977;16: 1-132.around the final restorations over 1 year. ● 2. G otfredsson K, Hjorting-Hansen E. Histologic and histomorphometric evaluation of submerged and non submerged titanium implants. In. Laney WR, Correspondence: Tolman DE, eds. Oral Orthopedic and maxillofacial reconstruction. Chicago: Dr Sudhindra Kulkarni Quintessence,1990:31-40. Faculty, Department of Periodontics and 3. B user D, Weber HP, Bragger U et al. Tissue integration of one stage ITI implants : Implantology 3 year results of longitudinal study with hollow cylinder and hollow screw SDM College of Dental Sciences and Hospital implants. Int J Oral Maxillofac Implants 1991;6:405-412. Dharwad, Karnataka, India 4. T arnow D, Emitiag S, Classi A. immediate loading of threaded implants at stage [email protected] one surgery in edentulous arches. Ten consecutive case reports with 1-5 year Ph: +91-836-2468142 data. Int J Oral Maxillofac implants 1997;12:319-324. Fax: +91-836-2467676 5. J okstad A, Carr AB. What is the effect on outcomes of time-to-loading of a fixed or removable prosthesis placed on implant(s)? Int J Oral Maxillofac Implants. 2007;22 Suppl:19-48. 6. N aele D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent 1994; 72:364-367. 7. K hourg K, Happe A. Soft tissue management in oral implantology: A review of surgical techniques for shaping an esthetic and functional peri-implant soft tissue structure. Quintessence Int 2000;31: 483-499. 8. S alama H, Rose LF, Salama M, Betts NJ. Immediate loading of bilaterally splinted titanium root form implants in fixed Prosthodontics- techniques reexamined: two case reports. Int J Periodontics Restorative Dent. 1995;15:344-361. 9. L anger B. Spontaneous insitu gingival augmentation. Int J Periodontics Restorative Dent 1994;14:524-535. 10. E vian CL, Al-Maseeh J, Symeonides E. Soft tissue augmentation for implant dentistry. Compend Educ Dent 2003;24:195-198. 11. Sclar AG. Vascularized interposition periosteal connective tissue (VIP-CT) flap. Sclar AG, ed. Soft tissue and esthetic considerations in Implant therapy. Chicago: Quintessence. 2003:163-168. 12. E l-Salam, El-Askary A. Use of a titanium papillary insert for the construction of the inter-implant papillae. Implant Dent 2000; 9:358-362. 13. Jaffin RA, Kumar A, Berman CL. Immediate loading of implants in partially and fully edentulous jaws: a series of 27 case reports. J Periodontol. 2000;71(5):833-838. 14. D e Bruyn H, Van de Velde T, Collaert B. Immediate functional loading of TiOblast dental implants in full-arch edentulous mandibles: a 3-year prospective study. Clin Oral Implants Res. 2008;19:717-723. 15. Glauser R, Zembic A, Ruhstaller P, Windisch S. Five-year results of implants with an oxidized surface placed predominantly in soft quality bone and subjected to immediate occlusal loading.J Prosthet Dent. 2007; 97(6 Suppl):S59-68. 16. M isch CE, Degidi M. Five year prospective study of immediate/ early loading of fixed prostheses in completely edentulous jaws with a bone quality-based implant system. Clin Impl Dent Rel Res 2003;5:17-28. 17. P iatelli A Corigliano M,Scarano, Quaranta M. Bone reactions to early occlusal loading of two stage titanium plasma sprayed implants. A pilot Study in monkeys. Int J Periodont Restorative Dent. 1997;17:162-169. 18. Piatelli A, Corigliano M,Scarano, Costigola G, Paolantonio M. Immediate loading of titanium plasma sprayed implants. An histologic analysis in monkeys. J Periodontol.1998; 69: 321-327. 19. M acintosh DCT, Sutherland M. Method for developing an optimal emergence profile using heat-polymerized provisional restorations for single-tooth implant- supported restorations. J Prosthet Dent 2004; 91:289-292. 20. Bain CA, Weisgold AS. Customized emergence profile in the implant crown- a new technique. Compend Contin Educ Dent 1997; 18:41-45. 21. M isch CE, Qu AL, Bidez MW. Mechanical properties of trabecular bone in the human mandible. Implications for dental implant treatment planning and surgical placement. J Oral Maxillofac Surg 1999;57:700-706. The Journal of Implant & Advanced Clinical Dentistry • 81

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Walia et alOral Bisphosphonates and Dental Implants: A Review and UpdateManpreet S Walia, MDS1 • Saryu Arora, MDS2 • Bhawana Singal, MDS3AbstractThis review was made to establish the con- jaw (BRONJ) is a well documented devastating venience of Dental Implant treatment in side effect of long term bisphosphonates (BP) patients receiving bisphosphonates. Cli- use. There is scarce information in the literaturenicians must be aware of the potential risk of on BRONJ associated with dental implants (DIs).Osteonecrosis in patients treated with bisphos- It would be of interest to design studies to evalu-phonates via the oral or intravenous route. ate the risk factors among dental implant patientsBisphosphonates related osteonecrosis of the receiving treatment with bisphosphonates. KEY WORDS: Bisphosphonates, Osteonecrosis, Dental Implants 1. Professor & Head Dept.of Prosthodontics, H.S.Judge Institute of Dental Sciences and Hospital Chandigarh 2. Senior Lecturer Dept. of Prosthodontics, Shri Sukhmani Dental College and Hospital, Derabassi, Punjab3. Senior Lecturer Dept. of Conservative Dentistry and Endodontics, Shri Sukhmani Dental College and Hospital, Derabassi, Punjab The Journal of Implant & Advanced Clinical Dentistry • 83

Walia et al INTRODUCTION nate, risedronate, pamidronate, zoledronic acid, andibandronate, which are called aminobisphos-Bisphosphonates (BPs) are drugs for inhibiting phonates, have much higher potency becausebone resorption, widely used for the treatment they contain nitrogen in a side chain (Table 1). Theof osteoporosis, multiple myeloma and skeletal non-aminobisphosphonates are metabolized bycomplications of bone metastases.1 The two osteoclasts to inactive nonhydrolyzable adenos-main categories of BPs are the non-nitrogen ine triphosphate analogues that are directly cyto-and nitrogen-containing BPs. Bisphosphonates toxic to the cell and induce apoptosis. The newercan be administered orally or intravenously. aminobisphosphonates have two actions: induc- tion of another adenosine triphosphate analogue Oral Bisphosphonates are also called nitro- that induces apoptosis, and inhibition of farnesylgen containing BPs. Their most common side diphosphonate synthase, which is part of the mev-effects are oral erosions, gastric ulcer, esoph- alonate pathway of cholesterol synthesis. Suchagitis and esophageal stenosis. The adverse inhibition results in dysregulation of intracellulareffects of intravenous bisphosphonates are transport, cytoskeletal organization, and cell pro-similar, but also include phlebitis, transient liferation, leading to inhibition of osteoclast func-febricula, chills, and pseudoinfluenza syndrome.2 tion. In addition, aminobisphosphonates reduceBisphosphonate-related osteonecrosis of the recruitment of osteoclasts and induce osteoblastsjaws (BRONJ) is a well-documented devastating to produce an osteoclast-inhibiting factor. Amino-side effect of long-term use of BPs.3 Osteone- bisphosphonates exert several antitumor effects,crosis (ON) presents as an exposure of alveo- including induction of tumor cell apoptosis, inhi-lar bone either spontaneously or secondary to bition of tumor cell adhesion to the extracellularinvasive oral surgical procedures. Radiologi- matrix, and inhibition of tumor invasion. Bisphos-cally, ON can manifest as normal bone, while phonates also have antiangiogenesis propertiesthe histological findings can correspond to and can activate T cells. The use of bisphospho-bone necrosis with bacterial colonization. This nates in patients with multiple myeloma and meta-article discusses the association of BRONJ and static cancer to the bones, such as breast, prostate,dental implants with its clinical presentation. lung, and renal cell carcinomas, has resulted in a statistically significant reduction in skeletal com- ACTIONS OF plications, including pathologic fractures, spinal BISPHOSPHONATES cord compression, hypercalcemia of malignant disease, and the need for subsequent radiother-Bisphosphonates are powerful inhibitors of osteo- apy or surgery to bone. Intravenous bisphospho-clastic activity. They are analogues of inorganic nates have improved bioavailability and do notpyrophosphates with low intestinal absorption, are produce gastrointestinal side effects, resultingexcreted through the kidneys without metabolic in better patient adherence. They have becomealteration, and have a high affinity for hydroxyapa- standard therapy in the management of patientstite crystals. Because they are incorporated into with multiple myeloma and metastatic cancer.4the skeleton without being degraded, they areremarkably persistent drugs; the estimated half-life for alendronate is up to 12 years. Alendro-84 • Vol. 3, No. 1 • December/January 2011

Walia et al Table 1: Bisphosphonate Formulations Generic Brand Manufacturer Dosage Nitrogen- Name Name and Location Forms Containing Etidronate Didronel Procter & Gamble 200-and No Disodium Pharmaceuticals 400-mg tablets No Cincinnati, OH No: Sulfer Moiety Clodronate Bonefos Schering AG, 400-and 800-mg Yes Disodium (Canada) Berlin, Germany tablets: Yes 60mg/mt. ampule* Yes Yes Tiludronate Skelid Sanofi-Synthelabo 200-mg tablet Yes Disodium Inc., New York, NY Yes Yes Alendronate Fosamax Merck & Co. Inc. 5-, 10-, 35-, 40-, Sodium Whitehorse and 70-mg tablets; Station, NJ 70mg/75kL oral solution Alendronate Fosamax Merck & Co. Inc 70-mg and 2800-U Sodium plus Plus D Whitehorse cholecalciferol Vitamin D Station, NJ tablet Pamidronate Aredia Novartis 30-, 60-, and Disodium Pharmaceuticals 90-mg vials* East Hanover, NJ Risedronate Actonel Procter & Gamble 35- and 500-mg Sodium Pharmaceuticals Calcium tablet Cincinnati, OH Risedronate Actonel Procter & Gamble 5-, 30- and Sodium with Calcium Pharmaceuticals 35-mg tablet plus Calcium Cincinnati, OH Zoledronic Zometa Novartis 4-mg vial* Acid Pharmaceuticals East Hanover, NJ Ibandronate Boniva Roche 2.5-mg tablet Sodium Laboratories, Inc. 150-mg tablet Nutley, NJ 3mg/3mL*FDA = Food and Drug Administration *Drug is administered intravenously The Journal of Implant & Advanced Clinical Dentistry • 85

Walia et al RISK FACTORS and BRONJ that developed atleast after 6 months was classified as spontaneous. According toVarious systemic and local factors could influence study done by Lazarovici et al 22.2% cases werethe incidences of BRONJ. There is a greater surgically related and 77.8% developed spon-occurrence of BRONJ with more potent BP’s taneously and occurred as a late complication.3and if they are taken for extended periods of time.Local risk factors which increase the incidence of The other issue is the route of administrationBRONJ include dental extractions, implant place- of drugs. Incidence of BPs associated ON ofment, surgical procedures including osteotomy, the jaw is estimated to the range of 0.8-12% forand anatomical structures such as tori. Sys- patients receiving intravenous formulations.15 16temic risk factors which increase the incidence For patients taking oral medication, the incidenceof BRONJ include: increasing age, diabetes mel- is estimated to be 0.7 per 1,000,000 persons perlitus, steroid use, cancer therapy, and smoking. year of exposure.17 Patient’s taking oral BPs mani- fest less bone exposure and mild symptoms com- ASSOCIATION OF BRONJ pared to patients with intravenous BP’s, since with WITH DENTAL IMPLANTS oral bisphosphonates it took longer to develop BP induced osteonecrosis because of a slower accu-As the aging population grows, the number of mulation rate in bone. Intravenous BP administra-patients with osteoporosis and skeletal disor- tion is regarded as an absolute contraindicationder increases, thus the number of patients taking to the placement of DIs. However, controversyBP’s for the treatment is also on the rise. Numer- arises in the cases of treatment with the oral BPs.ous reports of the occurrence of BRONJ suggestthat the dental extractions are the main triggering Madrid and Sanz reviewed 1 prospectiveevent for its development.5-7 However, there are and 3 retrospective studies and reported thatfew reports on BRONJ associated with the place- there was no BRONJ after implant placement inment of dental implants (DIs) or failure of DIs asso- 217 patients who took oral BPs for less than 5ciated with BP therapy. Fugazzotto et al8 placed years.18 According to Jeffcoat et al, there was a169 DIs in 61 patients, Grant et al9 placed 468 100% success rate with no clinical evidence ofDIs in 115 patients, Bell and Bell10 placed 101 infection, pain, or necrosis in the patients whoDIs in 42 patients, and Jeffcoat11 placed 102 received oral bisphosphonates for 1-3 years.11DIs in 25 patients. None of these researchersfound any cases of BRONJ associated with the Grant et al placed 468 implants in 115DIs. Moreover, some studies have demonstrated patients those were receiving oral biphos-a positive effect of oral BPs on the osseointe- phonate therapy. There was no evidencegration of DIs and treatment of periodontitis.12-14 of bisphosphonate-associated osteone- crosis of the jaw in any of the patients.9 One of the most important issues concerningBRONJ is the timing of the development of BRONJ DISCUSSIONin reference to the placement of the DIs. BRONJthat developed less than 6 months from the time of The demand of DIs has increased enormously inDI placement was classified as surgically related, recent years. A large percentage of the popula- tion requiring treatment with DIs is elderly per-86 • Vol. 3, No. 1 • December/January 2011

Walia et alsons over 65 years of age in which osteoporosis CONCLUSIONis very common. This increased demand for theplacement of DIs in osteoporotic patients treated Current evidence suggests the avoidance ofwith BPs makes necessary for dental profession- dental implant procedure in patients that haveals to improve their knowledge of this disease, its been receiving intravenous BPs. In the casetreatment, and the effects of BPs upon DI surgery. of administration via the oral route caution is required avoiding these procedures or indicat- The placement of DIs induces a series of met- ing them only when absolutely necessary. ●abolic changes around the implants that shouldlead to the formation of bone intrinsically bound Correspondence:to the implant surface. If the bone surrounding Dr. Manpreet S Waliathe DI presents a medium to high concentration of H.No. 477, Sector 6, PanchkulaBP’s, the turnover and remodeling processes will Phone: 09876644433be hindered or prevented, with the risk of necro- Email: [email protected] of the surrounding bone. If dental implants areto be placed, the physician should be contacted References:who has prescribed the oral BP’s prior to surgery, 1. S edghizadeh PP, Stanley K, Caligiuri M, Hofkes S, Lowry B, Shuler CF. Oralto suggest an alternate dosing, a drug holidayor an alternative to bisphosphonates therapy.19 bisphosphonate use and the prevalence ofosteonecrosis of the jaw: An institutional Oral bisphosphonate use and the prevalence of inquiry. J Am Dent The American Dental Association expert panel Assoc 2009; 140: 61-6.recommends that patients taking oral bisphos- 2. P onte-Fernández N, Estefanía-Fresco R, Aguirre-Urizar JM. Bisphosphonates anphonates be informed about benefits and risks oral pathology I. General and preventive aspects. Med Oral Patol Oral Cir Bucalrelating to possible implant failure and osteone- 2006 Aug 1; 11(6):E396-400.crosis of the jaw for patients taking oral BPs. They 3. L azarovici TS, Yahalom R, Taicher S, Schwartz-Arad D, Peleg O, Yarom N.further recommend that nonsurgical or less inva- Bisphosphonate-Related Osteonecrosis of the Jaw Associated With Dentalsive treatment alternatives be used when possible Implants. J Oral Maxillofac Surg 2010; 68:790-6.but they did not prohibit the placement of dental 4. W oo SB, Hellstein JW, Kalmar JR. Systemic Review: Bisphosphonates andimplants in patient receiving oral BPs treatment. osteonecrosis of the jaws. Ann Intern Med 2006;144: 753-61. 5. M igliorati CA, Casiglia J, Epstein J, et al: Managing the care of patients with When treatment plan involves the medullary bisphosphonate-associated osteonecrosis: An American Academy of Oralbone and/or periosteum in multiple sextants, Medicine position paper. J Am Dent Assoc 2005; 136:1658.treatment of one sextant or tooth at a time should 6. A merican Association of Oral and Maxillofacial Surgeons: Position paper onbe done and a 2 month disease free follow-up bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg 2007;before other sextant to be treated.17,19 Although 65:369.the patients may be at increased risk when 7. M avrokokki T, Cheng A, Stein B, et al: Nature and frequency of bisphosphonate-extensive implant placement or guided bone associated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg 2007;regeneration is necessary but the additional 65:415.research is necessary to guide the additional 8. F ugazzotto PA, Lightfoot WS, Jaffin R, et al: Implant placement with ordiagnostic testing, management or treatment without simultaneous tooth extraction in patients taking oral bisphosphonates:modifications for patients taking oral BPs. Postoperative healing, early followup, and the incidence of complications in two private practices. J Periodontol 2007; 8:1664. 9. G rant BT, Amenedo C, Freeman K, et al: Outcomes of placing dental implants in patients taking oral bisphosphonates: A review of 115 cases. J Oral Maxillofac Surg 2008; 66:223. 10. B ell BM, Bell RE: Oral bisphosphonates and dental implants: A retrospective study. J Oral Maxillofac Surg 2008; 66:1022. 11. J effcoat MK: Safety of oral bisphosphonates: Controlled studies on alveolar bone. Int J Oral Maxillofac Implants 2006; 21:349. 12. A nonymous: Alendronate may enhance implant osseointegration, study finds. J Am Dent Assoc 2008; 139:679. 13. Giro G, Sakakura CE, Gonçalves D, et al: Effect of 17betaestradiol and alendronate on the removal torque of osseointegrated titanium implants in ovariectomized rats. J Periodontol 2007; 78:1316. 14. S tadelmann VA, Gauthier O, Terrier A, Bouler JM, Pioletti DP. Implants delivering bisphosphonate locally increase periprosthetic bone density in an osteoporotic sheep model. a pilot study. European Cells and Materials 2008; 16: 10-6. 15. B amias A, Kastritis E, Bamia C, Moulopoulos LA, Melakopoulos I, Bozas G et al. Osteonecrosis of the jaw in cancer after treatment with bisphosphonates: Incidence and risk factors. J Clin Oncol. 2005 Dec 1; 23(34):8580-7. 16. Z avras AI, Zhu S: Bisphosphonates are associated with increased risk for jaw surgery in medical claims data; Is it osteonecrosis? J Oral Maxillofac Surg 2006; 64:917. 17. A merican Dental Association Council on Scientific Affairs: Dental management of patients receiving oral bisphosphonate therapy: Expert panel recommendations. J Am Dent Assoc 2006; 137: 1144. 18. M adrid C, Sanz M. What impact do systemically administrated bisphosphonates have on oral implant therapy? A systematic review. Clin Oral Implants Res 2009;20 Suppl 4:87-95. 19. Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, The Journal of Implant & Advanced Clinical Dentistry • 87