Maxillary Sinus Augmentation

VOLUME 1, NO. 8 NOVEMBER 2009 The Journal of Implant & Advanced Clinical Dentistry Maxillary Sinus Augmentation Histologic and Histomorphometric Analysis Single Surgery Comprehensive Gingival CE Credit Grafting Technique 2 Hours of



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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 13 Case of the Month Biologic Shaping Daniel Melker 19 JIACD Continuing Education Management of the Actively Bleeding and Hypovolemic Dental Patient Dan Holtzclaw, Nicholas Toscano 29 Single Surgery Comprehensive Gingival Grafting Utilizing Palatal Donor Tissue M. Thomas Wilcko, William M. Wilcko 49 Maxillary Sinus Floor Augmentation: A Histologic and Histomorphometric Human Grafting Study Comparing Two Anorganic Bovine Bone Minerals Aron Gonshor, Yoon-Je Jang The Journal of Implant & Advanced Clinical Dentistry 3



The Journal of Implant & Advanced Clinical Dentistry Table of Contents 59 Preservation of Buccal Bone Plate after Immediate Implant Placement/Function with the Flapless Approach: A Case Report Arthur B. Novaes Jr., Rafael R. de Oliveira, Valdir A. Muglia 69 Subperiosteal Dental Implants: A 25 Year Retrospective Survival Evaluation Antonio T. Di Giulio, Giancarlo Di Giulio, Enrico Gallucci 77 Dental 3D Imaging Centers - Usage and Findings: Part III – Bi d Canals and Other Deviations of the Inferior Alveolar Nerve Alan Alan A. Winter, Kouresh Yousefzadeh, Alan S. Pollack, Michael I. Stein, Frank J. Murphy, Christos Angelopoulos The Journal of Implant & Advanced Clinical Dentistry 5



The Journal of Implant & Advanced Clinical Dentistry Publisher Copyright © 2009 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD- Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest, constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article. the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA. or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry 7

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The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS A Minimally Invasive and SystematicEAdpiptororaiachl AtodSviinsuosrGyrBafotianrgd Tara Aghaloo, DDS, MD Richard Hughes, DDS George Priest, DMD Faizan Alawi, DDS Debby Hwang, DMD Giulio Rasperini, DDS Michael Apa, DDS Mian Iqbal, DMD, MS Michele Ravenel, DMD, MS Alan M. Atlas, DMD Tassos Irinakis, DDS, MSc Terry Rees, DDS Charles Babbush, DMD, MS James Jacobs, DMD Laurence Rifkin, DDS Thomas Balshi, DDS Ziad N. Jalbout, DDS Georgios E. Romanos, DDS, PhD Barry Bartee, DDS, MD John Johnson, DDS, MS Paul Rosen, DMD, MS Lorin Berland, DDS Sascha Jovanovic, DDS, MS Joel Rosenlicht, DMD Peter Bertrand, DDS John Kois, DMD, MSD Larry Rosenthal, DDS Michael Block, DMD Jack T Krauser, DMD Steven Roser, DMD, MD Chris Bonacci, DDS, MD Gregori Kurtzman, DDS Salvatore Ruggiero, DMD, MD Hugo Bonilla, DDS, MS Burton Langer, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Aldo Leopardi, DDS, MS Frank Setzer, DDS Ronald Brown, DDS, MS Edward Lowe, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Shannon Mackey Dennis Smiler, DDS, MScD Donald Callan, DDS Miles Madison, DDS Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Carlo Maiorana, MD, DDS Muna Soltan, DDS Daniele Cardaropoli, DDS Jay Malmquist, DMD Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Louis Mandel, DDS Ahmad Soolari, DMD John Cavallaro, DDS Michael Martin, DDS, PhD Christian Stappert, DDS, PhD Stepehn Chu, DMD, MSD Ziv Mazor, DMD Neil L. Starr, DDS David Clark, DDS Dale Miles, DDS, MS Eric Stoopler, DMD Charles Cobb, DDS, PhD Robert Miller, DDS Scott Synnott, DMD Spyridon Condos, DDS John Minichetti, DMD Haim Tal, DMD, PhD Sally Cram, DDS Uwe Mohr, MDT Gregory Tarantola, DDS Tomell DeBose, DDS Jaimee Morgan, DDS Dennis Tarnow, DDS Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA Douglas Deporter, DDS, PhD Peter K. Moy, DMD Tiziano Testori, MD, DDS Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Michael Tischler, DDS Nicolas Elian, DDS Ross Nash, DDS Michael Toffler, DDS Paul Fugazzotto, DDS Gregory Naylor, DDS Tolga Tozum, DDS, PhD Scott Ganz, DMD Marcel Noujeim, DDS, MS Leonardo Trombelli, DDS, PhD Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Ilser Turkyilmaz, DDS, PhD David Guichet, DDS Arthur Novaes, DDS, MS Dean Vafiadis, DDS Kenneth Hamlett, DDS Andrew M. Orchin, DDS Hom-Lay Wang, DDS, PhD Istvan Hargitai, DDS, MS Charles Orth, DDS Benjamin O. Watkins, III, DDS Michael Herndon, DDS Jacinthe Paquette, DDS Alan Winter, DDS Robert Horowitz, DDS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Huber, DDS Stan Presley, DDS Richard K. Yoon, DDS The Journal of Implant & Advanced Clinical Dentistry 9



Editorial Commentary We Have the Technology. Let’s Use It! Iam a big history buff and I am always amazed at the progress of mankind. When you think continuing education seminars. Third, they would about what we as a people have accomplished, sponsor presentations at large organizational meetings. The company sponsored campaigns it literally boggles the mind. As civilizations did an effective job of generating interest in developed in millennia past, the isolation of the new technique or product, but it was not different communities resulted in a great number until the articles were actually published that of technologies that were quite disparate from they gained full acceptance. Once the articles one another. The sheer distances between were published, hopefully, you subscribed to the these communities and the difficulties of travel journal publishing said articles. If not, you could imposed by various natural and human elements purchase the article for upwards of $30 or you hampered the sharing and dissemination of these were just simply out of luck. technologies. In ancient times, the main source When the Journal of Implant and Advanced of communication between civilizations rested in Clinical Dentistry (JIACD) was released in early the hands of merchant traders. As they traveled 2009, this process changed for the better. Firstly, to distant lands to exchange goods, these traders JIACD is available to everyone at no charge. also acquired knowledge; knowledge of different Second, JIACD is freely accessible via the internet. cultures and customs, knowledge of different arts With the simple click of a button, the entire world and humanities, and most importantly, knowledge has access to every article ever published in JIACD. of different technologies. Upon their return Third, because JIACD is an online publication home, this knowledge was imparted to their with an enormous peer review board, articles may native peoples and incorporated or adapted to be reviewed and published with extraordinary fit their needs. This process was difficult, often promptness. I suspect that it is only a matter of dangerous, and could take many years to complete. time before other journals begin to follow our lead. Now let’s shift gears and think about how The time has come for dental information to be free all of this relates to our beloved profession of and instantly accessible to all. dentistry. As recently as just a few years ago, Modern technology has made the world a much the dissemination of knowledge in our community smaller place, mainly through vast improvements was a painfully slow process. Essentially, if a in our ability to communicate with one another. new technique or product was to be discussed, Compared to our ancestors, when you think about it was first published in a print journal. As I have how easy it is for us to acquire knowledge in mentioned in a previous editorial, the peer review modern times, it is almost embarrassing. and publication process for such an article can take up to 24 months. While waiting for the articles to be published, companies wishing to promote their new product, or procedures using their products, would do a few things to get out information faster. First, they would advertise. Second, they would Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS hold company sponsored training sessions and Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 11

Kurtzman

Case of the Month Kurtzman Biologic Shaping Daniel Melker, DDS1 Abstract When performing conventional crown Considering these and other important lengthening, the existing margins of an aspects of crown lengthening, the concept old restoration or the cementoenamel of “Biologic Shaping” was established. Rea- junction (CEJ) of a non-restored tooth are used sons for Biologic Shaping include: 1) Replace to determine necessary bone removal to estab- or supplement the current indications for clini- lish adequate space for biologic width. Creat- cal crown lengthening; 2) Minimize ostectomy; ing proper space for biologic width ensures that 3) Facilitate supragingival or intrasulcular mar- the new margin will not infringe upon the peri- gins to preserve biologic width; 4) Eliminate odontal complex and reduces the likelihood for developmental grooves; 5) Eliminate previous future inflammation. One significant problem of subgingival restorative margins; 6) Reduce this procedure is that, at times, significant bone or eliminate furcation anatomy and thus facili- must be removed. This can weaken the stabil- tate margin placement; 7) Allow supragingi- ity of the tooth or create a weakened and vulner- val or intracrevicular impression techniques. able furcation area. The more bone removed The following article presents a series of Bio- in the furcation, the greater the likelihood of logic Shaping cases and the author discusses future problems with maintenance. It is critical requirements for successful treatment gleaned to preserve as much bone as possible to sup- over the past 33 years of his career in which he port the tooth, especially in the furcation area. has used this technique on over 30,000 teeth. KEY WORDS: Biologic shaping, biologic width, ostectomy, osteoplasty 1. Private practice limited to periodontics, Clearwater, Florida, USA The Journal of Implant & Advanced Clinical Dentistry 13

Melker The clinical prerequisites and steps for 8. Once the flaps are adapted, Potassium success with Biologic Shaping are as follows: oxylate should be used to help decrease post-surgical sensitivity. The liquid is applied 1. All previous restorative materials and decay to the root surface for 45-60 seconds and should be removed. then lightly air dried. Repeat 2-3 times. 2. A core buildup of composite bonded resin 9. Cement provisional prosthesis with a should be placed where necessary to Polycarboxlate cement such as Tylok® add volume to the teeth. The core helps (Dentsply International; York, Pennsylvania, determine where the final margin placement USA) or Durelon. of the new restoration will be placed. 10. Homecare instructions include rinsing with 3. Acrylic provisionals should be placed Chlorhexidine twice daily (morning and with Durelon (3M™ ESPE™; St. Paul, evening) and brushing with Prevident at Minnesota, USA) as the temporary bedtime. After meals the patient rinses cement. This cement is recommended for with water or Listerine to remove any food its antimicrobial properties and ability to particles. help decrease sensitivity. 11. At 4 weeks, the provisionals are either 4. Removal of provisional restorations at time remade or relined leaving 1mm of space of surgery to allow better access. for continued Biologic Width growth in a coronal direction. No margination of tooth 5. Shape root and remove old margin as surface at this time. well as 360 degrees of CEJ’s. Reduce or eliminate cervical enamel projections. 12. At 14 weeks Chamfer margins are placed Facilitate ideal restorative emergence at the gingival collar and impressions profile (Flat is better than fat contours). taken. When endodontics is present the Diamond burs are recommended for this new margin may be placed within the process. sulcus. 6. Correct any reverse architecture and 13. Facilitate hygiene and maintenance remove necessary bone where violation of procedures. biologic width may still be anticipated. Correspondence 7. If insufficient keratinized tissue is present at Dr. Daniel Melker the surgical site, add sufficient connective 28465 US HWY 19 N to protect bone from bacterial infiltration. Suite 204 The connective also protects underlying Clearwater, FL 33761 periodontal tissues from impression Phone: (727) 725-0100 material and cementation irritation. Email: [email protected] 14 Vol. 1, No. 8 November 2009

Melker The Journal of Implant & Advanced Clinical Dentistry 15

Melker 16 Vol. 1, No. 8 November 2009

Melker The Journal of Implant & Advanced Clinical Dentistry 17



JIACD Continuing EducatiJoIAnCD Continuing Education Management of the Actively Bleeding and Hypovolemic Dental Patient Abstract Background: With an increasing number of den- Results: Dental literature reported life threaten- tists incorporating surgical procedures such as ing hemorrhagic complications with common sur- implant dentistry into their daily practice, the ability gical dental procedures ranging from endosseous to manage hemorrhagic complications is indispens- implant placement to third molar extractions. In most able. The purpose of this article is to provide an cases, actively bleeding and hypovolemic patients updated review on contemporary oral hemostatic were managed with relatively simple local measures. measures and offer literature based recommen- dations on the perioperative management of the Conclusions: Under most circumstances, and with actively bleeding and hypovolemic dental patient. proper management, the risk of uncontrolled hem- orrhage attributed to dental procedures is minimal. Methods: The authors reviewed medical and Proper management in such scenarios involves dental literature for reports of dental related adequate pre-operative patient assessment, profi- hemorrhagic complications, oral hemostatic ciency with local hemostatic control measures, and measures, and treatment of hypovolemia. familiarity with hypovolemic treatment protocols. KEY WORDS: Hypovolemia, bleeding, hemostasis, emergency 1. Private practice limited to Periodontics and Implant Dentistry, Austin, TX, USA 2. Private practice limited to Periodontics and Implant Dentistry, Washington DC, USA This article provides 2 hours of continuing education credit. Please click here for details and additional information. The Journal of Implant & Advanced Clinical Dentistry 19

JIACD Continuing Education Learning Objectives plications, most providers commonly associate potential bleeding problems with patients taking After reading this article, the reader should be antiplatelet and/or anticoagulation medications. able to: 1. Recognize the signs and symptoms of Improved understanding of cardiovascular physiology and advances in the management and hypovolemia. treatment of cardiovascular disease have ren- dered oral anticoagulation therapy a mainstay of 2. Understand how to manage hypovolemia. modern medicine. It is estimated that more than 50 million Americans adhere to a low dose daily 3. Understand how to manage intraoral aspirin protocol and other anticoagulants such as hemorrhaging. warfarin sodium and clopidogrel bisulfate routinely rank among the top 50 medications prescribed INTRODUCTION in the United States.10,11 As such, the likelihood of encountering anticoagulated patients is signifi- Though rare, life threatening hemorrhage has been cant. Should clinicians be worried about uncon- reported with common surgical dental procedures trolled hemorrhage with these patients? Studies ranging from endosseous implant placement to examining the hemorrhagic effects of antiplatelet third molar extractions.1-3 With an increasing anticoagulants on dental procedures have found number of dentists now incorporating surgical negligible increases in intraoperative and postoper- procedures into their daily practice, their risk of ative bleeding when local measures were used.12- encountering hemorrhagic complications is likely 14 Likewise, similar studies evaluating coagulation to increase.4-8 Knowledge of predisposing factors, cascade anticoagulants have generally found physiologic responses to, and clinical management no increased risk of intraoperative or postopera- of excessive hemorrhage may prove useful for pro- tive bleeding that could not be controlled with viders in such situations. Accordingly, the purpose local measures when International Normal Ratio of this case report is to review hemorrhage man- (INR) values were within therapeutic levels.15-18 agement in the dental setting and to provide an example of practical application of such principles. In addition to pre-operative consideration of a patient’s medication profile, anticipated blood loss PRE-OPERATIVE from the planned procedure must be considered. CONSIDERATIONS Expectant blood loss from a restorative procedure such as a dental amalgam will be considerably dif- With systemically healthy patients, the possibility ferent from that of a surgical procedure such as of uncontrolled hemorrhage resulting from a den- dental implant placement, periodontal flap proce- tal procedure seems remote. In fact, the risk of dure, or impacted third molar extraction. Studies moderate to severe bleeding induced by dental evaluating blood loss from restorative procedures treatment is less than 1% for the average patient.9 have reported minimal hemorrhagic complications, While obvious conditions such as Hemophilia and while those evaluating surgical operations such as Von Willenbrand’s Disease may cause clinicians flap-osseous procedures have found up to 592ml to consider the possibility of hemorrhagic com- 20 Vol. 1, No. 8 November 2009

JIACD Continuing Education of blood loss from a single surgical site.19,20 Blood Figure 1: Blood clot removed from patient with slow loss from surgical procedures is also influenced continuous hemorrhaging secondary to osseous by the experience level of the provider. Surger- periodontal surgery. ies performed by less experienced providers have been shown to take up to three times lon- blood loss exceeds 1000ml, dental literature rec- ger and may result in nearly twice as much blood ommends fluid replacement when blood loss loss as those performed by more experienced exceeds 500ml to account for postoperative practitioners.20 In general, however, most stud- hemorrhagic oozing (figure 1).27,28 A pragmatic ies have found that blood loss from dental pro- approach to fluid resuscitation in outpatient dental cedures is under 200ml and may be even less if settings is limited to cases with less than 1000ml the duration of the procedure does not exceed 2 of blood loss and the ability to control hemor- hours.20-23 Considering that a pint of blood, the rhaging. Cases exceeding these parameters amount generally taken during blood donation, is should be referred to a higher echelon of care. 473ml, the amount of blood lost during most den- tal procedures is well within the limits of safety. HEMHORRAGE MANAGEMENT HYPOVOLEMIA RECOGNITION With proper management, nearly all sce- AND MANAGEMENT narios of excessive bleeding can be ade- quately managed with relatively simple Life threatening situations resulting from exces- local measures (Figure 2, Table 1) such as: sive blood loss are often due to hypovolemic induced hemorrhagic shock.24 Blood loss exceed- Positive Pressure ing 1000ml, or 1/5 of an adult’s average blood Positive pressure aids hemostasis by promot- volume, may precipitate hypovolemic shock and ing occlusion of the site of injury and provid- lead to inadequate tissue perfusion/oxygenation.25 ing mechanical aid to clot formation.29 Positive Compensatory signs of hypovolemia include tachy- pressure to intraoral wounds is typically accom- cardia, hypotension, tachypnea, pallor, diaphore- plished by compressing moistened gauze on the sis, anxiety, nausea, thirst, and light headedness. site of hemorrhaging. Suturing wound margins If left untreated, hemorrhagic shock may progress or severed vessels is another method in which to loss of consciousness, coma, or even death. compressive force may be applied to bleed- When the source of bleeding is known, pri- mary goals in the treatment of hemorrhagic shock are to stop the source of hemorrhaging and restore circulating blood volume. The “three-to- one” rule for the treatment of hemorrhagic shock dictates the administration of 3ml of crystalloid (Lactated Ringers solution or normal saline) for every 1ml of blood loss replaced.26 Although hemorrhagic shock does not typically occur until The Journal of Implant & Advanced Clinical Dentistry 21

JIACD Continuing Education Product or Action Composition Action Positive Pressure N/A Vasoconstrictor Manual occulusive aid Gelfoam® 1:100,000 Epinephrine to clot formation Surgicel® Porcine derived gelatin sponge Activation of adrenergic CollaCote®, CollaPlug® Plant derived -cellulose receptors CollaTape®, UltraFoamTM Bovine derived collagen UltraWrapTM Crustacean derived chitosan Occlusive matrix; activation HemCon® of intrinsic pathway Tranexamic acid 4.8% Tranexamic Acid Occlusive matrix: activation Mouth Rinse Bovine derived thrombin of intrinsic pathway, N/A Topical Thrombin antibacterial properties Electrocautery Occlusive matrix, activation of intrinsic pathway Positively charged chitosan attracts negatively negatively charged red blood cells, antibacterial properties Binds to lysine receptor sites on plasmin and plasminogen inhibiting brin binding and brinolysis Enhances conversion of brinogen to brin High frequency electric current cauterizes tissue and induces blood coagulation 22 Vol. 1, No. 8 November 2009

JIACD Continuing Education Figure 2: Products commonly used to aid hemostasis. whole blood.32 Absorbable collagen sponges Clockwise from top: Gelatin sponge, Collagen plug, aids hemostasis by providing a simple occlusive Collagen tape, Oxidized regenerated cellulose, Chitosan matrix and through contact activation of the intrin- derived. sic pathway.33 When used for oral applications, this material typically liquefies within 2-5 days. ing areas.30 In many cases, minor hemorrhaging is often controlled with positive pressure alone. Oxidized Regenerated Cellulose Oxidized regenerated cellulose based products Vasoconstrictor such as Surgicel® (Ethicon Inc, Somerville, NJ) Dental anesthetics contain vasoconstrictor pri- are derived from plant based alpha-cellulose and marily to increase their duration of action and function hemostatically in a manner similar to minimize the risk of local anesthetic toxicity.31 absorbable gelatin sponges.34 A unique property Epinephrine, the most commonly utilized vaso- of oxidized regenerated cellulose is antibacterial constrictor in dental local anesthetics, is a cat- activity. Because this product has a relatively low echolamine that facilitates vasoconstriction via pH, a broad range of gram negative, gram posi- the activation of alpha adrenergic receptors. tive, and antibiotic-resistant bacteria have proven Alpha adrenergic activation by sympathomim- to be locally susceptible to oxidized regenerated ietic drugs such as epinephrine induces smooth cellulose.35 When used for oral applications, muscle contraction within blood vessels and this product typically resorbs with 7-14 days. ultimately leads to short term vasoconstriction. Absorbable Collagen Products Absorbable Gelatin Sponge Absorbable collagen products such as col- Gelfoam® (Pfizer, New York, NY) is a resorb- lagen tape, collagen plugs, and collagen able gelatin sponge of porcine origin that is foam are derived from bovine deep flexor ten- capable of absorbing up to 45 times it weight in dons and typically resorb completely within 14 days.36 Additional bovine derived products such as Avitene®, UltraFoam™, and UltraWrap™ (Traatek, Inc, Fort Lauderdale, FL.) have simi- lar properties. In addition to providing a simple occlusive matrix, these products promote hemo- stasis by virtue of their collagen content which activates the intrinsic coagulation cascade. Chitosan Derived Products Chitosan derived products such as HemCon® (HemCon Medical Technologies Inc, Portland, OR.) are extremely effective at promoting hemo- stasis and have recently been used by United The Journal of Implant & Advanced Clinical Dentistry 23

JIACD Continuing Education States military medical personnel for treatment bin is often bovine derived and is typically sup- of battlefield injuries. Chitosan is a naturally plied as a freeze dried sterile powder that must occurring polysaccharide that is commercially be reconstituted with sterile saline. For gen- produced via the deacetylation of crustacean eral use in dental applications, a topical throm- chitin.37 Positively charged chitosan molecules bin solution of 100 International Units/ml is readily attract negatively charged red blood recommended.43 Topical thrombin is often deliv- cells and the two form an extremely strong seal ered via pump/syringe spray or combined with that acts as a primary occlusive barrier for hem- a carrier such as a hemostatic gelatin sponge. orrhagic sites. With hemorrhaging limited and/ or stopped by this initial seal, the natural coagu- Electrocautery lation cascade ensues. Like oxidized regener- Electrocautery involves the application of a high- ated cellulose, chitosan derived products have frequency electric current to cauterize tissue and locally active antibacterial properties.38 Unlike induce blood coagulation. In dentistry, this pro- oxidized regenerated cellulose which relies on cess is typically accomplished with monophasic low pH for its antibacterial activity, however, electrosurgical units. In comparison to other local chitosan derived products achieve antibacte- means of hemostasis management, electrocautery rial properties via active cell wall disruption.39 may induce collateral thermal damage to adjacent tissues.44,45 As such, this treatment option is typi- Tranexamic Acid cally reserved for severe hemorrhaging scenarios. Tranexamic acid is an anticoagulant oral rinse that binds to lysine receptor sites on plasmin PRACTICAL CASE REPORT and plasminogen, ultimately inhibiting fibrin binding and fibrinolysis.40 This rinse is sup- The primary author was contacted by a patient plied in a 4.8% solution and patients may with a chief complaint of “my mouth won’t stop be instructed to rinse with 10ml four times bleeding.” Telephonic interview revealed the daily for 7 days following surgery.41 Rinsing patient to be a 22 year old white male with a non- with tranexamic acid solution results in thera- contributory medical history. The patient had peutic levels ( >100mg/ml) within the saliva undergone impacted third molar extractions one for 2-3 hours. Wounds healing in the pres- week prior and was without complication until ence of tranexamic acid have demonstrated the bleeding episode. According to the patient, increased tensile strength, thus making the his lower right extraction site began to hemor- clot more resistant to mechanical disruption.42 rhage during dinner subsequent to traumatic disruption with a piece of partially masticated Topical Thrombin food. The patient had attempted to control the Topical thrombin facilitates clot stabilization by bleeding by biting on moistened paper towels enhancing the conversion of fibrinogen to fibrin for over 2 hours prior to contacting the clinic. and forming a reinforcing meshwork for initial platelet plugs. Medical grade topical throm- Upon arrival of the treatment provider to the dental clinic, the patient appeared ashen, dia- phoretic, and continued to actively bleed from 24 Vol. 1, No. 8 November 2009

JIACD Continuing Education the mouth. The patient was seated in a dental treatment protocols. As more general dentists chair and rapid evaluation revealed fast paced now routinely perform surgical procedures that active hemorrhaging from extraction site 32 induce blood loss, such a knowledge base is and vital signs of the following: blood pres- essential and may one day prove life saving. sure (90/48), pulse (99), and oxygen saturation (95%). Using the pace of the active hemor- Professional Dental Education and Pro- rhaging as a guide, it was estimated that the fessional Education Services Group patient had lost approximately 1000ml of blood are joint sponsors with The Academy at this point. As vital signs were being taken, of Dental Learning in providing this the patient began to complain of “dizziness” and continuing dental education activity. nausea. The patient was placed into Trendelen- burg position, oxygen was administered via nasal The Academy of Dental Learning canula at a rate of 6L/min, oral suction was ini- is an ADA CERP Recognized Pro- tiated, and intravenous access was obtained in vider. The Academy of Dental Learn- the left antecubital vein with an 18 gauge cath- ing designates this activity for two eter. As 2000ml of Lactated Ringers solution hours of continuing education credits. were delivered to the patient, attempts were made to stop the hemorrhaging. The patient ADA CERP is a service of the Ameri- was repositioned and site 32 was generously can Dental Association to assist den- infiltrated with 2% lidocaine/1:100,000 epineph- tal professionals in identifying quality rine. As the vasoconstrictor took effect, bleed- providers of continuing dental educa- ing from site 32 decreased significantly and the tion. ADA CERP does not approve or patient was instructed to bite with positive pres- endorse individual courses or instruc- sure on moist gauze as he received the remain- tors, nor does it imply acceptance of der of the Lactated Ringers solution. After 30 credit hours by boards of dentistry minutes of subsequent evaluation, hemorrhaging from extraction site 32 ceased and the patient’s Correspondence: vital signs stabilized to within normal limits. Dr. Dan Holtzclaw 3016 Hidden Bluff Cove CONCLUSION Round Rock, TX 78665 Dental literature clearly demonstrates that FOR 2 HOURS CE CREDIT TAKE under most circumstances, and with proper THE QUIZ ON THE NEXT PAGE management, the risk of uncontrolled hemor- rhage attributed to dental procedures is mini- mal. Proper management in these scenarios involves adequate pre-operative patient assess- ment, proficiency with local hemostatic con- trol measures, and familiarity with hypovolemic The Journal of Implant & Advanced Clinical Dentistry 25

JIACD Continuing Education Disclosure 15. Ward B, Smith M. Dentoalveolar procedures 31. Malamed S. Handbook of Local Anesthesia 5th The authors report no conflicts of interest with for the anticoagulated patient: literature Edition. Mosby 2004: 416. anything mentioned in this article. recommendations versus current practice. J References Oral Maxillofac Surg 2007; 65(8): 1454-60. 32. Council on Pharmacy and Chemistry: 1. Mason M, Triplett R, Alfonso W. Life-threatening Absorbable gelatin sponge – new and 16. Alexander R, Ferretti A, Sorensen JR. Stop the nonofficial remedies. JAMA 1947; 135: 921. hemorrhage from placement of a dental implant. J nonsense not the anticoagulants: a matter of life Oral Maxillofac Surg 1990; 48(2): 201-4. and death. NY State Dent J 2002; 68(9): 24-6. 33. Ongkasuwan J. Hemostatic agents. Baylor 2. Moghadam H, Caminiti M. Life-threatening College of Medicine Grand Rounds Archive hemorrhage after extraction of third molars: case 17. Cannon P, Dharmar V. Minor oral surgical 2005; 10: 1-9. report and management protocol. J Can Dent procedures in patients on oral anticoagulants- Assoc 2002; 68(11): 670-4. -a controlled study. Aust Dent J 2003; 48(2): 34. Surgicel, Surgicel Nu-Knit, and Surgicel Fibrillar 3. Kalpidis C, Konstantinidis A. Critical hemorrhage 115-8. Absorbable Hemostat (oxidized regenerated in the floor of the mouth during implant cellulose) for Dental Use package insert. placement in the first mandibular premolar 18. Evans I, Sayers M, Gibbons A, Price G, Snooks Somerville, NJ: Ethicon, Inc 2003; 1-14. position: A case report. Implant Dent 2005; H, Sugar A. Can warfarin be continued during 14(2): 117-24. dental extraction? Results of a randomized 35. Spangler D, Rothenburger S, Nguyen K, 4. Misch C. Implants and the general practitioner. controlled trial. Br J Oral Maxillofac Surg 2002; Jampani H, Weiss S, Bhende S. In vitro Dent Today 2007; 26(8): 48-52. 40(3): 248-52. antimicrobial activity of oxidized regenerated 5. Bitter R. The periodontal factor in esthetic smile cellulose against antibiotic-resistant design: Altering gingival display. Gen Dent 2007; 19. Rooney T. General dentistry during continuous microorganisms. Surg Infect 2003; 4(3): 255- 55(7): 616-22. anticoagulation therapy. Oral Surg Oral Med 62. 6. Cottrell D, Reebye U, Blyer S, Hunter M, Oral Pathol 1983; 56(3): 252-5. Mehta N. Referral patterns of general dental 36. Collagen Dental Wound Dressings package practitioners for oral surgical procedures. J Oral 20. Baab D, Ammons W, Selipsky H. Blood loss insert. Brockton, MA: Collagen Matrix, Inc: 1-2. Maxillofac Surg 2007; 65(4): 686-90. during periodontal flap surgery. J Periodontol 7. Lanning S, Best A, Hunt R. Periodontal services 1977; 48(11): 693-8. 37. HemCon Dental Dressing package insert. rendered by general practitioners. J Periodontol Portland, OR: HemCon Medical Technologies 2007; 78(5): 823-32. 21. McIvor J, Wengraf A. Blood-loss in periodontal Inc: 1-30 8. Starr C, Maksoud M. Implant treatment in an surgery. Dent Pract Dent Rec 1966; 16(12): urban general dentistry residency program: A 7 448-51. 38. Muzzarelli R, Tarsi R, Filippini O, Giovanetti E, year retrospective study. J Oral Implantol 2006; Biagini G, Varaldo P. Antimicrobial properties 32(3): 142-7. 22. Hecht A, App A. Blood volume lost during of N-carboxybutyl chitosan. Antimicrob Agents 9. Curtis J, McLain J, Hutchinson R. The incidence gingivectomy using two different anesthetic Chemother. 1990; 34(10): 2019-23. and severity of complications and pain following techniques. J Periodontol 1974; 45(1): 9-12. periodontal surgery. J Periodontol 1985; 56(10): 39. Andres Y, Giraud L, Gerente C, Le Cloirec 597-601. 23. Berdon J. Blood loss during gingival surgery. J P. Antibacterial effects of chitosan powder: 10. Ajani U, Ford E, Greenland K, Giles W, Mokdad Periodontol 1965; 36: 102-7. mechanisms of action. Environ Technol 2007; 28(12): 1357-63. A. Aspirin use among U.S. adults: Behavioral 24. Perry M, O’Hare J, Porter G. Advanced trauma Risk Factor Surveillance System. Am J Prev life support (ATLS) and facial trauma: Can one 40. Gaspar R, Brenner B, Ardekian L, Peled M, Med 2006; 30(1):74-7. size fit all? Part 3: Hypovolaemia and facial Laufer D. Use of tranexamic acid mouthwash to 11. Top 50 Drugs Prescribed 2007. Humana Inc. injuries in the multiply injured patient. Int J Oral prevent postoperative bleeding in oral surgery Publication 2007: 1-2. Maxillofac Surg 2008; 37(5): 405-14. patients on oral anticoagulant medication. 12. Ardekian L, Gaspar R, Peled M, Brener B, Quintessence Int 1997; 28(6): 375-9. Laufer D. Does low-dose aspirin therapy 25. Gutierrez G, Reines H, Wulf-Gutierrez M. complicate oral surgical procedures? J Am Dent Clinical review: hemorrhagic shock. Crit Care 41. Bandrowsky T, Vorono A, Borris T, Marcantoni Assoc 2000; 131(3): 331-5. 2004; 8(5): 373-81. H. Amoxicillin-related postextraction bleeding in 13. Madan G, Madan S, Madan G, Madan A. Minor an anticoagulated patient with tranexamic acid oral surgery without stopping daily low-dose 26. Healey M, Davis R, Liu F, Loomis W, Hoyt rinses. Oral Surg Oral Med Oral Pathol Oral aspirin therapy: a study of 51 patients. J Oral D. Lactated ringer’s is superior to normal Radiol Endod 1996; 82(6): 610-2. Maxillofac Surg 2005; 63(9): 1262-5. saline in a model of massive hemorrhage and 14. Partridge C, Campbell J, Alvarado F. The effect resuscitation. J Trauma 1998; 45(5): 894-9. 42. Björlin G, Nilsson I. The effect of antifibrinolytic of platelet-altering medications on bleeding agents on wound healing. Int J Oral Maxillofac from minor oral surgery procedures. J Oral 27. Gores R, Royer R, Mann F. Blood loss Surg 1988; 17(4): 275-6. Maxillofac Surg 2008; 66(1): 93-7. during operation for multiple extraction with alveoloplasty and other oral surgical procedures. 43. Thrombin, Topical U.S.P. (Bovine Origin) J Oral Surg 1955; 13(4): 299-306. package insert. Middleton, WI: GenTrac Inc 2007: 1-2. 28. Johnson R. Blood loss in oral surgery. J Dent Res 1956; 35(2): 175-84. 44. Noble W, McClatchey K, Douglass G. A histologic comparison of effects of 29. Meehan S, Schmidt M, Mitchell P. The electrosurgical resection using different international normalized ratio as a measure electrodes. J Prosthet Dent 1976; 35(5): of anticoagulation: Significance for the 575-9. management of the dental outpatient. Spec Care Dentist 1997; 17(3): 94-6. 45. Arashiro D, Rapley J, Cobb C, Killoy W. Histologic evaluation of porcine skin incisions 30. Purcell C. Dental management of the produced by CO2 laser, electrosurgery, and anticoagulated patient. N Z Dent J 1997; scalpel. Int J Periodontics Restorative Dent 93(413): 87-92. 1996; 16(5): 479-91. 26 Vol. 1, No. 8 November 2009

JIACD Continuing Education Continuing Education JIACD Quiz #4 1. The risk of moderate to severe bleeding 6. How much blood loss may precipitate induced by dental treatment is less than: hypovolemic shock and lead to a. 1% c. 5% inadequate tissue perfusion/ b. 2% d. 10% oxygenation? a. 100 ml c. 750 ml 2. An estimate of how many Americans b. 250 ml d. 1,000+ ml adhere to a low dose daily aspirin protocol? 7. Compensatory signs of hypovolemia a. 2 million c. 50 million include which of the following? b. 14 million d. 75 million a. Tachycardia d. Nausea b. Hypotension e. All of the above 3. Surgical operations such as flap- c. Tachypnea osseous procedures have found up to how much blood loss from a single 8. How many milliliters of crystalloid surgical site? should be administered for every 1 a. 100 ml c. 495 ml milliliter of blood lost? b. 250 ml d. 592 ml a. 1 ml c. 3 ml b. 2 ml d. 5 ml 4. Surgeries performed by less experienced providers have been shown to take 9. Methods of hemorrhage management include which of the following? up to how many times longer than a. Positive pressure d. Electrocautery b. Vasoconstrictor e. All of the above those performed by more experienced c. Absorbable gelatin sponge practitioners? a. 2 times longer c. 4 times longer b. 3 times longer d. 5 times longer 5. In general, most studies have found that 10. Rinsing with tranexamic acid solution blood loss from dental procedures is: results in therapeutic levels (>100mg/ a. Negligible c. < 200 ml ml) within the saliva for how long? b. < 100 ml d. > 500 ml a. 30 – 45 minutes c. 3 – 4 hours b. 2 – 3 hours d. 5 – 6 hours CLICK HERE TO TAKE THE QUIZ The Journal of Implant & Advanced Clinical Dentistry 27

Wilcko et al

Single Surgery Comprehensive Wilcko et al Gingival Grafting Utilizing Palatal Donor Tissue 2 M. Thomas Wilcko, DMD1 Abstract Background: As many as 24 teeth can be which multiple areas of gingival recession are grafted in a single surgical appointment utilizing treated in a single surgical appointment uti- the patient’s own palatal tissue. If more than a lizing autogenous palatal donor tissue. His- dozen teeth require grafting, thick free gingival torical background and clinical descriptions grafts (FGG’s) can be split and the resulting of the surgical techniques are presented. subepithelial connective tissue grafts (SCTG’s) can be utilized in a bilaminar approach. The Results: In all four cases, multiple areas of resultant thinner FGG’s can be used in conjunc- gingival grafting were accomplished in a single tion with a retained semilunar flap and marginal surgery resulting in root coverage and a struc- tissue lifting. This case series presents 4 cases turally enhanced zone of gingival attachment. in which SCTG’s or a combination of SCTG’s and FGG’s are utilized for multiple areas of gin- Conclusion: With the techniques described in gival grafting at the same surgical appointment. this paper, the palate can provide an adequate amount of donor tissue for single surgery com- Methods: Four cases are presented in prehensive gingival grafting of up to 24 sites. KEY WORDS: Subepithelial connective tissue graft, free gingival graft 1. Private practice limited to Periodontics, Erie, Pennsylvania, USA, Clinical Associate Professor of Periodontology, Case University, Cleveland OH, Consultant, Naval Dental Center, Bethesda, MD 2. Private practice limited to Orthodontics, Erie, Pennsylvania, USA, Consultant, Naval Dental Center, Bethesda, MD The Journal of Implant & Advanced Clinical Dentistry 29

Wilcko et al INTRODUCTION graft was no longer needed in these bilaminar approaches and, as such, the harvesting tech- Over the past 45 years, gingival grafting uti- nique from the palatal donor site evolved into lizing palatal donor tissue has evolved from the excision of connective tissue only, reduc- merely a functional application for increasing ing the palatal donor site to an internal pouch. the width and thickness of the gingival attach- This permitted almost complete surface closure ment to also addressing esthetics by provid- and healing of the palatal donor site by primary ing for reconstructive root coverage. The use intention. The disadvantage of this technique of the subepithelial connective tissue graft is that only a rather limited amount of connec- (SCTG) is now widely accepted as the gold tive tissue can be retrieved during harvesting. standard of care in root coverage grafting.1 MATERIALS AND METHODS Historical Perspective The use of the free gingival graft (FGG) was Single Surgery Comprehensive Grafting first reported by Björn in 1963 for repair of a When a pouch technique is utilized for graft functionally deficient zone of gingival attach- harvesting, adequate SCTG can usually be har- ment.2 This technique was later improved upon vested from one side of the palate to graft about by Miller to also provide for root coverage in 3 teeth on average, for a total of approximately Class I and Class II marginal tissue reces- half a dozen teeth if both sides of the palate are sion.3 The preparation of the recipient site was used. When SCTG is required for root cov- accomplished through the sharp dissection of a erage on more than 6 teeth and one wishes split thickness flap leaving a very thin exposed to accomplish the grafting in a single surgical vascular surface overlying the bone onto which appointment, it is necessary to abandon the the FGG was sutured. The FGG itself included internal pouch technique of graft harvesting and both the epithelium and underlying connective instead harvest multiple FGG’s from the palate. tissue and, consequently, the resulting donor If FGG’s are harvested from the palate and de- site in the palate was subject to relatively slow epithelialized, enough subepithelial connective healing through secondary intention. The use of tissue can be obtained to perform root cover- an acrylic palatal stent to cover the donor site age grafting on about a dozen teeth at a single during healing lessened the likelihood of any sig- surgical appointment. If more than a dozen nificant postoperative bleeding and discomfort. teeth require root coverage grafting and one wishes to utilize strictly subepithelial connective As the predictability of root coverage became tissue, grafting can be performed in two sepa- more of a priority, newer bilaminar techniques rate surgeries leaving enough time between evolved in which palatal connective tissue was the surgeries for the palate to regenerate. sandwiched between the denuded root surfaces and overlying partial or full thickness flaps.4-9 The manner in which single surgery compre- Another bilaminar technique using SCTG’s has hensive gingival grafting can be accomplished also been reported with tunnel procedures.10-15 when more than a dozen teeth require gingival The epithelial covering of the free gingival grafting is to place the emphasis for root cov- 30 Vol. 1, No. 8 November 2009

Wilcko et al Figure 1a: Thick free gingival graft. Figure 1b: Carefully splitting thick free gingival graft from gure 1a. erage on the areas of gingival recession in the upper arch where esthetics is typically more of Figure 1c: Results from splitting graft: (1) thinner free an issue and to place an emphasis on improv- gingival graft and (1) subepithelial connective tissue graft. ing the functional and structural integrity of the zone of gingival attachment on the areas of gin- palatine artery can be inadvertently cut during gival recession in the lower arch by striving to the graft harvesting. This is addressed by using increase the width, thickness, and continuity interrupted loop sutures over the area to com- of the gingival attachment. An attempt is also press the tissues and slow the bleeding. The made to achieve some degree of root coverage donor sites are then covered with an acrylic stent in the lower arch, but this is presented to the to apply slight pressure, improve comfort, and patient with lower expectations. In this manner, reduce the likelihood of postsurgical bleeding. up to two dozen teeth can usually be grafted Recipient Site Preperation for SCTGs in a single surgical appointment utilizing the The recipient sites for SCTG’s are prepared patient’s own palatal tissue. This is made pos- prior to graft harvest. When a bilaminar sible by removing thick FGG’s from the palate and then precisely splitting them (figures 1a,1b). Each thick FGG that is harvested from the pal- ate is thus transformed into a thinner FGG and a separate SCTG (figure 1c). By doing so, the amount of palatal tissue made available for grafting is quickly doubled with the SCTG’s utilized in a bilaminar approach in the upper arch and the FGG’s utilized in the lower arch. Because thick FGG’s are needed, the greater The Journal of Implant & Advanced Clinical Dentistry 31

Wilcko et al Figure 2: Multiple free gingival grafts harvested from the onal flap advancement, and to assure passive palate. adaptation at closure. Following reflection of the flap, intramarrow penetrations or cortical cuts approach is being used to maximize root cover- are made interradicularly in the exposed bone. age, full thickness flap reflection is utilized at the recipient sites. Partial thickness flap reflection Recipient Site Preparation for FGG’s can also be utilized at the recipient sites with When FFG’s are used at recipient sites, prepa- equally good results, but this technique results ration is done in a very different manner than that in a thinner flap that can easily tear during reflec- of SCTG’s. A semilunar incision is first made tion. Intrasulcular releasing incisions are utilized at the base of the remaining gingival attach- in the areas of gingival recession to include the ment. If there is insufficient keratinized gingiva, facial aspects of the interdental papillae. Verti- the semilunar incision is made in the mucosal cal releasing incisions are used at the opposite tissue. After the scalloped incision is made ends of the intrasulcular releasing incision and outlining the base of the semilunar flap, a split extended into the alveolar mucosa. In the pos- thickness flap is apically reflected through sharp terior areas, the most distal vertical releasing dissection leaving the thinnest soft tissue layer incision is frequently omitted and, occasionally possible as the vascular bed for the FGG’s. in isolated areas, no vertical releasing incisions The reflection is carried 3 to 5 mm apical to the are used. Regardless of whether or not verti- anticipated apical edge location of the FGG’s. cal releasing incisions are included, a periosteal releasing incision is always made at the base of The apical base of the semilunar flap the flap for increased mobility, facilitation of cor- semilunar flap is re-outlined with the tip of a #12 blade. This releases the collar over the root prominences and also slightly loos- ens 1 to 2 mm of the labial interdental papil- lae. The semilunar flap is then gently elevated coronally resulting in what is referred to as marginal tissue lifting. This is a delicate pro- cess requiring time and patience as care must be taken not to tear the semilunar flap. Considerations for Palatal FGG Harvesting and Preparation In the typical palate, 4 FGG’s (two from each side) can be harvested (figure 2). The size of the palate will of course determine the maximum width and length of the individual grafts. The bigger issue becomes the manner in which the grafts will be utilized. If 2 FGG’s are removed 32 Vol. 1, No. 8 November 2009

Wilcko et al Figure 3a: Superior edge of free gingival graft sutured. Figure 3b: Periodontal dressing covering free gingival graft. from the same side of the palate, 1 to 2 mm of palatal tissue is left between the donor sites to the superior edge of the FGG is very carefully reduce healing time. It is also important to keep sutured to the semilunar flap collars. Only the the border of the donor sites at least two milli- superior edge of the FGG is sutured (figure meters shy of the posterior border of the stent to 3a). The FGG is held in close approximation prevent exposing the donor site beyond the con- to the underlying vascular bed with a periodon- fines of the stent coverage. Generally, it is easier tal dressing containing rosin that provides for to remove a thicker FGG from the lateral aspect improved adherence to the teeth (figure 3b). of the palate, where there is a thicker zone of subepithelial connective tissue to work with. Recipient Site Suturing of the SCTG’s The coronal edge of the SCTG is first sutured Recipient Site Suturing of the FGGs interproximally (figure 4a) with a resorbable The superior edge of the FGG is placed at the grafting material; 5-0 plain gut, 5-0 chromic inferior border of the semilunar flap. For a start- gut, or 4-0 Vicryl (Ethicon) suture materials ing point, one end of the FGG is sutured inter- seem to work equally well. The superior edge proximally. The FGG is then stretched and the of the SCTG must not come to a thin knife- opposite end of the FGG is sutured at the most like edge and may need to be trimmed to pro- distant interproximal area. This results in the vide adequate thickness for suturing. The semilunar flap being elevated to cover some or full thickness flap is coronally advanced to all of the exposed root surfaces in the areas of cover as much of the SCTG as possible (fig- the gingival recession. The FGG is then secured ure 4b). Complete coverage of the SCTG is into position by suturing it at the remaining preferable, but not always possible. The flap interproximal areas. Over the root prominences, is sutured into position with a non-resorb- able suture material such as CV-5 ePTFE, 3-0 The Journal of Implant & Advanced Clinical Dentistry 33

Wilcko et al Figure 4a: Coronal edge of SCTG sutured. Figure 4b: Coronally positioned ap covering SCTG. PTFE, or 5-0 Polypropylene. Preferably, at The patient is asked to remain on a very soft diet least one sling suture should be used around until all of the sutures have been removed. each grafted tooth, and the SCTG should be re-engaged. No periodontal dressing is used. Patient Awareness and Expectations A well-informed patient with realistic expec- Post-operative Instructions and Follow up tations is critically important when treating The patient is instructed to stay on a liquid or gingival recession. To this end, it is empha- extremely soft food diet until told otherwise. sized to the patient that the most impor- The patient is given a very soft toothbrush tant aspect of any gingival grafting is to and instructed to brush only the tips of the create an environment where additional teeth. A palatal stent is delivered (figure 5) gingival recession is less likely to occur. and the patient is instructed not to remove it. The most critical pre-treatment marker in At one-week post surgery any periodontal determining the likelihood of achieving root cov- dressing remaining is removed in addition to erage is the interproximal distance between the the sutures at the superior border of the FGG’s. alveolar crest and the corresponding cemntoe- The patient is still cautioned to remain on a very namel junctions (CEJ) as seen on the periapical soft diet. The palatal stent is removed, cleaned, radiographs. Generally speaking, approximately and reinserted after the palate is cleansed. 2.5mm is considered to be representative of an adequate biologic width,16-21 and this has proven With SCTG’s, the removal of the non-resorb- to be an excellent measurement in predicting able sutures is usually done in stages beginning the likelihood of being able to achieve good two weeks post-operatively. Loose sutures are root coverage. If radiographically the interproxi- removed initially, but any tight functional sutures mal distance between the alveolar crest and the are left in place until three weeks postopera- corresponding CEJ’s is 2.5mm or less, the like- tively when the suture removal is completed. 34 Vol. 1, No. 8 November 2009

Wilcko et al Figure 5: Palatal stent covering palatal donor sites. that is present. The resultant enhanced zone of gingival attachment created with this technique lihood of achieving fairly complete root cover- is conducive to coronal advancement at a sec- age is high when a bilaminar approach with a ond surgery if eventually deemed appropriate.22 SCTG and coronally advanced flap is utilized. As this interproximal distance increases beyond Additional Considerations 2.5mm, there is a proportionate decrease in the Wilcko et al first reported on the use of intra- amount of root coverage that can be expected. marrow penetrations in conjunction with SCTG’s for root coverage in 2005.23 Intrama- The most unappealing aspect of the FGG rrow penetration stimulates a regional accel- esthetics is the “tire patch” appearance at the eratory phenomenon (RAP) which provides localized recipient site. Extending the FGG’s an increase in hard and soft tissue reorgani- to cover large numbers of teeth, even inter- zation activity in close approximation to the spersed teeth without gingival recession, can osseous insult. It also provides a pathway for eliminate this unsightly appearance. At times the rapid efflux of pluripotential stem cells and little or no root coverage is achieved, espe- capillary budding from the medullary spaces. cially if the collars of the semilunar flap over the root prominences are torn. Even if the inter- Other than scaling of exposed root sur- proximal distance between the CEJ’s and the faces prior to flap reflection, no specific corresponding alveolar crest is 2.5mm or less root preparation is needed. Large cervi- generally only a couple of millimeters of root cov- cal restorations are removed following erage can be expected with the semilunar flap flap reflection and any sharp edges in the + free gingival grafts and marginal tissue lifting areas of cervical abrasion are smoothed. regardless of the amount of gingival recession CASE REPORTS Multiple sites of gingival recession are addressed with the FTF/SCTG approach uti- lized in all 6 cases presented in this paper. Additionally, a SLF/FGG with MTL approach is also used in the lower arches of 3 of the cases presented. One of the cases was treated in anticipation of possible orthodontic treatment, 1 of the cases was treated as part of the PAOO treatment, and 3 of the cases had previously had orthodontic treatment. The Journal of Implant & Advanced Clinical Dentistry 35

Wilcko et al Figure 6a: Right presurgical view of case 1. Figure 6b: Left presurgical view of case 1. Figure 6c: Preparation of right side of case 1. Figure 6d: Preparation of left side of case 1. Case 1 of 4 SCTG’s and 4 FGG’s. The 4 SCTG’s were A female patient, age 54, presented with up to sutured at the recipient sites (figures 6e,6f) 6mm of Miller Class I-III facial gingival reces- and FTF’s were coronally advanced. Several sion on multiple teeth (figures 6a,6b). Since sutures were used at the donor sites to lessen less than a dozen teeth required root coverage the bleeding (figure 6g), and the donor sites grafting, FTFs/SCTGs were utilized in all of the were covered with an acrylic stent. The donor involved areas. Preparation of the recipient sites sites in the palate healed uneventfully (figure involved interproximal intramarrow cuts (figures 6h). Healing of the recipient sites at 6 months 6c,6d). Four thick FGG’s were removed from after surgery can be seen in figures 6i and 6j. the palate and de-epithelialized to yield a total 36 Vol. 1, No. 8 November 2009

Wilcko et al Figure 6e: SCTG secured on right side of case 1. Figure 6f: SCTG secured on left side of case 1. Figure 6g: Case 1 palatal donor site immediately post Figure 6h: Case 1 palatal donor site healed after surgery. surgery. Figure 6i: Right view of case 1 at 6 months after surgery. Figure 6j: Left view of case 1 at 6 months after surgery. The Journal of Implant & Advanced Clinical Dentistry 37

Wilcko et al Figure 7a: Right presurgical view of case 2. Figure 7b: Left presurgical view of case 2. Figure 7c: Right view of RAP inducing intramarrow Figure 7d: Left view of RAP inducing intramarrow penetrations of case 2. penetrations of case 2. Case 2 penetrating was performed interradicularly A female patient, age 46, presented with Miller (figures 7c, 7d). Three thick FGG’s were Class I and II gingival defects on the facials of removed from the palate and de-epithelialized. 9 maxillary teeth (figures 7a, 7b). Because only The three resulting SCTG’s were then sutured 9 teeth were involved, it was decided to strictly at the recipient sites (figures 7e, 7f). The full utilize full thickness flaps and SCTG’s. Full thickness flaps were coronally advanced to thickness flaps were reflected at the 2 upper passively cover the SCTG’s. Postsurgical results recipient sites. Sulcular and mesial vertical at 2 years are shown in figures 7g and 7h. releasing incisions were utilized and intramarrow 38 Vol. 1, No. 8 November 2009

Wilcko et al Figure 7e: SCTG secured on right side of case 2. Figure 7f: SCTG secured on left side of case 2. Figure 7g: Right view of case 2 at 2 years after surgery. Figure 7h: Left view of case 2 at 2 years after surgery. The Journal of Implant & Advanced Clinical Dentistry 39

Wilcko et al AADDVVERETIRSETWISITHE Case 3 A male patient, age 37, was referred for a peri- TODAY! odontal evaluation in preparation for periodon- tally accelerated osteogenic orthodontics™ Reach more customers (PAOO™) treatment to include decrowding with the dental and space opening (figure 8a).24-26 Free gin- profession’s first gival grafting had been performed in the lower truly interactive anterior area 18 years earlier. There was pres- ently 2 to 3 mm of Miller Class I marginal tissue paperless journal! recession on the facials of teeth #11 and #12. It was decided to perform the FTF/SCTG pro- Using recolutionary online technology, cedure in conjunction with the PAOO™ surgery. JIACD provides its readers with an Following full thickness flap reflection and experience that is simply not available bone activation in the upper arch (figure 8b) a with traditional hard copy paper journals. SCTG was harvested and sutured over the bony dehiscences on the facials of teeth #11 and #12 (figure 8c). Bone grafting material was then placed, as dictated by PAOO™ protocol, around the SCTG and over the activated bone (figure 8d). The flap was then coronally advanced to cover the SCTG (figure 8e). Final results 7 years after treatment are shown in figure 8f. WWW.JIACD.COM 40 Vol. 1, No. 8 November 2009

Wilcko et al Figure 8a: Presurgical view of case 3. Figure 8b: Full thickness ap re ection and bone activation in case 3. Figure 8c: SCTG secured in case 3. Figure 8d: Bone grafting material placed as dictated by PAOO™ protocol. Figure 8e: Flap coronally advanced to cover the SCTG in Figure 8f: Results at 7 years after surgery. case 3. The Journal of Implant & Advanced Clinical Dentistry 41

Wilcko et al Figure 9a: Right presurgical view of case 4. Figure 9b: Left presurgical view of case 4. Figure 9c: Right view of RAP inducing intramarrow Figure 9d: Left view of RAP inducing intramarrow penetrations of case 4. penetrations of case 4. Case 4 sites (figures 9c, 9d), 3 thick FGGs and 1 FGG of A 57 year old female presented with Miller Class average thickness were removed from the palate. I and II gingival recession on the facial aspect of Utilizing a #15 Bard Parker blade each graft was many of her upper and lower teeth (figures 9a,9b). split to provide a thinner FGG and a SCTG. This Because of the large number of teeth requiring resulted in 3 thinner FGG’s and 3 SCTG’s, which grafts, it was decided to do full thickness flaps in addition to the 1 FGG that was not split, pro- with SCTG’s in the upper arch and semilunar vided for a total of 7 grafts. Figures 9e-9h show flaps with FGGs and marginal tissue lifting in the the grafts sutured at the recipient sites and cov- lower arch. A total of 21 teeth were grafted, 9 ered with periodontal dressing. The results can be teeth in the upper arch and 12 teeth in the lower seen 6 months postoperatively in figures 9i and 9j. arch. Following the preparation of the recipient 42 Vol. 1, No. 8 November 2009

Wilcko et al Figure 9e: Grafts secured on right side of case 4. Figure 9f: Grafts secured on left side of case 4. Figure 9g: Right view of periodontal dressing covering Figure 9h: Left view of periodontal dressing covering grafts of case 4. grafts of case 4. Figure 9i: Right view of case 4 at 6 months after surgery. Figure 9j: Left view of case 4 at 6 months after surgery. The Journal of Implant & Advanced Clinical Dentistry 43

Wilcko et al DISCUSSION technique described in this report provides a solution to the limited nature or autogenous tis- Predisposing anatomic considerations that may sue harvest. By obtaining very thick FGG’s and contribute to gingival recession include, but precisely splitting them, resultant SCTG’s and are not limited to, tooth position, gingival bio- now thinner FGG’s may be utilized for coverage type, oral hygiene practices, destructive hab- of up to 24 teeth in certain instances. This paper its, smokeless tobacco use, bony dehiscence showed reports of 6 cases in which scores of over root prominences, and an accompanying mucogingival defects were successfully treated inadequate zone of gingival attachment.27-29 in a single sitting with autogenous tissue. Very prominently positioned teeth are likely to have a bony dehiscence over the prominent SUMMARY root surface.30 Additionally, to complicate mat- ters, the gingival attachment in these areas also As many as a dozen areas of Miller Class tends to be narrower and thinner than what is I / II marginal tissue recession defects can be found on teeth positioned more centrally in grafted utilizing the FTF/SCTG approach to the alveolus.31 In such teeth, chronic gingi- achieve an enhanced zone of gingival attach- val inflammation can readily result in the api- ment with root coverage. If more than a dozen cal migration of the epithelial attachment and areas of Miller Class I and II marginal tissue resultant gingival recession. If the patient has recession defects require gingival grafts, thick impeccable oral hygiene, on the other hand, the FGG’s can be split, with the resulting thinner likelihood of gingival recession is minimized. FGG’s used in the lower arch in conjunction with a semilunar flap and marginal tissue lift- Contemporary methods of treating gingival ing approach. A few millimeters of root cover- recession typically involve the use of SCTG’s. age are possible and the enhanced zone of Due to the anatomy of the palate, a limited gingival attachment will have an acceptable amount of SCTG is available for harvest. In appearance if multiple FGG’s are used in a most situations, SCTG harvest is restricted to continuous unerupted fashion over many teeth. an area distal to the canine and anterior to the The results of these 2 grafting approaches have mesial aspect of the first molar (Wara-aswapati). proved stable with adequate oral hygiene. Straying beyond these limits may result in an inadequate SCTG harvest and increased risk of Correspondence: damaging the greater palatine artery. The lim- M. Thomas Wilcko, DMD ited availability of SCTG, even when harvested 6074 Peach Street, Erie, PA 16509 bilaterally, often restricts perio-plastic surgical Phone: (814) 868-3669 treatment to a maximum of 6 teeth in a single sit- Fax: (814) 864-1368 ting. Because of this, alternate allograft materi- Email: [email protected] als for soft tissue surgery have been introduced Website: www.fastortho.com to the market. These materials, while of unlim- ited abundance, are technique sensitive and may provide results that degenerate over time. The 44 Vol. 1, No. 8 November 2009

Wilcko et al Disclosure 14. Mahn D. Treatment of gingival recession with 28. Löst C. Depth of alveolar bone dehiscences in The authors report no conflicts of interest with a modified “tunnel” technique and an acellular relation to gingival recession. J Clin Periodontol anything mentioned in this paper. dermal connective tissue allograft. Pract Proced 1984; 11: 583-589. Aesthet Dent 2001; 13: 69-74. References 29. Maynard JG, Ochsenbein D. Mucogingival 1. Wennström J. Mucogingival therapy. Section 15. Tözum TF, Dini FM. Treatment of adjacent problems, prevalence and therapy in children. J gingival recession with subepithelial connective Clin Periodontol 1975; 6: 437-442. 8. 1996 World Workshop in Periodontics. Ann tissue grafts and the modified tunnel technique. Periodontol 1996; 1: 671-701. Quintessence Int 2003; 34: 7-13. 30. Holbrook T, Oschsenbein D. Complete coverage of the denuded root surface with a 2. Björn H. Free transplantation of gingival propria. 16. Garglulo A, Wentz F, Orban B. Dimensions one-stage gingival graft. Int J Periodontics Rest Sven Tandlak Tidskr. 1963; 22: 684-689. and relations of the dento-gingival junction in Dent 1983; 3: 9-27. humans. J Periodontol 1961; 32: 261-267. 3. Miller P. Root coverage using a free soft tissue 31. Wennström JL. Mucogingival considerations autograft following citric acid application. Part 17. Maynard J, Wilson R. Physiologic dimensions in orthodontic treatment. Seminars in 1: Technique. Int J Periodontics Rest Dent 1982; of the periodontium significant to the restorative Orthodontics 1996; 2(1): 46-54. 2: 65-70. dentist. J Periodontol 1979; 50: 170-174. 32. Batenhorst KF, Bowers GM, Williams JE. 4. Raetzke P. Covering localized areas of root 18. Ingber J, Rose L, Caslet J. The “biologic width” Tissue changes resulting from facial tipping and exposure employing the “envelope” technique. J – a concept in periodontics and restorative extrusion of incisors in monkeys. J Periodontol Periodontol 1985; 56: 397-402. dentistry. Alpha Omegan 1977; December: 62. 1974; September: 660-668. 5. Langer B, Langer L. Subepithelial connective 19. Kois J. Altering gingival levels: the restorative 33. Artun J, Krogstad O. Periodontal status tissue graft technique for root coverage. J connecti-Part1: biologic variables. J Esthetic of mandibular incisors following excessive Periodontol 1985; 56: 715-720. Dent 1994; 6(1): 3-9. proclination: a study in adults with surgically treated mandibular prognathism. Am J Orthod 6. Nelson SW. The subpedicle connective tissue 20. De-Jacoby L, Ziafiro G, Ciancio S. The effect Dentofacial Orthop 1987; 91: 225-232. graft. A bilaminar reconstructive procedure of crown margin location on plaque and for the coverage of denuded root surfaces. J periodontal health. Int J Periodontics Rest Dent 34. Wehrbein H, Bauer W, Diedrich P. Mandibular Periodontol 1987; 58: 95-102. 1989; 9(3): 147-205. incisors, alveolar bone, and symphysis after orthodontic treatment. A retrospective study. 7. Harris RJ. The connective tissue and partial 21. Nevins M, Skurow H. The intercrevicular Am J Orhtod Dentofacial Orthop 1996; 110(3): thickness double pedicle graft: A predictable restorative margin, the biologic width, and 239-246. method of obtaining root coverage. J Periodontol the maintenance of gingival margin. Int J 1992; 63: 477-486. Periodontics Rest Dent 1984; 4(3): 31-49. 35. Nyman S, Karring T, Bergenholtz G. Bone regeneration in alveolar bone dehiscences 8. Müller H, Eger T, Schorb A. Alterations of gingival 22. Maynard J. Coronal positioning of a previously produced by jiggling forces. J Periodontal Res dimensions in a complicated case of gingival placed autogenous gingival graft. J Periodontol 1982; 17: 316-322. recession. Int J Periodontics Rest Dent 1998; 1977; 4(3): 151-155. 18: 345-353. 36. Karrying T, Nyman S, Thilander B, Magnusson I. 23. Wilcko M, Wilcko W, Murphy K, Carroll W, Bone regeneration in orthodontically produced 9. Chambrone L, Chambrone L. Subepithelial Ferguson D, Miley D, Bouquot J. Full-thickness alveolar bone dehiscences. J Periodontal Res Connective Tissue Grafts in the treatment flap/subepithelial connective tissue grafting with 1982; 17: 309-315. of Multiple Recession-type of Defects. J intramarrow penetrations: three case reports of Periodontol. 2006; 77(5): 909-916. lingual root coverage. Int J Periodontics Rest 37. Fuhrmann RAW. Three-dimensional evaluation Dent 2005; 25(6): 561-569. of periodontal remodeling during orthodontic 10. Allen AL. Use of the supraperiosteal envelope in treatment. Seminars in Orthodontics 2002; soft tissue grafting for root coverage. II. Clinical 24. Wilcko W, Wilcko M, Bouquot J, Ferguson D. 8(1): 23-28. results. Int J Periodontics Rest Dent 1994; 14: Rapid orthodontics with alveolar reshaping: Two 302-315. case reports of decrowding. Int J Periodontics 38. Reitan K. Some factors determining the Rest Dent 2001; 21: 9-19. evaluation of forces in orthodontics. Am J 11. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz Orthodont 1957; 43: 32. M. Treatment of multiple adjacent gingival 25. Wilcko W, Ferguson D, Bouquot J, Wilcko M. recessions with the tunnel subepithelial Rapid orthodontic decrowding with alveolar 39. Reitan K. Tissue reaction as related to the age connective tissue graft: A clinical report. Int J augmentation: case report. World J Orthodont factor. Dent Rec 1954; 74: 271. Periodontics Rest Dent 1999; 19: 199-206. 2003; 4: 197-505. 40. Reitan K. Continuous bodily movement and its 12. Blanes RJ, Allen EP. The bilateral pedicle flap- 26. Wilcko M, Wilcko W, Bissada N. An evidence- histologic significance. 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Maxillary Sinus Floor Augmentation: Gonshor et al A Histologic and Histomorphometric Human Grafting Study Comparing Two Anorganic Bovine Bone Minerals Aron Gonshor DDS, PhD1 2 Abstract Background: Autogenous grafts have been the Results: Histomorphometry showed aver- “Gold Standard” in bone grafting. However, this age vital bone content of 33% (±15) for often calls for a second surgical site and insuffi- NuOss™ and 33% (±17) for Bio-Oss®. cient bone quantities. A need exists for a surgi- Residual graft content was 29% (±11) for- cal technique that does not require autogenous NuOss™ and 24% (±17) for Bio-Oss®. bone harvesting and still results in sufficient bone formation within a relatively short time frame. Conclusions: This study showed the similar osteoconductive properties of both NuOss™ Materials and Methods: This study com- and BioOss®. Clinical findings revealed a high pares two anorganic bovine bone miner- bone density during the period of the post graft- als (ABBMs) - NuOss™ and Bio-Oss® ing study. The results confirm that grafting - in an ongoing clinical human sinus floor aug- materials from a bovine source will produce reli- mentation project. Histology and histomorphom- able bone foundations for implant placement. etry were performed 5-10 months after grafting. KEY WORDS: Bone grafts, maxillary sinus floor augmentation, anorganic bovine bone mineral, osteoblast(s), NuOss, Bio-Oss 1. Lecturer, McGill University, Department Oral and Maxillofacial Surgery, Montreal, Quebec, Canada 2. Clinical Assistant Professor, New York University, Department of Periodontics and Implant Dentistry, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry 49