Volume 3, No. 3 March/April 2011 The Journal of Implant & Advanced Clinical Dentistry Site Preservation with Placental Membrane Extracellular Membrane Gingival Grafting
Compatibility Innovation Value Shipping World Wide Order online at www.blueskybio.com Blue Sky Bio, LLC is a FDA registered U.S. manufacturer of quality implants and not affiliated with Nobel Biocare, Straumann AG or Zimmer Dental. SynOcta® is a registered trademark of Straumann AG. NobelReplace® is a registered trademark of Nobel Biocare. Tapered Screw Vent® is a registered trademark of Zimmer Dental. *activFluor® surface has a modified topography for bone apposition on the implant surface without additional chemical activity. **U.S. and Canada. Minimum purchase requirement for some countries.
Osteogenics New AdFlash File only supplied
BTI SURGICAL EXPLANTATION KIT PATENTED This innovative system ensures a non-traumatic extraction of both internal and external connection implants.200 Ncm counter-torque wrench. Implant extractors Set of extensors for Handle for Torque for external and counter-torque wrench tips to carry internal connection. wrench for the the extractor. different clinical situations. The extractor is fixed to the implant following its axial direction (after selecting the extractor according the connection). Next, torque is applied gently in counterclockwise direction until the implant is fully extracted.Set of non-traumatic trephine drills www.bti-implant.com / www.endoret.usBTI of North America Biotechnology Institute BTI Deutschland GmbH. BTI Implant Italia Srl. BTI de México BTI Portugal1730 Walton Road San Antonio 15 - 5º Mannheimer Str. 17 Piazzale Piola n.1 Lope de Vega 117, 701-702 R. Pedro Homem de MeloSuite 110 01005 Vitoria (ALAVA) 75179 Pforzheim 20131 Milano 11570 Col. Chapultepec Morales 55 S/6.03Blue Bell, PA 19422-1802 US SPAIN GERMANY ITALY México DF • MEXICO 4150-000 Porto • PORTUGALTel: (1) 215 646-4067 Tel.: (34) 945 140 024 Tel: (49) 7231 428060 Tel.: (39) 02 70605067 Tel.: (52) 55 52502964 Tel: (351) 22 618 97 91Fax: (1) 215 646-4066 Fax: (34) 945 135 203 Fax: (49) 7231 4280615 Fax: (39) 02 70639876 Fax: (52) 55 55319327 Fax: (351) 22 610 59 [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]
Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the mostsafe, reliable and successful manner for their patients.The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implantplacement to final crown restoration. The natural profile developed during healing is matched perfectly in permanentrestorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAMsolutions.Neoss Inc., 21820 Burbank Blvd. #220, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com
Introducing the FeaturesPLANMECA® ProMax® 3D • 5 selectable, single scan fields of viewMax... Most common uses: ø5 x 5.5 cm - Individual tooth or other point of interest ø10 x 5.5 cm - Mandible or maxilla ø10 x 9 cm - Mandible and maxilla ø10 x 13 cm - Mandible or maxilla and sinus ø23 x 16 cm - Full maxillofacial image, upper or lower skull • The smallest and largest fields of view on the market giving the ProMax 3D Max more versatility then any other comparable X-ray unit • Large view, single acquisition - dual scan for full maxillofacial and skull imaging ø23 x 26 - Full skull covers the whole head and is therefore extremely useful for surgical and orthodontic procedures, as well as TMJ, ear, sinus, and airway studies. Using the large volume size, it is possible to generate a 2D cephalometric image with a single mouse click. • Automatically adjusts volume sizes for children When the child patient size is selected, the fields of view (volume sizes) and the dosage parameters are slightly reduced • More than 36 pre-programmed targets From a single tooth scan to the whole skull, the ProMax 3D Max has 18 pre-programmed targets, 5 adult fields of view, 5 child fields of view, and more • Patented SCARA technology allows limitless imaging possibilities • Full view, open patient positioning for standing, sitting, and wheelchair accessibility • Space saving A small footprint and compact design make the ProMax 3D Max the smallest large FOV on the market • High resolution, flat panel technology • Now compatible with Mac OS environment PLANMECA®PLANMECA® For more information on PLANMECA ProMax 3D MaxProMax® 3D Max please call... 1-630-529-2300 or visit us on the web @ www.planmecausa.com
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 3 • March/April 2011 Table of Contents19 T he Use of DynaMatrix® Extracellular Membrane for Gingival Augmentation and Root Coverage: A Case Series Stephen Andrew Saroff35 B ioXclude™ Placental Allograft Tissue Membrane Used in Combination with Bone Allograft for Site Preservation: A Case Series Dan Holtzclaw, Nicholas Toscano The Journal of Implant & Advanced Clinical Dentistry • 5
one Graft by Any OtherB Name Wouldn’t be Fact not fiction... Scientifically-proven in vivo rat model to confirm osteoinductivity (Urist’s model) • Precisely sized mineral-retained cortical cancellous bone chips– osteoconductive • Biocompatible inert biological carrier that offers exceptional handling and stability at the graft site • Some clinicians report stabilized implant placement at 5.5-6 month re-entry.1 The moral of the story... Don’t be persuaded by tales that other products offer the same predictable results you’ve come to expect from Regenaform®.Regenafil®, Regenaform®, pericardium and cortical allograft bone pins are processed by RTI Biologics, www.exac.com/fact © 2011 Exactech, Inc.Inc. and are distributed by Exactech, Inc. Oralife® allografts are processed by LifeLink Tissue Bank and 1-866-284-9690distributed by Exactech, Inc.1. Publications on file at Exactech.
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 3 • March/April 2011 Table of Contents55 Decoronation for Ridge Preservation in Implant Dentistry: A Clinical Technique and Case Report Tareq Abu-Saleh69 N eck Dissection for Oral Cancer Fayette C. Williams, Brent B. Ward, Sean P. Edwards The Journal of Implant & Advanced Clinical Dentistry • 7
... over 1 ROXOLID®sold! THE NEW “DNA” OF IMPLANT MATERIALS ROXOLID – the first TiZr material developed for dental implantology. Confidence when placing small diameter implants Flexibility of having more treatment options Designed to increase patients’ acceptance of implant treatment Straumann® SLActive million im plants Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us
It’s Like a Magnetfor New BoneHEALOS® is an attractive choice for building new bone. © OraPharma, Inc. 2011 Rx only. Please refer to the package insert for further details. Distributed by: OraPharma, Inc. Manufactured by: DePuy Spine, Inc.HEALOS® Bone Graft Substitute for Dental Applications is intended to HEALOS® is a registered trademark of DePuy Spine, Inc.fill, augment, or reconstruct periodontal and/or bony defects in the HEA-178-10 3/11upper or lower jaw.• Excellent clinical handling properties• Provides an osteoconductive scaffold that supports cell adhesion• Biomimetic composition (70% collagen, 30% mineral) mimics immature bone to encourage new bone growth• 98% porosity allows material to soak up endogenous blood and draw in osteoprogenitor cells comprehensively within the material• Radiolucent so new bone is easily distinguished on a radiographHEALOS® is intended to fill, augment, or reconstruct periodontal and/or bonydefects of the upper or lower jaw. HEALOS® is a bone graft substitute that isresorbed and remodeled into new bone as part of the natural healing process.Order HEALOS® Bone Graft Substitute Today!Call a HEALOS® representative: 1-866-273-7846or visit us at www.healosfordental.com
Treat small spaces with confidence Laser-Lok 3.0 placed in Radiograph shows proper esthetic zone. implant spacing in limited site. Image courtesy of Cary Shapoff, DDS Image courtesy of Michael Reddy, DDSIntroducing the Laser-Lok® 3.0 implantLaser-Lok 3.0 is the first 3mm implant that incorporates Laser-Lok technology to create a biologic seal and maintain crestal boneon the implant collar1. Designed specifically for limited spaces in the esthetic zone, the Laser-Lok 3.0 comes with a broad array ofprosthetic options making it the perfect choice for high profile cases. • Two-piece 3mm design offers restorative flexibility in narrow spaces • Implant design is more than 20% stronger than competitor implant2 • 3mm threadform shown to be effective when immediately loaded3 • Laser-Lok microchannels create a physical connective tissue attachment (unlike Sharpey fibers) 4 For more information, contact BioHorizons Customer Care: 888.246.8338 or shop online at www.biohorizons.com1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010.2. Implant strength & fatigue testing done in accordance with ISO standard 14801.3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC.Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288.4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim.International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP10109 REV D SEP 2010
The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 3 • March/April 2011Publisher Copyright © 2011 by SpecOps Media, LLC. All rightsSpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company SpecOps Media, LLC (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 11
SURGICAL SUPPLY CO., INC.www.acesurgical.com 800.441.3100 BUY GET * When you buy 5 Vials or 5 Blocks in January you get the 6th FREE! alloOss™ combines natural collagen and minerals with the bony structure of allograft to The complete line of ACE alloOss™ products promote new bone formation. The existence of these natural minerals and collagen facilitate have been processed and sterilized to the remodeling of the host bone suitable for implantation. highest standards set forth by both American Association of Tissue Banks (AATB) and FDA, alloOss Particle Size – Volume .5 cc Vial 1 cc Vial 2 cc Vial providing one of the purest particulate and Small • 250-1000 mic. 01-107-001 01-107-002 01-107-003 blocks available today. CANCELLOUS Large •1000-2000 mic. 01-107-101 01-107-102 01-107-103 CORTICO / Small •250-1000 mic. 01-104-001 01-104-002 01-104-003 CANCELLOUS Large •1000-2000 mic 01-104-101 01-104-102 01-104-103 CORTICAL Small •250-1000 mic. 01-160-001 01-160-002 01-160-003 Large •1000-2000 mic 01-160-101 01-160-102 01-160-103 PRICE $104.99 $168.99 $79.99 alloOss Size of Block 18 x 6 x 8mm 18 x 10 x 8mm 18 x 15 x 8mm *Lowest priced item is the FREE item. Size of Block 01-241-006 01-241-010 01-241-015 Offer good during the month of January 2011. BLOCK GRAFT $499.99 $579.99 $649.99 Call today to place an order 1.800.441.3100 PRICE or order online @ www.acesurgical.com ACE Surgical Supply Company, Inc. • 1034 Pearl Street, Brockton, MA 02301
The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Michael Huber, DDS Terry Rees, DDSMichael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MSThomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDDonald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDNicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDSDaniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMDGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDSStepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMDDavid Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhDSpyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDSSally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDSTomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MAMassimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDSDouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDSNicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhDPaul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhDScott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhDDavid Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDSRonald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhDDavid Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSKenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDSIstvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDSMichael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 13
SURGYBONE piezoelectric ultrasonic surgeryNow ultrasound technology S028i tip for HPISEallows a mini-invasive Biosurgerywith a reliable High Power and HPISE tip forWaterproof handpiece Crestal Sinus LiftAREAS OF USE Available!EXTRACTIONAPICOECTOMY The Basic 7 tips completeBONE HARVESTING your Oral Surgeries!!RIDGE EXPANSIONSINUS LIFT RoPNitsaRorPyEMeCBroIfuSreercEstW!OSSoSoUrTlruRyEtGiOwoYTintBOhfOoMrNYE.HPISE (Hydrodynamic PiezoelectricInternal Sinus Elevation) TESTIMONIALSELEVATION OF SCHNEINER MEMBRANEOSTEOPLASTY \"Dr. Sohn does a great job of simplifying bone grafting andOSTEOTOMY sinus augmentation procedures. You'll leave the course withIMPLANT SITE PREPARATION the confidence to tackle more difficult cases. I'd highlyROOT PLANNING recommend this course to anyone who currently places, orand moreover plans to place implants.”ORTHODONTIC & ORTHOGNATHIC SURGERY Dr. Jeremy Moore (General Practioner) Baton Rouge, PAENDODONTICS “Dr. Sohn, I attended your piezoelectric bone surgery seminarPERIODONTOLOGY in Los Angeles last week and enjoyed it very much. Thank you again for the outstanding lecture/training course. It was very Easy & Predictable Hard Tissue Augmentation informative, educational and practical. I learned a lot.” using Ultrasonic Piezoelectric Bone Surgery Dr. Andrew Satlin (Periodontist) Lakewood, CA “Hi DS, Thank you for coming to LA! The course was great. 2 Day Hands-on Course My brother, future associate and I really enjoyed it. They felt like 12 CE $1800 ($1310 if registered before Apr 30, 11) it was better than Dr. Carl Misch because you teach less invasive June 4 - 5, 2011 / Burbank, CA techniques that have the same or better results. I agree! “ For more information, Dr. Paul Maupin (General Practioner) Roswell, NM Young’s Dental Toll free: 800,676.7474 Fax: 562.404.4500 [email protected] INSTRUCTOR *Seats are limited. Register Now!! Prof. Dong-Seok Sohn DDS, MSD PhD *First time course attendees are eligible to participate 2 additional Prof. Sohn’s lectures at free of charge. (There is only charge of meals.)Distributor of Silfradent Young’s Dental Inc. 12110 E. Park Street, Cerritos CA 90703Toll Free: 1.800.676.7474, Fax: 1.562.404.4500, Email: [email protected]
Editorial CommentaryFads Come and Go . . . So Do Some Dental ProductsIf you are like me, you probably have a big stack of old dental journals sitting in the it was platform switching. Then it was thread garage. I hate to admit it, but I actually have design. Then it was surface again. Wow! Implant design has certainly progressed over the pasta giant bookcase full of over one thousand decade and many new innovations have becomedental journals from the past decade. My wife commonplace. Other innovations, however,occasionally derides my huge collection of disappeared as fast as they showed up.“dental stuff.” Do you really need all of those The same thing held true with certainmagazines? You haven’t looked at most of them growth factors. In the older journals, certainin years, you know. You know what…she is right. growth factors were all the rage. ThereMost of those journals were read once and were advertisements. There were tons ofthen put on the shelf. I have this knack for articles. Then, suddenly, everyone quit usingkeeping dental lit just in case I might want to that particular growth factor and moved on tolook at it again one day in the future. Ninety something better…or they found that over thenine times out of one hundred, that day never long term, that growth factor didn’t really do ascomes. The journals just sit on the shelf and much as we thought it did.collect dust. If there is a truly amazing article, Dental products are just like everythingI now scan it and save it as a PDF in my else. Every company says they have the bestcomputer for future reference. Other than that, thing since sliced bread. In some cases, theyI am afraid that I have just been pack-ratting a are right…they do have a great new product. Inbunch of old dental journals. other cases, they simply have a new flavor of theI was recently doing some spring cleaning in month, much like bell bottom pants, Membersthe garage and decided that my library of ancient Only jackets, and Snuggies. The new productdental scrolls needed to go. Before I parted with has some sizzle and generates some buzz,my beloved, yet dusty, old journals, I decided to but it simply doesn’t last. It could be becauselook through some of them just one more time. something better came along, it was hard toWhat I found was truly interesting. use, or that it simply did not work as well as theAs I flipped through those old journals, many company claimed.of which had long since become defunct, merged When using something new, we shouldinto other journals, or simply went out of business, stick to our basic science backgrounds. Test.I noticed that I was paying more attention to the Evaluate. Compare. Understand the scienceadvertisements than to the actual articles. What behind the product and don’t simply rely on thecaught my attention was how much things have word of the rep. ●changed over the past decade…how dentalproducts tend to follow fads, much like everydayfashion. Take dental implant design, for example.In my older journals, implant companies wereadvertising “rough surfaces.” Then everyone wastalking about how their new “tapered” design Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MSwas best. Then it was contoured platforms. Then Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 15
© MIS Corporation. All rights reserved. Spring Special 20Buy FGeRt EE! SEVEN Implants Surgical kit (external irrigation), 20 Complete (at $175.00 each) Prosthetic Kits (CPK) or 20 Standard Cementing Posts (MAC10) and 1 box of 0.5cc BondBone.This offer is valid throughJune 30th 2010 (or while supplies last.) * Full payment by credit card must be made at the time of purchase. MIS Implants offers a wide range of implant designs, innovative kits and accessories that provide creative and simple solutions for the varied challenges encountered in implant dentistry. To learn more about MIS visit our website: misimplants.com or call us: 866-797-1333 (toll-free)
Implant Planning in 20 seconds withHigh quality 3D Implant planning system from CA, USA.• Extremely fast and easy • Software developed from Silicon Valley,• High quality and accurate visualizations • Surgical Guide made from California• No conversion, pre-processing, • Expert support provided from or preparationFind out why so many doctors choose Invivo5. Call for a demonstration today! www.anatomage.com Tel) 408-885-1474 Fax) 408-295-9786 111 N. Market St. #800 San Jose, CA 95113
All-Natural, Bioactive ProductsDesigned to Stimulate the Healing Process DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1 Biopsy of Biopsy of • The signaling proteins (growth factors,DynaMatrix autogeneous glycoproteins, glycosaminoglycans) gingival graft communicate with the body to help treated site stimulate the natural healing process2 Accell is an all-natural concentration • Accell has nearly 5 times more BMPs of Bone Morphogenetic Proteins than DBM alone and each lot is validated (BMPs) and Growth Factors with for osteoinductive properties 3,4 Demineralized Bone Matrix (DBM) that directs and charges stem cells • Accell in delivered as an easy-to-handle to acclerate the body’s natural putty in a pre-filled syringe healing response. • Accell is the only allograft product that contains this powerful combination of DBM, BMPs and Growth Factors 1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543. 2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5. 3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract). 4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract). Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Burlington, MA 01803 USA Call: +1-781-328-3490 Call: 1-866-902-9272 / Fax: 1-866-903-9272 Fax: +1-781-328-3400 [email protected] www.keystonedental.com
The Use of DynaMatrix Extracellular Membrane Sarofffor Gingival Augmentation and Root Coverage: A Case SeriesStephen Andrew Saroff, DDS, MSD1 AbstractO ver the years, mucogingival surgery spite of the many advances made in sur- has developed into an integral part of periodontal therapy. Mucogingi- gical techniques and materials, theval defects and deformities are conditionsthat deviate from the normal ana- coverage of denuded root surface hastomic relationship between the gingivalmargin and mucogingival junction. Some primarily focused on the soft tissueof the most common conditions aregingival recession, an absence or insuf- and not on the underlying bone loss.ficient amount of keratinized tissue,and the presence of probing depths This article presents a series of casesextending past the mucogingival junction.A common factor is, often, the exis- illustrating techniques that havetence of alveolar bone loss. However, in yielded favorable surgical outcomes in challenging circumstances involv- ing the incorporation of allogeneic bone putty and an extracellular matrix scaf- fold into the process of repair and reconstruction. KEY WORDS: Gingival augmentation, root coverage, periodontal plastic surgery, guided tissue regeneration1. Former Professor of Periodontics and Oral Medicine and Director of Pre-doctoral Periodontics and Implantology at Fairleigh Dickinson University, Hackensack, New Jersey, USA. The Journal of Implant & Advanced Clinical Dentistry • 19
Saroff Introduction augment the zone of attached keratinized gin- giva. Clinicians have utilized autogenous gin-The goal of mucogingival surgery has been gival or connective tissue grafts, freeze-driedto create, conserve, and preserve a function- skin allografts, and acellular dermal matrix. Eachally adequate band of gingival tissue. Lang and method yielded a variety of results, and eachLoe previously established that a minimal zone technique presented clinical compromises.14-18of 2mm of keratinized tissue was essential tomaintain gingival health.1 From studies by Ken- While autogenous soft tissue grafts havenedy and Dorfman, this band may be much nar- demonstrated clinical efficacy, they require arower than originally purported and is often donor site. Harvesting the tissue adds to patientpredisposed to inflammation and recession.2 discomfort and can increase the likelihood ofThe surgical techniques developed and used complications. The use of an allogeneic soft tis-in the past have essentially been grounded in sue grafts like Alloderm® (Lifecell Corp, Branch-manipulation and use of only soft tissue. Tra- burg, NJ, USA) an acellular dermal graft, was anditionally, a lateral positioned pedicle graft was attempt to offset many of the negative aspectsfirst introduced by Grupe and Warren3 and sub- associated with harvesting donor tissue. How-sequently outlined by Wilderman and Wentz.4 ever, the acellular dermal matrix presented certain clinical limitations in handling charac- For years the primary means of augment- teristics, surgical technique, and in enhanc-ing gingiva and covering roots was the free pal- ing the quality and quantity of keratinized tissue.atal tissue autograft. Bjorn,5 Pennel and King,6,7Cowan,8 and Nabers9,10 were all pioneers in It is generally accepted that attached kera-reporting the use of this procedure. Later in tinized tissue is an integral part of the periodon-1968 Sullivan and Atkins11 refined the technique tium, and serves to function as an effectiveand outlined the wound healing associated with barrier by facilitating resistance to tissue dam-the procedure. Over the years many additional age from traumatic insults. This observation wasinvestigators explored enhancements and altera- amplified in a recent study conducted at Har-tions to existing techniques in order to refine and vard University by Nevins et al.19 and publishedimprove outcomes. In 1977 Maynard12 and Ber- in 2010. Their investigation was conductednimoulin13 published on coronally positioning to assess the efficacy of an extracellular mem-of a previously placed autogenous gingival graft. brane (DynaMatrix®, Keystone Dental, Burlington, MA, USA) in augmenting keratinized tissue. The Tissue grafting procedures that increase the results suggested that the “membrane may pres-amount and quality of attached keratinized gin- ent a viable substitute for the autogenous gin-gival tissue, and cover exposed and denuded gival graft” when the objective is to increase theroot surfaces accomplish a number of objec- dimension of the keratinized attached gingival.tives: the prevention of additional root exposure,decreased or eliminated sensitivity to thermal The study by Nevins et al.19 compared treat-and other stimuli, decreased susceptibility to root ment utilizing a free gingival graft versus an extra-caries, and improved esthetics. As a result, vari- cellular matrix (DynaMatrix®) and determined thatous surgical techniques were developed to both techniques produced a significant increase20 • Vol. 3, No. 3 • March/April 2011
Saroffin the amount of keratinized gingival tissue. In Methodsaddition, the matrix-generated tissue was com-parable histologically to the tissue derived from Seven patients were selected for the study.the autograft. The study concluded that the Each patient had varying degrees of gin-DynaMatrix® extracellular matrix blended well gival recession and osseous destruction.with surrounding tissue, and it produced supe- Selection was based on a moderate torior esthetic outcomes when compared to the severe level of pathology with obvious clini-autogenous graft. Finally, the report suggested cally relevant defects, and with an inter-that the extracellular matrix be considered in the est in regenerating, reconstructing, andtreatment for patients with gingival recession. repairing the damage to the periodontium. This particular current investigation and case In essence, this series of cases wasseries builds on the study by Nevins and co- intended to evaluate the efficacy of theworkers. Seven case studies were documented DynaMatrix® extracellular matrix membraneduring 2009 and 2010 in Richmond, Virginia, in a variety of treatment modalities. Manyand involved a variety of periodontal issues of the articles written about this membraneand defects. A critical difference from previous have outlined the fundamental qualities of thestudies involved the treatment of gingival reces- matrix.20 The membrane is obtained from thesion and root denudation. This investigation small intestine submucosa of the pig and haswas not a controlled study. However, based been dubbed SIS technology by the produceron the clinical outcomes, perhaps a new para- Cook Biotech Incorporated. The matrix is uti-digm may be developing with respect to treat- lized as the structure to retain a construct ofing significant cases of gingival recession. The collagen (types I, III, IV, and VI), proteogly-author believes it is vital to explore the causal- cans, glycosaminoglycans, glycoproteins, andity associated with gingival recession. Certainly additional growth factors such as fibronectin.a common denominator in all cases of gingivalrecession and denudation is bone loss. How- Investigation into the formulation and fab-ever, when one reviews the literature on treat- rication of the matrix-membrane warrants addi-ment of gingival recession, seldom is there any tional explanation. Hodde and co-workers20mention of the role or treatment of lost alveolar investigated the effects of sterilization on thebone. matrix scaffold and determined that a “bio- logic scaffold can be prepared for human Some of the techniques outlined in this use and still retain significant bioactivity.”article add another dimension. The motiva-tion was to determine if it were feasible to DynaMatrix® has been successfully usedtreat some of the underlying bone loss, which in the treatment of a variety of damaged andcontributes to the recession along with obtain- or diseased tissues in humans. The biologicing root coverage. With that objective in scaffold stimulates the repair of compromisedmind a surgical methodology was adopted tissues and organs with tissue similar in formfor the majority of patients in this case study. and function to that which it replaced. It is not within the purview of this case study series to explore in depth the biology and biochemistry of The Journal of Implant & Advanced Clinical Dentistry • 21
SaroffFigure 1: Localized gingival recession on tooth #25. Figure 2: Flap design to allow for access to denuded root and bone.Figure 3: DynaBlast bone putty packed around exposed Figure 4: Extracellular membrane (DynaMatrix) placed androots hydrated with blood.Figure 5: Coverage of site with a laterally positioned flap Figure 6: 9 day post-op with tissue development.(pedicle); DynaMatrix is left exposed on donor site.22 • Vol. 3, No. 3 • March/April 2011
SaroffFigure 7: 6 week post-op with significant tissue Figure 8: 6 month post-op with developed keratinizeddevelopment and normal healing. tissue and successfully covered exposed root.the matrix. However, it is accepted that using a Resultscell-free wound dressing derived from the extra-cellular matrix of the small intestine of the pig can Case 1:facilitate the repair of damaged and diseased The patient presented with localized gingivaltissues. With these fundamental constructs recession and severe bone loss on the facial ofin place acting as a theoretical foundation, tooth #25 (figure 1). The gingival margin arounda series of cases was undertaken to assess the exposed tooth was resected (No. 15 Bard-the efficacy of the DynaMatrix® membrane. Parker blade) to the depth of the pocket using a v-shaped incision. A gingival flap was devel- A five step surgical process was adopted for oped which was somewhat larger than the recipi-the majority of the patients in this case study: ent site (figure 2). After the flap was elevated1. Exposure of the defect with thorough and reflected, the root surface was thoroughly scaled and planed. The bone putty (DynaBlast®) debridement was then placed around the exposed root and2. Placement of bone putty (DynaBlast®) extended coronally to the cemento-enamel3. Placement of DynaMatrix® membrane over junction (figure 3). Complete coverage of the denuded root was obtained with the bone putty. bone graft The extracellular matrix membrane (DynaMa-4. Ligation of the matrix to surrounding tissue trix®) was placed on the bone graft and com-5. S oft tissue coverage of the surgical site pletely covered the exposed roots (figure 4). The matrix was then hydrated with the patient’s blood Healing was evaluated and assessed sev- and secured with sutures (5-0 resorbable). Ineral times over the following months. The ini- this particular case, a laterally positioned flaptial postoperative evaluation took place 9-10 (pedicle) was used to cover the surgical sitedays following the surgical procedure. In addi- (figure 5). The patient was seen for follow-uption, follow-up visits were scheduled over thenext six months. Clinical images were obtainedand reproduced with the patients’ consent. The Journal of Implant & Advanced Clinical Dentistry • 23
SaroffFigure 9: Tooth #24 demonstrates localized gingival Figure 10: Mucoperiosteal flap developed to expose roots.recession and insufficient keratinized tissue along withaberrant frenum.Figure 11: DynaMatrix placed and hydrated with blood. Figure 12: Laterally positioned pedicle flap positioned over DynaMatrix and sutured.Figure 13: 9 days post op, epithelial tissue developmentover DynaMatrix. care nine days post operatively and healing was progressing uneventfully (figure 6). Six weeks24 • Vol. 3, No. 3 • March/April 2011 post-operatively there had been favorable tissue development along with normal healing (figure 7). Finally, the six-month follow-up demonstrates significant coverage of the denuded root with well-developed keratinized tissue (figure 8). Case 2 The patient presented with localized gin- gival recession and insufficient keratinized tissue along with a concomitant aberrant fre-
SaroffFigure 14: Teeth #24 and #25 have localized recession and Figure 15: Mucoperiosteal flap developed to expose rootinconsistent tissue heights due to severe bone loss. surfaceFigure 16: DynaMatrix® placed and hydrated with blood. Figure 17: Adjacent tissue was laterally positioned and DynaMatrix sutured into place.num associated with tooth #24 (Figure 9). Amucoperiosteal flap was created to expose Case 3:the root and to permit a frenectomy (figure The patient presented with localized gingival10). Debridement of the site was performed recession on teeth #25 and #25 (figure 14). Sig-and subsequently DynaMatrix® was placed, nificant crowding likely had an impact of the extanthydrated with the patient’s blood and secured facial bone loss. A mucoperiosteal flap was devel-(figure 11). In this particular case bone aug- oped to expose the roots and revealed extensivementation was not performed. A pedicle denudation (figure 15). Following debridementflap was used to gain soft tissue coverage of the site along with scaling and root plan-of the site (figure 12). The nine-day postop- ing, DynaMatrix® was placed, hydrated with theerative image (figure 13) reveals normal heal- patient’s blood, and secured (figure 16). Adja-ing and root coverage for this time period. cent tissue was laterally positioned to cover the site (figure 17). In this particular case an area of The Journal of Implant & Advanced Clinical Dentistry • 25
SaroffFigure 18: 7 days post op, successful healing and Figure 19: Shallow vestibule with little keratinized tissue.epithelialization of DynaMatrix. ther dissection resulted in removal of attachedmatrix was left exposed to evaluate claims that muscle fibers from the bone. DynaMatrix® wasno negative consequences are anticipated with adapted to the site and hydrated with bloodexposure and bone grafting was not performed. (figure 21). The membrane was secured byHowever, osseous augmentation would be per- sutures and then the site dressed. The heal-fectly justified based on expected outcomes. ing was uneventful and at ten days healthyAfter one week, uneventful healing was taking keratinized issue was developing (figure 22).place and the area of exposed membrane wasepithelializing without complications (figure 18). Case 5: The patient presented with severe gingivalCase 4: recession on teeth #24 and #25 (figure 23).The patient presented, following a refer- The likely source of the periodontal pathol-ral from an orthodontist, with a shallow man- ogy may well relate to the ongoing orthodonticdibular anterior vestibule characterized by a therapy. Both teeth demonstrated significantlimited amount of attached keratinized gin- loss of facial bone as well as alterations in thegiva (figure 19). An incision was made at the color, contour, texture, and consistency of themucogingival junction and reflected to expose gingiva. Two independent laterally positionedthe periosteum of the bone (figure 20). Fur- flaps were used in the treatment of this prob- lem and they were not performed on the same day. As in other instances a v shaped incision was used to remove the affected gingival tis- sue (figure 24). Debridement of the site as well as scaling and root planing of the teeth26 • Vol. 3, No. 3 • March/April 2011
SaroffFigure 20: Incision was made at the mucogingival Figure 21: DynaMatrix® was placed and hydrated withjunction. blood.Figure 22: 10 day post op, expanded vestibule and Figure 23: Teeth # 24 and #25 demonstrate severehealthy, keratinized tissue was developing. localized gingival recession and bone loss in association with orthodontic treatment.Figure 24: V-shaped flap was created to expose the root. Figure 25: DynaMatrix placed, hydrated with blood and sutured into place with adjacent tissue. The Journal of Implant & Advanced Clinical Dentistry • 27
SaroffFigure 26: 6 months post op with tissue development over Figure 27: 6.5 month post op with developed keratinizedexposed root. tissue.was performed. This was followed by place- was made at the mucogingival junction andment of the matrix and ligation of the membrane after reflection, dissection of muscle fibers,(figure 25). Closure was obtained by creat- DynaMatrix® was placed, hydrated with blooding a laterally positioned pedicle graft. Figures and secured with sutures to the adjacent tis-26 and 27 demonstrate favorable healing and sue (figure 32). The site was dressed withimproved root coverage after 24 and 26 weeks. periodontal pack and a six week follow-up image demonstrates a thicker and broaderCase 6: band of healthy keratinized tissue (figure 33).The patient presented with an insufficientzone of attached gingiva in the mandibular Conclusionanterior region (figure 28). A shallow vesti-bule was present and was noted by the refer- This case series demonstrates the effi-ring orthodontist. An incision was made at cacy of DynaMatrix® extracellular mem-the mucogingival junction and after reflec- brane for the treatment of both localizedtion and dissection of muscle fibers, DynaMa- gingival recession as well as for the devel-trix® was placed, hydrated with blood and opment of attached keratinized tissue. Post-sutured into place (figure 29). A six week fol- operative evaluation revealed successfullow up image revealed healthy tissue develop- tissue remodeling in the treated areas com-ment with an esthetic outcome (figure 30). bined with enhanced root coverage of areas of localized recession. Substantial increasesCase 7: in the volume of keratinized tissue were noted.The patient presented with a thin zone ofattached gingiva (figure 31). The referring In addition to the successful outcomes,doctor had requested augmentation of the DynaMatrix® extracellular membrane offers aattached and keratinized tissue. An incision number of advantages over traditional methods of soft tissue grafting. This is especially noted as it relates to the procurement of donor tissue.28 • Vol. 3, No. 3 • March/April 2011
SaroffFigure 28: Insufficient zone of attached gingiva. Figure 29: Incision made at mucogingival junction, DynaMatrix placed, hydrated with blood and sutured to adjacent tissue.Figure 30: 6 week post op with healthy tissue Figure 31: Thin zone of attached gingiva.development.Figure 32: Incision was made at mucogingival junction. Figure 33: 6 week post op with thicker tissue and healthyDynaMatrix was placed, hydrated with blood, sutured into keratinized tissue development.placed with adjacent tissue and left exposed. The Journal of Implant & Advanced Clinical Dentistry • 29
SaroffThe use of the matrix may reduce the need for Disclosurea surgical intervention in a secondary or donor The authors report no conflicts of interest with anything mentioned in this article.site as required in autogenous mucosal graftsincluding subepithelial connective tissue grafts. ReferencesFor patients, eliminating a donor site reduces 1. L ang NP, Loe H. The relationship between the width of keratinized gingiva andthe likelihood of post-operative pain, bleeding,and infection. Furthermore, it reduces the treat- gingival health. J Periodontol. 1972 Oct;43(10):623-627.ment time and enhances the patient’s overallexperience. The extracellular membrane does 2. K ennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation ofnot require enclosure within the patient’s exist- varying widths of attached gingiva. J Clin Periodontol. 1985 Sep;12(8):667-ing tissue and the material may be left exposed 675.in the surgical site. Ultimately, it blends withnative tissue and produces a fine esthetic result. 3. G rupe HE. Modified technique for the sliding flap operation. J Periodontol. 1966 Nov-Dec;37(6):491-495. Thus, results outlined here support the useof this extracellular matrix or scaffold. It pos- 4. W ilderman MN, Wentz FM. Repair of a Dentogingival Defect with a Pedicle Flap.ses unique attributes for periodontal surgery J Periodontol. 1965 May-Jun;36:218-231.acting as an alternative to autogenous muco-sal grafts. Furthermore, it may well enhance 5. B jorn HaL, J. Influence of periodontal instruments on the tooth surface. Athe surgical outcomes of achieving root cov- methodological study. Odont Rev. 1963;13:355.erage in the advanced case as well as aug-menting the keratinized tissue present. ● 6. P ennel BM, Higgason JD, Towner JD, King KO, Fritz BD, Salder JF. Oblique Rotated Flap. J Periodontol. 1965 Jul-Aug;36:305-309. Correspondence: Dr. Stephen Saroff 7. P ennel BM, King KO, Higgason JD, Towner JD, 3rd, Fritz BD, Sadler JF. Retention [email protected] of Periosteum in Mucogingival Surgery. J Periodontol. 1965 Jan-Feb;36:39-43. 8. C owan A. Sulcus Deepening Incorporating Mucosal Graft. J Periodontol. 1965 May-Jun;36:188-192. 9. N abers JM. Free gingival grafts. Periodontics. 1966 Sep-Oct;4(5):243-245. 10. N abers JM. Extension of the vestibular fornix utilizing a gingival graft--case history. Periodontics. 1966 Mar-Apr;4(2):77-79. 11. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968 Jun;6(3):121-129. 12. Maynard JG, Jr. Coronal positioning of a previously placed autogenous gingival graft. J Periodontol. 1977 Mar;48(3):151-155. 13. Bernimoulin JP, Luscher B, Muhlemann HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontol. 1975 Feb;2(1):1-13. 14. E del A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva. J Clin Periodontol. 1974;1(4):185-196. 15. G her ME, Jr., Williams JE, Jr., Vernino AR, Strong DM, Pelleu GB, Jr. Evaluation of the immunogenicity of freeze-dried skin allografts in humans. J Periodontol. 1980 Oct;51(10):571-577. 16. Harris RJ. Gingival augmentation with an acellular dermal matrix: human histologic evaluation of a case--placement of the graft on bone. Int J Periodontics Restorative Dent. 2001 Feb;21(1):69-75. 17. Y ukna RA, Tow HD, Caroll PB, Vernino AR, Bright RW. Comparative clinical evaluation of freeze-dried skin allografts and autogenous gingival grafts in humans. J Clin Periodontol. 1977 Aug;4(3):191-199. 18. Yukna RA, Tow HD, Carroll PB, Vernino AR, Bright RW. Evaluation of the use of freeze-dried skin allografts in the treatment of human mucogingival problems. J Periodontol. 1977 Apr;48(4):187-193. 19. N evins M, Nevins ML, Camelo M, Camelo JM, Schupbach P, Kim DM. The clinical efficacy of DynaMatrix extracellular membrane in augmenting keratinized tissue. Int J Periodontics Restorative Dent. 2010 Apr;30(2):151-161. 20. H odde J, Janis A, Hiles M. Effects of sterilization on an extracellular matrix scaffold: part II. Bioactivity and matrix interaction. J Mater Sci Mater Med. 2007 Apr;18(4):545-550.30 • Vol. 3, No. 3 • March/April 2011
IBneCtePsogatnrneaUStBenoedldauemtrio/$n1f0o0rkGo digital today. 3D tomorrow.Introducing Suni3D –All New 3-in-1 System! Go digital today, and upgrade to 3D cone beam when you’re ready!3D diagnosis and planning are rapidly emerging as the new standard for comprehensive dental care. With Suni’smodular design, you can choose a digital pan today, and cost-effectively upgrade to a One-shot Ceph and/or 3D conebeam whenever you’re ready. Or, simply go with cone beam right from the start. With Suni3D, you have the flexibility tochoose the system that works best for you. The base unit stays the same, so your investment is safe with Suni! Suni3Dcomes standard with 5X5 cm field of view (upgradable to 8 x 5 cm), ideal for implant, TMJ and endodontic procedures.Exceptional technology at a most affordable price from Suni – The value leader in digital imaging! The value leader in digital imaging Call now for a demo | 1 800 438 7864 | www.suni.com
PIEZOTOME2 and IMPLANT CENTER2- Three times more power than PIEZOTOME1 ! (60 watts vs 18 watts of output power in the handpiece). Procedures are faster than ever, giving you a clean and effortless cut- Selective cut: respect of soft tissue (nerves, membranes, arteries)- Less traumatic treatment: reduces bone loss and less bleeding- 1st EVER Autoclavable LED Surgical Ultrasonic Handpieces- NEWTRON LED and PIEZOTOME2 LED Handpieces output 100.000 LUX!- Extremely precise irrigation flow to avoid any risk of bone necrosis- Giant user-friendly 5.7\" color touch-control screen- Ultra-sharp, robust and resistant tips (25+ Surgical & 80+ Conventional) All the benefits of the PIEZOTOME2...PLUS... - Compatible with all electric contra-angles (any ratio) - Highest torque of any micro-motor on the market - Widest speed range on the marketGiant user-friendly 5.7\" color touch-control screen! 100,000 Lux! NfoerwtthroenPHieaznodtpoimecee2 and CImorpdlaanrteCoepnttieorna2l uitneitms.s and* * Micro-motor available on Implant Center2 only. . . . .124 Gaither Drive, Suite 140 Mount Laurel, NJ 08054 Tel - (800) 289 6367 Fax - (856) 222 4726 [email protected] www.acteongroup.com
“I have found that the BIOMET 3i OSSEOTITE ® Tapered Implant works well inimmediate extraction sites. Also, these implants improve cosmetics and spacingissues with the ability to platform switch at the restorative abutment level.”- Dr. T. Randall Napier, Maryville, Tennessee*“Having utilized several implant systems in the past, the BIOMET 3iTapered Implant has become my implant of choice. I have foundthat it provides exceptional insertion torque values and goodprimary stability. What a pleasant discovery!”- Dr. Mark Baker, Pocatello, Idaho*Natural Tapered ImplantPrimary Implant Stability Starts WithThe BIOMET 3i Tapered Implant System Call Your BIOMET 3i Representative Today. In The USA: 1-800-342-5454 Outside The USA: +1-561-776-6700 Or Visit Us Online At www.biomet3i.com *While these surgeon testimonials are true, the results are not necessarily typical, indicative or representative of all procedures in which the BIOMET 3i Tapered Implant and related components are used. The BIOMET 3i Tapered Implant and related components have been used successfully in patients. However as with any implant device, there are surgical and post-operative factors, which ultimately may result in unpredictable variable outcomes. These factors include, but are not limited to, the patient’s pre and post-operative health conditions, bone quality, number of surgical procedures and adherence to instructions regarding the procedural guidelines. Due to these variables, it is not possible to predict or warrant specific results, patient or clinician satisfaction. OSSEOTITE is a registered trademark of BIOMET 3i LLC. BIOMET is a registered trademark and BIOMET 3i and design are trademarks of BIOMET, Inc. ©2010 BIOMET 3i LLC. All rights reserved.
BioXclude™ Placental Allograft Tissue Holtzclaw et alMembrane Used in Combination with BoneAllograft for Site Preservation: A Case SeriesDan Holtzclaw, DDS, MS1 • Nicholas Toscano, DDS, MS AbstractSite preservation entails conservation of riers such as non-cross linked collagen plugs, existing bone during tooth removal and cross linked collagen membranes, chitosan plugs, augmentation of the tooth socket. A expande poytetrafluoroethylene (PTFE) mem-variety of materials may be used to augment the branes, and connective tissue grafts are oftensocket including bone allograft, xenograft, cal- used. BioXclude™, a resorbable amnion chorioncium sulfate, beta-tricalcium phosphate, collagen membrane, has recently been introduced as asponges, and growth factors such as platelet new barrier for site preservation. This case seriesrich fibrin. To contain these materials within the documents use of BioXclude™ amnion chorionsocket and protect them from the oral cavity, bar- membrane for the purpose of site preservation.KEY WORDS: Site preservation, tooth extraction, bone graft, guided bone regeneration, amnion 1. Private practice limited to periodontics and dental implants, Austin, Texas, USA 2. Private practice limited to periodontics and dental implants, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 35
Holtzclaw et al Background ure 1-2). The sectioned roots were removed (figure 1-3) leaving an intact bony septumContemporary dental implant treatment rec- (figure1- 4) which was adequate for immedi-ommends at least 1mm of bone surround all ate implant placement. The patient declinedaspects of the implant fixture.1 To achieve such this treatment due to finances and electeda goal, the concept of site preservation is fre- to have site preservation performed in con-quently employed. Site preservation entails sideration for future dental implant place-conservation of existing bone during tooth ment. The site was grafted with mineralizedremoval and augmentation of the tooth socket. freeze dried bone allograft (FDBA) (figure 1-5)A variety of materials may be used to augment and covered with a BioXclude™ amnion cho-the socket including bone allograft, xenograft, rion membrane (figure 1-6). The flap was thencalcium sulfate, beta-tricalcium phosphate, col- replaced with resorbable sutures (figure 1-7).lagen sponges, and growth factors such asplatelet rich fibrin. To contain these materials At 48 hours after surgery, rapid healing waswithin the socket and protect them from the seen with opacification of the BioXclude™ mem-oral cavity, barriers such as non-cross linked brane and granulation tissue evident over thecollagen plugs, cross linked collagen mem- treatment site (figure 1-8). By 96 hours, healingbranes, chitosan plugs, expande poytetrafluo- was advanced to a point where sutures couldroethylene (PTFE) membranes, and connective be removed. At this time, complete closure oftissue grafts are often used. BioXclude™, a the treatment site was achieved, thus protectingresorbable amnion chorion membrane, has the underlying site preservation bone graft (fig-recently been introduced as a new barrier for ure 1-9). At 10 days after surgery, continuedsite preservation. This membrane differs from maturation of the tissue covering the treatmentothers in the fact that it has inherent growth site was evident (figure 1-10). By 21 days afterfactors within its structure. This case series surgery, there was complete keratinization of thedocuments use of BioXclude™ amnion chorion gingival tissue covering the area of site preser-membrane for the purpose of site preservation. vation surgery (figure 1-11) and at 45 days after surgery, further maturation of the keratinized tis- Case 1 sue covering the site was seen (figure 1-12).This case demonstrates the rapidity with whichBioXclude™ seals an area treated with sitepreservation. A 56 year old Caucasian femalepresented for treatment of a hopeless maxillaryright first molar (tooth #3) (figure 1-1). Localanesthesia was achieved with via infiltrationusing 4% articaine with 1:100,000 epineph-rine. A sulcular full thickness mucoperiostealflap was minimally elevated and the tooth wassectioned with a high speed hand piece (fig-36 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et alFigure 1-1: Pre-surgical photo. Figure 1-2: Sectioned tooth.Figure 1-3: Extracted roots. Figure 1-4: Intact bony septum.Figure 1-5: Bone allograft placement. Figure 1-6: BioXclude placement. The Journal of Implant & Advanced Clinical Dentistry • 37
Holtzclaw et alFigure 1-7: Suture placement. Figure 1-8: 48 hours.Figure 1-9: 96 hours. Figure 1-10: 10 days.Figure 1-11: 21 days. Figure 1-12: 45 days.38 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et al Case 2 with BioXclude™ chorion amnion membrane (fig- ure 2-5) and temporized with a temporary transi-This case provides additional documentation of tional partial denture (TTP) with an ovate pontic.the ability of BioXclude™ chorion amnion mem- At 48 hours after surgery, complete closure of thebrane to achieve rapid closure of sockets dur- socket is evident (figure 2-6). Nearly completeing site preservation procedures. A 51 year old keratinization of the tissue covering the extractionHispanic female presented for treatment of a socket is evident by 1 week after surgery (figurenon-restorable maxillary left central incisor (tooth 2-7). Further maturation of the gingival tissues is#9) (figures 2-1, 2-2). Following administration seen at 3 months after surgery (figure 2-8) andof local anesthesia, tooth #9 was atraumatically there is radiographic evidence of significant bonyextracted (figure 2-3) and grafted with FDBA (fig- fill of the pre-surgical bony defect (figure 2-9).ure 2-4). The grafted socket was then coveredFigure 2-1: Pre-surgical photo.Figure 2-3: Tooth extraction. Figure 2-2: Pre-surgical radiograph. The Journal of Implant & Advanced Clinical Dentistry • 39
Holtzclaw et alFigure 2-4: Bone allograft placement. Figure 2-5: BioXclude placement.Figure 2-6 48 hours. Figure 2-7: 1 week. Figure 2-9: 3 month radiograph.Figure 2-8: 3 months.40 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et al Case 3 gery. A minimal full thickness flap was reflected at the location of the site preservation sur-A 45 year old Caucasian female presented with gery. The bone at the surgical site (figurean endodontically abscessed right maxillary lat- 3-12) was of type 2-3 quality and well vascu-eral incisor (tooth #7) (figures 3-1, 3-2). Follow- larized. Histologic analysis of a trephine coreing administration of local anesthesia, the tooth sample taken from this site revealed 46.3% vitalwas atraumatically extracted (figure 3-3) and bone, 20.6% residual graft material, and 33.1%probing of the socket revealed a dehiscence of connective tissue (figures 3-12a, 3-12b). Athe facial bony plate. Due to this lack of bone, 3.75x13mm dental implant was placed (fig-immediate implantation of a dental implant was ures 3-13, 3-14) and ISQ values of 75 werenot considered and site preservation was cho- achieved. Healing at 3 months revealed goodsen as the treatment of choice. The extraction bone contour and tissue quality (figure 3-15).site was grafted with FDBA (figure 3-4) and cov-ered with a BioXclude™ amnion chorion mem-brane (figure 3-5). A TTP with an ovate ponticwas delivered for site temporization (figure 3-6).One week following surgery, the surgical site wascompletely covered with granulation tissue (fig-ures 3-7, 3-8). At 10 weeks following surgery,complete keratinization of the tissue coveringthe surgical site was evident (figures 3-9, 3-10)and radiographic bone fill appeared adequatefor placement of a dental implant (figure 3-11). The patient was seen for dental implant sur-gery 12 weeks after the site preservation sur-Figure 3-1: Pre-surgical photo. Figure 3-2: Pre-surgical radiograph. The Journal of Implant & Advanced Clinical Dentistry • 41
Holtzclaw et alFigure 3-3: Tooth extraction. Figure 3-4: Bone allograft placement.Figure 3-5: BioXclude placement. Figure 3-6: Ovate pontic TTP delivery.Figure 3-7: 1 week. Figure 3-8: 1 week.42 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et alFigure 3-9: 10 weeks. Figure 3-10: 10 weeks. Figure 3-12: Bone at 10 weeks.Figure 3-11: 10 week radiograph. The Journal of Implant & Advanced Clinical Dentistry • 43
Holtzclaw et alFigure 3-12a: 50x magnification. Figure 3-12b: 200x magnification.Figure 3-13: Implant placement.Figure 3-15: 3 months healing. Figure 3-14: Implant radiograph.44 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et al Case 4 the initial site preservation surgery, keratinization of the tissue covering the area of site preservationA 42 year old Caucasian female presented for treat- was evident (figure 4-8). The only portion of thement of a maxillary right second premolar (tooth #4) surgical site which was not completely keratinizedthat was deemed non-restorable due to a vertical was an area where the apex of the ovate pontic ofroot fracture (figures 4-1, 4-2). Following adminis- the TTP supported the gingival tissue (figure 4-9).tration of local anesthesia, the tooth was atraumati-cally extracted (figure 4-3). The extraction socket The patient was seen for dental implant sur-was grafted with FDBA (figure 4-4) and covered gery 12 weeks after the site preservation sur-with a BioXclude™ membrane (figure 4-5). A photo gery. A minimal full thickness flap was reflectedwas taken 5 minutes after placement to demon- at the location of the site preservation sur-strate how the amnion chorion membrane thickens gery. The bone at the surgical site (figure 4-10)and opacifies upon coming in contact with blood was of type 2-3 quality and well vascularized. A(figure 4-6). A TTP with an ovate pontic was deliv- 4.2x11.5mm dental implant was placed (fig-ered for site temporization. At the initial 7 day follow ures 4-11, 4-12) and ISQ values of 72 wereup visit, complete tissue coverage of the extraction achieved. Healing at 3 months revealed goodsite was observed (figure 4-7). Ten weeks following bone contour and tissue quality figure 4-13)Figure 4-1: Pre-surgical photo. Figure 4-2: Pre-surgical radiograph.Figure 4-3: Tooth extraction. The Journal of Implant & Advanced Clinical Dentistry • 45
Holtzclaw et alFigure 4-4: Bone allograft placement. Figure 4-5: BioXclude placement.Figure 4-6: 5 minutes. Figure 4-7: 7 days.Figure 4-8: 10 weeks. Figure 4-9: 12 weeks.46 • Vol. 3, No. 3 • March/April 2011
Holtzclaw et alFigure 4-10: Bone at 12 weeks. Figure 4-11: Implant placement. Figure 4-13: 3 months healing.Figure 4-12: Implant radiograph. The Journal of Implant & Advanced Clinical Dentistry • 47
Holtzclaw et al Case 5 such, the patient elected to have site preserva- tion performed in consideration for future den-A 34 year old Caucasian male presented for tal implant placement. The extraction sockettreatment of a non-restorable left mandibular was grafted with FDBA (figure 5-4) and cov-first molar (tooth #19) (figures 5-1, 5-2). Local ered with a BioXclude™ amnion chorion mem-anesthesia was achieved with a standard infe- brane (figure 5-5). The flap was then replacedrior alveolar block injection using 4% articaine with resorbable sutures (figure 5-6). At thewith 1:100,000 epinephrine. A sulcular full initial 7 day follow up visit, the socket had fullythickness mucoperiosteal flap was minimally covered with tissue. By 2 weeks, maturationelevated and the tooth was sectioned with a of the tissue covering the socket was evidenthigh speed hand piece. Upon removal of the (figure 5-7). Forty five days after surgery, thetooth, adequate bone was present for an imme- site exhibited further maturation and completediate molar implant (figure 5-3), but the patient keratinization of the gingival tissue (figure 5-8)declined this treatment due to finances. AsFigure 5-1: Pre-surgical photo. Figure 5-2: Pre-surgical radiograph.Figure 5-3: Tooth extraction. Figure 5-4: Bone allograft placement.48 • Vol. 3, No. 3 • March/April 2011
Search
