The Agony and Ecstasy of Buying Cone Beam Technology Part 1: The Ecstasy

VOLUME 1, NO. 1 MARCH 2009 The Journal of Implant & Advanced Clinical Dentistry The Agony and Ecstasy of Buying Cone Beam Technology Part 1: The Ecstasy | Dale A. Miles Premiere Issue CASE OF THE MONTH: A New Smile Utilizing an Implant and Ten All Ceramic Restorations | Ross W. Nash



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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 11 Case of the Month: A New Smile Utilizing an 65 A Novel Dehydrated Amnion Allograft for Implant and Ten All Ceramic Restorations use in the Treatment of Gingival Recession: An Observational Case Series Ross W. Nash, Robert Passaro Brian Gurinsky 19 The Agony and Ecstasy of Buying Cone Beam Technology, Part 1: The Ecstasy Dale A. Miles 33 The Use of Cone Beam Computerized 75 Crestal Sinus Lift: A Minimally Invasive and Tomography Generated Surgical Template in Systematic Approach to Sinus Grafting the Mandibular Molar Region: A Case Report Samuel Lee, Grace Kang Lee, Kwang-bum Park Ilser Turkyilmaz, Jose Carlos Suarez Thomas Han 41 American Academy of Oral and Maxillofacial 91 Comparative Analysis of Interleukin-1 Beta Radiology Executive Opinion Statement on Concentrations and Crestal Bone Loss in Performing and Interpreting Diagnostic Patients Treated with Conventional Versus Cone Beam Computed Tomography Osteotome Expansion Techniques for Dental Implant Delivery: A Pilot Study Laurie Carter, Allan G. Farman, James Geist, William C. Scarfe, Christos Angelopoulos, Thallum Padmanabhan, Nandhini Unnikrishnan Madhu K. Nair, Charles F. Hildebolt, Donald Tyndall, Michael Shrout 101 Current Clinical Review 45 The Periodontally “Accelerated Osteogenic 2007 American Heart Association Guidelines for Prevention of Infective Orthodontics”™ (PAOO™) Technique: Endocarditis (IE) E cient Space Closing With either Orthopedic or Orthodontic Forces Gregory D. Naylor M. Thomas Wilcko, William M. Wilcko, Karen Breindel Omniewski, Jerry Bouquot, James M. Wilcko The Journal of Implant & Advanced Clinical Dentistry 3



The Journal of Implant & Advanced Clinical Dentistry Publisher Copyright © 2008 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 retrieval system, without prior written permission from the Production Manager publisher. Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify Copy Editor the reader to incorporate new techniques or procedures Bryant Duhon discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their Digital Conversion educational training, clinical experience, and professional NxtBook Media expertise when attempting new procedures. JIACD, its staff, and parent company SpecOps Media, LLC (hereinafter Internet Management referred to as JIACD-SOM) assume no responsibility or InfoSwell Media liability for the actions of its readers. Spanish Translation Opinions expressed in JIACD articles and communications Gustavo Fra are those of the authors and not necessarily those of JIACD- SOM. JIACD-SOM disclaims any responsibility or liability Subscription Information: Annual rates as follows: for such material and does not guarantee, warrant, nor Non-qualified individual: $99(USD) Institutional: $99(USD). endorse any product, procedure, or technique discussed in For more information regarding subscriptions, JIACD, its affiliated websites, or affiliated communications. contact [email protected] or 1-888-923-0002. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its Advertising Policy: All advertisements appearing in the affiliated websites, or affiliated communications. Journal of Implant and Advanced Clinical Dentistry (JIACD) must be approved by the editorial staff which has the right Conflicts of Interest: Authors submitting articles to JIACD to reject or request changes to submitted advertisements. must declare, in writing, any potential conflicts of interest, The publication of an advertisement in JIACD does not monetary or otherwise, that may exist with the article. constitute an endorsement by the publisher. Additionally, Failure to submit a conflict of interest declaration will result the publisher does not guarantee or warrant any claims in suspension of manuscript peer review. made by JIACD advertisers. Erratum: Please notify JIACD of article discrepancies or For advertising information, please contact: errors by contacting [email protected] [email protected] or 1-888-923-0002 JIACD (ISSN pending) is published on a monthly basis by Manuscript Submission: JIACD publishing guidelines SpecOps Media, LLC, Saint James, New York, USA. can be found at http://www.jiacd.com/author-guidelines or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry 5

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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 Tara Aghaloo, DDS, MD Editorial Advisory Board Israel Puterman, DMD Faizan Alawi, DDS Giulio Rasperini, DDS Michael Apa, DDS Richard Hughes, DDS Michele Ravenel, DMD, MS Alan M. Atlas, DMD Anil Idiculla, DMD Terry Rees, DDS Charles Babbush, DMD, MS Tassos Irinakis, DDS, MSc Laurence Rifkin, DDS Thomas Balshi, DDS James Jacobs, DMD Paul Rosen, DMD, MS Barry Bartee, DDS, MD Ziad Jalbout, DDS Joel Rosenlicht, DMD Lorin Berland, DDS John Johnson, DDS, MS Larry Rosenthal, DDS Peter Bertrand, DDS John Kois, DMD, MSD Steven Roser, DMD, MD Michael Block, DMD Joseph Kravitz, DDS, MS Salvatore Ruggiero, DMD, MD Chris Bonacci, DDS, MD Aldo Leopardi, DDS, MS Anthony Sclar, DMD Ronald Brown, DDS, MS Carlo Maiorana, MD, DDS Maurizio Silvestri, DDS, MD Bobby Butler, DDS Jay P. Malmquist, DMD Dennis Smiler, DDS, MScD Donald Callan, DDS Louis Mandel, DDS Muna Soltan, DDS Nicholas Caplanis, DMD, MS Michael Martin, DDS, PhD Michael Sonick, DMD Daniele Cardaropoli, DDS Ziv Mazor, DMD Ahmad Soolari, DMD John Cavallaro, DDS Dale Miles, DDS, MS Christian Stappert, DDS, PhD Stepehn Chu, DMD, MSD Robert Miller, DDS Eric Stoopler, DMD David Clark, DDS John Minichetti, DMD Scott Synnott, DMD Charles Cobb, DDS, PhD Uwe Mohr, MDT Haim Tal, DMD, PhD Spyridon Condos, DDS Jaimee Morgan, DDS Gregory Tarantola, DDS Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Dennis Tarnow, DDS Douglas Deporter, DDS, PhD Peter K. Moy, DMD Geza Terezhalmy, DDS, MA Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Tiziano Testori, MD, DDS Nicolas Elian, DDS Ross Nash, DDS Michael Tischler, DDS Paul Fugazzotto, DDS Gregory Naylor, DDS Tolga Tozum, DDS, PhD Scott Ganz, DMD Marcel Noujeim, DDS, MS Isler Turkyilmaz, DDS, PhD Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Dean Vafiadis, DDS David Guichet, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD Kenneth Hamlett, DDS Charles Orth, DDS Tom Wilcko, DDS Istvan Hargitai, DDS, MS Thallum Padmanabhan, MDS William Wilcko DMD, MS Michael Herndon, DDS Jacinthe Paquette, DDS Alan Winter, DDS Robert Horowitz, DDS Adriano Piattelli MD, DDS Glenn Wolfinger, DDS, FACP Michael Huber, DDS Stan Presley, DDS Richard K. Yoon, DDS George Priest, DMD The Journal of Implant & Advanced Clinical Dentistry 7

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Editorial Commentary Welcome to the evolution of dental literature If you take a dental journal and break it down to its lowest common denominator, its purpose of technology. Email and online chat sessions is simple: the transfer of knowledge from the are quickly replacing land based paper mail for personal and business communiqués. Internet author to the reader. Throughout human history, blogs and newsgroups are causing the agonizing the transfer of knowledge has occurred through an demise of traditional print based newspapers. ever changing cycle of communicatory evolution. In dentistry, we are not immune to this shift in Prior to the introduction of written language, communication. Paper records are being replaced ancient cultures preserved knowledge and customs by digital records. Paper bills are being replaced through communication such as song and dance. by electronic invoices. The time has come for paper Societal progression eventually rendered the based dental literature to follow suit and step into spoken word ineffective as a means of information the digital age. preservation, so this method of communication The Journal of Implant and Advanced Clinical gave way to writing around the 4th millennia BC. Dentistry (JIACD) is the dental profession’s first As different cultures began to exchange and trade completely paperless interactive journal. This format goods, written communication was developed to allows for options not available in traditional print document complex financial transactions and keep based media. Flash animation, audio, video, unlimited track of inventories. It was nearly 5,000 years use of photographs, and hyperlinks to external before the next breakthrough would dethrone the information are just a few of the features exclusive hand written word as the most effective means of to JIACD’s revolutionary online format. Additionally, communication. In 1439, Johannes Gutenberg’s JIACD’s elimination of physical print allows for rapid invention of the mechanical printing press allowed manuscript review and article publication. With for the mass production of movable type and JIACD, authors will no longer need to wait up to spurred the great advances of the European sixteen months to see their article in print. While Renaissance. To this day, variations of printed JIACD is pushing dental literature into the future, its type continue to remain an important method of focus remains on the traditional pillar of the dental communication. profession: the actively practicing clinician. Some say that “the printed word is timeless”, The future of dental literature is here. The future but in all reality, the time of the printed word as is JIACD. the predominant form of communication may be coming to an end. The development of computers and our movement into the digital age has facilitated yet another advance in communication: virtual communication. By its very nature, virtual communication is paperless. Improved efficiency, immediate access, and worldwide availability Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS are just a few of the benefits of this new form Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 9

Nash et al

Case of the Month: Nash et al A New Smile Utilizing an Implant and Ten All Ceramic Restorations Ross W. Nash, DDS1 2 Abstract Background: This case report documents were restored with a combination of all ceramic maxillary arch rehabilitation for a young female crowns, onlays, and veneers. patient. The patient suffered from internal resorption of her left maxillary central incisor and Results: A total of 10 all ceramic restorations was not satisfied with the state of her maxillary were delivered, restoring the patient with a dentition. harmonious and highly aesthetic maxillary arch. Methods: The patient’s left maxillary central Conclusion: Multidisciplinary treatment of the incisor was atraumatically extracted and replaced maxillary arch with all-ceramic restorations can with a single staged dental implant. Teeth 3-14 establish superior aesthetics and functionality. KEY WORDS: Dental implants, dental crowns, dental veneers, dental onlays 1. Private practice, Huntersville, NC. The Nash Institute for Dental Learning, Charlotte, NC, USA 2. Center for Ceramics, The Nash Institute for Dental Learning, Charlotte, NC, USA An attractive young woman suffered from first molars were prepared to receive onlays, while internal resorption of her maxillary left the premolars, canines, and incisors were prepared central incisor and was unhappy with the to receive a combination of full coverage crowns current state of her smile. Prognosis for the central and laminate veneers. Bisacrylic provisional incisor was poor, so the patient was referred to a restorations were fabricated after final polyvinyl- Periodontist for atraumatic extraction of tooth #9 siloxane impressions and occlusal registration were and replacement with a dental implant. A provisional taken. All ceramic crowns and porcelain veneers fixed partial denture was used to temporize site were fabricated by the dental laboratory in the #9 during implant osseointegration in lieu of a Center for Ceramics at the Nash Institute, Charlotte, removable temporary partial denture. N.C. In total, 10 all ceramic restorations were used to restore functionality to the maxillary arch and Following implant integration, final preparations establish superior aesthetics. of teeth 3-14 were accomplished. The maxillary Note: Implant #9 was restored with the Vericore System (Whip Mix, Louisville, KY). The Journal of Implant & Advanced Clinical Dentistry 11

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The Agony and Miles Ecstasy of Buying Cone Beam Technology Part 1: The Ecstasy Dale A. Miles, DDS, MS1 Abstract Background: Since Methods: The author arriving in North America reviews a number of CBCT in 2001, cone beam articles published in dental computed tomography literature and draws upon (CBCT) has been rapidly his personal experience and enthusiastically from analysis of over 3,700 embraced by the dental CBCT cases. profession. With nearly two dozen CBCT systems Results: CBCT currently available, dental applications, image providers are faced outputs and decision with a number of options when they consider points for purchase are discussed. 5 cases purchasing this new technology. This aim of with various CBCT applications are discussed. this article is to present introductory information on cone beam machines, the wide array of Conclusion: Use of CBCT technology applications made possible by the incredible provides unique and valuable information variety of image output choices, and decision that is unobtainable in any other format. This points to aid the reader in their decision making information can benefit practitioners in all process for purchasing CBCT systems. aspects of dental treatment. KEY WORDS: Cone beam computed tomography, digital radiography, radiographic image enhancemnet 1. Arizona School of Dentistry and Oral Health; Private Practice Fountain Hills, AZ, USA The Journal of Implant & Advanced Clinical Dentistry 19

MMiles Introduction The Ecstasy of CBCT: Applications, Image Output and Cone Beam Computed Tomography (CBCT) has been rapidly and enthusiastically embraced by the Decision Points for Purchase dental profession in a much more dramatic way than “digital x-ray imaging”. Introduced in 1988, Many recent articles on CBCT have reported quite it has taken our profession over 20 years to reach a number of applications.3-8 While these current a 40% adoption level with digital x-ray systems. applications may change somewhat over time, In contrast, since arriving in North America in table 1 presents what I feel will be the primary 20011, cone beam manufacturers have gone applications that may become the “standard of from one available system, the NewTom (initially care” or commonplace for particular dental tasks.9 QR Systems, Verona, Italy – acquired by AFP Imaging Corporation, Elmsford, NY), to over 13 Table 1 currently available systems. This does not count companies making more than one version of their Clinician Task(s) machine. A previous publication by Cattaneo and General Dentist Implant site assessment Melsen2, to which the reader is referred for an TMJ evaluation excellent CBCT resource, gives a more complete Paranasal sinus evaluation description of machine parameters such as scan Airway analysis (sleep disorders) size, voxel size, kilovoltage, and milliamperage. Endodontist Root form, pulp canal assessment Because of the rapid introduction and Periapical lesion assessment adoption of CBCT technology, dentists and Implant site assessment dental specialists have been offered so many “Re-treatment” choices that the decision making process is as complex and difficult as it was for digital x-ray Orthodontist Space analysis adoption. The primary difference, however, is Impactions the huge cost of cone beam machines which Treatment “records” can range in price from $120,000 to $350,000! Craniofacial anomaly assessment Despite this enormous investment, dentists TMJ evaluation are discovering the advantages of cone beam Supernumerary tooth assessment imaging and taking the plunge. Oral and Third molar assessment In the first part of this article, “the Ecstasy”, I Maxillofacial Orthognathic surgery present introductory information on cone beam Surgeon Pre-surgical planning for lesions machines, the wide array of applications made Paranasal sinus evaluation possible by the incredible variety of image output TMJ evaluation choices, and some decision points to help you decide which cone beam device might best suit Pediatric Dentist Tooth development your practice. Periodontist Bone grafting Implant site assessment TMJ evaluation Prosthodontist Implant site assessment 20 Vol. 1, No. 1 March 2009

MMiillees Figure 1a: A reconstructed panoramic image, simulating a Figure 1c: A 3D reconstructed color image reveals that conventional panoramic, showing the impaction of tooth the cuspid crown is palatal to the lateral incisor. Note the #6. From this image, the clinician cannot determine if the complete lack of space clinically for this tooth. tooth is impacted facially or palatally. 1e and 2a-2d, show 2 patients with different Figure 1b: A reconstructed MIP (Maximum Intensity Pro le) permanent tooth impactions and the advantage image provides improved clarity, but is still inadequate of having CBCT information for the surgeon and for determining tooth position. Note the complete root orthodontist. formation and the developing third molar follicle positions. Case 1: A fifteen year-old white female with an The cases below graphically illustrate the impacted maxillary right cuspid and developing impact of CBCT on the assessment of various third molars. relatively common patient problems encountered by dentists. Case 2: A fifteen year-old white female with an impacted maxillary right cuspid and developing Cases 1 and 2: Impacted Teeth in third molars. the Mixed Dentition Case 3: Pre-surgical One of the more common problems for dentists, Implant Imaging orthodontists, and oral & maxillofacial surgeons is to assess the position of impacted permanent Perhaps the most widely adopted application for teeth for exposure and repositioning into the CBCT to date is implant site assessment. Images correct occlusal position. We have all suffered from any cone beam machine are rendered in through and continue to use the “Buccal Object a precise 1:1 ratio in reconstruction software Rule” or “SLOB (Same on Lingual, Opposite provided by the vendor. Dentistry has never on Buccal) Rule” to determine the position of had this capability before. All of our previous impacted teeth.11 The cases below, Figures 1a- image applications (periapical, panoramic, and cephalometric) have been magnified and distorted because of the nature of the image capture. The precise 1:1 ratio of CBCT images allows the clinician to have very large and accurate implant The Journal of Implant & Advanced Clinical Dentistry 21

MMiilleess Figure 1d: (left) Axial image showing the crown position of tooth #6. (right) Sagittal view showing the crown position of tooth #6 and its follicular space palatal to tooth #7. site images rather than the older “life size” images displayed in medical CAT scan software of the past. The width and height of the proposed site are also measured with an accuracy of 0.1 mm. Figure 3a illustrates this concept. Image 3d depicts some of the ways to display implant information available in this third party software (OnDemand 3D, CyberMed International, Seoul, Korea). Figure 1e: A 3D reconstructed color image reveals the Cases 4-5: Assessment of “true” position of the impacted cuspid. This image and the Temporomandibular Joint related CBCT images allow for improved surgical planning in comparison to standard digital images. Complex Until now, dentists have had to rely on 2D grayscale images and radiographic interpretations of condylar changes to determine the severity of a condylar problem and how it should be managed. To visualize disc displacement problems, we still have to rely on magnetic resonance imaging or arthroscopy to see 22 Vol. 1, No. 1 March 2009

MMiilleess Figure 2a: A reconstructed panoramic image reveals the “soft tissues” to the TMJ complex. Bony changes, normal tooth development except for tooth #9. In this however, are easily and completely imaged by CBCT. image the tooth almost appears deformed or even Conditions such as osteoarthritic changes, synovial replaced by an odontogenic malformation such as an chondromatosis, and rheumatoid arthritis can be seen odontoma. in color in three dimensions. Additionally, it is simple to correlate vertebral body changes in the cervical Figure 2b: A sagittal view of this tooth shows normal spine with condylar and articular eminence changes. development of the crown and root, but a very unique The cases below demonstrate this capability. horizontal impaction. This image and related CBCT images allow for improved surgical planning in comparison to Case 4 standard digital images. This 59 year-old white female was referred for evaluation of tooth site #14 for implant placement. In addition to chronic sinus changes and a failing implant at another site, the following images depict osteoarthritic changes of the right TMJ condyle and certain vertebral bodies. Osteoarthritis (OA) is a common finding in adults and clinicians placing implants and possibly altering the patient’s occlusion should always image the TMJ complexes to rule out pre- existing problems like OA to ensure success of their case restoratively. In addition, orthodontists are justifying scanning patients in “adult orthodontic cases” to assess any joint problems which could alter the progress of their case. Case 5 This 68 year-old white female was referred for a preliminary assessment for orthodontic treatment. This case demonstrates a bilateral occurrence of “loose bodies” or synovial chondromatosis. The Journal of Implant & Advanced Clinical Dentistry 23

MMiles Figure 2c: (left) 3D color reconstruction using a “Cube” tool in OnDemand 3D third party software (CyberMed International, Seoul, Korea) shows the sub-mucosal position of developing teeth #6, 9, and 11. (right) The same image made “transparent” to remove the thin bone and allow better visualization of the dentition. Figure 2d: A 3D color panoramic reconstruction shows all tooth relationships and root development. Figure 2e: A 3D color skull reconstruction of the potential problems. 24 Vol. 1, No. 1 March 2009

MMiillees Figure 3a: (left) Multiple views of a proposed implant site. (right) View captured directly in the software, enlarged for planning and displaying to the patient in practice management software. Since image reconstruction is 1:1, the image may be displayed at any size on the monitor or if printed. The measurements depicted are accurate to within 0.1 mm. Figure 3b: (left) A 3D color reconstruction of the patient rotated to show left mandible. Note the detail of the bony anatomy. (right) This slice pseudopanoramic used to “paint” the inferior alveolar nerve canal, allows reconstruction of the anterior implant site showing the canal painted in red exiting the mental foramen. The Journal of Implant & Advanced Clinical Dentistry 25

MMiilleess Figure 3c: (top) This slice pseudopanoramic reconstructed at 1.0 mm thickness showing location and path of inferior alveolar nerve canal. (bottom) color rendition thickened to about 10mm. Figure 3d: (left) Selected “mini-implant” placed by operator into site for visualization. (right) A “Veri cation” tool allows precise adjustments to show an implant can be placed, veri ed in the axial and sagittal views. Conclusion dental practice. Each picture is, for the most part, worth 1000 words. In part II of this series, I will In Part I of this article I’ve briefly discussed some present the downside of this technology: “The current machines and common applications of Agony.” That is, the need for additional education CBCT. This part, called “the Ecstasy”, used many if you’re going to adopt cone beam imaging and cases to illustrate the power of these images for the absolute need for a formal radiographic report clinical decision making. The reader simply needs to from an oral & maxillofacial radiologist or medical look at the axial views and 3D color reconstructions radiologist with most cases. to know that this technology will help them in their 26 Vol. 1, No. 1 March 2009

MMiillees Figure 4a: Axial “slice” through the mid-condyle region Figure 4b: 3D color reconstruction of the right TMJ condyle showing a “cystic lesion” on the lateral pole of the right and related bony elements showing the osteophyte condylar head (blue arrow). formation and subchondral cyst on the lateral pole as well as some osteophyte formation on the anterior surface (blue arrows). Figure 4c1: 3D color reconstruction of right TMJ complex. The Journal of Implant & Advanced Clinical Dentistry 27

Miles Figure 4c2: The same process applied to the left TMJ complex for comparison showing a normal condylar head. Figure 4d: Midline sagittal view of the vertebral column showing osteophyte formation, subchondral sclerosis and subchondral cyst formation on C4 and C5. These images con rm osteoarthritis of the C-spine and TMJ condyles. 28 Vol. 1, No. 1 March 2009

Miles Figure 5a: A-P (top) and sagittal (bottom) image 3D color reconstructions of the right TMJ complex showing the “loose body” anterior to the lateral pole of the condyle. The Journal of Implant & Advanced Clinical Dentistry 29

Miles Figure 5b: A-P (top) and sagittal (bottom) 3D color reconstructions of the left TMJ complex showing the “loose body” anterior to the lateral pole of the condyle (white arrow, top image and blue arrow, bottom image). 30 Vol. 1, No. 1 March 2009

Miles Figure 5c: A-P 3D color reconstructions of the right and Disclosure left TMJ complexes showing the “loose body” anterior to The author reports no conflicts of interest with any the lateral pole of the condyle (blue arrows). Note also the products mentioned in this article. calci ed elongated stylohyoid ligaments. References Figure 5d: Side-by-side comparison of the right and left 1. Danforth R, Mah J. 3-D Volume for Dentistry: A New condyles in the “TMJ” program showing subchondral cyst formation in the condylar heads. Dimension. CDA Journal 2003; 31(11): 817-823. 2. Cattaneo PM, Melsen B. The use of cone-beam computed tomography in an orthodontic department in between research and daily clinic. World J Orthod 2008; 9(3): 269-82. 3. Miles D, Danforth R. A Clinician’s Guide to Understanding Cone Beam Volumetric Imaging. Academy of Dental Therapeutics and Stomatology Special Issue 2007; 1-13. 4. Nakajima A, Sameshima G, Arai Y, et al. Two and three-dimensional orthodontic imaging using limited cone-beam computed tomography; Angle Orthod 2005; 75: 895–903. 5. Scarfe W, Farman A, Sukovic P. Clinical applications of cone-beam computed tomography in dental practice. J Canadian Dent Assoc 2006; 72: 75–80. 6. Bourjeois M, Sikorski P, Taylor S. Cone Beam Volumetric Tomography. Oral Health 2007; 6: 14-16. 7. Miles D. Clinical Experience with Cone-Beam Volumetric Imaging – Report of Findings in 381 cases. US Dentistry 2006; 1(1): 39-42. 8. Danforth R, Miles D. Irish Dentist 2007; 10(9): 14-18. 9. Miles D: Color Atlas of Cone Beam Volumetric Imaging for Dental Applications. Quintessence. 2008: 47-303. 10. Miles D. The Future of Dental and Maxillofacial Imaging. Dent Clin N Am 2008; 52(4): 917–928. 11. Miles D, VanDis M, Williamson G, Jensen C. Radiographic Imaging for the Dental Team. SAUNDERS Elsevier, 4th Ed. 2008: 17-18. The Journal of Implant & Advanced Clinical Dentistry 31

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The Use of Cone Beam Turkyilmaz et al Computerized Tomography Generated Surgical Template in the Mandibular Molar Region: A Case Report Ilser Turkyilmaz, DDS, PhD1 2 Abstract Background: Pre-surgical planning is crucial to software. A CBCT generated surgical template achieve favorable clinical outcomes with implant was then fabricated using this same software. therapy. Because pre-operative assessment All implants were placed after flap elevation of the jaw using traditional radiographic and insertion of the CBCT generated surgical methods has some drawbacks, cone beam template. After a healing period of 2 months, a computerized tomography (CBCT), which definitive fixed dental prosthesis was delivered to provides 3-dimensional views and more accurate the patient. detection of anatomic landmarks, has recently been introduced. The aim of this report was to Results: All implants were placed uneventfully. present a patient restored with 3 implants in the The patient was recalled 2 weeks, 3, 6, and posterior mandible using a CBCT generated 12 months after the implant placement. At the surgical template. 1-year recall appointment, no implants were lost and 0.2mm (±0.1) mean marginal bone loss Methods: A 51-year-old male with three missing was noted. molars and a considerable lingual concavity in the posterior mandible was treated with three Conclusion: This case report demonstates how implants and an implant supported screw- a CBCT generated surgical template may be a retained fixed dental prosthesis. After obtaining safer method for implant placement, especially in 3-dimensional CBCT scans, all three implants the posterior mandible where mandibular canal were virtually placed using implant planning presents and lingual concavity is more likely. KEY WORDS: Dental implants, surgical template, computerized tomography, CBCT, mandible 1. Assistant Professor, Department of Prosthodontics, Dental School, University of Texas Health Science Center at San Antonio, Texas. 2. Implant Surgical Fellow, Department of Oral and Maxillofacial Surgery, College of Dentistry, The Ohio State University, Columbus, Ohio. The Journal of Implant & Advanced Clinical Dentistry 33

Turkyilmaz et al INTRODUCTION generated surgical templates are manufactured in such a way that they match the location, trajectory, Clinical reports have indicated promising results and depth of the planned implant with a high with dental implants.1 However, unfavorable degree of precision.8 As the dental practitioner positioning of implants may compromise esthetic places the implants, the guides stabilize drilling by outcome of implant-supported prostheses.2,3 restricting degrees of freedom for drill trajectory Therefore, presurgical planning is vital to attain and depth. Earlier studies have concluded that optimum esthetic and functional outcomes utilization of 3D implant planning software resulted with dental implants. Dental practitioners have in implant positioning with improved biomechanics commonly used traditional dental radiographs and esthetics.10 Use of CBCT scans, implant (panoramic and periapical radiographs)4 and planning software, and CBCT generated surgical conventionally fabricated surgical templates for templates usually extinguishes complications such implant placement.5 A panoramic radiograph as mandibular nerve damage, sinus perforations, is a two-dimensional image providing little fenestrations, or dehiscences.11 information about the buccal-lingual width of the jawbones.6 Surgical guides conventionally The aim of this clinical report was to present fabricated on diagnostic stone casts have a a patient with a significant lingual concavity in number of shortcomings. In addition to stability the posterior mandible, who was restored with issues following surgical flap reflection, they do not three implants using a CBCT generated surgical provide information about the varying thicknesses template. of the mucosa, topography of underlying bone, or anatomical structures such as the mandibular CLINICAL REPORT canal, maxillary sinus.5 A 51-year-old male with three missing mandibular CBCT has recently been introduced for molars was referred to the Implant Clinic, pre-surgical implant planning as a means to Department of Restorative and Prosthetic Dentistry, eliminate the concerns raised by the panaromic College of Dentistry, The Ohio State University or periapical radiographs.6,7 CBCT scans allow in 2008. Clinical examination revealed a non- dental practitioners to visualize cross-sectional, contributory medical history and a significant lingual axial, and panoramic views of the patient’s jaws concavity and lingually angulated edentulous area for more precise planning of implant therapy. The in the posterior mandible. Because the patient pre-surgical CBCT scan is often used for implant was seeking an implant-supported fixed dental selection and exact implant positioning. prosthesis, he was sent to the Department of Radiology for a CBCT scan (iCAT, Imaging With CBCT scans, dental practitioners can Sciences International, Hatfield, PA) to determine virtually place dental implants in optimum positions if available bone was present to place implants and and finalize treatment planning regarding precise also identify the amount of the lingual concavity. implant size, depth, and angulation. Currently, a An implant-supported fixed dental prosthesis small number of implant planning software systems supported by three implants placed using CBCT utilize CBCT scans to facilitate the creation generated surgical template was planned. of surgical drilling templates.8,9 These CBCT 34 Vol. 1, No. 1 March 2009

TuTurkrkyyilimlmaazzeet al Figures 1a, 1b: Treatment planning and implant selection using 3D computer simulation software and CBCT scans. Please notice the lingual concavity. Maxillary and mandibular preliminary proceeded to the next while the images of the impressions were made using irreversible previously planned implant remained on the axial hydrocolloid and then poured in stone. After slices. If necessary, implant position was adjusted obtaining the CBCT data, these data were in order to achieve an optimum outcome. The imported to the 3D implant planning software oral surgeon also used the 3D-view showing the (Facilitate, Materialise Dental Inc, Glen Burnie, shape of the jaw, the ideal prosthetic axis, and the MD) allowing both oral surgeon and restorative implants to improve the position of each implant. dentist to simulate implant placement on the 3D Thus, the implants were accurately positioned in model. Taking into consideration the anatomic the 3D volume (figures 1a and 1b). structures, the dental team interactively simulated the position of the dental implants on each plane. After virtual implant placement was completed, The oral surgeon worked on one implant and then data for the final plan and a preliminary stone case were used to fabricate a tooth-supported The Journal of Implant & Advanced Clinical Dentistry 35

Turkyilmaz et al Figure 2: The design of the CBCT generated surgical template. Figure 4: Guide pin confirmation following dental implant osteotomy preparation. Figure 3: Placement of tooth-supported CBCT generated Figure 5: All three implants were uneventfully placed. surgical template to guide the drilling procedure. SLA consists of a vat containing a liquid photo- CBCT generated surgical template (figure 2). A polymerized resin and a laser mounted on top of the rapid prototyping machine using the principle of vat moves in sequential cross-sectional increments stereolithography (SLA) was utilized to fabricate of 1 mm, corresponding to the slice intervals the CBCT generated surgical template. Briefly, the specified during the CT formatting procedure. The laser polymerizes the surface layer of the resin on contact. Once the first slice is completed, a 36 Vol. 1, No. 1 March 2009

TuTurkrkyyilimlmaazzeet al Figure 6: Delivery of the screw-retained fixed dental Figure 7: Periapical radiograph of the implants one year prosthesis. Access holes were covered with temporary after the implant placement. composite material. were attached to the implant body. After 2 weeks, mechanical table immediately below the surface the final impression was made and, subsequently, moves down 1 mm, carrying with it the previously the definitive implant-supported screw-retained polymerized resin layer of the model. The laser fixed dental prosthesis was delivered to the subsequently polymerizes the next layer adjacent patient (figure 6). to the previously polymerized layer. In this manner, a CBCT generated surgical template with Patients were recalled 2 weeks, 3 months, 6 stainless steel tubes attached into the cylindrical months, and 12 months after implant placement. guide was fabricated (figure 3). Implant success was based on the following criteria, which were suggested by Albrektsson After flap elevation, all three dental implants and Zarb; absence of mobility, painful symptoms, were placed using the tooth-supported CBCT periapical radiolucencies and less than 1 mm of generated surgical template under local anesthesia marginal bone resorption after a one-year period. with intra-venous sedation (figures 4,5). The drilling At one year following implant placement, all procedures were performed using appropriate implants were present and the mean marginal bone drills for each corresponding implant according to loss was 0.2mm (± 0.1) (figure 7). No periapical the manufacturer’s instructions. Following implant radiolucencies, bleeding on probing, or pathologic placement and cover screw delivery, the mucosa probing depths were recorded at these recalls. was sutured. At the second stage surgery, which Thus, all implants were considered successful. was 2 months after implant placement, the cover screws were removed and healing abutments DISCUSSION In contrast to conventional CT scanners, which are large and expensive to purchase/maintain, CBCT is suited for use in dental clinics where cost and dose considerations are important, space is usually The Journal of Implant & Advanced Clinical Dentistry 37

Turkyilmaz et al limited, and scanning requirements are limited to They concluded that SLA surgical guides using CT the head.7 When compared to conventional CT, data might be reliable in implant placement. the advantages of the use of CBCT for maxillofacial imaging in clinical practice can be considered as Van Steenberghe et al.,15 evaluated a concept follows: a reduction in the number of radiographic including a treatment planning procedure based images, image accuracy, rapid scanning time, on CT scan images and a prefabricated fixed dose reduction, and reduced image artifacts.7 prosthetic reconstruction for immediate function In addition, the introduction of computer-aided in upper jaws using a flapless surgical technique. manufacturing (CAM) of anatomic models and They placed 184 implants in 27 consecutive surgical templates generated from computer-aided patients with edentulous maxillae. Treatments were design (CAD) images has accurately allowed the performed according to the Teeth-in-an-Hour™ transfer of planning information to implant placement. concept (Nobel Biocare AB, Göteborg, Sweden) For implant planning and placement, the association including a CT scan–derived customized surgical of CAD/CAM techniques presents advantages template for flapless surgery and a prefabricated regarding 3D determination of the patient’s jaw prosthetic suprastructure. All patients received anatomy and fabrication of both anatomical models their final prosthetic restorations immediately and surgical templates. Rapid prototyping using (approximately 1 hour) after implant placement. stereolithographic modelling, which is a fast and They concluded that the prefabrication of both highly accurate CAM method, is used to produce surgical templates derived from 3D implant prototypes in various manufacturing industries.13,14 planning software for flapless surgery and dental Earlier studies concluded that CAD/CAM software prostheses for immediate loading was a very may enhance the association between dental reliable treatment option. implant planning and insertion.13,14 CONCLUSION Ersoy et al.,14 evaluated the match between the positions and axes of planned and placed implants This case report suggests that the use of a tooth- using stereolithographic surgical guides. They supported CBCT generated surgical template may placed a total of 94 implants using SLA surgical be a more predictable way to place implants in the guides generated from computed tomography. posterior mandible where surgical complications All patients used radiographic templates during such as mandibular nerve damage, fenestrations, or CT imaging and a new CT scan was taken for dehiscences are more likely. each patient following implant placement. Special software was used to fuse the images of both the Correspondance: planned and placed implants and the locations and Dr. Ilser Turkyilmaz axes were compared. They found that the placed Department of Prosthodontics. implants showed angular deviation of 4.9 degrees Dental School, University of Texas, (±2.36), while mean linear deviation was 1.22mm Health Science Center at San Antonio, (±0.85) at the implant neck and 1.51mm (±1.0) at 7703 Floyd Curl Drive, MSC 7912, the implant apex compared to the planned implants. San Antonio, Texas 78229-3900. email: [email protected] 38 Vol. 1, No. 1 March 2009

TuTurkrkyyilimlmaazzeet al Disclosure 7. Scarfe WC, Farman AG, Sukovic 12. Albrektsson T, Zarb GA. The authors report no conflicts of P. Clinical applications of cone- Determinants of correct clinical interest with anything mentioned in beam computed tomography in reporting. Int J Prosthodont this article. dental practice J Can Dent Assoc. 1998;11(5):517-521. 2006;72(1):75-80. References 13. Sarment DP, Sukovic P, 1. Turkyilmaz I. Clinical and 8. Kupeyan HK, Shaffner M, Clinthorne N. Accuracy of Armstrong J. Definitive CAD/CAM- implant placement with a radiological results of patients guided prosthesis for immediate stereolithographic surgical guide. treated with two loading protocols loading of bone-grafted maxilla: Int J Oral Maxillofac Implants for mandibular overdentures a case report. Clin Implant Dent 2003;18(4):571-577. on Brånemark implants. J Clin Relat Res. 2006;8(3):161-167. Periodontol 2006;33(3):233-238. 14. Ersoy AE, Turkyilmaz I, Ozan 9. Almog DM, LaMar J, LaMar O, McGlumphy EA. Reliability 2. el Askary AS, Meffert RM, Griffin T. FR, LaMar F. Cone beam of implant placement with Why do dental implants fail? Part I. computerized tomography- stereolithographic surgical Implant Dent 1999;8(2):173-185. based dental imaging for implant guides generated from computed planning and surgical guidance, tomography: clinical data from 3. el Askary AS, Meffert RM, Griffin Part 1: Single implant in the 94 implants. J Periodontol. T. Why do implants fail? Part II. mandibular molar region. J Oral 2008;79(8):1339-1345. Implant Dent 1999;8(3):265-277. Implantol. 2006;32(2):77-81. 15. van Steenberghe D, Glauser 4. Gahleitner A, Watzek G, Imhof 10. Sanna AM, Molly L, van R, Blombäck U, Andersson H. Dental CT: imaging technique, Steenberghe D. Immediately M, Schutyser F, Pettersson anatomy, and pathologic loaded CAD-CAM manufactured A, Wendelhag I. A computed conditions of the jaws. Eur Radiol fixed complete dentures using tomographic scan-derived 2003;13(2):366-376. flapless implant placement customized surgical template procedures: a cohort study of and fixed prosthesis for flapless 5. Lal K, White GS, Morea consecutive patients. J Prosthet surgery and immediate loading DN, Wright R. Use of Dent 2007;97(6):331-339. of implants in fully edentulous stereolithographic templates maxillae: a prospective for surgical and prosthodontic 11. Nickenig HJ, Eitner S. Reliability multicenter study. Clin Implant implant planning and placement. of implant placement after virtual Dent Relat Res. 2005;7 Suppl Part I. The concept. J Prosthodont planning of implant positions 1:S111-120. 2006;15(1):51-58. using cone beam CT data and surgical (guide) templates. 6. Angelopoulos C, Thomas SL, J Craniomaxillofac Surg Hechler S, Parissis N, Hlavacek 2007;35(4-5):207-211. M. Comparison between digital panoramic radiography and cone- beam computed tomography for the identification of the mandibular canal as part of presurgical dental implant assessment. J Oral Maxillofac Surg. 2008;66(10):2130-2135. The Journal of Implant & Advanced Clinical Dentistry 39

Miles

American Academy of Oral and Maxillofacial Radiology Executive Opinion Statement on Performing and Interpreting Diagnostic Cone Beam Computed Tomography The American Academy of Oral and criteria, dose optimization, technical proficiency, Maxillofacial Radiology (AAOMR) is the and assessed diagnostic or treatment needs. professional organization representing oral The following guidelines have been formulated to and maxillofacial radiologists in the United States. assist practitioners in providing appropriate CBCT The Academy is a nonprofit professional society radiologic care. These guidelines are not inflexible the primary purposes of which are to advance rules or requirements of practice and are not the science of radiology, improve the quality and intended, nor should they be used, to establish a access of radiologic services to the patient, and legal standard of care. encourage continuing education for oral and maxillofacial radiologists, dentists, and persons 1. Use of CBCT practicing oral and maxillofacial imaging in allied CBCT imaging involves exposure of the patient professional fields. The AAOMR embraces the to ionizing radiation. CBCT should be performed introduction of cone beam computed tomography only by an appropriately licensed practitioner or (CBCT) as a major advancement in the imaging certified radiologic operator under supervision of armamentarium available to the dental profession. a licensed practitioner with the necessary training. CBCT examinations should be performed only for The AAOMR is currently in the process of valid diagnostic or treatment reasons and with the developing a position paper on appropriate minimum exposure necessary for adequate image application of CBCT to provide evidence-based quality. guidelines. In the interim, the Executive Committee (EC) of the AAOMR considers it necessary to 2. Practitioner responsibilities provide an opinion document addressing the A practitioner who performs or supervises principles of application of CBCT as it relates CBCT examinations must hold a valid license. to acquisition and interpretation of maxillofacial Dentists using CBCT should be held to the same imaging in dental practice. standards as board certified oral and maxillofacial radiologists (OMFRs), just as dentists excising Recommendations oral and maxillofacial lesions are held to the same standards as OMF surgeons. It is the responsibility The AAOMR EC believes that the practitioner of the practitioner obtaining the CBCT images to should apply imaging procedures based on considerations of patient radiograph selection The Journal of Implant & Advanced Clinical Dentistry 41

SMcailrefes et al interpret the findings of the examination. responsibility for radiologic findings beyond those Just as a pathology report accompanies a needed for a specific task (e.g., implant treatment planning). This assumption is erroneous. biopsy, an imaging report must accompany a CBCT scan. CBCT operators should only be individuals who are legally permitted to perform CBCT Practitioners who operate a CBCT unit, or procedures prescribed by a licensed dental request CBCT imaging, should have thorough practitioner. Such individuals may be employed understanding of the indications for CBCT by the dental practitioner or may perform CBCT as well as a familiarity with the basic physical procedures in an independent facility pursuant to principles and limitations of the technology. all pertaining regulations. The CBCT operator must Practitioners should be familiar with alternative have a thorough understanding of the operating and complementary imaging and diagnostic parameters of the CBCT system and the effects procedures and should be capable of correlating of these parameters on image quality and radiation the results of these with CBCT findings. safety. The CBCT operator has the responsibility Practitioners using CBCT must have a thorough for patient comfort, preparing and positioning understanding of the operational parameters and the patient for the CBCT procedure examination, the effects of these parameters on image quality monitoring the patient during the examination, and and radiation safety. obtaining the image data in a manner prescribed by the referring practitioner. The CBCT operator It is desirable for practitioners to undergo should also perform calibration and the regular specific training to perform CBCT examinations quality control testing. successfully. The practitioner who operates a CBCT unit, or requests a CBCT study, Before delegating the operation of CBCT must examine the entire image dataset. This units, the dental practitioner must confirm the is predicated on a thorough knowledge of legal authority for technical performance of CBCT CT anatomy for the entire acquired image imaging in his or her specific locality. As the CBCT volume, anatomic variations, and observation system is considered to be a medical device of abnormalities. It is imperative that all image in some localities, a dental auxiliary certified to data be systematically reviewed for disease. The perform dental radiographic procedures might not field of view will vary with the system employed, be qualified to perform CBCT. positioning, and collimation, and can include intracranial structures, the base of the skull, 3. Documentation the paranasal sinuses, the cervical spine, the Documentary evidence should be provided to neck, and the airway spaces. Qualified specialist demonstrate the diagnostic or treatment guidance OMFRs may be able to assist diagnostically need of the CBCT examination. Appropriate when practitioners are unwilling to accept the demographic, clinical, and case history information responsibility to review the whole exposed tissue should be available to permit the proper performance volume. and interpretation of the CBCT examination. There may be a misconception on the part To support the diagnostic necessity of the of some practitioners that the user has no 42 Vol. 1, No. 1 March 2009

ScarfMe eilteasl procedure and facilitate patient understanding, responsible for the development of the program. it is desirable that a separate patient consent be The program should include documentation of the obtained for the CBCT procedure before imaging. performance of calibration tests, a log of the results To facilitate image retrieval, the dataset itself should of equipment performance monitoring, facility be stored in compliance with relevant legal and dosimetry results, and a legible chart of patient- regional stipulations and should be exportable in a and task-specific technique exposure parameters. format compatible with the International Standards Organization (ISO)-referenced Digital Imaging The AAOMR EC encourages the use of CBCT and Communications in Medicine (DICOM) technology within the practice of dentistry where Standard. Distributed images are a component of this results in health care benefits for the patient. the permanent record and should be stored in a The above represents the collective statement of suitable archival format. An interpretation report of the AAOMR EC as approved without dissent. Dr. the imaging findings should also be included in the William. patient’s record. William C. Scarfe was assigned the role of 4. Radiation safety and quality assurance primary editor and coordinator for development of Facilities operating CBCT should have specific this statement. policies and procedures for dose optimization. These include, but are not limited to, custom Laurie Carter, DDS, MA, PhD examination exposure protocols taking into account patient body size, field limitation to the Allan G. Farman, BDS, PhD, EdS, MBA, DSc, region of interest, and use of personal protective DDS, MS devices such as a lead torso apron and, where appropriate, a thyroid collar. Procedures should James Geist, DDS follow all pertaining regulations. William C. Scarfe, DDS The purpose of a quality control program is to minimize radiation risk to the patient, personnel, and Christos Angelopoulos, DDS public, while sustaining adequacy of the diagnostic information obtained. The dental practitioner is Madhu K. Nair, BDS, DMD, MS, Lic.Odont., PhD Charles F. Hildebolt, DDS, PhD Donald Tyndall, DDS, MSPH, PhD Michael Shrout, DMD, FAGD American Academy of Oral and Maxillofacial Radiology Executive Committee P.O. Box 1010 Evans, GA 30809-1010 The Journal of Implant & Advanced Clinical Dentistry 43



The Periodontally “Accelerated Osteogenic Orthodontics”™ (PAOO™) Technique: E cient Space Closing With Either Orthopedic or Orthodontic Forces M. Thomas Wilcko, DMD1 2 4 3 5 Abstract Background: For more than 50 years, the Methods: Three cases are presented in which mechanical mindset of “bony block movement” PAOO was utilized to accomplish complete has prevailed in the literature to erroneously orthodontic treatment. In all cases, orthodontics describe the rapid tooth movement associated were combined with full thickness flap reflection, with corticotomy facilitated orthodontics. Modern selective ostectomies, and bone grafting computerized tomography (CT) imaging and according to the PAOO protocol. histologic evaluation have revealed that it is the demineralization of the alveolar housing consistent Results: All cases demonstrated rapid tooth with the regional acceleratory phenomenon movement and stability up to 11.5 years after (RAP) process that provides the environment of treatment. decreased mineral content and increased bone turnover that is responsible for the facilitated tooth Conclusion: PAOO is a method that produces movement. This case series presents 3 cases efficient and stable orthodontic tooth movement. in which periodontally accelerated osteogenic Oftentimes, teeth can be moved 2 to 3 times orthodontics (PAOO) were utilized to treat dental further in 1/3 to 1/4 the time required for malocclusions. traditional orthodontic therapy alone. The basis . of these movements is physiologically based on principles of RAP. KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft 1. Private practice limited to Periodontics, Erie, PA. Associate Professor Periodontics, Case School of Dental Medicine, Cleveland, OH 2. Private practice limited to Orthodontics, Erie, PA 3. Private practice, Erie, PA 4. Chairman Department of Diagnostic Science, University of Texas Dental Branch Houston, Houston, TX 5. Private practice limited to Endodontics, Erie, PA The Journal of Implant & Advanced Clinical Dentistry 45

Introduction/Background housing even though lingual full thickness flaps had been reflected. Corticotomy cuts can result in In describing periodontally accelerated osteogenic significant demineralization of the alveolar housing, orthodontics (PAOO), Wilcko et al1 were the first but only in close approximation of the osseous insult. to attribute rapid tooth movement post-corticotomy During retention, the demineralized collagenous surgery to “bone matrix transportation” rather soft tissue matrix of the bone was found to than to the previously long-held notion of “bony remineralize, albeit to a much lesser degree in the block movement.”2-4 Utilizing hospital based high adult patient than in the adolescent patient. We resolution computed tomographic (CT) scanning, would attribute this discrepancy in remineralization analyses of the alveolar housing were performed to the increased vitality and recuperative potential on both adolescents and adults. Wilcko et al of adolescent tissues versus adult tissues. in 2001 reported that rapid tooth movement The rapid tooth movement was thus not the result in decrowding was the result of the apparent of “bony block movement” as previously thought, demineralization of a relatively thin layer of bone but rather to a demineralization-remineralization over the root prominences in the direction of the phenomenon within the alveolar housing consistent intended tooth movement.6,7 They suggested that with the wound healing pattern of regional the demineralized collagenous soft tissue matrix of acceleratory phenomenon (RAP) as described bone and islands of osteoid that remained following by Frost8 in long bones and by Yaffe et al9 in the the demineralization process could then be alveolus. Wilcko et al have also shown that it rapidly transported with the root surfaces into the is not the design of the “bone activation” that is desired positioning, hence the term “bone matrix responsible for the rapid tooth movement, but rather transportation.” At the time of the corticotomy the intensity and proximity to the osseous insult.7 surgery, full thickness mucoperiosteal flaps were reflected both facially and lingually around all teeth Ferguson et al10, Sebaoun et al11, Lee et al12, and in each surgerized arch, regardless of whether or Wilcko et al13 have provided histologic and systemic not the teeth would be corticotomized (activated). evidence to support the hypothesis proposed by That is to say that the full thickness flaps were Wilcko et al1,6,7 that the facilitated tooth movement reflected around not only the teeth that would subsequent to corticotomy surgery is attributable be activated, but also around the teeth that were to a demineralization/remineralization phenomenon designated for anchorage. Interestingly, it was rather than “bony block movement.” Sebaoun and observed that even though there was pervasive coworkers reported that in a rat model, selective demineralization of the thin layer of alveolar housing alveolar decortication resulted in a 3-fold increase over the root prominences in close approximation to in the catabolic response (osteoclastic count) the corticotomy cuts that even one tooth removed and anabolic process (formation response) from the corticotomy cuts there was no apparent at 3 weeks post surgery that dissipated to demineralization of the alveolar bone over the root normal steady state by 11 weeks post surgery.11 prominences. Additionally, when corticotomy cuts were made facially, but not lingually, there was no In this paper we would like to pay special apparent demineralization of the lingual alveolar attention to space closure of the extraction sites of the upper and lower first bicuspids. The most 46 Vol. 1, No. 1 March 2009

crucial point in being able to optimize space apices of the canine and second bicuspid or the closure at the first bicuspid sites is to remember wall of the maxillary sinus, whichever comes first. that the most optimal scenario following bone activation is to have a relatively thin layer of bone The ostectomy preparation is very similar to that (in close approximation to the osseous insult) over described by Köle.2 Köle reportedly retracted the the root surface in the direction of the intended canines with heavy orthodontic forces delivered tooth movement. Rapid tooth movement cannot through removable appliances and claimed to be be sustained through a large amount of bone in able to complete all major movements in 6 – 12 a mesiodistal orientation of the alveolus. If one weeks. Even though Köle talked in terms of “bony attempts to move a tooth through a large volume block movement”, his osseous preparations also of bone, the osteopenic effect at a distance from included alveolar thinning. This was especially the periodontal ligament (PDL) will resolve and evident in the uprighting of lingually tipped lower return to a regular rate of tooth movement before posterior teeth where he removed the entire 1/2 of the bicuspid space can be closed. Space buccal cortical plate of bone. Liou also employed closure should be initiated 2 to 4 weeks following the thinning of interseptal bone on the distal of the PAOO surgery. This will provide an adequate the canine prior to retraction, but this was done amount of time for the thin layer of bone over in the absence of flap reflection and the buccal the root surface to demineralize. The resulting and lingual cortical plates over the extraction collagenous soft tissue matrix of the bone and socket were not removed.14 Liou accomplished the islands of osteoid can then be rapidly carried space closure in three weeks by retracting the with the root surface into the desired positioning. canines with fixed orthopedic devices and the adjustments beginning immediately post surgery. In order to provide for a very thin layer of bone over the root surface in the direction of the intended Three case reports will be presented to tooth movement an ostectomy is performed at the demonstrate the most efficient manner in which bicuspid extraction site. The buccal and lingual to accomplish rapid space closure following cortical plates and the interspersed medullary first bicuspid removal utilizing either orthopedic bone are removed at the extraction site. Bone or orthodontic forces. A careful review of these thinning is then performed on what would have cases should aid in dispelling much of the been the interseptal bone on the distal of the confusion associated with surgically assisted rapid canine. Typically, the canine is being retracted into space closure utilizing the PAOO technique. the ostectomy site of the extracted first bicuspid. It is very important to assure that there is only an Case Reports extremely thin layer of bone on the distal of the canine from mid-facial to mid-lingual, extending Materials and Methods to the apex of the canine if possible. In the lower Three cases are presented that include arch, care must be taken to stay coronal to the extraction of the first bicuspids and retraction inferior alveolar nerve and in the upper arch one of the canines to close space. Adequate should stop at an imaginary line connecting the and inadequate surgical preparation of the extraction sites will be demonstrated. There was absolutely no luxation of any of the teeth or The Journal of Implant & Advanced Clinical Dentistry 47

any outline blocks of bone. The surgeries were Fig. 1a Patient 1, pre-treatment, right lateral view. performed under intravenous sedation and local anesthesia and orthodontic adjustments Fig. 1d Post suturing. were performed at strict 2-week intervals. lower canines (figures 3b, 3c). Ostectomies are Case #1 generally not needed to accomplish space closure A 29 year old female patient presented with a Class in the upper and lower anterior areas due to the I molar relationship, moderate upper crowding, sparseness of bone in these areas. The orthodontist severe lower crowding, anterior openbite, and an also determined that bone activation should be 8-millimeter anterior overjet (figures 1a, 2a, and 3a). accomplished in the manner of circumscribing The patient previously had traditional free gingival corticotomy cuts and intramarrow penetrations grafting done in the lower anterior/bicuspid areas both facially and lingually around all of the remaining because of gingival recession. The orthodontic upper and lower teeth. Approximately 9 ccs of treatment plan included the removal of the upper particulate bone grafting material consisting of first bicuspids and lower canines. Fortunately, the demineralized cortical powder (2 parts) and bovine roots of her teeth, including the roots of the lower bone (1 part) was then layered over the activated incisors and lower bicuspids, were relatively long,. The patient was bracketed and very light wires were placed in the week preceding PAOO surgery. Full thickness flaps were reflected both facially and lingually around all of the remaining upper and lower teeth except for the lingual aspects of the interdental papilla between teeth #8 and #9. Sulcular releasing incisions were employed. The orthodontist determined that ostectomies would be performed at the extraction sites of the upper first bicuspids (figure 1b). Care was taken to ensure that only a very thin layer of bone remained over the distal aspect of the roots of the upper canines extending to the apices of these two teeth. This would facilitate the closure of the upper first bicuspid extraction sites. Additionally, the bone was thinned on the linguals of the upper canines and upper incisors leaving only a thin layer of bone on the linguals of these teeth. This would facilitate tipping the upper anterior teeth lingually to resolve the severe proclination. Ostectomies were not performed at the extraction sites of the 48 Vol. 1, No. 1 March 2009