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

Fig. 1b Post bone activation and ostectomy, right lateral Fig. 1c Post bone grafting. view. Fig. 1e 1 month post-op, post insertion of the 0-0™ Fig. 1f 1.5 months post-op, extraction space about 50% retractor. closed. bone both facially and lingually and placed in the per the instruction of the orthodontist, the 0-0™ ostectomies (figure 1c). This bone grafting mixture retractors were inserted approximately 1 month was hydrated with a clindamycin phosphate/ after the PAOO surgery (figures 1e and 2b). The bacteriostatic water solution, approximately 5mgs/ 0-0™ retractors were adjusted on a daily basis ml. The full thickness flaps were coronally advanced by the patient as instructed by the orthodontist. to cover the grafting material and sutured with After 2 weeks of adjusting the 0-0™ retractors, interrupted loop 5-0 Gortex sutures (figure 1d). the upper first bicuspid spaces were about 50% closed (figure 1f) and after an additional two The lower canine spaces were closed by the weeks of home adjustments, the spaces were decrowding of the lower incisors (figures 3d and almost completely closed (figure 1g). The 0-0™ 3e). The extraction spaces of the first bicuspids in retractors were removed approximately 5 weeks the upper arch were closed with 0-0™ orthopedic after insertion (figure 2c). The active orthodontic retractors (Wilckodontics Inc., Erie, PA, USA). As The Journal of Implant & Advanced Clinical Dentistry 49

Fig. 1g 2 months post-op, extraction space almost closed. Fig. 1h 9 months post-op, active orthodontic work completed 0-0™ retractor removed 1 week later. Fig. 1i Day of debracketing, 11 months post-op. Fig. 1j 2.5 years retention. treatment was completed at 9 months post in a much improved chin profile (figures 4a and 4b) PAOO surgery (figures 1h and 2d). The patient was . scheduled to be debracketed during the following month. Unfortunately, the patient was in a fairly serious Case #2 automobile accident and it was almost two additional A 30 year old male presented with bi-maxillary months before she could be debracketed (figures 1i protrusion, an eight millimeter anterior open and 2e). Fortunately, the patient’s dentition was not bite, and moderate upper and lower anterior damaged as a result of the automobile accident. The crowding (figure 5a). In centric occlusion, patient’s case has remained stable at 1-year retention the patient occluded only on his molars and (figures 2f and 3f) and at 2.5 years retention (figure 1j). second bicuspids. The orthodontist designated Additionally, increasing the alveolar volume at B-point that all four upper and lower first bicuspids be by filling in the dentoalveolar deficiency has resulted removed, and that the upper and lower second bicuspids and molars be used for anchorage. 50 Vol. 1, No. 1 March 2009

The case was bracketed and light wires placed canines were closed with T-loops. Lingual chain during the week preceding PAOO surgery. Full elastics were also utilized to lessen rotation of the thickness facial and lingual flaps were reflected canines. The T-loops were inserted one month around all of the remaining upper and lower teeth after the PAOO surgery (figure 5g) and removed six utilizing sulcular-releasing incisions. The lingual of weeks later. One month after the insertion of the the interdental papilla between teeth #8 and #9 T-loops and 2 months following the PAOO surgery, was not reflected, but all of the other upper and the extraction spaces were about 50% closed lower interdental papillae were reflected with the (figure 5h). The T-loops had been removed two facial and lingual flaps. The orthodontist determined weeks later for a total time of six weeks of space that ostectomies would be performed at all four closing. At three months following the PAOO upper and lower first bicuspid sites and that bone surgery and two weeks after the T-loops were activation would be performed in the manner of removed, the incisors are seen being retracted circumscribing corticotomy cuts and intramarrow (figure 5i). Even though T-loops deliver typical penetrations both facially and lingually around the orthodontic forces, the extraction site spaces upper and lower anterior teeth (figures 5b and 5c). closed remarkably quickly. The canines were Since the upper and lower molars and second tipped into position and root paralleling followed. bicuspids would be used for anchorage, no bone activation was performed around these teeth. Care Total PAOO treatment time from bracketing was taken to extend the ostectomies as close to the to debracketing was nine months (figure 5j). At apices of the upper and lower canines as possible three years retention, this case has remained without encroaching on the lining of the maxillary stable with no re-opening of the first bicuspid sinuses or the inferior alveolar nerves. Extensive extraction site spaces and no re-opening of the bone thinning was performed on the distals of the anterior open bite. Since there was no significant canines leaving little more than the PDLs, lamina horizontal bone loss prior to the PAOO treatment, dura, and the thinnest layer of medullary bone the dark triangle found between teeth #26 and possible. The bone was also thinned on the linguals #27 at debracketing (figure 5j) self-corrected of the upper and lower anterior teeth. A mixture of over the following three years (figure 5k). demineralized cortical powder (3 parts) and bovine bone (1 part) was then spread over the activated Case #3 bone both facially and lingually, and placed in the A 37 year old male presented with Class II molar ostectomy sites (figures 5d and 5e). This bone and canine relationships, severe upper crowding, grafting mixture was hydrated with a solution moderate lower crowding, a moderately deep of clindamycin phosphate/bacteriostatic water bite, and a three to four mm anterior overjet. The solution, approximately 5mgs/ml. The full thickness upper first bicuspids were designated for removal flaps were then coronally repositioned to cover the which was accomplished approximately one month bone grafting mixture and sutured into place with prior to PAOO surgery. The upper and lower interrupted loop 5-0 Gortex sutures (figure 5f). molars were designated as the anchorage teeth. The extraction spaces of the upper and lower At the PAOO surgery, full thickness flaps were reflected both facially and lingually around all The Journal of Implant & Advanced Clinical Dentistry 51

Fig. 2a Patient 1, pre-treatment, palatal view. Fig. 2b 1 month post-op, post insertion of 0-0™ retractors. Fig. 2d 9 months post-op, active orthodontic work almost Fig. 2e Post debracketing, 11 months post-op. complete. and lower anterior teeth, lower bicuspids, and upper of the remaining upper and lower teeth. Limited second bicuspids (figure 6b). No bone activation ostectomies were performed at the extraction sites was performed around the upper and lower molars. of the upper first bicuspids and bone activation was The ostectomies eliminated the buccal and lingual performed both facially and lingually in the manner of cortical plates and any interspersed medullary circumscribing corticotomy cuts around the upper 52 Vol. 1, No. 1 March 2009

Fig. 2c 9 weeks post-op, 0-0™ retractors removed. the linguals of the upper anterior teeth. Since the roots of the upper canines were much longer Fig. 2f 1-year retention. than the roots of the upper first bicuspids and since the medullary bone in the apical one-third bone in the coronal two-thirds of the extraction site of the extraction sites was left in place, there was sockets with only the buccal and lingual cortical a substantial thickness of the medullary bone plates being removed over the apical one-third. remaining over the apical one-half of the distal root In the apical one-third, the medullary bone was surfaces of the upper canines. A 50/50 mixture left in place and the bone was not thinned on of demineralized cortical powder and bovine bone was then placed over the activated bone and into the ostectomy sites. The full thickness flaps were returned to their original positioning and sutured. Space closure at the upper first bicuspid extraction sites was accomplished with facially positioned space closing coils and chain elastics. Unfortunately, due to the substantial thickness of the medullary bone over the apical one-half of the distal root surfaces of the upper canines, space closure progressed very slowly. At four months post PAOO surgery, the extraction site spaces were only 50% closed (figure 6d) and space closure was not complete until eight months post PAOO surgery (figure 6e). From bracketing to debracketing, the total treatment time for this case was approximately 12 months (figure 6f). Even though only orthodontic forces were utilized, had the extraction sites been surgerized properly, space closure could have been accomplished in six to eight weeks and completed within two to three months following PAOO surgery. The total treatment time for this particular case could have been reduced to eight to nine months. In order to sustain rapid tooth movement, there can only be a very thin layer of bone over the root surface in the direction of the intended tooth movement. Unfortunately, in this case, we failed to create this situation on the distals of the upper canines. This case The Journal of Implant & Advanced Clinical Dentistry 53

Figs. 3a Patient 1, pretreatment, lower occlusal view. Fig. 3b Post extractions and bone activation, lower anterior area, facial view. Fig. 3d 2 weeks post-op, lower occlusal view. Fig. 3e 4 months post-op. has remained stable at 6-months retention would maintain their structural integrity and could (figure 6g) and 11.5-years retention (figure 6h) be moved rapidly due to the decreased resistance offered by the less dense connecting medullary Discussion bone. Modern CT imagery and re-entry surgeries have revealed that the structural integrity of these For the latter half of the 20th century, the rapid tooth small blocks of bone is not maintained following movement subsequent to one-stage (reflection of the corticotomy surgery.1 The rapid movement is both facial and lingual flaps) corticotomy surgery more likely attributable to a transient reversible was attributed to “bony block movement.”2-5 It was demineralization of the alveolar bone consistent widely believed that the small outline blocks of bone 54 Vol. 1, No. 1 March 2009

Fig. 3c Post extractions and bone activation, lower anterior area, lingual view. Fig. 4a Patient 1, pre treatment, chin pro le. Fig. 3f 1-year retention. Fig. 4b Patient 1, post treatment, chin pro le. with a RAP-like physiologic process.6,7,10,13 The remineralization process would appear to be almost complete in the adolescent, but much less complete in the adult. We would attribute this to the increased vitality and recuperative potential of adolescent tissues versus adult tissues. Ferguson has further defined this demineralization/ remineralization to be an osteopenic process.10 The degrees of the osteopenic response is The Journal of Implant & Advanced Clinical Dentistry 55

Fig. 5a Patient 2, pre-treatment, right lateral view. Fig. 5b Post bone activation and ostectomy, upper arch, right lateral view. Fig. 5e Post bone grafting, lower arch, right lateral view. Fig. 5f Post suturing, right lateral view. Fig. 5i 3 months post-op, The T-loops and lingual chain Fig. 5j Post Debracketing, total treatment time 9 months. elastics were removed 2 weeks earlier. The extraction site space closing was accomplished in 6 weeks. 56 Vol. 1, No. 1 March 2009

Fig. 5c Post bone activation and ostectomy, lower arch, Fig. 5d Post bone grafting, upper arch, right lateral view. right lateral view. Fig. 5g 1-month post-op, post insertion of T-loops and Fig. 5h 2 months post-op, 1-month post insertion of lingual chain elastics, right lateral view. T-loops and lingual chain elastics, extraction site spaces about 50% closed. Fig. 5k 3 years retention. directly related to the intensity of the surgical wounding.11,12 Goldie and King have demonstrated increased tooth movement and decreased root resorption in an experimentally induced osteoporotic condition in calcium deficient lactating rats.15 It would appear that under the conditions of increased osseous turnover, calcium depletion, and diminished bone density, tooth movement will occur in preference to root resorption. Perhaps the ability of the bone to more readily respond The Journal of Implant & Advanced Clinical Dentistry 57

Fig. 6a Patient 3, pre-treatment, right lateral view. Fig. 6b Incorrect preparation of the extraction site for space closure. Fig. 6e 8 months post-op, extraction site space closed. Fig. 6f Post debracketing, approximately 1 year post-op. to the forces applied to the teeth lessens the alveolus. Lino et al have clearly shown that the insult likelihood of PDL over compression that can result of circumscribing corticotomy cuts alone will not in hyalinization necrosis. Hyalinization of the PDL produce an osseous response that is sustainable has been shown to precede root resorption during enough to permit movement of tooth roots through orthodontic treatment and can be seen adjacent large amount of bone in the mesiodistal orientation to this process.16,17 Machado has reported of the alveolus.19 Tooth movement can only significantly less apical root resorption (1.1 mm) be sustained post-corticotomy surgery if a thin of the maxillary central incisors in corticotomy- layer of bone is present over the root surface in facilitated non-extraction orthodontic patients.18 the direction of the intended tooth movement.1 Additionally, continued tooth movement prevents Closing spaces in posterior areas requires tissues immediately adjacent to the root from moving teeth in the mesiodistal orientation of the 58 Vol. 1, No. 1 March 2009

Fig. 6c 1 month post-op, facial space closing coil and chain Fig. 6d 4 months post-op, extraction site space about 50% elastic used for space closure. closed. Fig. 6g 6 months retention. Fig. 6h 11.5 years retention. remineralizing. Conversely, alveolar bone further is the reason that the surgical preparation is these away from the root will remineralize quickly. This areas (bone activation) for decrowding is generally becomes readily apparent upon close comparison rather minimal, consisting of osseous insult in the of the case reports that have been presented. manner of circumscribing corticotomy cuts and/or intramarrow penetrations. In all three cass in this The movement following bone activation is report, this is the manner in which bone activation tipping followed by uprighting for parallelism. The was accomplished on the facials of the upper and situation that is most conducive to this is one in lower anterior teeth. If, however, there are facial which there is a very thin layer of bone over the entire exostoses in an area in which the teeth need to length of the root in the direction of the intended be decrowded, these thick dense areas of bone tooth movement. This is typically what one finds on need to be reduced leaving only a thin layer of bone. the facials of the upper and lower anterior teeth and The Journal of Implant & Advanced Clinical Dentistry 59

Likewise, if there is a thick layer of bone over the ostectomies have been performed. In a situation roots on the linguals of the teeth, and the teeth need like this, simply removing the buccal and lingual to be tipped lingually then this thick layer of bone cortical plates over the first bicuspid sockets will not must be thinned. The upper anterior teeth in case 1 suffice. After ostectomies, one must specifically are severely proclined and needed to be uprighted perform additional thinning of the bone on the by tipping them lingually. Generally speaking there is distal of the canines over the entire length of the a fairly substantial thickness of bone on the linguals roots, extending as close to the apices as is possible. of the upper anterior teeth, especially if the palatal vault is shallow. Thinning the palatal bone over If ostectomy site preparation is performed the lingual root surfaces in these areas will greatly properly leaving a very thin layer of bone left facilitate tipping the proclined upper anterior teeth remaining over the entire length of the distal canine lingually, and this is exactly what was done in case 1. root, the canine can readily be retracted to close the extraction site space of the first bicuspid in The more difficult situation is not when teeth are less then two months. If orthopedic forces are used being moved faciolingually, but rather when they to retract the canines, space closure can generally need to be moved mesiodistally through the long be accomplished in four to six weeks as was axis (mesiodistal orientation) of the alveolus. This is demonstrated in case 1. If orthodontic forces are a situation that often needs to be addressed in molar utilized, space closure can typically be accomplished uprighting. If the most distally positioned molars are in six to eight weeks as was demonstrated in case 2 tipped mesially then removing a wedge-shaped where space closure was accomplished in about six piece ofbonedistallyandleavingonlyaverythinlayerof weeks. It appears that the amount of utilized force is bone over the distal surface of the distal root will greatly not as critical as is assuring there is only the thinnest facilitate the molar uprighting. Another situation layer of bone possible left remaining on the distal in which teeth need to be moved in a mesiodistal aspect of the root of the canine. Orthopedic forces orientation is, of course, in posterior space closure. are generally more efficient than orthodontic forces, but both will suffice if the bone thinning is adequate. In situations where first bicuspid removal and space closure is deemed advisable, the canines Case 3 is an example of inadequate preparation are more often than not retracted. Accomplishing of the extraction sites and space closure in this this retraction movement in the most efficient case was not complete until eight months following manner possible will require a considerable amount surgery. The ostectomies only extended about half of alveolar preparation at the extraction site space. the distance to the apices of the canines leaving To provide for a very thin layer of bone over the entire the alveolar medullary bone covering the apical half length of the distal root surface of the canine requires of the distal root surfaces. There was no way to ostectomy in the area previously occupied by the establish the “bone matrix transportation” scenario root of the first bicuspid. Even this, however, may since the bone over the apical half of the roots not necessarily be sufficient. Generally, the roots on the distal of the canines was much too thick. of the canines are longer than the roots of the first Again note, that a thin layer of demineralized bone bicuspids and if these roots are divergent, there can matrix adjacent to a root will remain demineralized be a substantial amount of bone remaining after if the tooth movement is not interrupted, but that 60 Vol. 1, No. 1 March 2009

demineralized bone further away from the root will being able to move the teeth two to three times remineralize quickly. Even when an ideal surgical further than traditional orthodontics alone.1 preparation is achieved, the initiation of the space closure should be delayed for at least two weeks The inclusion of the bone augmentation makes and preferably up to four weeks to allow the thin it possible to provide for an increase in the alveolar layer of bone to demineralize. This will then leave volume post treatment. If the alveolar augmentation only the collagenous soft tissue matrix of the bone is not included for adult patients, the result will be and islands of osteoid to be transported with the less alveolar housing supporting the roots of the root of the canine, thus providing an environment teeth than was present at pretreatment. The alveolar favorable for “bone matrix transportation.” augmentation also makes it possible to cover pre- existing bony dehiscences and fenestrations over Truly ankylosed teeth are not amenable to vital root prominences. We can thus provide for PAOO treatment. A PDL is absolutely necessary a more intact periodontium with greater alveolar for the facilitated tooth movement subsequent to volume to help support the teeth during retention. the bone activation. The increase in the osseous A thin layer of bone is preferable in accomplishing turnover in conjunction with the diminished bone tooth movement post bone activation, but a thicker density creates an environment in which the layer of bone is preferable in helping provide for PDL mediation process occurs more readily, but stability during retention. In a study on mandibular a healthy PDL must be present. In a one-stage relapse, Rothe and coworkers have reported that corticotomy based procedure such as this, the patients with thinner mandibular cortices after teeth or outline blocks of bone must never be debanding were at greater risk for dental relapse.21 luxated. Luxation can lead to a disruption of In all three case reports presented in this paper, the the osseous blood supply which is needed to results have remained stable during retention; 2.5 support this physiologically driven process.20 years, 3 years and 11.5 years respectively. This is consistent with stability findings post PAOO Since the tooth movement post bone activation treatment in non-extraction cases.13 In an evaluation is accomplished through tipping followed by of stability in non-extraction therapy, immediate uprighting, the pretreatment angulations of the post orthodontic treatment results were statistically teeth will play an important role in determining the the same with or without PAOO treatment. During amount of tooth movement that can be expected. retention, however, the clinical outcomes of the If, at pretreatment, a tooth is tipped in the opposite PAOO patients improved and did not demonstrate direction of the intended movement then one would relapse. We would suggest that the improved anticipate being able to accomplish a substantial post treatment stability is not only attributable to amount of tooth movement with the tipping an increased thickness of the alveolar housing followed by uprighting. If, however, at pretreatment supporting the roots of the teeth, but also to the tooth is already tipped in the same direction of “memory loss” resulting from the demineralization/ the intended tooth movement, considerably less remineralization of the original alveolus.1,10,13 correction can be anticipated. With the PAOO technique, if pretreatment angulations of the teeth In case 1, the alveolar augmentation on the facial will accommodate, we can generally anticipate aspect of the lower anterior teeth not only corrected The Journal of Implant & Advanced Clinical Dentistry 61

the bony dehiscences (figure 3b), but by filling in the With the PAOO technique, teeth can be moved dentoalveolar deficiency at B-point, the chin profile 2 to 3 times further in 1/3 to 1/4 the time required was greatly improved (figures 4a, 4b). Additionally, for traditional orthodontic therapy alone. Moderate placement of the bone grafting material into the to severe malocclusions are amenable to treatment ostectomy sites helps consolidate space closure in both healthy adolescents and adults. The PAOO and lessens the likelihood of any significant residual treatmentcanbeusedinplaceofselectedorthognathic alveolar clefting. In all three of the cases that have surgeries, but is not appropriate for the treatment of been presented in this series, various mixtures of substantial anterior/posterior discrepancies such as demineralized cortical powder and bovine bone severe Class III skeletal malocclusions. The alveolar were utilized. Our preference is to use resorbable augmentation makes it possible to complete treatment bone grafting materials that will eventually be with an increased net alveolar volume. Even though replaced by the patient’s own natural bone. the chin prominence cannot be advanced, the chin profile can be rounded out dramatically by filling The rapid tooth movement stimulated by bone the dentoalveolar deficiency at B-point. The ability activation is facilitated by increased bone turnover to increase alveolar volume can also provide for a and calcium depletion. Medications that reduce significantreductionintheneedforbicuspidextractions. the rate of bone turnover and increase calcium uptake, such as bisphosphonates, could potentially CT scan analyses in decrowding cases have be problematic. Long-term corticosteroid therapy indicated that a thin layer of bone over the root can lead to areas of devitalized bone through which prominences in the direction of the intended tooth teeth cannot be moved. We also strongly suspect movement is preferable in facilitating tooth movement. the osteopenia that facilitates this tooth movement This thin layer of bone will demineralize subsequent is a sterile inflammatory process and certain to the bone activation leaving the collagenous soft medications such as non-steroidal anti-inflammatory tissue matrix of the bone and islands of osteoid drugs (NSAIDs) could counteract this process. that can readily be carried with the root surfaces into the desired positioning hence “bone matrix Conclusion transportation”. There are, of course, situations where bicuspid extractions cannot be avoided and such The PAOO technique is an in-office outpatient cases require ostectomy at the extraction sites. Bone treatment that combines both periodontal surgery thinning is imperative to assure the thinnest layer of and orthodontics. The development and refinement bone possible over the root surface in the direction of the PAOO technique over the past 15 years has of the intended tooth movement. When surgerized attempted not only to engineer an “optimal response” properly, most bicuspid extraction sites can be readily of the alveolar bone to the applied “optimal force”, closed in four to eight weeks with either orthopedic or but to also provide an increased alveolar volume and orthodontic force levels. Orthopedic forces are more more intact periodontium to support the teeth and efficient than orthodontic forces, but the thinness overlying soft tissues following treatment. PAOO of the bone is the more critical factor for efficient can also provide for the reduction of undesirable space closing. The bone grafting at the ostectomy side effects such as root resorption, relapse, and sites lessens the likelihood of alveolar clefting bacterial time/load factors, caries and infections. 62 Vol. 1, No. 1 March 2009

and assists in consolidating the closed spaces. preparation must reflect the physiologic realities Luxation is absolutely contraindicated and can and not the misconceptions of the past 50 years. only lead to possible devitalization of the teeth and Correspondance: ligamental damage. The rapid tooth movement M. Thomas Wilcko, DMD subsequent to corticotomy surgery is not due to 6074 Peach Street, Erie, PA 16509 “bony block movement as previously believed. Phone: (814) 868-3669 Because of the demineralization that ensues following Fax: (814) 864-1368. the corticotomy surgery, any outlined blocks of E-mail: [email protected] bone quickly lose their structural integrity. It is not Website: www.fastortho.com the design of the corticotomies that is important, but rather the physiologic response. The osseous References 8. Frost HA. The regional acceleratory 15. Goldie R, King G. Root 1. Wilcko MT, Wilcko WM, Bissada phenomena: a review. Henry Ford resorption and tooth movement in Hosp Med 1983; 31: 3-9. orthodontically treated, calcium- NF. An evidence-based analysis of deficient, and lactating rats. Am J periodontally accelerated orthodontic 9. Yaffe A, Fine N, Bindermen I. Ortho 1984; 83: 424-430. and osteogenic techniques: a Regional accelerated phenomenon in synthesis of scientific perspectives. the mandible following mucoperiosteal 16. Brudvik P, Rygh P. The initial phase Seminars in Orthodontics 2008; flap surgery. J Periodontol 1994; 65: of orthodontic root resorption 21(4): 305-316. 79-83. incident to local compression of 2. Köle H. Surgical operations of the periodontal ligament. Eur J Orthod alveolar ridge to correct occlusal 10. Ferguson DJ, Wilcko WM, Wilcko 11993; 14: 249-263. abnormalities. Oral Surg Oral Med MT. Selective alveolar decortication Oral Pathol 1959; 12: 505-529. for rapid surgical-orthodontic 17. Kurol J, Owman-Moll P. Hyalinization 3. Suya H. Corticotomy in orthodontics. resolution of skeletal malocclusion and root resorption during early In: Hösl E, Baldauf A (eds). treatment. Distraction Osteogenesis orthodontic tooth movement in Mechanical and Biological Basics in of the Facial Skeleton. Hamilton:BC adolescents. Angle Orthod 1998; Orthodontic Therapy. Heidelberg, Decker, 2006: 199-203. 68: 161-165. Germany: Hütlig Buch, 1991:207- 226. 11. Sebaoun JD, Ferguson DJ, Kantarci 18. Machado IM, Ferguson DJ, Wilcko 4. Anholm M, Crites D, Hoff R, A, Carvalho RS, VanDyke TE. WM, Wilcko MT. Reabsorcion Rathbun E. Corticotomy-facilitated Catabolic modeling of trabecular radicular despues del tratamiento orthodontics. Calif Dent Assoc J bone following selective alveolar ortodontcico con o sin cortictomia 1986; 7: 8-11. decortication. J Periodontol 2008; alveolar. Rev Ven Ort. 2002; 19; 5. Gantes B, Rathbun E, Anholm M. 79: 1679-1688. 647-653. Effects on the periodontium following corticotomy-facilitated orthodontics. J 12. Lee W, Karapetyan G, Moats R, 19. Lino S, Sakoda S, Ito G, Nishimori Periodontol 1990; 61: 234-238. Yuamashita D, Moon H, Ferguson T, Ikeda T, Ikyawaki S. Acceleration 6. Wilcko WM, Wilcko MT, Bouquot JE, D, Yen S. Corticotomy-/osteotomy- of orthodontic tooth movement by Ferguson DJ. Rapid orthodontics with assisted tooth movement micro-CTs alveolar corticotomy in the dog. Am alveolar reshaping: Two case reports differ. J Dent Res 2008; 87: 861- J Orthod Dentofacial Orthop 2007; of decrowding. Int J Periodontics 867. 131: 448.e l-8. Restorative Dent 2001; 21: 9-19. 7. Wilcko Wm, Ferguson DJ, Bouquot 13. Wilcko MT, Wilcko MW, Marquez 20. Bell WH, Levy BM. JE, Wilcko MT. Rapid orthodontic MG, Ferguson DJ. Chapter 4. The Revascularization and bone healing decrowding with alveolar contribution of periodontics to after maxillary corticotomies. J. Oral augmentation: case report. World J orthodontic therapy. In: Practical Surg 1972; 30: 640-648. Orthodont 2003; 4: 197-505 Advanced Periodontal Surgery. Wiley Blackwell 2007: 23-50. 21. Rothe LE, Bollen RM, Herring SW. Trabecular and cortical bone as risk 14. Liou E, Shing Huang C. Rapid factors for orthodontic relapse. Am canine retraction through distraction J Orthod Dentofacial Orthop 2006; of the periodontal ligament. Am J 130: 476-484.= Orthod Dentofacial Orthop 1998; 114(4):372-382. The Journal of Implant & Advanced Clinical Dentistry 63



A Novel Dehydrated Amnion Allograft for use in the Treatment of Gingival Recession: An Observational Case Series Brian Gurinsky, DDS, MS1 Abstract Background: Autograft Results: The average age tissue currently remains the of the five patients was 46 “gold standard” of periodontal years with the youngest plastic surgery. It provides being 30 and the oldest 65 excellent predictability, years of age. The average improved long-term root mucogingival defect size was coverage, and superior 3.3mm (±0.84). At three esthetics over other treatment months after surgery, there options. Unfortunately, was an average increase of autogenous graft tissue 3.2mm (±1.71) of new gingival is limited in supply and significantly increases tissue representing 97% (±0.5) defect coverage. patient morbidity. For these reasons, the dental profession continues to search for an effective Conclusion: Based on the data collected in and easy to use alternative. this cases series, processed dehydrated allograft amnion may provide an effective alternative to Methods: A novel allograft composed of autograft tissue in the treatment of shallow- amnion tissue has recently been introduced for to-moderate Miller Class I and II recession use in periodontal plastic surgery. The aim of defects. Additionally, the self-adherent nature this five patient observational case series was of the amnion allograft significantly reduces to document the use of allograft amnion in the surgical time and makes the procedure easier to treatment of shallow-to-moderate recession perform relative to techniques involving the use of defects at three months. autograft or allograft dermis tissue. KEY WORDS: Gingival recession, gingiva/surgery, allograft, amnion 1.. Private practice, Denver, CO, USA. Assistant clinical professor Periodontics, University of Colorado Denver School of Dental Medicine The Journal of Implant & Advanced Clinical Dentistry 65

Gurinsky Background patient morbidity while also lengthening the duration of surgery. Considering these pitfalls, Approximately one-quarter of the United States many patients have an aversion to periodontal adult population possesses gingival recession plastic procedures and delay or completely forgo defects.1 This loss of gingival tissue can result treatment. Ultimately, this may cause the condition in dental hypersensitivity, difficult plaque control, to worsen and possibly decrease the probability of root caries, bone loss, and impaired aesthetics. successful outcomes when eventually treated. For From a scientific and clinical perspective, covering these reasons, the dental profession has continued an exposed root surface with new gingival tissue to search for an alternative soft tissue graft material presents one of the most challenging scenarios for that is effective and easy to use. regeneration of new tissue in the entire body. The avascular and microbiologically affected nature of Recently, allograft alternatives to autogenous the root surface acts as a barrier to regenerative tissue grafts have been introduced in the form of efforts. Additionally, newly formed tissue must allograft dermis tissue products (Puros® Dermis, withstand the physical forces of mastication, Zimmer Dental, Warsaw, IN, USA and Alloderm®, speaking, and oral hygiene. LifeCell Corporation, Branchburg, NJ, USA). An additional allograft of alternative origin is derived Various surgical approaches and materials from human amnion tissue (BioCover™, Snoasis have been employed for the treatment of gingival Medical, Denver, CO, USA). This novel soft recession.2-8 In most of these approaches, the tissue allograft is composed of multiple layers of exposed root surface is cleansed of bacterial dehydrated human amnion tissue processed via endotoxins and regenerative material is placed Purion™, a proprietary tissue processing technology over the defect. The materials used in these that preserves the inherent structure of amnion procedures include autogenous free gingival while cleansing and fusing its layers together. grafts,9 autogenous connective tissue grafts,6 and allograft dermis tissue.10 Additionally, biologic To demonstrate the viability this allograft for the mediators such as enamel matrix derivative, treatment of mucogingival defects, the aim of this platelet-rich plasma, and recombinant platelet five patient observational case series was to record derived growth factor have been introduced into the use of processed dehydrated allograft amnion surgical protocols with the intent of accelerating in the treatment of shallow-to-moderate gingival and directing the wound healing.11-13 Despite the recession defects. introduction of allograft dermis tissue products and biologic mediators, autograft tissue remains Materials and Methods the “gold standard” of periodontal plastic surgery as it provides excellent predictability, improved The aim of this five patient observational case series long-term root coverage, and superior esthetics was to record the use of processed dehydrated over other treatment options.14 Despite these allograft amnion in the treatment of shallow-to- clinical outcomes, the use of autograft tissue has moderate recession defects defined as 3 mm of drawbacks. Autogenous graft tissue is limited in recession when there was no attached gingiva and supply and its procurement significantly increases or a lack of keratinized tissue around the defect and 3 mm of recession when the defect was surrounded 66 Vol. 1, No. 1 March 2009

Gurinsky Figure 1: Amnion allograft being placed over the defect site. Figure 2: Rehydrated allograft secured over the defect site. by healthy tissue. In all cases, only one tooth was flap. 7) De-epithelialization of adjacent papilla. 8) treated and all patients met the inclusion and The processed dehydrated allograft was placed exclusion criteria. All patients were treated using onto the exposed root surface and proximal bone the following surgical protocol: 1) 60-second pre- with the embossed side facing outward away operative rinse with 0.12% Chlorhexidine and local from the tooth (figure 1). Upon placement, the administration of 2% xylocaine with epinephrine, processed dehydrated amnion allograft becomes 1:100,000. 2) Measurement of gingival recession hydrated and self-adheres to the exposed root defect. A standard periodontal probe was used to and proximal bone, thus eliminating the need measure from the cementoenamel junction (CEJ) for suture techniques (figure 2). 9) Immediately to the apical extent of the gingival margin in the after placing the membrane, the reflected flap recession defect. 3) Preparation of exposed root was coronally positioned over the processed surfaces which involved minimal flattening with dehydrated amnion allograft and secured with hand instrumentation. 4) 2-minute application of either an interrupted or sling suture technique. tetracycline solution followed by saline rinse. 5) Care was taken not to move the allograft after Intrasulcular incisions at the buccal margin of placement and during flap closure. treated tooth and extending to the adjacent tooth to include the papillae with horizontal incisions All patients were prescribed Lortab 5.0 and made at right angles to the adjacent interdental over-the-counter ibuprofen pain medication. Oral papillae, at the level of the CEJ. Two oblique hygiene instructions included discontinuing tooth vertical incisions along the adjacent teeth were brushing near the surgical site and to use a 0.12% extended beyond the mucogingival junction Chlorhexidine rinse twice a day until instructed (MGJ) and a trapezoidal mucoperiosteal flap was by the clinician to do otherwise. Sutures were raised to the point of the MGJ. 6) Split thickness removed at two weeks after surgery. Patients dissection allowing for coronal positioning of the were seen two, four, and twelve weeks following surgery. At 12 weeks, grafted defect sites were The Journal of Implant & Advanced Clinical Dentistry 67

Gurinsky Figure 3: Patient 1 before treatment. Figure 4: Patient 1 three months after treatment. re-measured with a standard periodontal probe photos. Patient 3 was a 65 year old male, non- from the CEJ to the apical extent of the gingival smoker with a 3 mm recession defect on tooth margin. Gingivoplasty was not utilized in any case #22. Figures 7 and 8, respectively, show the pre to smooth newly formed tissue. and post operative (3 months) photos. Patient 4 was 52 year old male, non-smoker with a 3 mm Results recession defect on tooth #6. Figures 9 and 10, respectively, show the pre and post operative (3 Patient 1 was a 34 year old female, non-smoker months). Patient 5 was a 49 year old female, non- with a 2 mm recession defect on tooth #11 with smoker, with a 3.5 mm recession defect on tooth no attached gingiva present. Figures 3 and 4, #5. Figures 11 and 12, respectively, show the respectively, show the pre and post operative pre and post operative (3 months) photos. (3 months) photos. Patient 2 was a 30 year old female, non-smoker with a 4 mm recession defect The average age of the five patients was 46 on tooth #27. Figures 5 and 6, respectively, years with the youngest being 30 and the oldest show the pre and post operative (3 months) 65 years of age. The average defect size treated was 3.3mm (±0.84). At three month there was an Table 1: Summary of defect coverage average increase of 3.2mm (±1.71) of new gingival tissue representing 97% (±0.5) root coverage. A Patient Defect Residual Percent summary of the results in terms of root coverage Size Defect Coverage is provided in Table 1. 1 2mm 0mm 2 4mm 0mm 100% Discussion 3 3mm 0mm 100% 4 4mm 0mm 100% The amniotic sac encloses the developing fetus 5 0.5mm 100% through gestation and is composed of amnion and 3.5mm 88% chorion tissue. Amnion lines the inner most portion 68 Vol. 1, No. 1 March 2009

Gurinsky Figure 5: Patient 2 before treatment. . Figure 6: Patient 2 three months after treatment. Figure 7: Patient 3 before treatment. Figure 8: Patient 3 three months after treatment. of the amniotic sac and consists of a single layer collagen types III, IV, and V and cell-adhesion bioactive of epithelium cells, thin reticular fibers (basement factors including fibronectin and laminins. membrane), a thick compact layer, and a fibroblast layer (figure 13). The basement membrane contains Data suggests the amnion basement membrane closely mimics the basement membrane of human The Journal of Implant & Advanced Clinical Dentistry 69

Gurinsky Figure 9: Patient 4 before treatment. Figure 10: Patient 4 three months after treatment. oral mucosa.15 Of particular interest is the fact that bacterial contamination19 and multiple studies this amnion layer possesses several types of laminins, support amnion’s ability to decrease the host with Laminin-5 being the most prevalent. Laminin-5 immunologic response via mechanisms such as plays a role in the cellular adhesion of gingival cells localized suppression of polymorphonuclear cell and concentrations of this glycoprotein in amniotic migration.20 allograft may be useful for periodontal grafting procedures.16 Amniotic tissue has been used since the early 1900s for skin grafts, treatment of burns, and Amnion tissue contains growth factors treatment of ulcerated skin conditions. More recently that may aid in the formation of granulation it has been used for temporary biologic dressings for tissue by stimulating fibroblast growth and full-thickness wounds,21 reconstruction of damaged neovascularization.17 Additionally, the cells found or malformed organs,22 and prevention of tissue within tissue exhibit characteristics associated with adhesion.23 Additionally, use of amniotic tissue has stem cells and may enhance clinical outcomes.18 been reported to decrease post-operative pain when Amnion has shown an ability to form an early used as a wound dressing.21 Amnion tissue grafts physiologic “seal” with the host tissue precluding have also been routinely used for the past decade 70 Vol. 1, No. 1 March 2009

Gurinsky Figure 11: Patient 5 before treatment. Figure 12: Patient 5 three months after treatment. in ophthalmologic surgery. Cryo-preserved amnion24 Figure 13: The structure of amnion tissue. and dehydrated amnion25 have demonstrated equivalent results to conjunctive autograft tissue in Figure 14: Amniotic allograft with embossed markings. ocular reconstruction procedures. Note processed perforations for improved vascularization. In the production of the amnion allograft used in this study, pre-screened, consenting mothers donate the amnion and associated tissues during elective cesarean section surgery. All donated tissue follows strict guidelines for procurement, processing, and distribution, as dictated by the United States Food and Drug Administration (FDA) and the American Association of Tissue Banks (AATB). These safety measures include testing for serological infectious diseases such as human immunodeficiency virus (HIV) type 1 and 2 antibodies, human T-lymphotropic virus (HTLV) type 1 and 2 antibodies, Hepatitis C antibody, Hepatitis B surface antigen, Hepatitis B core total antibody, serological test for Syphilis, HIV type 1 nucleic acid test, and Hepatitis C virus nucleic acid test. Upon collection of the maternal tissue, the amnion and chorion tissues are carefully separated and the amnion is cleansed prior to processing. The allograft is terminally sterilized, dehydrated and The Journal of Implant & Advanced Clinical Dentistry 71

Gurinsky Figure 15: Amnion and chorion tissues being separated. Figure 16: Amnion tissue is cleansed before processing. embossed with the letters “SM” to allow for proper demanding and significantly decreases surgical orientation during placement (figure 14), perforated, time. The ability to self-adhere makes processed and terminally sterilized (SAL 10-6). Figure 15 shows dehydrated allograft amnion an attractive option separation of the amnion from the chorion while figure for multi-teeth procedures and recession defects 16 demonstrates amnion tissue prior to processing. in particularly hard to reach areas such as the molar region. The aim of this observational case series was to document the use of processed dehydrated Conclusion allograft amnion in the treatment of shallow- to-moderate mucogingival recession defects. Based on the data collected in this cases series, Collected data and subjective observation by processed dehydrated allograft amnion may the authors indicates that the use of processed provide an effective alternative to autograft tissue dehydrated allograft amnion provides good in the treatment of shallow-to-moderate Miller results in terms of root coverage, increased tissue Class I and II recession defects. Additionally, thickness, and increased attached gingival tissue. the self-adherent nature of the amnion allograft Although not specifically recorded during this significantly reduced surgical time and made the study, processed dehydrated allograft amnion procedure easier to perform relative to techniques demonstrated excellent esthetic results in terms of texture and color match. There were no adverse Correspondance: reactions during the course of this study and Brian Gurinsky, DDS, MS patients reported relatively little post-operative 1141 18th discomfort. The ability of processed dehydrated 303-296-8527 (office) allograft amnion to self-adhere eliminates the need [email protected] for sutures, making the procedure less technically 72 Vol. 1, No. 1 March 2009

Gurinsky involving the use of autograft or allograft dermis mucogingival defects, the limited number of tissue. Although this case series provides initially patients, lack of controls, and short duration of this promising results for utilization of processed study warrants additional research be conducted dehydrated allograft amnion in particular to confirm the results of this study. Disclosure 10. Harris R.J. Root coverage with 17. Koizumi N, Inatomi T, Sotozono Dr. Gurinsky serves on the Clinical a connective tissue with partial C, Fullwood N J., Quantock A J., Advisory Board for Snoasis Medical, thickness double pedicle graft and Kinoshita S. Growth factor mRNA Inc. and has a financial interest in the an acellular dermal matrix graft: a and protein in preserved human company. clinical and histological evaluation of amniotic membrane. Current Eye a case report. J. Periodontol 1998; Research 2000; 20(3): 173-77. References 69(11): 1305-11. 1. Albandar J.M., Kingman A. Gingival 18. Toda A, Okabe M, Yoshida T, 11. Hagewald S, Spahr A, Rompola E, Nikaido T. The Potential of Amniotic recession, gingival bleeding and Haller B, Heijl L, Bernimoulin J.P. Membrane/ Amnion-Derived Cells for dental calculus in adults 30 years of Comparative study of emdogain and Regeneration of Various Tissues. J. age and older in the United States. J. coronally advanced flap technique Pharmacol Sci 2007; 105: 215-28. Periodontol 1999; 70(1): 30-43. in the treatment of human gingival 2. Grupe H.E. Acrute necrotizing recessions. A prospective controlled 19. Talmi Y P., Sigler L, Inge E, Finkelstein gingivitis. Med. Bulletin U.S. Army Eur. clinical study. J. Clin. Periodontol Y, Zohar Y. Antibacterial Properties 1956; 13(8): 187-9. 2002; 29(1): 35-41. of Human Amniotic Membranes. 3. Nabers, J.M. Free Gingival Grafts. Placenta 1991; (12): 285-88. Periodontics 1966 Sept-Oct; 4(5): 12. Huang L.H., Neiva R.E., Soehren 243-5. S.E., Giannobile W.V., Wang H.L. 20. Hao Y, Hui-Kang D, Hwang D G., 4. Cohen D.W., Ross S.E. The The effect of platelet-rich plasma Kim W, Zhang F. Identification of Anti- double papillae repositioned flap in on the coronally advanced flap root angiogenic and Anti-inflammatory periodontal therapy. J. Periodontol coverage procedure: a pilot human Proteins in Human Amniotic 1968; 39(2): 65-70. trial. J. Periodontol 2005; 76(10): Membrane. Cornea 2000; 19(3): 5. Bernimoulin J.P., Luscher B, 1768-77. 348-52. Muhlemann H.R. Coronally repositioned periodontal flap. Clinical 13. Nevins, M.L. Aesthetic and 21. Robson M.C., Krizek T.J. The effect evaluations after 1 year. J. Clin. regenerative oral plastic surgery: of human amniotic membranes on Periodontol 1975; 2(1): 1-13. clinical applications in tissue the bacteria population of infected 6. Langer B, Langer L. Subepithelial engineering. Dentistry Today 2006; rat burns. Ann. Surg. 1973; 177(2): connective tissue graft technique for 25(10): 142, 144-6. 144-9. root coverage. J. Periodontol 1985; 56(12): 715-20. 14. Harris R.J. Gingival augmentation 22. Morton K.E., Dewhurst C.J. Human 7. Raetzke P.B. Covering localized with an acellular dermal matrix: amnion in the treatment of vaginal areas of root exposure employing the human histologic evaluation of a malformations. Br. J. Obstet. “envelope” technique. J. Periodontol case – placement of the graft on Gynaecol. 1986; 93(1):50-4. 1985 Jul; 56(7): 397-402. periosteum. International Journal 8. Tarnow D, Stahl S.S., Magner A, Periodontics Rest. Dent. 2004; 23. Muralidharan S, Gu J, Laub G.W., Zamzok J. Human gingival attachment 24(4): 378-85. Cichon R, Daloisio C, McGrath reponses to subgingival crown L.B. A new biological membrane for placement. Marginal remodeling. J. 15. Takashima S, Yasuo M, Sanzen N, pericardial closure. J. Biomed. Mater. Clin. Periodontology 1986; 13(6): Sekiguchi K, Okabe M, Yoshida T, Res. 1991; 25(10): 1201-9. 563-9. Toda A, Nikaido T. Characterization 9. Miller PD Jr. The frenectomy of laminin isoforms in human amnion. 24. Luanratanakorn P, Ratanapakorn combined with a laterally positioned Tissue and Cell 2008; 40: 75-81. T, Suwan-Apichon O, Chuck R.S. pedicle graft. Functional and esthetic Randomised controlled study of consideratons. J. Periodontol 1985; 16. Pakkala T, Virtanen I, Oksanen J, conjunctival autograft versus amniotic 56(2): 102-6. Jones J C.R., Hormia M. Function membrane graft in pterygium excision. of Laminins and Laminin-Binding British Journal of Ophthalmology Integrins in Gingival Epithelial Cell 2007; 90(12): 1476-1480. Adhesion. J. Periodontol 2002; 40: 709-19. 25. Memarzadeh F, Fahd A.K., Shamie N, Chuck R.S. Comparison of de- epithelialized amniotic membrane transplantation and conjunctival autograft after primary pterygium excision. Eye 2008; 22(1): 107-12. The Journal of Implant & Advanced Clinical Dentistry 73

Lee et al

Crestal Sinus Lift: Lee et al A Minimally Invasive and Systematic Approach to Sinus Grafting Samuel Lee1, Grace Kang Lee1, Kwang-bum Park2, Thomas Han3 Abstract Background: The placement of dental implants crestal window maxillary sinus augmentation in the posterior maxilla is often a challenge due approach. Preoperative radiograph and to pneumatization of the maxillary sinus. Dental CT scan analyses were performed on all patients. surgeons have predictably overcome this obstacle A combination of specialized trephines was used by performing bone grafting procedures such at slow speeds (40-50 RPM) to access the as lateral window maxillary sinus augmentation maxillary sinus. Multiple specialized elevators (modified Caldwell-Luc). Although predictable, were then used to elevate the Schneiderian this technique produces patient morbidity membrane via the crestal window and particulate including postoperative bruising, pain, and graft was added to the sinus. Dental implants swelling. To reduce such morbidity, many internal were placed, typically in a single staged approach. (crestal) approaches to sinus grafting have been introduced using a variety of specialized Results: All 5 cases in this series resulted in instruments. One problem associated with such successful clinical outcomes with adequate sinus techniques is lack of visibility when opening augmentation and implant survival. The patients the sinus floor and manipulating Schneiderian experienced minimal morbidity associated with membrane. This case series reports on a new the crestal window approach to maxillary sinus crestal approach to maxillary sinus augmentation augmentation. that results in reduced patient morbidity and improved intrasurgical visualization. Conclusion: The crestal window approach to maxillary sinus augmentation is a simple, Methods: 5 patients were treated with the predictable technique with low patient morbidity. KEY WORDS: Sinus lift, maxillary sinus, dental implants 1. Private practice, First Choice Dental Group, Buena Park, CA, USA. 2. Private practice, Mir Dental Hospital, Dae Gu, Republic of Korea 3. Private practice, Los Angeles, CA, USA, Department of Periodontics UCLA. The Journal of Implant & Advanced Clinical Dentistry 75

Lee et al Introduction may overcome poor bone quality by increasing bone to implant surface contact in addition to producing Due to pneumatization of the maxillary sinus, poor superior emergence profile.21 Use of such implants bone quality and quantity, treatment of posterior in molar areas may also decrease fracture risk, edentulism has been and continues to remain a crestal bone stress, and allows fabrication of a challenge for dental physicians. Traditionally, these natural occlusal table.20 The purpose of this paper obstacles are overcome by bone condensing is to describe an innovative surgical technique that and grafting into the maxillary sinus beneath combines a crestal internal sinus lift with use of the Schneiderian membrane.1-18 Bone grafting wide diameter implants. into the sinus has produced predictable results enabling clinicians to place longer implants for Description of Surgical Technique more stable prostheses and better long term outcomes.3 Although final outcomes have proved Flap Elevation satisfactory, sinus augmentation via lateral window Incision design that is at least 2 mm palatal to grafting procedures produces substantial patient desired implant position and flap elevation that morbidity.5-7, 15, 17, 18 Because this technique does not extend beyond the mucogingival junction involves flap elevation beyond the mucogingival is recommended (figure 1). This incision design junction, bruising, swelling, and pain are common allows for minimal pain, unilateral flap retraction, the postoperative complications.5-7, 15, 17, 18 An additional option of doing one or two stage implant placement intraoperative complication associated with this without losing keratinized tissue, and the ability to procedure may arise from the laceration of the treat oral antral communications in case of excessive intraosseous branch of posterior superior artery Schneiderian membrane perforation. (branch of maxillary artery).15 Finally, the technique sensitive nature of the lateral window approach Location of Crestal Window carries a risk of Schneiderian membrane perforation When performing this technique, the lowest point during window preparation and membrane of the maxillary sinus should be located by means elevation. In an attempt to forgo the risks and of radiographic or cone-beam/ct options (see arrow complications of lateral window sinus augmentation, in figure 2). It is most favorable when this position a number of internal (crestal) approaches to have coincides with implant position. If implant placement been introduced such as osteotome5-7, reamers17, at sites #2, 3, and 4 are anticipated with site #3 tapping drills18, piezoelectric, ISM17, and HSC.15 being the lowest point in the maxillary sinus floor, site With most of these internal techniques for sinus #3 should be used to lift the sinus membrane. augmentation, poor visibility during manipulation of the Schneiderian membrane remains a problem. Crestal Window Preparation and Membrane Lift While a great solution for the premolar region, To perform the crestal internal sinus lift, a round use of standard diameter implants (4.0mm) in window is made on the crestal bone with a set the molar region has limitations such as poor of specially designed trephine burs that have a emergence profile, implant fracture, and crestal diameter 1 mm less than the final implant size. bone strain.19-21 Large platform diameter implants 76 Vol. 1, No. 1 March 2009

Lee et al Figure 1: Palatal incision design. Figure 3: Pointed trephine used to mark precise location of crestal window position. Figure 2: Crestal sinus lift initiated from lowest point of Figure 4: Crestal marking after use of pointed trephine. maxillary sinus (arrow). Conventional trephining with precision is For example, if a 6mm implant is anticipated, a often challenging due to skipping or drifting of the 4.0mm (inner diameter) x 5.0mm (outer diameter) trephine during initial bone cutting. To minimize trephine is used. Unlike the conventional trephine this complication and maximize visualization and techniques that require 700-1000 rpm with ample precision of the trephine bur, a “pointed trephine” irrigation, this technique utilizes lower speeds is used at a speed of 50 rpm without irrigation of 40-50 rpm without irrigation and is referred (figure 3). The pointed trephine is used to mark the to as a “Waterless technique.” The waterless location of the intended crestal window and only technique has the advantage of not washing away penetrates the cortical crest (figure 4). autogenous bone filings during bone manipulation, thus allowing the surgeon to collect an increased The second step in this technique utilizes a amount of autogenous bone.18 trephine with an internal adjustable stopper (ASBE The Journal of Implant & Advanced Clinical Dentistry 77

Lee et al Figure 5: Adjustable stopper and bone ejector (ASBE) Figure 7: Specialized self-limiting diamond bur may be trephine used at 50 RPM to a point 1mm short of the sinus used to remove residual bone on sinus oor. oor. Figure 6: Sinus oor removed with trephine exposing Figure 8: Crestal window after use of specialized self- Schneiderian membrane. limiting diamond bur. trephine). Radiograph or cone-beam/CT is used to ASBE trephine is used to penetrate the ridge crest measure the width of residual native bone from the and remove a bone core (figure 5). Although the ridge crest to the floor of the sinus and 1 millimeter ASBE trephine is set to a length 1mm short of the is subtracted from this distance. The adjustable sinus floor, bone core removal will often expose the stopper within the ASBE trephine is then set to Schneiderian membrane (figure 6). In cases where such a length to prevent perforation of the maxillary the sinus floor is extremely dense or on an inclined sinus floor. For example, if 6mm of native residual plane, 1mm of cortical bone may remain at the floor bone remains from the ridge crest to the floor of of the maxillary sinus. In the event that 1mm of the maxillary sinus, the ASBE trephine adjustable residual bone remains at the sinus floor following stopper is set to 5 mm. At a speed of 50 rpm, the use of the ASBE trephine, a specialized wide 78 Vol. 1, No. 1 March 2009

Lee et al Figure 9: Mushroom elevator used to initiate Schneiderian Figure 10: Mushroom elevator may be used to remove membrane elevation. residual bony ledges at crestal window. diameter “sinus diamond bur” is used to expose Figure 11: Cobra elevator used to elevate Schneiderian the Schneiderian membrane. The specialized membrane mesially and distally. sinus diamond bur contains a shoulder stop that prevents drilling into the Schneiderian membrane. osteotomy site that interfere with sinus membrane Additionally, as the sinus diamond bur grinds the elevation (figure 10). After initial Schneiderian residual cortical bone, resultant fine bone particles membrane elevation, the “Cobra sinus elevator” act as a buffer between sinus membrane and is used to further elevate the sinus membrane and diamond bur (figure 7). scrape the bony sinus floor to promote bleeding in the sinus cavity (figures 11 and 12). With the third step in this technique, elevation of the maxillary sinus Schneiderian membrane is accomplished. Following preparation of the crestal window, a “mushroom elevator” is used as a probe for tactile feel of the sinus floor and detection of membrane exposure. The maxillary sinus floor is rarely perfectly flat, so it is common to find initial sinus membrane exposure at the corner of the osteotomy rather than at the center (figure 8). Once the mushroom elevator slightly drops into the maxillary sinus and the Schneiderian membrane is felt, membrane elevation is initiated (figure 9). This same elevator is also used to break away any remaining ledges of bone in the The Journal of Implant & Advanced Clinical Dentistry 79

Lee et al Figure 12: Cobra elevator further elevates Schneiderian Figure 13: Bone graft added to prepared maxillary sinus. membrane and may be used to scrape sinus oor to induce bleeding. to augment the sinus and produce additional lift of the Schneiderian membrane (figures 13 and Figure 16: Case 1 presurgical radiograph of left maxillary 14). Lateral bone graft condensation is critical to sinus. reducing pressure on the Schneiderian membrane and, thus, reducing the risk of perforation. This Bone Condensing and Implant Insertion method facilitates healing by increasing blood To accommodate a wide diameter implant of supply from the lateral and medial wall. Under- sufficient length, bone graft is added to the preparing the diameter of the osteotomy in relation maxillary sinus. A combination of lateral and to the implant is recommended to achieve bone vertical condensation of particulate bone is used compaction and improve initial fixture stabilization (figure 15). Case 1 A 29 year old non-smoking Asian female with a noncontributory medical history had extraction of tooth #14 three months prior to implant surgery and site #15 edentulism for 5 years. Preoperative radiographs showed 4-6 mm of residual bone height between the ridge crest and the maxillary sinus floor (figure 16). Cross sectional CT revealed no signs 80 Vol. 1, No. 1 March 2009

Lee et al Figure 14: Lateral condensation of bone graft into Figure 15: Implant insertion into prepared maxillary sinus. prepared maxillary sinus. Figure 17: Case 1 cross sectional CT images. of sinusitis, ostium patency, and a thin Schneiderian membrane (figure 17). Coincidentally, the patient of the Schneiderian membrane with the mushroom also had a very thin gingival biotype. There is and cobra elevators, slow bone compaction was no known study correlating gingival biotype with accomplished by inserting the condenser no more Schneiderian membrane thickness, but through the than initial height of residual bone (figure 19). Next, author’s clinical experience it has been observed lateral condensation was achieved by the use of a that patients with a thin gingival biotype tend to “sinus spreader” instrument (figure 20). have thinner sinus membranes (unless he/she is a smoker). To allow for single stage implant surgery, the The patient’s sinus floor was relatively flat, thus it was expected that the sinus floor could be removed with the bone core after use of ASBE trephine (figure 18). Trephine with the Waterless technique was used to remove the crestal bone core. Rotation of the bone core within the trephine is an indication that the sinus floor is broken and no further apical pressure of the trephine is recommended to avoid cutting sinus membrane. Autogenous bone collected from the trephine was made into particulate graft and condensedintothemaxillarysinus. Afterinitialelevation The Journal of Implant & Advanced Clinical Dentistry 81

Lee et al Figure 20: Case 1 lateral condensation of bone into maxillary sinus. Figure 18: Case 1 left maxillary ridge following use of ASBE trephine. Note exposure of intact Schneiderian membrane. Figure 19: Case 1 vertical condensation of bone into Figure 21: Case 1 closure. Note preservation of buccal maxillary sinus. keratinized gingiva due to palatal incision design. 82 Vol. 1, No. 1 March 2009

Lee et al Figure 22: Case 1 postsurgical radiograph and CT image. Figure 24: Case 2 postsurgical radiograph. Figure 23: Case 2 maxillary ridge following use of ASBE Case 2 trephine. Note exposure of intact Schneiderian membrane A 53 year old non-smoking Asian male with a noncontributory medical history presented for implant osteotomy was under-prepared in diameter implant placement. Preoperative radiographic and to achieve good initial stability through compaction CT scan evaluation revealed a patent ostium and no of porous quality bone during implant placement. A signs of sinusitis. The lowest point of the maxillary palatal incision design allowed for preservation of sinus floor was located at site #3 with residual keratinized tissue following placement of the healing bone height of 6.5mm. In this case, due to the high abutments. (figure 21). Panoramic and CT scans density of the sinus floor, removal of the trephine were accomplished after surgery to verify proper core left approximately 1mm of residual bone on the grafting of the maxillary sinus without perforation sinus floor. The self-limiting sinus diamond bur was and to note horizontal compaction of bone graft used to safely expose the Schneiderian membrane touching the medial and lateral walls (figure 22). (figure 23). Next, the Schneiderian membrane was elevated with the aforementioned elevators and bone grafting was achieved using demineralized freeze dried bone allograft (DFDBA) mixed with autogenous bone graft (figure 24). Case 3 A 60 year old Asian patient with a non- contributory medical history and current smoking status presented for implant treatment. Radiographic and CT scan evaluation revealed residual bone height of only 1.5mm at site #14. The Journal of Implant & Advanced Clinical Dentistry 83

Lee et al Figure 25: Case 3 maxillary ridge following preparation with Figure 27: Case 3 crestal osteotomy following ledge specialized self-limiting diamond bur. Note sinus membrane removal. at center of preparation. Figure 26: Case 3 membrane elevation with mushroom Figure 28: Case 3 post surgical radiograph. Note 12mm elevator. elevation at site #14. As this site was the lowest point of the maxillary used to penetrate to the bone directly instead sinus in relation to the residual ridge, site #14 of using trephine bur because the residual bone was used to lift the Schneiderian membrane height was only 1.5mm (figure 25). After visual and an implant was placed at sites #13 and confirmation of sinus membrane exposure, #14 after grafting. The sinus diamond bur was membrane elevation was accomplished with the 84 Vol. 1, No. 1 March 2009

Lee et al Figure 29: Case 3 cross sectional CT image. Note excellent lateral condensation. Figure 31: Case 4 cross sectional CT image of initial bone condensation. Figure 30: Case 4 presurgical radiographic image of left Figure 32: Case 4 radiographic image following additional maxillary sinus. implant placement. mushroom elevator (figure 26). A remaining ledge of 4.6 mm drill for 5.1 mm implant). Good primary of bone in the osteotomy was removed with an stabilization of the implant was achieved and implant osteotomy drill at low speed using the a postoperative radiograph revealed adequate waterless technique (figure 27). After bony ledge removal, introduction of “cobra elevator” was possible to further elevate the sinus membrane in all directions. Bone was then condensed into the sinus and the implant was inserted, skipping the last drill sequence (4.3 mm diameter drill instead The Journal of Implant & Advanced Clinical Dentistry 85

Lee et al Figure 33: Case 4 two year postsurgical radiograph. Figure 35: Case 5 membrane insertion into prepared maxillary sinus. Figure 34: Case 5 presurgical radiographic image of left maxillary sinus. smoker, the membrane is exceptionally thick. sinus augmentation (figure 28). Cross section Case 4 from a CT scan showed the medial and lateral A 53 year old patient with a non-contributory wall fully elevated to maximize blood supply to medical history and current heavy smoking status the graft (figure 29). Note the thickness of the presented for implant treatment. As was the Schneiderian membrane on the unelevated lateral case with the patient in Case 3 of this series, the and medial walls. Because this patient was a patient’s smoking history resulted in a Schneiderian membrane that was very thick. Radiographic and CT scans revealed a patent ostium, no signs of sinusitis, and 2mm of residual bone height at site #15 (figure 30). The lowest point of the maxillary sinus (site #15) was used to elevate the Schneiderian membrane. Sinus augmentation was achieved with DFDBA using mostly with lateral condensation rather than vertical condensation (figure 31). Implants were placed at sites #13, #14, and #15 (figure 32). One mistake that the author made was not overgrafting with DFDBA. It is the author’s experience that DFDBA tends to resorb faster and have more shrinkage than other bone graft materials. However, one advantage is that it is not too radiopaque. Therefore, when DFDBA 86 Vol. 1, No. 1 March 2009

Lee et al Figure 36: Case 5 postsurgical CT image. Note excellent implant osteotomy is crucial in this case to make lateral bone condensation and resorbable membrane (arrow). initial stabilization successful. As discussed above, the crestal window approach is easier if residual Figure 37: Case 5 post surgical radiograph. bone height is thin as in this case. To avoid bone shrinkage as observed in case 4, the author used is replaced by host bone, the clinician can have a long lasting resorbable membrane under the visual confirmation by observing radiopacity from Schneiderian membrane. new bone as well and new cortical bone formation on the new sinus floor (figure 33). The crestal window in this case was only 4mm Case 5 in diameter. Therefore, insertion of the resorbable A 39 year old non-smoking Asian patient presented membrane was achieved by rolling the membrane for implant treatment. Radiographic and CT scans after soaking in saline with tetracycline (figure 35). revealed a patent ostium, no signs of sinusitis, and Lambone has excellent plasticity, so once inserted a residual bone height only about 2mm at sites into sinus cavity via crestal window it will open #14 and #15 (figure 34). Under preparing the and return to its original shape (see arrow in figure 36). Postoperative radiograph evaluation revealed an adequate sinus augmentation housing implants at sites #13-15 (figure 37). Discussion The morbidity associated with lateral window sinus augmentation and the “blind” nature of closed sinus lifts necessitated the need for an alternative to these techniques. As shown in the many clinical cases of this series, the “Crestal Window Technique” predictably allows for elevation of the Schneiderian membrane without the morbidity associated with lateral window technique. With proper sinus instrumentation (mushroom, cobra, bone carrier, vertical condenser, lateral condenser) and bony cutting tools (pointed trephine, ASBE trephine, sinus diamond bur), the crestal window approach is predictable and results in similar outcomes to lateral window techniques in terms of membrane elevation and bone condensing. Indications for the crestal window technique are an edentulous maxillary posterior site with residual native bone height of 1-7mm. It is The Journal of Implant & Advanced Clinical Dentistry 87

Lee et al the author’s experience that elevation of the prior to bone grafting, the author recommends the Schneiderian membrane with the cobra elevator is cobra elevator be used to induce bleeding inside easiest when there is less residual bone height as the sinus by scraping the bony floor. this reduces interference of bone on the instrument during membrane elevation. In cases of extremely Conclusion thin residual bone, the author recommends that the sinus diamond bur be used to penetrate to The crestal window technique is an alternative to the bone directly instead of using the trephine. conventional lateral window and closed maxillary This will reduce the likelihood of Schneiderian sinus augmentation techniques. This technique membrane laceration. Finally, as a terminal step requires the use of specialized instrumentation that is unique to the procedure. Disclosure 7. Summers R. A new concept in 14. Soltan M, Smiler D. Antral * Dr. Samuel Lee is the inventor of, maxillary implant surgery: The membrane balloon elevation. osteotome technique. Compendium J Oral Implantol 2005; 31: 85-90. and has a financial interest in, the 1994; 15: 152-158. instrumentation kit described in this 15. Chen L, Cha J. An 8-year article. 8. Bori J. A new sinus lift procedure: retrospective study: 1,100 patients Sa-4/”O”. Dent Implantology receiving 1,557 implants using ** All instrumentation used in this article Update 1991; 2: 33-37. the minimally invasive hydraulic sinus manufactured by MegaGen Co., LTD condensing technique. J Periodontol 9. Smiler D. The sinus lift graft: 2005; 76: 482-491. References basic technique and variations. 1. Tatum H. Maxillary and sinus implant Pract Periodontics Aesthet Dent 16. Wallace S, Froum S. Effect of 1997; 9: 885-893. maxillary sinus augmentation on reconstruction. Den Clin North Am the survival of endosseous dental 1986; 30: 207-229. 10. Bruschi G. Scipioni A, Calesini G, implants. A systematic review. Bruschi E. Localized management Ann Periodontol 2003; 8: 328-343. 2. Boyne P, James R. Grafting of the of the sinus floor with simultaneous maxillary sinus floor with autogenous implant placement: a clinical report. 17. Yamada J, Park H. Internal sinus marrow and bone. J Oral Surg 1980; Int J Oral Maxillofac Implants manipulation (ISM) procedure: 38:613-616. 1998;13: 219-226. A technical report. Clin Implant Dent Relat Res 2007;9: 128-135. 3. Misch C. Maxillary sinus augmentation 11. Toffler M. Site development for endosteal implants: organized in the posterior maxilla using 18. Lee S, Lee G. Minimally invasive alternative treatment plans. osteocompression and apical sinus grafting with autogenous bone. Int J Oral Implant 1987; 4: 49-58. alveolar displacement. Implant Trib 2008;3: 8-10. Compend Contin Educ Dent 4. Garg J, Quinones C. Augmentation 2001;22: 775-784. 19. Petrie C, et al. Increasing implant of the maxillary sinus. A surgical diameter resulted in 3.5-fold technique. Pract Periodontics 12. Fugazzotto P, De P. Sinus floor reduction in crestal strain. Clin Oral Aesthet Dent 1997; 9: 211-219. augmentation at the time of maxillary Impl Res 2005;16: 486-494. molar extraction: success and failure 5. Summers R. The osteotome rates of 137 implants in function 20. Davarpanah M, et al. Wide diameter technique: part 3 – less invasive for up to 3 years. J Periodontol implants: New concepts. Int J methods of the elevating the sinus 2002; 73: 39-44. Periodontics Restorative Dent floors. Compendium 1994; 2001;21: 149-159 15: 698-704. 13. Winter A, Pollack A, Odrich R. Placement of implants in the 21. Degidi M, Piatelli A, Iezzi G, Carinci 6. Summers R. The osteotome severely atrophic posterior maxilla F. Wide diameter implant: Analysis technique: part 2 – the ridge using localized management of the of clinical outcome of 304 fixtures. expansion osteotomy (REO) sinus floor: a preliminary study. Int J J Periodontol 2007;78: 52-58 procedure. Compendium 1994; Oral Maxillofac Implants 2002; 17: 15 :422-426. 687-695. 88 Vol. 1, No. 1 March 2009

Lee et al

Padmanabhan et al

Comparative Analysis of Interleukin-1 BePatdamanabhan et al Concentrations and Crestal Bone Loss in Patients Treated with Conventional Versus Osteotome Expansion Techniques for Dental Implant Delivery: A Pilot Study Thallum Padmanabhan, MDS1 1 Abstract Background: Crevicular fluid analysis of various surgery and on the 60th day, radiovisuography was inflammatory mediators has been investigated as accomplished to measure the crestal bone loss. a means of providing objective criteria of gingival health. The measurement of interleukin-1 beta (IL-1 ) Results: Results indicate that inflammation was may be an important supplement to clinical findings present in all patients after implant placement in establishing a diagnosis of peri-implantitis. The and highest in cases of the osteotome expansion aim of this pilot study is to measure and compare technique. Both implant delivery techniques showed concentrations of the inflammatory marker IL-1 increased levels of IL-1 in comparison to healthy and crestal peri-implant bone loss for two different controls, with the osteotome expansion technique techniques of implant placement: the conventional showing statistically significant elevations of IL-1 in technique utilizing twist drills and the osteotome comparison to the conventional technique. Crestal expansion technique. bone loss and BOP were also elevated in the osteotome group. Methods: 5 subjects were selected with a minimum of two teeth missing in the anterior sextant. 2 dental Conclusion: This two month pilot study showed implants were placed: the 1st site treated with the that dental implants delivered with the osteotome conventional twist drill technique and the second expansion technique have elevated levels of the site with the osteotome expansion technique. pro-inflammatory cytokine IL-1 in comparison to Patients were recalled after an interval of 4 days for traditionally treated sites during the first 60 days of removal of sutures, enzyme linked immunosorbent healing. While the cytokine findings of this study assay (ELISA) sampling, bleeding on probing (BOP) are a convenient explanation for the elevated crestal scoring, and prosthesis insertion. ELISA sampling bone loss and gingival bleeding seen with the was accomplished on the 4th, 20th, 40th and 60th osteotome expansion technique, this was a short day after placement of implants. On the day of the term clinical trial with few subjects. KEY WORDS: Dental implants, interleukin-1 beta, enzyme-linked immunosorbent assay 1. Sri Ramachandra Dental College and Hospital, Sri Ramachandra University, Porur, Chennai, India The Journal of Implant & Advanced Clinical Dentistry 91

Paddmmaannaabbhhaanneet talal INTRODUCTION high speed rotating drills suggests a reduced inflammatory response and corresponding level of The loss of crestal bone associated with dental inflammatory mediators may occur. To investigate implants is a significant clinical phenomenon. this assumption, the present pilot study was Several investigators have indicated this to be conducted to compare levels of the inflammatory a normal occurrence as it eventually exhibits a marker IL-1 and crestal bone loss between steady state when an adequate mucosal barrier is conventionally delivered dental implants and dental formed by peri-implant epithelial connective tissue implants delivered by an osteotome expansion attachment. However, other views suggest that technique. crestal bone loss may result from surgical trauma, occlusal trauma, apical migration of crevicular MATERIALS AND METHODS epithelium to establish a biologic width, interruption of the blood supply when implants and abutments The study population consisted of 5 adults (2 are placed transmucosally, or development of a females and 3 males) aged 20-50 years from the pathogenic bacterial biofilm.1 Sri Ramachandra Medical College and Research Institute, Chennai, India. Inclusion criteria were A technique to counteract the surgical trauma a minimum of two missing teeth in the maxillary aspect of crestal bone loss during implant anterior sextant, a normal overjet/overbite occlusal placement is said to be based on the principle of relationship, and a minimum of 5mm bone width ridge expansion osteotomy (Summers osteotome and 7mm mesiodistal length at the edentulous technique) introduced by Summers in 1994.2 It site. Patients with systemic medical conditions has been suggested that the osteotome expansion were excluded from the study. A written informed technique improves recipient bone quality and consent was obtained from all patients prior to causes no bone overheating. However, histological study commencement. evaluation shows that fractured trabeculae in the condensed peri-implant bone results in an increase Screw tapered self threaded implants 3.7mm of pro-inflammatory and inflammatory mediators around the implant during the first 2 to 3 weeks Figure 1: Full thickness ap elevation following crestal after implant placement.3 incision. During the initial stages of healing following implant placement, clinical signs commonly associated with periodontal disease are present in peri-implant tissues.4 The presence of the potent pro-inflammatory mediator interleukin-1 beta (IL- 1 ) is inevitable following conventional implant delivery due to the initial inflammatory reaction associated with high speed rotating drills used during implant placement. With the osteotome expansion technique, gradual osteotome bone expansion and elimination of heat associated with 92 Vol. 1, No. 1 March 2009

PaPdadmmaannaabbhhaanneet al Figure 2: Conventional dental implant delivery. in diameter and 13mm in length (Equinox Medical Figure 3: Osteotomy preparation with threaded Technologies, Zeist, Holland) were used throughout osteotomes. this study. Preoperative antibiotics (Amoxicillin 500 mg) and local anaesthesia (Lignocaine with The dental implant was then inserted to full depth 1:100,000 epinephrine) were administered prior (figure 2). In the second site, which was treated to surgery. One site was selected for placement with the osteotome expansion technique, a 2mm of implants in the conventional manner while pilot drill was used to create the initial osteotomy. the second site was treated with the osteotome A threaded osteotome (MIS Implants Technologies expansion technique for implant placement. Crestal Ltd, Shlomi, Israel) was placed into the pilot incisions followed by full thickness mucoperiosteal osteotomy with finger pressure and then rotated flap reflection were accomplished in all surgical with the help of a hand wrench (figure 3). The hand areas (figure 1). wrench, unlike the conventional implant wrench, allows only a half a rotation at a time. It has to be In the area of conventional implant placement, disengaged, removed from the holder and then re pilot and twist drills were utilized according to the engaged into position for the next half rotation. After manufacturer instructions. A 2mm pilot drill was each rotation, an interval of 20–30 seconds was used to create an initial osteotomy and followed maintained to allow gradual expansion of the bone by successive increased diameter twist drills. The Journal of Implant & Advanced Clinical Dentistry 93

PPaaddmmaannaabbhhaanneet talal Figure 4: Final position of dental implants. Closure with impression posts in place. Prepared abutments after 4 days of healing. Final prosthesis. in an attempt to avoid fracture of the labial plate. loading, impressions were made with impression After the first osteotome was placed to a depth of posts after placement of sutures (figure 5). Patients 13 mm (laser marks are present on the threaded were dismissed with placement of gingival formers osteotome which indicate depths of 8, 10, and or healing abutments. Post-operative instructions 13mm), a second larger diameter osteotome was were provided and the patient was prescribed utilized following the same principle. a course of antibiotics, non-steroidal anti- inflammatory medication, and 0.2 % Chlorhexidine Once the required depth and width was oral mouth rinse. Patients were initially recalled achieved with the threaded osteotomes, the after an interval of 4 days for suture removal and dental implant was placed (figure 4). Since the prosthesis insertion (figures 6,7). suggested protocol was for early non-functional 94 Vol. 1, No. 1 March 2009

PaPdamdmananaabbhhaanneettaall Cytokine Assay Paper point sampling for ELISA. On days 4, 20, 40, and 60 following surgery, enzyme linked immunosorbent assay (ELISA) sampling was accomplished. The peri-implant crevicular fluid was examined for plaque and was air dried. Sterile paper points were placed in the peri-implant sulcus for an interval of 20 seconds (figure 8). Care was taken to avoid contamination of the paper points by collecting crevicular fluid samples before measurement of probing depth. Salivary contamination of the paper points was avoided by isolating sampled sites with cotton rolls. Paper points containing peri-implant crevicular fluid were transferred to a vial containing 700µl of Phosphate buffered saline. Within 24 hours of sampling, the samples were centrifuged and ELISA was performed according to the manufacturer’s directions (Abcam ltd, USA). For a comparative control, identical ELISA sampling and processing were also performed on healthy teeth in the same patient on day 4. Bleeding on Probing On days 4, 20, 40, and 60 following surgery, bleeding on probing (BOP) was used to assess peri-implant tissue conditions. The periodontal probe was inserted into the peri-implant sulcus with a pressure of 0.25 N and readings were recorded. Radiographic Monitoring Radiographic examination was carried out with standardized radiograph directional holders (RINN Corp, Dentsply, Elgin, IL, USA) using a paralleling long cone technique (figure 9). These examinations were accomplished on the day of implant placement and 6 months after the surgical procedure. The radiopaque implant length, implant shoulder, and alveolar crest were used as reference The Journal of Implant & Advanced Clinical Dentistry

Paddmmaannaabbhhaanneet talal Figure 9: Radiographic examination. Figure 11: Boxplot diagram illustrating bleeding score index ndings. Figure 10: Measurements of digital radiographs with SOPRO digital imaging software. points. The distance between the implant shoulder and alveolar crest were digitally measured on the Vol. 1, No. 1 March 2009 mesial and distal aspects, thrice for each implant, using SOPRO digital imaging software (SOPIX, La Ciotat, France) (figure 10). Mean measurement values were calculated and recorded for each implant. Crestal bone loss was analyzed by calculating the difference between measured bone levels in radiographs on the day of surgery and 180 days post operatively. Original implant length was used as a standard to calculate distortion of radiographs using the formula [x/x’ = y/y’] where “x” equals original implant height, “x’” equals apparent implant height, “y” equals original bone level, and “y’” equals apparent bone level. Statistical Analysis The IL–1 concentrations, BOP, and crestal bone loss data were analyzed using statistical packages (SPSS for Windows). Means, standard deviations, and ranges were calculated from the quantitative data. Paired t-tests were performed to discern the difference in IL–1 concentrations, BOP, and crestal bone loss between the conventional and

PaPdadmmaannaabbhhaanneet al Figure 12: Boxplot diagram illustrating IL-1β Figure 13: Boxplot diagram illustrating crestal bone loss concentrations determined by ELISA. ndings as determined by SOPRO imaging software. osteotome expansion techniques. P–values less statistical significance for bleeding was seen at than 0.05 were considered statistically significant. day 20 (p = 0.034). RESULTS IL–1 concentrations determined by ELISA are provided in table 2. In all patients, IL–1 Bleeding index scores are reported in table 1. ELISA findings were elevated at treatment sites Bleeding index scores for conventionally placed in comparison to healthy site controls (p < 0.05). implants averaged 1.2mm (± 0.69) versus 1.9mm When comparing conventional implant placement (± 0.55) for osteotome expansion delivered dental to the osteotome expansion technique, the latter implants. For all patients in this case series, consistently resulted in higher IL–1 concentrations bleeding index scores were highest in sites treated (figure 12). Statistical significance for these with the osteotome expansion technique (figure comparisons was seen at all measured time 11). When comparing the osteotome expansion intervals: Day 4 (p = 0.042), Day 20 (p = 0.004), and conventional implant placement techniques, Day 40 (p = 0.011), Day 60 (p = 0.010). 4th day 2 22 22 2 22 2 3 20th day 2 21 21 3 12 1 2 40th day 1 21 10 2 12 2 2 th day 1 20 10 2 11 1 1 The Journal of Implant & Advanced Clinical Dentistry

Padmanabhan et al 4th 20th 40th th Crestal bone loss findings as measured with In this study, IL–1 was detected in all SOPRO imaging software averaged 1.0mm (± samples, including those from natural control teeth 0.035) for conventionally placed implants and and all dental implant sites. These findings are 1.194mm (± 0.068) for osteotome expansion in agreement with previous studies in regards to delivered implants (figure 13). With all patients, peri-implant sampling,15,16 but differ from others in the osteotome expansion technique resulted in a regards to healthy controls.13,14 In comparison to statistically significant greater amount of crestal conventional twist drill techniques, implant sites bone loss in comparison to the conventional implant treated with the osteotome expansion technique delivery technique (p = 0.0001). displayed statistically significant elevated levels of IL-1 at all analysis intervals. DISCUSSION Several studies have evaluated the osteotome The clinical aspects of peri-implant inflammation expansion method for dental implant delivery, but are similar to those seen with natural teeth and none have examined the host inflammatory response bone loss is one of the most common features.5-8 in relation to traditional twist drill techniques. Sites Tissue destruction in periodontal disease is the treated with osteotome expansion may contain net result of the host’s inflammatory reaction with higher levels of IL-1 due to bony trabeculae fracture periopathogenic bacteria.9,10 A principle mediator of induced by the osteotome. Wound healing studies this response, detectable in gingival crevicular fluid, for bone have shown that IL-1 significantly increases is the cytokine IL–1 .11-14 The Summers osteotome the number of osteoblasts at the site of bone technique, or osteotome expansion technique, was injury.17 While IL-1 may increase the recruitment introduced as a way to improve recipient bone of osteoblasts to the site of bony injury, this cytokine quality and reduce bone heating.2 The authors of also possesses pro-inflammatory properties and has the present pilot study hypothesized that the level been implicated as a key factor in the development of inflammatory response would be less at sites of periodontal disease.18-20 Elevated IL-1 levels treated in this manner versus those treated with the may explain secondary findings of this study in conventional method employing twist drills. which sites treated with the osteotome expansion Vol. 1, No. 1 March 2009