GBR with Induced Periodontal Regeneration

VOLUME 2, NO. 1 FEBRUARY 2010 The Journal of Implant & Advanced Clinical Dentistry GBR with Induced Periodontal Regeneration Dr. Paul Fugazzotto 2 Hours of CE Credit on Treatment Planning Molar Furcations

... over 1 ROXOLID™sold! THE NEW “DNA” OF IMPLANT MATERIALS ROXOLID – the first TiZr material developed for dental implantology. Confidence when placing small diameter implants Flexibility of having more treatment options Designed to increase patients’ acceptance of implant treatment Straumann® SLActive million im plants Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us



800.441.3100 A Bone Matrix Product Containing Stem Cells. Before: exposed implant The Properties of Autograft without Associated Risks The proprietary processing technology that produces Osteocel® results in a viable bone matrix product that preserves the native stem cells found in marrow rich bone. It is the only product available today that has the desired beneficial properties of autograft - osteoconduction, osteoinduction and osteogenesis – and that allows surgeons to provide their patients with optimal bone growth conditions without the added risk and cost of a secondary procedure. Low Immunogenicity Bone Formation Stem cells contained in Osteocel are capable of www.acesurgical.com differentiating into bone cells. Every lot of Osteocel cells that do not stimulate a cellular immune response. is tested for bone forming potential. Osteocel bone graft in place Osteocel does not activate T cell proliferation, as shown prior to mesh fixation Viable Cell Content 4 months: After mesh removal The osteogenic potential arises from the stem cells in Histologic Evidence Osteocel. Following processing of marrow-rich bone, release strates bone-forming ability. Histology from a human testing demonstrates osteogenic potential sinus augmentation study using Osteocel shows according to the following criteria: substantial vital bone content at 16 weeks, with very low residual graft material.¹ For more information or to place an order call 800.441.3100 1 An Evening Lecture Series Limited February 4th New Jersey March 23rd Chicago, IL Availability* February 11th Cleveland, OH March 25th Washington, DC space today. March 1st Fort Lauderdale, FL April 1st Boston, MA March 3rd Tampa, FL March 4th Orlando, FL To register, please call For more details, please visit March 11th Atlanta, GA 800.441.3100 www.acesurgical.com



esthetics enhanced by technology Laser-Lok® Laser-Lok® dental implant at 8 years post-restoration showing superior microchannels crestal bone & tissue maintenance. Case courtesy of Cary A. Shapoff, DDS (Surgical); Jeffrey A. Babushkin, DDS (Restorative) BioHorizons is known for using science and innovation to create unique implants with proven surgical and esthetic results. Laser-Lok microchannels exemplify our dedication to evidence-based research and development. The effectiveness of Laser-Lok has been proven with over 15 years of in vitro, animal, and human studies at leading universities.† This patented precision laser surface treatment is unique within the industry as the only surface treatment shown to inhibit epithelial downgrowth, attract a true, physical connective tissue attachment to a predetermined zone on the implant and preserve the coronal level of bone; long term.‡ Laser-Lok is available on Tapered Internal, Single-stage, and Internal Implants. For more information, contact BioHorizons Customer Care: 1.888.246.8338 or shop online at www.biohorizons.com †Clinical References available. ‡Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim. The International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP09051 REV D JUN 2009

The Journal of Implant & Advanced Clinical Dentistry Table of Contents 19 Case of the Month Site Development for Dental Implant Placement with Forced Eruption and Site Preservation Ben Watkins 25 Combined Regenerative Techniques: Guided Bone Regeneration Associated with Induced Periodontal Regeneration – Preliminary Reports Euwe Egon, Giulio Rasperini, Maurizio Silvestri 41 Iatrogenic Peri-Implantitis: Treatment and One to Two Year Follow up Pradeep Padatrow, George Hilal, David Cagna, Paul Bland The Journal of Implant & Advanced Clinical Dentistry 5



The Journal of Implant & Advanced Clinical Dentistry Table of Contents 51 JIACD Continuing Education Osteocyte Density in Woven and Lamellar Peri-Implant Bone Raquel R. M. Barros, Arthur B. Novaes Jr., Adriano Piattelli, Giovanna Iezzi 63 Decision Making: The Furcated Molar Dr. Paul Fugazzotto 91 Does the Addition of an O -Angle View Improve Root Fracture Detection? Werner H. Shintaku, Jaqueline S. Venturin, Marcel Noujeim, Pirkka Nummikoski 99 The Wonders of Web 2.0: Community is King Shannon Mackey The Journal of Implant & Advanced Clinical Dentistry 7

Matrix Barrier ® is Back! An Engineered Synthetic Medical Device for Tissue Regeneration 1. 3. 4. 5. 6. 2. www.guidor.com 1-877-GUIDOR1 ©2009 Sunstar Americas, Inc. GDR09013

The Journal of Implant & Advanced Clinical Dentistry Publisher Copyright © 2010 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD- Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest, constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article. the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA. or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry 9

INNOVATION It’s Free. Just Ask for It! Purchase any MIS implants in multiples of 5 (minimum 10 implants) and receive one free CPK - Complete Prosthetic Kit, with each implant. MIS’ Complete Prosthetic Kit (CPK) contains the components you need to restore a \"straightforward\" implant case. First time MIS user? *The offer cannot be combined with other offers. Free items may not be returned or exchanged. Ask for our free implant delivery system. © MIS Corporation. All rights Reserved. MIS offers a wide range of innovative kits and ® accessories that provide creative and simple solutions for the varied challenges encountered USA in implant dentistry. To learn more about MIS visit our website: misimplants.com or call us: Make it Simple 866-797-1333 (toll-free)

The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS A Minimally Invasive and SystematicEAdpiptororaiachl AtodSviinsuosrGyrBafotianrgd Tara Aghaloo, DDS, MD Richard Hughes, DDS George Priest, DMD Faizan Alawi, DDS Debby Hwang, DMD Giulio Rasperini, DDS Michael Apa, DDS Mian Iqbal, DMD, MS Michele Ravenel, DMD, MS Alan M. Atlas, DMD Tassos Irinakis, DDS, MSc Terry Rees, DDS Charles Babbush, DMD, MS James Jacobs, DMD Laurence Rifkin, DDS Thomas Balshi, DDS Ziad N. Jalbout, DDS Georgios E. Romanos, DDS, PhD Barry Bartee, DDS, MD John Johnson, DDS, MS Paul Rosen, DMD, MS Lorin Berland, DDS Sascha Jovanovic, DDS, MS Joel Rosenlicht, DMD Peter Bertrand, DDS John Kois, DMD, MSD Larry Rosenthal, DDS Michael Block, DMD Jack T Krauser, DMD Steven Roser, DMD, MD Chris Bonacci, DDS, MD Gregori Kurtzman, DDS Salvatore Ruggiero, DMD, MD Hugo Bonilla, DDS, MS Burton Langer, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Aldo Leopardi, DDS, MS Frank Setzer, DDS Ronald Brown, DDS, MS Edward Lowe, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Shannon Mackey Dennis Smiler, DDS, MScD Donald Callan, DDS Miles Madison, DDS Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Carlo Maiorana, MD, DDS Muna Soltan, DDS Daniele Cardaropoli, DDS Jay Malmquist, DMD Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Louis Mandel, DDS Ahmad Soolari, DMD John Cavallaro, DDS Michael Martin, DDS, PhD Christian Stappert, DDS, PhD Stepehn Chu, DMD, MSD Ziv Mazor, DMD Neil L. Starr, DDS David Clark, DDS Dale Miles, DDS, MS Eric Stoopler, DMD Charles Cobb, DDS, PhD Robert Miller, DDS Scott Synnott, DMD Spyridon Condos, DDS John Minichetti, DMD Haim Tal, DMD, PhD Sally Cram, DDS Uwe Mohr, MDT Gregory Tarantola, DDS Tomell DeBose, DDS Jaimee Morgan, DDS Dennis Tarnow, DDS Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA Douglas Deporter, DDS, PhD Peter K. Moy, DMD Tiziano Testori, MD, DDS Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Michael Tischler, DDS Nicolas Elian, DDS Ross Nash, DDS Michael Toffler, DDS Paul Fugazzotto, DDS Gregory Naylor, DDS Tolga Tozum, DDS, PhD Scott Ganz, DMD Marcel Noujeim, DDS, MS Leonardo Trombelli, DDS, PhD Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Ilser Turkyilmaz, DDS, PhD David Guichet, DDS Arthur Novaes, DDS, MS Dean Vafiadis, DDS Kenneth Hamlett, DDS Andrew M. Orchin, DDS Hom-Lay Wang, DDS, PhD Istvan Hargitai, DDS, MS Charles Orth, DDS Benjamin O. Watkins, III, DDS Michael Herndon, DDS Jacinthe Paquette, DDS Alan Winter, DDS Robert Horowitz, DDS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Huber, DDS Stan Presley, DDS Richard K. Yoon, DDS The Journal of Implant & Advanced Clinical Dentistry 11

[ ]I - M i n i ® A true 3.0 mm \"mini\" implant OI-NMLIYN$I®69! For a limited time, purchase 20 I-Mini® dental implants and get the I-Mini® Kit for free Offer open to new OCO customers only Would you rather place a real 3.0 mm “mini” implant or a threaded pin? Offer your patients a solid, low cost solution for their implant needs by placing a true “mini” dental implant instead of a “threaded pin” with the bioengineering of a common woodscrew. Utilize as much bone as possible by placing a mini with an aggressive thread pat- tern and OCO’s proven auger, bull-nose tip designed to grow bone. The I-Mini’s simple, minimally invasive placement technique al- lows for predictable placements with a high rate of success. Learn more about the I-Mini placement procedure, at a one-day training session, coming soon to a city near you. Available in Crown & Bridge and 2010 DATES & LOCATIONS: August 7th - Memphis, TN O-Ball overdenture designs February 20th - Dallas, TX August 21st - Seattle, WA Indicated for long term use March 20th - Chicago, IL September 18th - Albuquerque, NM Safe, dependable flapless April 24th - Sacramento, CA October 8th - Hollywood, FL procedure May 22nd - San Diego, CA November 13th - Manhattan, NY Personalized Customer Service June 5th - Las Vegas, NV December 11th - Hollywood, FL July 24th - Raleigh, NC 800.228.0477 | ocobiomedical.com TOoCsOigBnIOupMEfoDrICaAoLne-day training session or to learn more about our I-Mini® Dental Implant System, call 800-228-0477

Editorial Commentary The Dentist, the Mechanic, and the Farmerespite the fact that we have been studying the human body for thousands Dof years, we still have much to learn. Although repairing the body is not quite as black and white as repairing a car, we are developing techniques that are improving Sure, we have a great understanding of anatomy both healing and predictability. During the and basic physiology, but complete understanding past 30 years, innovations such as guided of anomalies such as variations in wound healing tissue regeneration, guided bone regeneration, continues to escape us. For example, why do connective tissue grafts, dental implants, growth certain people just seem to heal better than factors and biologics have significantly improved others? Why does a connective tissue graft in the manner in which we treat our patients. Many Patient A look mature by day 10, while the same procedures have been replaced and upgraded exact graft in Patient B is nowhere close to this with techniques that are more productive and stage? Why will an implant torque to 45Ncm efficient…much like the way that fuel injection has in the preserved socket of Patient C and only replaced the carburetor in cars. 20Ncm in Patient D (even though both patients While we aren’t quite to the point of being able had the exact same method of extraction, the to repair the body as easily as we can repair a car, same bone graft, and the same healing period)? we are still better off than many other professions. I sometimes think that auto mechanics are Think of the farmer. The farmer not only has lucky. When something is broken, they fix it. to perform backbreaking labor with expensive When working on a car engine, the results are equipment that rivals or exceeds the cost of our simple; the car either runs well or it doesn’t. dental equipment, he also has to deal with a When speaking to patients about certain variety of factors that are beyond his control. The procedures, I sometimes like to use what I call the weather is a great example. Over the past few car analogy: “The body is not like a car. When weeks, it has been unusually cold here in the a car breaks down, more often than not you can United States. Because of this freezing weather, simply replace a part or two and the car will many farmers have lost their entire crop. They work again. It does not matter if it is your car or did everything they were supposed to do, they someone else’s car. You replace the bad part and followed all of the rules of farming, and they will you have fixed the problem. This is not always so still lose their crop. with the body. Everyone heals differently. Unlike a At least we don’t have to deal with things such car, you can perform the exact same procedure on as this. When I think about how healing of the two different people and still end up with different body is occasionally just a bit beyond our control, results. Even though your next door neighbor Mrs. I think of the farmer and realize how lucky we are. Jones had a wonderful result with her surgery, it does not mean that yours will turn out exactly the same.” When explained in layman terms such as this, my patients seem to have a better understanding about some of the risks involved with their procedure. Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 13



Letters to the Editors JIACD has been a great addition for and a camaraderie building experience with your dentists to learn about the latest in peers. Additionally, you can receive feedback techniques and interdisciplinary care. from readers in over 80 countries in as quickly as The thing that has impressed me the most 3 to 6 months following submission. TRY IT! about this journal is that the information Dr. Tom Wilcko, Erie, Pennsylvania, USA is online, easy to access, and the quality of the photos and case presentations is JIACD brings to all aspects of dentistry some amazing. things that are lacking with other journals. Dr. Paul Rosen, Philadelphia, The articles are timely, relate to all aspects of Pennsylvania, USA dentistry, and are relevant to all readers. As a researcher and clinician, I appreciate the I really appreciate JIACD because it’s a timeliness of getting my articles published fundamental tool for both practitioner and AND reading the current research performed researcher in the field of Periodontology and by others in the field. This is what dentistry dental implant continuing education. What I has needed for a long time to help us all move prefer most is the reliability, the friendly use, and forward more quickly to deliver the best, latest, the extremely high quality of the images and the state-of-the-art care to our patients. interesting topics. Clinicians and scientists can Dr. Robert Horowitz, Scarsdale, New York, USA find clear clinical suggestions and solutions to new and old problems for daily practice. My complements on what you have Dr. Giulio Rasperini, Italy accomplished with this online publication. Content has been superb. What a service JIACD is a very informative and educational to implantology. online journal. Each issue educates with cutting Dr. Gary Henkel, Horsham, Pennsylvania, USA edge clinical technology. The best advantages of JIACD are unlimited openness to clinicians After reading several informative, well written all over the world. I highly recommend dental articles by highly respected educators and clinicians to become subscribers of JIACD. clinicians I was inspired to submit my own article Dr. Dong-Seok Sohn, Republic of Korea to JIACD. The editorial process was speedy and painless and the reviewers made some very The internet is now the medium of choice helpful suggestions actually improving my original for the timely distribution and collection of submission. I intend to continue writing for the knowledge. The editors and reviewers of journal as I am anxious to be a part of this superb JIACD understand the concept of “timely”. The online educational process. JIACD review process is thorough but streamlined Dr. Michael Toffler, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry 15

OSSEAN INTRALOCK AD NXTBOOK PLEASE PICKUP FROM JAN/FEB 2010 ISSUE PAGE 37

January 29th Grand Hyatt Hotel New York, New York January 30th Intra-Lock CE Center Boca Raton, Florida 9am-6pm, Didactic morning session & Hands-on afternoon workshop 8 CE ADA C. E. R. P. credit units P20la10teChleoutk-roRuniclehcturFe isberrieins Exclusively Sponsored by SYSTEM www.intra-lock.com Limited Attendance. Make your reservations today. For full details visit us on the web or call Intra-Lock Customer Service: 1 877-330-0338. In association with:



Case of the Month Kurtzman Site Development for Dental Implant Placement with Forced Eruption and Site Preservation Ben Watkins, DDS1 Abstract Background: It is known that the extraction with a bone graft. The site was temporized of a tooth leads to the resorption of approxi- with a transitional partial denture. Upon osse- mately 1mm of facial bone alveolar bone. This ous healing, an implant surgical guide was fabri- expected resorption of bone can lead to gingi- cated and a dental implant (Biomet/3i Nanotite val asymmetries with results that may be unac- Certain Prevail implant 4/5/4 x 11.5mm) was ceptable to patients, particularly when the area delivered to the site. The final restoration was is associated with a maxillary central incisor. In achieved with a Zirconia abutment and crown. the case presented, a 22 year old female pre- sented with a history of trauma to the right max- Results: Utilization of orthodontic forced erup- illary central incisor (tooth #8) due to sports tion and site preservation allowed for the creation related injuries, once in 2000 and the sec- of a proper gingival complex and harmonious res- ond in 2004. These injuries resulted in non- toration with a dental implant. The patient was restorable external resorption of the tooth. very happy with the final results of treatment. Methods: To establish proper gingival architec- Conclusion: To achieve optimal esthet- ture and preserve osseous structures, the tooth ics with dental implants, significant plan- was endodontically treated and forcibly erupted ning is often necessary to achieve desired with orthodontics. After coronally positioning results. This planning may project months or the gingival complex, tooth #8 was atraumati- years from initial treatment and requires anal- cally extracted and site preservation was achieved ysis from a multi-disciplinary point of view. KEY WORDS: Dental implants, prosthetics, bone graft 1. Private practice limited to prosthodontics, Washington DC, USA The Journal of Implant & Advanced Clinical Dentistry 19

Watkins 20 Vol. 2, No. 1 February 2010

Watkins The Journal of Implant & Advanced Clinical Dentistry 21

Watkins 22 Vol. 2, No. 1 February 2010

Watkins Correspondence Dr. Ben Watkins 2440 M St Nw Ste 610 Washington, DC 20037 Ph: 202-466-3333 The Journal of Implant & Advanced Clinical Dentistry 23

Does your bone grafting material measure up? Improvements in clinical and radiographic parameters in the GEM 21S® pivotal trial compare favorably with or exceed, documented outcomes for other regenerative therapies in studies examining defects with similar baseline characteristics.1,2,3,4 Radiographic Percent Bone Fill (BF%) Radiographic Linear Bone Growth (LBG) Clinical Attachment Level (CAL) Gain 60 3.0 4.0 57 3.7 40 2.6 3.0 2.0 2.7* Mean % BF 2.0 Mean LBG (mm) CAL Gain (mm) 0 20 1.0 1.1* GEM 21S® Enamel Matrix 14* Derivative (EMD) 0 0 GEM 21S® Enamel Matrix GEM 21S® Enamel Matrix Derivative (EMD) Derivative (EMD) *EMD results at 8 months, GEM 21S® results at 6 months To learn more, please visit us online at www.osteohealth.com or call 1-800-874-2334 View prescribing information: www.osteohealth.com/documents/52.pdf IMPORTANT SAFETY INFORMATION GEM 21S® Growth-factor Enhanced Matrix is intended for use by clinicians familiar with periodontal surgical grafting techniques. It should not be used in the presence of untreated acute infections or malignant neoplasm(s) at the surgical site, where intra-operative soft tissue coverage is not possible, where bone grafting is not advis- able or in patients with a known hypersensitivity to one of its components. It must not be injected systemically. The safety and effectiveness of GEM 21S® has not been established in other non-periodontal bony locations, in patients less than 18 years old, in pregnant or nursing women, in patients with frequent/excessive tobacco use (e.g. smoking more than one pack per day) and in patients with Class III furcations or with teeth exhibiting mobility greater than Grade II. In a 180 patient clinical trial, there were no serious adverse events related to GEM 21S®; adverse events that occurred were considered normal sequelae following any periodontal surgical procedure (swell- ing, pain). For full prescribing information, go to www.osteohealth.com or call 1-800-874-2334 and a copy will be sent to you. References: 1. Nevins M, Giannobile WV, McGuire MK, Mellonig JT, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE. Platelet Derived Growth Factor (rhPDGF-BB) Stimulates Bone Fill and Rate of Attachment Level Gain. Results of a Large Multicenter Randomized Controlled Trial. J Periodontol 2005; 76: 2205-2215. 2. Heijl L, Heden G, Svardstrom G, Ostgren. Enamel matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997; 24: 705-714. 3. Zetterstrom O, Andersson C, Driksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontol defects. J Clin Periodontol 1997; 24: 697-704. 4. See full prescribing infromation for more detail. Emdogain® is a registered trademark of BioVentures BV Corporation. ©COPYRIGHT Osteohealth Company 2008. All rights reserved. OHD235e Rev. 9/2009.

Combined Regenerative Techniques: Egon et al Guided Bone Regeneration Associated with Induced Periodontal Regeneration – Preliminary Reports Euwe Egon, DDS1 2 3 Abstract Background: Guided Bone Regeneration (GBR) preparation of the defect’s area and root planning, technique by means of autogenous bone graft a mono-cortical bone graft from the chin was har- and non-resorbable ePTFE membrane in atro- vested in adequate size and shape and fixated. phic alveolar ridge allows regeneration of bone The exposed root surfaces were etched with EDTA in both vertical and horizontal dimension. The and then EMD was applied. An ePTFE membrane regeneration of periodontium with Induced Peri- was adapted to cover the graft without touch- odontal Regeneration (IPR) through the appli- ing the tooth. After a periosteal incision, a free- cation of Enamel Matrix Derivative Proteins tension primary closure of the flap was obtained. (EMD) onto the root surface, with formation of Six months later the membrane was removed new cementum, new periodontal ligament and and a dental implant was placed in the regener- new bone is well known. Regeneration of bone ated bone. One year after implant loading, clini- directly against the root surface of natural teeth cal and radiographic evaluation was performed. next to the implant site has been avoided so far. Results: The average PAL gain was 4.3 mm and Aims: To investigate the combination of the the average PD gain was 4mm. A maximum PAL GBR and EMD techniques in cases of severe gain of 10mm and 9mm of PD were obtained. horizontal bone loss next to a natural tooth. The average bone gain was 5.4mm with a maxi- mum of 8mm and a minimum of 4mm. 1 year Methods: 4 patients have been enrolled in the after loading all the implants were osseointe- study and 10 sites were treated. All the cases grated and the clinical and aesthetic results presented a severe bone resorption in an area satisfied both the patients and the clinicians. where the tooth was missing and the next natural tooth was stable, but with a mesial or distal bone Conclusions: Motivated by these encouraging defect and a PAL of 7mm to 13mm. All 5 defects clinical results, further studies should be initiated were located in an aesthetic area of the mouth. to investigate the efficacy of the combined GBR- Periodontal and diagnostic measurements were IPR technique, as well as the predictability and the taken. After a wide flap elevation and a meticulous long-term results in the hands of more clinicians. KEY WORDS: Guided bone regeneration, GBR, dental implants, enamel matrix derivative 1. Private Practice, Lurago d’Erba (CO) - Italy 2. Unit of Periodontology, Dept. Surgical, Reconstructive and Diagnostic Sciences- University of Milan, Italy 3. Private Practice, Pavia -Italy The Journal of Implant & Advanced Clinical Dentistry 25

Egon et al INTRODUCTION surface of natural tooth, as well as for GTR in the case of suprabony defects. The aim of this In years past, application of the principle of study is to evaluate clinically and radiographi- guided bone regeneration (GBR) has provided cally the possibility of combining GBR and IPR clinicians with the ability to augment the width techniques in cases of severe horizontal bone of deficient alveolar ridges1-9 to treat dehis- loss next to a natural tooth. Additionally, simul- cence10-18 and implant fenestration defects.19,20 taneous vertical ridge augmentation of the eden- More recently, technical developments of bar- tulous area and a significant PAL gain to the rier membrane materials have allowed improve- adjacent periodontally involved tooth is desired. ments in space maintenance and resulted in the ability to vertically augment bone in atrophic MATERIAL & METHODS alveolar ridges.21-26 The presence of an adja- cent natural tooth with horizontal bone loss and Patient selection a significant loss of attachment can interfere This Study included 4 patients: two 30 year old with the vertical ridge augmentation technique. females and two 35 year old males. The overall In order to minimize the risk of membrane expo- number of treated sites was 10. All the patients sure and infection, all vertical ridge augmentation were systemically healthy, not pregnant, and non- techniques involving membranes suggest trim- smoking. Each patient presented with a localized ming the membrane at least 3mm from natural severe periodontal defect in aesthetic area and the teeth. In fact, if a membrane for GBR is in con- missing adjacent tooth, and radiographic evidence tact with the root surface of an adjacent tooth, it of severe bony defect, and bone loss in the becomes a membrane for guided tissue regen- edentulous area. The investigation was conducted eration (GTR). Several studies have indicated in accordance with the Helsinki declaration on that exposure of membranes to the oral environ- experimentation involving human subjects (1975). ment is a frequent complication and is a possible Informed consent for participation in this study cause of contamination and infection of the newly was obtained from all patients. formed tissue under the membrane.27-32 Like- wise, several studies indicate that GTR outcomes Presurgical Procedure and Measurements may be altered by bacterial contamination.33-37 Each patient was treated with initial therapy con- sisting of oral hygiene instructions with scaling Some studies have elucidated the role of and root planing. 4 weeks after completion of enamel matrix proteins (EMD) in the develop- the initial phase, re-evaluation was performed. At ment of periodontal tissues, their effectiveness in baseline, patients showed full mouth plaque score the regeneration of the periodontium,38-42 and in (FMPS) and full mouth bleeding score (FMBS) improving clinical attachment level in humans.43-48 of less than 20%. Periapical radiographs, follow- EMD applied to root surfaces in a wound site ing the cone paralleling technique by Rinn (Rinn induces periodontal regeneration (IPR) with- Corp. Elgin, Il USA), were obtained from each out the help of a barrier membrane. There is no surgical site at baseline as well as 6, 12 and 24 evidence in the literature about regeneration of months post operative. At each selected site, bone in the implant site directly against the root 26 Vol. 2, No. 1 February 2010

Egon et al Figure 1: Panoramic radiographic initial situation of Figure 2: Clinical situation before the blade implant patient (A). removal at site #’s 7 and 10. probing pocket depth (PPD), probing attachment maceuticals, Macclesfield, Cheshire, England), level (PAL), and marginal recession (REC) were the patients were covered with sterile sheets to recorded to the nearest millimeter with a manual minimize bacterial contamination. The surgical pressure-sensitive probe (PCP-UNC15, Hu- field was locally anesthetized with articaine chlo- Friedy) calibrated at a force of 0.25N. After 1 year, rhydrate and epinephrine 1:100,000. Intrasul- 2 years, and in 4 sites at 3 years, the same mea- cular incision was performed on the distal tooth, surements were performed. One of the patients followed by a crestal incision within the kerati- presented with two failing blade-shape implants nized tissue in the edentulous ridge, ending with in positions 7 and 10 (figures 1, 2). In this case an intrasulcular incision to the next mesial adja- the two blades were removed while trying to cent tooth. Vertical releasing incisions were preserve as much hard and soft tissue as pos- placed at the mesio and distobuccal line angles sible. The surgery in this patient was performed as well as in the lingual aspect. The wide full- after a period of healing of 8 weeks. The patients thickness mucoperiosteal flaps were reflected received antibiotics prophylaxis for 10 days to gain sufficient access for graft and membrane (Amoxicillin, 1g, 12 and 2 hours preoperatively placement. The bony lesions were carefully and every 12 postoperatively) and an anti-inflam- degranulated and the roots scaled and planed. matory agent (ketoprofen) 50mg every 12 hours The surgical area was then protected with gauze for 7 days in accordance with Simion et al 1994.30 soaked with sterile saline solution (figures 3, 4). Surgical technique Panoramic radiographic evaluation resulted in The surgical protocol was the same in all 4 the chin being selected as the donor site for treat- patients. After perioral skin disinfection and ment. A monocortical bone block was harvested a two minute oral rinse with 0.2% chlorhexin- from the chin in accordance with the technique dine gluconate solution (Corsodyl, ICI Phar- proposed by Hunt & Jovanovich 1999,49 in size and shape adequate to the recipient site. In one The Journal of Implant & Advanced Clinical Dentistry 27

Egon et al Figure 3: Periapical radiographs showing blade implant at Figure 4: Surgical site #10 following implant removal. site #7. case, two blocks were harvested from the same chin (figure 5) in order to treat two defects simultaneously. The cortical bone of the recipi- ent site was then perforated with a round bur to expose the cancellous bone and favor bleeding. The exposed root surface was etched with 24% EDTA for 2 minutes and then enamel matrix derivative (EMD) gel (Emdogain®, Biora, Malmö, Sweden) was applied onto the root sur- face following the surgical protocol proposed 28 Vol. 2, No. 1 February 2010

Egon et al Figure 5: Chin block grafts. Figure 6: EMD application to root of tooth 11. by Rasperini et al. 199943 (figure 6). The bone Patients used modified oral hygiene procedures block was grafted to overfill the defect and avoiding brushing and interdental devices in positioned to the incipient site. The graft was treated areas during the first 2 months post- perforated and fixed to the basal bone with a op (figure 11). All patients were then recalled screw (Memfix System, Straumann, CH) (fig- at 3 and 6 months. No attempt at probing or ures 7, 8). A non-resorbable ePTFE GTAM deep scaling was made during this period. membrane (WL Gore, Flagstaff, Az USA) was trimmed to cover and protect the graft without Membrane Removal and Implant Placement touching the teeth and fixed with an additional 6 months after healing, the second surgery was Memfix screw (figure 9). Periosteal releasing performed (figure 12). Following flap reflec- incisions were made at the base of the buc- tion, the fixation screws and membrane were cal flap to achieve a tension-free adaptation at removed. By means of a surgical template, the closure. Closure was performed with internal mattress sutures alternated with interrupted sutures; a 5-0 non-resorbable monofilament (Gore-Tex®) was used and additional EMD was injected into the sulcus (figure 10). A provi- sional resin bonded bridge was then cemented while avoiding any pressure on the wound area. Post-surgical follow-up The patients were instructed to rinse twice a day with the 0.2% chlorhexidine solution during the first 8 weeks and professional tooth clean- ing was performed weekly for the first 8 weeks. The Journal of Implant & Advanced Clinical Dentistry 29

Egon et al Figure 7: GBR graft placed at site #10. Figure 8: Radiographic image of GBR at site #’s 7 and 10. Figure 9: GBR with e-PTFE membrane at site #10. Figure 10: Sutures after GBR combined with IPR. Figure 11: Healing at 2 months. implant fixture in adequate length and diam- eter (Replace™, Nobel Biocare AB, Göteborg, 30 Vol. 2, No. 1 February 2010 Sweden), was placed into the regenerated bone in the correct prosthetic position (fig- ures 13,14). The patients followed the same postsurgical follow up previously described. Six months after the insertion of the implant, one year from the baseline, the implant was connected with the abutment and the crown and clinical periodontal measurements were recorded (figures 15-17). The patient was then enrolled in a recall protocol for maintenance.

Egon et al Figure 12: Radiographic healing of site #7. Figure 13: Surgical placement of implant at site #7. Statistical Analysis PD, REC) of interest. Results obtained by using Treatment gain was defined at each of the 10 a classical maximum-likelihood approach to the sample sites as the difference between the val- problem were compared with those obtained ues of the indicator of interest (PAL, PD, REC) from a Bayesian analysis of variance compo- at baseline and its corresponding value 360 nents method to make sure that the conclusions days later. A formal statistical analysis of the are not artifacts due to the small sample size. data was undertaken to decompose the treat- The analysis yielded an estimated overall mean ment gain variation across sites into a between- effect for each of the four indicators of interest, patients component and a within-patient corrected for the effect of within-individual varia- component, via analysis of variance components tion and adjusted with respect to the indicator’s separately for each of the four indicators (PAL, baseline level. Confidence intervals and Bayes- The Journal of Implant & Advanced Clinical Dentistry 31

Egon et al Figure 15: Healing of site #7 one year from baseline. Figure 14: Radiographic placement of implant at site #7. Figure 17: Final prosthetics on implants #’s 7 and 10. Figure 16: Probing depth at implant restoration #10 distal. 32 Vol. 2, No. 1 February 2010

Egon et al Table 1: ian credible intervals were computed. These gain was 4.7 mm, with a standard error of 1.04 results turned out to be little sensitive to either and a 95% classical confidence interval given the inference approach (classical or Bayesian) by (2.35, 6.41). The estimated overall mean or a logarithmic transformation of treatment gain. PD gain was 4.395 mm, with a standard error of 1.98 and 95% confidence interval given by RESULTS (0.7, 8.19), which indicates that evidence of a beneficial treatment effect on PD is only bor- Observations made on the 10 sample units derline significant. The estimated overall mean are summarized in Tables 1, 2, and 3 respec- REC gain has a 95% confidence interval of tively for PAL, PPD, and REC. The PAL, PPD (-2.04 mm, 2.13 mm), indicating no evidence and REC gains were positive in each of the at all of a beneficial treatment effect on REC. ten sites; REC gains were occasionally nega- tive. Table 1 betrays a tendency of the PAL DISCUSSION gain to increase with its baseline value, which was confirmed as 5% significant in our statis- The aim of this study was to evaluate clinically tical analysis. The estimated overall mean PAL the possibility to combine the GBR and IPR The Journal of Implant & Advanced Clinical Dentistry 33

Egon et al Table 2: techniques in case of severe horizontal bone that weigh considerably on the overall 10 sites. loss next to a natural tooth. In addition, simulta- The REC results at one year show both posi- neous vertical ridge augmentation of the eden- tive and negative results. Three sites showed tulous area and a significant PAL gain to the a decrease in REC gain up to 3mm, probably next periodontally involved tooth was achieved. due to the predictable tissue shrinkage caused The results of this study suggest that this inno- by the multiple surgeries. PAL gain results vative technique to obtain supracrestal bone betray a tendency to increase with its base- regeneration can result in clinical attachment line value, which was confirmed as 5% signifi- gain. The mean PAL gain of 4.7mm was both cant in our statistical analysis, but the method clinically and statistically very significant. Evi- adopted to analyze the values removes this bias. dence of a beneficial treatment effect on PD is only borderline significant in the statistical The analysis was accomplished in order for evaluation. However, it is considered a clini- the four patients not to influence the multiple cal improvement. This can be explained due to site results, ensuing as ten separate sites of the small sample size and with the low base- ten different patients. Even though the statis- line PPD values of three sites (PPD 4mm) tical analysis was conducted and formulated in a way to overcome the small patient sample, 34 Vol. 2, No. 1 February 2010

Egon et al it must be noticed that these results must be gain, in spite of a concerted effort to systemi- considered preliminary due to the small popula- cally and mechanically control bacterial growth tion enrolled in the study. However, the results with antibiotics and topical antimicrobials. obtained are encouraging and it must be per- ceived that there are no studies demonstrating All ten sites in our study, showed no adverse predictable supracrestal regenerative proce- events during and after the surgeries. The two dures adjacent to natural teeth. An attempt was techniques implied are well documented and made in periodontally compromised anterior reported in the literature. A recent study50 teeth with the use of DFDBA in forms of par- inquired to what extent GBR affected the ticles, struts and laminar forms in combination periodontium of contiguous teeth. It quanti- with guided tissue regeneration.51 The mean fied changes in the proximal gingiva and bone attachment gain for 7 patients with horizon- levels at teeth adjacent to sites augmented by tal periodontal defects ranged from 2.6mm to conventional GBR procedures in 30 patients. 3.0mm. They reported early membrane expo- They concluded that GBR treatment might have sure as their major contraindication and its a small negative effect on the levels of the free direct contribution to a loss in attachment gingival margin and alveolar bone at adjacent teeth, which is in most cases not clinically rel- The Journal of Implant & Advanced Clinical Dentistry 35

Egon et al evant. This interesting study, however, does not Disclosure involve adjacent teeth that already have lost a The authors report no conflicts of interest with anything mentioned in this article. significant level of attachment, extremely com- Aknowledgements mon scenario when a critical horizontal bone We would like to express our gratitude to Professor Carlo Berzuini of the deficiency (where GBR is required to be able Systematic and Statistic Department, University of Pavia, for the data analysis and to place implants) is present next to them. statistic elaboration. We also thank Edoardo Bianco and Stefano Milani for their help in writing this article. CONCLUSIONS References 1. Nyman, S. Lang, N.P., Buser, D. & Bragger, U. (1990) Bone regeneration Due to these encouraging preliminary results, it can be concluded that the combination of adjacent to titanium implants using guided tissue regeneration: A report of two guided bone regeneration and induced peri- cases. International Journal of Oral and Maxillofacial Implants 5: 9-14. odontal regeneration in a site where there 2. Buser, D., Bragger, U., Lang, N.P. & Nyman, S. (1990a) Regeneration and is a severe horizontal bone deficiency adja- enlargement of jaw bone using guided tissue regeneration. Clinical Oral cent to a compromised periodontal tooth Implant Research I: 22-32. with loss of attachment, can be considered a 3. Buser, D., Dula, K., Belser, U., Hirt, H.P. & Berthold, H. (1993) Localized ridge viable technique to gain periodontal attach- augmentation using guided bone regeneration. I. Surgical procedure in the ment and vertical bone height, which can Maxilla. International Journal of Periodontics and Restorative Dentistry 13: support osseointegrated implants. Further 29-45. studies with a larger sample population are 4. Lang, N.P., Hammerle, C.H.F., Bragger, U., Lehmann, B. & Nyman, S.R. (1994) needed in the future to confirm these results Guided tissue regeneration in jawbone defects prior to implant placement. Clinical Oral Implants Research 5: 92-97. Correspondence: 5. Buser, D., Dula, K., Belser, U., Hirt, H.P. & Berthold, H. (1995) Localized ridge Giulio Rasperini augmentation using guided bone regeneration . II. Surgical procedure in the Via xx Settembre, 119 Mandible. International Journal of Periodontics and restorative Dentistry 15: I-29100 Piacenza Italy 11-29. e-mail: [email protected] 6. Buser, D., Dula, K., Lang, N.P. & Nyman, S. (1996a) Long-term stability of osseointegrated implants in bone regenerated with the membrane technique. 5-year results of a prospective study with 12 implants. Clinical Oral Implants research 7: 175-183. 7. Buser, D., Dula, K., Hirt, H.P. & Schenk, R.K. (1996b) Lateral ridge augmentation using autografts and barrier membranes: A clinical study with 40 partially edentulous patients. Journal of Oral and Maxillofacial Surgery 54: 420-432. 8. Nevins, M. & Mellonig, J.T. (1992) Enhancement of the damaged edentulous ridge to receive dental implants: A combination of allograft and Gore-Tex membrane. International Journal of Peiodontics and Restorative Dentistry 12: 97-111. 9. Nevins, R. & Mellonig, J.T. (1994) The advantage of localized ridge augmentation prior to implant placement: A two stage event. International Journal of periodontics and Restorative dentistry 14: 97-111. 10. Jovanovic, S.A., Spiekermann, E., Richter, E.J. & Koseoglu, M. (1992) Guided tissue regeneration around titanium dental implants. From: Laney, W.R. & Tolman, D.E., eds. Tissue Integration in Oral, Orthopedic & Maxillofacial Reconstruction (Procededing of the Second International Congress on Tissue Integration in Oral, Orthopedic, and Maxillofacial reconstruction. Mayo Medical Center. Rochester, MN. September 23-27, 1990). Pp. 208-215. Carol Stream, IL: Quintessence. 11. Shanaman, R.H. (1994) A retrospective study of 237 sites treated consecutively with guided tissue regeneration. International Journal of periodontics and restorative dentistry 14: 239-301. 12. Dahlin, C., Lekholm, U., Becker, W., Becker, B., Higuchi, K., Callen, A. & van Steenberghe, D. (1995) Treatment of fenestration and dehiscence bone defects around oral implants using the guided tissue regeneration technique: A prospective multicenter study. International Journal of Oral and maxillofacial Implants 10: 312-318. 13. Lundgren, D., Sennerby, L., Falk, H., Friberg, B. & Nyman, S. (1994) The use of a new bioresorbable barrier for guided bone regeneration in connection with implant installation. Case reports. Clinical Oral Implants Research 5: 177-184. 14. Lungren, A.K., Sennerby, L., Lundgren, D., Taylor, A., Gottlow, J. & Nyman, S. (1997) Bone augmentation at titanium implants using autologous bone grafts and a bioresorbable barrier. Clinical Oral Implant Research 8: 82-89. 15. Mayfield, L., Nobreus, N., Attstrom, R. & Linde, A. (1997) Guided bone regeneration in dental implant treatment using a bioasorbable membrane. Clinical Oral Implants Research 8: 10-17. 36 Vol. 2, No. 1 February 2010

Egon et al 16. Mayfield, L., Skoglund, A., Nobreus, N. & Attsrom, R. (1998) Clinical and 34. Mombelli, A., Lang, N. & Nyman, S. (1993) Isolation of periodontal species after radiographic evaluation, following delivery of fixed reconstructions, at GBR guided tissue rigeneration. Journal of Periodontology 64, 1171-1175. treated tiatnium fixtures. Clinical Oral Implants Research 9: 292-302. 35. Sander, L. & Karring, T. (1995) New attachment and bone formation in 17. Mellonig, J.T. & Tripplet, R.G. (1993) Guided tissue regeneration and periodontal defects following treatment of submerged roots with guided tissue endosseous implants. International Journal of Periodontics and Restorative regeneration. Journal of Clinical Periodontology 22, 295-299. Dentistry 13: 109-119. 36. Yoshinari, N., Tohya, T., Mori, A., Koide, M., Kawase, H., Takada, T., Inagaki, K. 18. Simion, M., Misitano, U., Gionso, L. & Salvato, A. (1997) Treatment of & Noguchi, T. (1998) Inflammatory cell population and bacterial contamination dehiscences and fenestrstion around dental implants using resorbable and non- of membranes used for guided tissue regenerative procedures. Journal of resorbable membranes associated with bone autografts: a comparative clinical Periodontology 69, 460-469. study. International Journal of Oral and Maxillofacial Implants 12: 159-167. 37. Smith MacDonald, E., Nowzari, H., Contreras, A., Flynn, J., Morrison, J. & Slots, 19. Dahlin, C., Andersson, L. & Londe, A. (1991a) Bone augmentation at J. (1998) Clinical and microbiological evaluation of a bioabsorbable and a fenestrated implants by an osteopromotive membrane technique. A controlled nonresorbable barrier membrane in the treatment of periodontal intraosseous clinical study. Clinical Oral Implants Research 2: 159-165. lesions. Journal of Periodontology 69, 445-453. 20. Dahlin, C., Lekholm, U. & Linde, A. (1991b) Membrane-induced bone 38. Hammarström, L. (1997) Enamel Matrix,Cementum Development and augmentation at titanium implants. A report of ten fixtures followed from 1 to Regeneration. Journal of Clinical Perodontology 24, 658-668. 3 years after loading. International Journal of Periodontics and Restorative Dentistry 16: 273-281. 39. Hammarström, L., Heijl L. & Gestrelius, S. (1997) Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix 21. Simion, M., Trisi, P. & Piattelli, A. (1994a) Vertical ridge augmentation using a proteins. Journal of Clinical Perodontology 24, 669-677. membrane technique associated with osseointegrated implants. International Journal of Periodontics and Restorative Dentistry 14: 497-511. 40. Gestrelius, S., Andersson, C., Johansson, A. C., Persson, E., Brodin, A., Rydhag, L. & Hammarström, L. (1997) Formulation of enamel matrix derivative 22. Simion, M., Jovanovic, S.A., trisi, P., Scarano, A. & Piattelli, A. (1998) Vertical for surface coating. Kinetics and cell colonization. Journal of Clinical ridge augmentation around dental implantnts using a membrane technique and Perodontology 24, 678-684. autogenous bone or allografts in humans. International Journal of Periodontics and Restorative Dentistry 18: 9-23. 41. Gestrelius, S., Andersson, C. & Lidstrom, D. (1997) In vitro studies on periodontal ligament cells and enamel matrix derivative. Journal of Clinical 23. Simion, M., Jovanovic, S.A., Tinti, C., Parma Benfenati, S. (2001) Long-term Perodontology 24, 685-692. evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1-5 years follow-up. 42. Mellonig, J. T. (1999) Enamel Matrix Derivative for periodontal reconstructive Clinical Oral Implants Reasearch 12: 35-45. surgery:technique and clinical and histologic case report. International Journal of Periodontics and Restorative Dentistry 19, 9-19. 24. Jovanovic, S.A., Schenk, R.K., Orsini, M. & Kenney, E.B. (1995) Supracrestal bone formation around dental implants: An experimental dog study. International 43. G. Rasperini, G. Ricci, M. Silvestri. (1999) Surgical technique in treatment of Journal of Oral and Maxillofacial Implants 10: 23-31. infrabony defect with enamel matrix derivative (Emdogain).Three Case report. International Journal of Periodontics & Restorative Dentistry; 19: 579-587. 25. Tinti, C., Parma-Benfenati, S. & Ploizzi, G. (1996) Vertical ridge augmentation: What is the limit? International Journal of Periodontics and Restorative Dentistry 44. G. Rasperini,M. Silvestri, R.K. Schenk, M L. Nevins. (2000) Clinical and 16: 221-229. Histologic evaluation of human gingival recession treated with a subepithelial connective tessue graft and enamel matrix derivative (Emdogain).A Case report. 26. Tinti, C. & Parma-Benfenati, S. (1998) Vertical riodge augmentation: Surgical International Journal of Periodontics & Restorative Dentistry; 20: 269-275. protocol and retrospective evaluation of 48 consecutively inserted implants. International Journal of Periodontics and Restorative Dentistry 18: 445-443. 45. Heden, G. (2000) A case report study of 72 consecutive Emdogain-treated intrabony periodontal defects: clinical and radiographic findings after 1 year. 27. Selvig, K. A., Nilveus, R. E., Fitzmorris, L., Kersten, B. & Khorsandi, S. S. (1990) International Journal of Periodontics & Restorative Dentistry 20 (2), 127-39 Scanning electron microscopic observations of cell population and bacterial Okuda, K., Momose, M., Miyazaki, A., Murata, M., Yokoyama, S., Yonezawa, contamination of membranes used for guided periodontal tissue regeneration in Y., Wolff, L.F. & Yoshie, H. (2000) Enamel matrix derivative in the treatment of humans. Journal of Periodontology 61, 515-520. human intrabony osseous defects. Journal of Periodontology 71 (12), 1821-8. 28. Tempro, J. P. & Nalbandian, J. (1993) Colonization of retrieved 46. Silvestri, M., Ricci, G., Raperini, G., Sartori, S. & Cattaneo, V. (2000) polytetrafluoroethylene membranes: Morphological and microbiological Comparison of treatments of infrabony defects with enamel matrix derivative, observations. Journal of Periodontology 64, 162-168. guided tissue regeneration with a nonresorbable membrane and Widman modified flap. A pilot study. Journal of Clinical Periodontology 27 (8), 603-10. 29. Nowzari, H. & Slots, J. (1994) Microorganisms in polytetrafluoroethylene barrier membranes for guided tissue rigeneration. Journal of Clinical Perodontology 21, 47. M. Silvestri, S. Sartori, G. Rasperini, G. Ricci , C. Rota & V. Cattaneo. (2003) 203-210. Comparison of infrabony defects treated with Enamel Matrix Derivative versus Guided Tissue Regeneration with a non-resorbable membrane. A Multicenter 30. Simion, M., Trisi P., Maglione, M. & Piattelli, A. (1994b) A preliminary report on Controlled Clinical Trial, Journal Clinical Periodontology; 30:5 accepted for a method for studying the permeability of expanded polytetrafluoroethylene pub. 6 May 2002 membrane to bacteria in vitro: A scanning electron microscopic and histological study. Journal of Periodontology 65, 755-761. 48. Zucchelli, G., Bernardi, F., Montebugnoli, L., De Sanctis, M. (2002) Enamel Matrix Proteins and Guided Tissue Regeneration with titanium-reinforced 31. Ricci, G., Rasperini, G., Silvestri, M. & Cocconcelli, P. S. (1996) In vitro expanded polytetraflouroethylene membranes in the treatment of infrabony permeability evaluation and colonization of membranes for periodontal defects. A comparative controlled clinical trial. Journal of Periodontology 73:3- regeneration by porphyromonas gingivalis DSM 20709. Journal of 12 Periodontology 67, 490-496. 49. Hunt, D.R., Jovanovic, S.A. (1999) Autogenous bone harvesting: a chin graft 32. Zucchelli, G., De Sanctis, M. & Clauser, C. (1997) Integrated Connective tissue technique for particulate and monocortical bone blocks. International Journal of in bioabsorbable barrier material and periodontal regeneration. Journal of l Periodontics and Restorative Dentistry 19(2):165-73. Periodontology 68, 996-1004. 50. Van der Zee E., Oosterveld P., Van Waas MA. (2004) Effect of GBR and fixture 33. Selvig, K., Kersten, B., Chamberlain, A., Wikesjo, U. M. & Nilveus, R. E. (1992) installation on gingival and bone levels at adjacent teeth. Clinical Oral Implants Regenerative surgery of intrabony periodontal defects using ePTFE barrier Research 15(1):62-5. membranes. Scanning electron microscopic evaluation of retieved membranes versus clinical healing. Journal of Periodontology 63, 974-978. The Journal of Implant & Advanced Clinical Dentistry 37

Successful Bone Regeneration– Strategy Not Chance Our in vivo testing and carrier technology are two strategic moves for improving patient outcomes. Offering only an optimum DBM concentration that is demonstrated by histology* to meet our high osteoinductive standards after sterilization places us in the leading position. Having a human clinical study that proves bone growth...checkmate! © 2009 Exactech, Inc. *Each lot of product is tested using the athymic nude rat assay to verify osteoinductive potential. www.exac.com/dental Regenaform® is processed by RTI Biologics, Inc. and distributed by Exactech, Inc.

Change is inevitable. Growth is our choice. Our family of bone grafting products continues to expand, offering a wide range of effective and cost-conscious options for guided bone regeneration. Oralife® allografts offer high-quality grafting alternatives for routine grafting procedures. Our precision-machined cortical allograft bone pin is easy-to-prepare, easy-to-use and comes pre- rely on time after time. Exactech dental biologics products—growing to meet your needs. BonePin® Cortical Allograft BonePin Cortical Allograft © 2009 Exactech, Inc. Oralife® allografts are processed by LifeLink Tissue Bank and distributed by Exactech, Inc. www.exac.com/growth Cortical allograft bone pins are processed by RTI Biologics and distributed by Exactech, Inc.



Iatrogenic Peri-Implantitis: Padatrow et al Treatment and One to Two Year Follow up Pradeep Padatrow, DDS, MSD, MPH1 2 4 3 Abstract Background: Peri-implantitis may be associated Results: Peri-implant clinical signs of infec- with a number of variables ranging from patient tion abated and radiographic evidence of related to iatrogenic factors. Peri-implant muco- bone regeneration occurred following sur- sal tissues may be more vulnerable to plaque gical intervention on the affected implants. induced inflammatory changes due to differences Patients were placed on three month main- in gingival attachment between implants and natu- tenance schedules. Clinically detectable ral teeth. Local factors that encourage bacterial implant stability was discernable one and growth and reduce implant integration should be two years following active patient therapy. considered when diagnosing and treating inflam- matory lesions identified around restored implants. Conclusions: Factors that promote peri- implant bacterial retention can be detrimen- Methods: Two patients presented with clini- tal to long term success. Excess subgingival cal and radiographic signs consistent with cement in close approximation to implant and infection adjacent to restored dental implants. abutment surfaces appeared to be a signifi- During surgical therapy of the affected areas, cant causative factor in the two cases pre- dental cement was discovered adhering to sented in this article. Cement removal abutment and implant surfaces. Management during surgical intervention, decontamina- involved thorough debridement of granuloma- tion of involved surfaces, and bone grafting tous tissue, removal of subgingival cement, resulted in a clinically stable outcome over implant detoxification, and regenerative therapy. the two years of post-operative maintenance. KEY WORDS: Peri-implantitis, iatrogenic causes, peri-implantitis treatment 1. Director, Pre-Doctoral Periodontics, Department of Periodontology, University of Tennessee College of Dentistry 2. Private Practice, Memphis, TN, USA 3. Director, Graduate Prosthodontics, Department of Restorative Dentistry, University of Tennessee College of Dentistry 4. Chair, Department of Periodontology, University of Tennessee The Journal of Implant & Advanced Clinical Dentistry 41

Padatrow et al INTRODUCTION: Figure 1: Initial presentation with abscess. Inflammatory lesions that develop adjacent to must also be considered and specific implant implants are collectively referred to as “peri- design and surface characteristics may also implant diseases” and may include peri-implant contribute to the risk and progression of peri- mucositis and peri-implantitis. Peri-implantitis implantitis.3 Failure to remove excess cement is characterized by the presence of inflamma- following placement of cement-retained pros- tion in the mucosa along with loss of support- theses may also contribute to the development ing bone.1 The frequency of peri-implantitis and progression of peri-implantitis. This report has been reported in many long term studies. documents two patients in whom excess sub- However, due to variation in assessment meth- gingival cement was associated with signs of odology, reliable consensus in the literature peri-implantitis. Clinical management strategies is unavailable. Nevertheless, a recent system- and long term therapeutic results are discussed. atic review of cross sectional and longitudinal studies with 50 subjects and 5 years of CASE REPORTS: occlusal function, reported that peri-implanti- tis was identified in 12-46% of implant sites.2 Case 1: A 64 year old partially edentulous female was Peri-implantitis is often asymptomatic and referred for evaluation of a draining fistula typically detected during routine recall examina- adjacent to implants #28 and #29. Her medi- tions. Several clinical indicators used to evalu- cal history was unremarkable. An implant in ate periodontal health have also been used to area #30 had been in place for 14 years, and evaluate peri-implant health, including assess- the implants in area #28 and #29 had been in ment of oral hygiene, peri-implant marginal place for 4 years. Several months following the tissues, and the bone implant interface. Rec- surgical placement of implants #28 and #29, ommended diagnostic parameters for assess- the patient complained to her general dentist of ing peri-implant health are: probing depth swelling and a bad taste in her mouth. The gen- measurements using conventional probing eral dentist removed the crowns and attempted with a light probing force (0.25N), presence or absence of bleeding or suppuration on probing using a light probing force (0.25N), and radio- graphic assessment of supporting bone levels.1 A number of patient-related and implant- related factors may contribute to the devel- opment and progression of peri-implantitis. Compelling evidence is available for increased susceptibility to peri-implantitis in patients who smoke, have a history of periodontal dis- ease, and exhibit poor oral hygiene.3 The impact of IL-1 positive genotype and diabetes 42 Vol. 2, No. 1 February 2010

Padatrow et al Figure 2: Initial radiograph. Figure 3: Flap elevated showing cement lm on the mesial of Implant in area of #29. Figure 4: Implants debrided and detoxi ed. Figure 5: Bio-Oss Bovine bone graft placed around the implants. non-surgical therapy around the implants. The implant #28 and vertical bone loss around peri-implant infection persisted and the gen- implant #29 (figure 2). The decision was made eral dentist referred the patient for consultation. to perform an exploratory surgical procedure Upon clinical examination (figure 1), a fluctuant to investigate possible etiologic factors and swelling was noted on the buccal mucosa inter- determine the prognosis of involved implants. proximal to implants # 28 and 29, with bleeding and suppuration evident on probing. Probing Under local anesthesia, crestal and sul- depths ranged from 4-8mm around implant #28 cular incisions were made and full thickness and 8-9 mm around implant #29. A periapical mucoperiosteal flaps elevated around the radiograph revealed horizontal bone loss around implants. A thin white film was found adhering to the mesial aspect of implant #29, extend- The Journal of Implant & Advanced Clinical Dentistry 43

Padatrow et al Figure 6: Clinical Presentation at 6 months post surgery. ing from the implant abutment interface to the first thread (figure 3). On close examination, Figure 7: Radiographic Presentation at 6 months post the white film was determined to be glass iono- surgery. mer cement. The surgical area was thoroughly debrided and degranulated. Plastic curettes Figure 8: Radiographic presentation at 24 months. and a rotary rubber cup with pumice were used to completely remove the glass ionomer 44 Vol. 2, No. 1 February 2010 cement from the implant surface. The implant surface was then decontaminated using H2O2, chlorhexidine 0.12%, and 50mg/ml tetracy- cline applied for 2 minutes. Decortications were accomplished on the peri-implant bone and Bio-Oss®, bovine cortical bone particles (Osteohealth, Shirley, NY) were placed in the osseous defect (figures 4,5). Two holes cor- responding to the implants abutments were made through a 20mm x 30mm Biomend® col- lagen membrane (Zimmer Dental, Carlsbad, CA) and the membrane was placed over the abutments to cover the bone graft material. The flaps were replaced and sutured with 4-0 Vicryl® sutures (Ethicon, New York, NY) and the patient was placed on 500-mg Augmentin (GlaxoSmithKline, Pittsburg, PA) three times a day for 7 days and a 0.12 % chlorhexidine rinse. Post-operative healing was uneventful. Implants/abutments remained unrestored dur- ing the healing period. At six months, firm keratinized gingiva was identified around both implants and radiographs suggested bone fill associated with implant #29 (figures 6, 7). New crowns were fabricated and deliv- ered. The patient was instructed on oral hygiene techniques and placed on a 3-month maintenance protocol. At 24 months fol- lowing surgical intervention, the implant was clinically determined to be functioning well without signs of recurrent infection (figure 8).

Padatrow et al Case 2: Figure 9: Initial radiographic presentation. A 50-year-old partially edentulous female pre- sented to the clinic complaining of pain in the Figure 10: Cement adhering to the abutment. mandibular right posterior sextant. Her medi- cal history was positive for Type II Diabetes with Figure 11: Immediate post surgical radiographic the condition being well controlled with oral presentation. hypoglycemic medications. She had an implant placed and restored in the area #30 one year ago. She reported developing a swelling around the implant about 4 months prior, which then dis- appeared after a only few days. Upon examina- tion, probing depths ranging from 7-10mm with bleeding and suppuration were noted. Radio- graphic examination revealed severe vertical bone loss adjacent to the implant (figure 9). Inci- sion and drainage of the fluctuant mass was performed and the patient was placed on 500 mg Augmentin (GlaxoSmithKline, Pittsburg, PA) three times per day and 0.12% chlorhexidine mouth rinse for 7 days. Ten days later, heal- ing progressed with minimal complications. A determination was made to surgically explore the area of concern and attempt bone regeneration around the implant. Upon pre- operative removal of the implant crown, a white material film was noted adhering to the apical aspect of the abutment along the implant-abut- ment interface. Closer examination revealed that the white material was glass ionomer cement (figure 10). A full thickness mucoperi- osteal flap was accomplished local anesthe- sia. Upon flap reflection, all granulation tissue was removed and the implant was decontami- nated using H2O2, chlorhexidine 0.12%, and 50mg/ml tetracycline applied for 2 minutes. Decortications were made in the peri-implant bone and Bio-Oss® bovine cortical bone par- ticles (Osteohealth, Shirley, NY) were placed The Journal of Implant & Advanced Clinical Dentistry 45

Padatrow et al Figure 12: Radiographic presentation at 6 months. Figure 13: Radiographic presentation at 14 months. in the osseous defect. A hole correspond- DISCUSSION ing to the center of the implants was made on a Biomend® collagen membrane (Zimmer Attachment of peri-implant tissues to implant and Dental, Carlsbad, CA) and the membrane was abutment surfaces occurs by junctional epithe- placed over the implant using a healing abut- lium mediated through basal lamina and hemides- ment to secure the membrane in place (fig- mosomes.4 In contrast to the dento-gingival unit, ure 11). The flaps were replaced and sutured there are no connective tissue fiber insertions with Vicryl® sutures (Ethicon, New York, NY). into the implant surface and connective tissue fiber orientation is predominantly parallel to the Post-operative healing was unevent- implant surface.5 Coronally, connective tissue ful and the implant remained unrestored dur- fiber orientation is circumferential and it exhib- ing the healing period. Six months after its a lower degree of vascularization compared surgery, firm keratinized gingiva surrounded to periodontal attachment.6 It has been theo- the implant and radiographs suggested suc- rized that these differences between peri-implant cessful bone fill (figure 12). Clinically there and dento-gingival tissues render the former were no signs of peri-implant infection and more susceptible to plaque induced inflamma- probing depths decreased to 3-4 mm. At this tion. The peri-implantitis cases identified and point, the original abutment and implant crown managed in this article were characteristically were replaced. The access opening was filled rapid in development and progression, and may with flowable light cure composite and occlu- have been a pathologic response to residual sal adjustments were completed. The patient subgingival cement serving as a local plaque was instructed in oral hygiene techniques and retentive factor at the bone-implant interface. was placed on a 3 month maintenance pro- tocol. At 14 months following treatment the Treatment of peri-implantitis may include non- implant was determined to be functioning well surgical and surgical phases. Non-surgical ther- without signs of recurrent infection (figure 13). apy consists of mechanical debridement using ultrasonic or laser devices, either alone or com- 46 Vol. 2, No. 1 February 2010

Padatrow et al bined with antiseptic and/or antibiotic agents. This information provides a basis for determining Surgical intervention may involve either resective therapeutic approach; implant removal, resec- or regenerative techniques. To date, no meth- tive surgery, and/or regenerative procedures. odology has been established as the gold stan- dard for the treatment of peri-implantitis. Based Resective therapy is used to reduce pock- on the Consensus Statement of the Sixth Euro- ets, correct negative osseous architecture, pean Workshop on Periodontology,1 non-surgical smooth rough implant surfaces (implantoplasty), therapy for peri-implantitis is unpredictable. Nev- and improve the dimensions and/or location ertheless, the use of systemic and local antibiot- of keratinized gingiva. Regenerative therapy is ics in conjunction with non-surgical mechanical used to reduce pockets with the goal of regen- debridement has been shown effective in reduc- eration of favorable bone dimensions. A recent ing bleeding on probing and probing depths in review,7 addressing open debridement, surface cases of mild to moderate peri-implantitis.1 In the decontamination, and peri-implant regenera- first case presented in this paper, even though tive procedures, revealed encouraging results in the peri-implantitis was qualified as moderate, it animals, but a paucity of data in humans. A did not respond to non-surgical therapy. Subse- prospective cohort receiving access surgery, quent surgical intervention revealed the apparent implant decontamination, and systemic antibi- etiology and removal of residual cement success- otics recorded favorable defect resolution for fully established peri-implant tissue health. In the 58% of the implants treated.8 With regard to second case reported in this paper, the patient occlusive membranes, varying degrees of bone presented with peri-implantitis of greater sever- regeneration and re-osseointegration have been ity and non-surgical therapy, consisting of inci- reported for regenerative procedures with or sion/drainage and systemic antibiotic therapy without the use of barrier membranes.7 In both followed by surgical intervention was required. of the cases presented in this article, regenera- tive procedures incorporated barrier membranes The primary objective of surgical treatment of and favorable radiographic bone fill resulted. peri-implantitis is to gain access to the implant surface for debridement and decontamination CONCLUSION: in order to facilitate resolution of inflammatory lesions. The determination of appropriate surgi- Two partially edentulous patients with restored cal treatment is influenced by the amount of bone and functional implants presented for evaluation lost, the nature of the osseous defect, and the of peri-implant tissue problems identified by the aesthetic impact of the implant in question. Sur- patients and their restorative dentists. Upon refer- gical techniques used to manage peri-implant ral, surgical access revealed subgingival cement lesions are essentially modifications of surgical on the implant and abutment surfaces. Removal periodontal techniques. Peri-implant probing and of the cement, decontamination of the implant bone sounding of suspected peri-implant osseous surface, and bone grafting resulted in resolution defects in conjunction with radiographic evalu- of the infections, reduction of probing depths, ation should be accomplished early in therapy. and radiographically apparent bone fill. Using a three month maintenance schedule, favorable The Journal of Implant & Advanced Clinical Dentistry 47