Augmentation of Severe Ridge Defect with rhBMP-2 and ... · Augmentation of Severe Ridge Defect...

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 4 July/August 2016

Mandibular Overdentures with Mini-Implants

Augmentation of Severe Ridge Defect with rhBMP-2

and Titanium Mesh

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The Journal of Implant & Advanced Clinical DentistryVolume 8, No. 4 • July/August 2016

Table of Contents

6 Dehydrated Human Amnion- Chorion Barrier used to Assist Mucogingival Coverage of Titanium Mesh and rhBMP-2 Augmentation of Severe Maxillary Alveolar Ridge Defect: A Case Report Dr. Dan Holtzclaw

18 Long-Term Retrospective Clinical and Radiographic Follow-up Evaluation of 108 OsteoCare™ Mini and Midi Ball-Type Implants Subjected to Immediate Loading of Mandibular Overdentures Amr Zahran, Rania Abdulmaguid, Ziad Rabie, Basma Mostafa

2 • Vol. 8, No. 4 • July/August 2016

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

30 Long-term Efficacy of Occlusal Loading on an Implant with Low Stability: A Case Report Souheil Hussaini, Seyed Milad Nejat

36 A Modified Split-Crest Technique using Piezoelectric Surgery and Immediate Implant Placement in the Atrophic Maxilla Amr Zahran, Basma Mostafa, Ahmed Hanafy, Mona Darhous


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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefLeon Chen, DMD, MS, DICOI, DADIA



Holtzclaw

Recombinant human bone morphogenetic protein (rhBMP-2) is a potent osteoin-ductive protein that has proven to be a

valuable tool for augmentation of severe alveolar dental defects. Because rhBMP-2 must be com-bined with a collagen carrier, it lacks space main-tenance and must therefore be combined with ridged materials such as Titanium mesh. While effective for space maintenance and a proven aid in bone augmentation procedures, Titanium mesh has a documented history of premature exposure which can reduce final outcome gains. Amnion-chorion barriers contain a variety of proteins that have a documented promotion of epithelial migra-tion and improved wound closure. The current

Case Report documents use of an amnion-cho-rion barrier to assist mucogingival coverage of a Titanium mesh barrier and rh-BMP2 augmenta-tion of a severely atrophic anterior maxillary ridge. Although prior studies show that augmentation procedures utilizing Titanium mesh may suffer pre-mature exposure rates of 80%, the current Case Report experienced no exposure of the Titanium mesh during 240 days of healing. The rhBMP-2/Titanium mesh/amnion-chorion combination pro-duced significant hard tissue gains facilitating the placement of three dental implants and ultimate restoration of the anterior maxilla. At 18 months of follow up maintenance, the dental implants and regenerated bone have remained stable.

Dehydrated Human Amnion-Chorion Barrier used to Assist Mucogingival Coverage of Titanium Mesh

and rhBMP-2 Augmentation of Severe Maxillary Alveolar Ridge Defect: A Case Report

Dan Holtzclaw, DDS, MS1

1. Private practice limited to dental implants, Austin, Texas, USA

Abstract

KEY WORDS: Dental implants, amnion-chorion, rhBMP-2, titanium mesh, guided bone regeneration

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BACKGROUNDDental literature has thoroughly documented alveolar ridge resorption following the extraction of teeth.1-3 In many cases, even when extrac-tion site preservation is performed, edentulous spaces are of inadequate dimensions to facili-tate the placement of dental implants. Rec-ommendations for minimum dental implant alveolar housings range from 5-6mm of width prior to implant placement4,5 or 1-1.5mm of cir-cumferential bone width around all aspects of the implant following its delivery.6,7 A vari-ety of augmentation techniques have been successfully employed to achieve such bony dimensions, including: guided bone regenera-tion (GBR) with particulate graft,8 block grafts obtained from ramus,9 symphysis,10 iliac crest,11 or calvarial bone,12 ridge expansion osteotomy,13 and ridge splitting.14 Depending on the intra-oral location of treatment and the anatomical variations of the recipient site, each procedure has inherent advantages and disadvantages. In many cases, deficiencies of extreme mag-nitude preclude many of the aforementioned procedures and many patients decline treat-ment when autogenous procedures are pro-posed due to secondary surgical site morbidity. In such situations, utilization of biologic growth factors such as recombinant human bone mor-phogenetic protein-2 (rhBMP-2) has proven effective for the regeneration of bone to facili-tate the placement of dental implants.15-20

Bone morphogenetic protein-2 is a mem-ber of the transforming growth factor-ß super-family of cytokines and has demonstrated in-vitro osteoinductive properties in multiple studies.21,22 rhBMP-2 combined with absorb-able collagen sponges (ACS) has been used a

biologic growth factor in multiple dental studies and has shown the ability to clinically enhance bone formation at sites of ridge deficiencies.15-20 Because rh-BMP2 is only approved by the Food and Drug Administration (FDA) for use in combination with ACS, it lacks the ability for space maintenance and must therefore be combined with wound stabilizing products such as titanium mesh.16,18-20 While titanium mesh can provide necessary space maintenance and wound stability, it has been associated with early exposure in 36% - 80% of cases.23,24 The problem of early membrane exposure has been addressed in previous studies uti-lizing amnion-chorion barriers.25-27 Amnion-chorion is a placental based allograft that has demonstrated the ability to facilitate faster wound closure in dental surgery proce-dures.25-27 As such, adding an amnion-cho-rion barrier over titanium mesh may reduce early exposure when the product is used for space maintenance for rh-BMP2 applica-tions. The goal of this Case Report is to docu-ment the reconstruction of a severely resorbed atrophic anterior maxilla which was recon-structed using a combination of rh-BMP2 + ACS titanium mesh, and an amnion-chorion barrier.

METHODSA 56 year old Asian female presented to our dental clinic with a chief complaint of “I want dental implants to replace missing teeth in my top jaw.” The patient was missing teeth 7-13 and had a severely atrophic anterior maxilla (Figure 1). The patient noted that she had seen other dentists who informed her that “she did not have enough bone for dental implants and that nothing could be fixed with surgery.”

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The patient was seeking a third opinion and asked if there was any possible way to restore her smile with dental implants while maintaining the teeth that she currently still had in the mouth.

A cone beam computed tomography (CBCT) scan and clinical examination were performed. Analysis of this data revealed that the patient had a severe horizontal deficiency in the anterior maxilla with bone thickness as

little as 0.98mm. Additionally, the defects were concave in nature with a prominent nasal spine anteriorly. Multiple treatment options were considered including autogenous block grafts, rh-BMP2 augmentation with titanium mesh, ridge splitting, and particulate guided bone regeneration (GBR). The concave nature and extreme thinness of the residual bone eliminated the possibility of ridge splitting and particulate

Figure 1: Intraoral view of initial presentation. Teeth 7-13 are missing and the residual ridge displays extreme horizontal resorption.

Figure 2: Full thickness mucoperiosteal incision in the anterior maxilla revealing alveolar defects of a concave nature. Bone thickness in some areas of the ridge was 1mm or less.

Figure 3: Titanium mesh countered to fit the residual bony ridge and secured with surgical tacks.

Figure 4: rhBMP-2 mixture being applied to collagen sponge.


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Figure 5: rhBMP-2 soaked collagen placed into the concave alveolar defects beneath the Titanium mesh.

Figure 6: Amnion-chorion barrier overlaid on the Titanium mesh.

Figure 7: Primary closure of the surgical site.

Figure 8: Healing at 10 days following surgery. Note that there is no exposure of the Titanium mesh.



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GBR was ruled out due to the large size of the defects. The patient declined to have autoge-nous grafting performed so rh-BMP2 augmen-tation was agreed upon between all parties.

Following the administration of local anesthesia, a full thickness mucoperios-teal flap was elevated from teeth 6-14 revealing bone morphology that con-

firmed what was seen on the CBCT (Figure 2). Multiple pieces of titanium mesh (Osteogenics, Lubbock, Texas, USA) were measured, trimmed, and shaped to fit the alveolar defects. The titanium mesh was secured apically with tacks (Ace Surgi-cal Supply, Brockton, Massachusetts, USA.) (Figure 3). The mesh was not tacked coro-


Figure 11: CBCT scan showing horizontal and vertical gains in the anterior maxillary alveolar ridge.

Figure 12: CBCT scan showing horizontal and vertical gains in the anterior maxillary alveolar ridge.

Figure 13: Full thickness flap reflection for removal of Titanium mesh. Note that the mesh is covered with pseudoperiosteum like tissue.


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nally due to the thin nature of the residual ridge as it was feared such action would pos-sibly fracture the fragile native bone. After securing the titanium mesh, rh-BMP2 (Infuse, Medtronic, Minneapolis, Minnesota, USA) was prepared according the manufacturer’s direc-tion to achieve a concentration of 1.5mg/ml. The rh-BMP2 solution was applied to the

ACM (Figure 4), allowing fifteen minutes for the solution to fully penetrate the carrier, and was then placed beneath the titanium mesh (Figure 5). To conform with FDA guidelines and manufacturer’s directions, no additional allograft or other growth factors were combined with the rh-BMP2. Following placement of the rh-BMP2, the titanium mesh was then covered

Figure 14: Anterior maxillary ridge following removal of Titanium mesh. Note formation of new bone induced by the rhBMP-2 soaked collagen sponges.

Figure 15: Bone condenser used to prepare dental implant osteotomy site.

Figure 16: Multiple bone condensing drills placed in the regenerated bone. Note that the patient bit down on the drill during the preparation of site #11 causing out-fracture of the newly generated facial plate of bone.

Figure 17: Placement of 4mm diameter dental implants in the rhBMP-2 regenerated bone. Although facial dehiscence defects remained in some locations, all implants achieved torque of at least 32Ncm.


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(Figure 6) with a single layer of amnion-chorion allograft barrier (BioXclude, Snoasis Medical, Denver, Colorado, USA). Periosteal releas-ing incisions were then employed to allow for mucoperiosteal flap advancement and pri-mary closure of the surgical site (Figure 7). The patient was prescribed non-steroidal anti-inflammatory medications, narcotics, antibiotics, and steroids following the procedure. Follow up appointments were carried out at 10, 21, 42, 84, 120, and 180 days after surgery. At no

time after the surgery did the patient have any exposure of the titanium mesh (Figures 8-10).

A follow up CBCT scan was performed 200 days after the surgical procedure and evaluated for bone formation (Figures 11,12). Two hundred forty days after the initial surgi-cal procedure, dental implant surgery was performed on the patient. Following the administration of local anesthesia, a full thick-ness mucoperiosteal flap was elevated from teeth 6-15 revealing the titanium mesh which was covered with a “pseudoperiosteum” (Figure 13) as described by Boyne.28 The tita-nium mesh and tacks were removed reveal-ing significant new bone growth in the anterior maxilla (Figure 14). The regenerated bone was type 3 quality, so bone condensers (MIS Dental Implants, Fair Lawn, New Jersey, USA) were used in lieu of dental implant drills when preparing osteotomy sites (Figure 15). During condensation of the bone at osteotomy site for implant #11, the patient bit down on the con-densing drill causing a fracture of the facial plate of bone (Figure 16). A total of four den-

Figure 18: Bone allograft placement over dehiscence defects

Figure 19: Healing abutment delivery.

Figure 20: Healing abutments just prior to final prosthesis delivery.


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tal implants (Nobel Speedy Replace, Nobel Bio-care, Yorba Linda, California, USA) were placed and all achieved torque of at least 35 Ncm. Although all dental implants achieved significant toque values, placement of the dental implants results in fenestrations through the facial bony plate at sites 7, 9, 11, and 13 (Figure 17). Accordingly, freeze dried bone allograft (Maxx-eus Dental, Kettering, Ohio, USA) was used to augment the entire anterior maxilla (Figure 18) and covered with amnion-chorion barriers.

Figure 21: Facial view of final prosthesis. Figure 22: Palatal view of final prosthesis

Figure 23: Patient’s initial extraoral presentation.

Figure 24: Patient’s final extraoral presentation.


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A periosteal releasing incision was employed and primary closure was achieved with 4-0 chro-mic gut sutures. Post-surgical visits and medi-cations were delivered in a similar fashion to the previous rh-BMP2 augmentation procedure.

After 4 months of healing following the placement of dental implants, the patient was seen for healing abutment delivery (Figure 19). During this appointment, all dental implants were reverse torque tested to 35 Ncm without any movement of the fixtures. One month after delivery of the healing abutments (Figure 20), the patient was seen by a prosthodontist for fabrication of an implant supported fixed partial denture. Following impressions and lab analy-sis with a restorative wax-up, it was decided to fabricate the final restoration with a combi-nation of zirconia and pink porcelain to main-tain teeth of appropriate size and shape for the patient’s facial profile. The final screw retained restoration (Figures 21, 22) was delivered and torqued to 35 Ncm. The patient was very happy with the form and function of the final restoration (Figures 23, 24) and has remained problem free at 16 months after delivery.

RESULTS The final result for this patient was a successful fixed dental implant restoration in an area where multiple providers had informed the patient that no hope existed for such a treatment. During the initial surgery with rh-BMP2 and titanium mesh the patient experienced no significant complications other than moderate edema and bruising. At no point during the 240 day heal-ing process following rh-BMP2 augmentation was there any exposure of the supporting tita-nium mesh. The rh-BMP2 augmentation pro-

duced horizontal bone gains up to 3.21mm horizontally and 2.83mm vertically. Dental implants with diameters of at least 4.0mm were placed in the newly regenerated bone and all were able to achieve torque of at least 35 Ncm. The patient received a screw retained zirconia/ceramic restoration and has been in function for 18 months without complication.

DISCUSSIONA variety of techniques currently exist for the aug-mentation of deficient alveolar ridges with each having inherent advantages and disadvantages. For defects of a substantial nature, procedures such as autogenous ramus/symphysis block graft-ing and ridge splitting have been employed to achieve horizontal gains averaging around 4mm.29-

32 Autogenous block grafting has the advantage of osteoinductive native bone and space mainte-nance, but has the disadvantage of a secondary surgical site which induces additional pain and morbidity for the patient.33 Ridge splitting has the advantage of converting a one walled defect into a four walled defect and space maintenance, but has the disadvantage of being very technique sensitive and is non-amenable to concave or very thin defects.29 In cases where large alveolar ridge deficiencies exist and the patient declines autog-enous procedures such as block grafting or ridge splitting, use of osteoinductive recombinant pro-teins such as rh-BMP2 have proven effective.15-20

BMP’s are biologic growth factor members of the TGF-β superfamily with osteoinductive prop-erties that induce differentiation of mesenchymal cells into osteoblasts.34 These osteoblasts, in turn, stimulate osteogenesis allowing for the for-mation of bone. BMP’s must be combined with a biodegradable carrier system that allows for a


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slow and continuous release.35 Presently, the only Food and Drug Administration (FDA) approved carrier for rh-BMP2 is collagen.36 While this car-rier has proven effective for initial adherence and subsequent slow release of of rh-BMP2, it is pli-able and lacks space maintenance properties.33 Accordingly, rh-BMP2 soaked collagen sponges are commonly combined with Titanium mesh barri-ers to achieve stabilized space maintenance.16,18-20 While the rigid nature of Titanium mesh is desir-able for space maintenance, this same rigid nature of the product increases the risk of surgical site exposure when covered with soft mucogingival tissue.23,24 In the case of being combined with rh-BMP2 utilization, titanium mesh exposure risk may be further exacerbated by the fact that rh-BMP2 is known to induce moderate to severe amounts of edema during the initial healing pro-cess.37,38 Studies examining early exposure of tita-nium mesh during the healing process show that bone augmentation results may be reduced by an average of 30.2%.24 In the present Case Report, the Titanium mesh was covered with an amnion-chorion barrier in an effort to aid mucogingival healing and prevent early exposure of the mesh.

Amnion-chorion barriers have demonstrated an ability to facilitate improved wound closure and healing with dental surgeries such as guided tissue regeneration26 and extraction socket pres-ervation with non-primary closure.25,27 Amnion-chorion barriers possess a number of properties that may aid soft tissue closure over Titanium mesh. Previously published studies have doc-umented the anti-inflammatory properties of amnion-chorion.39,40 The ability of amnion-cho-rion barriers to reduce inflammation during the healing process may decrease mucoperiosteal flap tension at the incision line and thus pare the

potential for post-surgical barrier exposure sec-ondary to edematous flap retraction. In the event that post-surgical edema does open the incision line over the titanium mesh, the overlying amnion-chorion may stimulate rapid epithelial granulation closure of the exposure. Amnion-chorion barriers contain a variety of proteins including collagen types I, III, IV, V, and VI, laminin-5, platelet-derived growth factor-a (PDGF-a), PDGF-b, fibroblast growth factor; and transforming growth factor-b that help to facilitate wound healing.40 Recently published studies in which amnion-chorion bar-riers were exposed to the oral cavity during the healing process of guided tissue regeneration and site preservation surgeries demonstrated rapid epithelial granulation coverage of the exposed graft materials.25-27 These studies sug-gest that the various proteins found in amnion-chorion barriers, Laminin-5 in particular, may be responsible for this rapid epithelial granulation formation. Laminin-5 is an extracellular matrix component prominent in basement membranes and has been shown to stimulate epithelial cell migration.41 It is possible that the high con-centration of Laminin-5 found in amnion-chorion barriers is a contributing factor to the rapid epi-thelial granulation formation seen when amnion-chorion barriers are exposed to the oral cavity.

In the present study, Titanium mesh was cov-ered for 240 days during the healing process of rh-BMP2 ridge augmentation. At no point during the healing process was any of the Tita-nium mesh prematurely exposed. Accordingly, augmentation gains resulting from rh-BMP2 utilization completely filled the space created by the Titanium mesh and satisfied pre-surgical expectations. Had the Titanium mesh become prematurely exposed, reduced augmentation


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DisclosureDr. Holtzclaw is a member of the Clinical Advisory Board of Snoasis Medical and has interests in the company.

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27. Holtzclaw D, Toscano N. Amnion-Chorion Allograft Barrier Used for Guided Tissue Regeneration Treatment of Periodontal Intrabony Defects: A Retro-spective Observational Report. Clinical Advances in Periodontics 2012;June:1-7.

28. Holtzclaw D. Extraction site preservation using new graft material that combines mineralized and demineralized allograft bone: a case series report with histology. Compend Contin Educ Dent 2014;35(2):107-12.

29. Boyne PJ, Cole MD, Stringer D, Shafqat JP.A technique for osseous restoration of deficient edentulous maxillary ridges. J Oral Maxillofac Surg 1985;43(2):87-91.

30. Holtzclaw DJ, Toscano NJ, Rosen PS. Reconstruc-tion of posterior mandibular alveolar ridge deficien-cies with the piezoelectric hinge-assisted ridge split technique: a retrospective observational report. J Periodontol 2010;81(11):1580-6.

31. Pikos MA. Mandibular block autografts for alveolar ridge augmentation. Atlas Oral Maxillofac Surg Clin North Am 2005; 13(2):91-107.

32. Pikos MA. Facilitating implant placement with chin grafts as donor sites for maxillary bone augmentation-Part I. Dent Implantol Update 1995; 6(12):89-92.

33. Sethi A, Kaus T. Ridge augmentation using man-dibular block bone grafts: preliminary results of an ongoing prospective study. Int J Oral Maxillofac Implants 2001; 16(3):378-388

34. Levin BP. Alveolar ridge augmentation: combin-ing bioresorbable scaffolds with osteoinductive bone grafts in atrophic sites. A follow-up to an evolving technique. Compend Contin Educ Dent 2013;34(3):178-86.

35. Phan TC, Xu J, Zheng MH. Interaction between osteoblast and osteoclast: impact in bone disease. Histol Histopathol 2004;19(4):1325-44.

36. Peres JA, Lamano T. Strategies for stimulation of new bone formation: a critical review. Braz Dent J 2011;22(6):443-8.

37. Huh JB, Yang JJ, Choi KH, Bae JH, Lee JY, Kim SE, Shin SW. Effect of rhBMP-2 Immobilized Anorganic Bovine Bone Matrix on Bone Regeneration. Int J Mol Sci 2015;14;16(7):16034-52.

38. Perri B, Cooper M, Lauryssen C, Anand N. Adverse swelling associated with use of rh-BMP-2 in ante-rior cervical discectomy and fusion: a case study. Spine J 2007;7(2):235-9.

39. Tumialán LM, Rodts GE.Adverse swelling associ-ated with use of rh-BMP-2 in anterior cervical discectomy and fusion. Spine J 2007;7(4):509-10.

40. Kim JS, Kim JC, Na BK, Jeong JM, Song CY. Amniotic membrane patching promotes healing and inhibits proteinase activity on wound healing following acute corneal alkali burn. Exp Eye Res 2000;70(3):329-37.

41. Chen E., Tofe A. A literature review of the safety and biocompatibility of amnion tissue. The Journal of Implant & Advanced Clinical Dentistry 2009;2(3):67–75.

42. Hintermann E, Quaranta V. Epithelial cell motility on Laminin-5: Regulation by matrix assembly, pro-teolysis, integrins, and erbB receptors. Matrix Biol 2004;23(2):75-85.

gains would be anticipated as demonstrated in the Lizio study.24 While the current Case Report provides proof of principle that amnion-chorion may aid soft tissue closure when overlaid on Titanium mesh, thus reducing the potential for post-surgical barrier exposure, additional studies should be performed to confirm these findings. ●

Correspondence:Dr. Dan Holtzclaw4010 Sandy Brook Dr.Suite 204Round Rock, TX [email protected]

Holtzclaw

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Zahran et al

Background: Dental implants have provided major changes in the treatment planning of com-pletely edentulous patients with atrophic ridges Objectives: the present contemplate retro-spectively evaluated OsteoCare™ Mini and Midi one-piece ball-type dental implants for immediate loading of mandibular overden-tures with an emphasis on long-term survival, implant stability, peri-implant soft and hard tissue conditions, and patient satisfaction Methods: One hundred and eight one-piece ball-type implants were placed in the man-dibular interforaminal area of 31 patients (15 females and 16 males) with an age range at the start of the treatment of 28 to 80 years with a mean of 61 years. All implants were placed flaplessly followed by immediate deliv-ery of overdentures. Clinical criteria evaluated were survival rate, probing depth, Periotest M values and patient satisfaction. In addition to

radiographic and crestal bone level recordings

Results: Follow-up averaged 5.4 years (range between 5-11 years) and the cumulative survival rate (CSR) was 100%. The mean marginal bone loss at the end of the follow-up period was 0.42 ± 0.14 mm while the mean pocket depth was 1.79 ± 0.09 mm. The mean Periotest M value (PTM) at the end of the follow-up period was -0.9. Review of the patients’ satisfac-tion questionnaires showed a very high scale of satisfaction from the treatment outcomes

Conclusion: OsteoCare™ Mini and Midi one-piece ball-type implants have demon-strated excellent long-term survival, mar-ginal bone response, and soft tissue conditions with immediately loaded man-dibular overdentures. They have proved to be a viable and predictable treatment option for completely edentulous mandibles.

Long-Term Retrospective Clinical and Radiographic Follow-up Evaluation of 108 OsteoCare™

Mini and Midi Ball-Type Implants Subjected to Immediate Loading of Mandibular Overdentures

Amr Zahran, BDS, MDS, PhD1 • Rania Abdulmaguid, BDS, MDS2

Ziad Rabie, BDS, MDS3• Basma Mostafa, BDS, MDS, PhD4

1. Professor, Department of Periodontology, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.

2. Lecturer of Oral Medicine and Periodontology, Faculty of Dentistry, MSA University, Cairo, Egypt

3. Private Practice, Cairo, Egypt.

4. Assistant Professor, Department of Surgery and Oral Medicine, Oral and Dental Research Division, National Research Centre, Cairo, Egypt.

Abstract

KEY WORDS: Mini dental implants, immediate loading, overdenture, prosthetics

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INTRODUCTIONThe edentulous state presents a major impair-ment of oral function in addition to aesthetic and psychological challenges.1-3 In general, eden-tulous patients are treated with complete den-tures which require adaptation and a complex learning process when considered on somatic and psychological basis.4 Overtime, patients whom were originally adaptive to complete den-tures become maladaptive due to residual ridge resorption which is significantly greater in the mandible than in the maxilla, physiological intra-oral changes and the development of altered muscular patterns.5,6 Historically, overdentures supported by roots have been a traditional ele-ment of prosthodontics treatment planning2 and were significantly popular as an alternative to complete dentures.7 Subsequently, implant-supported overdentures became the standard of treatment for edentulous patients after the overwhelming success of osseointegration.8-10

Although, there is no general agreement on the number of implants to be used to support a mandibular overdenture, many clinicians currently use between 2 to 6 implants. A consensus was reached in 2002 at McGill University that effec-tively established the two-implant supported over-denture as the first preference of treatment for the edentulous mandible.11 Furthermore, in 2009, the New York Consensus Statement concluded that a large body of evidence supports the proposal of a two-implant-supported mandibular overdenture as the minimum presented to edentulous patients.12

The implant-retained overdenture, therefore, presents as a treatment option that improves the quality of life and the oral health of the edentu-lous patient.13 It also offers several advantages such as higher stability and retention, improved

function and aesthetics, and the reduction of the residual resorption of the alveolar process when compared to conventional complete dentures.14,15 Although removable dentures do not possess the elegance and finesse of fixed restorations, they are simpler in construction, can require fewer implants and are subsequently lower in cost.16 Initially the recommended time as proposed by Branemark between the placement and func-tional loading of oral implants in the mandible has been three months,17 however with the turn of the millennia, more studies have verified increased bone-to-implant contact occurring at a faster rate, this earlier healing time supports the concept of immediate loading with mandibular overden-tures than was previously recommended.10,18-20

Immediate loading with mandibular overden-tures has been proposed as an alternative to delayed loading as a mean to reduce treatment time and patient discomfort. Immediate load-ing is not new and was initially suggested with the introduction of dental implants, with a wide range of clinical survival rates10,21,22 which were demonstrated in some studies for more than 20 years.23 The most important guidelines for immediate loading protocol include having suffi-cient bone height to place implants of moderate length and good bone quality, favourable occlu-sion and enough inter-maxillary arch space.10,24

Because of the favourable outcomes and low costs associated with two-implant man-dibular overdentures, they are recommended as the standard of care for edentulous patients when compared to other forms of implant treat-ment,11,12 although the application can be limited for some cases. Such limitations may be attrib-uted to the patient’s fear of surgery and psycho-logical issues,25 the cost could be high for some

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individuals,26 and systemic disease can pose restrictions on operative procedures and the dura-tion of the treatment especially in the elderly.27 Additionally, local area morphology may limit the use of standard sized implants without the use of additional augmentation procedures which again will incur higher costs, greater discom-fort and higher risks of postoperative morbidity.28

The use of Mini and Midi one-piece ball-type implants presents an efficient and economical alternative to standard implants because their smaller diameter and tapered design allows insertion in narrow ridges without the need for adjunctive grafting procedures.10,29 Similarly, the insertion protocols are also faster and simpler requiring a single drill and flapless protocols10,30 which are more relevant to the elderly.31 Further-more, these narrow diameter implants have dem-onstrated similar survival rates when used for mandibular overdentures as standard implants.32

MATERIALS AND METHODSThe clinical outcome of OsteoCare™ Mini and Midi one-piece ball-type implants supporting overdentures was retrospectively examined. One hundred and eight (108) implants were placed at the first author’s private dental practice from the year 2004 to 2010. The study protocol was approved by the Ethical Committee at the Fac-ulty of Oral and Dental Medicine, Cairo University.

A total of 31 consecutive patients compris-ing 16 males and 15 females, were included in the study. The patients’ age ranged from 28 to 80 years displaying an average of 61 years. All patients were completely eden-tulous in the mandible, and all implants were inserted in the interforaminal region in the man-dible for immediate prosthetic restoration.

Inclusion CriteriaAt least 18 years of age to place an implant, systemically healthy, having sufficient bone height to accommodate an implant of 13 mm in length and ridge width of at least 4 mm, dem-onstrating the ability to sustain oral hygiene and showing willingness and ability to attend fol-low up to provide a signed informed consent.

Exclusion CriteriaPatients with lack of skeletal maturity ridges that required significant augmentation for implant site development, ridge width less than 4 mm or ridge height that could not accommodate 13 mm implant, uncontrolled diseases or condi-tions that could impede bone healing or soft tis-sue health, mental, emotional or lifestyle factors that could adversely impact treatment or follow up were excluded from the current contemplate.

Patient PopulationAll patients had at least 4 mm of ridge width for the placement of implants. The ridge width of each patient is evaluated by ridge-mapping or by using bone callipers. The patients, who had ridge width of 4 mm to 4.5 mm, received Mini implants of 2.8 mm diameter, while oth-ers who had a ridge width more than 4.5 mm received Midi implants with a diameter of 3.3 mm or 3.8 mm. The patients were carefully informed of the immediate loading protocol and of all the risks associated with this type of pro-cedure. They all gave their full informed consent.

The treatment plan for the patients in this study included placement of 2 to 5 Mini or Midi implants in the mandibular interforami-nal area. The selection of the number of the implants to be positioned was dependent


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on the clinical assessment of the individ-ual patient. Clinical considerations included the ridge width and shape, the opposing jaw (being partially or completely edentu-lous) and the allocation of the occlusal forces.

There were two patients suffering from aggressive periodontitis, eleven patients were smokers, two patients developed lung cancer and were subjected to chemother-apy after placement of the implants by 2 and 4 years. Five patients started bisphosphonate therapy three years after implant placement.

Pre-Surgical EvaluationPre-surgical radiographic assessment was car-ried out with panoramic radiographs, periapi-cal radiographs and cone beam computed tomography (CBCT) whenever indicated. The ridge width was evaluated through the diagnos-tic casts, ridge-mapping or directly using cal-lipers. Prior to surgery, final impressions of the arches were taken and working model casts were made. The models were mounted on an articulator after bite registration on occlusal rims for establishing the centric relation. Try-in was made and the fit was confirmed with the patients.

ImplantsOne hundred and eight (108) OsteoCare™ Mini and Midi one-piece ball-type implants (OsteoCare™ Implant System, London, United Kingdom) (53 Mini, 55 Midi) were used in the current contemplate. Mini implants are of 2.8 mm diameter, while Midi implants have diameters larger than 3 mm. 53 Mini implants with diameter 2.8 mm, 28 Midi implants with diameter 3.3 mm, and 27 Midi implants with diameter 3.8 mm and lengths 13 or 16 mm

were placed. The implants comprised a grit-blasted and acid-etched surface combined with high load buttress, self-tapping threads that permit maximum bone to implant con-tact. This design resulted in achieving high initial stability even in poor quality bone. The conical macro-design of the Mini and Midi implants offered the advantage of allowing compression and expansion of the bone dur-ing insertion. The amount of bone expansion required can be guided with variant tapers, created using incremental implant diameter.

SURGICAL PROTOCOL (FLAPLESS TRANSMUCOSAL

TECHNIQUE)Marking of the Drilling Sites Using a skin marker, marks were prepared directly onto the patient’s dried mucosa cov-ering the alveolar ridge to establish the drill-ing positions of the implants, as planned from the diagnostic casts and panoramic radiograph.

Site PreparationOnly one perforation profile drill (1.3 mm diam-eter) was used for site preparation to give nee-dle point accuracy for position, angle and depth. The use of saline was paramount during making the perforation. As the drill passed through the mucosa (transmucosal), it firstly reached the cor-tical bone then the cancellous bone. Verification of reaching the cancellous bone was achieved via the physical feel, as drilling was harder through the tough cortical plate and became far easier when engaging the softer cancel-lous bone. Preparation of the osteotomy did not surpass the implant length as the Mini and Midi implants have a strong self-tapping property.


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Implant PlacementThe implant was removed from its protec-tive pouch and delivered to the site, then manually placed after the transmucosal site preparation. It was rotated clockwise for approxi-mately three revolutions or until the plastic car-rier could no longer rotate the implant. Then the hex driver with the ratchet wrench was used to complete the seating of the implants.

Immediate Loading (Same day of implant placement)The initial stability (primary fixation) of the Mini and Midi implants was checked by the torque wrench to validate that initial pri-mary fixation was beyond 30Ncm which was crucial to commencement of loading.

Relief of Denture to Accommodate the HousingsHoles were done in the denture at the pre-

marked positions by means of a labora-tory bur. The polycarbonate housings were fixed to the implants and checked to guar-antee that they were steadily seated with full passivity. Try-in of the denture was made to check full seating without biting the housings.

Pick-up of the Housing (chair-side pickup procedures)Once the spaces for the housings had been relieved, they were packed with self-cured acrylic resin and the denture was placed over the hous-ings. The patient was allowed to bite in centric occlusion. After setting of the self-cured acrylic resin, all the excess was removed and the den-ture was trimmed and polished. After implant placement and the delivery of the overden-ture, the patients were instructed to consume easily chewable food for two months. No pre-operative or postoperative antibiotics were pre-scribed. Analgesics were used when needed.

Figure 1: Clinical photograph showing 4 Mini ball-type implants placed in 2004.

Figure 2: After 11 years postoperative clinical photograph of the same patient from Figure 1 showing the 4 Mini ball-type implants in 2015.


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FOLLOW-UPThe follow up period extended to the end of year 2015 and ranged from 5 to 11 (Figures 1-4) years with a mean of 5.4 years. Each patient underwent comparative radiographic evaluation using the 6-months postoperative implant place-ment panoramic radiograph against the previ-ous follow-up radiograph of the follow-up period.

The clinical criteria evaluated at the follow-up intervals were survival rate, pocket depth, Periotest M (Medizintechnik Gulden, Bensheim, Germany) values and radiographic crestal bone level. The following criteria were used to evalu-ate implant success: (1) Lack of clinically evi-dent mobility, (2) No indication of peri-implant radiolucency on periapical radiographs, (3) Absence of peri-implant infection, (4) No com-plaint of pain at the location of treatment, (5) Lack of neuropathies or paraesthesia, (6) Crestal bone loss not more than 1.5 mm by the end of first year of functional loading and less

than 0.2 mm/year in the ensuing years accord-ing to the criteria proposed by Albrektsson et al, 1986,33 (7) Through the follow-up time, pan-oramic and periapical radiographs were obtained at implant insertion and consequently at the follow-up intervals to assess crestal bone loss.

Periotest M was used to evaluate the implant stability. Periotest M values (PTM) of (-8 to 0) are considered the ideal values that signify successful osseointegration. For appraisal of patient satisfaction, questionnaires were com-pleted by the patients at the six-month follow-up visit. The questions were based on the questionnaire proposed by Branemark et al.29,34

RESULTSThe study evaluated 108 mini and midi implants placed in 31 patients that were restored immedi-ately with mandibular overdentures. The patients’ age range was between 28 years and 80 years with a mean of 61 years. The sex distribution was 15 females and 16 males. The patients

Figure 3: Immediate post-operative panoramic radiograph from Figure 1 after placement of the 4 Mini implants in year 2004.

Figure 4: After 11 years postoperative panoramic radiograph of the same case from Figure 1 in year 2015.


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received between 2 and 5 implants to sup-port the overdentures. Eight patients received 2 implants, two patients received 3 implants, 19 patients received 4 implants, and two patients received 5 implants. The number of implants was decided upon an individual case basis and sub-ject to the available bone in the anterior region of the mandible between the mental foramina. Three implant diameters were used, 2.8 mm (53 implants), 3.3 mm (28 implants), and 3.8 mm (27 implants). The lengths of the implants were 13mm (102 implants) and 16mm (6 implants).

Complete soft tissue healing was gen-erally monotonous in all patients within the first two weeks after implant placement. The patients reported minimal postoperative swell-ing or pain experiences with no incidence of hematoma and minimal need for medica-tions and analgesics. Most patients returned to their normal lives the day subsequent surgery.

All the patients were followed-up for a mini-mum of 5 years with a mean of 5.4 years; two patients were followed-up for six years, one for eight years, and one for 11 years. Two patients (each had two implants) developed lung cancer after 3 years of implant placement and they were subjected to chemotherapy. Five patients started bisphosphonate therapy after three years from implant placement. Eleven patients were smokers.

Fifteen O-rings housings were replaced due to damage or loss. Two patients presented with a broken denture one after 5 years and the other after 11 years and new dentures were remade.

The patients whom started chemotherapy were instructed to decrease the use of their dentures to the absolute minimum during the period of the treatment and for a period of 4 weeks following the end of the chemotherapy.

One of the two patients also was under bisphos-phonate treatment with the chemotherapy.

The baseline data for the evaluation was set at the readings obtained after six months of implant placement, with comparative evaluation of the parameters being performed at the end of the entire follow-up period. The mean marginal bone loss at the end of the follow-up was 0.42 ± 0.14 mm for all the 108 implants. Paired-t test was used to conduct the statistical analysis between the baseline and the follow-up which concluded insignificance: with a p value: 1.22 (significance at < 0.001) and at a confidence interval of 95%. The mean Periotest M values (PTM) at the end of the follow-up period was -0.9. Paired-t test was used to do the statistical analysis between the baseline data and the follow-up which con-cluded insignificance with a p value: 1.87 (sig-nificance at < 0.001) and a confidence interval of 95%. The mean pocket depth at the end of the five year follow-up was 1.79 mm ± 0.09 for all the 108 implants. Paired-t test was used to perform the statistical analysis between the baseline and the follow-up which concluded insignificance with a p value: 1.73 (significance at < 0.001) at a con-fidence interval of 95%. The total survival rate of the implants was 100%. Review of the patients’ satisfaction questionnaires showed subjective answers that demonstrated a very high degree of satisfaction from the treatment outcome.

DISCUSSIONThe survival and success rates attained in the present study are consistent with the results of Griffitts et al.35 whom presented success rates over 97.4% and concluded that, “the use of mini-dental implants are a highly successful treatment option” and that the implants are “relatively afford-


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able and overall patient satisfaction is excellent”. Nearly the same results were reported by Zah-ran et al.36 with a survival rate of 97.3% attested after 18 months follow-up period. Furthermore, a retrospective study on 510 narrow diameter implants over a period of 88 months by Degidi et al.37 have shown survival rates of 99.4%. The high success rate in this study may be attrib-uted to the fact that the location of the implants was in the anterior mandible which presents good bone density, therefore providing an ideal bed to attain excellent initial stability for the implants. It is considered that the macro geomet-ric design of the implants played a main role in achieving this primary stability, as was reported by several authors38,39 that the conical implant design in conjunction with an undersized drill form leads to initial higher stability than conven-tional implants, this was evident by the Periotest M values obtained. In addition, the survival rates of the mini and midi implants are comparable to that of immediate-loaded conventional-diameter implants supporting mandibular overdentures.40,41

Regarding the Periotest M values attained; the results are similar to other studies on mini and small diameter implants42,43 but are higher than those reported with standard-diameter implants in the anterior mandible.43,44 These results may be attributable to the fact that mini-implants possess a higher flexural modulus than standard-diameter implants.43

It should be noted that the decreased implant diameter does not affect osseointegration as was demonstrated by Block et al.45 who examined the effect of implant diameter on the required pull out force after 15 weeks for osseointegra-tion, and concluded that no correlation was found to the diameter but only with its length. Fur-

thermore, in a clinical study by Renouard and Nisand46 it was concluded that short implants were often accompanied by failure but long nar-row implants demonstrate good prognosis.

The bone loss associated with the study of mini and midi implants is similar to that reported for narrow and standard-diameter implants.42,43,47 This may be related to the fact that although the reduced implant diameters are subjected to higher load transfer through horizontal forces as compared to conventional diameter implants causing increased marginal bone loss,48 the utilization of a flapless approach results in minimal disruption to the perios-teum, preserves peri- and endosteal blood sup-ply and preserves the bone height around the implant post surgically.10,49 Another factor that aids in bone change maintenance around mini implants is their design which allows an auto-advance technique that results in increasing the bone density in the immediate surrounding area and thus minimising crestal bone loss due to their osseo-compressive properties.50 Further-more, the prosthetic connection and the pick-up technique of the attachment play a major role in bone preservation. Since the pick-up of the attachment is done under bite force, most of the vertical forces are borne by the soft tissue.51 Finally, the use of resilient O-ring attachments allows for shock absorbing properties and a reduction of the bending movements on the mini-implants.49,52 The effect of smoking on mar-ginal bone loss was insignificant in this study, which is in accordance to the findings of Sanna et al.53 whom, when using flapless implant inser-tion, did not observe any significant change in marginal bone levels between smoking and non-smoking patients after 1-year follow-up.


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Chemotherapy has been identified as an abso-lute but temporary contraindication to implant therapy by Zitzmann et al.,54 but there was no direct association between implant failure and survival rate and a history of chemotherapy.55

Due to the limited available literature on the management of implant patients subjected to chemotherapy, the management of the patients in this study was both preventive and symptom-atic. As the more common oral complications with chemotherapy are mucositis, xerostomia and bleeding tendency (which are all reversible if not complicated with infection) are all inter related and in severe conditions, the develop-ment of osteonecrosis (ON),56 management should be preventive. Therefore the patients were instructed to reduce the use of their den-tures in an attempt to reduce tissue injury due to mucositis during the treatment period. Usu-ally the oral side effects of chemotherapy sub-side after a period of two to four weeks57 after which the patients could use their dentures again, and it is recommended to use sialo-gogues thereafter to counteract the effects of xerostomia and prevent mucosal ulcerations.56

Bisphosphates (BP) are used for the treatment of osteoporosis, some bone dis-eases as Paget’s disease and may also be used in the management of cancer patients in conjunction with chemotherapy.58 The major complication associated with BP is ON of the jaws, which has been related to the strength and half-life of the BP.59

There is much controversy in available litera-ture about the effects of BP and dental implants in relation to the development of ON. Several studies reported no correlation between them as reported in the present study. One retro-

spective study by Fugazzoto et al.60 reported no cases of ON in 61 patients treated with BP for periods ranging from 1 to 5 years (an aver-age of 3.3 years). Also in a controlled study on ON around dental implants by Jeffcoat,61 it was reported that there were no statistical significances between osteoporotic patients under BP treatment and the control group.

The American Association of Oral and Max-illofacial Surgeons62 presented performance guidelines for patients treated with BP. The guidelines divided these patients into two cat-egories: 1) patients under intravenous BP therapy for cancer therapy, present a con-traindication to dental implants, 2) patients undergoing oral BP therapy may be divided into three possible subcategories: (a) Treat-ment for less than 3 years have no clinical risk to dental implants, (b) Treatment for less than 3 years in combination with corticoids, BP must be stopped for at least 3 months and should not be re-administered before com-plete healing of the bone, (c) Treatment for more than 3 years, dental implants could be placed only if the BP are stopped for at least 3 months and should not be re-administered until complete healing of the bone occurs.

CONCLUSIONThe use of Mini and Midi implants for the reten-tion of mandibular overdentures has been proven to be a viable and predictable option for the management of mandibular edentulism. They are of particular importance in clinical situ-ations that would otherwise disregard larger implants as a treatment option. In addition, from a patient’s perspective: the high success rate associated with this treatment option in consid-


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Correspondence:DR. Basma Mostafa Assistant Professor of Oral Medicine and Periodontology, Surgery and Oral Medicine Dep., Oral and Dental Research Division, National Research Centre. 33 El Bohouth Street, 12622 Dokki, Cairo, Egypt.e-mail: [email protected] no.: 0020237623537Fax no.: +20233387803.

eration with the advantages gained from implant size, minimal surgical technique, lack of need for further surgical intervention and long-term ser-viceability provide additional comfort and satis-faction. Based on the long-term results of Mini and Midi implants and the increased life span of patients due to advancements in medical care and life styles, it is recommended that further controlled studies be formulated to evaluate the effects of medical conditions and medica-tions on the use and serviceability of previously placed implants to be able to reach special consensus for such arising conditions. ●

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17. Brånemark, P.I., Zarb, G.A., Albrektsson, T. Tissue Integrated Prostheses -

Osseointegration in Clinical Dentistry. Chapter 16 and17 Pp 241-282/ Pp 199-209 Quintessence Publishing Co. Inc. Chicago, USA, 1985

18. Gatti C, Haefliger W, Chiapasco M. Implant-retained mandibular overdentures with immediate loading: a prospective study of ITI implants. Int J Oral Maxillofac Implants. 2000; 15: 383-388.

19. Roynesdal AK, Amundrud B, Hannaes HR. A comparative clinical investigation of 2 early loaded ITI dental implants supporting an overdenture in the mandible. Int J Oral Maxillofac Implants. 2001; 16: 246-251.

20. Payne AGT, Tawse-Smith A, Warwick D. Kumara R. Conventional and early loading of unsplinted ITI implants supporting mandibular overdentures: Two-year results of a prospective randomized clinical trial. Clin Implant Dent Res. 2002; 4: 33-42.

21. Strock AE, Strock M. Experimental work on a method for the replacement of missing teeth by direct implantation of a metal support into the alveolus. Am J Orthod Oral Surg. 1939; 25: 467–472.

22. Kapur KK. Veterans Administration co-operative dental implant study comparison between fixed partial dentures supported by Blade-Vent implants and partial dentures. J Prosthet Dent. 1987; 59: 499–512.

23. Linkow LI, Donath K, Lemons JE. Retrieval analysis of a blade implant after 231 months of clinical function. Implant Dent. 1992; 1: 37–43.

24. Misch CE, Hahn J, Judy KW, Lemns JE, Linkow LI, Lozada JL, Mills E, Misch CM, Salama H, Sharawy M, Testori T, Wang H-L. Workshop guidelines on immediate loading in implant dentistry. J Oral Implantol. 2004; 30: 283-288.

25. Assunção WG, Zardo GG, Delben JA, Barão VA. Comparing the efficacy of mandibular implant-retained overdentures and conventional dentures among elderly edentulous patients: satisfaction and quality of life. Gerodontology. 2007; 24: 235–238.

26. Mundt T, Polzer I, Samietz S, Grabe HJ, Messerschmidt H, Dören M, Schwarz S, Kocher T, Biffar R, Schwahn C. Socioeconomic indicators and prosthetic replacement of missing teeth in a working-age population: results of the Study of Health in Pomerania (SHIP). Community Dent Oral Epidemiol. 2009; 37: 104–115.

27. Mundt T, Schwahn C, Stark T, Biffar R. Clinical response of edentulous people treated with mini dental implants in nine dental practices. Gerodontology. 2015; 32: 179–187.

28. Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: comparison of donor site morbidity and complications. Clin Implant Dent Relat Res. 2003; 5: 154–160.

29. de Souza RF, Ribeiro AB, Della Vecchia MP, Costa L, Cunha TR, Reis AC, Albuquerque Jr RF. Mini vs. Standard Implants for Mandibular Overdentures: A Randomized Trial. J Dent Res. 2015; 94: 1376-1384.

30. Mazor Z, Steigmann M, Leshem R, Peleg M. Mini-implants to reconstruct missing teeth in severe ridge deficiency and small interdental space: a 5-year case series. Implant Dent. 2004; 13: 336–341.

31. Griffitts TM, Collins CP, Collins PC. Mini dental implants: an adjunct for retention, stability, and comfort for the edentulous patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005; 100: e81–e84.

32. Sohrabi K, Mushantat A, Esfandiari S, Feine J. How successful are small-diameter implants? A literature review. Clin Oral Implants Res. 2012; 23: 515–525.


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33. Albrektsson T, Jansson T, Lekholm U. Osseointegrated dental implants. Dental Clinics of North America. 1986; 30: 151-174.

34. Henry PJ, van Steenberghe D, Blomback U, Polizzi G, Rosenberg R, Urgell JP, Wendelhag I. Prospective multicentre study on immediate rehabilitation of edentulous lower jaws according to the Branemark Novum® Protocol. Clini Implant Dent and Relat Res. 2003; 5: 137-142.

35. Griffitts TM, Collins CP, Collins PC. Mini dental implants: an adjunct for retention, stability, and comfort for the edentulous patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005; 100: 81-84.

36. Zahran A, Darhous M, Sherien M, El-Nimr T, Mostafa B, Amir T. Evaluation of conical self-tapping one-piece implants for immediate loading of maxillary over-dentures. Journal of American Science. 2010; 6: 1774-1781.

37. Degidi M, Piattelli A, Carinci F. Clinical outcome of narrow diameter implants: a retrospective study of 510 implants. J Periodontol. 2008; 79: 49-54.

38. Sakoh J, Wahlmann U, Stender E, Al-Nawas B, Wagner W. Primary Stability of a Conical Implant and a Hybrid,Cylindric Screw-Type Implant In Vitro. Int J Oral Maxillofac Implants. 2006; 21: 560–566.

39. O’Sullivan D, Sennerby L, Meredith N. Measurements Comparing the Initial Stability of Five Designs of Dental Implants: A Human Cadaver Study. Clinical Implant Dentistry and Related Research. 2000; 2: 85–92.

40. Gatti C, Haefliger W, Chiapasico M. Implant-retained mandibular overdentures with immediate loading: a prospective study of the ITI implants. Int J Oral Maxillofac Implants. 2000; 15: 383–388.

41. Chiapasco M, Abati S, Romeo E, Vogel G. Implant-retained mandibular overdentures with Branemark System MK II implants. A prospective comparative study between delayed and immediate loading. Int J Oral Maxillofac Implants. 2001; 16: 537–546.

42. Morneburg TR, Proschel PA. Success rates of microimplants in edentulous patients with residual ridge resorption. Int J Oral Maxillofac Implants. 2008; 23: 270–276.

43. Romeo E, Lops D, Amorfini L, Chiapasco M, Ghisolfi M, Vogel G. Clinical and radiographic evaluation of small-diameter (3.3-mm) implants followed for 1–7 years: a longitudinal study. Clin Oral Implants Res. 2006; 17: 139–148.

44. Rungcharassaeng K, Lozada JL, Kan JY, Kim JS, Campagni WV, Munoz CA. Peri-implant tissue response of immediately loaded, threaded, HA-coated implants: 1-year results. J Prosthet Dent. 2002; 87: 173–181.

45. Block MS, Delgado A, Fontenot MG.The effect of diameter and length of hydroxylapatite coated dental implants on ultimate pullout force in dog alveolar bone. Journal of Oral and Maxillofacial Surgery 1990; 48: 174-8.

46. Renouard F, Nisand D. Impact of implant length and diameter on survival rates. Clinical Oral Implants Research. 2006; 17: 35-51.

47. Behneke A, Behneke N, d’Hoedt B. The longitudinal clinical effectiveness of ITI solid-screw implants in partially edentulous patients: a 5-year follow-up report. Int J Oral Maxillofac Implants. 2000; 15: 633–645.

48. Himmlova L, Dostalova T, Kacovsky A, Konvickova S. Influence of implant length and diameter on stress distribution: a finite element analysis. J Prosthet Dent. 2004; 91: 20–25.

49. Bulard RA, Vance JB. Multi-clinic evaluation using minidental implants for long-term denture stabilization: a preliminary biometric evaluation. Compend Contin Educ Dent. 2005; 26: 892–897.

50. Nishioka RS, Souza FA. Bone spreader technique: a preliminary 3-year study. J Oral Implantol. 2009; 35: 289–294.

51. Elsyad MA, Gebreel AA, Fouad MM, Elshoukouki AH. The clinical and radiographic outcome of immediately loaded mini implants supporting a mandibular overdenture. A 3-year prospective study. J Oral Rehab. 2011; 38: 827–834.

52. Baker PS, Ivanhoe JR. Fabrication of occlusal device for protection of implant overdenture abutments with O-ring attachments. J Prosthet Dent. 2003; 90: 605–607.

53. Sanna AM, Molly L, van Steenberghe D. Immediately loaded CAD-CAM manufactured fixed complete dentures using flapless implant placement procedures: A cohort study of consecutive patients. J Prosthet Dent. 2007; 97: 331–339.

54. Zitzmann, N.U., et al., Patient assessment and diagnosis in implant treatment. Australian Dental Journal. 2008; 53: S3-10.

55. Wood MR, Vermilyea SG. A review of selected dental literature on evidence based treatment planning for dental implants: Report of the Committee on Research in Fixed Prosthodontics of the Academy of Fixed Prosthodontics. J Prosthet Dent. 2004; 92: 447-462.

56. Chaveli López B, Gavaldá Esteve C, Sarrión Pérez MG. Dental treatment considerations in the chemotherapy patient. J Clin Exp Dent. 2011; 3: e31-42.

57, Raber-Durlacher JE, Elad S, Barasch A. Oral mucositis. Oral Oncol. 2010; 46: 452-456.

58. Marx RE, Sawatari Y, Fortin M, Broumand V. Bisphosphonateinduced exposed bone (osteonecrosis/osteopetrosis) of the jaws: risk factors, recognition, prevention, and treatment. J Oral Maxillofac Surg. 2005; 63: 1567-1575.

59. Flichy-Fernández AJ, Balaguer-Martínez J, Peñarrocha-Diago M, Bagán JV. Bisphosphonates and dental implants: Current problems. Med Oral Patol Oral Cir Bucal. 2009; 14: E355-360.

60. Fugazzotto PA, Lightfoot WS, Jaffin R, Kumar A. Implant placement with or without simultaneous tooth extraction in patients taking oral bisphosphonates: postoperative healing, early follow-up, and the incidence of complications in two private practices. J Periodontol. 2007; 78: 1664-1669.

61. Jeffcoat MK. Safety of oral bisphosphonates: controlled studies on alveolar bone. Int J Oral Maxillofac Implants. 2006; 21: 349-353.

62. Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws. J Oral Maxillofac Surg. 2007; 65: 369-376.]


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Background: Primary stability plays an impor-tant role in successful osseointegration. Primary stability is defined as the contact of implant and bone during the surgical implant placement. This contact is crucial for direct bone depo-sition between the bone/implant interface as well as subsequent mineralization process of osteogenesis. Secondary stability, however, is not purely a mechanical stability of the implant, unlike the primary stability; it is a biological sta-bility which is formed within few weeks after implant placement during bone remodeling. This case report demonstrates that the secondary stability can be controlled by progressive load-ing and it dictates the percentage of functionally and biologically integrated bone-implant con-tact which in turn dictates its loading schedule. Materials and methods: 5.8x9mm implant was placed in the upper right 1st molar area. The patient was unable to attend the follow-ing visit for uncovering and restoration for a

period of 3 years; however, upon uncover-ing the ISQ readings were 20. A provisional crown on the implant was made using a light cured zirconium silicate micro ceramic indi-rect restoration called Ceramage which was kept 3 mm out of occlusion. The occlusion was adjusted periodically till the ISQ value reached above 65 indicating its safety for loading. Results: the ISQ value increased from 20 to 77 over a period of 6 months with periodic occlusal adjustments resulting from progressive loading. Discussion: Rather than diagnosing the implant in the category of failed implant it was decided to load the implant progres-sively below occlusion and improve its stability.

Conclusion: Placing the implant with low ISQ value on controlled progressive load-ing protocol in 6 months can improve the stability and ISQ value of the implant.

Long-Term Efficacy of Occlusal Loading on an Implant

with Low Stability: A Case Report

Souheil Hussaini BDS, MS1 • Seyed Milad Nejat, DDS1

1. Private practice, Dubai, UAE

Abstract

KEY WORDS: Dental implants, primary stability, bone density, progressive loading, resonance frequency analysis

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INTRODUCTIONImplant stability plays a critical role in success-ful Osseointegration, which is viewed as a direct structural and functional connection between bone surface and surface of the load carrying implant.1-7 Primary stability of an implant con-sists of a mechanical attachment between the implant and the cortical bone.3 Primary stabil-ity is directly related to the quantity and quality of the supporting bone, during the inflammatory early phases of the proliferation stage during oss-teogenesis.8 Secondary stability is achieved by the growth and remodeling of bone around the

implant which is indirectly related to the primary stability while the process of bone formation and remodeling is taking place.9 Factors influencing primary implant stability are predominantly related to the bone quality, implant design, patient ana-tomical structures and the surgical technique.1

However, factors which influence the second-ary implant stability are related to the enhance-ment of the stability as a result of peri-implant bone formation through gradual bone remodel-ing and osteogenesis, with the possibility of new bone formation at the implant-bone interface.9

There are three non-invasive methods to mea-sure the implant stability at the time of uncovery; percussion test, damping capacity assessment (Periotest- damping capacity assessment) and resonance frequency analysis (RFA) is a method used to determine stability (the level of osseoin-tegration) in dental implants (Osstell, Gothenburg, Sweden). The stability is presented as an implant stability quotient (ISQ) value. Studies by zix et al.10 have demonstrated that Periotest is more sus-ceptible to clinical measurement variables when compared to Osstell readings, upon comparison with provided reproducible results Lachman et al

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Figure 1: Diagnostic panoramic radiograph. Figure 2: Panoramic radiograph after implant placement.

Figure 3: Implant placement.


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concluded that Osstell was shown to be a more precise technique for measuring implant stability.11

CASE REPORT A 48 year old male patient came for a dental consultation on the 27th August 2009. After a thorough clinical and radiographic (figure 1) exam-ination of tooth # 16, a periodontal abscess and distal pocket with the depth of 13 mm was found. Full mouth subgingival scaling and curettage was performed on the 5th of September 2009 along with antibiotic therapy. Extraction of tooth #16 was performed on September 28th 2009. An Implant with the dimensions of 5.8 x 9mm (Bioho-rizons, Birmingham, AL USA) was placed on tooth

#16 (FDI tooth numbering system) a week post extraction on 5th October 2009 (figure 2-3). Plans

Figure 4: Open-tray impression technique.

Figure 5: Osstell reading at uncover stage.

Figure 6: UCLA Provisional crown 3mm out of occlusion.


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Figure 7: Osstell reading after 3 months of loading with the provisional restoration.

Figure 9: After 3 years, maintenance follow up/ buccal view.

Figure 8: Osstell reading after 6 months of loading.

Figure 10: After 3 years, maintenance follow up/ occlusal view demonstrating pink and healthy gingival around the crown with bad oral hygiene and no maintenance recall in these years.were made for implant uncovery after 6 months

due to type IV bone quality, but the patient was unable to attend for the uncovery appointment.

After approximately 3 years on August 18th 2012 the patient reported for the Uncovery visit

(figure 4), the implant stability was assessed by means of Osstell device. The ISQ readings for buccal, occlusal, palatal area were 14, 20


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and 17 respectively (figure 5). A screw retained provisional restoration (using a light cured zir-conium silicate micro ceramic indirect restora-tion called Ceramage (SHOFU Dental GmbH, Ratingen, Germany) was fabricated approxi-mately 3 mm out of the occlusion and the patient was asked to chew on it with caution (figure 6).

After 3 months, September 3rd 2012, the patient returned and the stability of the implants

was re-examined using the Osstell device. The provisional restoration proved to be more suc-cess due to the increased ISQ readings 19, 44 and 44 for buccal, Occlusal and palatal respec-tively (figure 7). There was a noticeable improve-ment in regards to the stability of the implant after the controlled loading of the implant by using a provisional composite crown. The occlusion was adjusted 1mm a month regularly and the ISQ measured. The height of the provisional compos-ite crown was increased to 1mm out of occlusion. After 3 months, February 13th 2013 the patient returned to the clinic and the ISQ readings for buccal, occlusal and palatal were 77, 77 and 77 respectively (figure 8). Finally, a permanent full contoured Ceramage UCLA crown was fabri-cated for the patient as a long term restoration.

After 3 years on May 3rd 2016, since the first ISQ value assessment of 14, 20 and 17 and initial loading date which was on August 18th 2012 the patient came for a follow-up main-tenance and checkup visit, whereby the ISQ reading for buccal, occlusal and palatal was 80, 80 and 80 respectively (figures 9-12).

Figure 11: Insertion of the osstell device. Figure 12: Osstell reading after 4 years of loading.

Figure 13: Peri-apical radiograph demonstrating only one third of implant is covered by bone after 7 years post placement and 4 years of loading.


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DisclosureThe authors report no conflict of interest with anything mentioned in this article.

References1. Javed, Fawad, et al. Implant surface morphology

and primary stability: is there a connection? Implant Dentistry2011;11:40-46.

2. Lum, Lawrence B, O. Ross Beirne, Curtis D. Histologic Evaluation of Hydroxylapatite Coated Versus Uncoated Titanium Blade Implants in Delayed and Immediately Loaded Applications. Int J Oral Maxillofac Implants 1991;6(4).

3. Szmukler-Moncler, S., et al. “Timing of loading and effect of micromotion on bone-dental implant interface: review of experimental literature.” Journal of biomedical materials research 43.2 (1998): 192-203.

4. De Smet, Els, et al. “Positive effect of early loading on implant stability in the bi‐cortical guinea‐pig model.” Clinical oral implants research 16.4 (2005): 402-407.

5. Esposito, Marco, et al. “The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials.” International Journal of Oral & Maxillofacial Implants 22.6 (2007).

6. Javed, Fawad, and George E. Romanos. “The role of primary stability for successful immediate loading of dental implants. A literature review.” Journal of dentistry 38.8 (2010): 612-620.

7. Park, Jong-Chul, et al. Implant Stability-Measuring Devices and Randomized Clinical Trial for ISQ Value Change Pattern Measured from Two Different Directions by Magnetic RFA. INTECH Open Access Publisher, 2011.

8. Eriksson, A. R. “The long-term efficacy of currently used dental implants: a review and proposed criteria of success.” The International journal of oral and maxillofacial implants 1 (1986): 11-25.

9. Strand, Jakub, et al. “secondary stability assessment of titanium implants with alkali-etched surface: a resonance frequency analysis study in beagle dogs. International journal of oral and maxillofacial implants, 23(3)

10. Zix, Jürgen, Gerda Kessler-Liechti, and Regina Mericske-Stern. “Stability measurements of 1-stage implants in the maxilla by means of resonance frequency analysis: a pilot study.” International Journal of Oral & Maxillofacial Implants 20.5 (2005).

11. Al-Jetaily, Samer, and Abdullah AlFarraj Al-dosari. “Assessment of Osstell™ and Periotest® systems in measuring dental implant stability (in vitro study).» The Saudi dental journal 23.1 (2011): 17-21.

12. Romanos, George E., et al. “Histologic and histomorphometric evaluation of peri-implant bone subjected to immediate loading: an experimental study with Macaca fascicularis.” International Journal of Oral & Maxillofacial Implants17.1 (2002).

13. Aparicio, Carlos, Niklaus P. Lang, and Bo Rangert. “Validity and clinical significance of biomechanical testing of implant/bone interface.” Clinical oral implants research 17.S2 (2006): 2-7.

14. Atsumi, Mihoko, Sang-hoon Park, and Hom-Lay Wang. “Methods used to assess implant stability: current status.” International Journal of Oral & Maxillofacial Implants 22.5 (2007).

15. Barewal, Reva M., et al. “Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface.” International Journal of Oral & Maxillofacial Implants 18.5 (2003).

16. Beer, Andreas, et al. “Correlation of insertion torques with bone mineral density from dental quantitative CT in the mandible.” Clinical oral implants research 14.5 (2003): 616-620.

17. Alghamdi, A. D., et al. “Influence of Dimensions on the Primary Stability and Removal Torque of Short Dental Implants.” of 4 (2015): 2.

18. Glauser, Roland, et al. “Resonance frequency analysis of implants subjected to immediate or early functional occlusal loading.” Clinical Oral Implants Research 15.4 (2004): 428-434.

19. Herrero-Climent, Mariano, et al. “Assessment of Osstell ISQ’s reliability for implant stability measurement: A cross-sectional clinical study.” Medicina oral, patologia oral y cirugia bucal 18.6 (2013): e877.

20. Alsaadi, Ghada, et al. “A biomechanical assessment of the relation between the oral implant stability at insertion and subjective bone quality assessment.” Journal of clinical periodontology 34.4 (2007): 359-366.

21. Atsumi, Mihoko, Sang-hoon Park, and Hom-Lay Wang. “Methods used to assess implant stability: current status.” International Journal of Oral & Maxillofacial Implants 22.5 (2007).

DISCUSSIONThis study presents that when the ISQ measure-ment of the implant during uncovery was insuffi-cient, by sequential occlusal loading, the implants stability and ISQ measurement increased over time.5 The RFA measurements during uncov-ery after 3 years from placement showed an RF of 2.00 kHz (ISQ 14) as a mean value, indicat-ing that such a low primary stability even after 6 months of healing period will not improve if more time is allotted for osseointegration. For the major-ity of the implants that fall under 60 ISQ we gen-erally wait a period of four weeks to achieve better osseointigration.9-10 Romanos et al.12 performed a histological and histomorphometrical evalua-tion peri-implant bone in the posterior mandible. And he found that peri-implant mineralized bone areas presented statistically significant higher density of bone between the threads of loaded implants.13-21 Loading of the implants seemed

to increase the ossification of the alveolar bone around endosseous implants.17 Even though, in the periapical radiograph the bone quality level do not seem to be sufficient enough for implant load-ing, however, the ISQ value of 80 demonstrates sufficient bone contact for loading5 (figure 13).

CONCLUSIONPlacing the implant with low ISQ value on controlled progressive loading proto-col over a period of 6 months can improve the stability and ISQ value of the implant. ●

Correspondence:Dr. Souheil HussainiOral Implantology Research Institute, Knowledge Village, #39, Block 18 Dubai, UAEP.O. Box 39695 DubaiE-mail: [email protected]


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Background: The successful placement of dental implants is limited by the presence of a deficient maxillary alveolar ridge. This study reports a modified approach to the split-crest technique using piezoelectric surgery in com-bination with immediate implant placement in management of atrophic maxillary ridges.

Methods: The first author has developed an approach within which expansion of the alveolar ridge and implant placement are combined into a single procedure. A limited number of instru-ments were required and implants were posi-tioned into predetermined osteotomy sites within the split channel. This placement was utilized to

expand the bone during seating. 28 patients were treated by this modified split-crest technique and in total received 56 tapered self-tapping implants.

Results achieved showed a significant increase in the mean maxillary ridge width by 2.93 ± 0.13 mm. The survival rate of the implants was 100%. Implant stability was measured using the Periotest M and ranged between -2.3 and -5.3 at 6 months postoperatively.

Conclusion: This study showed that the modi-fied approach to split -crest technique as pre-sented, is a successful technique for augmenting narrow maxillary ridges and implant placement.

A Modified Split-Crest Technique using Piezoelectric Surgery and Immediate

Implant Placement in the Atrophic Maxilla

Amr Zahran, BDS, MDS, PhD1 • Basma Mostafa, BDS, MDS, PhD2 Ahmed Hanafy, BDS, MDS3 • Mona Darhous, BDS, MDS, PhD4

1. Professor, Department of Periodontology, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.

2. Assistant Professor, Department of Surgery and Oral Medicine, National Research Centre, Cairo, Egypt.

3. Assistant Lecturer, Department of Periodontology, Faculty of Dentistry, Beni-Suef University, Egypt.

4. Professor and Chairman of the Department of Periodontology, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.

Abstract

KEY WORDS: Dental implants, split ridge, maxilla, implant survival

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INTRODUCTIONThe success of dental implant placement pre-dominantly depends on the presence of adequate bone quantity and quality for the edentulous site. Optimal osseous volume bears a positive influ-ence on osseointegration, long term stability and the final esthetic and prosthetic outcomes of the dental implant.1,2 A deficient alveolar ridge is a major limiting factor in achieving a success-ful outcome for implant placement. For extreme cases of ridge width deficiency, it would be necessary to prepare the ridge through aug-mentation procedures3. Established bone aug-mentation techniques for consideration are: distraction osteogenesis, guided bone regenera-tion, onlay grafting, inter-positional grafting, ridge splitting or expansion, sinus augmentation and in some cases ridge shortening.4,5 Ridge splitting to achieve bone expansion as a technique for aug-mentation has received growing acceptance.6,7

In 1992, Simion et al.11 was the first to intro-duce the split-crest bone manipulation tech-nique. In his study, five patients displaying adequate vertical bone height but insufficient width of bone were chosen for treatment using the split-crest technique combined with guided tissue regeneration, followed by implant place-ment. The technique involved the splitting of the alveolar ridge longitudinally into two parts, creat-ing a greenstick fracture. A chisel was then used to make a fine cut and split apart the two corti-cal plates and was followed by implant insertion. The implants and the existing defects were cov-ered with guided bone regeneration (GBR) bar-riers. After osseointegration of the implants was assured, it was reported that the final increase in the width of the maxillary ridge was 3-4 mm while in the mandible it was 1-1.5 mm (this was

attributed to the stiffness of the compact bone of the mandible). Histological examination of specimens obtained from the newly formed bone (using a trephine bur between the split cortical plates) revealed the regeneration of bone tissue of normal structure which was of little difference in mineralization rate from the pre-existing bone.8

The gap created in-between the split-crestal plates is utilized for the positioning of implants. The space unoccupied by the implants can be filled with biomaterials such as; autologous bone grafts, particulate bone, or plasma derivatives like platelet-rich plasma (PRP).9,10 The advantages of ridge splitting when compared to other tech-niques were proven. Secondary surgical sites are not mandatory, and immediate implant place-ment can be accomplished during the procedure. The method allows for prostrate dilatation of the vestibular and palatal crest walls, providing a bone bed of mesenchymal cells from marrow ori-gin therefore possessing a strong osteogenic potential that can assist the regenerative pro-cess without the need to use autologous donor zones. Favorable results are thus reached, with high predictability and low morbidity compared with those techniques that utilize autologous donor sites.11,12 Another clinical study conducted on ridge splitting techniques featured the imme-diate placing of implants for restoration of single maxillary anterior teeth. It was reported that split-ting is indicated for narrow ridges where suf-ficient spongy bone is found between labial and palatal cortices. The study described the bone-splitting procedure as a safe and predictable technique when carefully performed on selected patients, with the use of proper instrumentation.13

As previously highlighted, the split-crest tech-nique is a flexible technique that allows many

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modifications. Such modifications are performed with a choice of devices for the cutting of bone. The most common instruments implemented were fissure burs,14 micro-saw/discs,15,16,17 osteotome chisels6,14,18,19 and piezo-electric knives.12,16,19,20,21 Piezoelectric bone surgery was introduced to the dental profession in order to perform precise and minimally traumatic bone surgeries. This ultrasonic device provides the capability to cut mineralized hard tissues such as bone accurately and in a very safe way, with minor tissue damage.22, 23, 24 Soft tissues such as nerves, blood vessels, or the Schneiderian membrane are not affected by the cutting tip because of their capability to oscil-late at the same speed and amplitude as the tip. Various clinical contemplates have reported the potential use of ultrasonic bone surgery in the splitting and expansion technique with satisfac-tory results in most cases.25 The aim of the pres-ent study is to clinically evaluate the suitability of piezoelectric bone surgery when adopted for a modified approach to the split-crest tech-

nique in the maxilla in combination with simul-taneous implant placement. The approach presented herein provides an increase to the ridge width through the use of tapered implants and without the use of any defect filling materials.

PATIENTS AND METHODSThis study was conducted on 28 patients (18 males and 10 females) with an age range of 27- 58 years and a mean age of 38.4 ± 2.37. A total of 56 implants were placed in the selected patients. The patients were selected from the out-patient clinic at the Faculty of Oral and Dental Medicine, Cairo University. The study protocol was reviewed and approved by the Ethical Committee at the Faculty of Oral and Dental Medicine, Cairo University. Patients were chosen according to the following inclusion criteria: one or more missing teeth in the maxilla, the alveolar ridge in the eden-tulous site demonstrated insufficient bucco-pala-tal ridge width (less than 6 mm) with more than 10 mm of residual bone height and sufficient verti-

Figure 1: Intraoral photograph showing the creation of bone channel using the piezoelectric surgical tip.

Figure 2: Intraoral photograph reporting the use of the 3.25 mm Ultra drill for implant site osteotomy.


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cal inter-maxillary arch space, upon centric occlu-sion. Exclusion criteria were: presence of any local or systemic condition that may contraindicate minor oral surgeries, active growth stage with partially erupted teeth and presence of oral hab-its that might endanger the osseointegration pro-cess, such as smoking or parafunctional habits.

All patients participating in the study were fully informed of the study protocol

and the associated risks of the study proce-dures. All participants signed an informed consent form to document their approval.

Pre-surgical evaluation included visual examination and palpation of the entire oral and para-oral tissues. Study casts were pre-pared to evaluate the inter-maxillary space and type of occlusion. The bucco-palatal alveolar ridge width at the implant site was measured using a bone caliper. Periapical and panoramic radiographs for the recipient site were taken. Cone Beam Volumetric Tomography (CBVT) was performed on the assigned sites for the study in order to determine the bucco-pala-tal alveolar ridge width at the implants’ site.

Surgical ProceduresPatients were anesthetized locally by infiltration anesthesia. A palatal sub-crestal incision was created for the surgical site. Two oblique releas-ing incisions were then created on the buccal aspect. Dissection of the full thickness mucoperi-

Figure 3: Intraoral photograph showing implant placement creating bone expansion during seating.

Figure 4: Pre-surgical and post-surgical (6 months) CBCT scan showing increased ridge width and positioned dental implants.

Figure 5: Dental implants with fixed cover screws.


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osteal flap was performed providing complete exposure of the alveolar bone. Using piezoelec-tric surgery unit (tip model: SG1, NSK Variosurg ultrasonic surgical system, Japan) a horizontal crestal cut was produced along the crest of the bone (Figure 1). The cut depth extended through the cortical bone to reach the spongy bone. The depth of the horizontal cut was approximately 1 mm shorter than the overall length of the implant to be placed. Two vertical cuts were made and these were connected to the horizontal crestal cut (except in two patients having a long span ridge for which vertical cuts were not needed). After ridge splitting, the osteotomy site was pre-pared using a 3.25 mm Ultra drill (Figure 2) and OsteoCare™ Maxi Z (OsteoCare™ Implant Sys-tem, London, United Kingdom) two-piece and Maxi Z flat-end tapered dental implants were placed according to the manufacturer’s protocol (Figure 3). Careful screwing and seating of these tapered implants into the bone was performed

until all exposed threads were submerged and the platform remained flush with the crestal bone. This positioning of the implants created expansion through deformation between the split bony plates (Figure 4). Cover screws were then fixed to the implants (Figure 5). Closure of the flap was per-formed using interrupted sutures with a 4-0 black silk suture material (Assut sutures®. Switzerland).

Post-surgery Patient Management1. Augmentin® (Medical Union Pharmaceuticals

Co. Egypt) 1g tablets were prescribed twice daily for 5 days.

2. Analgesics were prescribed as following: Voltaren® (Novartis Pharma, S.A.E., Cairo, Egypt) 75 mg IM once.

3. Brufen® (Khaira Pharmaceuticals and Chemical Industries Company, Cairo, Egypt) 200 mg t.d.s for 5 days was prescribed.

4. Oral hygiene recommendations were pro-vided including the use of soft toothbrush.

Figure 6: Intraoral photograph showing soft tissue healing at 6 months after initial surgery.

Figure 7: Intraoral photograph with the re-entry 6 months after initial surgery with complete bone fill and regeneration.


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The Second StageAfter a healing period of 6 months (Figure 6), surgical re-entry was undertaken in order to assess the clinical success of the modified split-crest technique and to position the healing col-lars on the newly exposed implants (Figure 7).

Prosthetic ProceduresTen days after positioning of the healing col-lars, indirect impressions were taken using OsteoCareTM impression transfers for the open tray transfer technique. Impressions were pro-vided to dental laboratories for construction of the final porcelain-fused-to-metal or porcelain-fused-to-Zirconium crowns. After fixation of the abutments, the final crowns were perma-nently cemented using zinc phosphate cement.

Follow-Up Evaluation and Success CriteriaEvery patient underwent immediate ‘post sur-gery’ evaluation and examination and again 6 months post-operatively. The examination and evaluation criteria included review for: absence of peri-implant infection, no complaint of local pain at the site of treatment and no com-plaint of neuropathies or paraesthesia. In addi-tion the patients were evaluated for absence of clinically detectable mobility. Periotest M (Periotest® M, Medizintechnik Gulden, Ben-sheim, Germany) was used to test implant sta-bility at 6 months before cementing the crowns.

Radiographic EvaluationStandardized periapical radiographs using the parallel technique in addition to panoramic radiographs and CBVT were undertaken pre-operative, immediately post-operative (within the first 24 hours) and 6 months post-operative.

CBVT scans were used to evaluate the total gain in alveolar ridge width, in the bucco-palatal dimension. They were also used to assess the stability of the marginal bone around the implant after the procedure and to record the post-oper-ative ridge width. The raw data obtained from the CBVT scan was imported into bespoke third party software for secondary reconstruction and further clinical interpretation. The results obtained from each of the data sets were compared. The pre-operative image was fused to the postoperative image by manual registration through landmarks in the cranium. Accurate registration (superimposi-tion) was automatically performed by the software. Each image (primary and secondary) was color coded for identification. Firstly, key point measure-ments were recorded onto the primary image. The measurements on the primary image were held and the primary image was removed to leave the secondary image. New measurements were then recorded on the secondary image in the identi-cal plane, direction and cut as that of the primary image to ensure standardization. The obtained data was then subjected to statistical analysis.

Statistical AnalysisNumerical data were displayed as mean ± standard deviation (SD) values. Qualita-tive data were presented as frequencies and percentages. Paired student t-test was conducted to compare the pre and the post-operative ridge widths. The significance level was set at p ≤ 0.05. Statistical analysis was performed with SPSS 18.0, Chicago, IL, USA.

RESULTSA total of 56 implants were placed in 28 pre-selected patients. Six patients received one


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implant; 17 patients received two implants; three patients received three implants and two patients received 4 implants. The diameter of 53 of the implants was 3.75 mm and 3 implants had a diam-eter of 4.5 mm. The length of 43 implants was 13 mm and length of the remaining 13 implants was 10 mm. Wound healing was normal in all patients without any signs of infection, suppuration or mucositis. Ini-tial pain and minor swelling was noted in all patients. These conditions were completely resolved by the tenth day post-operatively.

The preoperative ridge width of the patients ranged between a minimum of 3.58 mm and a maximum of 5.12 mm with the mean ± SD ridge width of 4.52 ± 0.41 mm. The 6 months postoperative ridge width ranged between a minimum of 6.46 mm and a maximum of 8.15 mm with a mean value of 7.44 ± 0.42 mm. The mean increase of the maxillary ridge width was 2.93 ± 0.13. Statistical analysis revealed a significant increase in the ridge width mea-surements with a p-value of 0.0001 (Table 1). All the implants were successfully osseo-integrated when clinically tested at 6 months postoperatively. The degree of implant stabil-ity measured by Periotest M ranged between -2.3 and -5.3 after 6 months postoperatively.

DISCUSSIONRidge split-crest bone manipulation tech-nique is one form of augmentation proce-dures for narrow ridges. This procedure can be used for ridge expansion with immedi-ate implant placement, providing an over-all reduction in the time required for implant therapy.26 Since the introduction of this technique various studies have reported the use of osteotomes and ridge expand-ers to increase ridge width for the placement of implants with successful outcomes.27,28,29

In the current study, tapered implants were used to expand the bone instead of using ridge expanders or osteotomes and this was con-sidered as a valuable modification to the split-crest technique. Tapered implants provide more control over the expansion procedure by easing the bone plates apart in a gradual man-ner which minimizes the risk of fracturing the buccal plate. The expansion of the ridge and placement of the implants are combined into a single procedure. Few instruments were employed: the piezoelectric cutting tip, the tapered drill and the tapered, self-tapping, self-drilling implants which are placed into prede-termined osteotomies within the split channel. No bone grafts or barriers were used to aug-

Table 1: The Comparison Between Pre- and Post-operative Ridge Widths

Pre-operative width Post-operative width Mean ± (SD) Mean ± (SD) ρ-value

4.52 ± 0.41 7.44 ± 0.42 0.0001*

* Statistically significant different, p-value ≤ 0.05


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ment the osteotomy site. The self-space-making nature of the split channel allowed for natural bone regeneration by the osteogenic cells.30

The results of the current contemplate revealed a total mean maxillary ridge bone gain of 2.93 mm after 6 months post-operative, with no use of bone graft material or barrier membrane to fill the defect gap. The 100% success rate of the present study coincides with the results of several studies which have reported satisfactory ridge bone gain without the use of grafting mate-rials. Chiapasco et al.31 reported a final mean bone gain of 4 mm and Holtzclaw et al.32 showed a mean bone gain of 4.03 mm. Meanwhile, Sohn et al.33 reached a bone gain of 2.7 mm.

Various studies of the split-crest technique using osteotomes or bone expanders with bone grafts and/or barrier membranes to fill the remain-ing defect gaps have been reviewed.30,34 Sethi et al.29 reported the use of autologous bone and hydroxyapatite achieving a total gain of ridge width of 2.8 mm. Anitua et al.30 used a barrier membrane and platelet rich growth factor achiev-ing a final mean bone gain of 3.35 mm. Blus et al.35 reached a final mean bone gain of 2.7 mm after combining allograft and PRP together with using a barrier membrane. Rahpeyma et al.36 only used allograft and reached a mean bone gain of 2 mm. The survival rate of the implants in these studies collectively ranged between 95.3-100 %.

Our results documented a reduction in instru-mentation used during the surgical procedures and the lack of requirement for using of any addi-tional augmentation materials while still achieving a similar level of bone gain. The tapered design of the implants initiated the expansion of bone without the need of osteotomes or expanders.

In this contemplate, ridge splitting and

implant placement were undertaken during the same visit as followed in other studies1, 37 that stated ridge splitting with simultaneous implant placement as the preferable procedure when used in the maxilla, due to the thinner corti-cal plates and the softer medullary bone which provided easier and controlled expansion.26

The use of piezoelectric tips was suc-cessfully documented assuring the pre-cise cutting of bone with preservation of the surrounding soft tissues, which was in accordance with other studies.18,38,39,40

CONCLUSIONThe results of this study showed that the modi-fied approach to split -crest technique as presented, is a successful technique for aug-menting narrow maxillary ridges. This modifi-cation utilized a fewer number of instruments with the implants acting as bone expand-ers. Simultaneous implant placement was performed without the need for any graft-ing materials or use of GBR barriers. ●

Correspondence:Dr. Basma Mostafa Assistant Professor of Oral Medicine and Periodontology, Surgery and Oral Medicine Dep., Oral and Dental Research Division, National Research Centre. 33 El Bohouth Street, 12622 Dokki, Cairo, Egypt.e-mail: [email protected] no.: 0020237623537Fax no.: +20233387803.


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DisclosureProf. Amr Zahran is the scientific consultant for OsteoCare™ Implant System (UK) and is involved in the designing of the whole range of the Maxi Z dental implants. All other authors claim to have no financial interest in this product.

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