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The Journal of Implant & Advanced Clinical Dentistry

Volume 5, No. 4 April 2013

Laser Decontamination of Dental Implants

Treatment of Intrabony Defects with Enamel Matrix Derivative

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Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

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The Journal of Implant & Advanced Clinical Dentistry • 5

The Journal of Implant & Advanced Clinical DentistryVolume 5, No. 4 • April 2013

Table of Contents

Built-in platform shiftingDual-function prosthetic connection

Bone-condensing property

Adjustable implant orientation for optimal final placement

High initial stability, even in compromised

bone situations

NobelActive™

A new direction for implants.

Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

NobelActive equally satisfies surgical and restorative clinical goals. NobelActive thread design progressively condenses bone with each turn during insertion, which is designed to enhance initial stability. The sharp apex and cutting blades allow surgical clinicians to adjust implant orientation for optimal positioning of the prosthetic

connection. Restorative clinicians benefit by a versatile and secure internal conical prosthetic connec-tion with built-in platform shifting upon which they can produce excellent esthetic results. Based on customer feedback and market demands for NobelActive, theproduct assortment has been expanded – dental professionals will

now enjoy even greater flexi bility in prosthetic and implant selection. Nobel Biocare is the world leader in innovative evidence-based dental solutions. For more information, con-tact a Nobel Biocare Representative at 800 322 5001 or visit our website.

www.nobelbiocare.com/nobelactive

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All

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TIUNITE® SURFACE,

10-YEAR EXPERIENCE

New data confi rm

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NOW AVAILABLE

WITH NOBELGUIDE™

64_NA2010_8125x10875.indd 1 8/1/11 1:37:30 PM

13 Customized Impression Post: An Innovative Approach for Esthetic Implant Restorations Dr. Jay Matani, Dr. Shantanu S. Jambhekar, Dr. Mohit G. Kheur, Dr. Sumit Sethi, Dr. Supriya Kheur

19 Evaluation of Contaminated Implant Surfaces Irradiated by Er, Cr: YSGG Laser Gizem Berk, Rene Franzen, Kubra Atici, Sema S. Hakki, Nuket Berk, Norbert Gutknecht

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Biopsy of DynaMatrix

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• As an ECM, DynaMatrix retains both the 3-dimensional structure and the signaling proteins important for soft tissue regeneration1

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1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543.

2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5.

3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract).

4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract).

Accell is an all-natural concentration of Bone Morphogenetic Proteins (BMPs) and Growth Factors with Demineralized Bone Matrix (DBM) that directs and charges stem cells to acclerate the body’s natural healing response.



Table of Contents

29 Enamel Matrix Derivative in Advanced Intrabony Defect: Radiographic Bone Fill Resolution at 1 Year Follow up: A Case Series Paulo Sérgio, Gomes Henriques, André Antonio Pelegrine, Ana Amália Nogueira, Mônica Martinez Borghi, Daiane Peruzzo

39 Clinical Application of Xenogenic Porcine Bilayer Collagen Matrix (Mucograft®) in the Treatment of Miller Class I and II Gingival Recession Defects: A Retrospective Consecutive Case Series Nicholas Toscano, Dan Holtzclaw, Brian Margolis

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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

Editorial Advisory Board

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

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS

The Journal of Implant & Advanced Clinical Dentistry

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Wilcko et al

An esthetic and functional implant sup-ported restoration in the esthetic zone is a clinical challenge. The correct three

dimensional positioning of the implant in the apico-coronal, mesio-distal and bucco-lingual dimensions and proper management of the peri-implant soft tissue is required to achieve the desired emergence profile. Various sur-

gical and restorative techniques have been employed for achieving ideal soft tissue con-tours. This article describes an easy conve-nient method of customizing impression posts to prevent soft tissue collapse or distension of the gingival cuff during the impression proce-dure and accurately recording and transferring the soft tissue situation onto the master cast.

Customized Impression Post: An Innovative Approach for Esthetic Implant Restorations

Dr. Jay Matani1 • Dr. Shantanu S. Jambhekar MDS2 • Dr. Mohit G. Kheur, MDS3

Dr. Sumit Sethi, MDS4 • Dr. Supriya Kheur, MDS5

1. Post Graduate Student, Dept Of Prosthodontics, M A Rangoonwala College Of Dental Sciences and Research Centre, Pune, India.

2. Dept Of Prosthodontics, Senior Lecturer, Dept Of Prosthodontics, Terna Dental College And Hospital , Nerul, Navi Mumbai, India.

3. Professor And PG Guide, Dept Of Prosthodontics, M A Rangoonwala College Of Dental Sciences and Research Centre, Pune, India.

4. Senior Lecturer, Dept Of Prosthodontics, Sri Sukhmani Dental College And Hospital,Mohali, Punjab, India.

5. Dept Of Oral Pathology, D Y Patil Dental College And Research Centre, Pimpri, Pune, India.

Abstract

KEY WORDS: Dental implants, impressions, esthetics, proshteticis


14 • Vol. 5, No. 4 • April 2013

INTRODUCTIONAn esthetic and functional implant supported restoration in the esthetic zone is a clinical chal-lenge. The correct three dimensional positioning of the implant in the apico-coronal, mesio-distal and bucco-lingual dimensions and proper man-agement of the peri-implant soft tissue is required to achieve the desired emergence profile. Vari-ous surgical and restorative techniques have been employed for achieving ideal soft tissue contours.1, 2 Use of customised abutments to develop and maintain the interdental papilla is one such example of a non-surgical technique.3

The soft tissue profile around a central incisor is rounded triangular in shape. The geometry of the stock impression posts is generally round cylindrical in shape. Due to this discrepancy in shape, they do not allow proper reproduction of the desired soft tissue emergence profile onto the master cast. Customized impression posts pre-vent soft tissue collapse or distension of the gin-

gival cuff during the impression procedure and a better record of the soft tissue is obtained. This results in a proper reproduction of the implant and soft tissue situation onto the master cast.4 An impression post can be easily customised to support the soft tissue profile present around the implant.5, 6 A simple and cost effective tech-nique has been described below by which the soft tissue contours around the implants can be recorded and transferred to the master cast.

PROCEDUREAt the second stage implant surgery, the heal-ing abutment is customized to the preferred emergence profile using light cured compos-ite resin (Filtek Z350, 3M, St. Paul, MN, U.S.) (Figure 1). At the appointment for recording the impression, the customized healing abut-ment is removed from the mouth and is attached to the laboratory analog. This assembly is then embedded in silicone putty (Speedex, Coltene

Figure 1: Healing abutment in situ.

Matani et al


Whaledent, Coltène Whaledent AG, Altstätten, Switzerland). The buccal surface of the abut-ment is marked out on the putty block to assist in orientation of the impression post in the future (Figures 2a, 2b). Keeping the laboratory analog in place within the putty, the customized healing abutments is then unscrewed and a stock impres-

Figure 2a: Healing abutment and lab analogue embedded in a silicone putty block.

Figure 2b: Embedded lab analog.

Figure 3: Temporary restorative resin (Protemp 4) flowed around the stock impression post attached to the lab analogue.

Figure 4: Customized impression post.

Matani et al

16 • Vol. 5, No. 4 • April 2013

sion post is attached in its place. Customization of the impression post is done by flowing Pro-temp 4 (3M, St. Paul, MN, U.S) within the space between the impression post and the silicone putty (Figure 3). On setting, the resin portion of the customised impression post is smoothened and polished (Figure 4). The other materials that can be used to customise the impression posts can be pattern resin and flowable composites.

The customised impression post is then fitted onto the implant and the soft tissue contours are checked (Figure 5). An open tray impression is made using polyvinylsiloxane. A laboratory analog is attached to the customized impression post and gingival silicone (Gingitech, Ivoclar Vivadent Inc, Amherst, New York) is flowed around the impres-sion post. The master cast is made thereafter. In this case an abutment was customized using zir-conia (Figure 6) (Lava, 3M, St. Paul, MN, USA) in the per mucosal region to support the recorded soft tissue contour. An Emax crown (Ivoclar Viva-

dent, Ivoclar Vivadent Inc, Amherst, New York) was used as the final implant restoration (Figure 7).

SUMMARYThe technique discussed above is a precise and simple way of recording the peri-implant soft tissue contours. It can be routinely used to record and transfer the desired emergence pro-file onto the master models in order to fabricate well contoured, esthetic implant restorations. ●

Figure 5: Customized impression post in situ.

Correspondence:Dr.Shantanu S Jambhekar Mds Prosthodontics And ImplantologySenior Lecturer, Dept Of Prosthodontics,1603-Datta TowerTerna Dental College And Hospital, Nerul, Navi Mumbai - 400012IndiaPhone Numbers: + 91 989 269 3994E-Mail: [email protected]

Matani et al


Figure 6: Customized Zirconia abutment.

Figure 7: Final restorations in situ on the day of cementation.

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

References1. Walter F. Biggs and Allen L. Litvak, Jr.

Immediate provisional restorations to aid in gingival healing and optimal contours for implant patients. J Prosthet Dent 2001; 86:177-80.

2. Daniel C.T. Macintosh and Mark Sutherland. Method for developing an optimal emergence profile using heat-polymerized provisional restorations for single-tooth implant-supported restorations. J Prosthet Dent 2004; 91:289-92.

3. Avi Donitza. Prosthetic procedures for optimal aesthetics in single tooth implant restorations: A case report. Pract Periodont Aesthet Dent 2000; 12(4): 347-352.

4. Larry C. Breeding et al. Transfer of gingival contours to a master cast. J Prosthet Dent 1996; 75: 341-43.

5. Mariano A. Polack. Simple method of fabricating an impression coping to reproduce peri-implant gingiva on the master cast. J Prosthet Dent 2002; 88: 221-3.

6. Panagiota-Eirini Spyropoulou et al. Restoring implants in the esthetic zone after sculpting and capturing the periimplant tissues in rest position: A clinical report. J Prosthet Dent 2009;102:345-347.

Matani et al

Wilcko et al

Background: The aim of the study was to eval-uate the efficiency of an Er,Cr:YSGG laser to remove the biofilm of the contaminated implant surfaces and to examine the possible alterations on the surface structure after laser irradiation.

Methods: Nine failed SLA surfaced dental implants were used for laser irradiation and one unused implant served as control. Of the nine contaminated implants, eight were marked verti-cally to create two sides on the same implant, and the ninth contaminated implant was kept as a control implant of the failed implant group. One side of the contaminated implants was treated with Er,Cr:YSGG laser while the other side remained untreated. The surfaces were irradiated with a pulsed Er,Cr:YSGG laser with a power setting of 1.5 W, 15 Hz, 140 μs pulse duration for 30 seconds per thread in

the non-contact mode. After macroscopic pic-ture evaluation, light microscopic evaluation and SEM analysis were performed subsequently.

Results: SEM and light microscopy images demonstrated that Er,Cr:YSGG laser treat-ment with predetermined settings for titanium surfaces was able to remove all the contami-nants and debris from the implant surfaces without any surface alteration which was also noticeable in the macroscopic pictures. Conclusion: It was concluded that the use of Er,Cr:YSGG laser with current settings was efficient to decontaminate implant surfaces and the results of this study suggested that Er,Cr:YSGG laser can be used safely in the clin-ics for the treatment of peri-implantitis for biofilm removal without damaging the implant surface.

Evaluation of Contaminated Implant Surfaces Irradiated by Er, Cr: YSGG Laser

Gizem Berk, DDS, MSc1 • Rene Franzen, PhD2 • Kubra Atici, DDS, PhD3 Sema S. Hakki, DDS, PhD4 • Nuket Berk, DDS, PhD5

Norbert Gutknecht, DDS, PhD6

1. Master of Science in Lasers In Dentistry, Private practice, DENTA FORM Dental Clinic, Ankara, TURKEY

2. Physicist, Department of Restorative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University Hospital, Aachen, GERMANY

3. Periodontist, The UIC College of Dentistry, Chicago, USA

4. Periodontist, Associate Professor, Selcuk University, Faculty of Dentistry, Department of Periodontology, Konya, TURKEY

5. Orthodontist, Private practice, DENTA FORM Health Center, Ankara, TURKEY

6. Restorative Dentist, Professor, Clinic of Restorative Dentistry, Periodontology and Preventive Dentistry, RWTH Aachen University Hospital, Aachen, GERMANY

Abstract

KEY WORDS: Lasers, Biofilms, Dental Implants


20 • Vol. 5, No. 4 • April 2013

IntRODuCtIOnThe host response to biofilm formation on the implant surfaces includes a series of inflamma-tory reactions which initially occur in the soft tissue but which may subsequently progress and lead to loss of supporting bone.1-3 The bio-film that formed on the implant during the tissue breakdown phase alters the surface characteris-tics of the titanium body. It is well known that the implant is made of commercially pure titanium but covered with a thin layer of titanium dioxide. This dioxide layer gives the implant a high surface energy that facilitates the interaction between the implant and the cells of the host tissues. Con-tamination of a titanium surface, however, mark-edly alters its characteristics. It results with an implant that has a low surface energy. Such a surface may not allow tissue integration to occur but rather provokes a foreign body reaction.1

Several treatments have been proposed for cleaning and decontaminating of the implant sur-faces. Some osseointegrated titanium implants, plasma-spray-coated or sandblasted ones for instance, are designed to have a rough sur-face to increase areas of attached surface and anchorage force in alveolar bone.4 However, the roughness makes it difficult to eliminate bacte-ria from the surface by conventional procedures such as scaling.5 Various methods for cleaning of implant surfaces have been described in order to treat failing implants. Among other treatment options; citric acid, air powder abrasive treatment, mechanical cleaning with curettes or scalers or the application of plastic-coated ultrasonic scalers are used.3,6 Mechanical treatment of the implant body might cause some alterations on the implant surface. Damage to the surface of the implant could delay or prevent osteoblastic cell attach-

ment to titanium surfaces and extracellular matrix synthesis, which is required for osseointegra-tion.7 Recently, in addition to these conventional tools, the use of different laser systems has also been proposed for treatment of peri-implant infec-tions.3, 5, 6 As lasers can perform excellent tissue ablation with high bactericidal and detoxification effects, they are expected to be one of the most promising new technical modalities for treatment of failing implants.8-10 Various advantageous char-acteristics, such as easy handling, haemostatic effects, effective calculus ablation, or bactericidal effects against periodontopathic pathogens have been suggested to improve treatment outcomes. Recent in vitro studies have demonstrated that, in an energy-dependent manner, only the CO2 laser, the diode lasers in the spectral range between 810 and 980 nm, and the Er:YAG laser may be suitable for the irradiation and the instrumenta-tion of titanium surfaces, because their specific wavelength is poorly absorbed by titanium and the implant body temperature did not increase signifi-cantly during irradiation.11 These benefits are not applicable for all lasers due to their wavelengths. Regarding the effect of other wavelengths on tita-nium surfaces such as the Nd:YAG laser, is not suitable for implant therapy since the titanium layer could easily be ablated by the Nd:YAG laser irre-spective of output energy.11-14 The application of high-energy lasers in dentistry, however, requires special consideration of potential risks of inad-vertent tissue and material damage. With regard to the treatment of peri-implantitis, this refers to possible implant surface alterations and exces-sive heat generation in the peri-implant bone.2

Most recently, an erbium, chromium- doped: yttrium, scandium, gallium, garnet (Er,Cr:YSGG) laser with a wavelength of 2,780 nm, which is

Berk et al


more highly absorbed by OH- ions than water molecules, has been introduced to improve hard tissue ablation. A commercially available Er,Cr:YSGG laser device has an improved per-formance for the removal of bacterial contami-nants from implant surfaces.15 It was found that this laser type is safe for applications on root surfaces16 and also for bone surgery by means of limited temperature rise in several studies.17,18

The findings of Schwarz et al.15 was that usage of Er,Cr:YSGG laser did not cause any thermal damages on SLA titanium implant surfaces at energy settings of up to 2.5 W. Also, it had been pointed out that in a time that was needed for implant surface irradiation and energy dependent manner, the effectiveness of Er,Cr:YSGG laser for plaque biofilm removal seems to be superior to that of chlorhexidine digluconate solution or vari-ous ultrasonic devices. Within the range of that reported for Er:YAG laser, irradiation resulted in a statistically significant decrease of initial plaque biofilm areas grown on SLA titanium implants.15

The aim of this study was to observe the effect of the Er,Cr:YSGG laser irradiation on the failed implant surfaces for the removal of the contami-nated biofilm and to compare laser treated con-taminated surfaces and unused implant surfaces to examine possible changes on the surfaces.

MAtERIAlS AnD MEthODSØ 3.3 mm [5 pcs.], Ø 4.1 mm [3 pcs.] and Ø 4.8 mm [2 pcs.] total of 10 SLA surface implants (ITI® Dental Implant System, Strau-mann AG, Waldenburg, Switzerland) were used. Nine [9] of them were failed, contami-nated implants which were applied to male and female patients within the age range of 35 to 45 for the treatment of missing tooth in

different quadrants of the mouth and one was an unused implant. The surfaces of 8 contami-nated implants were divided into two parts. One side was marked to be irradiated with laser and other side kept as the control group of each implant for the light microscope evaluation.

In order to have a better visual aspect of the biofilm on the implant surface, we decided to stain all the implants with a conventional, erythrosine-free, disclosing agent (Trace, Young Dental, Earth City, MA, USA). Even though the implants were totally dry, the parts where the biofilm and other organic debridement were located had stained by the disclosing agent. Regarding the staining, this idea may guide the clinical surgical use of the lasers by means of detecting the exact area that has to be treated.

The disclosing agent was placed into 10 separate labeled glass tubes, the implants were placed into each tube. After 1 minute, each implant was removed from the tubes and rinsed with distilled water and saline solution subsequently. The implants were placed into dry flat surface for drying. The first macroscopic pictures were taken after the discoloration occurred on the implants.

lasing ProcedureEr,Cr:YSGG Laser (Waterlase MD, Biolase,San Clemente, CA, USA), 2,780 nm wavelength, a fiber guided system, was used with 600 micron sapphire tips (MG4-4 mm length) with 15 Hz, 100 mJ pulse energy, 140 μs pulse duration (H Mode) and 1.5 W, 65% air and 55% water.

The selected parts of the 8 implants (half of the implants) were lased 5 seconds for the 3.3 mm implants, 7 seconds for the 4.1 mm implants and 8 seconds for the 4.8 mm implant;

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per one thread on the selected half without any contact with an irradiation distance of 1.5-2 mm from the tip to the surface of the implants. So the total time of irradiation time for the 3.3 mm implants was 30 seconds for 8 mm long implant, 40 seconds for 10 mm long implant, 50 seconds for 12 mm long implants and 60 sec-onds for 14 mm implant. For 4.1 mm implants, the total irradiation time was 42 seconds for 8 mm long implants and 70 seconds for the 4.8 mm diameter and 12 mm long implant (Table 1). The time of the irradiation was applied regardless of the level of discoloration on the implant surface. One of the failed implants and the unused implant were kept as the control implants. After the lasing procedure, a visual evaluation of the samples was completed with light and scanning electron microscopy (SEM).

light Microscopy and SEM Evaluation:All the samples were placed in separate clean,

dry, sealed tubes and were sent to Konya Selçuk University, Research Center of Fac-ulty of Dentistry for the microscopic observa-tion (Transmision Light Microscope; Olympus, Tokyo, Japan) and digital imaging of the implant surfaces. Light Microscopy results were evalu-ated at x10, x20 and x40 magnification levels.

After the microscopic evaluation, only the lased section of each specimen and the con-trol implants were prepared for SEM analysis by sputter-coating with gold by a special device (Hummer VII, Sputtering System, Anatech LTD, Alexandria, VA, USA) in Middle East Techni-cal University, SEM Laboratories, Ankara. After sputtering, the specimens were investigated by the scanning electron microscope (JEOL, JSM.6400, Tokyo, Japan) and analyzed with high-resolution digital pictures. SEM results were evaluated at x20, x300 and x3500 magni-fication levels. Some specimens were evaluated at x100 and x1000 magnification levels as well.

Table 1: Combinations of implant dimensions and applied energies/doses

Implant Implant Length L Total Time of Total Energy Dose Diameter D (mm) (mm) Irradiation (s) Applied (j) (j/cm2)

3.3 8 30 45 109

3.3 10 40 60 116

3.3 12 50 75 121

3.3 14 60 90 124

4.1 8 42 63 122

4.8 12 70 105 116

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RESultSMacroscopic Evaluation After laser IrradiationThe color difference after lasing was clearly vis-ible by the naked eye. Also it was obvious that the unused implant did not get stained whereas the non-irradiated failed implant (implant #1) was significantly pink in color just like the control parts of the irradiated 8 implants.

light Microscopy EvaluationMicroscopic evaluation was also similar to the macroscopic one. In all range of magni-fications, the staining and the biofilm were easily recognizable for implant #1 (non-irra-diated, failed control implant). For the sec-ond control implant (implant #2, non-irradiated implant), there was almost no staining that could be observed with x40 magnification.

The microscopic pictures were taken from 3 different parts of the each irradiated implant. The

first picture was taken from the non-irradiated part, left side of the line; the second picture was taken on the line and the last picture was taken from the lased part, right side of the line. For all the implants, there were obvious color and residual differences between the lased and non-lased parts of the implants (Fig-1 and Fig-2).

SEM Evaluation Scanning electron microscopic examination showed no surface alteration, melting or changes of the surface characteristics of the implant sur-faces. The examination of the control implant #1 showed the obvious trace of a biofilm in all the magnifications, and also the metal surface could almost not be examined (Fig-3). On the control implant #2, there were no signs of a biofilm, and the typical characteristic of sand blasting (longer grooves) and acid etching (round holes) could be seen on the implant surface (Fig-4 and Fig-5). For the rest of the laser cleaned part of the

Figure 1: Microscopic image of the contaminated implant # 6 with x10 magnification. Upper part of the midline is the laser cleaned part, bottom part of the midline is the control part.

Figure 2: Microscopic image of the contaminated implant # 6 with x20 magnification. Upper part of the midline is the laser cleaned part; bottom part of the midline is the non-lased control part.

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24 • Vol. 5, No. 4 • April 2013

eight implants, they had similar visual appear-ance to the unused control implant #2 (Fig-6). There were also some control pictures taken from the border of the line separating the control part and the lased part of the implants (Fig-7).

DISCuSSIOnDental lasers have been used successfully in the removal of hard tissues and for their bactericidal

effects. They have been used to uncover sub-merged implants and recently used as a method to decontaminate implant surfaces for treatment of peri-implantitis. The use of lasers for cleaning and detoxifying implant surfaces has been proposed. Therefore, it is important to examine the effects of lasers on titanium implant surfaces when treating complications following implantation.6

Due to most of the in vitro studies, Er: YAG

Figure 3: SEM evaluation of contaminated, non-irradiated, failed control implant #1 with x300 magnification.

Figure 4: SEM evaluation of non-irradiated control implant #2 with x300 magnification.

Figure 5: SEM evaluation of unused control implant #2 with x3500 magnification.

Figure 6: SEM examination of the contaminated implant #7, laser cleaned part with x3500 magnification.

Berk et al


lasers had been found successful on reduction of probing depth and clinical attachment level gain. However, no difference had been found between conventional treatment and laser in terms of prob-ing depth and clinical attachment level gain.13 Takasaki et al. showed on their animal study that the Er:YAG laser irradiation can be safely and effectively utilized for degranulation and implant surface debridement in the surgical treatment of peri-implant infection with 20Hz, 200 μs pulse duration and 62 mJ pulse energy without any ther-mal damage to the implant surface and support-ing bone.10 Also Er:YAG laser treatment had been found successful histologically and radiographi-cally in the study done by Schwarz et al. on dogs with ligature induced peri-implantitis lesions.19

In an investigation conducted by Kreisler et al.2, the energy densities and the time of irra-diation applied were determined subsequent to temperature measurements by means of an in vitro bone model as well as by an SEM and

energy dispersive spectrometry investigation of laser treated implants at various pulse ener-gies. Er:YAG laser irradiation at pulse ener-gies over 120 mJ may cause visible alterations in the implant surfaces investigated;2 however according to the findings of Schwarz et al.15 with Er,Cr:YSGG laser irradiation, with 125 mJ (2.5 W, 20 Hz) there was no melting, or loss of porosity ,and significant removal of the bacte-rial biofilms on the titanium disks was observed.15

As a newer wavelength of 2780 nm, Er,Cr:YSGG laser had been used previously in two studies. In the study performed by Miller R.J., he found no measurable change in the TPS implant surface morphology at the high-est power setting of 6 W (300 mJ) with 20 Hz, H mode (140 μs pulse duration) and at a rela-tively low water settings. There was no biofilm and the surface remained the same as the con-trol implant due to SEM evaluation. The lack of an organic debris creates the ideal environment for the re-growth of bone and potential reintegra-tion of the exposed or contaminated area of the implant body.7 The second study by Schwarz et al. was about the effects of the Er,Cr:YSGG laser on the biocompability and surface structure of the titanium disks and the influence on the removal of early plaque biofilms grown on titanium disks of SLA surface. They used 2.0 and 2.5 W with 20 and 25 Hz in S mode (700 μs pulse duration) for settings and they recorded fast removal of the biofilm with no surface alteration or thermal dam-age on the titanium surface. On the other hand, they stated that to reestablish the biocompat-ibility of contaminated titanium surfaces failed.15

In our study, the Er,Cr:YSGG laser had no negative effect on implant surface when remov-ing the organic debris caused by the biofilm

Figure 7: SEM examination of the contaminated implant #7, upper part of the midline is the non-lased control part, bottom part of the midline is the laser cleaned part with x100 magnification.

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Berk et al

formation and no surface alterations had been observed. The setting of the irradiation proto-col had been chosen according to our clinical experience. As for the pulse duration, H mode (140 μs) had been chosen in order to avoid the thermal damage or increased temperature risk.

In our study, the regular disclosing agent was used to make the biofilm layer on the implant surfaces visible even by the naked eye. Using the disclosing agent during sur-gery may guide clinicians by means of detect-ing the exact area that has to be treated.

COnCluSIOnWe concluded that using an Er,Cr:YSGG laser with 1.5 W, 15 Hz, 100 mJ pulse enrgy, 140 μs pulse duration (H Mode), 65% air and 55% water is efficient for the removal of biofilm without dam-aging the implant surface. The Er,Cr:YSGG laser seems to be an effective tool for peri-implant treatment by means of removal of biofilm, how-ever, further in vivo and in vitro studies are also required to gain a better understanding of osteo-blastic cell behavior on different types of contami-nated implant surfaces, and to confirm its clinical applications and to optimize laser parameters. ●

Correspondence:

Gizem BERK,DDS,MSc.

DENTA FORM Health Center

Mahatma Gandi Cad. No: 34 06700

G.O.P.-ANKARA / TURKEY

www.dentaform.com.tr

phone: +90 312

fax: +90 312 4462782

e-mail: [email protected]

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

References1. Lindhe J.,Karring T., Lang N. P. Clinical Periodontology and Implant

Dentistry, Fourth Edition: Blackwell Munksgaard; 2003.

2. Kreisler M, Kohnen W, Morinello C, et al. Bactericidal effect of the Er:YAG laser on dental implant surfaces: An in vitro study. J Periodontol 2002;73:1292-1298.

3. Schwarz F, Becker J. Treatment of periodontitis and peri-implantitis with an Er:YAG laser: Experimental and clinical studies. Medical Laser Application 2005;20(1):47–59

4. Carlsson L, Rostlund T, Albrektsson B, Albrektsson T. Removal torques for polished and rough titanium implants. Int J Oral Maxillofac Surg 1988;3:21–24.

5. Kato T, Kusakari H, Hoshino E. Bactericidal efficacy of carbon dioxide laser against bacteria-contaminated titanium implant and subsequent cellular adhesion to irradiated area. Lasers Surg Med 1998;23:299–309.

6. Park C., Kim S., Kim M., Eom T., Yoon J., Ahn S. Surface Properties of Endosseous Dental Implants After Nd:YAG and CO2 Laser Treatment at Various Energies. J Oral Maxillofac Surg 2005;63:1522-1527.

7. Miller RJ. Treatment of the contaminated implant surface using the Er,Cr:YSGG laser. Implant Dent 2004;13:165-170.

8. Kreisler M, Götz H, Duschner H, d’Hoedt B. Effect of Nd:YAG, Ho:YAG, Er:YAG, CO2 and GaAlAs Laser Irradiation on Surface Properties of Endosseous Dental Implants. Int J Oral Maxillofac Implants 2002;17:202-211.

9. Oyster DK, Parker WB, Gher ME. CO2 lasers and temperature changes of titanium implants. J Periodontol 1995;66:1017–1024.

10. Takasaki AA, Aoki A, Mizutani K, Kikuchi S, Oda S, Ishikawa I. Er:YAG laser therapy for peri-implant infection: a histological study. Lasers Med Sci 2007;22(3):143-57.

11. Schwarz F, Nuesry E, Bieling K, Sculean A, Becker J. Clinical and Histological Healing Pattern of Peri-Implantitis Lesions Following Non-Surgical Treatment With an Er:YAG Laser. Laser Surg Med 2006;38:663–671.

12. Shafik S, Kheir S, Ahmad O. Lasers as an Adjunct to Scaling and Root Planning. J Oral Laser Appl 2004;4:55-63.

13. Schwarz F, Sculean A, Rothamel D, Schwenzer K, Georg T, Becker J. Clinical evaluation of an Er:YAG laser for nonsurgical treatment of peri-implantitis. Clin Oral Impl Res 2005;16(1):44–52.

14. Schwarz F, Papanicolau P, Rothamel D, Beck B, Herten M, Becker J. Influence of plaque biofilm removal on reestablishment of the biocompatibility of contaminated titanium surfaces. J Biomed Mater Res A 2006;77(3):437-444.

15. Schwarz F, Nuesry E, Bieling K, Herten M, Becker J. Influence of an Erbium, Chromium-Doped Yttrium, Scandium, Gallium, and Garnet (Er,Cr:YSGG) Laser on the Reestablishment of the Biocompatibility of Contaminated Titanium Implant Surfaces. J Periodontol 2006;77(11):1820-7.

16. Hakki SS, Korkusuz P, Berk G et al. Comparison of Er,Cr:YSGG Laser and Hand Instrumentation on the Attachment of Periodontal Ligament Fibroblasts to Periodontally Diseased Root Surfaces: an In Vitro Study. J Periodontol 2010; 81(8):1216-1225.

17. Kimura Y, Yu DG, Fujita A, Yamashita A, Murakami Y, Matsumoto K. Effects of erbium,chromium:YSGG laser irradiation on canine mandibular bone. J Periodontol 2001;72(9):1178-82.

18. Wang X, Ishizaki NT, Suzuki N, Kimura Y, Matsumoto K. Morphological changes of bovine mandibular bone irradiated by Er,Cr:YSGG laser: an in vitro study. J Clin Laser Med Surg 2002;20(5):245-50.

19. Schwarz F, Jepsen S, Herten M, Sager M, Rothamel D, Becker J. Influence of different treatment approaches on non-submerged and submerged healing of ligature induced peri-implantitis lesions: an experimental study in dogs. J Clin Periodontol 2006;33:584–595.

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Wilcko et al

Background: The aim of this study was to evaluate radiographic bone fill of advanced intrabony defects 1 year fol-lowing regenerative periodontal sur-gery with enamel matrix derivative (EMD).

Methods: 10 advanced intrabony defects in 10 subjects with were treated with a combination of scanning and rooting planning (SRP), mini-mally invasive surgical technique (MIST) and EMD. Intrabony defect depth was assessed from peri-apical radiographs. The radiography was taken to measure, quantitatively, the bone gain after 12 months. Radiographic bone fill parameters were compared at baseline and after 12 months, using a computer software program.

Results: There were no adverse reactions related by subjects. The treatments resulted in a radio-graphically significant bone fill of the defects. One year after the reconstructive procedure the radio-graphic appearance suggested that the interproxi-mal bone defect had been improved, evidencing lamina dura integrity and bone fill. It was observed a significantly (p = 0.0022) enhanced in the mean of pixels, before and after treatment (8,264 ± 2,013 and 12,256 ± 2,451, respectively).

Conclusions: Within the limits of the present case series, the findings suggest that intrabony defects can be treated successfully by regenera-tive strategies dealing with EMD, resulting in a significant radiographic bone fill of the periodontal intrabony defects in a short-term period (1 year). Further studies with a larger number of treated defects are necessary to verify these findings.

Enamel Matrix Derivative in Advanced Intrabony Defect: Radiographic Bone Fill Resolution

at 1 Year Follow up: A Case Series

Paulo Sérgio Gomes Henriques1 • André Antonio Pelegrine2 Ana Amália Nogueira2 • Mônica Martinez Borghi2 • Daiane Peruzzo2

1. Department of Periodontics, São Leopoldo Mandic - Faculty of Dentistry and Dental Research Center, Campinas, São Paulo, SP, Brazil

2. Department of Periodontics, São Leopoldo Mandic, Campinas, São Paulo, SP, Brazil.

Abstract

KEY WORDS: Enamel matrix proteins; periodontal surgery; intrabony defects


30 • Vol. 5, No. 4 • April 2013

INTRODUCTION The goal of regenerative periodontal therapy is the reconstitution of the lost periodontal struc-tures (i.e. the new formation of root cementum, periodontal ligament and alveolar bone).1 In recent years, enamel matrix derivative (EMD) has been successfully used in periodontal regen-erative treatment of deep intrabony defects.1-3 When treated with EMD, sites with intra-bony defects showed significantly better results.4,5

Minimally invasive surgical techniques (MIST) have been developed recently and proposed for periodontal regeneration.6 The recent pro-cedure MIST blending the concepts of the mini-mally invasive surgery and its clinical rationale includes the following: (1) reduction of surgical trauma, (2) increase in flap/wound stability and (3) improvement of primary closure of the wound.6

Results from basic research have pointed to the important role of the EMD in the periodontal wound healing, indicated that EMD may stimulat-ing the proliferation of pre osteoblasts cells and the differentiation of immature osteoblasts.7-9 His-

tological results from animal and human studies have provided evidence that treatment of various types of periodontal defects with EMD promotes healing that is characterized by formation of new connective tissue attachment and new alveo-lar bone.10-13 Moreover, results from controlled clinical studies showed that therapy of intrabony defects with EMD application evidenced bone fill.14-16 Clinically the application of EMD in intra-osseous defects have shown similar results when compared with guided tissue regeneration (GTR) gains in the clinical attachment level.17,18

Observations from cited studies above have been used to develop clinical decision trees based on the morphology of the defect for the selection of the regenerative strategy. The appli-cation of EMD in the inherently more supportive two-to three-wall and/or narrower defects and in furcations with class II involvement showed significant results on periodontal tissues.2 This limits the use of EMD in any periodontal defect. Data regarding long-term outcomes following treatment of intrabony defects with EMD are still

Figure 1a: Preoperative radiographic view. Figure 1b: Clinical view, showing an 8mm probing depth at the mesial aspect of a lower third molar.

Henriques et al


limited. Thus, the aim of this case series study was to present radiographic bone fill at 1 year after treatment of intrabony defects with EMD.

MATERIALS AND METHODS Study Populations and DesignThe study was designed as a prospective case-control study with one treatment group. Ten non-smoking subjects (6 females and 4 males),

aged between 34 and 52 years (mean age, 46 years), with moderate to severe chronic peri-odontitis were included from January 2008 to August 2009, all subjects gave written informed consent, and the inclusion criteria were: (1) no smoking; (2) good oral hygiene; (3) pres-ence of advanced periodontal tissue destruc-tion;(4) presence of intrabony defects (1, 2 and/or 3 wall defects), (5) no systemic dis-

Figure 1f: 12 months postoperative radiographic view presenting bone fill.

Figure 1e: Vertical coronal mattress suture.

Figure 1d: EMD application after scaling, root planning and PrefGel.

Figure 1c: Full-thickness opened flap after debridement.

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32 • Vol. 5, No. 4 • April 2013

ease; (6) the selected defects assessed (pre - and postoperative) by intra-oral radiographs.

Patients provided signed informed consent prior to the initial procedures. Before the start of the study, each patient received initial peri-odontal therapy, which consisted of motivation, oral hygiene instructions, scaling and root plan-ning. Patients were enrolled in a 3-month peri-odontal supportive care program for 12 months.

Radiographs were taken at baseline and after 12 months. The study protocol was in accordance with the declaration of Hel-sinki of 1975, last revised in Tokyo in 2004.

SURgICAL PROCEDUREAll patients received local anesthesia (2% lido-caine). The sites were accessed using MIST with the application of the papilla preservation techniques for application in isolated intra-bony defects. The clinical application of the MIST requires the adoption of an operating microscope (DF Vasconcelos – Sorocaba, São Paulo, Brazil) (or high-power magnification loops, that was used in this cases) in order to increase the visual acu-ity and allow for a precise and careful flap man-agement in spite of minimal flap reflection. The incisions were strictly intrasulcular to preserve all the height and width of the gingiva. The flap was extended to include the defect-associated inter-dental papilla of the two-neighboring teeth that were accessed with either the simplified papilla preservation flap (SPPF). The mesio-distal exten-sion of the flap was kept to a minimum to allow the reflection of a very small full-thickness flap to expose 1-2 mm of the defect-associated residual bone crest. The vertical-releasing incisions were avoided and periosteal incisions were never per-formed. If possible, the body of the papilla was

elevated. All granulation tissue was removed from the defects, and the roots were thoroughly scaled and planed using hand (mini curettes) instru-ments1. After defect debridement, the root sur-faces adjacent to the defect were conditioned for 2 minutes with PrefGel (EDTA - pH 6.7) to remove the smear layer. The defects were carefully rinsed with sterile saline to remove all EDTA residues.

Following this, EMD2 was applied on the root surfaces and then into the defects. When the defect(s) showed bleeding tendency, care was taken to reduce bleeding in order to be to apply EMD on dried root surfaces. This was accom-plished by compacting a wet sterile gauze.8 After EMD application the flaps were reposi-tioned at their original level without any coro-nal displacement and sutured with two modified internal mattress sutures applies at the defect-associated inter-dental sites preserved papillae in the absence of any tension. Primary flap clo-sure was achieved in all cases (Figures 1a-1f).

POSTOPERATIvE CARE Postoperative care consisted of administra-tion of acetaminophen 750 mg and rinsing with 0.12% chlorhexidine twice a day for one month. Patients were instructed to continue soft tooth brushing around the surgical sites. Sutures were removed 14 days after surgery.

RADIOLOgICAL/RADIOgRAPHIC EvALUATION

Standardized periapical radiographs were obtained immediately before surgery and 12 months of follow-up by long-cone parallel tech-nique. All x-rays were obtained using the same radiographic equipment (Gnatus, Ribeirão Preto-SP, Brazil), film (Ultra-speed DF 58, Kodak), expo-

1 2

Henriques et al


Figure 2b: Twelve month post-surgical radiograph showing bone fill of the intrabony defect from figure 2a.

Figure 2a: Preoperative radiographic view showing a vertical bone defect in a mandibular canine tooth.

Figure 2d: Twelve month post-surgical radiograph showing bone fill of the intrabony defect from figure 2c.

Figure 2c: Preoperative radiographic view showing a vertical bone defects in a mandibular molar tooth.

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34 • Vol. 5, No. 4 • April 2013

sure, and development conditions. Individually customized bite blacks were used to obtain reproducible films at each radiographic con-trol. The x-rays served to evaluate the intrabony radiographic parameters by the measurement of defect depth at baseline and 12 months post-operatively. The digitalized radiographs was analyzed by Image Tool 1.27 program, where Region of Interested (ROI) was selected and quantitative analyze was performed. The fig-ures (Figs. 2a – 2d) show the radiological find-ings before and 12-months after the treatment.

STATISTICAL ANALYSISMean values and standard deviation of pixel were determined for each group and com-pared statistically using the t Test (α=0.05).

RESULTSIn total, ten teeth were treated with enamel matrix derivatives. Five molar teeth, three premolar teeth and two canines were

enrolled in the study. All volunteers from the baseline measurements could be exam-ined (radiographic procedure) after 12 months and no adverse effects were seen.

All patients showed a statistically (p=0.0022) augmentation of radiographic bone fill, represented by gray levels (pixels) at 1 year follow-up (12,256 ± 2,451), compared with the baseline radiographs (8,264 ± 2,013) (Fig-ure 3). Improved radiographic results could be seen for all sites that received this clinical and surgical protocol, evidencing lamina dura integ-rity and bone fill. The radiographic gain was compared to the baseline gray levels between the cement-enamel junction and the bottom of the defect, when compared with the defect angle. The postoperative healing was unevent-ful in all eight subjects. No post-surgical com-plications were observed throughout the study period in any of the treated sites. The clini-cal evaluation and radiographs demonstrated excellent clinical healing showing the real ben-efit of these procedures in intrabony defects involving SRP, MIST and EMD application.

DISCUSSIONApplication of EMD has been introduced as an alternative method for periodontal regen-erative therapy. It is claimed that this approach provides periodontal regeneration by a bio-logical approach, i.e. creating a matrix on the root surfaces that promotes cementum, peri-odontal ligament and alveolar bone regen-eration, thus mimicking the events occurring during tooth development.19 Findings from basic research indicate that EMD has a key role in periodontal wound healing and histo-logical results from animal and human stud-

Figure 3: Mean and standard deviation gray levels for baseline group and 1 year pos-operative group. Mean values followed by * at the top of each bar indicate statistical differences determined by an intergroup analysis (α=0.05, t-test).

Henriques et al


ies have shown that treatment with EMD promotes periodontal regeneration.1 Moreover, clinical studies have indicated that treatment with EMD positively influences periodontal wound healing in humans.14-18 The findings of the present case series have shown that the treatment of intrabony defects with EMD is able to lead to a radiographic bone fill over a period of 1 year. At 1 year, the radiographic bone fill was significantly improved compared to baseline. It is well known that intrabony defects have greater healing potential, even after conventional periodontal surgery.20

The application of EMD in the context of non-surgical periodontal therapy has failed to result in periodontal regeneration. Surgical peri-odontal therapy of deep intrabony defects with EMD may lead to significantly higher improve-ments of the clinical parameters than open flap debridement alone.1 Supplementary application of enamel matrix derivative in intrabony pockets had a positive effect on attachment level after surgical periodontal therapy.23 In a systematic review the use of EMD after 1 year evidenced significant attachment improvements and a positive effects of enamel matrix derivatives on wound healing are described in the litera-ture.24 In the present case series, a significant bone fill gain was radiographically observed after 12 months, demonstrated by enhance in the mean of pixels (8,264 ± 2,013 and 12,256 ± 2,451, before and after treatment, respec-tively). Radiological data from another study revealed a significant bone fill after 12 months from baseline when compared with open flap debridement alone.22 The important factor that produces influence in the outcome of bone fill is smoking. However, in the present study,

none of the patients were smokers, which can be attributed, at least in part, to the obtained results,25 as well as good plaque control.

Furthermore, the treatment with EMD may be as operator-sensitive as any other regen-erative procedure.21 Cortellini and coworkers2 designed a cohort study to evaluate the healing response of a MIST in combination with EMD in isolated deep intrabony defects in forty deep intrabony defects. After 1-year clinical attach-ment level gain was 4.9 +/- 1.7 mm. Seventy percent of defects gained > or = 4 mm. Clini-cal attachment level gain was significantly associated with the depth of the three-wall component of the defect, with the intraopera-tive bleeding tendency of the defect, and with its interaction with the baseline amount of bone loss. Defect morphology and bleeding ten-dency seem to influence clinical outcomes from the use of MIST in combination with EMD. In the present case series, of isolated intrabony defects, confirm the studies based in perfor-mance and the intra-operative and post-oper-ative morbidity of a MIST in combination with an EMD in the regenerative treatment of mul-tiple adjacent deep intrabony defects. The surgical technique used in the present study resulted in a re-positioned and very stable flap with limited surgical trauma and corroborated findings from a previous study.2,6 It can be con-cluded that refined techniques such as MIST have applicability on regenerative strategies with EMD, accordingly Fickl and coworkers.22

Other important point of view is that some studies analyzed the combination of scaling and root planning with EMD in non-surgical periodon-tal therapy presenting poor results. Applied in a nonsurgical environment, adequate coating of

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36 • Vol. 5, No. 4 • April 2013

the root surface and containment of the EMD may not be as effective, what represent a major obsta-cle to maintaining effective concentrations of an agent within a pocket.26-27 This shows a surgical need, which can represent a limit to the clinicians.

This study using EMD procured evidentiary that even in advanced periodontal disease with deep intrabony defects and probable a hopeless prognosis, where extraction would be the first choice of most general dentists, is possible to maintain the teeth, specially these third molars that have migrated to the second molar posi-tion, with good periodontal health, corroborant a great literature about this area. Finally, under the limitations of the case series study, our results reveal that new alveolar bone formation, by an accelerated osteoconductive mechanism, are achieved with application of EMD and MIST.

CONCLUSIONSWithin the limits of the present case series, the findings suggest that intrabony defects can be treated successfully by regenerative strate-gies dealing with EMD, resulting in a signifi-cant radiographic bone fill of the periodontal intrabony defects in a short-term period (1 year). Further studies with a larger number of treated defects are necessary to verify these findings. ●

Correspondence:Dr. Paulo Sérgio Gomes Henriques,Adress: Rua Dr. José B. C. Nogueira 214, Jd. Madalena, Cep: 13091-611,Campinas, São Paulo, Brazil. Phone: 5519-32550288Fax: 5519-32944815Email: [email protected]

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JIACD wants to publish your article!For complete details regarding publication in JIACD, please refer

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Henriques et al


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

AcknowledgmentsThe authors would like to thank Department of Radi-ology (São Leopoldo Mandic - Faculty of Dentistry and Dental Research Center, Campinas, São Paulo, SP, Brazil).

References1. Sculean A, Pietruska M, Arweiler NB, Auschill

TM, Nemcovsky C. Four-year results of a prospective-controlled clinical study evaluating healing of intra-bony defects following treatment with an enamel matrix protein derivative alone or combined with a bioactive glass. J Clin Periodontol. 2007 Jun;34(6):507-13.

2 Cortellini P, Pini Prato G, Nieri M, Tonetti M S. Minimally invasive surgical technique and enamel matrix derivative in intrabony defects: 2.Factors associated with healing outcomes. Int J Periodontics Restorative Dent 2009;29:257-265.

3. Needleman IG, Worthington HV, Giedrys-Leeper E, Tucker RJ. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database Syst Rev 2006 19:CD001724.

4. Francetti L, Del Fabro M, Basso M, Testori T, Weinstein R. Enamel matrix proteins in the treatment of intra-bony defects. A prospective 24-month clinical trial. J Clin Periodontol 2004;31:52-59.

5. Jentsch H, Purschwitz R. A clinical study evaluating the treatment of supra-alveolar-type defects with access flap surgery with and without an enamel matrix protein derivate: a pilot study. J Clin Periodontol 2008;35:713-718.

6. Cortellini P, Nieri M, Pini-Prato G, Tonetti MS. Single minimally invasive surgical technique with an enamel matrix derivative to treat multiple adjacent intra-bony defects: clinical outcomes and patient morbidity. J Clin Periodontol 2008;35:605-613.

7. Van der Pauw MT, Van den Bos T, Everts V, Beertsen W. Enamel matrix-derived protein stimulates attachment of periodontal ligament fibroblasts and enhances alkaline phosphatase activity and transforming growth factor α1 release of periodontal ligament and gingival fibroblasts. J Periodontol 2000;71:31-43.

8. Lyngstadaas SP, Lundberg E, Ekdahl H, Andersson C, Gestrelius S. Autocrine growth factors in human periodontal ligament cells cultured on enamel matrix derivative. J Clin Periodontol 2001;28:181-188.

9. Schwartz Z, Carnes DL, Pulliam R, et al. Porcine fetal enamel matrix derivative stimulates proliferation but not differentiation of pre-osteoblastic 2T9 cells, inhibits proliferation and stimulates differentiation of osteoblast-like MG63 cells, and increases proliferation and differentiation of normal human osteoblast NHOst cells. J Periodontol 2000;71:1287-1296.

10. Saito A, Hayakawa H, Ota K, Fujinami K, Nikaido M, Makiishi T. Treatment of periodontal defects with enamel matrix derivative: clinical evaluation at early healing stages. Bull Tokyo Dent Coll. 2010;51(2):85-93.

11. Mellonig JT. Enamel matrix derivative for periodontal reconstructive surgery: technique and clinical and histologic case report. Int J Periodontics Restorarative Dent 1999;19:9-19.

12. Sculean A, Donos N, Brecx M, Reich E, Karring T. Treatment of intrabony defects with enamel matrix proteins and guided tissue regeneration. An experimental study in monkeys. J Clin Periodontol 2000;27:466-472.

13. Sculean A, Chiantella GC, Windisch P, Donos N. Clinical and histologic evaluation of treatment of intrabony defects with an enamel matrix proteine derivative (Emdogain). Int J Periodontics Restorative Dent 2000;20:375-381.

14. Sculean A, Windisch P, Chiantella GC, Donos N, Brecx M, Reich E. Treatment of intrabony defects with enamel matrix proteins and guided tissue regeneration. A prospective controlled clinical study. J Clin Periodontol 2001;28:397-403.

15. Tonetti MS, Lang NP, Cortellini P, et al. Enamel matrix proteins in the regenerative therapy of deep intrabony defects. A multicenter randomized controlled clinical trial. J Clin Periodontol 2002;29:317-325.

16. Wachtel H, Schenk G, Bohm S, Weng D, Zuhr O, Hurzeler MB. Microsurgical access flap and enamel matrix derivative for the treatment of periodontal intrabony defects: A controlled clinical study. J Clin Periodontol 2003;30:496-504.

17. Meyle J, Gonzales JR, Bodeker RH, Hoffmann T, Richter S, Heinz B, Arjomand T, Reich E, Sculean A, Jepsen K, Jepsen S. A randomized clinical trial comparing enamel matrix derivative and membrane treatment of buccal class II furcation involvement in mandibular molars. Part II; secondary outcomes. J Periodontol 2004;75:1188-1195.

18. Crea A, Dassatti L, Hoffmann O, Zafiropoulos GG, Deli G. Treatment of intrabony defects using guided tissue regeneration or enamel matrix derivative: A 3-year prospective randomized clinical study. J Periodontol 2008;79:2281-2289.

19. Sakallioglu U, Açikgöz G, Ayas B, Kirtiloαlu T, Sakallioαlu E. Healing of periodontal defects treated with enamel matrix proteins and root surface conditioning--an experimental study in dogs. Biomaterials. 2004 May;25(10):1831-40.

20. Tonetti MS, Pini Prato G, Cortellini P. Factors affecting the response of intrabony defects following guided tissue regeneration and access flap surgery. J Clin Periodontol 1996;23:548-556.

21. Tonetti MS, Lang NP, Cortellini P, et al. Enamel matrix proteins in the regenerative therapy of deep intrabony defects. A multicenter randomized controlled clinical trial. J Clin Periodontol 2002;29:317-325.

22. Fickl S,Thatmair T, Kebschull M, Bölun S, Wachtel H. Microsurgical access flap in conjunction with enamel matrix derivative for the treatment of intra-bony defects: a controlied clinical trial. J Clin Periodontol 2009;36:784-790.

23. Francetti L, Del Fabro M, Basso M, Testori T, Weistein R. Enamel matrix proteins in the treatment of intra-bony defects. A prospective 24-month clinical trial. J Clin Periodontol 2004;31:52-59.

24. Esposito M, Grusovin MG, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain) for periodontal tissue regeneration in intrabony defects. Cochrane Database of Systematic Review 19 CD 003875.

25. Tonetti MS, Pini Prato GP, Cortellini P. Effect of cigarette smoking on periodontal health following GTR in infrabony defects. A preliminary retrospective study. J Clin Periodontol 1995;22:229-234.

26. Gutierrez MA, Mellonig JT, Cochran DL. Evaluation of enamel matrix derivative as an adjunct to non-surgical periodontal therapy. J Clin Periodontol 2003;30:739-745.

27. Mombelli A, Brochut P, Plagnat D, Casagni F, Giannopoulou C. Enamel matrix proteins and systemic antibiotics as adjuncts to non-surgical periodontal treatment: Clinical effects. J Clin Periodontol 2005;32:225-230.

Henriques et al

IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!

Toscano et al

A lthough the connective tissue graft con-tinues to be regarded as the gold stan-dard treatment for gingival recession

defects, the need for a secondary harvest sur-gery along with limited tissue availability con-tinue to encourage the search for alternative methods of treatment. The current consecu-tive 24-patient case series examines one such material. Mucograft® collagen matrix is a por-cine derived, double layer natural material recently evaluated for treatment effectiveness

for a number of soft tissue deficiencies, includ-ing gingival recession defects. In the present retrospective study, isolated and contiguous Miller Class I and II recession defects were treated with Mucograft® collagen matrix. At the end of six months multiple parameters, includ-ing percent root coverage and linear root cov-erage gain, were examined. The results of this study suggest that Mucograft® may be a viable alternative to CT grafts when treat-ing Miller Class I and II recession defects.

Clinical Application of Xenogenic Porcine Bilayer Collagen Matrix (Mucograft®) in the Treatment of Miller

Class I and II Gingival Recession Defects: A Retrospective Consecutive Case Series

Nicholas Toscano DDS, MS1 • Dan Holtzclaw DDS, MS2

Brian Margolis, DDS3

1. Private Practice limited to periodontics and dental implants, Manhattan, New York, USA

2. Private Practice limited to periodontics and dental implants, Austin, Texas, USA

3. Private Practice limited to periodontics and dental implants, Old Brookville, New York, USA

Abstract

KEY WORDS: Mucogingival defects, gingival grafting, Mucograft, collagen matrix


IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!

40 • Vol. 5, No. 4 • April 2013

IntRODuctIOnGingival recession, with well-known negative sequelae, including cervical caries, dentinal root sensitivity, difficulty in allowing adequate plaque control, and esthetic deficiencies, demands effective surgical intervention with minimum intra-operative and post-operative complica-tions. In recent years a number of systematic reviews have examined clinical outcomes of var-ious surgical approaches to recession defects, including the coronally advanced flap (CAF) alone and the CAF in combination with the sub-epithelial connective tissue graft (CTG), guided tissue regeneration (GTR), enamel matrix deriv-ative (EMD), and acellular dermal matrices (ADM).1-5 Although current alternatives to the CTG + CAF appear effective when examin-ing specific clinical parameters, only the CTG + CAF appears consistently effective in relation to all clinical efficacy endpoints, especially long-term maintenance of root coverage.6-20 Although

such evidence based data has led many cli-nicians to view the CTG as the gold standard treatment in reducing or eliminating gingival recession, such disadvantages as the need for a distant donor site, increased morbidity asso-ciated with graft harvest, and limited amounts of available donor tissue have continued to stimulate the search for comparably effective, alternative therapies to autologous grafts.21,22

Recently, a 510(K)-FDA cleared xenogenic porcine bilayer collagen matrix (CM) (Muco-graft®, Osteohealth Company, Shirley, NY) com-posed of pure type I and III collagen obtained by standardized, controlled manufacturing pro-cesses without further cross-linking or chemi-cal treatment has been cleared for multiple regenerative indications, including treatment of gingival recession defects around teeth. Designed to support tissue ingrowth and regen-eration, CM’s enhanced bilayer thickness facili-tates surgical manipulation, provides support

Figure 1a: Mucograft® collagen matrix is made of porcine Type I and III collagen without cross-linking or chemical treatment.

Figrure 1b: Mucograft® has a thin, cell-occlusive superior layer that allows for tissue adherence, wound healing, and can accommodate suturing. The thick, porous bottom layer, placed next to host tissue, aids in clot formation and supports cell ingrowth and tissue integration.

Toscano et al


for mucosal cellular migration and regenera-tion, and supports clot stabilization and sub-sequent soft and hard tissue ingrowth (Figures 1a & 1b).23-26 A number of recently published prospective clinical trials investigating CM’s efficacy in treating both keratinized mucosal deficiencies and gingival recession defects suggest that CM may provide a viable alterna-tive to autogenous soft tissue grafts as well as to other currently favored approaches.26-28 The following consecutive case series study was designed to further investigate CM’s poten-tial indication as an effective alternative in the treatment of gingival recession defects.

MAtERIAlS AnD MEthODSTwenty-four healthy patients, 10 female and 14 male, ranging from 22 to 64 years of age with Miller Class I or II gingival recession defects of > 3 mm deep, with a mean defect depth of 3.79 mm, were included in this retrospec-

tive consecutive case series study. The major-ity of patients were non-smokers, although a number of patients at the time of treatment smoked up to 10 cigarettes per day. Many of the patients presented with multiple con-tiguous gingival recession defects, although single defects were also included. Of the 24 cases, 15 were treated in the maxilla and 9 in the mandible. In all treated defects a mini-

Figure 3: All exposed root surfaces were recontoured to allow confinement within the surrounding alveolar housing.

Figure 2: Representative example of the type of recession defects seen in this case series, i.e. Miller Class II recession defects on teeth #s 11 and 12 and a Miller Class I defect on tooth #13.

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42 • Vol. 5, No. 4 • April 2013

mum of 1 mm of marginal keratinized gin-giva was present at initiation of treatment.

clInIcAl EvAluAtIOn At the initial visit the defect sites were exam-ined clinically, photographic documentation performed and defect measurements recorded (Figure 2). Following the initial baseline screen-ing and surgery, all patients were followed for a minimum of 6 months. Radiographs were taken at baseline and at week 24. The follow-ing baseline clinical parameters were recorded for each consecutively treated patient: gingival recession depth; height of keratinized tissue from the free gingival margin to the mucogin-gival margin; buccal and proximal probing pocket depths; and degree of gingival inflamma-tion. At six months post-surgery photographic documentation was again obtained as were the clinical parameters measured at baseline.

SuRgIcAl PROcEDuRE Prior to any surgery, all subjects received oral hygiene instructions, received full-mouth prophylaxis, and were not appointed for surgery until capable of demonstrat-ing adequate supra-gingival plaque control.

At surgery, local anesthesia was administered and a reversed bevel intrasulcular incision without vertical releasing incisions was made. A full-thick-ness mucoperiosteal flap was reflected apically to the mucogingival junction, followed by an apical partial thickness dissection to eliminate muscle tension and to facilitate coronal repositioning of the flap. The root surfaces were then planed and recontoured by odontoplasty in order to assure root confinement within the surrounding alveolar housing (Figure 3). In addition to hand instrumen-tation, rotary finishing burs or ultrasonics with dia-mond-coated inserts may be used to perform the odontoplasty. The root surfaces were then decon-taminated with tetracycline paste to eliminate

Figure 4: Following proper sizing of Mucograft®, the matrix is positioned to cover the exposed root surfaces and become saturated with the patient’s blood. In this case a double layer of Mucograft® was used and sutured to the adjacent interdental papillae.

Figure 5: Once the mucoperiosteal flap is coronally advanced without tension to the level of the CEJ, it is sutured in place to the de-epithelialized surfaces of the interdental papillae.

Toscano et al


Figure 6a: Pre-operative image of significant gingival recession defects about teeth #’s 11 – 13.

Figure 6b: Six month post-operative examination reveals maintenance of 100% root coverage in these significant Miller Class II recession defects.

Figure 7a: Pre-operative image of significant gingival recession defects about teeth #’s 11-13.

Figure 7b: Six month post-operative examination reveals maintenance of 100% root coverage in these significant Miller Class II recession defects.

the bacterial smear layer. The buccal portions of the interdental papillae were then de-epithelial-ized to create a connective tissue bed for sub-sequent suturing of the coronally advanced flap.

Mucograft® collagen matrix was then prop-erly sized, positioned to cover the exposed roots, allowed to saturate with the patient’s blood,

and sutured to the interdental papillae (Fig-ure 4). The fully mobile flap was then coronally advanced with minimal to no tension to the level of the CEJ and sutured with 5.0 Chromic gut sutures to the de-epithelialized surfaces of the interdental papillae (Figure 5). Care was taken to avoid compression of the collagen matrix graft.

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44 • Vol. 5, No. 4 • April 2013

Patients were instructed not to brush the teeth in the treated area but to use chlorhexi-dine (0.2%) mouth rinse twice daily the first two weeks. During the next two weeks patients were instructed to apply chlorhexidine with a cot-ton swab to the treated areas. Following this period patients were instructed in a brushing technique that avoided apical directed tooth-brush trauma to the surgerized segments.

RESultS Patient centered ResultsDuring the six-month follow-up period no signifi-cant treatment related adverse events occurred. Immediate post-operative swelling, inflamma-tion and discomfort were minimal. For all treated areas the color, texture and tissue thickness at month six appeared indistinguishable from the adjacent anatomic areas (Figures 6a, 6b, 7a, 7b). Objective clinical ResultsThe mean root coverage gain at the end of nine months was 3.11 mm, with a mean per-cent root coverage gain of 89.24%. The mean residual recession depth was 0.59 mm. 41% of the 24 patients experienced 100% root coverage. At the end of the 6-month follow-up period, a mean gain of 1.21 mm of marginal keratinized tissue was realized.

DIScuSSIOnIn an attempt to reduce surgical morbidity second-ary to graft harvest as well as to avoid inherent autogenous tissue supply limitations, alternatives to the CTG continue to be desired goals in the treatment of gingival recession defects. The cur-rent case series, when examined along side other recently published studies, provides additional

insight into the utility and efficacy of the porcine derived collagen matrix, Mucograft®, as an alter-native to the CTG and acellular dermal matrices for the treatment of gingival recession defects.

In a recent 6 month prospective, randomized, split-mouth designed clinical trial McGuire et al compared Mucograft® to palatal CT grafts in the treatment of Miller Class I and II reces-sion defects.28 On multiple parameters, includ-ing recession depth, percent root coverage, width of keratinized tissue, color and texture of treatment sites, and subject esthetic satisfac-tion, Mucograft® proved a viable alternative to the CTG. When patient centered outcomes were considered, Mucograft® was particularly attrac-tive in eliminating the need for an invasive har-vesting procedure. The results of the current study compare favourably to this randomized pro-spective study, with comparable gains in mean root coverage gain and percent root coverage.

In evaluating procedural effectiveness, sys-tematic reviews are particularly instructive. In the Oates et al 2003 systematic review2, coronally advanced flap + CTG data from 10 published randomized controlled studies (RCT) with a mini-mum 6-month follow-up period yielded the follow-ing mean results: percent root coverage 77.90 (+10.0)%; root coverage gain 2.68 (+0.45) mm; percent achieving 100% root coverage 48.10 (+7.2)%. The results of the current study compare favorably with this CTG-related data. In the same systematic review,2 coronally advanced flap + allogenic dermal graft RCTs were also examined. Acellular dermal matrices failed to achieve com-parable gains in linear root coverage and percent root coverage seen in this current case series.

In addition to favorable clinical outcomes, the increased thickness of Mucograft® facilitated

Toscano et al


surgical manipulation of this material. Of particu-lar note was the ease of suturing this matrix to the de-epithelialized papillary surfaces second-ary to enhanced density of the superior layer.

Although the current case series suggests Mucograft® may be a viable and advantageous alternative to treating gingival recession defects, further randomized controlled clinical trials with increased patient enrollment and follow-up times are needed. Additionally, studies examining what the potential effects of adding growth factor pro-teins, i.e. rhPDGF-BB, to Mucograft® may have on both clinical and attachment type outcomes in treating recession defects will be instruc-

tive in clearly defining the range of clinical indi-cations for this newly introduced material. ●

correspondence:Dr. Nicholas Toscano45 W. 54th Street, Suite 1ENew York, NY 10019 [email protected]

Dr. Dan Holtzclaw711 W. 38th Street, Suite G5Austin, TX [email protected]

AcknowledgmentSpecial thanks to Dr. Stuart Kay, science writer and consultant (Huntington, NY) for his help with the organization and production of this manuscript.

Disclosure:Drs. Holtzclaw and Toscano have been compensated lecturers for Osteohealth.

References1. Roccuzzo M, Bunino M, Needleman I, Sanz

M. Periodontal plastic surgery for treatment of localized gingival recessions: a systematic review. J Clin Periodontol 2002;29(Suppl. 3):178-194.

2. Oates T, Robinson M, Gunsolley JC. Surgical Therapies for the Treatment of Gingival Recession. A Systematic Review. Ann Periodontol 2003;8:303-320.

3. Academy Report. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol 2005;76:1588-1600.

4. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J Clin Periodontol 2008;35:136-162.

5. Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root coverage procedures for the treatment of localized recession-type defects. Cochrane Database Syst Rev 2009;(Issue 2):CD007161 10.1002/14651858.CD007161.pub2.

6. Harris RJ. Root Coverage With Connective Tissue Grafts: An Evaluation of Short- and Long-Term Results. J Periodontol 2002;73:1054-1059.

7. da Silva RC, Joly JC, de Lima AF, Tatakis DN. Root coverage using the coronally positioned flap with or without a subepithelial connective tissue graft. J Periodontol 2004;75:413-419.

8. Rossberg M, Eickholz P, Raetake P, Ratka-Kruger P. Long-Term Results of Root Coverage with Connective Tissue in the Envelope Technique: A Report of 20 Cases. Int J PeriodonticsRestorative Dent 2008;28:19-27.

9. Zucchelli G, Clauser C, De Sanctis M, Calandriello M. Mucogingival versus guided tissue regeneration procedures in the treatment of deep recession type defects. J Periodontol 1998;69:138-145.

10. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: Comparison of clinical parameters. J Periodontol 2003;74:1110-1125.

11. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 2001;72:998-1005.

12. Novaes AB, Grisi DC, Moina GO, Sergio LS, Taba M, Grisi F.M. Comparative 6-Month Clinical Study of a Subepithelial Connective Tissue Graft and Acellular Dermal Matrix Graft for the Treatment of Gingival Recession. J Periodontol 2001;72:1477-1484.

13. Paolantonio M, Dolci M, Esposito P, D’Archivio D, Lisanti L, De Luccio A, Perinetti G. Subpedicle Acellular Dermal Matrix Graft and Autogenous Connective Tissue Graft in the Treatment of Gingival Recessions: A Comparative 1-Year Clinical Study. J Periodontol 2002;73:1299-1307.

14. Tal H, Moses O, Zohar R, Meir H, Nemcovsky C. Root Coverage of Advanced Gingival Recession: A Comparative Study Between Acellular Dermal Matrix Allograft and Subepithelial Connective Tissue Grafts. J Periodontol 2002;73:1405-1411.

15. Woodyard JG, Greenwall H, Hill M, Drisko C, Lasella JM, Scheetz J. The Clinical Effect of Acellular Dermal Matrix on Gingival Thickness and Root Coverage Compared to Coronally Positioned Flap Alone. J Periodontol 2004;75:44-56.

16. Harris RJ. A Short-Term and Long-Term Comparison of Root Coverage With an Acellular Dermal Matrix and a Subepithelial Graft. J Periodontol 2004;75:734-743.

17. Gapski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: a meta-analysis. J Periodontol 2005;76(11)1814-1822.

18. Santos A, Goumenos G, Pascual A. Management of Gingival Recession by the Use of An Acellular Dermal Graft Material: A 12-Case Series. J Periodontol 2005;76:1982-1990.

19. Mahajan A, Dixit J, Verma UP. A Patient-Centered Clinical Evaluation of Acellular Dermal Matrix Graft in the Treatment of Gingival Recession Defects. J Periodontol 2007;78:2348-2355.

20. Barker TS, Cueva MA, Hidalgo FR, Beach M, Rossmann JA, Kerns DG, Crump TB, Schulman JD. A Comparative Study of Root Coverage Using Two Different Acellular Dermal Matrix Products. J Periodontol 2010 online publication prior to print.

21., Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative complications following gingival augmentation procedures. J Periodontol 2006;77:2070-2079.

22. Wessel JR, Tatakis DM. Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures. J Periodontol 2008;79:425-430.

23. Herford AS, Boyne PJ. Evaluation of a Special Collagen Implant Material as a Substitute for Free Mucosal or Skin Grafts in Oral Soft Tissue Surgery. Unpublished report.

24. FDA Premarket Notification, Review of Mucograft and Acceptance of 510(K) Mucograft Submission. May 23, 2008.

25. Mucograft FDA approved Package Insert.26. Herford AS, Akin L, Cicciu M, Maiorana C,

Boyne PJ. Use of a Porcine Collagen Matrix as an Alternative to Autogenous Tissue for Grafting Oral Soft Tissue Defects. J Oral Maxillofac Surg 2010; 68:1463-1470.

27. Sanz M, Lorenzo JJ, Martin C, Orsini M. Clinical evaluation of a new collagen matrix (Mucograft® prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: a randomized clinical trial. J Clin Periodontol 2009;36:868-876.

28.. McGuire MK, Scheyer ET. Xenogeneic Collagen Matrix With Coronally Advanced Flap Compared to Connective Tissue With Coronally Advanced Flap for the Treatment of Dehiscence-Type Recesssion Defects. J Periodontol 2010;81:1108-1117.

Toscano et al

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