Treatment of Oral Maxillofacial Trauma - JIACD · Maxillofacial Trauma Biologic Shaping for...

The Journal of Implant & Advanced Clinical Dentistry

Volume 5, No. 8 August 2013

Treatment of Oral Maxillofacial Trauma

Biologic Shaping for Prosthetic Treatment

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 5, No. 8 • August 2013

Table of Contents

Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com

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10 Case of the Month Comprehensive Treatment for Maxillary Locator Implant Retained Denture in the General Practitioner’s Office Ara Nazarian

17 Predictable Immediate Implant Stabilization and Restoration Charles D. Schlesinger



Table of Contents

27 Biologic Shaping From a Restorative Prospective Danny A. Melker

35 Contemporary Surgical Care of a Traumatic Oral Maxillofacial Injury in a Very Remote Location William Hartel, Steven Keir, Callief Shand, Ben Smith, Ralph Pickard

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Less pain for your patients.1

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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...

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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...

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

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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

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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


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!

10 • Vol. 5, No. 8 • August 2013

The ability for the general practitioner to deliver comprehensive dental care under one roof, in many cases, increases patient

acceptance of treatment. The following case demonstrates patient treatment with a maxillary locator implant retained denture. The patient had all hopeless maxillary teeth removed and site preservation was performed at the time of surgery. After a healing phase, a surgical guide

was fabricated to assist in the placement of dental implants. Following an osseointegra-tion healing phase, locator attachments were placed onto the healed dental implants and the maxillary denture was modified to secure to these attachments. All care was delivered in one office, by one practitioner. Care in this manner streamlined the patient’s visits and allowed faster delivery of the final prosthesis.

Case of the MonthComprehensive Treatment for Maxillary

Locator Implant Retained Denture in the General Practitioner’s Office

Ara Nazarian, DDS1

1. Private Practice, Troy Michigan, USA

Abstract

KEY WORDS: Dental implants, dentures, maxilla, prosthetics

Wilcko et al


Nazarian

12 • Vol. 5, No. 8 • August 2013

Nazarian


Nazarian

14 • Vol. 5, No. 8 • August 2013

Nazarian


Nazarian

DisclosureDr. Nazarian reports no financial disclosures for this article.

Correspondence:Dr. Ara Nazarian1857 East Big Beaver RdTroy, Michigan 48083USA248-457-0500

Wilcko et al

Background: This paper describes the use of a dental implant with dual sta-bilization technology to immediately restore a single tooth edentulous space.

Methods: A dual stabilization dental implant was placed using a flapless tech-nique. After placing this one piece implant, an immediate impression for the final res-toration was taken and full contour tempo-rary restoration was put into full function.

Results: By attaining an ISQ reading of 62, an insertion torque of 50 N/cm at the time of placement due to the unique features of the dual stabilization implant used in this paper, an immediate restoration was possible.

Conclusions: Primary stability is a neces-sary tenant for implant survival and it is even more crucial when immediately loading a den-tal implant. The macro structure of the dental implant used in this paper allowed for immedi-ate loading capability for this particular case.

Predictable Immediate Implant Stabilization and Restoration

Charles D. Schlesinger, DDS1

1. Director of Education and Clinical Affairs, OCO Biomedical

Abstract

KEY WORDS: Dental implants, immediate load, prosthetics


18 • Vol. 5, No. 8 • August 2013

BACKgROunDIn 2000, Buser and Schenk postulated that pri-mary stability was a necessary tenant for an implant to be successful.1 Stability at the time of placement must be sufficient to enable the implant to resist micro-movement until sufficient biologic stability (secondary stability) is ade-quately established.2 During this period of transi-tion between primary and secondary stability, the implant faces the greatest risk of micro-motion and potential failure. Extrapolating from research in dogs, it is estimated that this period in humans occurs roughly two to three weeks after implant placement.3 A micro-movement of more than 50-150 microns will disrupt Osseointegration.4

Primary stability can be characterized by two different methods; insertion torque value and ISQ readings. An insertion torque value of > 35N/cm is considered stable enough to load clinically. Johansson & Strid described a tech-nique whereby bone quality as a function of density and hardness could be derived from the torque forces needed during the implant inser-tion.5 ISQ readings (RFA-resonance frequency analysis) utilizing an Osstell unit have been proven to be a reliable indicator of implant sta-bility. Implant stability above 65 ISQ should be regarded as optimal, above which few failures should be expected.6 An ISQ of < 50 may indi-cate potential failure or increased risk of failure.7

Research has shown a relevant depen-dency between insertion torque and bone qual-ity and a very weak dependency between RFA and bone quality. Again, the statistical analy-sis shows a quite weak correlation between length or diameter and insertion torque, but it shows a relevant correlation between length and RFA.8 Implant stability can be categorized in

two ways; short-term stability (primary stability) and long-term stability(secondary stability). Pri-mary stability is dependent on the macro struc-ture of the implant while long-term stability is dependent on the microstructure of the implant and its ability to promote laminar bone growth.

Primary stability can be improved by adapt-ing the surgical technique and by implant selec-tion. For instance, the use of thinner drills and wider and tapered implant designs will result in a high primary stability. This improvement is due to lateral compression of the bone trabeculae and an increase of the interfacial bone stiffness. A high ISQ value achieved after such a proce-dure should not be relied upon as an indica-tion for immediate loading, since this value may decrease over time as a result of mechanical relaxation. This means that a high ‘manipulated’ ISQ value after using thinner drills and wider and tapered implants describes a temporary increase of stiffness rather than the true load-bearing capacity of the bone-implant complex.5

In a review of the literature focusing on early wound healing adjacent to endosseous den-tal implants, Raghavendra et al9 point out that a critical period occurs after implant placement, when osteoclastic activity has decreased the ini-tial mechanical stability of the implant, but not enough new bone has been produced to provide an equivalent or greater amount of compensa-tory biological stability. ISQ values significantly decreased at 3 weeks and increased at 6 weeks10

The dental implant used in this case report (OCO Biomedical, New Mexico, USA) uses a patented macro structure to not only provide exceptional primary stability, but maintain that stability while biological healing occurs. The combination of the imbedded tapered platform

Schlesinger


Schlesinger

and the auger tip place healing bone under ten-sion. This tension potentially speeds up the healing of bone and decreases remodeling by increasing the expression of TGF-β1/OPG and results in the disappearance of osteoclasts.11

In this paper, a case is presented which not only results in outstanding primary sta-bility, but allows at the time of surgery to take the final impression, immediately load with a temporary restoration and allowed the patient to leave the office without the need for an acrylic temporary partial.

CliniCAl CASEA 33 year old female presented to the clinic with an edentulous space at #20. The bicuspid had been extracted approximately 17 years prior with-out socket preservation and her previous dentist had placed a banded orthodontic retention device at the time of extraction, thus resulting in a nar-rowed ridge. This was confirmed by CBCT scan.

After local infiltrate anesthesia was achieved using Septocaine with 1:100,000 epinephrine (Septodont Inc., New Castle, Delaware) a flapless approach was decided upon to gain access. The

Figure 1: Pre-op edentulous space #20. Figure 2: CBCT scan image of intended implant site.

Figure 3: 1.8mm pilot drill with 8mm depth stop. Figure 4: Paralleling pin placed for position verification.

20 • Vol. 5, No. 8 • August 2013

osteotomy position was marked using a #8 surgi-cal round bur through the gingival complex and making a purchase point in the crestal bone. This is important in order to avoid having the pilot drill skip across the crestal bone prior to engaging it.

Orientation in 3 dimensions was estab-lished, and a 1.8mm pilot drill with an 8mm depth stop was used to establish the path of the osteotomy. A paralleling pin with a 3.25mm platform was inserted into the pilot hole to verify position, trajectory and evalu-

ate the mesiodistal space requirements. A 3.0 guided tissue punch was used to

remove a plug of keratinized tissue and expose the osseous crest. A 3.25mm countersink was used to the appropriate platform depth to pre-pare the upper portion of the osteotomy to accept the imbedded tapered platform of the 3.0 Mini implant. The countersink also negated any variations in ridge topography. The combi-nation of the embedded tapered platform, cor-tico micro threads and the patented auger tip of

Figure 5: Guided tissue punch. Figure 6: Pilot drill with 10mm depth stop to create final depth and direction of osteotomy.

Figure 7: Verification and adjustment of depth indicator on final osteotomy former.

Figure 8: Final osteotomy former to depth.

Schlesinger


Figure 9: 3.0 Mini implant. Figure 10: Ratchet used to drive implant.

Figure 12: ISQ reading of 62 on Osstell unit.Figure 11: Final torque reading of 50N/cm.

the implant, makes dual stabilization possible.Once the countersink procedure was

completed, the 1.8mm pilot with a 10mm depth stop was taken to the intended implant length. It was determined that the bone den-sity was of a Type 3 variety. The black O-ring depth indicator was adjusted to approxi-mate the proper depth/length of the implant to compensate for the soft tissue thickness.

A 3.0 x 10mm mini-implant is taken to the mouth utilizing an insertion driver and thumb-

wheel. Once resistance was encountered, it was driven to its final position with a ratchet and finally a torque driver. A final torque value of 50N/cm was achieved. An ISQ reading of 62 for both M-D and B-L direction was recorded.

Since such a high primary stability was attained and ideal soft tissue architecture was present, the decision to immediately restore was decided upon. The 3.0 Mini is a one piece implant with a 5.5mm tall abutment. A TRIP (tis-sue retraction impression pickup) was snapped

Schlesinger

22 • Vol. 5, No. 8 • August 2013

Figure 13: Fully seated implant. Figure 14: Final impression taken with TRIP.

Figure 16: Acrylic coping in place. Figure 15: Final impression.

into place and a polyvinylsiloxane (PVS) impression taken along with a bite registra-tion. The impression was kept in the clinic until the two week follow-up appointment just in case soft tissue changes were present.

A full contour temporary was fabricated with a Protemp crown (3M ESPE, Irvine, CA). This temporary crown is made of unpo-lymerized Protemp material and once con-toured to the abutment, it can be polymerized using a standard curing light. Once occlu-sion was adjusted, the patient was dis-missed with a temporary under full function.

Two weeks post implant placement, the patient returned to the clinic in order to evaluate the soft tissue for esthetics and any possible change. At that point the final impression was sent to the laboratory for fab-rication of the definitive restoration. If any significant changes in soft tissue architec-ture were observed, the patient would have been reappointed in one month for re-eval-uation and possibly take a new impression.

The final IPS e.max crown (Ivo-clar Vivadent, Amherst, NY) was tried-in. Once the occlusion was properly

Schlesinger


Figure 17: Fabrication of temporary with Protemp crown. Figure 18: Final impression taken with TRIP.

Figure 20: Final X-ray at delivery.Figure 19: Final crown delivered.

adjusted, the restoration was cemented with RelyX (3M ESPE, Irvine, CA) cement.

DiSCuSSiOnIn this world of immediate gratification, some patients are demanding shorter durations prior to final implant restoration. Up until now, with typical implant protocols, the pros and cons of immediate loading made this a risky proce-dure which many practitioners were unwilling to experiment with. The case shown in this paper demonstrates that immediate implant loading may be a possible option for some patients. ●

Correspondence:

Dr. Charles Schlesinger

9550 San Mateo Blvd. NE, Suite C

Albuquerque, NM 87113

1-800-228-0477

Schlesinger

24 • Vol. 5, No. 8 • August 2013

Schlesinger

Disclosure

Dr. Schlesinger is an employee of OCO Biomedical.

References

1. Shenk, RK, Buser, D, Osseointegration: A Reality. Periodontology 2000 vol.17 issue1, 1998 (22-35)

2. Szmukler-MonclerS,SalamaH,ReingewirtzYetal. Timing of Loading and the Effect of Micro-Motion on Bone-implant Interface: a review of experimental literature. J Biomed Mat Res 1998;43:192-203.

3. Meltzer, Allen M, Primary Stability and Initial Bone-to-Implant contact: The Effects on Immediate Placement and Restoration of Dental Implants. Journal of Implant and Reconstructive Dentistry. 2009 vol.1, issue 1

4. Szmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations Preliminary to Application of Early and Immediate Loading Protocols in Implant Dentistry. Clin Oral Implants Res 2000;11:12-25

5. Johansson P, Strid KG. Assessment of Bone Quality From Placement Resis-tance During Implant Surgery. Int J Oral Maxillofac Implants 1994;9:279-88.

6. Glauser R, Portmann M, Ruhstaller P, Gottlow J, Schδrer P. Initial Implant Stabil-ity Using Different Implant Designs and Surgical Techniques. A comparative clinical study using insertion torque and resonance frequency analysis. Appl Osseointegr Res 2001;2:6-8.

7. Gahleitner A, Monov G, Assessment of Bone Quality: Techniques, procedures, and Limitations. In: Watzek G(ed). Implants in Qualitatively Compromised Bone. Chicago: Quintessence, 2004: 55-66

8. Degidi M, Daprile G, Piattelli A., Primary Stability Determination by Means of Insertion Torque and RFA in a Sample of 4,135 Implants. Clin Implant Dent Relat Res. 2010 Sep 17. doi: 10.1111/j.1708-8208.2010.00302.x. [Epub ahead of print]

9. Raghavendra S, Wood MC, Taylor TD. Early Wound Healing Around En-dosseous Implants: a review of the literature. Int J Oral Maxillofac Implants 2005:20:425-431.

10. Makary C, Rebaudi A, Sammartino G, Naaman N., Implant Primary Stability Determined by Resonance Frequency Analysis: correlation with insertion torque, histologic bone volume, and torsional stability at 6 weeks. Implant Dent. 2012 Dec;21(6):474-80

11. Kobayashi,Y et al., Force-Induced Osteoclast Aptosis in Vivo is Accompanied by Elevation in Transforming Growth Factor and Osteoprotegerin Expression. Journal of Bone and Mineral Research. Volume 15, Number 10, 2000.

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Melker

The following paper presents the concept of biologic shaping to facilitate the place-ment of restorations without impingement

of biologic width. Biologic shaping is a surgical

technique that is significantly different than tra-ditional crown lengthening. This paper will pres-ent the advantages of biologic shaping along with photographic examples of the technique.

Biologic Shaping From a Restorative Prospective

Danny A. Melker, DDS1

1. Private practice, Clearwater, Florida, USA

Abstract

KEY WORDS: Biologic width, osseous surgery, crown lengthening, dental prosthetics


28 • Vol. 5, No. 8 • August 2013

In today’s world of advanced dental procedures and technology, traditional or classic dental principles can easily be lost. This may espe-

cially be true with the decision-making process of saving teeth. Implants are wonderful options when appropriate, but they should not be selected when a tooth can be saved using a predictable peri-odontal or restorative protocol that yields excel-lent long-term prognoses. Too often today, good teeth are being removed in favor of implant place-ment that is occurring in a clinical environment of inadequate bone and soft tissue, as well as biome-chanical compromise. Biologic shaping and soft tissue grafting offer a classic, proven methodol-ogy for treating teeth with absolute predictability.

Often our restorative treatment plans lead us to subgingival margins, furcation involve-ment, root flutes and concavities, in addition to a multitude of complex issues. Many of the issues we face are in the subgingival environ-ment and require periodontal corrective proce-dures to return the foundation to a healthy state. Traditionally, crown lengthening was indicated for deep subgingival margins, not only to facili-tate impression making but also to correct bio-logic width infringements. Biologic shaping is a periodontal corrective procedure reported in the literature1 that may complement traditional crown lengthening, yet it differs from tradi-tional crown lengthening in the following ways.

Figure 1: This patient will undergo a maxillary full-arch restoration to correct occlusal issues and mild periodontal disease. When performing definitive restorative procedures, it is critical to have an ideal periodontal foundation to restore. There was an initial discussion on whether to restore the bicuspids. After review of occlusal issues, it was decided to include the bicuspids in the provisional phase of treatment.

Figure 2: Upon reflection of the tissue with a full-thickness flap due to the existing thick bone, the tooth surfaces exhibited calculus located in concavities.

Melker


● Traditional crown lengthening moves the bone away from the margin. Biologic shap-ing moves the margin away from the bone.

● Traditional crown lengthening requires osse-ous surgery to re-establish the biologic width. Biologic shaping may require minor osseous surgery, but it generally avoids major osseous surgery and still re-establishes bio-logic width because you have the choice to locate your restorative margin coronal to the old restorative margin (0.5 mm api-cal to the core is the coronal extent).

● Traditional crown lengthening may open furcations and render a poor prognosis. Biologic shaping preserves the integrity of the furcation because aggressive osseous surgery was not needed. Traditional crown lengthening does not eliminate flutes, con-cavities or root clefts, leaving the postopera-tive lengthened crown at risk for disease recurrence due to increased susceptibility for plaque, calculus and caries formation. Biologic shaping leaves the subgingival area as smooth as glass; there are no areas for plaque, calculus or caries to hide.

● Traditional crown lengthening worsens crown-to root ratio. Biologic shap-ing maintains crown-to-root ratio.

● Traditional perio is about pockets and prob-ing. Biologic shaping is about preserving bone, smoothing out the rough spots, and making restorative dentistry predictable and a joy to perform.

The concept of biologic shaping is presented in the case that follows. The procedure stresses a 360-degree removal of tooth surface irregu-larities as well as all cementoenamel junctions (CEJs) and existing margins. An important

aspect of the procedure is to remove any con-cavities or furcation involvements. Once the root surfaces are perfectly smooth, the flap is placed just coronal to the osseous surface and sutured in place. After 12 to 14 weeks of heal-ing, the restorative dentist simply places a new margin just coronal to the gingival collar, which allows for a perfect impression to be taken. This case also features the specific correction of a mesial concavity on an upper first bicuspid ●

Article continues on following pages

Melker

30 • Vol. 5, No. 8 • August 2013

Melker

Figure 5: Once the gross removal of tooth structure is completed, an F847-016 diamond bur (Axis Dental) is used to smooth the root surface.

Figure 6: A C801L-023 diamond round bur (Axis Dental) is then used to properly contour the bone to mimic the soft tissue. The term for this procedure is “creating a parabolic architecture,” and it is the key to forming an ideal interface between bone, tooth and tissue. This phase of the surgery helps to avoid the formation of pockets between the bone and soft tissue when the tissue is replaced.

Figure 3: From a slightly different angle, the irregular contours of the bone can be seen. Osseous contouring will be necessary to create contours that will be compatible with the soft tissue when it is replaced. Once the flap is reflected, a split-thickness dissection is used to preserve the periosteum for suturing of the flap and for stability.

Figure 4: Using a C847-016 diamond bur (Axis Dental; Coppell, Texas), the tooth surface is gently smoothed to remove any irregularities of the root surface, as well as all CEJs. The concavity on the upper first bicuspid is also removed by gently blending the line angles approximating the concavity. Removal of the middle tooth surface of the bicuspid was avoided so as not to deepen the concavity.


Melker

Figure 7: Upon completion of the biologic shaping and osseous contouring, an ideal foundation is created over which the soft tissue can be sutured in place.

Figure 8: 5-0 chromic gut suture material is used to replace the flap just coronal to the osseous underlying foundation. An important aspect of suturing the flap is to involve the periosteum as an attachment apparatus for the suture. The suture grabs the periosteum apically to allow for perfect placement of the flap so that no movement or displacement of the flap can occur. There is no need for any dressing to be placed.

Figure 9: An occlusal view showing as much primary closure of the flaps as possible. This allows for decreased discomfort in the healing phase. Also note that no CEJs are present on any of the teeth. A recent article by Rapley and Cobb, et al.2 demonstrated with electron microscopy that the CEJs tend to hold biofilm and that these areas can be a source of periodontal breakdown. It is the belief of the author that by removing the CEJs, we are treating a cause of future breakdown, thus changing the environment for long-term maintenance.

Figure 10: The day of the reline appointment after four weeks of healing. The provisionals will be closed to fit the teeth, leaving 1 mm of space between the provisional and the tooth surface to allow for future biologic width growth in a coronal direction. No prepping of the tooth surface is done at this appointment.

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Figure 12

Figure 11: Impressions day, 12 weeks post-op. All margins are placed just coronal to the gingival collars. A size 7/00 SilTrax® cord (Pascal International; Bellevue, Wash.) is placed in the sulcus to allow for the lab technicians to trim the dies.

Figures 12–14: Final restorations placed. All are IPS e.max® crowns (Ivoclar Vivadent; Amherst, N.Y.) with the exception of full-coverage gold on the second molars. All margins are supragingival. Ideal health exists between the crowns and the soft tissue with no inflammation present. (Restorations courtesy of Dr. Howard Chasolen of Sarasota, Fla.)

Figure 13

Figure 14

Melker

Correspondence:Dr. Daniel Melker is in private practice in Clearwater, FL and lectures nationwide on periodontics and prosthodontics. Contact him at 727-725-0100.

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

References1. Melker DJ, Richardson CR. Root reshaping: an integral component of

periodontal surgery. Int J Periodontics Restorative Dent. 2001 Jun;21(3):296-304.

2. Satheesh K, MacNeill SR, Rapley JW, Cobb CM. The CEJ: a biofilm and calculus trap. Compend Contin Educ Dent. 2011 Mar;32(2):30, 32-7.

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Wilcko et al

This case report is of a mid-20 year old male of slight build with an unknown medical history. The patient was involved

in a firefight while patrolling an unstable area of a Middle Eastern country. He was struck from behind with by a small caliber projectile in the right lower occipital region. The bullet entered inferior to the occipital bone, posterior to the right ear, slightly lateral to the mastoid pro-cess. The projectile transected the right lat-eral pharangeal space, entering the oral cavity superior to the tongue, entered the mid hard palate obliterating a section of the palate as well as the maxillary alveolus and teeth 10, 11

and 12. The bullet exited the oral cavity barely grazing the superior labus. The patient suffered a fracture of the right mandibular body, per-haps in his fall or possibly as a result of blunt force trauma following the gunshot wound.

Due to the remote location where the injury occurred, limited prosthetic care was avail-able. The patient’s injuries were diagnosed clinically and with state of the art radiographic techniques. Once medically stabilized, the patient’s oral maxillofacial deficiencies were treated with a prosthetic obturator. This treat-ment provided the patient with a suitable aes-thetic outcome and improved his functionality.

Contemporary Surgical Care of a Traumatic Oral Maxillofacial Injury in a Very Remote Location

William Hartel, DMD1 • Steven Keir, DDS2 • Callief Shand, DDS3

Ben Smith4, DDS, MD • Ralph Pickard, MD5

Abstract

KEY WORDS: Trauma, prosthetics, maxillofacial surgery


36 • Vol. 5, No. 8 • August 2013

CASE REPORTMr. G, a thin, twenty-something year old man serv-ing with the XXX National Police in XXX (Coun-try location removed for security reasons), was involved in a fire fight with members of an insur-gent group. In the fight, he was shot in the back if the head by a small caliber bullet. Within min-utes, medics performed an emergency cricothy-roidotomy in the field to facilitate respiration. The patient was evacuated by helicopter to a Com-bat Hospital arriving in less than an hour from the time of his injury. He was stabilized in the trauma bay and taken to radiology where a 64 slice CT scan was exposed. The resulting study revealed that the bullet entered just below right occipi-tal bone, missing the right lateral process of the C1 by millimeter, fracturing the styloid process. Three dimensional reconstructions showed the projectile transected the lateral pharyngeal space, entered the oral cavity, and obliterated the left anterior hard palate and floor of the left maxil-lary sinus as well as teeth 10, 11 and 12 and the associated alveolus as it exited the oral cavity. The patient also suffered a fracture of the right man-dible. This wound was treated successfully dur-ing his initial surgery and is not addressed here.

Within hours, the patient was taken to the operating room where the surgical team replaced the field tracheostomy with conventional tracheal apparatus. Pulsating hemorrhage in the pharynx made examination impossible. Once the arterial source was located, sutured and cauterized, intra-oral examination was performed revealing a 4x5 cm oblong communication between the oral cav-ity and the left maxillary sinus. An alginate impres-sion was made of the upper arch using twice the normal volume of impression material to fill the upper arch and left maxillary sinus. As anticipated,

the resulting impression separated upon removal due to undercuts in the sinus and the fact that the impression material extruded from the nose. Arch bars were placed on teeth #s 3, 4, 5, 6, and 13, 14 and ligated into position with circumdental wires. The mandible fracture was reduced and fixated and the external soft tissue injuries closed.

In the dental clinic, the alginate impression was reassembled using cyanoacrylate glue, the excess material trimmed with a scalpel. It was then poured with dental stone in the usual man-ner. After setting, the resulting cast was sepa-rated and trimmed, leaving a hole in the base for access to the planned obturator. The entire treatment team evaluated the resulting cast to permit surgeons to determine how to revise the wounds and dentists to determine a method to fabricate a prosthesis. The model was modified to match the anticipated outcome of the surgery and a duplicate made reflecting those changes.

While the patient convalesced in the ICU, the dentist mixed denture repair acrylic creating a 3 x 4cm ball which was inserted into the sinus void of the duplicate model. After initial curing, the mass was removed and allowed to bench cure. This portion was adjusted to permit inser-tion on and removal from the cast. Denture teeth were chosen from a very limited selection and affixed to the cast with self-cure acrylic “dots.” Using a “salt and pepper technique,” the palatal portion of the obturator/partial denture was fab-ricated, extending the borders into the interproxi-mal embrasures. After curing was complete, the device was removed from the cast by finger pres-sure from the underside of the model where a hole had been made for that purpose. The device was then seated on the original model where the labial extension was added. Upon comple-

Hartel et al


tion, four small holes were made along the sides of the sinus extension of the acrylic and den-tal amalgam was condensed so the appliance could be visualized during radiologic examination.

Several days later the patient was returned to the operating room and anesthetized via the tracheostomy. The wounds were surgically modified, eliminating some boney undercuts as planned on the cast. The obturator was inserted into the oral/nasomaxillary defect with excellent approximation. Because the right and left por-tions of the remaining hard palate were quite mobile, the obturator appliance was wired into position with 25 gage stainless steel circum-dental wires utilizing holes drilled through the

prosthesis in the OR with a fissure burr. Wired to teeth #’s 7, 8 and 13, the prosthesis served as a surgical stent to permit healing. Solid occlusion was verified on the right side. ●

Hartel et al

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Hartel et al Hartel et al


Hartel et al

DisclosureThe information contained in this article is the opinion of the author and does not reflect the views of the United States Army, United States Department of Defense, nor the United States Government.

Correspondence:Dr. William Hartel Role 3 MMUAPO AE09355

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