Volume 1, No.

5 J uly/August 2009

The Journal of Implant & Advanced Clinical Dentistry

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 The Journal of Implant & Advanced Clinical Dentistry
Volume 1, No. 5 • July/August 2009

Table of Contents
09 Tridimensional Bone Reconstruction 45 Immediate Loading of SybronPro™
in an Atrophic Ridge with a XRT Implants in the Symphyseal Region
Misplaced Dental Implant: A Case Report Neal Gittleman
Carlo Maiorana, Mario Beretta, Marco Cicciù

51 JIACD Continuing Education

23 Bone and Crescent Shaped Free Gingival
Grafting for Anterior Immediate Implant
Placement: Technique and Case Report
Thomas Han, Chul Woong Jeong
Oral Implications of Cancer Chemotherapy
Nicholas Toscano, Dan Holtzclaw, Istvan A. Hargitai,
Nicholas Shumakerl, Heather Richardson,
Greg Naylor, Robert Marx

35 Short Sintered Porous-Surfaced Dental

Implants with Indirect Sinus Elevation to
Restore the Resorbed Posterior Maxilla
Douglas A. Deporter

71 Labial Protection Device for a Child Patient

with Cerebral Palsy: A Case Report
Candice B. Zemnick, Richard K. Yoon,
Steven Chussid, Kim Soleimani

81 Current Clinical Review

The Role of Corticosteroids in Dentistry
Istvan A. Hargitai

The Journal of Implant & Advanced Clinical Dentistry • 3

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 The Journal of Implant & Advanced Clinical Dentistry
Volume 1, No. 5 • July/August 2009

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The Journal of Implant & Advanced Clinical Dentistry • 5

 Does your bone grafting material measure up?
Improvements in clinical and radiographic parameters in the GEM 21S® pivotal trial compare favorably with or
exceed, documented outcomes* for Emdogain® pivotal trials examining defects with similar baseline
characteristics.1,2,3,4 GEM 21S® was found to provide:
MORE radiographic bone fill
MORE radiographic linear bone growth
GREATER clinical attachment level gain
Radiographic Percent Bone Fill (BF%) Radiographic Linear Bone Growth (LBG) Clinical Attachment Level (CAL) Gain
60 3.0 4.0
57 3.7
2.6
Mean LBG (mm)

40 2.0
CAL Gain (mm)

3.0
Mean % BF

2.7*

20 1.0 1.1* 2.0

14*

0 0 0
GEM 21S® Enamel Matrix GEM 21S® Enamel Matrix GEM 21S® Enamel Matrix
Derivative (EMD) Derivative (EMD) Derivative (EMD)

*EMD results at 8 months, GEM 21S® results at 6 months

To learn more, please visit us online at www.osteohealth.com or call 1-800-874-2334

View prescribing information: www.osteohealth.com/documents/52.pdf

IMPORTANT SAFETY INFORMATION

GEM 21S® Growth-factor Enhanced Matrix is intended for use by clinicians familiar with periodontal surgical grafting techniques. It should not be used in the presence of
untreated acute infections or malignant neoplasm(s) at the surgical site, where intra-operative soft tissue coverage is not possible, where bone grafting is not advis-
able or in patients with a known hypersensitivity to one of its components. It must not be injected systemically. The safety and effectiveness of GEM 21S® has not been
established in other non-periodontal bony locations, in patients less than 18 years old, in pregnant or nursing women, in patients with frequent/excessive tobacco use (e.g.
smoking more than one pack per day) and in patients with Class III furcations or with teeth exhibiting mobility greater than Grade II. In a 180 patient clinical trial, there
were no serious adverse events related to GEM 21S®; adverse events that occurred were considered normal sequelae following any periodontal surgical procedure (swell-
ing, pain). For full prescribing information, go to www.osteohealth.com or call 1-800-874-2334 and a copy will be sent to you.
References: 1. Nevins M, Giannobile WV, McGuire MK, Mellonig JT, McAllister BS, Murphy KS, McClain PK, Nevins ML, Paquette DW, Han TJ, Reddy MS, Lavin PT, Genco RJ, Lynch SE. Platelet Derived Growth Factor
(rhPDGF-BB) Stimulates Bone Fill and Rate of Attachment Level Gain. Results of a Large Multicenter Randomized Controlled Trial. J Periodontol 2005; 76: 2205-2215. 2. Heijl L, Heden G, Svardstrom G, Ostgren. Enamel
matrix derivative (EMDOGAIN) in the treatment of intrabony periodontal defects. J Clin Periodontol 1997; 24: 705-714. 3. Zetterstrom O, Andersson C, Driksson L, et al. Clinical safety of enamel matrix derivative (EMDOGAIN)
in the treatment of periodontol defects. J Clin Periodontol 1997; 24: 697-704. 4. See full prescribing infromation for more detail. Emdogain® is a registered trademark of BioVentures BV Corporation. ©COPYRIGHT Osteohealth
Company 2008. All rights reserved. OHD235e Iss. 7/2009.
 The Journal of Implant & Advanced Clinical Dentistry
Founder, Co-Editor in Chief
Dan Holtzclaw, DDS, MS
A Minimally Invasive and Systematic Approach to Sinus Grafting
Tara Aghaloo, DDS, MD
Faizan Alawi, DDS
Michael Apa, DDS
Alan M. Atlas, DMD
Charles Babbush, DMD, MS
Thomas Balshi, DDS
Barry Bartee, DDS, MD
Lorin Berland, DDS
Peter Bertrand, DDS
Michael Block, DMD
Chris Bonacci, DDS, MD
Gary F. Bouloux, MD, DDS
Ronald Brown, DDS, MS
Bobby Butler, DDS
Donald Callan, DDS
Nicholas Caplanis, DMD, MS
Daniele Cardaropoli, DDS
Giuseppe Cardaropoli DDS, PhD
John Cavallaro, DDS
Stepehn Chu, DMD, MSD
David Clark, DDS
Charles Cobb, DDS, PhD
Spyridon Condos, DDS
Sally Cram, DDS
Massimo Del Fabbro, PhD
Douglas Deporter, DDS, PhD
Alex Ehrlich, DDS, MS
Nicolas Elian, DDS
Paul Fugazzotto, DDS
Scott Ganz, DMD
Arun K. Garg, DMD
David Guichet, DDS
Kenneth Hamlett, DDS
Istvan Hargitai, DDS, MS
Michael Herndon, DDS
Robert Horowitz, DDS
Michael Huber, DDS
Founder, Co-Editor in Chief
Nicholas Toscano, DDS, MS
Editorial Advisory Board
Richard Hughes, DDS Giulio Rasperini, DDS
Debby Hwang, DMD Michele Ravenel, DMD, MS
Anil Idiculla, DMD Terry Rees, DDS
Mian Iqbal, DMD, MS Laurence Rifkin, DDS
Tassos Irinakis, DDS, MSc Paul Rosen, DMD, MS
James Jacobs, DMD Joel Rosenlicht, DMD
Ziad N. Jalbout, DDS Larry Rosenthal, DDS
John Johnson, DDS, MS Steven Roser, DMD, MD
John Kois, DMD, MSD Salvatore Ruggiero, DMD, MD
Jack T Krauser, DMD Anthony Sclar, DMD
Gregori Kurtzman, DDS Frank Setzer, DDS
Burton Langer, DMD Maurizio Silvestri, DDS, MD
Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD
Miles Madison, DDS Dong-Seok Sohn, DDS, PhD
Carlo Maiorana, MD, DDS Muna Soltan, DDS
Jay Malmquist, DMD Michael Sonick, DMD
Louis Mandel, DDS Ahmad Soolari, DMD
Michael Martin, DDS, PhD Christian Stappert, DDS, PhD
Ziv Mazor, DMD Neil L. Starr, DDS
Dale Miles, DDS, MS Eric Stoopler, DMD
Robert Miller, DDS Scott Synnott, DMD
John Minichetti, DMD Haim Tal, DMD, PhD
Uwe Mohr, MDT Gregory Tarantola, DDS
Jaimee Morgan, DDS Dennis Tarnow, DDS
Dwight Moss, DMD, MS Geza Terezhalmy, DDS, MA
Peter K. Moy, DMD Tiziano Testori, MD, DDS
Mel Mupparapu, DMD Michael Tischler, DDS
Ross Nash, DDS Michael Toffler, DDS
Gregory Naylor, DDS Tolga Tozum, DDS, PhD
Marcel Noujeim, DDS, MS Leonardo Trombelli, DDS, PhD
Sammy Noumbissi, DDS, MS Ilser Turkyilmaz, DDS, PhD
Arthur Novaes, DDS, MS Dean Vafiadis, DDS
Andrew M. Orchin, DDS Hom-Lay Wang, DDS, PhD
Charles Orth, DDS Benjamin O. Watkins, III, DDS
Jacinthe Paquette, DDS Alan Winter, DDS
Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS
Stan Presley, DDS Richard K. Yoon, DDS
George Priest, DMD
The Journal of Implant & Advanced Clinical Dentistry • 7
Maiorana et al
 Maiorana et al
Tridimensional Bone Reconstruction
in an Atrophic Ridge with a
Misplaced Dental Implant: A Case Report

Carlo Maiorana MD, DDS1 • Mario Beretta DDS, PhD2

Marco Cicciù DDS, PhD2

Abstract

Background: Ideal dental implant placement
is best achieved with a team approach involv-
ing all providers treating the patient. Failure to
properly plan in advance, including consulta-
tion with appropriate dental specialists, may
result in complications that can require sub-
stantial investments of time and resources to
overcome. This case report documents treat-
ment of a severely misplaced dental implant
which led to significant iatrogenic complications.
obtain increased amounts of keratinized tissue
around the implants. Final prosthetic restoration
was achieved 12 months after the first surgery.
Results: At the 24-month follow up visit,
all implants were osseointegrated and func-
tioning without complication. Clinical and
radiological investigation confirmed no infec-
tion, no bone loss around the implants,
and good healing of the soft tissues.

Methods: Treatment of this case involved mul-
tiple surgeries. At the first surgery, the mis-
placed implant was removed and the alveolar
ridge was tridimensionally reconstructed. Six
months later, a sinus lift was performed and 4
dental implants were placed. Before prosthesis
positioning, soft tissues surgery was needed to
Conclusion: Implant placement without proper
planning and consultation can lead to dire conse-
quences including, but not limited to, loss of adja-
cent teeth and significant ossesous defects. This
case reports demonstrates how one improperly
placed implant can require an exceptional allo-
cation of time and resources to restore properly.

KEY WORDS: Dental implants, bone augmentation, misplaced dental implant

1. Chairman and Head, Department of Oral Surgery, University of Milan, Milano, Italy
2. Department of Oral Surgery, University of Milan, Milano, Italy

The Journal of Implant & Advanced Clinical Dentistry • 9

Maiorana et al
IntRODuCtIOn
The oral rehabilitation of the maxilla often repre-
sents a clinical challenge. Long term clinical stud-
ies have shown that maxillary molars are the teeth
with the highest loss rate.1-3 Following this loss of
teeth, multiple studies have demonstrated resorp-
tion patterns that may adversely affect future dental
implant placement.4,5 The typical bone resorption
pattern in the maxilla provides for continuous buc-
cal and occlusal atrophy which results in palatal
dislocation of the residual ridge. The palatal vault
becomes flat and the residual ridge approaches
the nasal spine anteriorly and the zygomatic pro-
cess posteriorly.6 Other investigations have
analyzed how crestal bone resorption of the pos-
terior maxilla associated with pneumatization of
the maxillary sinus often results in an inadequate
bone volume for dental implant placement.7-9
Some clinical reports have evaluated maxillary
sinus augmentation procedures using a variety of
bone grafting materials such as autogenous bone
from extra oral sites (iliac crest) or intra oral sites,10-
13
as well as bone substitutes such as freeze-dried
demineralized bone,14,15 and xenograft.16-18 The
main source of cancellous bone is represented by
the iliac crest, which has documented osteoinduc-
tive and osteoproliferative properties. Nevertheless,
its use requires highly specialized surgical teams,
prolonged operative time, two surgical sites and the
possibility of postoperative complications and mor-
bidity for the patients. Xenograft materials may pro-
duce bone formation by osteconduction. This event
allows outgrowth of osteogenic cells from exposed
bone surfaces into adjacent graft material, such as
calcium phosphate, that acts as an inert scaffold.19-21
Sinus augmentation procedures using a variety
of bone grafting materials can increase bone vol-
ume to allow implant placement where insufficient
10 • Vol. 1, No. 5 • July/August 2009
bone is present. Controlled histologic investiga-
tions evaluating different bone grafting materials
for sinus augmentation have clearly demonstrated
that bovine deproteinized xenograft can be con-
sidered just as safe and predictable as autolo-
gous bone.22,23 This case report documents use
of bovine deproteinized xenograft for augmenta-
tion treatment of a patient with iatrogenic dental
implant placement. The misplaced dental implant
in this case was so far out of proper alignment,
that its removal required significant tridimen-
sional bone reconstruction of the alveolar ridge.
CASE REpORt
A 47 year-old woman was referred to the Implantol-
ogy Department of the University of Milan because
of pain in the upper right canine area. Clinical
examination revealed the presence of a signifi-
cant space between the maxillary canine and lat-
eral incisor (figures 1-2). The patient reported
that the diastema developed within the past few
months and was associated with the initial pain at
the canine site. Radiographic examination (figure
3) revealed a misplaced dental implant in contact
with the apical aspect of the canine root (figure 4).
The canine was endodontically treated and had a
radiolucent area around the apex. A complex treat-
ment plan involving the misplaced dental implant,
canine removal, bone reconstruction, and dental
implant positioning was proposed to the patient by
the surgery team. The patient agreed to undergo
treatment and informed consent was signed.
The patient was started on antimicrobial ther-
apy 1 day prior to surgery with 1,000 mg amoxi-
cillin twice a day. At surgery, local anesthesia
was induced by infiltration with 4% articaine with
1:100,000 epinephrine and 4mg dexamethasone
administered by submucosal injection. A mucope-
 Maiorana et al

Figure 1: Preoperative frontal view. Figure 3: Preoperative panoramic radiograph.

Figure 4: Close-up view of misplaced dental implant.

Figure 5: Intrasurgical view of implant invading canine

Figure 2: Preoperative occlusal view. extraction site.

The Journal of Implant & Advanced Clinical Dentistry • 11

Maiorana et al

Figure 6: Buccal view of osseous defect after implant and

canine extraction.

riostal flap was elevated with an incision running

from the lateral incisor distally to the first molar
exposing the buccal area of the maxillary wall. The
canine was extracted and the misplaced implant
was firstly divided into two parts using a bur by
buccal approach and then removed in the most
coronal part with a trephine bur (figures 5-7). The
surgical area was then irrigated with saline solution,
bovine deproteinized bone (Bio-Oss Geistlich CH
®) was used for ridge reconstruction (figures 8,9),
and two resorbable membranes were positioned Figure 7: Occlusal view of osseous defect after implant
upon the bone grafts (figure 10). The incision was and canine extraction.
closed with 4-0 and 5-0 non-resorbable sutures.
Post surgical analgesic treatment was performed and no infection was revealed. At this time, it was
with 100 mg Nimesulide (Aulin®, Roche CH) twice determined that the quantity of buccal keratinized
a day for 3 days and sutures were removed 10 days mucosa was insufficient (figure 17). For this reason,
later. The patient was placed on a soft diet for 3 a connective tissue graft was taken from the palate
days and oral hygiene instructions were provided. and buccally positioned to increase the thickness
Postsurgical healing was uneventful (figures of the keratinized mucosa at the time of the implant
11-13). Six months after the initial surgery, a sinus uncovering (figures 18-26). Three weeks later, pro-
lift (figure 14) was performed and four Camlog® visional prosthetic crowns were positioned for soft
implants were delivered (figures 15, 16). Soft tis- tissue conditioning (figures 27, 28). Approximately
sue healing at 10 days was within normal limits one year after the initial surgery, removal of the provi-

12 • Vol. 1, No. 5 • July/August 2009

 Maiorana et al

Figure 8: Osseous defect grafted with BioOss. Buccal view. Figure 10: Application of resorbable membranes.

Figure 9: Osseous defect grafted with BioOss.

Occlusal view.
Figure 11: Postsurgical healing.

The Journal of Implant & Advanced Clinical Dentistry • 13

Maiorana et al

Figure 12: Radiographic healing at 6 months after surgery. Figure 14: Sinus lift surgery.

sional crowns revealed excellent soft tissue healing

at the implant sites (figure 29). Gingivoplasty was
performed on the buccal surface to reduce excess
tissue bulk and final ceramic crowns were cemented
into place. At 24 months after surgery, the patient
showed a good amount of keratinized mucosa (fig-
ure 30) and radiographic investigation revealed
osseointegration of the dental implants (figure 31).

Figure 13: Grafted ridge at 6 months after surgery.
DISCuSSIOn
Ideal implant placement is ultimately determined
by the requirements of the final restoration. For
the surgeon placing dental implants, proper
angulation, parallelism, and spacing are critical
to the final restoration. The use of a stainless-
steel drill guide sleeve in an acrylic resin sur-
gical template can make it possible to achieve
optimal placement. Communication between
prosthodontist, surgeon, and lab technician is
enhanced by this system and this allows the sur-
geon to negotiate bony irregularities and defects
while preparing a more concentric implant site.
Other factors to consider for facilitation of
dental implant placement are evaluations of bony
topography. A barium-coated template with exter-

14 • Vol. 1, No. 5 • July/August 2009

 Maiorana et al

Figure 15: Dental implant osteotomies. Figure 16: Dental implant placement.

nal guide wires used in conjunction with a com-

puted tomography scan and interactive software
may provide superior presurgical diagnostics, treat-
ment planning, and prosthetically directed implant
placement. Predetermined measurements on the
computed tomography scan can be accurately
transferred to the diagnostic/surgical template by
use of a precision milled cylinder placed into the
template at the proper angulation and linear dimen-
sions. The diagnostic/surgical template shows the
surgeon the optimal position for implant place- Figure 17: Inadequate buccal keratinized tissue.

The Journal of Implant & Advanced Clinical Dentistry • 15

Maiorana et al
Figure 18: Incision design for soft tissue augmentation.
ment, thus establishing greater clinical confidence
when placing implants.24,25 The patient in this case
report presented with a significantly misplaced
dental implant which resulted in additional iatro-
genic complications. It appeared that during the
placement of the original implant, an attempt was
made to avoid a pneumatized maxillary sinus. Mul-
tiple studies have shown that dental implants are
often misplaced to avoid contact with anatomical
structures.26-29 Proper presurgical planning and
16 • Vol. 1, No. 5 • July/August 2009
Figure 19: Partial thickness flap reflection.
consultation with providers of multiple special-
ties could have likely avoided the undesirable out-
come seen with the original treatment of this case.
COnCluSIOn
In the maxilla, advanced atrophy is often observed,
and implant placement may become difficult or
impossible. For this reason, pre-prosthetic plan-
ning is essential for proper implant placement.
Failure to properly plan in advance, including
 Maiorana et al

Figure 20: Connective tissue harvest from palate. Figure 21: Connective tissue harvest from palate.

consultation with appropriate dental specialists,

may result in iatrogenic complications such as
those seen with the initial presentation of this
case. The case documented in this report dem-
onstrates the need for proper presurgical plan-
ning and the extensive treatment that is often
required to recover cases in where this does not
occur. The final outcome of this case documents
how a team approach can successfully rehabilitate
a patient with an atrophied posterior maxilla. ● Figure 22: Adjustments to CTG.

The Journal of Implant & Advanced Clinical Dentistry • 17

Maiorana et al

Figure 25: Apically positioned flap covering CTG.

Figure 23: CTG secured to recipient site. Occlusal view. Occlusal view.

Figure 24: CTG secured to recipient site. Buccal view. Figure 26: Apically positioned flap covering CTG.
Buccal view.

18 • Vol. 1, No. 5 • July/August 2009

 Maiorana et al

Figure 27: Provisional crowns placed to guide soft tissue

healing. Buccal view.

Figure 29: Occlusal view of soft tissue healing at implant

sites.

Correspondence:
Dr Marco Cicciù Department of Oral Surgery,
Dental Clinic, IRCCS, Milan
Via Commenda n°10, 20122, Milano, Italy.
Tel.: 0039-02-55032621
Fax: 0039-02-666686
Figure 28: Provisional crowns placed to guide soft tissue E-mail: acromarco@yahoo.it
healing. Occlusal view.

The Journal of Implant & Advanced Clinical Dentistry • 19

Maiorana et al
Figure 30: Final restorations at 24 months. Buccal view.
Disclosure
The authors report no conflicts of interest with
anything mentioned in this article.
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analysis of bone grafts augmented with adult stem
cells. Implant Dent 2007; 16(1): 42-53.
18. Greenstein G, Cavallaro J, Romanos G, Tarnow
D. Clinical recommendations for avoiding and
managing surgical complications associated with
implant dentistry: a review. J Periodontol 2008;
79(8): 1317-29.
19. Papa F, Cortese A, Maltarello MC, Sagliocco R,
Felice P, Claudio P. Outcome of 50 consecutive
sinus lift operations. Br J Oral Maxillofac Surg
2005; 43(4): 309-13.
20. Cordaro L. Bilateral simultaneous augmentation
of the maxillary sinus floor with particulated
mandible. Report of a technique and preliminary
results. Clin Oral Implants Res 2003; 14(2):
201-6.
21. Vachiramon A, Wang WC, Vachiramon T.
Delayed immediate single-step maxillary sinus
lift using autologous fibrin adhesive in less than
4-millimeter residual alveolar bone: A case report.
J Oral Implantol 2002; 28(4): 189-93.
22. Armand S, Kirsch A, Sergent C, Kemoun P, Brunel
G. Radiographic and histologic evaluation of a
sinus augmentation with composite bone graft:
a clinical case report. J Periodontol 2002; 73(9):
1082-8.
23. Murakami K, Itoh T, Watanabe S, Itoh T, Naito T,
Yokota M. Periodontal and computer tomography
scanning evaluation of endosseous implants in
conjunction with sinus lift procedure. A 6-case
series. J Periodontol 1999; 70(10): 1254-9.
25. Ewers R. Maxilla sinus grafting with marine algae
derived bone forming material: A clinical report of
long-term results. J Oral Maxillofac Surg 2005;
63(12): 1712-23.
26. Ferrigno N, Laureti M, Fanali S. Dental implants
placement in conjunction with osteotome sinus
floor elevation: a 12-year life-table analysis from a
prospective study on 588 ITI implants. Clin Oral
Implants Res 2006; 17(2): 194-205. Erratum in:
Clin Oral Implants Res. 2006; 17(4):479.
27. Scarano A, Degidi M, Iezzi G, Pecora G, Piattelli
M, et al. Maxillary sinus augmentation with
different biomaterials: A comparative histologic
and histomorphometric study in man. Implant
Dent 2006; 15(2): 197-207.
28. Krennmair G, Krainhöfner M, Schmid-Schwap
M, Piehslinger E. Maxillary sinus lift for single
implant-supported restorations: a clinical
study. Int J Oral Maxillofac Implants 2007;
22(3): 351-8.
29. Crespi R, Vinci R, Capparè P, Gherlone E,
Romanos G. Calvarial versus iliac crest for
autologous bone graft material for a sinus lift
procedure: a histomorphometric study. Int J Oral
Maxillofac Implants 2007; 22(4): 527-32.
30. Peñarrocha M, Boronat A, Carrillo C, Albalat S.
Computer-guided implant placement in a patient
with severe atrophy. J Oral Implantol 2008;
34(4): 203-7.
 Maiorana et al

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Han et al
 Han et al
Bone and Crescent Shaped Free Gingival
Grafting for Anterior Immediate Implant Placement:
Technique and Case Report

Thomas Han, DDS, MS1 • Chul Woong Jeong, DDS, MS, PhD2

Abstract

I
mmediate implant placement in a single staged
approach, with or without provisionalization,
can be advantageous in preserving gingival
anatomy around dental implants. However, plac-
ing implants immediately in the changing alveolar
bone of an extraction socket may result in pro-
gressive recession of the gingival labial margin
over the implant restoration. This negative out-
come may be overcome
with enhanced labial
thickness. Thicker labial
gingiva and bone of the
peri-implant tissue have shown to pro-
mote long-term stable gingival margins.
This article presents a simple surgical tech-
nique utilizing crescent shaped free gingival tis-
sue and bone grafting to promote thicker labial
bone and biotype. The surgical procedure
as well as the biologic and clinical rationale is
described. One-year post-restoration results
are evaluated and show
a stable, favorably posi-
tioned labial gingival mar-
gin at the implant site.

KEY WORDS: Immediate dental implant, connective tissue graft, bone graft

1. Adjunct Professor, Dept. of Periodontics, UCLA School of Dentistry, Los Angeles, California, USA
2. Private practice, Kwang Ju, Korea

The Journal of Implant & Advanced Clinical Dentistry • 23

Han et al
INTRODUCTION
Alveolar ridge resorption following the loss of
anterior teeth often creates challenging esthetic
problems in implant dentistry. Horizontal and
vertical bone change surrounding the extraction
socket may create papilla loss, labial tissue reces-
sion, and poor unstable gingival foundations for
an esthetic final restoration. If a harmonious gin-
gival form exists around the tooth proposed for
extraction, immediate implant placement and pro-
visionalization may effectively preserve the vertical
height of the interdental papilla.1 However, with
this approach, the propensity for labial gingival
recession over time can alter the appearance of
the final restoration.2,3 While proper implant place-
ment and correct fabrication of the restoration are
important for esthetics in implant dentistry,4,5 it
appears that for long term stable esthetics around
dental implants, favorable peri-implant soft and
hard tissues are also necessary.6 Studies support
that grafting the extraction socket decreases the
amount of horizontal resorption and can enhance
the bone thickness.6 A modified ridge preserva-
tion technique called “socket seal surgery” which
combines bone and soft tissue grafting to pre-
serve/enhance hard and soft tissue profiles has
been used with immediate implant placement.7
While this technique provides a thick biotype,
stable labial gingiva, negligible loss of inter-
dental papillary height, and preservation of bone
graft material by sealing the socket with a gingi-
val graft, it requires a second-stage surgery and
immediate provisionalization is not possible. A dif-
ferent technique attempting to preserve/enhance
hard and soft tissue profiles involves a bilaminar
subepithelial connective tissue graft used in con-
junction with provisionalized immediate implant
placement and bone grafting in the esthetic zone.8
24 • Vol. 1, No. 5 • July/August 2009
While this technique shows enhanced labial bio-
type over the implants, it requires a large piece
of connective tissue (approximately 9mm long
and 1.5mm thick) which may increase the surgi-
cal morbidity of the donor site. Additionally, this
technique does not adequately address situa-
tions where there are initially unfavorable gingi-
val margins and/or underlying bony architectures.
This article describes a relatively simple gin-
gival tissue augmentation technique used with
immediate implant placement in a single stage
approach, either with or without provisional-
ization, to convert unfavorable initial labial gin-
gival level and thin biotype to a more stable
biotype with a favorable gingival margin for bet-
ter long term final esthetics. One year follow-
up of the implant restoration showing stability
of the peri-implant gingival tissue is included.
MATERIAlS AND METhODS
Soft and hard Tissue Assessment
The advantage of single stage immediate
implant placement is more predictable
preservation of the periimplant gingival tissue
with less patient discomfort and less treatment
time. Nonetheless, if mere preservation of
the existing tissue is insufficient to provide an
adequate peri-implant gingival foundation for
esthetic restoration, other surgical approaches
better suited to augmenting the deficient tissue
should be utilized. The criteria and techniques
for proper immediate implant placement have
previously been established and reported
with successful long-term outcomes.5,7,9 One
of the more difficult aspects of immediate
implant placement is positioning the implant
with sufficient primary stability in an extraction
socket, often without elevating a flap. The

Figure 1: Gingival fracture of the maxillary right lateral
incisor.
alveolar architecture in relation to the angle
of the implant, the presence or absence of
bone concavity apical to the extracted tooth,
the amount of existing bone apical and palatal
to the extraction socket, as well as the quality
of the bone and soft tissues of the ridge
should all be thoroughly evaluated clinically
and radiographically prior to surgery. Many
clinicians perform successful immediate implant
placement without the aid of a computerized
tomographic (CT) scan, but if any questions
exist regarding the proposed delivery site, use
of a CT scan is advised.
In this case, the patient was 54-year-old male
with a fractured right lateral incisor at the dentog-
ingival junction. There were no medical contraindi-
cations for dental implant treatment. The fractured
root was in a slightly labial position, with the labial
gingival margin already at the tangent line join-
Han et al
Figure 1a: Probing of extraction socket.
ing the labial margins of the adjacent canine and
the central incisor (figure 1). The labial biotype
was considered to be slightly thin. Placing an
implant immediately after the removal of the root
in this situation would most likely result in a less
than ideal labial gingival margin without surgically
compensating for the post treatment recession
at the time of implant placement. Interproximal
papilla height was within normal range and the
underlying bone levels were within 3mm from
the margin based on probing (figures 1, 1a, 2).
Socket Preparation
Atraumatic extraction results in minimal damage to
the surrounding alveolar bone. If the root needs
to be elevated, the elevator should be placed at
mesio-palatal or disto-palatal line angles to mini-
mize damage to labial, mesial, and distal inter-
proximal bone. Use of a periotome to initiate the
The Journal of Implant & Advanced Clinical Dentistry • 25
Han et al
Figure 2: Preoperative periapical radiograph.
separation of the tooth from the alveolar peri-
odontal ligament (PDL) junction can decrease
the chance of labial bone fracture during the
extraction. The fresh extraction socket should
be thoroughly degranulated and all walls pal-
pated with hand instruments to assess osseous
integrity. The gingival walls of the socket orifice
are de-epithelialized with the use of a 15C blade,
or gently with a high-speed diamond bur. The
exposed, bleeding lamina propria will enhance
the revascularization of the connective tissue graft
which will be placed after implant placement.
Implant Placement
Implant placement starts with determining the final
desired labial gingival margin for the implant res-
26 • Vol. 1, No. 5 • July/August 2009
toration. This may be different from the existing
gingival margin. Once this is decided, the proper
apical position for implant placement can then be
determined with the implant platform 2-4mm api-
cal to the anticipated gingival margin. An implant
with sufficient length should be used to engage
the bone 3-5mm beyond the apex of the extrac-
tion socket to provide initial primary stability; this
is the single most important factor for its success.
The angulations of the implant should
avoid adjacent roots and be no more than 15
degrees off, bucco-lingually, from the long axis
of the ideal position. One common mistake is
to angle the implant too labially to accommo-
date the existing bone for primary stabilization.
This will not only cause restorative difficulties,
but increase labial recession problems as well.
In addition, bucco-lingual positioning of the
implant must be within the outline of the crown,
with 1-2mm of space present between the inner
surface of the labial osseous wall and the labial
surface of the implant (figure 3). This also helps
engage the palatal wall for primary stabilization.
The mesio-distal position must ensure that there
is sufficient room for the interdental papilla.
Placing the implant in this manner will ensure
both proper implant restoration emergence pro-
file and hygiene. After placing the implant in a
proper position, a bone profiler is used to profile
the interproximal bone so that a slightly flared
healing abutment or a provisional restoration
fits passively. A healing abutment of 2-4mm in
length, an appropriate abutment for a cement or
screw-retained provisional is placed with appro-
priate torque. If a healing abutment is used, a
removable denture or a tooth attached to an
adjacent tooth can be placed over the abutment
for the healing period. For a cement-on type of

Figure 3: Extraction Socket with implant immediately
placed in palatal position.
abutment, the margin of the provisional should
stay supragingival at this stage for minimal dis-
ruption of the grafted site. Chemical irritation
from the monomer should be avoided during the
fabrication and polymerization of the cement-on
provisional. There should be at least 1.5-2mm of
space labial to the abutment or provisional resto-
ration to accommodate a connective graft with-
out excessive horizontal and vertical pressure.
The provisional restoration emergence profile
should be under-contoured and out of occlusion.
Bone Grafting
The space between the inner surface of the labial
bony wall and the labial surface of the implant
is filled with either mineralized freeze-dried par-
ticulate bone allograft (FDBA) or particulate
xenograft. There is evidence that the space
fills without grafting,10-12 but filling the socket
Han et al
Figure 4: Bone graft material packed in the gap between
the implant and facial bone.
with graft material minimizes both vertical and
horizontal resorption of the labial bone.13 Many
clinicians prefer the use of xenograft because
there seems to be less shrinkage over time, but
the choice of grafting material does not appear
to influence the survival of the connective tissue
graft. The use of autograft is not recommended
due to greater horizontal shrinkage of the ridge.
The bone graft is lightly packed to 3mm below
the height of labial gingival margin. If the graft
is packed too shallow or too deep, it can affect
the final result. At this point there should be a
crescent-shaped depression, about 3mm deep,
around the mesio-labial-distal aspect of the
stable implant abutment or provisional, lined by
the inner lining of the labial gingiva with sulcu-
lar epithelium removed at the socket prepara-
tion stage (figure 4). This is the space that will
receive the crescent shaped free gingival graft.
The Journal of Implant & Advanced Clinical Dentistry • 27
Han et al
Figure 5: Crescent shaped free gingival graft is harvested
from the ipsilateral palate.
Crescent Free Gingival Tissue harvesting
A crescent shaped free gingival graft with epithe-
lium intact is usually harvested from the ipsilat-
eral palate, approximately 5mm below the palatal
gingival margin of the canine or premolars. The
crescent shape follows the palatal gingival out-
line of the adjacent dentition (figure 5). This
will ensure the proper fitting of the graft in the
recipient site. A 15C blade is ideal for this pro-
cedure. The blade is penetrated perpendicular
to the palatal surface of the underlying alveolar
bone, following the shape of a crescent as much
as possible. The length and width of the graft are
determined by the mesio-distal dimension of the
socket, with the bucco-lingual dimension approxi-
mately 3mm. Due to the flexibility of the gingival
wall, this dimension does not need to be exact.
The resulting graft is usually about 3mm in thick-
ness, which will fit snugly into to the recipient site.
28 • Vol. 1, No. 5 • July/August 2009
Figure 6: Collacote is placed into the donor site and
sutured.
The graft tissue is either immediately placed into
the recipient site or maintained in a moist environ-
ment to prevent desiccation. A small piece col-
lagen dressing material (Collacote or Gelfoam)
is placed into the donor site and an interrupted
suture is placed at the middle part of the donor
site. Most of the time this is sufficient for the clo-
sure, but one or two more interrupted sutures may
be necessary if hemorrhaging continues (figure 6).
Securing the Free Gingival Graft
In order to maintain the blood supply and nutri-
ents to the donor tissue, it is important that the
outer surface of the crescent graft has intimate
contact with the bleeding lamina propria of
the labial gingiva with the graft should pushing
against the gingival wall. The donor tissue will fit
into the recipient site with the inner side of the
graft in snug contact with the implant abutment

Figure 7a: Crescent shaped free gingival graft lightly
pushes against gingival wall.
Figure 7b: Diagram of crescent shaped free gingival graft
in place.
Han et al
Figure 8: Suture entering from the graft to labial tissue.
or provisional restoration (figure 7a). The graft-
implant margin will usually be approximately
1mm coronal to the existing gingival margin.
With the epithelium of the graft to the oral cav-
ity side, the bone graft and the exposed socket
environment are essentially sealed from the
oral cavity (figure 7b). Since the bucco-lingual
thickness of the graft is slightly thicker than the
recipient space, it may have a tendency to dis-
place. It is kept in the site using gentle pressure
with a blunt instrument while initiating suturing.
Placing a crescent graft that is too thick can
create excessive pressure and hinder blood and
nutrient flow to the graft. In such a situation, the
graft should be trimmed as needed. The suture
recommended is P-3 5-0 chromic gut or Vicryl™
suture. The first suture is started at the mid-
labial area with the needle entering through the
epithelium of the graft at the mid bucco-lingual
The Journal of Implant & Advanced Clinical Dentistry • 29
Han et al
Figure 9: Free gingival graft secured with three sutures.
thickness level. It penetrates through the graft
and the labial gingiva approximately 2-3mm api-
cal to the gingival margin (figure 8). Without
cutting, the suture is wrapped around the pro-
visional or slung over the abutment and tied to
the palatal tissue. This ensures that the labial
side of the graft is in good stable contact with
the labial gingival inner bleeding surface and
prevents the graft from being displaced coro-
nally out of the recipient site. The same type of
suture is placed in the mesial and distal aspects
of the graft. Most of the time, three sutures are
sufficient, but one or two more may be neces-
sary in larger grafts. The site should exhibit a
socket completely sealed with the epithelium of
the crescent connective tissue graft and a heal-
ing abutment or a provisional restoration (figure
9). It is also very important that the resulting
gingival margin at this point is usually 0.5-1mm
30 • Vol. 1, No. 5 • July/August 2009
Figure 10: 1 week postsurgical visit.
coronal to the final desired gingival margin
to compensate for possible future shrinkage.
Postoperative Instructions
The patient is instructed not to brush the area of
the surgery, but to apply chlorhexidine glucon-
ate (0.12%) twice daily and stay on a soft diet.
Direct functioning on the implant provisional is
not advised for a period of at least 2-3 months.
Antibiotics and analgesics should be prescribed
appropriately and the patient should be seen for a
1-2 week post-operative visit. A pinkish graft with
some sloughing epithelium indicates live tissue (fig.
10). Yellowish or white tissue appearance indi-
cates unsuccessful grafting. If the latter occurs,
remove the necrotic portion of the tissue with a
sharp scissors. The patient can return to normal
light brushing in 2 weeks and is advised to apply
chlorhexidine to the area twice a day after brushing.

Figure 11: Facial view of final restoration after 1 year in
function.
RESUlTS
The labial gingival margin one year after the final
implant restoration is stable at 1mm coronal to the
original gingival margin. There is a thick biotype
without gingival discoloration (figure 11). The peria-
pical radiograph indicates stable alveolar bone sur-
rounding the implant at a normal level (figure 12).
DISCUSSION
Immediate implant placement in a single staged
approach with or without provisionalization after
extraction, has been shown to preserve the ver-
tical height of the existing interdental papilla.5
There is, however, a propensity for labial gingival
recession over time. The difficulty in immediately
placing an implant in the changing environment
of an extraction socket lies in predicting which
socket will result in an unstable labial gingival
margin and which will remain stable over time. 14
Han et al
Figure 12: Periapical radiograph 1 year after restoration.
Factors which seem to matter most in deter-
mining labial marginal stability are not clear,
hence there is some controversy. Most would
agree that thickness and position of the underly-
ing bone and the biotype of the labial gingival
are important factors. However, determining the
adequate thickness of bone and biotype in rela-
tion to the patient’s physiology and function after
implant placement is difficult. If there exists in
the extraction socket a 2-3mm thickness of labial
bone within a 3mm distance from the final desired
The Journal of Implant & Advanced Clinical Dentistry • 31
Han et al
facial margin, additional bone or gingival graft-
ing may not have additional benefit on the gingi-
val stability.13 Placing implants with a distance
of 2mm(+) between the implant and the labial
socket wall will most likely result in 2-3mm of
labial bone thickness with minimal gingivial reces-
sion. This concept seems to be supported by a
recently published retrospective study by Chen.14
Other anatomical factors which may affect
the stability of the labial margin have been dif-
ficult to document. The results of studies which
examine the esthetics and stability of the labial
gingival margin can vary depending on the type
of implants used and which combinations of sur-
gical and restorative approaches were employed.
Without a controlled study that examines each
single factor and its significance, it would be
premature to dismiss any of the factors as being
most important for the stability of gingival margin.
Therefore, when placing an immediate implant
with a single staged approach in the esthetic
zone, a prudent strategy would be to overcom-
pensate for both soft and hard tissues to improve
the quality and quantity of labial gingival tissue.
Bone grafting of the socket gap up to
3mm of the facial gingival margin and enclos-
ing with crescent graft as described in this
technique can create a surgical healing envi-
ronment that promotes bone formation and
maintenance of thicker gingival tissue. The
crescent free gingival graft may result in retar-
dation of epithelial growth into the socket
and enhance healing of the surgical site.16
Additionally, thickening of the biotype at the
implant site with the crescent graft may inhibit
the facial gingival recession associated with
immediately placed dental implants in thin bio-
types.17-20 This concept is supported by several
32 • Vol. 1, No. 5 • July/August 2009
other studies which utilized different surgical
approaches to enhance the labial biotype and
reported stable gingival margins over time.21-23
SUMMARY
Optimal esthetics for implant therapy in the
esthetic zone depends on a synergistic relation-
ship between the underlying osseous architecture,
gingival anatomy, implant position, and implant
restoration. The bone and crescent shaped free
gingival augmentation technique described in this
article can help to preserve/enhance the labial soft
and hard tissues involved with immediately-placed
implants in a single staged approach. The epithe-
lial barrier provided by the crescent graft maintains
the labial socket space and keeps bone graft iso-
lated from the insults of the oral environment. The
free gingival graft can enhance the labial biotype
and improve the labial gingival marginal height.
One year post-restoration results showed stable
improved labial gingival margins over the implants
immediately placed in a one-stage approach. ●
Correspondence:
Dr. Thomas Han
3700 Wilshire Blvd., Ste 780
Los Angeles, CA 90010
213-380-7900
Email: thomhan@gmail.com
 Han et al

Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
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The Journal of Implant & Advanced Clinical Dentistry • 33

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 Deporter
Short Sintered Porous-Surfaced Dental Implants
with Indirect Sinus Elevation to Restore
the Resorbed Posterior Maxilla

Douglas A. Deporter, DDS, PhD1

Abstract

U
sing short sintered porous-surfaced dental
implants with the indirect sinus elevation
procedure is a minimally invasive approach
to replacing teeth in the resorbed posterior maxilla.
7mm long implants may be used at sites with as
little as 3mm of original subantral bone height with
predictable success if certain principles are recog-
nized and followed. In this short paper, the author
reviews the rationale, techniques used, and long
term patient outcomes with this innovative approach.

KEY WORDS: Dental implants, sinus lift, maxilla

1. Professor, Disciple of Periodontology, Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada

The Journal of Implant & Advanced Clinical Dentistry • 35

Deporter
IntRODUctIOn
Grafting of the maxillary sinus using an open
window approach1 and later placement of
long, threaded dental implants is recognized
as standard of care treatment in the manage-
ment of posterior maxillary partial edentulism
where inadequate native bone height exists.2,3
Factors affecting outcomes with such grafting
procedures include implant length and surface
roughness,2 as well as tobacco use, implants
replacing molar teeth, implant staging,4 and pre-
operative subantral bone height.5 Pre-operative
subantral bone height of ≥5mm and delayed
implant placement (i.e. not at the time of sinus
grafting) have provided the best outcomes.
Where pre-operative subantral bone height
was ≤ 4mm, implant failure rates of 8% were
reported to be the norm.4 Obtaining patient
consent for open sinus grafting is sometimes
not possible, however, because of extra costs
and associated risks.6 As a result, Summers7
introduced the concept of placing threaded
implants simultaneously with localized indirect
sinus floor elevation and graft placement using
hand osteotomes. However, where pre-oper-
ative subantral bone height was ≤ 4mm, unac-
ceptably high failure rates of 14% or more were
experienced with this approach.8,9 If long (mean
length 10.5mm) acid-treated threaded implants
were placed in 7mm of original subantral bone
height, failure rates were found to 2.5%.10
Sintered porous-surfaced press-fit (SPS) den-
tal implants have been shown to perform well
with 7mm implant lengths and as little as 3mm
of original subantral bone height with 3-year in
function failure rates of 1.9%.11 This paper out-
lines prerequisites for success with the indirect
sinus elevation approach using SPS implants.
36 • Vol. 1, No. 5 • July/August 2009
Figure 1: 11 year postsurgical radiograph of a 7.0 x 4.1mm
SPS implant placed with a modified Summers approach.
DIScUSSIOn
Over the past 15 years the author has devel-
oped and used the techniques to be reported
herein.11,12 Figure 1 shows a radiograph of
the first implant placed by the author using
the indirect sinus elevation approach after
11 years in function. The key to success is in
understanding differences in implant design
and mode of integration between threaded
implants of moderate surface roughness (e.g.
acid-washed with or without particle blasting,
Ti-Unite® etc.)13 and sintered surface press-fit
dental implants. Threaded implants are inte-
grated by surface contact with bone and often
need long lengths and/or wide diameters to
minimize unfavorable stress-related crestal
bone loss14-16 under function and maintain suc-
cessful long-term integration. In contrast, SPS
implants develop integration by bone ingrowth
into spaces (diameter size range 50 to 200um)
within a 3-dimensional porous surface layer
created by a proprietary high temperature sin-
tering process.17 This attachment mechanism
 Deporter

offers significant resistance to off-axis force

vectors on both the tensile and compres-
sive sides of the implant and helps to promote
more physiologic force levels and minimize
crestal bone loss even in short lengths (7mm
or less) and standard diameters (4.1mm).18
The author has used a slightly modified
Summers’ approach to place 7mm long SPS
implants in the posterior maxilla since 1995.12
The graft material of choice has been a bovine
xenograft (Bio-Oss®, Osteohealth Corp., Shir-
ley, NY) generally accepted as being appro-
priate for sinus elevation procedures.19-23 The Figure 2: 5 year postsurgical radiograph of two 7.0 x
major modification of the Summers’ approach7 4.1mm SPS implants placed in ≤3mm of existing subantral
made by the author was in the allowed depth bone using a modified Summers approach.
of penetration of osteotome tips into the sinus
domain. Summers7 had insisted that the cut- to achieve actual elevation of the Schneiderian
ting ends of all osteotome tips should not pen- membrane by contact with added graft par-
etrate beyond the original sinus floor, preferring ticles and the original apically impacted native

Table 1: Keys to Success with SPS Implants When Used

with the Indirect Sinus Elevation Approach
1. Non-smoking patients

2. No history of chronic use of steroidal nasal sprays for sinusitis

3. Pre-op loading dose (2 gms) of amoxicillin

4. Strictly sterile technique

5. Wide alveolar ridge

6. Secure press-fit implant stabilization

7. Submerged implant placement; only the healing cap above the alveolar crest

8. Adequate healing time to allow new bone formation

9. Careful prosthetic restoration ideally with screw-retained crowns

The Journal of Implant & Advanced Clinical Dentistry • 37

Deporter
bone collected by the instrument tip during its
advancement. In contrast, the author allows
osteotome tips to advance along with the plug
of native bone and added graft to the full depth
of 7mm needed for the osteotomy to receive a
7mm long SPS implant.12 This approach has
not created sinus complications likely because
of the short (7mm) implant length used. Even
where original subantral bone height is only
3mm (figure 2), maximum elevation of the mem-
brane would be 4mm and this is unlikely to lead
to significant tears in the sinus membrane.24-27
While alveolar ridge height is generally not
a limiting factor when using SPS implants and
the indirect sinus elevation technique, alveo-
lar ridge width is crucial. Others have shown
that to avoid unfavorable resorption of buc-
cal bone following implant placement, a mini-
mum of approximately 2mm thickness of this
bone should remain after osteotomy site prep-
aration.28,29 This is particularly important with
“rough” implant surfaces such as that on SPS
implants. Indeed, the wider the alveolar ridge,
the better. Therefore, if a 4.1mm diameter SPS
implant is to be placed in the posterior maxilla
using the osteotome sinus elevation technique,
an initial ridge width of 6mm or more is pre-
ferred. Advancement of the osteotomes will
produce some ridge expansion but, if the buc-
cal bone plate ends up being < 2mm in thick-
ness, it should immediately be augmented with
a graft and barrier material. Alternatively, the
site should be considered for ridge augmen-
tation grafting in preparation for later delayed
SPS implant placement or for a direct open win-
dow sinus grafting procedure to increase bone
height as well as ridge width and allow use of
another but longer dental implant device.10 This
38 • Vol. 1, No. 5 • July/August 2009
respect for buccal bone is extremely important.
One complicating factor with the osteot-
ome approach is that bone quality in the poste-
rior maxilla is not always of low density and on
occasion may require excessive tapping force
with the surgical mallet that would be unpleas-
ant for the patient and even lead to vertigo.30,31
To improve patient experience, the author rou-
tinely uses light oral sedation with triazolam
(a short-acting benzodiazepine) in all patients
to be managed with osteotomes. To avoid
the risk of vertigo in dense bone or where the
actual cortical sinus floor is unusually thick and
dense, a 2mm diameter pilot bur may be used
to establish initial osteotomy site depth before
using osteotomes to achieve the actual sinus
floor up-fracture and membrane elevation.32
When Summers first presented his indi-
rect osteotome sinus elevation procedure, he
included added graft particles intended to repo-
sition and support the Scheiderian membrane,
and most subsequent investigators including
the author have continued to follow his lead.33-
39
Other investigators, however, have confirmed
that in both open window and osteotome sinus
elevation techniques, outcomes may be equally
successful, assuming adequate initial implant
stability, without adding graft material(s).40-43
Provided that the sinus membrane can be ele-
vated and supported by the implant apex without
damaging the former, new bone will form within
the isolated blood-filled cavity contained by the
repositioned membrane. My colleagues and I
have studied this issue in rabbits.44 The rabbit
maxillary sinus has approximately 2mm of sub-
antral bone thickness. Implant osteotomies were
prepared in this bone and small SPS implants
(3mm long x 1mm diameter) placed, one per

Figure 3a: Immediate postsurgical radiograph of 7.0 x
4.1mm and 7.0 x 5.0mm SPS implants placed without
added graft particles.
side in 28 rabbits. Each rabbit received one
test implant site where the implant was placed
without added graft and one control implant
site where implant site development included
the use of Bio-Oss® graft particles. All implants
became successfully integrated. Histomor-
phometric assessment of site healing up to 8
weeks post-implantation showed bone ingrowth
into the sintered surface of all implants. While
there was a trend to more ingrowth with sites
that had received Bio-Oss®, it was not pos-
sible to detect a statistically significant differ-
ence between test and control sites. Armed
with this animal data, the author has eliminated
the use of added graft particles for any implant
site with a minimum of 4mm (and in some
cases even less) of original subantral bone
height. A sample case is depicted in figure 3.
A short dental implant has recently been
redefined as one with a “designed intrabony
length” (i.e. length of implant surface intended
to achieve and maintain contact with bone) of
Deporter
Figure 3b: 2 year postsurgical radiograph of the implants
from figure 3a.
≤ 8mm.45 The SPS implant length routinely
used by the author with the indirect sinus
placement procedure is 7mm but, since the
machined collar height of the implant is 2mm,
the “designed intrabony length” ends up being
only 5mm. This would appear to be the short-
est dental implant that has been successfully
used with a modified Summers approach. The
failure rate after 3 years in function of a group
of 104 SPS implants in 70 patients placed in
a mean subantral bone height of 4.2mm was
1.9%11 although a somewhat higher failure rate
has been observed in a teaching clinic environ-
ment with novice surgeons providing the same
treatment.10 Despite the short implant length
used with SPS implants, resulting crown-to-
root ratios (C/R) of restored implants did not
affect implant failure or crestal bone loss.46
If an intended implant site presents with
< 3mm of original subantral bone height, an
SPS implant can still be used to avoid an
open sinus grafting procedure. The author has
The Journal of Implant & Advanced Clinical Dentistry • 39
Deporter
Figure 4: 12 month postsurgical radiograph of a 7.0 x
5.0mm SPS implant placed with “future site development.”
used two approaches in this situation. The
first approach was to employ Summers “future
site development” procedure.47 Summers pre-
sented this technique for sites with ≤ 4mm of
original subantral bone where long threaded
implants were planned. He used a trephine to
free a plug of subantral bone that could then
be impacted upwards with a large diameter
osteotome and added exogenous graft parti-
cles. A separate future site development was
needed for each intended implant site. After
a healing interval of 7 or more months a den-
tal implant was inserted into each site that had
earlier received the localized trephine/bone
plug sinus elevation. Figure 4 shows an exam-
ple of a site at which this approach was taken
to allow later placement of an SPS implant.
Fugazzotto42 presented a somewhat simi-
lar crestal approach with a trephine in sites
with a minimum of 4mm of original subantral
bone height. A trephine with an internal diam-
eter of 3mm was used to create a plug of sub-
antral bone to a depth approximately 1 to 2mm
40 • Vol. 1, No. 5 • July/August 2009
short of the sinus floor, after which the plug
was mobilized and impacted upwards with a
matching osteotome tip and surgical mallet to
a depth of ~1mm short of the full osteotomy
site depth required. Following this step, a
surface-textured threaded implant was placed
so as to force the plug of trephined bone to
its fully seated depth within the sinus domain.
The author has used a further modification of
Fugazzotto’s approach to place SPS implants in
sites with < 3mm of original subantral bone. A
trephine with a 2mm internal diameter is used
to demarcate the plug to a depth within 1mm
from the sinus floor. This plug is then impacted
with osteotomes to a depth just beyond the
sinus floor. Added exogenous graft particles,
generally Bio-Oss, are then used with appro-
priate osteotome tips to create a 7mm deep
osteotomy following which a 7mm SPS implant
is placed using submerged technique. A sam-
ple site is shown in figures 5a-d. Two SPS
implants were used in the right maxilla. The
second molar site (Figure 5a) had 4mm of origi-
nal subantral bone height and was managed
successfully with the usual indirect sinus eleva-
tion procedure. However, the first molar site
had ~1mm of original subantral bone height
(Figure 5b). This latter site was managed with
the described trephine approach, the implant
being installed immediately (Figure 5c). There
was little risk of losing the implant into the sinus
cavity at the moment of insertion because of its
tapered conical shape. The author is not rec-
ommending this trephine approach to SPS
implant placement at this time as insufficient
relevant data exists. However, the approach
does support the conclusion that truly short45
SPS dental implants do perform extremely

Figure 5a: Presurgical radiograph demonstrating alveolar
ridge height of 3.5 – 4.0mm at the second molar site.
Figure 5b: Presurgical radiograph demonstrating alveolar
ridge height of 1.0 – 1.5mm at the first molar site. While
the first molar site had excellent alveolar ridge width, it had
only 1.0 to 1.5mm of original subantral bone; therefore, the
trephine technique was used at this site.
well in association with indirect sinus eleva-
tion in minimal original subantral bone height.
Some published guidelines meant to assist
the clinician in choosing the appropriate sinus
procedure for a particular clinical situation do
exist,48 but do not include SPS implants placed
Deporter
Figure 5c: Immediate postsurgical radiograph of 7.0 x
4.1mm and 7.0 x 5.0mm SPS implants placed at the sites
depicted in figures 5a and 5b.
Figure 5d: Five year postsurgical radiograph of the
implants from figure 5c.
with the indirect approach. Others10 have
designed a decision tree approach for the clini-
cian that includes SPS implants. In this decision
tree, it was suggested that for intended implant
sites with ≤ 3mm of subantral bone, espe-
cially where multiple implants are needed and
The Journal of Implant & Advanced Clinical Dentistry • 41
Deporter

where the clinician has chosen to use threaded 7mm of pre-treatment subantral bone height;
implants, a direct sinus elevation with delayed otherwise, a open sinus procedure with simul-
implant placement is indicated. For sites with taneous threaded implant placement may be
≤ 4mm bone height, where the clinician wishes more predictable especially if more than one
to use a single threaded implant, an indirect implant is needed. Open sinus grafting would,
sinus elevation using the “future site develop- however, always supersede indirect sinus
ment” approach of Summers47 and delayed elevation with implant placement when there
implant placement could be used. Sites with 3 was inadequate alveolar ridge width super-
to 7mm of existing bone height, adequate alve- imposed on limited subantral bone height. ●
olar ridge width (≥ 6mm) and need for one or
more implants can be handled by placing SPS
correspondence:
implants with the indirect sinus approach.11,12
Dr. D.A. Deporter, Faculty of Dentistry
Since only 7mm long SPS implants need
be used in the posterior maxilla,11,49 where University of Toronto
7mm of bone height exists, the use of SPS 124 Edward Street, Toronto, Ontario, Canada
implants can avoid the need for sinus proce- M5G 1G6
dures. However, if the clinician needs to use a Tel: (416) 979-4915 Ext. 4445
threaded implant (e.g. to satisfy the preference Fax: (416) 979-4936
of the referring dentist) with the indirect sinus douglas.deporter@dentistry.utoronto.ca
approach, it is recommended that there be ≥

Disclosure:
The authors report no conflicts of interest with
anything mentioned within this article.
Acknowledgements
The authors wish to thank Ms. Lynda Woodcock for
her administrative assistance.
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The Journal of Implant & Advanced Clinical Dentistry • 43
Gittleman
 Gittleman
Immediate Loading of
SybronPro™ XRT Implants in
the Symphyseal Region

Neal Gittleman, DMD, PC1

Abstract

Background: Past studies have often sup-
ported the use of a two-stage surgical pro-
tocol ensuring predictable osseointegration
for dental implants. More recent literature
reviews conclude, however, that after the
placement of dental implants, where multiple
teeth are extracted, both the patient and clini-
cian experience many challenges including dis-
comfort and inconvenience. This article will
discuss the use of several techniques that sup-
port an immediate load provisional prosthesis.
Methods: Five SybronPro™ XRT dental implants
were placed in the mandible and immediately
loaded with provisional prostheses. The technique
for fabricating these prostheses is described.
Results: Immediate loading of den-
tal implants may accomplish the following:
1) ensures patient comfort and more rapid func-
tion; 2) reduces number of denture adjustments;
3) eliminates need for tissue relining or condi-
tioning; 4) eliminates need for second surgical
procedure reducing treatment time; 5) positively
impacts patient’s psychological well being.
Conclusions: The technique described in this
article employs a novel approach for ensuring
the proper alignment of an immediate load man-
dibular prosthesis. This technique can also be
used when the opposing arch is immediately
edentulated, provided that the immediate upper
denture is fully seated and sufficiently stable.

KEY WORDS: Dental implants, implant supported prostheses, implant abutments

1. Private practice, Houston Prosthodontic Associates, Houston, TX, USA

The Journal of Implant & Advanced Clinical Dentistry • 45

Gittleman
IntRODuCtIOn
The discovery of the biocompatible properties
of titanium have improved the success rates of
implant dentistry and changed the quality of life
for many patients.1,2 Early and traditional implant
studies supported a two-stage surgical protocol
which often ensured predictable osseointegra-
tion.1 Typically, implants placed in the mandible
heal were allowed to heal for 3-4 months prior
to loading while this time was extended to 5-6
months in the maxilla.3 Unfortunately, the healing
phase following implant placement presents the
patient and clinician with many difficulties, espe-
cially if multiple teeth have been extracted or if
large edentulous spans exist.4 The discomfort,
inconvenience, and anxiety associated with this
healing time often tops the list of these difficulties.
Immediate loading of dental implants in the
edentulous mandible has gained popularity among
clinicians and patients due to the many benefits
over the traditional two-stage protocols.1-5 Patient
comfort and function are superior with immediate
loading of dental implants and the need for tissue
relining or conditioning of the mandibular denture
is eliminated. Additionally, secondary surgery for
abutment delivery is not required and total treat-
ment time is thus decreased. Lastly, there is a pos-
itive psychological impact for the patient as they do
not leave the office without functional “teeth” and
are not required to wear a non-implant retained
immediate denture, which is often frustrating.5
Many different techniques have been devel-
oped for immediate loading of dental implants in
the edentulous mandible. One technique involves
the placement of multiple implant fixtures with the
largest number concentrated between the mental
foramina and two fixtures located distolingual to the
foramina. A few fixtures were selected to support
46 • Vol. 1, No. 5 • July/August 2009
the prosthesis while the remaining were allowed
to heal in the conventional manner.6 The reason-
ing behind this concept was that sufficient support
for the prosthesis would be provided with the con-
ventional healing implants, even if the immediately
loaded implants failed.7 A second technique uses
transitional implants to support the temporary pros-
thesis. The transitional implants are usually located
between or posterior to the definitive implants.
Once osseointegration of the definitive implants is
achieved, these smaller diameter, screw-type pro-
visional implants are removed.5 A third technique
involves immediately loading the definitive implant
fixtures with the immediately placed dental prosthe-
sis.2 When controlled surgical and restorative pro-
tocols are followed, success rates for this technique
are well supported by the literature with findings of
up to 100% survival with long term follow up.8-10
This purpose of this case report is to dem-
onstrate an immediate loading protocol using
five SybronPro™ XRT (Sybron Implant Solutions,
Orange, CA) implants to support an immedi-
ately loaded mandibular provisional prosthesis.
ClInICAl tEChnIquE
A patient presented for treatment with teeth
numbers 22 through 27 and an ill-fitting man-
dibular partial prosthesis opposing a maxillary
complete denture. The patient requested that
his lower prosthesis be “bolted to his jawbone”
to eliminate its poor fit and mobility. A treatment
plan was devised to include the extraction of the
remaining mandibular teeth, alveloplasty, and
insertion of five implants for a fixed immediate
load mandibular prosthesis. The patient’s maxilla
was treated with a conventional upper denture.
The surgical aspect of the treatment plan was car-
ried out using both a surgical guide and cone beam
 Gittleman

Figure 1: Presurgical CBCT scan.

Figure 2: Placement of 5 dental implant fixtures. Figure 3: Transitional prosthesis adjusted to accommodate
implant abutments.

computed tomography (CBCT) technology (figure

1). Following extraction of teeth 22-27 and subse-
quent alveloplasty, five 4.1mm x 13mm SybronPro
XRT implants were placed anterior to the mental
foramina with five Octa abutments tightened to 25
Ncm. Flap closure was accomplished in the tradi-
tional manner and preparations were made for the
transitional restorative phase of treatment (figure 2).
Prior to surgery, a transitional prosthesis was
fabricated with the lingual aspect of the teeth Figure 4: Orthodontic cleats added to prosthesis to aid
carefully adjusted to accommodate five previously orientation.

The Journal of Implant & Advanced Clinical Dentistry • 47

Gittleman

Figure 5: Radiographic confirmation of abutment seating.

Figure 8: Initial abutment attachment to prosthesis.

Figure 6: Prosthesis relationship to abutments secured

with acrylic.

Figure 9: Finished prosthesis. Occlusal view.

Figure 7: Prosthesis maximum intercuspation achieved

with orthodontic bands.

casted abutments (figure 3). Orthodontic cleats Figure 10: Finished prosthesis. Intaglio view.
were placed on both the immediate load prosthesis
and the existing maxillary prosthesis for orientation
purposes (figure 4). In the laboratory, provisional
abutments were sandblasted to increase surface
area and provide improved mechanical retention.
The sandblasted abutments were then seated and

48 • Vol. 1, No. 5 • July/August 2009

 Gittleman

COnCluSIOn
The technique describei in this case report
employs a novel approach for ensuring the
proper alignment of an immediate load mandibu-
lar prosthesis. This technique can also be used
when the opposing arch is immediately edentu-
lated, provided that the immediate upper den-
ture is fully seated and sufficiently stable. ●

Figure 11: Intraoral fixture delivery.

Correspondence:
Dr. Neal B. Gittleman
accuracy of fit was confirmed radiographically (fig- 50 Briar Hollow Lane, Suite 150 West
ure 5). A rubber dam was then placed around the Houston, Texas 77027
hardware to protect the surgical site. With both Tel: 1-866-717-2329
the upper and lower prosthesis in place, a small Fax: 1-713-993-0223
amount of acrylic resin was bead-brushed onto the nealgittleman@msn.com
center three abutments (figure 6). The key to this
technique is to secure two or three implants to the
transitional prosthesis while minimizing any poten- Disclosure
The author reports no conflicts of interest with anything mentioned in this
tial movements that might disturb the orientation of article.
the prosthesis. At this point in time, the technique References
1. Gapski R, Wang H-L, Mascarenhas P, Lang N. Critical review of immediate
requires that the practitioner secure four orthodon- implant loading. Clin. Oral Impl Res 2003; 14: 515-527.

tic bands to the orthodontic cleats to aid in stability
by maintaining maximum intercuspation (figure 7).
After adequate curing time for the acrylic resin to
2. Ibanez J, Jalbout Z. Immediate Loading of Osseotite implants: Two- Year
Results. Implant Dent 2002; 11(2): 128-136.
3. Becker W, Becker B, Huffstetler S. Early Functional Loading at 5 days for
Branemark Implants Placed into Edentulous Mandibles: A Prospective,
Open-Ended Longitudinal Study. J Periodontol 2003; 74: 695-702.

lock into the sandblasted implant abutments, the
provisional prosthesis is adequately secured. The
rubber bands can now be removed and the pros-
thesis is unscrewed in order to fill voids and further
secure the provisional abutments to the prosthe-
sis. Once this is accomplished, the remaining
two abutments are once again attached using the
bead-brush technique as previously described (fig-
ure 8). The remaining acrylic work is completed
in the laboratory (figures 9, 10) and the finished
immediate load prosthesis seated appropriately
in the mouth. Screws are torque tightened to
4. Nagata M, Nagaoka S, Mukunoki O. The efficacy of modular transitional
implants placed simultaneously with implant fixtures. Compend Contin Educ
Dent 1999; 20: 39-42.
5. Misch C. Immediate Loading of Definitive Implants in the Edentulous Mandible
Using a Fixed Provisional Prosthesis: The Denture Conversion Technique. J
Oral Maxillofac Surg 2004, Suppl 2; 62: 106-115.
6. Schnitman P, Wohrle P, Rubenstein J. Immediate fixed interim prosthesis
supported by two-stage threaded implants. J Oral Implant 1990; 16(2): 96-
105.
7. Balshi T, Wolfinger G. Immediate loading of Branemark implants in edentulous
mandibles: A preliminary report. Implant Dent 1997; 6: 83-88.
8. Ganeles J, Rosenberg M, Holt R, et al. Immediate loading of implants with
fixed restorations in the completely edentulous mandible: Report of 27
patients from a private practice. Int J Oral Maxillofac Implants 2001; 16: 418-
426.
9. Grunder U. Immediate functional loading of immediate implants in edentulous
arches: Two-year results. Int J Periodont Restorative Dent 2001; 21: 545.
10. Cooper L, Rahman A, Moriarty J. Immediate mandibular rehabilitation with
endosseous implants: Simultaneous extraction, implant placement, and
loading. Int J Oral Maxillofac Implants 2002; 17: 517.

25 Ncm (figure 11) and occlusion is reverified.

The Journal of Implant & Advanced Clinical Dentistry • 49

JIACD Continuing Education

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 JIACD Continuing Education
JIACD Continuing Education
Oral Implications
of Cancer Chemotherapy

Nicholas Toscano1 • Dan Holtzclaw 2 • Istvan A. Hargitai 3

Nicholas Shumaker4 • Heather Richardson 5 • Greg Naylor6 • Robert Marx 7

Abstract

C
ancer ranks among the leading causes apy is of paramount importance. With optimal
of death in the world today. Although coordination of efforts of the entire treatment
chemotherapy has decreased mortal- team, including medical and dental provid-
ity rates of patients with cancer, the morbidity ers, the patient’s survival and quality of life will
associated with treatment continues. Initiation be enhanced. The purpose of this article is to
and implementation of a review cancer chemother-
comprehensive oral health apy, its associated compli-
program that monitors and cations, and management
treats patient before, dur- of the morbidity associ-
ing, and after chemother- ated with this treatment.

KEY WORDS: Cancer chemotherapy, oral complications, mucositis, xerostomia,

osteonecrosis, management

1. Private practice, Washington DC, USA

2. Department of Periodontics, US Naval Hospital, Pensacola, Florida, USA
3. Department of Orofacial Pain and Oral Medicine, US Naval Hospital, Naples, Italy
4. Department of Periodontics, Naval Health Clinic, Quantico, Virginia, USA
5. Private Practice, Denver, Colorado, USA
6. Former Associate Professor, Naval Postgraduate Dental School, Bethesda, Maryland, USA
7. Professor and Chief of Oral & Maxillofacial Surgery, University of Miami Leonard M. Miller School of Medicine

This article provides 2 hours of continuing education credit.

Please click here for details and additional information.

The Journal of Implant & Advanced Clinical Dentistry • 51

JIACD Continuing Education
Learning Objectives
After reading this article, the reader should be
able to:
1. Describe cancer treatment options and
the agents involved in chemotherapy.
2. Discuss the dental complications asso-
ciated with cancer chemotherapy.
3. Identify and manage the dental complica-
tions associated with cancer chemotherapy.
IntRODuCtIOn
Cancer ranks among the leading causes of
death in the world today. As dentists we may
be called upon to manage patients undergo-
ing cancer therapy. While chemotherapy has
decreased mortality rates of patients with cancer,
the morbidity associated with the treatment can
impair quality of life and interrupt cancer treat-
ment. The goal of dental management for these
patients is to prevent the development of oral
complications. The oral health team needs to be
involved with the patient’s treatment before, dur-
ing and after cancer therapy. The purpose of
this article is to review cancer chemotherapy,
the complications involved, and management
of the morbidity associated with this treatment.
Cancer entails a variety of disease states
characterized by the uncontrolled growth and
spread of abnormal cells. When this uncontrolled
growth is allowed to continue unchecked and
untreated, death is likely to occur. The etiology
of cancer can be grouped into both external fac-
tors and internal factors. External factors include
tobacco, alcohol, chemicals, solar and ionizing
radiation, infectious microorganisms, environmen-
tal pollutants, medications, and even nutrients.
52 • Vol. 1, No. 5 • July/August 2009
Internal factors include inherited mutations, hor-
mones, immune conditions, and mutations occur-
ring from errors in metabolism.1,2 All of these
factors may act synergistically or in sequence to
initiate the process of carcinogenesis. All can-
cer is caused by the malfunction of genes that
control cell growth, division, and maturation.
In 2005, the American Cancer Society esti-
mated that 1,372,910 new cancer cases would be
diagnosed in the United States.1,3-10 This estimate
did not include carcinoma in situ of any site except
the urinary bladder, and also did not include basal
and squamous cell carcinomas on the skin. It
was further estimated that approximately 570,280
Americans were expected to die of cancer in
2005, which equates to more than 1500 people
per day. Overall, cancer is the second leading
cause of death in the United States accounting
for 1 of every 4 deaths, and is exceeded only by
heart disease. For all cancer sites combined, Afri-
can American men have a 25% and 43% higher
cancer incidence and mortality rate than white
men. For all cancer sites combined, African-
American women have lower incidence rates than
do white women, but have a 20% higher mortal-
ity rate. The five-year survival rate for all cancer
sites has increased from 50% in 1974-1976, to
53% in 1983–1985, to 63% from 1992-1999.3-10
CAnCER tREAtmEnt AnD
CHEmOtHERAPY
Cancer is treated by surgery, chemotherapy, radi-
ation therapy, hormones and immunotherapy.1-3
Surgery is the most common method of treatment
for primary tumors and may be curative in well
circumscribed tumors. When a primary tumor
spreads and metastasizes, radiation therapy and
chemotherapy are necessary for definitive care.

Rapidly dividing cancer cells are extremely radi-
osensitive making radiation therapy an effective
adjunct or alternative for the regional treatment
of cancer. Chemotherapeutic regimens are used
effectively for disseminated cancer and may ulti-
mately provide relief of symptoms, prolong life,
and/or cure the disease. It is frequently used in
conjunction with surgery and radiation therapy
to ensure treatment success, and may be used
initially to decrease the size of the primary tumor
prior to surgery. Chemotherapy is responsible
for the long term survival of patients with hema-
tologic and other malignancies.11-13 A major
advantage of chemotherapy is its ability to treat
widespread or metastatic cancer, whereas sur-
gery and radiation therapies are limited to treat-
ing cancers that are confined to specific areas.
Chemotherapeutic regimens are intended to
destroy rapidly proliferating cancer cells. How-
ever, these agents are nonspecific and normal
host cells with high mitotic activity may also be
adversely affected. Normal tissues that are sus-
ceptible to injury by chemotherapeutic agents
include the oral and gastrointestinal mucosa, the
hematopoietic system, and hair follicles.12,17,18
Alkylating Agents. The alkylating agents are
considered proliferation-dependent, but cell-cycle
phase nonspecific. DNA alkylation can occur
anytime in the cell cycle. Examples of alkylating
agents used in chemotherapy include: mechlore-
thamine, cyclophosphamide, chlorambucil, ifosf-
amide, procarbazine, cisplatin, and oxaliplatin.12,17,18
Antimetabolites. These drugs replace the
natural building blocks in DNA molecules and
may alter the function of enzymes required for
cell metabolism and protein synthesis. Addi-
JIACD Continuing Education
tionally, they induce cellular starvation as they
mimic nutrients required for cell growth. Anti-
metabolites are cell-cycle specific and are
most effective during the S-phase of cell divi-
sion. Toxicities associated with these drugs
are seen in cells with elevated mitotic activ-
ity. Examples of antimetabolites include purine
antagonists, pyrimidine antagonists, and folate
antagonists such as 6-mercaptopurine, 5-fluo-
rouracil, gemcitabine, and methotrexate.12,17,18
Anti-tumor Antibiotics. These are a
diverse group of compounds that are cell cycle
nonspecific. These agents bind with DNA,
preventing RNA synthesis, disrupting protein
formation, and ultimately causing cell death.
Anti-tumor antibiotics are not the same as anti-
biotics used to treat bacterial infections. These
drugs cause uncoiling of DNA and prevent cell
reproduction. These agents are widely used
in the treatment of a variety of cancers. Some
examples of antitumor antibiotics include: dox-
orubicin, mitoxantrone, and bleomycin.12,17,18
Steroid and Hormonal Agents. These
agents include adrenocorticosteroids, estrogens,
antiestrogens, progesterones, and androgens.
Hormonal agents alter the hormonally dependent
intracellular environment of cancer cells. These
drugs may act as agonists to activate certain
receptors that ultimately inhibit tumor growth.
Alternately, they may act as antagonists that
compete with natural hormones that promote
tumor growth. Although the specific mechanism
of action is not entirely clear, steroid hormones
modify the growth of certain hormone-depen-
dent cancers. Tamoxifen, for example, is used
for estrogen-dependent breast cancer.12,17,18
The Journal of Implant & Advanced Clinical Dentistry • 53
JIACD Continuing Education
Plant Alkaloids. Plant derived alkaloids are
anti-tumor agents that act specifically by blocking
cell division during mitosis. They are commonly
used in the treatment of acute lymphoblastic leu-
kemia, Hodgkin’s and non-Hodgkin’s lymphomas,
neuroblastomas, Wilms’ tumor, and cancers of the
lung, breast and testes. Commonly used plant
alkaloids include vincristine and vinblastine.12,17,18
Bisphosphonates. As a class, they are
divided into two main categories: nitroge-
nous bisphosphonates and non-nitrogenous
bisphosphonates. Bisphosphonates inhibit
osteoclast action and are typically used in the
prevention or treatment of osteoporosis, osteitis
deformans, bone metastasis, multiple myeloma
and other conditions featuring bone fragility.
Newer Agents. Nitrosoureas act similarly to
alkylating agents and also inhibit changes nec-
essary for DNA repair. These agents cross the
blood-brain barrier and are therefore used to
treat brain tumors. They are also used to man-
age lymphomas, multiple myeloma, and malig-
nant melanoma. Carmustine and lomustine are
the major drugs in this category. Other newer
chemotherapeutic drugs target specific, active
proteins or processes in cancer cells, such as
receptors, growth factors, or kinases. Because
the targets are cancer-specific proteins, the hope
is that these drugs will be much less toxic to nor-
mal cells than conventional cancer drugs.17,18
ORAl COmPlICAtIOnS
Chemotherapeutic agents are toxic compounds
that target rapidly proliferating cells, both malig-
nant and normal. The level and type of toxicity
of the regimen depends on the patient, the type
54 • Vol. 1, No. 5 • July/August 2009
of tumor, and therapy-related variables. Patient-
related variables include the overall health and
immunity of the patient before and during che-
motherapy. Therapy-related variables involve
the regimen, frequency of treatment, dosage,
and route of administration. Fortunately, many
normal adult cells do not divide rapidly and are
less sensitive to the toxic effects of the chemo-
therapy. Certain normal cells, however, such as
those of the oral and gastrointestinal mucosa,
hemopoietic system, and hair follicles divide
more rapidly. Thus, the effects of chemother-
apy may result in a myriad of oral complications
which include: mucositis, pain, infection, hem-
orrhage, xerostomia, neurologic and nutritional
problems. It is extremely important to antici-
pate and recognize the conditions that predis-
pose patients to complications so that they can
be prevented or minimized by proper manage-
ment before, during, and after chemotherapy.12
mucositis
Mucositis is the inflammation of the mucous lin-
ings of the digestive tract which can lead to frank
ulceration. It is the most common oral complica-
tion associated with the use of chemotherapeu-
tic agents, occurring in approximately half of the
patients undergoing chemotherapy.12,13,19-21 When
both chemotherapy and radiation therapy are
used concomitantly, the incidence of mucosi-
tis increases to 80-90%.13,23 It is both a painful
and debilitating condition that is a dose and rate-
limiting adverse effect of chemotherapy. Within
the oral cavity, the non-keratinized areas such
as the buccal mucosa, floor of mouth, ventral
tongue, and soft palate are the most commonly
affected sites. 58 Mucositis can be assessed clini-
cally and with subjective input from the patient.

Table 1: The WHO Mucositis Scale
Grade Clinical Presentation
0 Normal
1 Soreness with or without erythema
2 Ulceration and erythema
3 Ulceration and erythema, patient cannot swallow solid food
4 Ulceration/pseudomembrane formation of such severity that feeding is not possible
The World Health Organization (WHO) mucosi-
tis scale combines the objective and the sub-
jective into a useful grading system (Table 1).
Pain is the most frequent symptom resulting
from chemotherapy-induced mucositis. Another
notable concern is the susceptibility to infec-
tion from normal oral flora and transient micro-
organisms due to breakdown of the mucosal
barrier. In addition to the chemotherapeutic regi-
mens, certain patient variables may influence
the incidence of mucositis such as age, nutri-
tional status, oral hygiene, oral microflora, sali-
vary function, and immunologic function.12,13,19
The current working biological model for
mucositis is based on 5 phases: initiation, mes-
sage generation, signal amplification, ulceration,
and healing phase. In the initiation phase, the
chemotherapeutic agents cause cellular damage
directly and indirectly via the generation of free
radicals. In the message generation phase, tran-
scription factors are activated, which induce the
release of pro-inflammatory cytokines and tumor
necrosis factors. The resulting inflammation ulti-
mately increases the concentration of chemo-
therapeutic agents at the site. During the signal
JIACD Continuing Education
amplification phase, positive feedback loops are
activated which contribute directly to cellular and
tissue injury. The result is erythema and epithe-
lial atrophy 5 days after the initiation of chemo-
therapy. Ulceration can be induced by trauma
from day-to-day activities, such as speech, swal-
lowing, and mastication. Bacteria within the
ulcers produce endotoxins in the mucosal tis-
sues. This ulceration phase is most responsible
for the pain and decreased food intake associated
with mucositis. During the fifth and final healing
phase, cell proliferation occurs with re-epithe-
lialization of ulcer. Reconstitution of the white
blood cells regains local control of bacteria, which
also contributes to resolution of the ulcer.21,24
Clinically, the earliest change is characterized
by leukoedema. This change presents as a dif-
fuse, poorly defined area of pallor or milky-white
opalescence most noticeable on the buccal
mucosa. Leukoedema will disappear when the
mucosa is stretched. Clinical mucositis begins
5-10 days following the initiation of chemotherapy
and resolves in 2-3 weeks in more than 90% of
patients and correlates with a normal white blood
cell count.19,24 Mucositis manifests as areas of
The Journal of Implant & Advanced Clinical Dentistry • 55
JIACD Continuing Education
erythema and atrophy on the mucosa that break
down to form ulcers which are covered by a yel-
lowish white fibrin clot or pseudomembrane
(Figure 1). Peripheral erythema is usually pres-
ent. Ulcers may range from 0.5 cm to greater
than 4 cm in maximum dimension. Mucositis
pain results in difficulty opening the mouth, dys-
phagia, and difficulty with oral hygiene.19,21,24
Management. Treatment is primarily empiri-
cal and designed to improve patient comfort and
to minimize infections. Though much research has
been dedicated to this topic, results are difficult to
interpret. The grading of mucositis is not consis-
tent study to study, and many protocols were not
placebo-controlled. With this in mind we begin
by discussing mucositis prevention. Cryotherapy
or local utilization of ice chips in the mouth 5 min-
utes before and during the first 30 minutes of
drug infusion has been shown to reduce mucosi-
tis with certain chemotherapeutic regimens.39,53
Cryotherapy is thought to reduce blood flow to
the oral mucosa, minimizing exposure to the toxic
effects of chemotherapy. Recent attention has
been given to keratinocyte growth factors (KGF)
such as palifermin in oral mucositis prevention for
hematologic cancers.54-55 KGF is protective of epi-
thelial tissues and one study showed that palifer-
min given for three consecutive days (60 µg/ kg)
before total body radiation and high dose che-
motherapy resulted in a 35% reduction in WHO
grade 3 or 4 mucositis, decreased mucositis dura-
tion from 9 to 3 days, and resulted in fewer inci-
dents of febrile neutropenia compared to placebo.
55 Side effects included rash and taste alteration.
Further studies are needed to assess KGF use-
fulness and safety in other forms of malignancy.
Immediately after chemotherapy, a base-
56 • Vol. 1, No. 5 • July/August 2009
Figure 1: Patient presenting with mucositis during
chemotherapy.
line mucositis grading should be performed and
repeated once a day until resolution. The provider
should also assess for pain, nutrition, and saliva
production. An essential part of the oral care
is the frequent and liberal use of a mouthrinse
for the removal of debris.37 When selecting a
mouthrinse, avoid those containing alcohol, phe-
nol, aromatics, astringents, oils, and antiseptics.
A sodium bicarbonate rinse of one-half teaspoon
of saline and one-half teaspoon of baking soda in
sixteen ounces of water reduces acidity, dilutes
accumulating mucus, and minimizes yeast colo-
nization. Avoid products irritating to the oral tis-
sues such as alcohol, tobacco, spicy and course
foods, high acid containing foods and beverages
and refrain from using removable prostheses20,23.37
For patients who have difficulty performing oral
hygiene or eating because of pain, topical anes-
thetic agents can be utilized. Examples of topical
anesthetics include viscous lidocaine, dyclonine,
or diphenhydramine hydrochloride.38 These topi-
cal agents are frequently combined with coating
agents such as kaolin with pectin (Kaopectate),
magnesium hydroxide or aluminum hydroxide (Milk

Figure 2: Radiograph suggests presence of periapical
infection with possible spread to adjacent bone.
of Magnesia, Mylanta) to prolong patient comfort.
The KLB suspension is available on most hospital
formularies and consists of equal parts kaolin, vis-
cous lidocaine, and diphenhydramine (Benadryl).
Patients need to be counseled that these agents
may initially burn upon application, increase the
risk of self-induced trauma, decrease taste acuity,
and interfere with swallowing that could lead to
aspiration by depression of the gag reflex.19 Low-
level laser therapy (LLLT) has found to be stimu-
lating on epithelial cells. Advances in LLLT have
shown efficacy both as a treatment to heal ulcers
and as a preventive measure for mucositis.56-57
If systemic analgesia is necessary, acetamino-
phen or opioids in combination with acetamino-
phen are the most appropriate.19 Preparations
also available in elixir form for easier swallowing.
Infection
Bacterial infections dramatically contribute to
morbidity and mortality in patients receiving che-
motherapy and oral sources account for 25 to
50% of the infections in these patients.23 Che-
motherapy-related oral infections may involve the
JIACD Continuing Education
teeth, gingiva, salivary glands, or mucosa (Figure
2).12 It is of paramount importance to remember
that the cardinal signs of infection are not always
present in the myelosuppressed patient. Ery-
thema and swelling may not be present, therefore
monitoring for more reliable indicators such as
fever, pain, and the presence of lesions is nec-
essary. Coagulase-negative staphylococci and
streptococci oral flora are other common sources
of infection in myelosuppressed individuals.13,19,23
Additional opportunistic microorganisms that
cause infections include: Klebsiella pneumo-
nia, Pseudomonas aeruginosa, and Escherichia
coli.12,13,25 When the patient’s granulocyte count
falls below 1,000 mm3, pathogenic microorgan-
isms found subgingivally or in the periradicular
area may cause acute exacerbations of pre-exist-
ing periodontal or periradicular infections.13,26
Brushing teeth 2 to 3 times a day and daily
flossing should be continued during chemo-
therapy as the increased risk of infection associ-
ated with inadequate oral hygiene may outweigh
the increased risk of bleeding.19 However dur-
ing the thrombocytopenic phase of chemo-
therapy, a modified mechanical approach using
a piece of gauze, or cotton swab with a topi-
cal antimicrobial agent such as chlorhexidine
or povidone iodine solutions, may be prudent.
Should an acute odontogenic infection arise
during this period that may require dental inter-
vention, consultation with the primary care physi-
cian is needed to determine the patient’s ability
to tolerate dental care. Furthermore, even if there
is no infection present, but emergency dental
care needs to be provided, the need for antimi-
crobial prophylaxis should be determined based
on the patient’s white blood cell count (WBC).
A WBC under 2,500/mm3 or an absolute neutro-
The Journal of Implant & Advanced Clinical Dentistry • 57
JIACD Continuing Education
phil count of less than 500/mm3 warrants antimi-
crobial prophylaxis before dental procedures that
produce bleeding and lead to bacteremia.59-60
Fungal infections can be one of the most
dangerous complications for the chemother-
apy patient. The most common infection is from
Candida sp.13,23 Systemic fungal infections
have a higher mortality rate than any other infec-
tion in the myelosuppressed patient. The major-
ity of systemic fungal infections are believed to
originate from the oral cavity.13 Under normal
conditions, C albicans growth is inhibited by
other microorganisms such as Lactobacillus aci-
dophilus, and an intact immune system. Both
these inhibitors are altered during chemotherapy.
Clinically, C albicans infection, or candido-
sis, may present in several forms. The lesions
are either a white or a red patch, and are either
acute or chronic. In the myelosuppressed, low
grade chronic infections can have acute exac-
erbations. Acute pseudomembranous candi-
dosis, is an infection of the superficial layers
of the oral mucosa (Figure 3). It presents as
a white plaque which can easily be rubbed off.
Removal of the pseudomembrane reveals a
raw, red ulcer or area of erythema. There may
be a burning symptom reported. Acute atro-
phic candidosis is a raw, red, painful patch. It
lacks a pseudomembrane. Chronic atrophic
candidosis includes angular cheilitis and den-
ture stomatitis. Ill fitting or porous maxillary den-
ture bases are sources of chronic irritation and
serve as a nidus for C albicans. Angular cheili-
tis is an infection of the corner of the mouth
occasionally with a Staphylococcus species
co-infection. Chronic hyperplastic candidosis
is a white patch that does not rub off, char-
acterized by deeper invasion of the mucosa.
58 • Vol. 1, No. 5 • July/August 2009
Figure 3: Patient presenting with oral candida infection
post chemotherapy treatment.
Management. Due to the increased mor-
bidity and mortality associated with fungal infec-
tions and the difficulty with early diagnosis, any
superficial evidence of fungal infection in the
oral cavity or oropharynx necessitates immedi-
ate aggressive intervention to prevent systemic
spread.40 Fluconazole is the most reliable and
frequently recommended prophylactic agent to
prevent oropharyngeal candidosis in the myelo-
suppressed patient.40 A loading dose of two 100
mg tablets of Fluconazole followed by one tab-
let per day should be continued for 2-3 weeks.
Fluconazole is not effective against Aspergil-
lus species and some resistant Candida spe-
cies. Itraconazole and Ketoconazole may be used
for resistant cases with Amphotericin B as the
drug of last resort. For patients with dental pros-
theses, dentures can be left out of the mouth or
treated with nystatin ointment or powder inside
the denture base after it is cleaned at each meal.
Viral infections most commonly seen in the
chemotherapy patients include the herpes sim-
plex virus (HSV), varicella zoster virus (VZV),
and cytomegalovirus (CMV). These herpes fam-

Figure 4: Outbreak of CMV during chemotherapy.
ily viruses are known for their latency stage fol-
lowing primary infection and can be reactivated
during immunosupression.27 The incidence of
recurrent HSV infection has been shown to
occur in 48% of the patients undergoing chemo-
therapy.28 HSV recurrence may appear 7 to 14
days following administration of chemotherapy.27,28
The severity of the case is directly related to the
degree of immunosuppression.27 Recurrent HSV
lesions can be found on the lip or on keratinized
gingival or palatal surfaces as a small cluster of
vesicles that rapidly ulcerate and coalesce. The
condition is self-limiting and resolves in 2 weeks.
Recurrent VZV infection is termed herpes
zoster or shingles. It can occur on any dermatome
of the body. When it occurs within the trigeminal
dermatome, lesions can be found on the face or
intraorally. They follow and stay confined to their
respective trigeminal divisions. Characteristi-
cally they abruptly halt at the midline. As in HSV,
intraoral VZV recurrence is confined to kerati-
nized tissues. In the chemotherapy patient, herpes
zoster manifests several weeks after completion
of chemotherapy. In immunosuppressed patients,
an atypical widespread distribution may occur.
JIACD Continuing Education
Lesions are painful and may last several weeks.
CMV infections result in a fever that resolves
in 3 to 5 days. The most common clinical find-
ings involve esophagitis, gastritis, colitis, hepatitis,
pneumonitis, and retinitis. Intraoral CMV infections
may present as irregular pseudomembranous ulcer-
ations with a granulomatous base (Figure 4). Dis-
semination of CMV may occur and such infections
are often fatal in immunosuppressed patients.29
A number of oncology treatment centers rec-
ommend prophylactic antiviral agents in the patient
with evidence of previous viral exposure.19,26,27,29
For HSV seropositive patients undergoing stem
cell transplantation, intravenous acyclovir adminis-
tration is the standard of care to reduce the risk
of recurrent infection and to treat mucocutane-
ous infection.27,29 For patients with less severe
myelosuppression, oral acyclovir, famciclovir, or
valacyclovir may be effective. The famciclovir oral
regimen for HSV is 500 mg bid for seven days.
Clinical findings reveal that antiviral prophylaxis
for recurrent VZV is not effective and only delays
reactivation and increases development of resis-
tance. Initial therapy for herpes zoster with valacy-
clovir is 1,000 mg tid for seven days. For treatment
of resistant HSV and VZV, foscarnet is the drug of
choice. Either foscarnet or ganciclovir are recom-
mended in the prophylaxis and treatment of CMV.27
Hemorrhage
Chemotherapeutic agents may secondarily induce
thrombocytopenia, which is the most common
cause of intraoral bleeding. Hemorrhage may
occur anywhere in the mouth and may be spon-
taneous, traumatically induced, or result from
existing disease. Hemorrhage may present clini-
cally as gingival bleeding or submucosal bleeding
with hematoma formation. Profound thrombocy-
The Journal of Implant & Advanced Clinical Dentistry • 59
JIACD Continuing Education
Figure 5: Patients often present with beefy red tongue
from xerostomia.
topenia ( <20,000 mm3) is responsible for these
changes, however qualitative platelet character-
istics are also altered during chemotherapy.12,30-33
When the hemopoietic tissues are suppressed
by chemotherapeutic regimens and reach their
nadir, maximum stomatotoxicity occurs. Recovery
of the oral mucosa precedes recovery of the bone
marrow by about 2 to 3 days and ultimately pre-
dicts the recovery of the hemopoietic tissues.12,31
Bleeding potential can be assessed by laboratory
testing. The thrombocyte count gives the provider
the quantity of platelets and the bleeding time
will show the quality and function of the platelets.
Management. Prevention is the key to con-
trolling hemorrhage. This is accomplished before
chemotherapy begins by eliminating potential areas
of trauma such as sharp restorations, fractured
teeth, orthodontic brackets, or any other pre-exist-
ing oral disease. When platelet counts are below
20,000 mm3, conventional oral hygiene may be too
traumatic.26 In these cases, the modified mechan-
ical approach discussed earlier should be imple-
mented. Accumulated blood should be removed
60 • Vol. 1, No. 5 • July/August 2009
in order to identify the bleeding site and then
pressure should be applied with moist gauze, peri-
odontal packing, or a mucosal guard. A variety of
topical antihemorrhagic agents may be used, such
as absorbable gelatin sponges, oxidized cellulose,
aminocaproic acid, thrombin, or tranexamic acid.
If necessary, dental treatment may be accom-
plished at this time if platelet counts are greater
than 50,000 mm3. However, if platelet counts
fall below this level, the benefit of dental care
may not outweigh the risk. If the hemorrhage
is the result of an infection and surgical inter-
vention is necessary, a platelet transfusion
should be accomplished prior to the surgery.33
Xerostomia
The subjective report of a dry mouth is xerosto-
mia. It may be real or perceived. Although only a
small number of chemotherapeutic agents cause
xerostomia, the effect may be devastating when it
occurs in conjunction with an existing mucositis.
Alterations in salivary flow and may predispose the
patient to oral candidosis, dysphagia, and malnu-
trition. Reduced amounts of salivary amylase and
IgA levels may result in increased incidence of oral
infections by opportunistic microorganisms.13,34
Also, the salivary secretion of chemotherapeutic
agents may contribute to the incidence of mucosi-
tis.19 Xerostomia may also be influenced by the
patient’s hydration levels and medications. The
most common medications known to cause xeros-
tomia are diuretics, antihistamines, antipsychot-
ics, beta blockers, and tricyclic antidepressants.
A decrease in saliva causes the oral mucosa
to appear shiny, atrophic, and desiccated (Fig-
ure 5). Lack of saliva promotes the accumula-
tion of bacteria, plaque, and material alba, which
increases the patient’s susceptibility to caries and

periodontal disease. Lipstick sticking to the teeth
and the tongue sticking to the intraoral mirror are
signs of a dry mouth. Milking the parotid gland
for saliva or observing its build up in the floor of
the mouth are other measures to assess salivary
flow. Better saliva measurement techniques are
available such as the use of a Carlson-Crittenden
cup to measure parotid salivary flow, but they are
not utilized much outside the research setting.
Management. Chemotherapy-induced xeros-
tomia is usually of short duration and normal sali-
vary function frequently returns several months
after completion of chemotherapy. During che-
motherapy, patients may manage dry mouth by
frequently sipping on water, ice chips, and chew-
ing xylitol-containing gum. Other measures would
be those that conserve hydration. Avoiding smoke
tobacco, alcohol based mouthwashes and bev-
erages, caffeine, and mouth breathing. A humidi-
fier by the bedside may also be of value at night
time. A number of over the counter saliva sub-
stitutes, moisturizers, and stimulants are avail-
able for patient use. The saliva substitutes are
predominantly carboxymethylcellulose-based and
although they provide viscosity, they are inad-
equate substitutes for saliva. Biotene oral prod-
ucts, such as toothpaste, chewing gum, and
mouthwash used in combination with oral lubri-
cant may mimic the actions of saliva and have
found acceptance by a number of patients.41
Alternative treatments such as acupuncture and
electric stimulation of the salivary glands have
shown limited success and acceptance.62-63
When local measures are insufficient, the
parasympathomimetics like pilocarpine 5 mg
taken 3-5 times daily has shown success when
used in radiation-induced xerostomia and is effec-
JIACD Continuing Education
tive in patients that have reduced salivary gland
function.63 Common side effects, except for the
sweating, are usually mild and include headache,
rhinorrhea, increased lacrimation, and urinary fre-
quency. A newer medication is cevimeline which
does not bind as strongly to muscarinic recep-
tors on sweat glands and thus is an improvement
over pilocarpine.64 It is a 30 mg tablet taken tid.
neurological Problems
Chemotherapy-induced neuropathy may be char-
acterized by pain or paresthesia, especially with
the administration of plant alkaloids such as vin-
cristine, vinblastine, and etoposide.12,13,30,31,35
Other agents capable of causing neuropathy
are altretamine, carboplatin, cisplatin, cladribine,
docataxel, oxaliplatin, paclitaxel, procarbazine, and
thalidomide.18,36 Neurological symptoms frequently
disappear after the chemotherapeutic agent is dis-
continued.12,31 Therefore, the diagnosis of oral pain
may be challenging because the symptomatology
may be either quiescent or aggravating, depend-
ing on the stage of chemotherapeutic regimen.
Bisphosphonate-Induced Osteonecrosis
Although the class of drugs known as bisphos-
phonates are not anti-cancer chemotherapy drugs
because they are not cytotoxic to cancer cells, they
nevertheless produce a serious side effect limited
to the jaws: bisphosphonate induced osteonecro-
sis of the jaws (BIONJ).43 The mechanism of their
therapeutic value is the same as their toxic effect.
That is, they induce apoptosis (cell death) in nor-
mal osteoclasts and osteoclast precursors.44, 45
Two drugs associated with BIONJ are
pamidronate (Aredia), usually given intravenously
at 90 mg monthly, and zoledronate (Zometa) usu-
ally given at a dose of 4 mg monthly. Their indi-
The Journal of Implant & Advanced Clinical Dentistry • 61
JIACD Continuing Education
Figure 6: Significant spontaneous bone exposure (BIONJ)
in a patient who received intravenous Zometa therapy for
four years.
cation is to limit the bone resorption of metastatic
cancer deposits in bone and to lower serum
calcium levels in hypercalcemia of malignancy.
The toxicity of intravenous bisphosphonates
results from depleting the osteoclast population
and the osteoclast precursors in bone marrow so
that normal bone turnover, which is important to
bone maintenance and bone renewal, is severely
suppressed. Since most bisphosphonates have
a half life in bone of over 11 years,47 their bone
toxicity is related to the length of time which the
patient has taken the medication. For intravenous
bisphosphonates, such toxicity begins at about the
fifth dose and increases thereafter. The jaws are
targeted because of their rapid turnover48,49 and,
therefore, depend more significantly on osteo-
clastic function than any other bone in the adult
skeleton. As such, diseases or interventions that
require elevated levels of bone turnover such as
periodontal disease, tooth extractions, and implant
placements are known to precipitate BIONJ
expressed clinically as exposed nonhealing bone50.
Since its initial description in 2003,51 over
62 • Vol. 1, No. 5 • July/August 2009
Figure 7: Significant post extraction bone exposure
(BIONJ) in a patient who received intravenous Zometa
therapy for four years.
4,000 cases of intravenous BIONJ have been
reported to the United States Food and Drug
Administration (FDA). In addition, the profession
has learned important lessons about BIONJ and
has developed reasonable protocols to prevent
many cases and manage this drug complication.
The primary lessons learned are that minor
office-based debridements of BIONJ typically
result in additional bone exposure and should
be avoided. Secondary bacterial colonization
and direct infection of exposed bone typically
incite pain. Because of the long half life of bis-
phosphonates in bone, discontinuation of intrave-
nous bisphosphonates does not result in healing
of the bone. Almost 25% of cases occur spon-
taneously, indicating that these are unlikely to be
prevented by dental means and are instead due
to the length of time over which a patient has
received the drug (Figure 6).52 About 75% of
cases are a result of a surgical procedure in the
either the maxilla or mandible (Figure 7) which
suggest that many cases are preventable by pre-
ventative dental care and periodontal mainte-

Figure 8: Dental implant placements in individuals who
have already received intravenous bisphosphonates posses
a significant risk for the development of BIONJ.
nance.52 Active periodontal disease and healing
extraction sockets are the two most consistent
inciting events due to the rapid turnover of bone.
Management. Since intravenous bisphospho-
nates accumulate in bone rapidly and risk of BIONJ
may be realized after as little as five doses, it is
best to begin dental preventative measures prior to
or within the first three months of bisphosphonate
administration.52,47 It would be ideal for the den-
tal profession to develop a closer working relation-
ship with the medical oncologists who prescribe
these drugs in their treatments and gain referrals
prior to therapy or at the start of therapy. During
this time, unsalvageable teeth should be removed
first and then followed by any required periodontal
surgery and maintenance. This should be followed
by endodontic, restorative and prosthodontic care
aimed at stabilizing the dentition and reducing
the need for extractions, periodontal surgeries,
and other procedures that may require bone heal-
ing and regeneration. Although not well studied,
dental implant placements are thought to pose a
JIACD Continuing Education
Figure 9: Colony of Actinomyces with Eikenella on the bone
surface of a patient with BIONJ.
much higher risk for BIONJ (Figure 8) Adult ortho-
dontics should only be considered with caution.
After five doses of intravenous bisphospho-
nates, its accumulation in bone increases BIONJ
risk. Therefore, after the fifth dose, surgical proce-
dures in the jaws should be avoided if possible.
Discontinuing intravenous bisphosphonates does
not seem to significantly reduce the risk for BIONJ.
It is preferable to treat nonrestorable teeth with
root canal therapy and crown amputation rather
than risk BIONJ from an extraction. By the same
token, mobile teeth that are not abscessed and
have a reasonable amount of bone around their
root surfaces are best splinted than extracted.
If teeth are abscessed with no options other
than extraction, it should be accomplished with
informed consent describing the high likelihood
of exposed bone that will not heal and may result
in a fracture or the need for resective surgery.
The treatment goals in cases of BIONJ are
infection control, pain control, and limitation
of extension. This is based on the experience
that only major jaw resections can predictably
The Journal of Implant & Advanced Clinical Dentistry • 63
JIACD Continuing Education
resolve BIONJ and that due to their cancers
and/or their cancer therapies many are not
good candidates for extensive surgery. Instead,
it has been found that 89% of such patients
can be managed to a pain free state with ade-
quate function with the use of antibiotic regi-
mens and a 0.12% chlorhexideine rinse.52
Because the four most common microorgan-
isms seen in BIONJ are Actinomyces, Moraxella,
Eikenella, and Viellonella (Figure 9), the most use-
ful antibiotic for the treatment of BIONJ is oral
phenoxymethyl penicillin (penicillin V-K) 500 mg.
Penicillin VK 500 mg four times daily combined
with 0.12% chlorhexidine (Peridex) oral rinses
three times daily is baseline therapy. Due to the
lack of human toxicity of penicillin VK and its long
term gastrointestinal tolerance it has been used
continuously over many months and even years.
That is, after an initial control of pain at four times
daily a twice daily maintenance schedule can be
used. However, if the referring physician or the
patient expresses a concern about long term anti-
biotic use, the penicillin VK may be limited to use
only at the time of pain recurrence. Clindamycin
is not recommended due to its reduced or even
total lack of activity against these organisms.
If the patient is penicillin allergic, levoflaxa-
cin (Levaquin) 500 mg once daily, clarithromy-
cin (Biaxin) 500 mg twice daily or doxycycline
(Vibramycin) 100 mg twice daily are useful second
choices. However, these antibiotics each have
their own toxicity and are best used as 21-day
courses at times of painful episodes. If the patient
has a minimal response to any of these baseline
antibiotic regimens or has frequent exacerba-
tion, the addition of metronidazole (Flagyl) 500
mg three times daily has shown to be very useful.
Patients that are refractory to these regimens with
64 • Vol. 1, No. 5 • July/August 2009
frequent or painful episodes or who develop a
pathologic fracture are candidates for a resection.
Resections of the mandible for refractory
cases have been necessary in only 13 of 134
(10%) of patients in our experience.52 In each
case, the BIONJ was resolved and did not recur.
With resections of the mandible, immediate or
even delayed reconstruction with bone grafts
is a risk and has not been adequately explored.
Rigid titanium plate reconstruction has been the
mainstay in retaining jaw continuity, form, and
function without infections or plate exposures.
In maxillary resections, a prosthodontist should
be consulted to provide an obturator appli-
ance as is done for maxillary cancer resections.
nutritional Problems
Chemotherapy-induced mucositis may signifi-
cantly impair the patient’s nutritional and caloric
intake. Further compromising the patient’s nutri-
tional status is chemotherapy-induced nausea,
vomiting, diarrhea, anorexia, enteritis, malabsorp-
tion, and impaired liver function. The diet dur-
ing mucositis is tailored to the patient’s ability to
eat solid foods. If chewing is too painful, a liquid
diet can be prescribed. Food that would take
shape of its container would be characterized
as a liquid (broth, pudding, mashed potatoes,
baby food). If the patient is unable to tolerate liq-
uids, total parenteral nutrition will be prescribed.
SummARY
Chemotherapy patients may experience acute and
chronic oral complications. The severity of oral
complications may necessitate modification or
cessation of the chemotherapy regimen, negatively
impacting patient survival. Thus, the oral health-
care provider plays an important role in the multi-

disciplinary approach for overall treatment of these
patients. The goal of the oral healthcare provider
is to minimize, to the extent possible, interruption of
chemotherapy from dental and oral complications.
Ideally, prior to chemotherapy, patients should
undergo a thorough oral examination to include
both a clinical and radiographic evaluation. Even
if chemotherapy must begin immediately or
has already commenced, this examination pro-
vides a baseline for comparison and assists in
the monitoring and treatment of oral complica-
tions. It also serves to rule out any tumor metas-
tases to the mouth or jaws. Ultimately, the effect
of the chemotherapy on the patient’s oral health
is unpredictable and close follow-up is necessary.
Time and hematologic status permit-
ting, potential sources of infection and irrita-
tion should be treated and minimized at this
time. Initially, the patient should receive a den-
tal prophylaxis. Any teeth deemed unrestorable
or those with severe periodontal involvement
should be extracted. Any endodontically involved
teeth should be treated via root canal therapy
or extracted. In an ideal situation, all surgi-
cal procedures should be completed at least
10 days prior to the onset of neutropenia.12,13,31
Post-chemotherapeutic dental manage-
ment of the patient is essential. In most
cases, previously postponed dental proce-
dures can now be completed. It is important
to continually monitor the patient and to rein-
force proper oral homecare. Post-treatment
dental care should be directed at minimizing
recurrence of dental disease, providing pallia-
tion, and improving the patient’s quality of life.
Although chemotherapy has decreased
mortality rates of patients with cancer, the
morbidity associated with the treatment con-
JIACD Continuing Education
tinues. Initiation and implementation of a
comprehensive oral health program that moni-
tors and treats the patient before, during and
after chemotherapy is of paramount impor-
tance. With optimal coordination of efforts of
the entire treatment team, the patient’s sur-
vival and quality of life will be enhanced. ●
Professional Dental Education and Pro-
fessional Education Services Group
are joint sponsors with The Academy
of Dental Learning in providing this
continuing dental education activity.
The Academy of Dental Learning
is an ADA CERP Recognized Pro-
vider. The Academy of Dental Learn-
ing designates this activity for two
hours of continuing education credits.
ADA CERP is a service of the Ameri-
can Dental Association to assist den-
tal professionals in identifying quality
providers of continuing dental educa-
tion. ADA CERP does not approve or
endorse individual courses or instruc-
tors, nor does it imply acceptance of
credit hours by boards of dentistry.
Correspondence:
Dr. Nicholas Toscano
Periodontics Department Head
Branch Health Clinic Washington Navy Yard
Adjunct Faculty Periodontics Department
Naval Postgraduate Dental School
navygumdoc@aol.com
The Journal of Implant & Advanced Clinical Dentistry • 65
JIACD Continuing Education
Disclosure:
The opinions and assertions contained in this article are the private ones of the
authors and are not to be construed as official or reflecting the views of the
Department of the Navy, Department of Defense or the US Government.
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44. Van Beek ER, Lowck CWGM, Papaoulous SE. Bisphosphonates Suppress
Bone Resorption by a Direct Effect on Early Osteoclast Precursors
Without Affecting the Osteoclastogenic Capacity of Osteogenic Cells.
The role of protein geranylgeranylation in the action of nitrogen-containing
bisphosphonates on osteoclast precursors. Bone 30:64-70, 2002
45. Russell RGG, Crowler PI, Rogers MJ. Bisphosphonates: Pharmacology,
Mechanism of Action and Clinical Uses. Osteoporosis. International Suppl
2:566-580, 1999
46. Major P. The use of Zoledronic Acid, a Novel, Highly Potent Bisphosphonate,
for the Treatment of Hypercalcemia of Malignancy. The Oncologist 7:481-491,
2002
47. Lasseter KC, Porros AG, Denker A, et al. Pharmacokinetic Considerations in
Determining the Terminal Elimination Half Lives of Bisphosphonates. Clin Drug
Invest. 25:107-114, 2005
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48. Dixon RB, Tricker ND, Garetto LP. Bone Turnover in Elderly Canine Mandible
and Tibia [abstract 2579]. J Dent. Res 76:336, 1997
49. Viznery A, Baron R. Dynamic Histomorphometry of Alveolar Bone
Remodeling in the Adult Rat. Anat Res, 196:191-200, 1980
50. Marx RE ed. Oral and Intravenous Bisphosphonate Induced Osteonecrosis
of The Jaws History, Etiology, Prevention, and Treatment. Quintessence Publ
Co Inc. Chicago 2007 pp 49-76
51. Marx RE. Pamidronate (Aredia) and Zoledronate (Zometa) Induced Avascular
Necrosis of the Jaws: A growing epidemic. J Oral Maxillofac Surg 61:1151-
1157, 2003
52. Marx RE, Sawatari Y, Fortin M, et al. Bisphosphonate Induced Exposed
Bone (osteonecrosis/osteopetrosis) of the Jaws: Risk Factors, Recognition,
Prevention and Treatment. J Oral Maxillofac Surg 63:1567-1575, 2005
53. Rocke LK, Loprinzi CL, Lee JK, Kunselman SJ, Iverson RK, Finck G, Lifsey D,
Glaw KC, Stevens BA, Hatfield AK, et al. A randomized clinical trial of two
different durations of oral cryotherapy for prevention of 5-fluorouracil-related
stomatitis.Cancer. 1993 Oct 1;72(7):2234-8.
54. Keefe D, Lees J, Horvath N. Palifermin for oral mucositis in the high-dose
chemotherapy and stem cell transplant setting: the Royal Adelaide Hospital
Cancer Centre experience. Support Care Cancer. 2006 Jun;14(6):580-2.
Epub 2006 May 3.
55. Spielberger R, Stiff P, Bensinger W, Gentile T, Weisdorf D, Kewalramani
T, Shea T, Yanovich S, Hansen K, Noga S, McCarty J, LeMaistre CF, Sung
EC, Blazar BR, Elhardt D, Chen MG, Emmanouilides C. Palifermin for oral
mucositis after intensive therapy for hematologic cancers. N Engl J Med.
For 2 hours
CE CrEdit
2004 Dec 16;351(25):2590-8.
56. Nes AG, Posso MB. Patients with moderate chemotherapy-induced
mucositis: pain therapy using low intensity lasers. Int Nurs Rev. 2005
Mar;52(1):68-72.
57. Arora H, Pai KM, Maiya A, Vidyasagar MS, Rajeev A. Efficacy of He-Ne Laser

takE thE
in the prevention and treatment of radiotherapy-induced oral mucositis in oral
cancer patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008
Feb;105(2):180-6, 186.e1.
58. Treister N, Sonis S. Mucositis: biology and management. Curr Opin

Quiz on thE
Otolaryngol Head Neck Surg. 2007 Apr;15(2):123-9.
59. Brennan MT, Sankar V, Baccaglini L, Pillemer SR, Kingman A, Nunez O,
Young NS, Atkinson JC. Oral manifestations in patients with aplastic anemia. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Nov;92(5):503-8.

nExt pagE
60. Silverman S, Eversole LR, Truelove EL Essentials of Oral Medicine 1st ed,
2001, BC Decker Inc
61. Cho JH, Chung WK, Kang W, Choi SM, Cho CK, Son CG. Manual
acupuncture improved quality of life in cancer patients with radiation-induced
xerostomia. J Altern Complement Med. 2008 Jun;14(5):523-6.
62. Hargitai IA, Sherman RG, Strother JM. The effects of electrostimulation on
parotid saliva flow: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. 2005 Mar;99(3):316-20.
63. Fox PC, Atkinson JC, Macynski AA, Wolff A, Kung DS, Valdez IH, Jackson
W, Delapenha RA, Shiroky J, Baum BJ. Pilocarpine treatment of salivary
gland hypofunction and dry mouth (xerostomia). Arch Intern Med. 1991
Jun;151(6):1149-52.
64. Petrone D, Condemi JJ, Fife R, Gluck O, Cohen S, Dalgin P. A double-blind,
randomized, placebo-controlled study of cevimeline in Sjögren’s syndrome
patients with xerostomia and keratoconjunctivitis sicca. Arthritis Rheum.
2002 Mar;46(3):748-54

The Journal of Implant & Advanced Clinical Dentistry • 67

JIACD Continuing Education

Continuing Education JIACD Quiz #1

1. External etiologic factors of cancer 6. Viral infections most commonly seen in

include all the following except: chemotherapy patients include all the
a. tobacco following except:
b. alcohol a. herpes simplex virus
c. chemicals b. varicella zoster virus
d. hormones c. rhinovirus
d. cytomegalovirus (CMV)
2. Cancer is treated by:
a. surgery 7. Systemic fungal infections have a low
b. chemotherapy mortality rate in myelosuppressed
c. radiation therapy, hormones, and patients.
immunotherapy a. true
d. All of the above b. false

3. Which agents bind with DnA, preventing 8. the most common medications known
RnA synthesis, disrupting protein to cause xerostomia include all the
formation, and ultimately causing cell following except:
death? a. diuretics
a. Anti-tumor Antibiotics b. antihistamines
b. Antimetabolites c. antibiotics
c. Alkylating Agents d. beta blockers
d. Plant Alkaloids
9. the treatment goals in cases of BIOnJ
4. mucositis is the inflammation of the are infection control, pain control, and
mucous linings of the digestive tract limitation of extension.
which can lead to frank ulceration. a. true
a. true b. false
b. false
10. Commonly used plant alkaloids include
5. KlB suspension is used in the treatment a. Valium
of which of the following? b. Tamoxifen
a. infections c. Vincristine
b. candida d. Zoledronate
c. mucositis
d. osteonecrosis

CliCk hErE to takE thE Quiz

68 • Vol. 1, No. 5 • July/August 2009
 JIACD Continuing Education

Continuing Education JIACD Quiz #1

11. Internal factors of cancer include: 16. Chemotherapy-induced neuropathy

a. inherited mutations may be characterized by pain or
b. hormones paresthesia.
c. immune conditions a. true
d. All of the Above b. false

12. Cancer is caused by the malfunction of 17. Which of the following contributes to
genes that control cell growth, division, cancer chemotherapy induced nutritional
complications?
and maturation.
a. true a. nausea
b. false b. diarrhea
c. impaired liver function
13. Chemotherapy is responsible for the d. All of the above
long term survival of patients with
hematologic and other malignancies. 18. Prevention is the key to controlling
a. true hemorrhage.
b. false a. true
b. false
14. A major advantage of surgery and
radiation is the ability to treat 19. KlB suspension is available on most
widespread or metastatic cancer, hospital formularies and consists of
whereas chemotherapy is limited to equal parts kaolin, viscous lidocaine,
treating cancers that are confined to and diphenhydramine (Benadryl).
specific areas. a. true
a. true b. false
b. false
20. Common microorganisms seen in
15. nitrosoureas act similarly to alkylating BIOnJ include all of the following
agents and also inhibit changes except:
necessary for: a. Actinomyces
a. RNA repair b. E. Coli
b. DNA transcription c. Moraxella
c. DNA repair d. Eikenella
d. mRNA transcription

CliCk hErE to takE thE Quiz

The Journal of Implant & Advanced Clinical Dentistry • 69
Zemnick et al
 Zemnick et al
Labial Protection Device for a
Child Patient with Cerebral Palsy:
A Case Report

Candice B. Zemnick, DMD, MPH, MS1 • Richard K. Yoon, DDS2

Steven Chussid, DDS3 • Kim Soleimani4

Abstract

S
elf-injurious behav-
ior (SIB) involv-
ing the oral cavity
is often observed in the
developmentally and physically challenged patient
populations requiring a treatment protocol that is
both creative and customized to accommodate
the condition while prosthetically addressing
the particular needs of the patient. Depending
on the severity and duration of the self-inflicted
trauma, there exist numerous approaches that
range from conserva-
tive to invasive. Careful
consideration is required
to determine which
reversible or irreversible intervention is most
appropriate. This case report describes a child
patient with cerebral palsy that repeatedly mac-
erated her lower lip through SIB. A remov-
able appliance was developed and designed
to promote healing and prevent future injury
through protection of the macerated area.

KEY WORDS: Self injurious behavior, appliance, lip biting

1. Assistant Professor and Maxillofacial Prosthodontist, Division of Maxillofacial Prosthetics, Division of Prosthodontics,
Columbia University College of Dental Medicine, New York City, New York, USA.
2. Assistant Professor and Program Director, Pediatric Dentistry Residency, Columbia-New York Presbyterian Hospital.
3. Associate Professor and Division Director, Division of Pediatric Dentistry, Columbia University College of Dental Medicine,
New York City, New York, USA.
4. Fourth year dental student, Columbia University College of Dental Medicine, New York City, New York, USA.

The Journal of Implant & Advanced Clinical Dentistry • 71

Zemnick et al
IntRODuctIOn
Self-injurious behavior (SIB) is associated with
a repetitive, damaging behavior that is typically
intentional but not suicidal. Commonly seen
in children with psychiatric ailments, congeni-
tal disorders, physical disabilities and learning
impediments, the causes of SIB may range from
functional to structural. Functional SIB is induced
through emotional triggers and as a stress man-
agement response whereas structural defects are
of a genetic or a neurophysiological nature such
as with Lesch-Nyhan syndrome, Down syndrome,
Chiara malformation, seizure disorders, autism,
sensory neuropathy, and the comatose patient.1- 7
Commonly encountered in the dental setting
with potential evidence of functional-structural
SIB, cerebral palsy (CP) afflicts approximately
0.2% of the US infant population and is a non-pro-
gressive neuromotor disorder that causes motor
function impairment.8 Appreciating the biobe-
havioral factors involved in its presentation and
expected effects on the oral cavity are essential.
Normally, CP is classified as either spastic,
hypotonic, or athetotic. Spastic is associated
with individuals who experience hypertonicity with
poor posture control. These children may present
with a tongue that is hypertonic and cigar-shaped
with thrusts during speech and swallowing.
Because the upper lip is underdeveloped, inad-
equate pressure on the front teeth causes mala-
lignment. Hypotonic is used to describe those
with abnormal muscle tone and may present with
a large, flat, and protruded tongue, weak facial
movements and an inactive upper lip. Athetotic,
caused by extrapyramidal problems, entails suffer-
ing from involuntary movements of hands and feet.
Children with this form present with spontane-
ous wave-like tongue movements and rapid wide
72 • Vol. 1, No. 5 • July/August 2009
openings of the mouth may cause jaw dislocation.9
Consequently, children with CP are at risk to
contract several oral conditions including brux-
ism, oral skill dysfunction, drooling, gross mal-
occlusion, and poor oral hygiene.10 Because
more than 90% of children with CP suffer from
an oral motor dysfunction, practitioners are well
aware of its sociomedical implications ranging
from challenges for the cerebral palsied child to
be sufficiently nourished to an increased likeli-
hood of a SIB of oral origin. Common injuries
include tongue, cheek, and lip biting, and finger,
arm, and hand chewing. The principle cause of
these injuries is a lack of neuromuscular coordi-
nation between the tongue, lips, and cheeks. In
instances when neurological maturation is nonex-
istent or delayed, oral SIB is principally linked to
a decreased protective reflex which is character-
ized by excessive horizontal occlusal contacts.11
Oral SIB is also more of an issue in the CP
community relative to other populations due to
the fact that over 90% of CP patients have seri-
ous malocclusions. This condition, coupled
with a difficulty in mouth closure, alterations
in muscle tone, and spastic or clonic move-
ments, predispose CP patients to serious SIB.
These injuries can be caused by probing for-
eign objects within the gingiva or repetitive tis-
sue biting which results in ulceration, gingivitis,
periodontitis, hyperkeratosis and maceration.10
Treatment to prevent or inhibit SIB’s such as lip
biting and self mutilation includes a combination
of extraoral and intraoral appliances including soft
mouth guards, acrylic trays and lip bumpers.12-15
If these methods are unsuccessful, physical
restraints, extractions of the offending teeth, and
orthognathic surgery have been described.16
The wide spectrum of SIB’s is matched

Figure 1: Initial presentation of SIB induced trauma to
lower lip.
by the numerous treatment methods that have
been described. Dental literature has limited
reports on lip-biting in the conscious patient.
This clinical report details and describes the
use of a removable prosthesis for a CP child
patient that had a SIB involving the lower lip.
cASE REpORt
A seven-year-old female, diagnosed with CP pre-
sented to the pediatric dental residency clinic for
evaluation. Clinical extraoral examination revealed
the presence of a large traumatic ulcer on the
patient’s lower lip. The lip lesion encompassed a
large portion of the labial mucosa and extended
to the vermilion border, however it appeared to
be without infection (Figure 1). Presence of the
primary dentition with incomplete eruption of
deciduous molars was noted during the intraoral
examination. Upon interviewing the patient’s
mother, it was discovered that the child has a his-
tory of self-induced lip trauma which coincided
with the patient’s health status. The mother fur-
ther explained that when the child was not feeling
Zemnick et al
Figure 2: Initial wire placement through interdental
spaces.
well, she reinjured the area with uncontrolled lip
biting. The patient’s current injury was linked with
a concomitant otitis media condition. According
to the mother, previous endeavors to fabricate
an effective preventative appliance had failed
because of instability or intolerance. However,
the current SIB condition warranted an additional
attempt before considering prophylactic extraction
of anterior teeth. A removable lip bumper appli-
ance was chosen as an appropriate treatment.
An irreversible hydrocolloid preliminary impres-
sion was made using a stock tray. Dystonic
posturing of the neck with inability to perform vol-
untary movements of the oral musculature created
a challenge for taking diagnostic impressions.
Patient agitation during the process required sta-
bilization of her feeding tube to prevent dislodge-
ment. The impression was poured with Type III
gypsum (Whip-mix Corporation, Louisville, KY).
The generated cast was examined to determine
if it was accurate enough to continue with pros-
thesis fabrication, or if it would be used in the
creation of a custom tray for a secondary impres-
The Journal of Implant & Advanced Clinical Dentistry • 73
Zemnick et al
Figure 3a: Occlusal view of device.
Figure 4: Intaglio view of device.
sion. The capture of occlusal surfaces lacked
definition, however, the buccal and lingual ves-
tibular accuracy was acceptable for the intended
design of the prosthesis. Orthodontic 0.040”
stainless steel round wires (Masel Orthodontics,
Carlsbad, CA) were bent with a retentive design
and placed on the mandibular cast to extend from
the anterior buccal to lingual area (Figure 2). The
74 • Vol. 1, No. 5 • July/August 2009
Figure 3b: Intaglio view of device.
wire passed through existing areas of spacing to
ensure that the wire would not interfere with full
closure of anterior dentition or the eruption of
permanent dentition. The wire was then fixed to
cast with visible light cure Triad gel (Dentsply Tru-
byte, York, PA) and the cast was boxed with putty
polyvinylsiloxane preparation for autopolymerizing
resin (OrthoJet, Lang Dental Manufacturing Com-
pany Inc., Wheeling, IL) application. Two layers
of tin foil substitute (Coe-Sep, Kerr, GC America,
Alsip, IL), was painted on the cast and allowed to
dry. The acrylic was injected and applied manu-
ally to create the body and stabilization flanges of
the appliance and then placed in a pressure pot
for 15 minutes. The prosthesis was then removed
from the cast and adjusted to ensure that the lin-
gual extensions were concave to allow tongue
space and stabilization of the prosthesis (Figures
3a,b). A duplicate cast was fabricated to allow the
prosthesis to be refitted and reduce the number
of chairside adjustments (Figure 4). The buccal
and lingual flanges extended to within two millime-
ters of the functional depth of the vestibule and

Figure 5a: Healing after 2 weeks of appliance use.
Figure 5b: Note how appliance displaces lower lip facially.
the superior aspect of the flanges was maintained
short of the unattached tissue to prevent gingival
hypertrophy. The wire was positioned with relief
to further prevent irritation or hypertrophy, the
outer surface was polished, and the intaglio was
relined with medium soft Sof-Reliner® (Tokuyama
America Inc., Encinitas, CA) for additional comfort.
Upon delivery, the appliance was checked for
path of insertion and stability. The wires were
adjusted for a more retentive and passive fit by
simply pinching the exposed area of wire tran-
Zemnick et al
sitioning from the buccal to lingual areas. This
approximated the flanges and provided a tighter fit
with the soft relining material acting as a cushion
while resisting destabilization. The patient was
observed for a period of time to ensure comfort
and prosthesis retention, especially during spas-
tic motion and tongue flexure. For security, dental
floss was attached to the appliance to help pre-
vent possible aspiration by permitting easy retriev-
ability should the appliance become dislodged.
Demonstration of insertion and removal was made
in the presence of the patient’s primary care-
giver, her mother. Instructions were given for the
patient to wear the appliance for as long as pos-
sible to address her lip lesion and allow resolution.
The patient returned two weeks after appli-
ance insertion and primary healing of the lip ulcer-
ation was observed (Figures 5a,b). The mother
was not implementing the appliance consistently
according to the original instructions, so it was
advised that the child wear the prosthesis20-30
minutes per day in order to remain acclimated to
its sensation. This in due course would reduce
agitation when the appliance was needed dur-
ing bouts of illness and enable the appliance to
serve as an effective means of preventing SIB’s.
DIScuSSIOn
Limited studies examining preventive methods
for addressing SIB exist. Lip bumper appliances
have been reported as a viable option in treat-
ing transient, mild or acute episodes of SIB’s
involving the lower lip and buccal mucosa.4, 14, 15,
17- 19
Nevertheless, the design of the prosthesis
used for treatment in this report varies from previ-
ous approaches. There were several factors that
needed to be considered and accommodated
for this particular patient in order to make the
The Journal of Implant & Advanced Clinical Dentistry • 75
Zemnick et al
appliance more effective than previous guards.
Three key features and considerations were
noted for this patient which guided the cus-
tom design of the prosthesis: (1) the SIB was
diagnosed as not habitual which directed the
approach to type of fixation; (2) the appli-
ance should not interfere with eruption, the
occlusion should not be altered, and the ver-
tical dimension must not be raised; and (3)
hygiene and tissue health must be maintained.
(1) SIB was diagnosed as not habitual which
directed the approach. The patient’s CP condi-
tion and previous behavior pattern inferred that
the SIB was associated with illness and perhaps
was a reaction to or an expression of discom-
fort rather than a habitual, chronic, or a declin-
ing condition. Future injury is still expected to
be tissue destructive, though transient. As such,
fixed appliances are therefore unnecessary and
contraindicated. Any appliance that would be
difficult for the mother or caretaker to remove
or insert would also be ill-advised. This ease of
usage of this prosthesis also permitted the patient
to avoid sustaining multiple office visits except
for follow-up or if the need for a new prosthe-
sis arose. The incomplete eruption of the pri-
mary molars precluded the option of orthodontic
banding which would support retentive elements
for an appliance.4 In addition, application of
these bands would have likely required sedation.
(2) Appliance should not interfere with erup-
tion, the occlusion should not be altered, and the
vertical dimension must not be raised. The appli-
ance was designed particularly to accommodate
continued dentition eruption and developing occlu-
sion. Disruption may compromise occlusal stabil-
ity or patient comfort during the extended periods
between SIB episodes. Interdental spacing,
76 • Vol. 1, No. 5 • July/August 2009
common during the mixed dentition phase, was
utilized for placement of the two appliance wires.
Lip bumpers stabilized by orthodontic bands
have been commonly used to distalize molars and
manipulate arch form to address dental crowding.4
However, tooth movement and expansion of the
arches was not desired in this case, and this was
an additional reason for not using this form of fixa-
tion. A benefit of the appliance designed for this
case is that there is no need to take an impression
of the opposing dentition if the interocclusal/arch
spaces can be visualized. The elimination of a
second impression process is less stressful for the
patient and makes for a more pleasant appoint-
ment. In contrast, full occlusal coverage with an
acrylic splint requires flush contact of the oppos-
ing arch upon closure for stability and patient
comfort at an inherently raised vertical dimen-
sion of occlusion. This excessive vertical dimen-
sion may instigate more SIB’s and, in general,
may not be tolerated by the patient. This is dif-
ficult to discern in the non-communicative patient.
Heavy gauge orthodontic wires allow for reten-
tion adjustability by carefully contracting labial and
lingual components closer to each other. Care-
ful adjustment of the extent of the flanges, espe-
cially in the retrolingual and mylohyoid areas, is
essential for patient comfort and appliance stabil-
ity. In this case, the patient’s CP-related spastic-
ity often retained the prosthesis in place rather
than dislodging it. However, this may not be
true for all patients and scrutiny chairside as well
as primary caregiver observation is essential to
monitor the suitability of a removable prosthesis.
(3) Hygiene and tissue health must be main-
tained. Preservation of tissue health is essen-
tial for patient comfort and sufficient relief must
be provided in areas of unattached tissue to

prevent hyperplasia. The non-invasive, remov-
able nature of this appliance allows for mainte-
nance of oral health and prosthetic cleanliness
and is less likely to exacerbate the patient’s SIB.
cOncluSIOn
Neurodevelopmental impairment resulting in the
demonstration of self-mutilation presents an enor-
mous challenge to address effectively. Treatment
planning must consider derivation of the medi-
cal condition, duration, as well as the severity of
SIB, previous attempts at intervention, and con-
sequences of no intervention. Cyclic remissions
and re-emergence of self-mutilative behavior
often times frustrates and complicates determi-
nation of definitive treatment. The duality of the
prosthesis described in this report offers protec-
tion for the lip in addition to having the potential
to eliminate aberrant behavior. The inherent non-
invasive, reversible nature of the prosthesis is also
appealing as interdisciplinary efforts are made
to alleviate the occurrence and duration of SIB,
and thus, enhance the patient’s quality of life. ●
correspondence:
Richard K. Yoon, DDS
Division of Pediatric Dentistry
Columbia University College of Dental
Medicine
722 West 168th Street, Rm 8-841, BOX 165
New York City, New York 10032
Telephone: 212-305-1043
Facsimile: 212-342-5619
Email: rky1@columbia.edu
The Journal of Implant & Advanced Clinical Dentistry
Zemnick et al
Disclosure:
The authors report no conflicts of interest with anything mentioned in this report.
References
1. Fardi K, Topouzelia N, Kotsanos N. Lesch-Nyham syndrome: a preventive
approach to self-mutilation. Int J Paediatr Dent 2003; 13(1): 51-6.
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with Lesch-Nyhan syndrome: review of literature. J Dent Child 2001; 68(3):
175-8.
3. Rashid N, Yusuf H. Oral self-mutilation by a 17-month-old child with Lesch-
Nyhan syndrome. Int J Paediatr Dent 1997; 7(2): 115-7.
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neuropathy: review and a case report with dental implications. J Oral Rehabil
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Gynecol 2008; 51(4): 816-28.
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parafunctional oral habits in patients with cerebral palsy. J Oral Rehabil 2007;
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acrylic splint retained by a head gear. Pediatr Dent 1996; 18: 408-10.
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Pedod 1983; 7: 209-220.
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Dent Child 1985; 52: 188-190.
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case report. Turk J Med Sci 2006; 36(3): 187-9.
• 77
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Current Clinical Review
 CurrentCurrent
Clinical Review
Clinical Review

The Role of Corticosteroids

in Dentistry
Istvan A. Hargitai, DDS, MS1

Abstract

T
he dental practitioner should be knowledge-
able about corticosteroid drugs for several
purposes. Firstly, patients will present who
are currently taking corticosteroids or have taken
them recently. Depending on the dose, treatment
may or may not need modification as it relates
to supplementing a stress response. Secondly,
corticosteroids can play an important anti-inflam-
matory role peri-operatively for more extensive
oral or periodontal surgical procedures. Thirdly,
corticosteroids represent the first line of defense
in managing immune mediated vesiculobullous
oral diseases. Corticosteroids possess a wide
range of physiologic effects and the clinician must
be aware of how the drug’s positive therapeu-
tic effects relate to their negative or side effects.

KEY WORDS: Dental, oral, corticosteroid, supplementation

1. Director Orofacial Pain/Oral Medicine Clinic, U.S. Naval Hospital, Naples, Italy

Disclosure: The opinions and assertions contained in this article are the private ones of the
authors and are not to be construed as official or reflecting the views of the
Department of the Navy, Department of Defense or the US Government.

The Journal of Implant & Advanced Clinical Dentistry • 81

Current Clinical Review
InTRODucTIOn
Corticosteroids are used to treat a wide variety
of medical disorders.1,2 In dentistry, they are pri-
marily used to decrease post-operative edema
and manage oral inflammatory diseases. Dental
patients with a history of corticosteroid use may
require special consideration prior to receiving
dental treatment. The purpose of this article is
to review the use of corticosteroids in dentistry
and the special considerations for dental patients
who present with a history of corticosteroid use.
Physiology of corticosteroids
Corticosteroids are chemically similar to endog-
enous cortisol which is important in protein, car-
bohydrate and fat metabolism, maintenance of
vascular reactivity, and adapting the body to
stress.1,2 The adrenal gland normally produces
24-30 mg of cortisol each day, but may produce
up to 300 mg of cortisol during times of extreme
stress.3-5 Cortisol secretion is regulated by circa-
dian rhythm, a stress-related response and nega-
tive feedback mechanism between the adrenals,
pituitary and hypothalamus.3 When supraphysi-
ologic doses of corticosteroids ( >30 mg corti-
sol equivalent) are administered for over 2 weeks,
the hypothalamic-pituitary-adrenal (HPA) axis
may become suppressed and may take up to 12
months to recover. However, a functional ability
to respond to stress has been demonstrated to
return within 14-30 days.3 Cortisol and corticos-
teroids have a variety of effects on many systems.
Anti-inflammatory. Cortisol stabilizes lyso-
somal membranes, decreases capillary perme-
ability and decreases white blood cell chemotaxis
and phagocytosis. It also inhibits the activa-
tion and proliferation of T cells, antibody pro-
82 • Vol. 1, No. 5 • July/August 2009
ducing plasma cells and cytokine production.6
Carbohydrate and protein metabo-
lism. Cortisol decreases the peripheral
utilization of glucose, stimulates gluconeogen-
esis in the liver from amino acids and inhib-
its protein synthesis in the muscle. This
elevates blood glucose and liver glycogen.6
Lipid metabolism is affected by corticoster-
oids as fat is redistributed to the back, shoul-
ders, abdomen, and face resulting in a cushinoid
effect with a “moon facies” and “buffalo hump.”
Electrolyte and water balance. Corti-
costeroids stimulate reabsorption of sodium
and excretion of potassium, calcium, and
hydrogen ions. Thus, prolonged corti-
costeroid use may lead to hypernatremia,
hypokalemia, hypocalcemia, and alkalosis.
Endocrine effects. Corticosteroids may pro-
vide feedback inhibition of pituitary
adrenocorticotropic hormone (ACTH)
and thyroid stimulating hormone (TSH).
Contraindications. Corticosteroids should
not be routinely used in patients with a his-
tory of chronic infection such as tuber-
culosis, viral infections, peptic ulcers,
diabetes mellitus, osteoporosis, psychiat-
ric disorders, cataracts, and hypertension.2,7,8
Adverse effects. Hyperglycemia, myopathy
(muscle weakness and wasting), osteoporosis,
osteonecrosis, growth suppression, peptic ulcers
(secondary to decreased secretion of prosta-
glandin E2 which protects the gastric mucosa),
 Current Clinical Review

increased intraocular pressure, cataracts, and

edema may result.8 Central nervous system Table 1: Common Corticosteroid
effects include psychosis, euphoria, sleepless- Topical Ointments
ness, and restlessness. Corticosteroids may also
predispose patients to infections, acne, weight Potency Drug Strength
gain, poor wound healing, thinning of the skin,
and hirsutism. Finally, candidosis is commonly Low Hydrocortisone 2.5%
seen and antifungal treatment may be required. Triamcimolone 0.025%
Suppression of the HPA axis occurs as
Medium Triamcimolone 0.1%
a result of long-term supraphysiologic doses
of corticosteroids. In these patients, extreme High Clobetasol 0.05%
stress or sudden withdrawal of corticoster- Fluocinonide 0.05%
oids may result in adrenal crisis due to the
Triamcimolone 0.5%
lack of endogenous cortisol required to main-
tain homeostasis.1-3 Adrenal crisis may feature
severe hypotension, weakness, dehydration, Table 2: Corticosteroid Comparison
gastrointestinal symptoms, and even death.1
Drug Equivalent Relative
clinical Applications of corticosteroids dose (mg) potency
Corticosteroids are available in various forms,
Hydrocortisone 20 1
strengths and potencies (table 1). Rela-
tive potency (table 2) is a useful way of Prednisone 5 4
comparing different corticosteroids. Hydrocor-
tisone (cortisol) is the standard for comparison. Prednisolone 5 4

Control of Edema. Corticosteroids are ben- Methylprednisolone 4 5

eficial in reducing post-surgical edema, which
Triamcimolone 4 5
may cause post-operative pain.10,11 They are
indicated for those procedures likely to pro- Dexamethasone 0.75 25
duce post-operative edema. Procedures such
as extraction of partial or total bony impac-
tions and osseous periodontal surgeries are (4 mg) Dex tablets the morning of surgery and
good indications for corticosteroids. Alexan- for both a.m. and p.m. cases- inject 8-12 mg dex-
der11 has suggested the following regimens: amethasone acetate intramuscular (IM) into the
masseter or deltoid muscle at the start of surgery.
Intramuscular: For an a.m. case- Give two
(4-mg) dexamethasone (Dex) tablets at bedtime Intravenous: Administer 12mg dex-
the night prior to surgery. For p.m. case-Give two amethasone sodium phosphate intrave-

The Journal of Implant & Advanced Clinical Dentistry • 83

Current Clinical Review
nously (IV). An oral pre-operative and
a post-operative dose is not necessary.
Control of oral vesiculobullous diseases.
Oral lichen planus, pemphigus, pemphig-
oid, erythema multiforme, recurrent aphthous
stomatitis and allergic reactions may respond
favorably to topical or systemic corticoster-
oids.7,8 Corticosteroids should be avoided in
viral lesions such as herpes simplex because
of the potential for exacerbation of the infec-
tion due to immune system suppression.
When the severity of disease impacts the
patient’s ability to concentrate, eat, and/or func-
tion, aggressive treatment with 40 to 60 mg of
oral prednisone daily should be considered. The
patient should be instructed to take prednisone
each morning with a meal until the symptoms are
resolved. In most cases, symptoms wane in one
to two weeks. Morning dosing mimics the body’s
diurnal release of endogenous cortisol and mini-
mizes the side effects. No tapering dose of the
medication is required if treatment is expected
to be less than 2 weeks. Tapering should be
considered if therapy will exceed 2 weeks.
Localized or mild vesiculobullous conditions
can be treated topically when the lesions are
few and easily accessible. Topical corticoster-
oid ointments and gels such as fluocinonide, tri-
amcinolone, and clobetasol are applied 3-4 times
daily with a finger or cotton tip applicator. These
agents may be compounded by a pharmacist with
equal parts carboxymethylcellulose (Orabase)
to facilitate adhesion and improve contact time.
In the oral mucosa, topical steroids are poorly
absorbed systemically and usually do not sup-
press the HPA axis.12 Clobetasol, an ultrapotent
corticosteroid, is an exception and is not recom-
84 • Vol. 1, No. 5 • July/August 2009
mended for more than 2 weeks of use due to
increased risk of HPA axis suppression. When
lesions are confined to the gingiva, custom fit-
ted trays may be fabricated and filled with fluoci-
nonide gel and worn for 15 minutes four times a
day, or even continuously between meals and at
night.13,14 Corticosteroid creams are better indi-
cated for dermatologic use and should be avoided
intraorally. When lesions are too numerous or
inaccessible for topical treatment, dexamethasone
elixir (0.5 mg/5ml) may be utilized as an oral rinse.
The patient should vigorously rinse for 3-4 min-
utes four times a day after meals and expectorate.
Recalcitrant lesions may require direct injec-
tion of corticosteroids around the margins of the
lesion. An injection of 0.5-1.0 ml dexamethasone
phosphate (4 mg/ml) or triamcimolone (10mg/ml)
can be given twice a week until healing occurs.8,14
Prior or current history of corticosteroid
use. Patients with a history of current or previ-
ous glucocorticoid therapy may require supple-
mental corticosteroids prior to stressful dental
procedures.1,3,8 If the patient is receiving or has
undergone therapy with supraphysiologic doses
(>2 weeks) within the past 30 days, the HPA
axis may be suppressed and supplementation
should be provided.3 Supplemental doses of
corticosteroids should be given on the morning
of the appointment and correlated to the level of
expected stress exerted on the patient and should
be equivalent to no more than 300 mg of cortisol.3
To minimize risk of adrenal crisis, effective long act-
ing anesthesia should be obtained along with con-
sideration for sedation in the apprehensive patient
and appropriate post-operative analgesics.3 If the
patient’s corticosteroid therapy was terminated
over 30 days ago, no supplementation is required.

Patients undergoing glucocorticoid therapy on
an alternate day dosing schedule do not require
supplementation on the “off day.” Ideally, patients
should be treated on the off day, as the functional
stress response is greater at that time. Topical
and inhaled corticosteroids do not require supple-
mentation. When in doubt, consult the patient’s
physician or err on the side of supplementation.
Scenario 1: Patient requiring extractions
took a 7 day course of 20 mg of prednisone
for exacerbation of asthma one week ago.
Action: No supplementation required. Even
though the dose was supraphysiologic, the course
of time it was taken was less than 2 weeks.
Scenario 2: Patient requiring extrac-
tions is taking 10 mg of prednisone for
the past year to treat rheumatoid arthritis.
Action: This patient’s HPA axis is probably sup-
pressed due to supraphysiologic dose of corticos-
teroids for longer than 2 weeks. Supplement with
at least 100 mg of cortisol equivalent (25 mg pred-
nisone) in the morning on the day of the surgery.
Scenario 3: Patient requiring extrac-
tions is taking 2.5 mg of prednisone daily
for the past 3 months to treat his psoriasis.
Action: No supplementation required. Even
though the patient has been on prednisone for
over 2 weeks, the dose is subphysiologic and
will not adversely impact his stress response.
Scenario 4: Patient requiring extractions was
previously taking 50 mg of prednisone for Crohn’s
disease. He was on a 6-month course of pred-
nisone but took his last dose 5 weeks ago.
Action: No supplementation needed. A func-
Current Clinical Review
tional stress response returns in 14-30 days
after the last dose of supraphysiologic steroids.
Scenario 5: Patient requiring extrac-
tions is taking 75 mg of prednisone daily
for the past 8 weeks to treat pemphigus.
Action: No supplementation needed as 75
mg of prednisone is the maximum dose equiv-
alent to 300 mg of endogenous cortisol. ●
correspondence:
CDR Istvan Hargitai
PSC 827 Box 122
FPO, AE, 09617
Tel: 39-081-811-6007
Fax: 39-081-811-6497
Istvan.hargitai@med.navy.mil
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glucocorticoids. Med Clin North Am 1973; 57(5):1155-65.
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The Journal of Implant & Advanced Clinical Dentistry • 85