Specops Jiacd 200911

Volume 1, No.
8 NoVember 2009
The Journal of Implant & Advanced Clinical Dentistry
Maxillary Sinus
Augmentation
Histologic and Histomorphometric Analysis
Single Surgery
Comprehensive Gingival
d it
Grafting Technique C r e
C E
s of
u r
o
2H
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Volume 1, No. 8 • NoVember 2009
Table of Contents
13 Case of the Month

Biologic Shaping
Daniel Melker
19 JIACD Continuing Education

Management of the Actively
Bleeding and Hypovolemic
Dental Patient
Dan Holtzclaw, Nicholas Toscano
29 Single Surgery Comprehensive

Gingival Grafting Utilizing
Palatal Donor Tissue
M. Thomas Wilcko, William M. Wilcko
49 Maxillary Sinus Floor

Augmentation: A Histologic
and Histomorphometric Human
Grafting Study Comparing Two
Anorganic Bovine Bone Minerals
Aron Gonshor, Yoon-Je Jang
The Journal of Implant & Advanced Clinical Dentistry • 3

Table of Contents
59 Preservation of Buccal Bone

Plate after Immediate Implant
Placement/Function with
the Flapless Approach:
A Case Report
Arthur B. Novaes Jr., Rafael R. de Oliveira,
Valdir A. Muglia
69 Subperiosteal Dental Implants:

A 25 Year Retrospective
Survival Evaluation
Antonio T. Di Giulio, Giancarlo Di Giulio,
Enrico Gallucci
77 Dental 3D Imaging Centers -

Usage and Findings:
Part III – Bifid Canals and
Other Deviations of the Inferior
Alveolar Nerve
Alan Alan A. Winter, Kouresh Yousefzadeh,
Alan S. Pollack, Michael I. Stein, Frank J.
Murphy, Christos Angelopoulos

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Stephanie Belcher
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Founder, Co-Editor in Chief Founder, Co-Editor in Chief

Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS
A Minimally Invasive and SystematicEditorial

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

Editorial Commentary
We Have the Technology. Let’s Use It!
I
am a big history buff and I am always amazed continuing education seminars. Third, they would
at the progress of mankind. When you think sponsor presentations at large organizational
about what we as a people have accomplished, meetings. The company sponsored campaigns
it literally boggles the mind. As civilizations did an effective job of generating interest in
developed in millennia past, the isolation of the new technique or product, but it was not
different communities resulted in a great number until the articles were actually published that
of technologies that were quite disparate from they gained full acceptance. Once the articles
one another. The sheer distances between were published, hopefully, you subscribed to the
these communities and the difficulties of travel journal publishing said articles. If not, you could
imposed by various natural and human elements purchase the article for upwards of $30 or you
hampered the sharing and dissemination of these were just simply out of luck.
technologies. In ancient times, the main source When the Journal of Implant and Advanced
of communication between civilizations rested in Clinical Dentistry (JIACD) was released in early
the hands of merchant traders. As they traveled 2009, this process changed for the better. Firstly,
to distant lands to exchange goods, these traders JIACD is available to everyone at no charge.
also acquired knowledge; knowledge of different Second, JIACD is freely accessible via the internet.
cultures and customs, knowledge of different arts With the simple click of a button, the entire world
and humanities, and most importantly, knowledge has access to every article ever published in JIACD.
of different technologies. Upon their return Third, because JIACD is an online publication
home, this knowledge was imparted to their with an enormous peer review board, articles may
native peoples and incorporated or adapted to be reviewed and published with extraordinary
fit their needs. This process was difficult, often promptness. I suspect that it is only a matter of
dangerous, and could take many years to complete. time before other journals begin to follow our lead.
Now let’s shift gears and think about how The time has come for dental information to be free
all of this relates to our beloved profession of and instantly accessible to all.
dentistry. As recently as just a few years ago, Modern technology has made the world a much
the dissemination of knowledge in our community smaller place, mainly through vast improvements
was a painfully slow process. Essentially, if a in our ability to communicate with one another.
new technique or product was to be discussed, Compared to our ancestors, when you think about
it was first published in a print journal. As I have how easy it is for us to acquire knowledge in
mentioned in a previous editorial, the peer review modern times, it is almost embarrassing. ●
and publication process for such an article can take
up to 24 months. While waiting for the articles to
be published, companies wishing to promote their
new product, or procedures using their products,
would do a few things to get out information faster.
First, they would advertise. Second, they would Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS
hold company sponsored training sessions and Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief

Kurtzman
Kurtzman
Case of the Month
Biologic Shaping
Daniel Melker, DDS1
Abstract
W
hen performing conventional crown Considering these and other important
lengthening, the existing margins of an aspects of crown lengthening, the concept
old restoration or the cementoenamel of “Biologic Shaping” was established. Rea-
junction (CEJ) of a non-restored tooth are used sons for Biologic Shaping include: 1) Replace
to determine necessary bone removal to estab- or supplement the current indications for clini-
lish adequate space for biologic width. Creat- cal crown lengthening; 2) Minimize ostectomy;
ing proper space for biologic width ensures that 3) Facilitate supragingival or intrasulcular mar-
the new margin will not infringe upon the peri- gins to preserve biologic width; 4) Eliminate
odontal complex and reduces the likelihood for developmental grooves; 5) Eliminate previous
future inflammation. One significant problem of subgingival restorative margins; 6) Reduce
this procedure is that, at times, significant bone or eliminate furcation anatomy and thus facili-
must be removed. This can weaken the stabil- tate margin placement; 7) Allow supragingi-
ity of the tooth or create a weakened and vulner- val or intracrevicular impression techniques.
able furcation area. The more bone removed The following article presents a series of Bio-
in the furcation, the greater the likelihood of logic Shaping cases and the author discusses
future problems with maintenance. It is critical requirements for successful treatment gleaned
to preserve as much bone as possible to sup- over the past 33 years of his career in which he
port the tooth, especially in the furcation area. has used this technique on over 30,000 teeth.
KEY WORDS: Biologic shaping, biologic width, ostectomy, osteoplasty
1. Private practice limited to periodontics, Clearwater, Florida, USA

Melker
The clinical prerequisites and steps for 8. Once the flaps are adapted, Potassium
success with Biologic Shaping are as follows: oxylate should be used to help decrease
1. All previous restorative materials and decay post-surgical sensitivity. The liquid is applied
should be removed. to the root surface for 45-60 seconds and
then lightly air dried. Repeat 2-3 times.
2. A core buildup of composite bonded resin
should be placed where necessary to 9. Cement provisional prosthesis with a
add volume to the teeth. The core helps Polycarboxlate cement such as Tylok®
determine where the final margin placement (Dentsply International; York, Pennsylvania,
of the new restoration will be placed. USA) or Durelon.
3. Acrylic provisionals should be placed 10. Homecare instructions include rinsing with
with Durelon (3M™ ESPE™; St. Paul, Chlorhexidine twice daily (morning and
Minnesota, USA) as the temporary evening) and brushing with Prevident at
cement. This cement is recommended for bedtime. After meals the patient rinses
its antimicrobial properties and ability to with water or Listerine to remove any food
help decrease sensitivity. particles.
4. Removal of provisional restorations at time 11. At 4 weeks, the provisionals are either
of surgery to allow better access. remade or relined leaving 1mm of space
for continued Biologic Width growth in a
5. Shape root and remove old margin as coronal direction. No margination of tooth
well as 360 degrees of CEJ’s. Reduce surface at this time.
or eliminate cervical enamel projections.
Facilitate ideal restorative emergence 12. At 14 weeks Chamfer margins are placed
profile (Flat is better than fat contours). at the gingival collar and impressions
Diamond burs are recommended for this taken. When endodontics is present the
process. new margin may be placed within the
sulcus.
6. Correct any reverse architecture and
remove necessary bone where violation of 13. Facilitate hygiene and maintenance
biologic width may still be anticipated. procedures.
7. If insufficient keratinized tissue is present at

the surgical site, add sufficient connective Correspondence
to protect bone from bacterial infiltration. Dr. Daniel Melker
The connective also protects underlying 28465 US HWY 19 N
Suite 204
periodontal tissues from impression
Clearwater, FL 33761
material and cementation irritation.
Phone: (727) 725-0100
Email: djmelker@yahoo.com
14 • Vol. 1, No. 8 • November 2009

Melker

Melker
16 • Vol. 1, No. 8 • November 2009

Melker

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JIACD Continuing Education
Management of the Actively
Bleeding and Hypovolemic Dental Patient
Dan Holtzclaw, DDS, MS • Nicholas Toscano, DDS, MS

Abstract
Background: With an increasing number of den- Results: Dental literature reported life threaten-
tists incorporating surgical procedures such as ing hemorrhagic complications with common sur-
implant dentistry into their daily practice, the ability gical dental procedures ranging from endosseous
to manage hemorrhagic complications is indispens- implant placement to third molar extractions. In most
able. The purpose of this article is to provide an cases, actively bleeding and hypovolemic patients
updated review on contemporary oral hemostatic were managed with relatively simple local measures.
measures and offer literature based recommen-
dations on the perioperative management of the Conclusions: Under most circumstances, and with
actively bleeding and hypovolemic dental patient. proper management, the risk of uncontrolled hem-
orrhage attributed to dental procedures is minimal.
Methods: The authors reviewed medical and Proper management in such scenarios involves
dental literature for reports of dental related adequate pre-operative patient assessment, profi-
hemorrhagic complications, oral hemostatic ciency with local hemostatic control measures, and
measures, and treatment of hypovolemia. familiarity with hypovolemic treatment protocols.
KEY WORDS: Hypovolemia, bleeding, hemostasis, emergency
1. Private practice limited to Periodontics and Implant Dentistry, Austin, TX, USA
2. Private practice limited to Periodontics and Implant Dentistry, Washington DC, USA
This article provides 2 hours of continuing education credit.

Please click here for details and additional information.

plications, most providers commonly associate

Learning Objectives potential bleeding problems with patients taking
After reading this article, the reader should be antiplatelet and/or anticoagulation medications.
able to: Improved understanding of cardiovascular
1. Recognize the signs and symptoms of physiology and advances in the management and
hypovolemia. treatment of cardiovascular disease have ren-
dered oral anticoagulation therapy a mainstay of
2. Understand how to manage hypovolemia.
modern medicine. It is estimated that more than
3. Understand how to manage intraoral 50 million Americans adhere to a low dose daily
hemorrhaging. aspirin protocol and other anticoagulants such as
warfarin sodium and clopidogrel bisulfate routinely
rank among the top 50 medications prescribed
INTRODUCTION in the United States.10,11 As such, the likelihood
Though rare, life threatening hemorrhage has been of encountering anticoagulated patients is signifi-
reported with common surgical dental procedures cant. Should clinicians be worried about uncon-
ranging from endosseous implant placement to trolled hemorrhage with these patients? Studies
third molar extractions.1-3 With an increasing examining the hemorrhagic effects of antiplatelet
number of dentists now incorporating surgical anticoagulants on dental procedures have found
procedures into their daily practice, their risk of negligible increases in intraoperative and postoper-
encountering hemorrhagic complications is likely ative bleeding when local measures were used.12-
to increase.4-8 Knowledge of predisposing factors, 14
Likewise, similar studies evaluating coagulation
physiologic responses to, and clinical management cascade anticoagulants have generally found
of excessive hemorrhage may prove useful for pro- no increased risk of intraoperative or postopera-
viders in such situations. Accordingly, the purpose tive bleeding that could not be controlled with
of this case report is to review hemorrhage man- local measures when International Normal Ratio
agement in the dental setting and to provide an (INR) values were within therapeutic levels.15-18
example of practical application of such principles. In addition to pre-operative consideration of a
patient’s medication profile, anticipated blood loss
PRE-OPERATIVE from the planned procedure must be considered.
CONSIDERATIONS Expectant blood loss from a restorative procedure
With systemically healthy patients, the possibility such as a dental amalgam will be considerably dif-
of uncontrolled hemorrhage resulting from a den- ferent from that of a surgical procedure such as
tal procedure seems remote. In fact, the risk of dental implant placement, periodontal flap proce-
moderate to severe bleeding induced by dental dure, or impacted third molar extraction. Studies
treatment is less than 1% for the average patient.9 evaluating blood loss from restorative procedures
While obvious conditions such as Hemophilia and have reported minimal hemorrhagic complications,
Von Willenbrand’s Disease may cause clinicians while those evaluating surgical operations such as
to consider the possibility of hemorrhagic com- flap-osseous procedures have found up to 592ml
20 • Vol. 1, No. 8 • November 2009

of blood loss from a single surgical site.19,20 Blood

loss from surgical procedures is also influenced
by the experience level of the provider. Surger-
ies performed by less experienced providers
have been shown to take up to three times lon-
ger and may result in nearly twice as much blood
loss as those performed by more experienced
practitioners.20 In general, however, most stud-
ies have found that blood loss from dental pro-
cedures is under 200ml and may be even less if Figure 1: Blood clot removed from patient with slow
the duration of the procedure does not exceed 2 continuous hemorrhaging secondary to osseous
hours.20-23 Considering that a pint of blood, the periodontal surgery.
amount generally taken during blood donation, is
473ml, the amount of blood lost during most den- blood loss exceeds 1000ml, dental literature rec-
tal procedures is well within the limits of safety. ommends fluid replacement when blood loss
exceeds 500ml to account for postoperative
HYPOVOLEMIA RECOGNITION hemorrhagic oozing (figure 1).27,28 A pragmatic
AND MANAGEMENT approach to fluid resuscitation in outpatient dental
Life threatening situations resulting from exces- settings is limited to cases with less than 1000ml
sive blood loss are often due to hypovolemic of blood loss and the ability to control hemor-
induced hemorrhagic shock.24 Blood loss exceed- rhaging. Cases exceeding these parameters
ing 1000ml, or 1/5 of an adult’s average blood should be referred to a higher echelon of care.
volume, may precipitate hypovolemic shock and
lead to inadequate tissue perfusion/oxygenation.25 HEMHORRAGE MANAGEMENT
Compensatory signs of hypovolemia include tachy- With proper management, nearly all sce-
cardia, hypotension, tachypnea, pallor, diaphore- narios of excessive bleeding can be ade-
sis, anxiety, nausea, thirst, and light headedness. quately managed with relatively simple
If left untreated, hemorrhagic shock may progress local measures (Figure 2, Table 1) such as:
to loss of consciousness, coma, or even death.
When the source of bleeding is known, pri- Positive Pressure
mary goals in the treatment of hemorrhagic shock Positive pressure aids hemostasis by promot-
are to stop the source of hemorrhaging and ing occlusion of the site of injury and provid-
restore circulating blood volume. The “three-to- ing mechanical aid to clot formation.29 Positive
one” rule for the treatment of hemorrhagic shock pressure to intraoral wounds is typically accom-
dictates the administration of 3ml of crystalloid plished by compressing moistened gauze on the
(Lactated Ringers solution or normal saline) for site of hemorrhaging. Suturing wound margins
every 1ml of blood loss replaced.26 Although or severed vessels is another method in which
hemorrhagic shock does not typically occur until compressive force may be applied to bleed-

Table 1: Local Hemostatic aids

Product or Action Composition Action
Positive Pressure N/A Manual occulusive aid

to clot formation
Vasoconstrictor 1:100,000 Epinephrine Activation of a adrenergic

receptors
Gelfoam® Porcine derived gelatin sponge Occlusive matrix; activation

of intrinsic pathway
Surgicel® Plant derived a-cellulose Occlusive matrix: activation

of intrinsic pathway,
antibacterial properties
CollaCote®, CollaPlug® Bovine derived collagen Occlusive matrix, activation

CollaTape®, UltraFoamTM of intrinsic pathway
UltraWrapTM
HemCon® Crustacean derived chitosan Positively charged

chitosan attracts negatively
negatively charged
red blood cells,
antibacterial properties
4.8% Tranexamic Acid Tranexamic acid Binds to lysine receptor

Mouth Rinse sites on plasmin and
plasminogen inhibiting
fibrin binding
and fibrinolysis
Topical Thrombin Bovine derived thrombin Enhances conversion of

fibrinogen to fibrin
Electrocautery N/A High frequency electric

current cauterizes tissue
and induces blood
coagulation
22 • Vol. 1, No. 8 • November 2009

whole blood.32 Absorbable collagen sponges

aids hemostasis by providing a simple occlusive
matrix and through contact activation of the intrin-
sic pathway.33 When used for oral applications,
this material typically liquefies within 2-5 days.
Oxidized Regenerated Cellulose

Oxidized regenerated cellulose based products
such as Surgicel® (Ethicon Inc, Somerville, NJ)
are derived from plant based alpha-cellulose and
function hemostatically in a manner similar to
absorbable gelatin sponges.34 A unique property
of oxidized regenerated cellulose is antibacterial
Figure 2: Products commonly used to aid hemostasis. activity. Because this product has a relatively low
Clockwise from top: Gelatin sponge, Collagen plug, pH, a broad range of gram negative, gram posi-
Collagen tape, Oxidized regenerated cellulose, Chitosan tive, and antibiotic-resistant bacteria have proven
derived.
to be locally susceptible to oxidized regenerated
cellulose.35 When used for oral applications,
ing areas.30 In many cases, minor hemorrhaging this product typically resorbs with 7-14 days.
is often controlled with positive pressure alone.
Absorbable Collagen Products
Vasoconstrictor Absorbable collagen products such as col-
Dental anesthetics contain vasoconstrictor pri- lagen tape, collagen plugs, and collagen
marily to increase their duration of action and foam are derived from bovine deep flexor ten-
minimize the risk of local anesthetic toxicity.31 dons and typically resorb completely within 14
Epinephrine, the most commonly utilized vaso- days.36 Additional bovine derived products
constrictor in dental local anesthetics, is a cat- such as Avitene®, UltraFoam™, and UltraWrap™
echolamine that facilitates vasoconstriction via (Traatek, Inc, Fort Lauderdale, FL.) have simi-
the activation of alpha adrenergic receptors. lar properties. In addition to providing a simple
Alpha adrenergic activation by sympathomim- occlusive matrix, these products promote hemo-
ietic drugs such as epinephrine induces smooth stasis by virtue of their collagen content which
muscle contraction within blood vessels and activates the intrinsic coagulation cascade.
ultimately leads to short term vasoconstriction.
Chitosan Derived Products
Absorbable Gelatin Sponge Chitosan derived products such as HemCon®
Gelfoam® (Pfizer, New York, NY) is a resorb- (HemCon Medical Technologies Inc, Portland,
able gelatin sponge of porcine origin that is OR.) are extremely effective at promoting hemo-
capable of absorbing up to 45 times it weight in stasis and have recently been used by United

States military medical personnel for treatment bin is often bovine derived and is typically sup-
of battlefield injuries. Chitosan is a naturally plied as a freeze dried sterile powder that must
occurring polysaccharide that is commercially be reconstituted with sterile saline. For gen-
produced via the deacetylation of crustacean eral use in dental applications, a topical throm-
chitin.37 Positively charged chitosan molecules bin solution of 100 International Units/ml is
readily attract negatively charged red blood recommended.43 Topical thrombin is often deliv-
cells and the two form an extremely strong seal ered via pump/syringe spray or combined with
that acts as a primary occlusive barrier for hem- a carrier such as a hemostatic gelatin sponge.
orrhagic sites. With hemorrhaging limited and/
or stopped by this initial seal, the natural coagu- Electrocautery
lation cascade ensues. Like oxidized regener- Electrocautery involves the application of a high-
ated cellulose, chitosan derived products have frequency electric current to cauterize tissue and
locally active antibacterial properties.38 Unlike induce blood coagulation. In dentistry, this pro-
oxidized regenerated cellulose which relies on cess is typically accomplished with monophasic
low pH for its antibacterial activity, however, electrosurgical units. In comparison to other local
chitosan derived products achieve antibacte- means of hemostasis management, electrocautery
rial properties via active cell wall disruption.39 may induce collateral thermal damage to adjacent
tissues.44,45 As such, this treatment option is typi-
Tranexamic Acid cally reserved for severe hemorrhaging scenarios.
Tranexamic acid is an anticoagulant oral rinse
that binds to lysine receptor sites on plasmin PRACTICAL CASE REPORT
and plasminogen, ultimately inhibiting fibrin The primary author was contacted by a patient
binding and fibrinolysis.40 This rinse is sup- with a chief complaint of “my mouth won’t stop
plied in a 4.8% solution and patients may bleeding.” Telephonic interview revealed the
be instructed to rinse with 10ml four times patient to be a 22 year old white male with a non-
daily for 7 days following surgery.41 Rinsing contributory medical history. The patient had
with tranexamic acid solution results in thera- undergone impacted third molar extractions one
peutic levels ( >100mg/ml) within the saliva week prior and was without complication until
for 2-3 hours. Wounds healing in the pres- the bleeding episode. According to the patient,
ence of tranexamic acid have demonstrated his lower right extraction site began to hemor-
increased tensile strength, thus making the rhage during dinner subsequent to traumatic
clot more resistant to mechanical disruption.42 disruption with a piece of partially masticated
food. The patient had attempted to control the
Topical Thrombin bleeding by biting on moistened paper towels
Topical thrombin facilitates clot stabilization by for over 2 hours prior to contacting the clinic.
enhancing the conversion of fibrinogen to fibrin Upon arrival of the treatment provider to the
and forming a reinforcing meshwork for initial dental clinic, the patient appeared ashen, dia-
platelet plugs. Medical grade topical throm- phoretic, and continued to actively bleed from
24 • Vol. 1, No. 8 • November 2009

the mouth. The patient was seated in a dental treatment protocols. As more general dentists
chair and rapid evaluation revealed fast paced now routinely perform surgical procedures that
active hemorrhaging from extraction site 32 induce blood loss, such a knowledge base is
and vital signs of the following: blood pres- essential and may one day prove life saving. ●
sure (90/48), pulse (99), and oxygen saturation
(95%). Using the pace of the active hemor- Professional Dental Education and Pro-
rhaging as a guide, it was estimated that the fessional Education Services Group
patient had lost approximately 1000ml of blood are joint sponsors with The Academy
at this point. As vital signs were being taken, of Dental Learning in providing this
the patient began to complain of “dizziness” and continuing dental education activity.
nausea. The patient was placed into Trendelen-
burg position, oxygen was administered via nasal The Academy of Dental Learning
canula at a rate of 6L/min, oral suction was ini- is an ADA CERP Recognized Pro-
tiated, and intravenous access was obtained in vider. The Academy of Dental Learn-
the left antecubital vein with an 18 gauge cath- ing designates this activity for two
eter. As 2000ml of Lactated Ringers solution hours of continuing education credits.
were delivered to the patient, attempts were
made to stop the hemorrhaging. The patient ADA CERP is a service of the Ameri-
was repositioned and site 32 was generously can Dental Association to assist den-
infiltrated with 2% lidocaine/1:100,000 epineph- tal professionals in identifying quality
rine. As the vasoconstrictor took effect, bleed- providers of continuing dental educa-
ing from site 32 decreased significantly and the tion. ADA CERP does not approve or
patient was instructed to bite with positive pres- endorse individual courses or instruc-
sure on moist gauze as he received the remain- tors, nor does it imply acceptance of
der of the Lactated Ringers solution. After 30 credit hours by boards of dentistry
minutes of subsequent evaluation, hemorrhaging
from extraction site 32 ceased and the patient’s Correspondence:
vital signs stabilized to within normal limits. Dr. Dan Holtzclaw
3016 Hidden Bluff Cove
CONCLUSION Round Rock, TX 78665
Dental literature clearly demonstrates that
under most circumstances, and with proper
management, the risk of uncontrolled hemor-
rhage attributed to dental procedures is mini- For 2 hours CE CrEdit takE
mal. Proper management in these scenarios thE Quiz on thE nExt pagE
involves adequate pre-operative patient assess-
ment, proficiency with local hemostatic con-
trol measures, and familiarity with hypovolemic

Disclosure 15. Ward B, Smith M. Dentoalveolar procedures 31. Malamed S. Handbook of Local Anesthesia 5th
The authors report no conflicts of interest with for the anticoagulated patient: literature Edition. Mosby 2004: 416.
anything mentioned in this article. recommendations versus current practice. J
Oral Maxillofac Surg 2007; 65(8): 1454-60. 32. Council on Pharmacy and Chemistry:
References Absorbable gelatin sponge – new and
1. Mason M, Triplett R, Alfonso W. Life-threatening 16. Alexander R, Ferretti A, Sorensen JR. Stop the nonofficial remedies. JAMA 1947; 135: 921.
hemorrhage from placement of a dental implant. J nonsense not the anticoagulants: a matter of life 33. Ongkasuwan J. Hemostatic agents. Baylor
Oral Maxillofac Surg 1990; 48(2): 201-4. and death. NY State Dent J 2002; 68(9): 24-6. College of Medicine Grand Rounds Archive
2005; 10: 1-9.
2. Moghadam H, Caminiti M. Life-threatening 17. Cannon P, Dharmar V. Minor oral surgical
hemorrhage after extraction of third molars: case procedures in patients on oral anticoagulants- 34. Surgicel, Surgicel Nu-Knit, and Surgicel Fibrillar
report and management protocol. J Can Dent -a controlled study. Aust Dent J 2003; 48(2): Absorbable Hemostat (oxidized regenerated
Assoc 2002; 68(11): 670-4. 115-8. cellulose) for Dental Use package insert.
Somerville, NJ: Ethicon, Inc 2003; 1-14.
3. Kalpidis C, Konstantinidis A. Critical hemorrhage 18. Evans I, Sayers M, Gibbons A, Price G, Snooks
in the floor of the mouth during implant H, Sugar A. Can warfarin be continued during 35. Spangler D, Rothenburger S, Nguyen K,
placement in the first mandibular premolar dental extraction? Results of a randomized Jampani H, Weiss S, Bhende S. In vitro
position: A case report. Implant Dent 2005; controlled trial. Br J Oral Maxillofac Surg 2002; antimicrobial activity of oxidized regenerated
14(2): 117-24. 40(3): 248-52. cellulose against antibiotic-resistant
microorganisms. Surg Infect 2003; 4(3): 255-
4. Misch C. Implants and the general practitioner. 19. Rooney T. General dentistry during continuous 62.
Dent Today 2007; 26(8): 48-52. anticoagulation therapy. Oral Surg Oral Med
Oral Pathol 1983; 56(3): 252-5. 36. Collagen Dental Wound Dressings package
5. Bitter R. The periodontal factor in esthetic smile insert. Brockton, MA: Collagen Matrix, Inc: 1-2.
design: Altering gingival display. Gen Dent 2007; 20. Baab D, Ammons W, Selipsky H. Blood loss
55(7): 616-22. during periodontal flap surgery. J Periodontol 37. HemCon Dental Dressing package insert.
1977; 48(11): 693-8. Portland, OR: HemCon Medical Technologies
6. Cottrell D, Reebye U, Blyer S, Hunter M, Inc: 1-30
Mehta N. Referral patterns of general dental 21. McIvor J, Wengraf A. Blood-loss in periodontal
practitioners for oral surgical procedures. J Oral surgery. Dent Pract Dent Rec 1966; 16(12): 38. Muzzarelli R, Tarsi R, Filippini O, Giovanetti E,
Maxillofac Surg 2007; 65(4): 686-90. 448-51. Biagini G, Varaldo P. Antimicrobial properties
of N-carboxybutyl chitosan. Antimicrob Agents
7. Lanning S, Best A, Hunt R. Periodontal services 22. Hecht A, App A. Blood volume lost during Chemother. 1990; 34(10): 2019-23.
rendered by general practitioners. J Periodontol gingivectomy using two different anesthetic
2007; 78(5): 823-32. techniques. J Periodontol 1974; 45(1): 9-12. 39. Andres Y, Giraud L, Gerente C, Le Cloirec
P. Antibacterial effects of chitosan powder:
8. Starr C, Maksoud M. Implant treatment in an 23. Berdon J. Blood loss during gingival surgery. J mechanisms of action. Environ Technol 2007;
urban general dentistry residency program: A 7 Periodontol 1965; 36: 102-7. 28(12): 1357-63.
year retrospective study. J Oral Implantol 2006;
32(3): 142-7. 24. Perry M, O’Hare J, Porter G. Advanced trauma 40. Gaspar R, Brenner B, Ardekian L, Peled M,
life support (ATLS) and facial trauma: Can one Laufer D. Use of tranexamic acid mouthwash to
9. Curtis J, McLain J, Hutchinson R. The incidence size fit all? Part 3: Hypovolaemia and facial prevent postoperative bleeding in oral surgery
and severity of complications and pain following injuries in the multiply injured patient. Int J Oral patients on oral anticoagulant medication.
periodontal surgery. J Periodontol 1985; 56(10): Maxillofac Surg 2008; 37(5): 405-14. Quintessence Int 1997; 28(6): 375-9.
597-601.
25. Gutierrez G, Reines H, Wulf-Gutierrez M. 41. Bandrowsky T, Vorono A, Borris T, Marcantoni
10. Ajani U, Ford E, Greenland K, Giles W, Mokdad Clinical review: hemorrhagic shock. Crit Care H. Amoxicillin-related postextraction bleeding in
A. Aspirin use among U.S. adults: Behavioral 2004; 8(5): 373-81. an anticoagulated patient with tranexamic acid
Risk Factor Surveillance System. Am J Prev rinses. Oral Surg Oral Med Oral Pathol Oral
Med 2006; 30(1):74-7. 26. Healey M, Davis R, Liu F, Loomis W, Hoyt Radiol Endod 1996; 82(6): 610-2.
D. Lactated ringer’s is superior to normal
11. Top 50 Drugs Prescribed 2007. Humana Inc. saline in a model of massive hemorrhage and 42. Björlin G, Nilsson I. The effect of antifibrinolytic
Publication 2007: 1-2. resuscitation. J Trauma 1998; 45(5): 894-9. agents on wound healing. Int J Oral Maxillofac
Surg 1988; 17(4): 275-6.
12. Ardekian L, Gaspar R, Peled M, Brener B, 27. Gores R, Royer R, Mann F. Blood loss
Laufer D. Does low-dose aspirin therapy during operation for multiple extraction with 43. Thrombin, Topical U.S.P. (Bovine Origin)
complicate oral surgical procedures? J Am Dent alveoloplasty and other oral surgical procedures. package insert. Middleton, WI: GenTrac Inc
Assoc 2000; 131(3): 331-5. J Oral Surg 1955; 13(4): 299-306. 2007: 1-2.
13. Madan G, Madan S, Madan G, Madan A. Minor 28. Johnson R. Blood loss in oral surgery. J Dent 44. Noble W, McClatchey K, Douglass G.
oral surgery without stopping daily low-dose Res 1956; 35(2): 175-84. A histologic comparison of effects of
aspirin therapy: a study of 51 patients. J Oral electrosurgical resection using different
Maxillofac Surg 2005; 63(9): 1262-5. 29. Meehan S, Schmidt M, Mitchell P. The electrodes. J Prosthet Dent 1976; 35(5):
international normalized ratio as a measure 575-9.
14. Partridge C, Campbell J, Alvarado F. The effect of anticoagulation: Significance for the
of platelet-altering medications on bleeding management of the dental outpatient. Spec 45. Arashiro D, Rapley J, Cobb C, Killoy W.
from minor oral surgery procedures. J Oral Care Dentist 1997; 17(3): 94-6. Histologic evaluation of porcine skin incisions
Maxillofac Surg 2008; 66(1): 93-7. produced by CO2 laser, electrosurgery, and
30. Purcell C. Dental management of the scalpel. Int J Periodontics Restorative Dent
anticoagulated patient. N Z Dent J 1997; 1996; 16(5): 479-91.
93(413): 87-92.
26 • Vol. 1, No. 8 • November 2009

Continuing Education JIACD Quiz #4
1. The risk of moderate to severe bleeding 6. How much blood loss may precipitate
induced by dental treatment is less than: hypovolemic shock and lead to
a. 1% c. 5% inadequate tissue perfusion/
b. 2% d. 10% oxygenation?
a. 100 ml c. 750 ml
2. An estimate of how many Americans b. 250 ml d. 1,000+ ml
adhere to a low dose daily aspirin
protocol? 7. Compensatory signs of hypovolemia
a. 2 million c. 50 million include which of the following?
b. 14 million d. 75 million a. Tachycardia d. Nausea
b. Hypotension e. All of the above
3. Surgical operations such as flap- c. Tachypnea
osseous procedures have found up
to how much blood loss from a single 8. How many milliliters of crystalloid
surgical site? should be administered for every 1
a. 100 ml c. 495 ml milliliter of blood lost?
b. 250 ml d. 592 ml a. 1 ml c. 3 ml
b. 2 ml d. 5 ml
4. Surgeries performed by less experienced
providers have been shown to take 9. Methods of hemorrhage management
up to how many times longer than include which of the following?
those performed by more experienced a. Positive pressure d. Electrocautery
practitioners? b. Vasoconstrictor e. All of the above
a. 2 times longer c. 4 times longer c. Absorbable gelatin
b. 3 times longer d. 5 times longer sponge
5. In general, most studies have found that 10. Rinsing with tranexamic acid solution
blood loss from dental procedures is: results in therapeutic levels (>100mg/
a. Negligible c. < 200 ml ml) within the saliva for how long?
b. < 100 ml d. > 500 ml a. 30 – 45 minutes c. 3 – 4 hours
b. 2 – 3 hours d. 5 – 6 hours
CliCk hErE to takE thE Quiz

Single Surgery Comprehensive Wilcko et al
Gingival Grafting Utilizing

Palatal Donor Tissue
M. Thomas Wilcko, DMD1 • William M. Wilcko, DMD, MS2

Abstract
Background: As many as 24 teeth can be which multiple areas of gingival recession are
grafted in a single surgical appointment utilizing treated in a single surgical appointment uti-
the patient’s own palatal tissue. If more than a lizing autogenous palatal donor tissue. His-
dozen teeth require grafting, thick free gingival torical background and clinical descriptions
grafts (FGG’s) can be split and the resulting of the surgical techniques are presented.
subepithelial connective tissue grafts (SCTG’s)
can be utilized in a bilaminar approach. The Results: In all four cases, multiple areas of
resultant thinner FGG’s can be used in conjunc- gingival grafting were accomplished in a single
tion with a retained semilunar flap and marginal surgery resulting in root coverage and a struc-
tissue lifting. This case series presents 4 cases turally enhanced zone of gingival attachment.
in which SCTG’s or a combination of SCTG’s
and FGG’s are utilized for multiple areas of gin- Conclusion: With the techniques described in
gival grafting at the same surgical appointment. this paper, the palate can provide an adequate
amount of donor tissue for single surgery com-
Methods: Four cases are presented in prehensive gingival grafting of up to 24 sites.
KEY WORDS: Subepithelial connective tissue graft, free gingival graft
1. Private practice limited to Periodontics, Erie, Pennsylvania, USA, Clinical Associate Professor of Periodontology, Case
University, Cleveland OH, Consultant, Naval Dental Center, Bethesda, MD
2. Private practice limited to Orthodontics, Erie, Pennsylvania, USA, Consultant, Naval Dental Center, Bethesda, MD

Wilcko et al
INTRODUCTION graft was no longer needed in these bilaminar

Over the past 45 years, gingival grafting uti- approaches and, as such, the harvesting tech-
lizing palatal donor tissue has evolved from nique from the palatal donor site evolved into
merely a functional application for increasing the excision of connective tissue only, reduc-
the width and thickness of the gingival attach- ing the palatal donor site to an internal pouch.
ment to also addressing esthetics by provid- This permitted almost complete surface closure
ing for reconstructive root coverage. The use and healing of the palatal donor site by primary
of the subepithelial connective tissue graft intention. The disadvantage of this technique
(SCTG) is now widely accepted as the gold is that only a rather limited amount of connec-
standard of care in root coverage grafting.1 tive tissue can be retrieved during harvesting.
Historical Perspective MATERIALS AND METHODS

The use of the free gingival graft (FGG) was Single Surgery Comprehensive Grafting
first reported by Björn in 1963 for repair of a When a pouch technique is utilized for graft
functionally deficient zone of gingival attach- harvesting, adequate SCTG can usually be har-
ment.2 This technique was later improved upon vested from one side of the palate to graft about
by Miller to also provide for root coverage in 3 teeth on average, for a total of approximately
Class I and Class II marginal tissue reces- half a dozen teeth if both sides of the palate are
sion.3 The preparation of the recipient site was used. When SCTG is required for root cov-
accomplished through the sharp dissection of a erage on more than 6 teeth and one wishes
split thickness flap leaving a very thin exposed to accomplish the grafting in a single surgical
vascular surface overlying the bone onto which appointment, it is necessary to abandon the
the FGG was sutured. The FGG itself included internal pouch technique of graft harvesting and
both the epithelium and underlying connective instead harvest multiple FGG’s from the palate.
tissue and, consequently, the resulting donor If FGG’s are harvested from the palate and de-
site in the palate was subject to relatively slow epithelialized, enough subepithelial connective
healing through secondary intention. The use of tissue can be obtained to perform root cover-
an acrylic palatal stent to cover the donor site age grafting on about a dozen teeth at a single
during healing lessened the likelihood of any sig- surgical appointment. If more than a dozen
nificant postoperative bleeding and discomfort. teeth require root coverage grafting and one
As the predictability of root coverage became wishes to utilize strictly subepithelial connective
more of a priority, newer bilaminar techniques tissue, grafting can be performed in two sepa-
evolved in which palatal connective tissue was rate surgeries leaving enough time between
sandwiched between the denuded root surfaces the surgeries for the palate to regenerate.
and overlying partial or full thickness flaps.4-9 The manner in which single surgery compre-
Another bilaminar technique using SCTG’s has hensive gingival grafting can be accomplished
also been reported with tunnel procedures.10-15 when more than a dozen teeth require gingival
The epithelial covering of the free gingival grafting is to place the emphasis for root cov-
30 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 1a: Thick free gingival graft. Figure 1b: Carefully splitting thick free gingival graft from
figure 1a.
erage on the areas of gingival recession in the

upper arch where esthetics is typically more of
an issue and to place an emphasis on improv-
ing the functional and structural integrity of the
zone of gingival attachment on the areas of gin-
gival recession in the lower arch by striving to
increase the width, thickness, and continuity
of the gingival attachment. An attempt is also
made to achieve some degree of root coverage
in the lower arch, but this is presented to the
patient with lower expectations. In this manner, Figure 1c: Results from splitting graft: (1) thinner free
up to two dozen teeth can usually be grafted gingival graft and (1) subepithelial connective tissue graft.
in a single surgical appointment utilizing the
patient’s own palatal tissue. This is made pos- palatine artery can be inadvertently cut during
sible by removing thick FGG’s from the palate the graft harvesting. This is addressed by using
and then precisely splitting them (figures 1a,1b). interrupted loop sutures over the area to com-
Each thick FGG that is harvested from the pal- press the tissues and slow the bleeding. The
ate is thus transformed into a thinner FGG and donor sites are then covered with an acrylic stent
a separate SCTG (figure 1c). By doing so, to apply slight pressure, improve comfort, and
the amount of palatal tissue made available for reduce the likelihood of postsurgical bleeding.
grafting is quickly doubled with the SCTG’s
utilized in a bilaminar approach in the upper Recipient Site Preperation for SCTGs
arch and the FGG’s utilized in the lower arch. The recipient sites for SCTG’s are prepared
Because thick FGG’s are needed, the greater prior to graft harvest. When a bilaminar

Wilcko et al
onal flap advancement, and to assure passive

adaptation at closure. Following reflection of the
flap, intramarrow penetrations or cortical cuts
are made interradicularly in the exposed bone.
Recipient Site Preparation for FGG’s

When FFG’s are used at recipient sites, prepa-
ration is done in a very different manner than that
of SCTG’s. A semilunar incision is first made
at the base of the remaining gingival attach-
ment. If there is insufficient keratinized gingiva,
the semilunar incision is made in the mucosal
tissue. After the scalloped incision is made
outlining the base of the semilunar flap, a split
thickness flap is apically reflected through sharp
dissection leaving the thinnest soft tissue layer
Figure 2: Multiple free gingival grafts harvested from the possible as the vascular bed for the FGG’s.
palate. The reflection is carried 3 to 5 mm apical to the
anticipated apical edge location of the FGG’s.
approach is being used to maximize root cover- The apical base of the semilunar flap
age, full thickness flap reflection is utilized at the semilunar flap is re-outlined with the tip of
recipient sites. Partial thickness flap reflection a #12 blade. This releases the collar over
can also be utilized at the recipient sites with the root prominences and also slightly loos-
equally good results, but this technique results ens 1 to 2 mm of the labial interdental papil-
in a thinner flap that can easily tear during reflec- lae. The semilunar flap is then gently elevated
tion. Intrasulcular releasing incisions are utilized coronally resulting in what is referred to as
in the areas of gingival recession to include the marginal tissue lifting. This is a delicate pro-
facial aspects of the interdental papillae. Verti- cess requiring time and patience as care
cal releasing incisions are used at the opposite must be taken not to tear the semilunar flap.
ends of the intrasulcular releasing incision and
extended into the alveolar mucosa. In the pos- Considerations for Palatal FGG
terior areas, the most distal vertical releasing Harvesting and Preparation
incision is frequently omitted and, occasionally In the typical palate, 4 FGG’s (two from each
in isolated areas, no vertical releasing incisions side) can be harvested (figure 2). The size of
are used. Regardless of whether or not verti- the palate will of course determine the maximum
cal releasing incisions are included, a periosteal width and length of the individual grafts. The
releasing incision is always made at the base of bigger issue becomes the manner in which the
the flap for increased mobility, facilitation of cor- grafts will be utilized. If 2 FGG’s are removed
32 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 3a: Superior edge of free gingival graft sutured. Figure 3b: Periodontal dressing covering free gingival
graft.
from the same side of the palate, 1 to 2 mm of the superior edge of the FGG is very carefully
palatal tissue is left between the donor sites to sutured to the semilunar flap collars. Only the
reduce healing time. It is also important to keep superior edge of the FGG is sutured (figure
the border of the donor sites at least two milli- 3a). The FGG is held in close approximation
meters shy of the posterior border of the stent to to the underlying vascular bed with a periodon-
prevent exposing the donor site beyond the con- tal dressing containing rosin that provides for
fines of the stent coverage. Generally, it is easier improved adherence to the teeth (figure 3b).
to remove a thicker FGG from the lateral aspect
of the palate, where there is a thicker zone of Recipient Site Suturing of the SCTG’s
subepithelial connective tissue to work with. The coronal edge of the SCTG is first sutured
interproximally (figure 4a) with a resorbable
Recipient Site Suturing of the FGGs grafting material; 5-0 plain gut, 5-0 chromic
The superior edge of the FGG is placed at the gut, or 4-0 Vicryl (Ethicon) suture materials
inferior border of the semilunar flap. For a start- seem to work equally well. The superior edge
ing point, one end of the FGG is sutured inter- of the SCTG must not come to a thin knife-
proximally. The FGG is then stretched and the like edge and may need to be trimmed to pro-
opposite end of the FGG is sutured at the most vide adequate thickness for suturing. The
distant interproximal area. This results in the full thickness flap is coronally advanced to
semilunar flap being elevated to cover some or cover as much of the SCTG as possible (fig-
all of the exposed root surfaces in the areas of ure 4b). Complete coverage of the SCTG is
the gingival recession. The FGG is then secured preferable, but not always possible. The flap
into position by suturing it at the remaining is sutured into position with a non-resorb-
interproximal areas. Over the root prominences, able suture material such as CV-5 ePTFE, 3-0

Wilcko et al
Figure 4a: Coronal edge of SCTG sutured. Figure 4b: Coronally positioned flap covering SCTG.
PTFE, or 5-0 Polypropylene. Preferably, at The patient is asked to remain on a very soft diet
least one sling suture should be used around until all of the sutures have been removed.
each grafted tooth, and the SCTG should be
re-engaged. No periodontal dressing is used. Patient Awareness and Expectations
A well-informed patient with realistic expec-
Post-operative Instructions and Follow up tations is critically important when treating
The patient is instructed to stay on a liquid or gingival recession. To this end, it is empha-
extremely soft food diet until told otherwise. sized to the patient that the most impor-
The patient is given a very soft toothbrush tant aspect of any gingival grafting is to
and instructed to brush only the tips of the create an environment where additional
teeth. A palatal stent is delivered (figure 5) gingival recession is less likely to occur.
and the patient is instructed not to remove it. The most critical pre-treatment marker in
At one-week post surgery any periodontal determining the likelihood of achieving root cov-
dressing remaining is removed in addition to erage is the interproximal distance between the
the sutures at the superior border of the FGG’s. alveolar crest and the corresponding cemntoe-
The patient is still cautioned to remain on a very namel junctions (CEJ) as seen on the periapical
soft diet. The palatal stent is removed, cleaned, radiographs. Generally speaking, approximately
and reinserted after the palate is cleansed. 2.5mm is considered to be representative of an
With SCTG’s, the removal of the non-resorb- adequate biologic width,16-21 and this has proven
able sutures is usually done in stages beginning to be an excellent measurement in predicting
two weeks post-operatively. Loose sutures are the likelihood of being able to achieve good
removed initially, but any tight functional sutures root coverage. If radiographically the interproxi-
are left in place until three weeks postopera- mal distance between the alveolar crest and the
tively when the suture removal is completed. corresponding CEJ’s is 2.5mm or less, the like-
34 • Vol. 1, No. 8 • November 2009

Wilcko et al
that is present. The resultant enhanced zone of

gingival attachment created with this technique
is conducive to coronal advancement at a sec-
ond surgery if eventually deemed appropriate.22
Additional Considerations
Wilcko et al first reported on the use of intra-
marrow penetrations in conjunction with
SCTG’s for root coverage in 2005.23 Intrama-
rrow penetration stimulates a regional accel-
eratory phenomenon (RAP) which provides
an increase in hard and soft tissue reorgani-
zation activity in close approximation to the
osseous insult. It also provides a pathway for
the rapid efflux of pluripotential stem cells and
Figure 5: Palatal stent covering palatal donor sites. capillary budding from the medullary spaces.
Other than scaling of exposed root sur-
lihood of achieving fairly complete root cover- faces prior to flap reflection, no specific
age is high when a bilaminar approach with a root preparation is needed. Large cervi-
SCTG and coronally advanced flap is utilized. cal restorations are removed following
As this interproximal distance increases beyond flap reflection and any sharp edges in the
2.5mm, there is a proportionate decrease in the areas of cervical abrasion are smoothed.
amount of root coverage that can be expected.
The most unappealing aspect of the FGG CASE REPORTS
esthetics is the “tire patch” appearance at the Multiple sites of gingival recession are
localized recipient site. Extending the FGG’s addressed with the FTF/SCTG approach uti-
to cover large numbers of teeth, even inter- lized in all 6 cases presented in this paper.
spersed teeth without gingival recession, can Additionally, a SLF/FGG with MTL approach
eliminate this unsightly appearance. At times is also used in the lower arches of 3 of the
little or no root coverage is achieved, espe- cases presented. One of the cases was
cially if the collars of the semilunar flap over the treated in anticipation of possible orthodontic
root prominences are torn. Even if the inter- treatment, 1 of the cases was treated as part
proximal distance between the CEJ’s and the of the PAOO treatment, and 3 of the cases
corresponding alveolar crest is 2.5mm or less had previously had orthodontic treatment.
generally only a couple of millimeters of root cov-
erage can be expected with the semilunar flap
+ free gingival grafts and marginal tissue lifting
regardless of the amount of gingival recession

Wilcko et al
Figure 6a: Right presurgical view of case 1. Figure 6b: Left presurgical view of case 1.
Figure 6c: Preparation of right side of case 1. Figure 6d: Preparation of left side of case 1.
Case 1
A female patient, age 54, presented with up to of 4 SCTG’s and 4 FGG’s. The 4 SCTG’s were
6mm of Miller Class I-III facial gingival reces- sutured at the recipient sites (figures 6e,6f)
sion on multiple teeth (figures 6a,6b). Since and FTF’s were coronally advanced. Several
less than a dozen teeth required root coverage sutures were used at the donor sites to lessen
grafting, FTFs/SCTGs were utilized in all of the the bleeding (figure 6g), and the donor sites
involved areas. Preparation of the recipient sites were covered with an acrylic stent. The donor
involved interproximal intramarrow cuts (figures sites in the palate healed uneventfully (figure
6c,6d). Four thick FGG’s were removed from 6h). Healing of the recipient sites at 6 months
the palate and de-epithelialized to yield a total after surgery can be seen in figures 6i and 6j.
36 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 6e: SCTG secured on right side of case 1. Figure 6f: SCTG secured on left side of case 1.
Figure 6g: Case 1 palatal donor site immediately post Figure 6h: Case 1 palatal donor site healed after surgery.
surgery.
Figure 6i: Right view of case 1 at 6 months after surgery. Figure 6j: Left view of case 1 at 6 months after surgery.

Wilcko et al
Figure 7c: Right view of RAP inducing intramarrow Figure 7d: Left view of RAP inducing intramarrow
penetrations of case 2. penetrations of case 2.
Case 2
A female patient, age 46, presented with Miller penetrating was performed interradicularly
Class I and II gingival defects on the facials of (figures 7c, 7d). Three thick FGG’s were
9 maxillary teeth (figures 7a, 7b). Because only removed from the palate and de-epithelialized.
9 teeth were involved, it was decided to strictly The three resulting SCTG’s were then sutured
utilize full thickness flaps and SCTG’s. Full at the recipient sites (figures 7e, 7f). The full
thickness flaps were reflected at the 2 upper thickness flaps were coronally advanced to
recipient sites. Sulcular and mesial vertical passively cover the SCTG’s. Postsurgical results
releasing incisions were utilized and intramarrow at 2 years are shown in figures 7g and 7h.
38 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 7e: SCTG secured on right side of case 2. Figure 7f: SCTG secured on left side of case 2.
Figure 7g: Right view of case 2 at 2 years after surgery. Figure 7h: Left view of case 2 at 2 years after surgery.

Wilcko et al
Case 3
A male patient, age 37, was referred for a peri-
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40 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 8a: Presurgical view of case 3. Figure 8b: Full thickness flap reflection and bone
activation in case 3.
Figure 8c: SCTG secured in case 3. Figure 8d: Bone grafting material placed as dictated by
PAOO™ protocol.
Figure 8e: Flap coronally advanced to cover the SCTG in Figure 8f: Results at 7 years after surgery.
case 3.
Wilcko et al
Figure 9c: Right view of RAP inducing intramarrow Figure 9d: Left view of RAP inducing intramarrow
penetrations of case 4. penetrations of case 4.
Case 4
A 57 year old female presented with Miller Class sites (figures 9c, 9d), 3 thick FGGs and 1 FGG of
I and II gingival recession on the facial aspect of average thickness were removed from the palate.
many of her upper and lower teeth (figures 9a,9b). Utilizing a #15 Bard Parker blade each graft was
Because of the large number of teeth requiring split to provide a thinner FGG and a SCTG. This
grafts, it was decided to do full thickness flaps resulted in 3 thinner FGG’s and 3 SCTG’s, which
with SCTG’s in the upper arch and semilunar in addition to the 1 FGG that was not split, pro-
flaps with FGGs and marginal tissue lifting in the vided for a total of 7 grafts. Figures 9e-9h show
lower arch. A total of 21 teeth were grafted, 9 the grafts sutured at the recipient sites and cov-
teeth in the upper arch and 12 teeth in the lower ered with periodontal dressing. The results can be
arch. Following the preparation of the recipient seen 6 months postoperatively in figures 9i and 9j.
42 • Vol. 1, No. 8 • November 2009

Wilcko et al
Figure 9e: Grafts secured on right side of case 4. Figure 9f: Grafts secured on left side of case 4.
Figure 9g: Right view of periodontal dressing covering Figure 9h: Left view of periodontal dressing covering
grafts of case 4. grafts of case 4.
Figure 9i: Right view of case 4 at 6 months after surgery. Figure 9j: Left view of case 4 at 6 months after surgery.

Wilcko et al
DISCUSSION technique described in this report provides a

Predisposing anatomic considerations that may solution to the limited nature or autogenous tis-
contribute to gingival recession include, but sue harvest. By obtaining very thick FGG’s and
are not limited to, tooth position, gingival bio- precisely splitting them, resultant SCTG’s and
type, oral hygiene practices, destructive hab- now thinner FGG’s may be utilized for coverage
its, smokeless tobacco use, bony dehiscence of up to 24 teeth in certain instances. This paper
over root prominences, and an accompanying showed reports of 6 cases in which scores of
inadequate zone of gingival attachment.27-29 mucogingival defects were successfully treated
Very prominently positioned teeth are likely to in a single sitting with autogenous tissue.
have a bony dehiscence over the prominent
root surface.30 Additionally, to complicate mat- SUMMARY
ters, the gingival attachment in these areas also As many as a dozen areas of Miller Class
tends to be narrower and thinner than what is I / II marginal tissue recession defects can be
found on teeth positioned more centrally in grafted utilizing the FTF/SCTG approach to
the alveolus.31 In such teeth, chronic gingi- achieve an enhanced zone of gingival attach-
val inflammation can readily result in the api- ment with root coverage. If more than a dozen
cal migration of the epithelial attachment and areas of Miller Class I and II marginal tissue
resultant gingival recession. If the patient has recession defects require gingival grafts, thick
impeccable oral hygiene, on the other hand, the FGG’s can be split, with the resulting thinner
likelihood of gingival recession is minimized. FGG’s used in the lower arch in conjunction
Contemporary methods of treating gingival with a semilunar flap and marginal tissue lift-
recession typically involve the use of SCTG’s. ing approach. A few millimeters of root cover-
Due to the anatomy of the palate, a limited age are possible and the enhanced zone of
amount of SCTG is available for harvest. In gingival attachment will have an acceptable
most situations, SCTG harvest is restricted to appearance if multiple FGG’s are used in a
an area distal to the canine and anterior to the continuous unerupted fashion over many teeth.
mesial aspect of the first molar (Wara-aswapati). The results of these 2 grafting approaches have
Straying beyond these limits may result in an proved stable with adequate oral hygiene. ●
inadequate SCTG harvest and increased risk of
damaging the greater palatine artery. The lim-
Correspondence:
ited availability of SCTG, even when harvested
bilaterally, often restricts perio-plastic surgical M. Thomas Wilcko, DMD
treatment to a maximum of 6 teeth in a single sit- 6074 Peach Street, Erie, PA 16509
ting. Because of this, alternate allograft materi- Phone: (814) 868-3669
als for soft tissue surgery have been introduced Fax: (814) 864-1368
to the market. These materials, while of unlim- Email: wilcko@velocity.net
ited abundance, are technique sensitive and may Website: www.fastortho.com
provide results that degenerate over time. The
44 • Vol. 1, No. 8 • November 2009

Wilcko et al
Disclosure 14. Mahn D. Treatment of gingival recession with 28. Löst C. Depth of alveolar bone dehiscences in
The authors report no conflicts of interest with a modified “tunnel” technique and an acellular relation to gingival recession. J Clin Periodontol
anything mentioned in this paper. dermal connective tissue allograft. Pract Proced 1984; 11: 583-589.
References Aesthet Dent 2001; 13: 69-74.
29. Maynard JG, Ochsenbein D. Mucogingival
1. Wennström J. Mucogingival therapy. Section 15. Tözum TF, Dini FM. Treatment of adjacent problems, prevalence and therapy in children. J
8. 1996 World Workshop in Periodontics. Ann gingival recession with subepithelial connective Clin Periodontol 1975; 6: 437-442.
Periodontol 1996; 1: 671-701. tissue grafts and the modified tunnel technique.
30. Holbrook T, Oschsenbein D. Complete
2. Björn H. Free transplantation of gingival propria. Quintessence Int 2003; 34: 7-13.
coverage of the denuded root surface with a
Sven Tandlak Tidskr. 1963; 22: 684-689. 16. Garglulo A, Wentz F, Orban B. Dimensions one-stage gingival graft. Int J Periodontics Rest
3. Miller P. Root coverage using a free soft tissue and relations of the dento-gingival junction in Dent 1983; 3: 9-27.
autograft following citric acid application. Part humans. J Periodontol 1961; 32: 261-267.
31. Wennström JL. Mucogingival considerations
1: Technique. Int J Periodontics Rest Dent 1982; 17. Maynard J, Wilson R. Physiologic dimensions in orthodontic treatment. Seminars in
2: 65-70. of the periodontium significant to the restorative Orthodontics 1996; 2(1): 46-54.
4. Raetzke P. Covering localized areas of root dentist. J Periodontol 1979; 50: 170-174.
32. Batenhorst KF, Bowers GM, Williams JE.
exposure employing the “envelope” technique. J 18. Ingber J, Rose L, Caslet J. The “biologic width” Tissue changes resulting from facial tipping and
Periodontol 1985; 56: 397-402. – a concept in periodontics and restorative extrusion of incisors in monkeys. J Periodontol
5. Langer B, Langer L. Subepithelial connective dentistry. Alpha Omegan 1977; December: 62. 1974; September: 660-668.
tissue graft technique for root coverage. J 19. Kois J. Altering gingival levels: the restorative 33. Artun J, Krogstad O. Periodontal status
Periodontol 1985; 56: 715-720. connecti-Part1: biologic variables. J Esthetic of mandibular incisors following excessive
6. Nelson SW. The subpedicle connective tissue Dent 1994; 6(1): 3-9. proclination: a study in adults with surgically
graft. A bilaminar reconstructive procedure 20. De-Jacoby L, Ziafiro G, Ciancio S. The effect treated mandibular prognathism. Am J Orthod
for the coverage of denuded root surfaces. J of crown margin location on plaque and Dentofacial Orthop 1987; 91: 225-232.
Periodontol 1987; 58: 95-102. periodontal health. Int J Periodontics Rest Dent 34. Wehrbein H, Bauer W, Diedrich P. Mandibular
7. Harris RJ. The connective tissue and partial 1989; 9(3): 147-205. incisors, alveolar bone, and symphysis after
thickness double pedicle graft: A predictable 21. Nevins M, Skurow H. The intercrevicular orthodontic treatment. A retrospective study.
method of obtaining root coverage. J Periodontol restorative margin, the biologic width, and Am J Orhtod Dentofacial Orthop 1996; 110(3):
1992; 63: 477-486. the maintenance of gingival margin. Int J 239-246.
8. Müller H, Eger T, Schorb A. Alterations of gingival Periodontics Rest Dent 1984; 4(3): 31-49. 35. Nyman S, Karring T, Bergenholtz G. Bone
dimensions in a complicated case of gingival 22. Maynard J. Coronal positioning of a previously regeneration in alveolar bone dehiscences
recession. Int J Periodontics Rest Dent 1998; placed autogenous gingival graft. J Periodontol produced by jiggling forces. J Periodontal Res
18: 345-353. 1977; 4(3): 151-155. 1982; 17: 316-322.
9. Chambrone L, Chambrone L. Subepithelial 23. Wilcko M, Wilcko W, Murphy K, Carroll W, 36. Karrying T, Nyman S, Thilander B, Magnusson I.
Connective Tissue Grafts in the treatment Ferguson D, Miley D, Bouquot J. Full-thickness Bone regeneration in orthodontically produced
of Multiple Recession-type of Defects. J flap/subepithelial connective tissue grafting with alveolar bone dehiscences. J Periodontal Res
Periodontol. 2006; 77(5): 909-916. intramarrow penetrations: three case reports of 1982; 17: 309-315.
10. Allen AL. Use of the supraperiosteal envelope in lingual root coverage. Int J Periodontics Rest 37. Fuhrmann RAW. Three-dimensional evaluation
soft tissue grafting for root coverage. II. Clinical Dent 2005; 25(6): 561-569. of periodontal remodeling during orthodontic
results. Int J Periodontics Rest Dent 1994; 14: 24. Wilcko W, Wilcko M, Bouquot J, Ferguson D. treatment. Seminars in Orthodontics 2002;
302-315. Rapid orthodontics with alveolar reshaping: Two 8(1): 23-28.
11. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz case reports of decrowding. Int J Periodontics 38. Reitan K. Some factors determining the
M. Treatment of multiple adjacent gingival Rest Dent 2001; 21: 9-19. evaluation of forces in orthodontics. Am J
recessions with the tunnel subepithelial 25. Wilcko W, Ferguson D, Bouquot J, Wilcko M. Orthodont 1957; 43: 32.
connective tissue graft: A clinical report. Int J Rapid orthodontic decrowding with alveolar 39. Reitan K. Tissue reaction as related to the age
Periodontics Rest Dent 1999; 19: 199-206. augmentation: case report. World J Orthodont factor. Dent Rec 1954; 74: 271.
12. Blanes RJ, Allen EP. The bilateral pedicle flap- 2003; 4: 197-505.
40. Reitan K. Continuous bodily movement and its
tunnel technique: A new approach to cover 26. Wilcko M, Wilcko W, Bissada N. An evidence- histologic significance. Acta Odontol Scand
connective tissue grafts. Int J Periodontics Rest based analysis of periodontally accelerated 1947; 6:115.
Dent 1999; 19: 471-479. orthodontic and osteogenic techniques: a
41. Hirschfeld I. A study of skulls in the American
13. Santarelli G, Ciacaglini R, Campanari F, Dinoi C, synthesis of scientific perspectives. Seminars in
Museum of Natural History in relation to
Ferraris S. Connective tissue grafting employing Orthodontics 2008; 21(4): 305-316.
periodontal disease. J Dent Res 1923; 5: 241.
the tunnel technique: A case report of complete 27. Bernimoulin J, Curilivic Z. Gingival recession
root coverage in the anterior maxilla. Int J and tooth morbidity. J Clin Periodontol 1977; 4:
Periodontics Rest Dent 2001; 21: 77-83. 208-219.

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Gonshor et al
Maxillary Sinus Floor Augmentation:
A Histologic and Histomorphometric
Human Grafting Study Comparing
Two Anorganic Bovine Bone Minerals
Aron Gonshor DDS, PhD1 • Yoon-Je Jang, DDS, PhD2
Abstract
Background: Autogenous grafts have been the Results: Histomorphometry showed aver-
“Gold Standard” in bone grafting. However, this age vital bone content of 33% (±15) for
often calls for a second surgical site and insuffi- NuOss™ and 33% (±17) for Bio-Oss®.
cient bone quantities. A need exists for a surgi- Residual graft content was 29% (±11) for-
cal technique that does not require autogenous NuOss™ and 24% (±17) for Bio-Oss®.
bone harvesting and still results in sufficient bone
formation within a relatively short time frame. Conclusions: This study showed the similar
osteoconductive properties of both NuOss™
Materials and Methods: This study com- and BioOss®. Clinical findings revealed a high
pares two anorganic bovine bone miner- bone density during the period of the post graft-
als (ABBMs) - NuOss™ and Bio-Oss® ing study. The results confirm that grafting
- in an ongoing clinical human sinus floor aug- materials from a bovine source will produce reli-
mentation project. Histology and histomorphom- able bone foundations for implant placement.
etry were performed 5-10 months after grafting.
KEY WORDS: Bone grafts, maxillary sinus floor augmentation, anorganic bovine bone mineral,
osteoblast(s), NuOss, Bio-Oss
1. Lecturer, McGill University, Department Oral and Maxillofacial Surgery, Montreal, Quebec, Canada
2. Clinical Assistant Professor, New York University, Department of Periodontics and Implant Dentistry,
New York, New York, USA

Gonshor et al
INTRODUCTION with or without autogenous bone. Hising et al16

A lack of vertical height in the posterior maxilla showed much higher implant survival rates when
often precludes implant placement. The loss of an ABBM was used alone (92.2%), than when it
maxillary molars often results in very large reduc- was used together with autogenous bone (77.2%).
tions of bone volume in both horizontal and ver- The present article highlights the use of two
tical directions, precluding implant placement.1 ABBMs- NuOss™ (ACE Surgical, Brockton, Mass,
In addition to this quantitative loss there is also USA) and Bio-Oss® (Geistlich, Wolhusen, Switzer-
the factor of bone quality affecting the implant land) - in an ongoing clinical human sinus augmen-
anchorage. Often there is little or no corti- tation project. Histologic studies have shown that
cal bone in the posterior maxilla, as well as very the ABBMs have bone-conductive properties17, 18
low density cancellous bone. Both of these fac- and that they have prolonged resorption times.19
tors decrease the chance of achieving good
primary stability during implant placement.2 MATERIALS AND METHODS
Greater bone volume and height can be Materials
achieved by augmentation of the maxillary The inorganic component of bone is comprised
sinus floor, so as to provide a sufficient vol- of calcium-based minerals of apatite structure,
ume of bone for mechanical support. The tech- mainly of carbonate apatite, containing small
nique for antral augmentation was developed amounts of magnesium, sodium, potassium,
by Tatum in the 1970s and reported in 1986,3 chloride, etc. It has been demonstrated that the
but the first clinical results were presented organic part of bone can be removed without sig-
by Boyne and James.4 Apart from the tech- nificantly altering the native structure of the bone
nique itself, one of the key features in the suc- mineral.20 Methods have been developed that
cess of the procedure involves the selection can produce this anorganic bone mineral from
of the appropriate augmenting graft material.5 a bovine source, while maintaining the struc-
Autogenous bone has long been considered ture of the mineral similar to that in native bone.
the gold standard in grafting procedures,6 but is Essentially the method consists of a chemical
often limited by the morbidity of a second surgi- extraction process and heat treatment to remove
cal site and the frequent inadequate amounts the organic components of the bone resulting
of graft obtained.7 This has led to the use of a in an anorganic bovine bone mineral, a natural
myriad of substitutes as grafting material, includ- calcium phosphate salt in a carbonate apatite
ing allografts,8 coralline hydroxylapatite,9 synthetic structure. In the present study the ABBM gran-
calcium phosphates,10 anorganic bovine bone,11-13 ules were cancellous, in the 250 to 1000µ size.
or a combination of these materials.14 In particu-
lar, there has been considerable clinical evidence Patients
that anorganic bovine bone mineral (ABBM) gives This multicenter study took place from May,
very similar results to autogenous bone as a sinus 2005 to February, 2007. Twelve patients (1
grafting material.15 Froum et al11 showed similar female, 11 males), with a mean age of 52
implant survival rates when an ABBM was used years (range 41 to 70) took part in the study.
50 • Vol. 1, No. 8 • November 2009

Gonshor et al
Figure 1a: Cross sectional CBCT image after grafting. Figure 1c: Cross sectional CBCT image after case
completion.
Figure 1b: Panoramic CBCT image after grafting. Figure 1d: Panoramic CBCT image after case completion.
There were 4 totally and 8 partially edentulous ing, diabetes or autoimmune disease, abscess
patients, all with bilateral posterior maxillary with soft-tissue swelling, oral bisphospho-
bone loss and sinus pneumatization, preclud- nates, and active sinus disease or sinus pathol-
ing the placement of implants. This created 22 ogy. Each patient was given information about
maxillary sinus augmentations. The inclusion the study and gave written and oral consent.
criterion was that the residual alveolar bone be
no higher than 5mm, as determined by Com- Surgical Procedure
puterized or Cone Bean Scans (figures 1a,1b). All of the patients underwent the sinus floor aug-
The average residual bone height was 3.8mm mentation under local anesthetic. The surgical
(±0.4mm). The exclusion criteria were smok- procedure has been described elsewhere.4 An

Gonshor et al
incision was made in a slightly palatal portion of

the residual ridge crest while vertical releasing
incisions were made both anteriorly and posteri-
orly. The creation of a superiorly-lifted mucope-
riosteal flap permitted visualization of the lateral
maxillary bone with a view of the buccal sinus
wall. Using diamond-tipped burs, a window
was created in the lateral maxillary buccal wall,
revealing the Schneiderian membrane. The lat-
ter was separated from the underlying bone so
as to create a submembrane cavity into which
Figure 2: ABBM placement into maxillary sinus. the graft material was placed. There was no
infracturing of the buccal wall. In each case,
the treatment was to augment the sinuses with
the ABBM - NuOss™ on one side and Bio-Oss®
on the other (figure 2). In one of the patients
platelet rich plasma (PRP) was mixed with the
ABBM’s. Implants were placed at a later date.
In all cases, after the graft material was placed,
the window opening was covered with a long
acting resorbable collagen membrane (RCM-6,
ACE Surgical, Brockton, Mass, USA). Closure
was performed with 3.0 Vicryl® sutures (John-
son and Johnson, Langhorne, PA, USA) in both
continuous and horizontal-mattress fashion.
Core Biopsies
After an average of 6.4 months of healing,
cores were taken for histologic and histo-
morphometric analysis (figure 3) and dental
implants were placed. Biopsy cores were
taken with trephines of 2.7 mm internal diam-
eter (3.5 mm external diameter). The Biop-
sies were left within the trephine and placed
in 10% neutral buffered formalin for fixation.
Histological Preparation
Figure 3: Histologic core sample. Histological preparations were performed at
52 • Vol. 1, No. 8 • November 2009

Gonshor et al
Figure 4a: High resolution histology of bone formation in Figure 4b: High resolution histology of bone formation in
graft with Bio-Oss® graft with NuOss™
the Department of Oral Pathology, Yonsei Uni- The cores were digitized at the same magnifi-
versity College of Dentistry, Seoul, Korea and cation using a Leica DMR HC and a Jenoptic
at the Periodontal Bone Center, McGill Univer- ProgRes C14 Digital camera. Histomorpho-
sity, Montreal, Quebec, Canada. Upon receipt, metric measurements were completed using
specimens were dehydrated with a graded ser- Bioquant Nova Prime Bone Morphometry, ver-
ies of alcohols for 9 days. The specimens were sion 6.50.10 (Bioquant Image Analysis Corp.
then infiltrated with a light-curing embedding - Nashville, Tenn, USA). Parameters evaluated
resin. After a further 20 days, the specimens were the total area of the core, the percentage
were embedded and polymerized by 450 nm of new bone formation, and the percentage of
light. The specimens were then prepared by the residual graft material. The remainder of the
cutting/grinding method of Donath21 and Roh- area was considered as being soft-tissue, void
rer.22 The cores were then polished to a thick- or osteoid. The primary slide evaluated for each
ness of 45-65 µm, followed by a final polish with specimen was from the most central region of
0.3 micron alumina polishing paste. The slides the obtained core. No comparison was made
were stained with Hematoxylin-Eosin (H&E) and between the apical and coronal sections.
coverslipped for histologic analysis by means of
bright field and polarized microscopic evaluation. RESULTS
Histology
Histomorphometry The histologic results are represented in figures
Following non-decalcified histologic prepara- 4a and b. In all cases, even those that had an
tion, the cores were evaluated morphometrically 8-10 month healing period between grafting
at McGill University, Montreal, Quebec, Canada. and core removal, residual particles of ABBM

Gonshor et al
were still clearly visible. For both Bio-Oss® and factor affecting the percentage of new bone
NuOss™ there was significant bone growth in formation. It would seem that individual healing
intimate contact with the grafted particles. The response, rather than the time the bone mate-
bone was mostly of the woven variety, but there rial was in place, had the greatest effect on
was also ample evidence of more mature lamel- the ABBM integration. There were also large
lar bone formation. The newly-formed bone variations in bone healing around the ABBM’s
could be easily distinguished from the grafted regardless of age and sex of the subjects.
ABBM as the bovine bone mineral exhibited
empty lacunae, with no osteocytic nuclei and DISCUSSION
no lamellar layering. This was contrasted by the Bio-Oss and NuOss are both sterile anorganic
new viable bone with osteocyte nuclei. In addi- bovine bone materials with porosity in the range
tion, there was bridging of new bone between of 75-80%. The inner macropores of ABBM’s
particles - a cardinal sign of active bone growth. are similar to natural cancellous bone.23 No
The ABBM particles were often thick and jag- B-cell or T-cell inflammatory responses have
ged-edged as opposed to the new viable bone been reported with the use of the ABBM.24 Bio-
which exhibit long lamellae with indefinite bound- Oss has been shown to be biocompatible with
aries. There was also evidence of connective oral osseous tissue, fulfilling a major require-
tissue distributed amongst the graft particles ment of an osteoconductive material. The deg-
and new bone trabeculae, containing blood ves- radation of these materials has been studied
sels, collagenous fibers and fibroblasts. There extensively. When ABBM’s were first used, they
were no signs of inflammation. Although there were considered as bioresorbable materials that
were few signs of active osteoclasts, the new would be replaced by autogenous bone over
bone ingrowth was evidence of slow replace- time. More recent studies have shown histologi-
ment of the grafted particles by new viable bone. cal evidence that ABBMs are not resorbed with
time. Hallman et al,19 working with human sub-
Histomorphometry jects, demonstrated that residual ABBM content
The histomorphometric analysis revealed did not decrease from 6 months to 3 years after
remarkably similar results for both ABBM’s. grafting. Other authors have confirmed this slow
The average percentage of new vital bone was resorption, with very few resorption lacunae,25
33%, with a large standard deviation in the or almost no resorption at all.26 Working with
24-29% range. The ABBM amounts were also Bio-Oss, Avera et al27 showed particles pres-
close in value, with an average of 24% (±11) ent after 44 months, and Piattelli et al confirmed
for NuOss™ and 29% (± 17) for Bio-Oss®. particle presence after 4 years.18 Instead, it
The amount of soft tissue was also similar, with appears that the graft particles become embed-
39% (±21) for NuOss™ and 43% (± 14) for ded in the newly generated lamellar bone, creat-
Bio-Oss®. Notwithstanding a period of 5 to10 ing a more radiopaque, dense bone than would
months before removing the bone cores, the be the case if the ABBM had resorbed.28 In
duration of waiting time was not a significant fact, it has been suggested that the resistance
54 • Vol. 1, No. 8 • November 2009

Gonshor et al
of ABBM’s to resorption may help in maintain- rate when only 3mm of residual bone remained.
ing initial stability in the augmented areas.11,29 The histomorphometric analysis showed that
As has been described elsewhere,13,30 in the amount of new bone formation for the two
this study newly generated bone was seen in bone materials was about 33%, with the non-
intimate contact with the ABBM particles. The vital particle percentage around 26%. These
length of wait from grafting to core samples results are close to the findings of other stud-
was not identifiable as a factor in the percent- ies with using autogenous bone alone as
ages of new bone creation. It may be assumed a graft material in sinus augmentation26 or
that the variation in percentage is more a factor in defects around dental implants.33 All of
of individual healing and regeneration response. these studies, as well as the present results,
The percentages were also not related to indicate that the use of this bovine mate-
patient age or sex. The amount of vital bone rial will lead to predictable bone formation.
is nevertheless substantial for that post-graft
time period, rising to above 30%. In addition CONCLUSION
there is still a high percentage of non-vital bone This study showed the osteoconductive prop-
remaining. This is consistent with the general erties of both NuOss™ and BioOss® and con-
fact that these bovine minerals resorb slowly.25 firms their effectiveness as natural bone grafting
Lastly, the remaining marrow and fibrous tissue substitutes. The clinical findings revealed
showed no signs of inflammatory response or significant bone formation during the period
giant cell invasion. This highlights the fact that of the post grafting study. The results high-
both of these materials are well accepted by the light and confirm the fact that grafting materi-
recipient. There was no significant difference in als from a bovine source will produce reliable
percentages of vital or non-vital bone between bone foundations for implant placement. ●
the case where PRP was added and the remain-
ing cases in the study. This is not unexpected, Correspondence:
since the effect of PRP is most pronounced Dr Aron Gonshor
when it is associated with autogenous tissue, 4980 Glencairn Ave
which contains living cells. Its effect on non-vital Montreal, Quebec
grafts such as the ABBM’s is not significant.31 Canada, H3W 2B2
The inclusion criteria used for sinus floor Phone: 514 941 4502
augmentation are important determinants of the email: arongonshor@gmail.com
eventual clinical result. It is likely that with the
decreasing amount of residual bone below the
sinus floor, the role played by the grafted bone
in achieving implant support becomes increas-
ingly important. In that regard, Jensen and
Greer32 showed a 100% survival rate when
the residual bone was 7mm and a 29% survival

Gonshor et al
Disclosure 13. Yildirim M, Spiekermann H, Biesterfeld S, 23. Berglundh T, Lindhe J. Healing around
The authors report no conflicts of interest with Edelhoff D. Maxillary sinus augmentation implants placed in bone defects treated with
anything mentioned in this article. using xenogenic bone substitute material Bio-Oss: An experimental study in the dog.
Bio-Oss in combination with venous Clin Oral Implants Res 1997;8:117-124.
References
blood. A histologic and histomorphometric
1. Watzek G, Ulm CW, Haas R (eds). The 24. McAllister B, Margolin M, Cogan A, Taylor
study in humans. Clin Oral Implants Res
Sinus Bone Graft. Anatomic and physiologic M, Wollins J. Residual lateral wall defects
2000;11:217-219.
fundamentals of sinus floor augmentation. following sinus grafting with recombinant
Chicago: Quintessence, 1999. 14. Moy PK, Lundgren S, Holmes RE. Maxillary human osteogenic protein-1 or Bio-Oss in the
sinus augmentation: Histomorphometric chimpanzee. Int J Periodontics Restorative
2. Misch CE. Effect on treatment plans, surgical
analysis of graft materials for maxillary sinus Dent 1998;18:227-239.
approach, healing, and progressive bone
floor augmentation. J Oral Maxillofac Surg
loading. Int J Oral Implantol 1990; 6: 23-31. 25. Storgard-Jensen S, Aaboe M, Pinholt E,
1993; 51: 857-862
3. Tatum OH. Maxillary and sinus implant Hjorting-Hansen E, Melsen F, Ruyter I. Tissue
15. Hallman M, Sennerby L, Lundgren S. A reaction and material characteristics of
reconstructions. Dental Clin North Am 1986;
Clinical and Histologic Evaluation of Implant four bone substitutes. Int J Oral Maxillofac
30: 207-229.
Integration in the Posterior Maxilla After Sinus Implants 1996;11:55-66.
4. Boyne PJ, James RA. Grafting of the maxillary Floor Augmentation with Autogenous Bone,
sinus floor with autogenous marrow and bone. 26. Valentini P, Abensur D, Densari D, Graziani
Bovine Hydroxyapatite, or a 20:80 Mixture. Int
J Oral Surg 1980; 38(8): 613-616. JN, Hammerle C. Histological evaluation of
J Oral Maxillofac Implants 2002;17:635-643.
Bio-Oss in a 2-stage sinus floor elevation and
5. Jensen OT, Shulman LB, Block MS, Iacono VJ. 16. Hising P, Bolin A, Branting C. Reconstruction implantation procedure. A human case report.
Report of the Sinus Consensus Conference of of severely resorbed alveolar crests with Clin Oral Implants Res 1998; 9: 59-64.
1996. Int J Oral Maxillofac Implants 1998;13 dental implants using a bovine bone mineral
Suppl:11-45. 27. Avera SP, Stampley WA, McAllister BS.
for augmentation. Int J Oral Maxillofac
Histologic and clinical observations of
6. van den Bergh JPA, ten Bruggenkate CM, Implants 2001;16:90-97.
resorbable and nonresorbable barrier
Krekeler G, Tuinzing DB. Sinus floor elevation 17. Hallman M, Lundgren S, Sennerby S. membranes used in maxillary sinus graft
and grafting with autogenous iliac crest bone. Histological analysis of clinical biopsies containment. Int J Oral Maxillofac Implants
Clin Oral Implants Res 1998;9:429-435. taken 6 months and 3 years after maxillary 1997;12:88-94.
7. Kalk WW, Raghoebar GM, Jansma J, Boering sinus floor augmentation with 80% bovine
28. Schlegel A, Donath K. Bio-Oss: A resorbable
G. Morbidity from iliac crest bone harvesting. J hydroxyapatite and 20% autogenous bone
bone substitute? J Long Term Eff Med
Oral Maxillofac Surg 1996;54:1424-1429. mixed with fibrin glue. Clin Implant Dent Relat
Implants 1998;8:201-209.
Res 2001;2:87-96.
8. Nishibori M, Betts NJ, H. S, Listgarten MA. 29. Scarano A, G. P, Piattelli M, Piattelli A.
Short term healing of autogenous and allogenic 18. Piattelli M, Favero GA, Scarano A, Orsini G,
Osseointegration in a Sinus Augmented With
bone grafts after sinus augmentation: A report Piattelli A. Bone reactions to anorganic bovine
Bovine Porous Bone Mineral: Histological
of 2 cases. J Periodont 1994;65:958-966. bone (Bio-Oss) used in sinus augmentation
Results in an Implant Retrieved 4 Years
procedures: A histologic long-term report
9. Smiler DG, Holmes RE. Sinus lift procedure After Insertion. A Case Report. J Periodontol
of 20 cases in humans. Int J Oral Maxillofac
using porous hydroxyapatite: A preliminary 2004;75:1161-1166.
Implants 1999;14:835-840.
clinical report. J Oral Implantol 1987;13:239- 30. Skoglund A, Hising P, Young C. Clinical
253. 19. Hallman M, Cederlund A, Lindskog S, S. L,
and histologic examination in humans of
Sennerby L. A clinical histologic study of
10. Zijderveld SA, Zerbo IR, van den Bergh the osseous response to implanted natural
bovine hydroxyapatite in combination with
JPA, Schulten EAJM, ten Bruggenkate CM. bone mineral. Int J Oral Maxillofac Implants
autogenous bone and fibrin glue for maxillary
Maxillary sinus floor augmentation using a 1997;12:194-199.
sinus floor augmentation. Results after 6-8
beta-tricalcium phosphate (Cerasorb) alone 31. Froum S, Wallace S, Tarnow D, Cho S. Effect
months of healing. Clin Oral Implants Res
compared to autogenous bone grafts. Int J of Platelet-Rich Plasma on Bone Growth and
2001;12:135-143.
Oral Maxillofac Implants 2005;20:432-440. Osseointegration in Human Maxillary Sinus
20. Johnson G, Mucalo M, Lorier M. The
11. Froum SJ, Tarnow DP, Wallace SS, Rohrer Grafts: Three Bilateral Case Reports. Int J
processing and characterization of animal-
MD, Cho SC. Sinus floor elevation using Periodontics Restorative Dent 2002;22:45-
derived bone to yield materials with
anorganic bovine bone matrix (OsteoGraf/N) 53.
biomedical applications: part 1: modifiable
with and without autogenous bone: a 32. Jensen O, Greer R, . (eds). Immediate
porous implants from bovine condyle
clinical, histologic, radiographic, and placing of osseointegrating implants into the
cancellous bone and characterization of bone
histomorphometric analysis-Part 2 of an maxillary sinus augmented with mineralized
materials as a function of processing. J Mater
ongoing prospective study. Int J Periodontics cancellous allograft and Gore-Tex: Second-
Sci Mater Med 2000;11:427-441.
Restorative Dent 1998;18:528-543. stage surgical and histological findings.
21. Donath K, Breuner G. A method for the
12. Froum SJ, Wallace SS, Cho S-C, Elian N, Chicago: Quintessence 1992.
study of undecalcified bones and teeth
Tarnow DP. Histomorphometric comparison of 33. Hammerle C, Chiantella G, Karring T, Lang
with attached soft tissues. The Sage-Schliff
a biphasic bone ceramic to anorganic bovine N. The effect of a deproteinized bovine bone
(sawing and grinding) technique. J Oral
bone for sinus augmentation: 6 to 8-month mineral on bone regeneration around titanium
Pathol 1982;11:318-326.
postsurgical assessment of vital bone dental implants. Clin Oral Implants Res
formation. A pilot study. Int J Periodontics 22. Rohrer M, Schubert C. The cutting-grinding
1998;9:151-162.
Restorative Dent 2008;28:273-281. technique for histologic preparation of
undecalcified bone and bone-anchored
implants. Improvements in instrumentation
and procedures. Oral Surg Oral Med Oral
Pathol 1992;74:73-78.
56 • Vol. 1, No. 8 • November 2009

Wilcko et al
Does your bone grafting material measure up?
Improvements in clinical and radiographic parameters in the GEM 21S® pivotal trial compare favorably with or
exceed, documented outcomes for other regenerative therapies in studies examining defects with similar baseline
characteristics.1,2,3,4
Radiographic Percent Bone Fill (BF%) Radiographic Linear Bone Growth (LBG) Clinical Attachment Level (CAL) Gain
60 3.0 4.0
57 3.7
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 Rev. 9/2009.
Novaes et al
Preservation of Buccal Bone Plate after
Immediate Implant Placement/Function with
the Flapless Approach: A Case Report
Arthur B. Novaes Jr., DDS, MScD, DSc1 • Rafael R. de Oliveira, DDS, MScD2
Valdir A. Muglia, DDS, MScD, DSc3
Abstract
Background: Immediate placement of implant was conducted 12 months later in order to

into an extraction socket provides both patient verify the status of the cervical buccal plate, as
and the clinician with the advantages of sig- well as the regression of the periapical lesion.
nificantly decreasing treatment time by mini-
mizing the surgical stages and helping to Results: The 12-month post-opera-
maximize the esthetic outcome by prevent- tive CT shows the complete healing of
ing alveolar ridge and gingival resorption. the periapical lesion in addition to pres-
ervation of the cervical buccal plate.
Methods: An immediate implant was placed
through flapless approach in order to replace Conclusion: The benefit of the combina-
the hopeless right central incisor due to an tion of immediate implant placement/function
extensive periapical lesion. After implant place- and flapless approach can make possible the
ment, a minimally functional fixed provisional maintenance of cervical buccal bone plate.
restoration was inserted. A CT scan analysis
KEY WORDS: Dental implants, immediate function/loading, computed tomography, dental esthetics
1. Professor & Chairman of Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo,
Ribeirão Preto, SP, Brazil.
2. Graduate Student of Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo,
3. Assistant Professor of Prosthodontics, School of Dentistry of Ribeirão Preto, University of São Paulo,

Novaes et al
INTRODUCTION
One of the most challenging procedures in
implant dentistry is the replacement of teeth in
the esthetic zone. Today, the development of
an esthetic restoration that matches the adja-
cent natural dentition has become the focus
of attention in implant dentistry. Evaluation of
the periodontal tissues is critical to achieve an
esthetic outcome as the alveolar bone has a
tendency to resorb following tooth loss and the
soft tissues generally shrink.1-4 This is especially
obvious in the anterior region where thin buc-
cal bone plates are often present.5,6 This loss of
bone and soft tissue lead to esthetic issues that
may compromise the restorative outcomes.7-9
Observations on cadaver specimens indicated
that following tooth loss in the maxilla, the height
of the ridge reduces and the crest shifted pala-
tally.10 Tylman & Tylman stated that following the
removal of teeth, the buccal alveolar bone plate Figure 1: Periapical radiograph of the right central incisor.
resorbed much faster than the palatal plate.11
A paradigm shift from the restoration-driven
implant placement to a tissue-related, esthetically
driven approach has recently favored the concept placement often results in two major problems:
of immediately implants placed into extraction reduction of primary initial stability and soft tis-
sites.12,13 This concept helps to preserve soft and sue ingrowth during the healing period.14 Most
hard tissue architecture and therefore reduces often, the initial stability can be preserved by plac-
the potential risk for the resorptive processes at ing an implant that is longer that the extracted
the alveolar ridge. A goal of current research in root or wider in diameter in the apical third. The
implantology is to improve patient satisfaction and maintenance of the existing gingival architecture
the esthetics of restored dental implants. Imme- is essential in achieving an esthetic result, and
diate placement of an implant into an extraction for this purpose, the flapless approach may be
socket provides both patient and clinician with indicated. Therefore, the prevention of soft tis-
the advantages of significantly decreasing treat- sue ingrowth and/or gingival recession around
ment time by minimizing the surgical stages and the implant is a prerequisite in esthetically driven
helping to maximize the esthetic outcomes by implant dentistry. Recent investigations have
reducing alveolar ridge and gingival resorption. reported high survival rates of immediately pro-
However, immediate post-extraction implant visionalized single-tooth implants in the maxilla
60 • Vol. 1, No. 8 • November 2009

Novaes et al
Figure 2: Cross-sectional tomography image showing Figure 3: Negative image of figure 2 .

an apical hypodense area and the cervical position of the
buccal bone plate.
after a follow-up of 12 to 18 months.15-17 This CASE DESCRIPTION

approach guides the healing and the matura- AND RESULTS
tion of the soft tissues, favoring formation of the The patient was diagnosed through radiographic
papillae through the orientation of the emergency examination with a hopeless maxillary right central
profile shaped by the temporary prosthesis. incisor (figure 1) due to an extensive apical lesion
Moreover, the loss of bone after tooth extraction, and long post and core restoration. The treatment
followed by additional bone loss in the first year plan was to replace the tooth with an implant-
after implant loading, could severely modify the supported crown using the flapless approach and
architecture of hard and soft tissues, compromis- immediate provisionalization. The patient signed an
ing the final esthetic outcome of implant therapy. informed consent form and treatment was initiated.
The aim of this case report is to demonstrate At the first periodontal visit, the compro-
through computed tomography (CT) scan analy- mised periodontal sites were detected, com-
sis, the possibility of maintenance of the cervical prehensive oral hygiene and full-mouth scaling
buccal bone plate after immediate implant place- and root planning was performed. Following the
ment followed by immediate function protocol. achievement of satisfactory levels of plaque con-

Novaes et al
Figure 4: Flapless approach. Implant placed 1-1.5mm Figure 5: Full-thickness flap elevated .
away from the buccal bone wall.
trol the patient was scheduled for the surgery. that the third dose was taken one hour before the
Based on the information gained from initial surgery. A flapless surgery was carried out with
radiographs and bone mapping, a diagnostic wax- atraumatic extraction of the hopeless tooth using
up was made on articulated casts. The final posi- a periotome. After the root was mobilized, it was
tion of the gingival margins and the apicocoronal carefully removed with forceps in a manner that
dimensions of the crown were established in this minimized trauma to soft tissue and alveolar bone.
preoperative diagnostic procedure by taking into The extraction socket was thoroughly debrided,
account the thickness of the gingiva at the site of bone walls were instrumented with bone chisels
implantation and the existing gingival architecture in order to remove any soft tissue tags and stimu-
around the natural teeth. Based on the wax-up, a CT late the opening of the marrow cavities, and lastly
scan of the maxilla (figures 2, 3) and a three dimen- irrigated with a saline solution. The socket walls
sional (3D) model were obtained. This allowed for and apex were carefully inspected to determine
the construction of a surgical template and precise the morphology of the socket and to establish if
planning of the surgical and prosthetic treatment. the buccal plate was intact. Upon decision that
Simulation of the implantation surgery was per- the site was adequate for the implantation, the sur-
formed and it was possible to individualize the abut- gical template was inserted and the implant site
ment and to fabricate the provisional restoration. was sequentially enlarged with pilot and spiral
Following review of all planning procedures, the drills according to the standard surgical protocol
surgery was scheduled. The surgical procedure for an implant 4.5mm in diameter and 15.0mm in
was performed under local anesthesia with mepi- length (Xive S Plus, Dentsply Friadent, Mannheim,
vacaine chlorhydrate with epinephrine 1:100,000. Germany). A blasted and acid-etched self-tapping
Antimicrobial treatment (amoxicillin 875 mg) was screw-type implant was placed 1 to 1.5mm away
given every 12 hours for 10 days, starting 24 from the buccal bone wall (figure 4). The implant
hours prior to surgery and was programmed so was anchored in the floor of nasal cavity and was
62 • Vol. 1, No. 8 • November 2009

Novaes et al
Figure 6: A bioactive glass material grafted over the thin Figure 7: Flap closure and provisional restoration in
apical buccal plate. position.
found to be stable. Based on the CT scan and days if needed. The patient was placed in on a strict
clinical inspection, a thin buccal bone plate in follow-up regime until soft tissue healing was com-
the apical third of the implant site was a concern. plete. The final implant impression was made after
An apicoectomy-type incision was made at the 3 months and a definitive ceramic abutment (Cer-
mucogingival junction and a full-thickness flap was con, Dentsply Friadent, Mannheim, Germany) was
raised leaving the coronal aspect of the gingiva connected to the implant and the definitive metal-
undisturbed (figure 5). A bioactive glass mate- free ceramic restoration was cemented (figure 8).
rial (Biogran, Biomet 3i, Palm Beach Gardens, FL, A new CT scan was performed 12 months
USA) was grafted over the thin buccal plate (figure after implant placement in order to verify the sta-
6) and flap closure was achieved using 5-0 nylon tus of buccal bone plate as well as the osseointe-
sutures. In sequence, the gap between implant and gration of the implant (figures 9, 10). The implant
bone walls was also grafted with the bioactive glass. was stable during all observation periods and no
Immediately following implant placement, the complications such as screw loosening, ceramic
initial restorative treatment was initiated. The pro- fracture, or pain during chewing were regis-
visional restoration which was fabricated based tered. The 12-month post-operative CT scan
on the previously performed prototyping was showed complete healing of the periapical lesion
then cemented for refinements on contour and and preservation of the cervical buccal plate.
occlusal adjustment (figure 7). In sequence, a
periapical radiograph was taken using the long- DISCUSSION
cone paralleling technique to check the adapta- Providing patients with optimal esthetics remains
tion of the prosthetic components and restoration. challenging when teeth require replacement with
The patient was instructed to eat a soft diet for implant-supported crowns. However, it can be
4 weeks post surgery. Analgesics were given on a source of great satisfaction for the patient and
the day of surgery and postoperatively for the first 3 clinician when the outcome is excellent. Mainte-

Novaes et al
Figure 8: The definitive restoration.
nance of soft tissue contours is a requisite in gain-

ing an ideal esthetic result. In turn, maintenance
of soft tissue contours is dependent on extraction
techniques that generate less trauma to bone and
soft tissues followed by providing interim sup-
port for the overlying soft tissue. Optimal sup-
port of the soft tissues during healing following
tooth extraction in the esthetic region might best
be provided through immediate implant place-
ment and insertion of an immediate minimally func-
tional fixed provisional and the flapless approach.
Araújo et al.17 demonstrated that marked hard Figure 9: Twelve month cross-sectional CT.
tissue alterations occurred during healing follow-
ing tooth extraction and implant installation in evident during the initial phase of wound healing
fresh sockets using full thickness flap. The mod- than during later periods following tooth removal.
eling in the marginal defect region was accom- Johnson20 reported that most dimensional altera-
panied by marked attenuation of the dimensions tions, horizontal as well vertical, occurred during
of both buccal and lingual bone plate. However the first three months of healing.20 Carlsson et al
in addition to other factors such as position of evaluated tissue changes through the analysis of
the implants within the sockets, the results may human biopsy specimens of the anterior maxillary
be due to the full thickness flap that was raised. extraction sites.21 During an observation period of
Loss or reduction of the bony walls due to tooth 3 to 210 days, the authors reported that the first
extraction is not a new observation.18 The healing sign of osteoclastic activity was after 7 days and
process following tooth removal results in more pro- after about 20 days, additional resorption resulted
nounced resorption on the buccal than the lingual/ in a considerable thinning of the buccal bone
palatal aspects of the ridge.19 Further, the process plate. After about 40 days, practically all of the
that resulted in tissue reduction seemed to be more original plate was resorbed and partially replaced
64 • Vol. 1, No. 8 • November 2009

Novaes et al
tissue attachment at the bone surface will induce

an acute inflammatory response which, in turn,
will mediate resorption of the surface layer of the
alveolar bone in the exposed area.5,23-25 Wilder-
man et al, when studying the healing of mucogin-
gival flaps and its effects on the bone, found that
within the first week, 5mm of buccal bone height
was lost.26 Half of this lost was recovered during
the healing process, but after 185 days, a loss of
2.5mm in height was realized. This loss in height
of the buccal bone occurred in the presence of the
tooth and the periodontal ligament, proving that
the loss in buccal bone height is due to the mucog-
ingival flap that compromises the vascularization
of the periosteum to the bone. Similar findings
regarding the healing of mucogingival flaps and
the sequence of events was shown by Kon et al.27
The buccal plate in the cervical area is very thin
and mainly cortical. It has no vascularization or mar-
row spaces, so it depends on the vascularization
that comes in part from the periodontal ligament
and the periosteum. When tooth extraction is per-
Figure 10: Negative image of figure 9. formed, a good part of vascularization of the buccal
plate is lost. Additionally, if a full thickness flap is
by new bone. This new bone, however, was not raised, the remaining vascularization of the buccal
continuous and lamellar as the original one. More plate is removed leading to a resorption process.28
recently, Botticelli et al assessed dimensional With the flapless approach, the vascularization
alterations that occurred in the alveolar ridge from the periosteum to the thin buccal plate is pre-
during a 4-month period following implant place- served, minimizing the possibility of resorption. ●
ment in fresh extraction sockets.22 The authors
concluded that the buccal bone dimension had
Correspondence:
undergone horizontal resorption that amounted
Arthur Belém Novaes Jr.
to about 56% while the corresponding reduc-
tion of the lingual/palatal bone plate was 30%. Faculdade de Odontologia de Ribeirão Preto,
This loss is greatly due to the full thickness flap Universidade de São Paulo, Avenida do Café
that is frequently used. It is well documented that s/n, 14040-904, Ribeirão Preto, SP, Brasil.
surgical trauma which includes the separation of novaesjr@forp.usp.br
the periosteum and the rupture of its connective

Novaes et al
Disclosure 12. Lazzara R. Immediate implant placement 24. Staffileno H, Levy S, Gargiulo A. Histologic
The authors report no conflicts of interest with into extraction sites: surgical and restorative study of cellular mobilization and repair
anything mentioned in this paper. advantages. Int J Periodontics Restorative following a periosteal retention operation via
Dent1989; 9: 332-43. split thickness mucogingival flap surgery. J
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Immediate loading of single-tooth implants:
3. Becker W, Ochsenbein C, Tibbetts L, Becker
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B. Alveolar bone anatomic profiles as measured
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4. Salama H, Salama M, Garber D, Adar P. The
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in the anterior maxilla: a prospective 5-year 28. Araújo MG, Lindhe J. Dimensional ridge
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7. Buser D, Brägger U, Lang N, Nyman S.
Regeneration and enlargement of jaw bone using
19. Pietrokovski J, Massler M. Alveolar ridge
guided tissue regeneration. Clin Oral Implants
resorption following tooth extraction. J Prosthet
Res 1990; 1: 22-32.
Dent 1967; 17: 21–27.
8. Dahlin C, Andersson L, Linde A. Bone
20. Johnson K. A study of the dimensional changes
augmentation at fenestrated implants by
occurring in the maxilla following tooth
an osteopromotive membrane technique. A
extraction. Aust Dent J 1969; 14: 241-244.
controlled clinical study. Clin Oral Implants Res
1991; 2: 159-165. 21. Carlsson G, Thilander H, Hedegard B.
Histologic changes in the upper alveolar
9. Jovanovic S, Spiekermann H, Richter E. Bone
process after extractions with or without
regeneration around titanium dental implants in
insertion of an immediate full denture. Acta
dehisced defect sites: a clinical study. Int J Oral
Odontol Scand. 1967; 25: 21-43.
Maxillofac Implants 1992; 7: 233-245.
22. Botticelli D, Berglundh T, Lindhe J. Hard-
10. Rogers W, Applebaum E. Changes in the
tissue alterations following immediate
mandible following closure of the bite with
implant placement in extraction sites. J Clin
particular reference to edentulous patients. J
Periodontol. 2004; 31: 820-828.
Am Dent Assoc 1941; 28: 1573.
23. Wilderman M. Repair after a periosteal
11. Tylman S, Tylman S. Theory and Practice of
retention procedure. J Periodontol 1963; 34:
Crown and Bridge Prosthodontics 1960; 4th
487–503.
edition, 69–71. St. Louis: The C.V. Mosby
Company.
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Giulio et al
Giulio et al
Subperiosteal Dental Implants:
A 25 Year Retrospective Survival Evaluation
Antonio T. Di Giulio1 • Giancarlo Di Giulio1 • Enrico Gallucci2
Abstract
Background: Making long term retentive den- Results: 66 patients received a chrome-
tures for patients with inadequate bone for cobalt total subperiosteal implant between
endosseous dental implants is a challenge. In 1984 and 1995. 54 patients received a tita-
such situations, utilization of subperiosteal den- nium total subperiosteal implant between
tal implants is a viable yet often overlooked 1996 and 2008. Statistical analysis of Kaplan-
option. The aim of this study was to determine Meier demonstrated a survival rate of 95.5%
the long term survival rates of subperiosteal at 7 years and 89.1% at 20 years for chrome-
dental implants placed between 1985-2008. cobalt implants. Titanium subperiosteal dental
implants had a survival rate of 81.1% at 7 years.
Material and methods: All candidates for
subperiosteal dental implants underwent com- Conclusions: This study demonstrates that
puted tomography (CT) scans to reproduce subperiosteal dental implants offer a viable alter-
the bone crest in maximum detail. A ste- native to endosseous dental implants when
reolithographic model for both maxilla and inadequate bone is present. Presurgical evalu-
mandible was constructed, upon which a sub- ation with computerized tomography and utiliza-
periosteal prosthesis was then constructed. tion of stereolithic models allows for reduced
surgical time and properly fitting structures.
KEY WORDS: Subperiosteal dental implants, chrome-cobalt, titanium, maxilla, mandible,

stereolithography
1. San Babila Day Hospital, via Stoppani 36, Milano, Italy

2. Farmaco-Biologico Department, Università degli Studi di Bari, Italy

Giulio et al
INTRODUCTION
In 1965, Brånemark1 placed the first titanium
dental implant into a human maxilla ushering in
a new era in the field of dentistry. Decades of
data provide overwhelming evidence that implan-
tology is a safe therapeutic intervention and pro-
vides recipients with function, aesthetics, and
comfort following a minimally invasive surgical
approach. Furthermore, computer-assisted navi-
gation systems, which improve intra-operative
safety by preventing damage to nerves and other
critical structures, have recently been successfully
applied to implant dentistry. At a technical level,
this has led implantology to achieve maximum pre-
cision. However, although surgical dental implant
placement is safe and rigorously programmed, it
is sometimes not without complications deriving
from the many variables involved in the procedure. Figure 1: Maxillary stereolithographic model.
Though there are many ways of making implants
feasible, inadequate osseous structures sometime
render this option inaccessible. In such situa-
tions, utilization of subperiosteal dental implants
is a viable yet often overlooked option. The first
subperiosteal implant in Europe was carried out
by Dahl2 back in 1940 followed by Goldberg and
Gershkoff3 later utilizing this treatment modality
in the USA. Linkow4 further advanced use of the
subperiosteal implant with the design referred to
as the “tripodal mandibular subperiosteal implant.”
This article focuses on over 25 years of
the authors’ clinical experience with subpe-
riosteal dental implants including the sur- Figure 2: Mandibular stereolithographic model.
gical procedure, post-operative follow up,
and statistical analysis of long term survival. ined 120 consecutive patients. A total of 65
female patients (mean age of 51.5 ± 11.0 years)
MATERIALS AND METHODS and 55 males (mean age of 49.3 ± 12.0 years)
A retrospective survival study of subperiosteal were evaluated. All patients treated in this study
dental implants placed from 1984 to 2008 exam- were completely edentulous and typically pre-
70 • Vol. 1, No. 8 • November 2009

Giulio et al
Figure 3: Example of maxillary subperiosteal implant fit. Figure 4: Suturing following maxillary subperiosteal
implant delivery.
sented with severely resorbed maxillas and/or tal implant, constructed of either chrome-cobalt
mandibles. Smokers and those suffering from or titanium, has a palatal bar connected to two
chronic systemic conditions such as diabetes, vestibular bars simulating roots of the molars (fig-
cardiovascular disease, severe osteoporosis, or ure 1). The framework of the mandibular subpe-
those undergoing chemo/radiation therapies were riosteal dental implant (figure 2) embraces the
not included in this study. Candidates for subpe- alveolar crest, reminiscent of the tripodal mandib-
riosteal implant therapy received panoramic radio- ular subperiosteal implant proposed by Linkow.4
graphs and computed tomography (CT) scans All patients were treated under local anesthesia
with 64 multislices (General Electric Co, USA) to with occasional use of sedation. An incision was
reproduce osseous structures in maximum detail. made on the alveolar crest and mucoperiosteal
Such pretreatment analysis allowed us to become flaps were elevated to facilitate fixture delivery. It
familiar with the patient’s three-dimensional (3D) should be noted that before this procedure was
bony architecture and critical anatomical struc- introduced (2003), the protocol described by
tures so as to plan the subperiosteal implant. Linkow4 and Moore5 had been followed. With the
This analysis allowed for fabrication of maxil- newer procedure, the fit of the implant was evalu-
lary and mandibular stereolithographic models ated by pulling it to make sure of perfect contact
used in constructing custom fabricated subpe- with the bone. Before suturing of the gingiva, the
riosteal dental implants. The exacting detail of implant was covered with hydroxyapatite (n=34
the models allowed for fixtures that intimately patients) or demineralized bone allograft (n=15
adapted to the patients’ osseous anatomy before patients), whereas in another 5 subjects no graft
any surgical procedure was ever undertaken. was used (Figures 3 and 4). Postsurgical instruc-
The structure of the maxillary subperiosteal den- tions were given to the patient and follow-up CT’s

Giulio et al
and panoramic radiographs were performed in

all cases. A 4-month healing period was allowed
prior to placing prosthetic restorations for full
function. The evolution of the treatment was eval-
uated by pulling the implant in all possible direc-
tions and additional radiographs were taken to
identify bone apposition over the abutment. Fig-
ure 5 shows healed bone covering portions of
the subperiosteal dental implant from figure 3.
Annual check-ups were required to verify the
success of the implant. The parameters assess-
ing implant success were based on subjective and
objective clinical criteria such as: 1) absence of
clinically-detectable implant mobility; 2) absence
of pain; 3) absence of inflammation; 4) comfort of
patient; 5) bleeding on probing; 6) pocket-prob-
ing depth; 7) absence of foreign body sensation. Figure 5: New bone covering subperiosteal implant from
Statistical analysis of survival rates at 7 and figure 3.
20 years were performed applying the method
of Kaplan-Meier.6 Graphpad PrismTM version Five implants failed in males (3 maxillary, 2 man-
3.0 (Graph Pad Software, Inc, http://www.graph- dibular) and 2 failed in females (1 maxillary,
pad.com) was used to calculate survival fractions 1 mandibular). Allergy to chrome-cobalt was
using the product limit and report the uncertainty determined to be the cause of 5 implant failures
of the fractional survival as standard error calcu- while other causes included: a) 1 case of meno-
lated by the method of Greenwood. Furthermore, pausal osteoporosis; b) 1 case of excessive long
comparison among different survival curves was term osseous resorption in an elderly subject
automatically performed by means of logrank test. (73 years of age). In the latter two cases, the
Success rates were calculated as a percentage. implants were removed after 13 and 19 years
respectively. Statistical analysis was performed
RESULTS on the chrome-cobalt study cohort minus deaths
Sixty six patients received chrome-cobalt total and patients failing to respond to recall. Survival
subperiosteal implants between April 1984 and rate at 7 years of observation was 95.5% while
February 1995. Of those, 51.5% (n=34) were survival rate at 20 years was 78.1% (figure 6).
female and 48.5% (n=32) were male patients. Fifty four patients received titanium total sub-
43 of the 66 implants were placed in the max- periosteal implants between September 1996
illa and 23 in the mandible. The total number and March 2008. Of those, 57.4% (n=31) were
of failed chrome-cobalt subperiosteal implants female and 42.6% (n=23) were male patients.
during the total observation period was seven. Some patients in this study cohort received a
72 • Vol. 1, No. 8 • November 2009

Giulio et al
Figure 6: Kaplan–Meier estimate of survival rates of

chrome-cobalt implants as a function of time since Figure 7: Kaplan–Meier estimate of survival rates of
installation. chrome-cobalt and titanium implants as a function of time
since installation.
treatment modification as select cases were of χ2 = 2.43 and a p-value of P = 0.12, indicating
grafted with hydroxyapatite or demineralized bone that the two curves are not significantly different.
allograft. As this was a newer procedure, only
seven year survival rate was determined. The total DISCUSSION
number of failed titanium subperiosteal implants Multiple studies have shown that the various
during this observation period was four (2 male, endosseous dental implants available today suc-
2 female). The causes of failure were determined cessfully osseointegrate and have good long term
to be: a) 3 cases of severe osteoporosis; b) 1 prognoses. In most of these studies, patients
implant fracture after one year of function. Sta- typically have adequate bone for implant fixture
tistical analysis was performed on the titanium delivery or osseous structures conducive to rea-
study cohort minus deaths and patients failing sonable grafting procedures. For patients with
to respond to recall. Survival rate at 7 years of inadequate mandibular and/or maxillary bone,
observation was 87.1%. As a side note, it should treatment with endosseous dental implants is not
be mentioned that use of demineralized bone always feasible. In such situations, treatment with
allograft did not occur until the period of 2002- subperiosteal dental implants may be the patient’s
2008. Although follow up on these cases is short only option for fixation of dental prostheses.7,8
compared with the previous subperiosteal implant This study reported on survival rates of 120
techniques, it is worth noting that 100% of these subperiosteal dental implants placed over 24
cases have survived and are still in function. years (1985-2008). The survival rates seen in
A comparison of the survival curves of chrome- this study are comparable to results published
cobalt and titanium subperiosteal dental implants by other authors who reported a survival rates of
is reported in figure 7. The analysis gives a value 87%, 98%, 79%, 78%, and 98.7% over approxi-

Giulio et al
mately 10 years, respectively.9-12 Although a viable alternative treatment option. Over a 24

these survival rates are less than those typically year retrospective evaluation, the survival rates
reported with endosseous dental implants, one of subperiosteal dental implants seen in this
must remember that most cases treated with sub- and other studies prove this treatment modal-
periosteal dental implants have osseous struc- ity to be a feasible treatment option in select
tures of an often compromised nature. In many patient populations. The most important aspect
of these cases, treatment with endosseous dental for long term success of subperiosteal dental
implants was neither a feasible nor a safe option. implants is precise manufacturing of the implant
It is worth noting that in some patients who to fit the patient’s osseous profile. Additionally,
showed chrome-cobalt allergy or severe osteo- proper prosthetic restoration and periodic follow
porosis, their implants lasted a mean of 5.0 ± 2.3 up visits are required. All of the patients seen
years after surgery. Complications due to chrome- in this study profess complete satisfaction with
cobalt allergy were overcome by the use of tita- their implants in terms of improvements to their
nium, which has excellent biocompatibility and social life and stomatognathic functionality. This
high corrosion resistance.13-16 Additionally, the is of considerable importance owing to the rela-
recent addition of demineralized bone allograft to tively young age of our patients. Indeed, to para-
the subperiosteal implant procedure has improved phrase Brånemark’s famous remark, “nobody
survival rates at the 7 year benchmark. Further should have to live a nightly bedtime drama
evaluation at the 20 year benchmark will pro- with his/her overdentures in a glass of water.” ●
vide additional data for long term survival of con-
temporary use of subperiosteal dental implants. Correspondence:
The successful delivery of subperiosteal den- Dr. Enrico Gallucci
tal implants is aided by three-dimensional com- Dipartimento Farmaco-Biologico
puted tomography reconstructions enabling the Università degli Studi di Bari
precise reconstruction of the patient’s osseous via E. Orabona 4, 70126 Bari, Italy
profile upon which the subperiosteal implant Tel/Fax: +39 0805442796
is to be placed. Particular mention should Email: gallucci@farmbiol.uniba.it
be made of the stereolithographic technique,
which enables a model to be created from a CT
data set. This template of the mandible and/
or maxilla provides precise guidance for sub-
periosteal implant design and delivery in vivo.
CONCLUSION
For patients with severe inadequacies of man-
dibular and/or maxillary bone, treatment with
endosseous dental implants is not always fea-
sible and the subperiosteal dental implant offers
74 • Vol. 1, No. 8 • November 2009

Giulio et al
Disclosure
The authors report no conflicts of interest with anything mentioned in this
article.
Acknowledgements
The authors would like to thank their colleague Anthony Green for
proofreading and providing linguistic advice. The following collaborators:
Engineer F. Davolio, Radiologist A. Zerbi, Technician E. Puntieri are gratefully
acknowledged for their collaboration.
References
1. Brånemark P. Available at: http://en.wikipedia.org/wiki/Dental_
implant#cite_ref-2
2. Dahl G. Dental implant and superplants. Rassegna Trimestrale Odontoiatria
1956; 4: 25-36.
3. Goldberg N, Gershkoff A. Implant lower denture. Dent Dig 1949; 55: 490-
494.
4. Linkow L, Wagner J, Chanavaz M. Tripodal mandibular subperiosteal
implant: basic sciences, operational procedure, and clinical data. J Oral
Implantol 1998; 24:16-36.
5. Moore JD, Hansen PA. A descriptive 18-year retrospective review of
subperiosteal implants for patients with severely atrophied edentulous
mandible. J Prosthet Dent 2004;92:145-150.
6. Kaplan EL, Meier P. Nonparametric estimation from incomplete
observations. J Amer Stat Assoc 1958; 53: 457-48.
7. Kurtzman G, Schwartz K. The subperiosteal implant as a valuable long-term
treatment modality in the severely atrophied mandible: a patient’s 40-years
case history. J Oral Impantol 1995; 21: 35-39.
8. Kusek E. The use of laser technology (ER;CR:YSGG) and
stereolithography to aid in the placement of a subperiosteal implant: A case
study. J Oral Implantol 2009; 35: 5-11.
9. James R. Subperiosteal implant design. NY J Dent 1983; 53: 407-14.
10. Golec T, Krauser J. Long-term retrospective studies on hydroxyapatite
coated endosteal and subperiosteal implants. Dent Clin North Am 1992;
36: 39-65.
11. Yanase R, Bodine R,Tom J, White S. The mandibular subperiosteal implant
denture: a prospective survival study. J Prosthet Dent 1994; 71: 369-74.
12. Bodine R, Yanase R, Bodine A. Forty years of experience with
subperiosteal implant dentures in 41 edentulous patients. J Prosthet Dent
1996; 75: 33-44.
13. Albrektsson T, Hansson H, Ivarsson B. Interface analysis of titanium and
zirconium bone implants. Biomaterials 1985; 6: 97-101.
14. Steinemann S, Eulenberg J, Maeusli P, Schroeder A. Biological
and Biochemical Performance of Biomaterials, 1st edition, Elsevier,
Amsterdam 1986; 409-414 .
15. Rae T. The biological response to titanium and titanium-aluminium-
vanadium alloy particles I. Tissue culture studies. Biomaterials 1986; 7:
30-36.
16. Lindigkeit J. Titanium and titanium alloys: Fundamentals and Applications,
Wiley-VCH Verlag GmbH & Co. KGaA 2005; 453-466.

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Winter et al
Dental 3D Imaging Centers - Usage and Findings:
Part III – Bifid Canals and Other Deviations
of the Inferior Alveolar Nerve
Alan A. Winter, DDS1 • Kouresh Yousefzadeh, DDS2 • Alan S. Pollack, DDS3

Michael I. Stein, DMD4 • Frank J. Murphy, DDS5
Christos Angelopoulos, DDS6
Abstract
Background: This is part 3 of a 5 part study evalu- did not demonstrate evidence of a bifid canal. In
ating data obtained from dental referral usage of contrast, 110 patients (37.16%) had one or more
radiological labs for three dimensional (3D) ana- bifid canals. Of the 110 patients demonstrating bifid
tomical scans. The purpose of this current study canals, 56 (50.9%) had one bifid canal, 37 (33.6%)
was to gather data on bifid mandibular canals and had two canals, and 17 (15.45%) had three or more
other deviations of the inferior alveolar nerve (IAN). canals. Slightly more than half (55.45%) of bifid
canals were unilateral. Two thirds (67%) of the uni-
Methods: Data from 500 consecutive patients lateral bifid canals were on the right side of the man-
sent to i-dontics dental radiological centers from dible; one third (33%) of the unilateral bifid canals
9 centers locations in 3 states were evaluated. were on the left side of the mandible. 9 bifid canals
Of these patients, the current study evaluated (8.18%) were located at the mental foramen, 94
296 mandibles for the following: the incidence (85.45%) were posterior to the mental foramen, and
of bifid branches of the inferior alveolar canal, the 7 (6.36%) continued anterior to the mental foramen.
number of branches present when the IAN was
observed to split, laterality of the bifid canals, and Conclusions: The incidence of bifid mandibular
the location of the bifid canal in relation to the canals (37%) from the current study was greater
mental foramen (anterior, equal to, or posterior). than that reported in other studies. Presurgical
identification of bifid canals reduces risk of dam-
Results: 296 mandibular scans were included in age to vital structures and may explain difficulty
the study. Of these scans, 186 patients (62.84%) in obtaining local anesthesia in certain situations.
KEY WORDS: Cone beam computed tomography, inferior alveolar nerve, bifid canals mandible, dental implants
1. Assistant Clinical Professor, Department of Periodontics and Implant Dentistry, New York University College of Dentistry
2. Private practice, New York, USA
6. Director Maxillofacial Dental Radiology and Associate Professor of Clinical Dentistry, Columbia School of Dental Medicine

Winter et al
IntRODuCtIOn
The recent advent of cone beam computed
tomography (CBCT) technology has vastly
increased the diagnostic options for dental treat-
ment. While this technology is continually improv-
ing in terms of quality, equipment size, and cost,
most dental offices do not own CBCT scanners
at this time. Accordingly, many practices cur-
rently refer patients to freestanding dental radio-
logical labs for three dimensional (3D) anatomical
scans. The purpose of this series of studies was
to determine how and for what reason den-
tists currently utilize dental 3D imaging centers. Figure 1: Prevalence of bifid canals in 296 patients.
Part one of this study series evaluated demo-
graphic data and the reasons why patients were
referred for 3D evaluation. Part two of this study
series evaluated anatomical features of the lin-
gual artery in relation to dental implant treat-
ment. The purpose of this current study was to
gather data on bifid mandibular canals and other
deviations of the inferior alveolar nerve (IAN).
A bifid mandibular canal is a relatively uncom-
mon anatomical variation typically seen in less
than 1% of the population. The incidence of
bifid canals has been evaluated with both con-
ventional panoramic and computed tomography Figure 2: Of the mandibles demonstrating bifid canals,
(CT) images. Findings indicate that the canals 50.9% had one branch, 33.6% had branches, and 15.45%
may split in different positions along the length of had three or more branches.
the IAN and one branch may be smaller than the

other.1,2 Langlais et al3 reported a 0.95% preva- anesthetic injection technique, prosthetic design,
lence of bifid mandibular canals while Sanchis4 and surgical procedures can be modified to pre-
reported an incidence of 0.4% in an evaluation vent pain and discomfort during treatment pro-
of 2,012 mandibles. Multiple studies agree that cedures10 and ultimately improve final outcomes.
the bifid anatomical variations need to be identi-
fied when surgical procedures such as removal MAtERIALS AnD MEtHODS
of impacted third molars, insertion of dental CBCT scans of the dental arches from 500
implants, and osteotomies, are to be performed.5-9 consecutive patients taken in 9 centers located
Once bifid canals are identified, the local in 3 states were uploaded to the main pro-
78 • Vol. 1, No. 8 • November 2009

Winter et al
tinuous with the main inferior alveolar canal

in each slice. For consistency, all studies
were examined by a single examiner (KY).
RESuLtS
number
296 mandibular scans were included in the
study. Of these scans, 186 patients (62.84%)
did not demonstrate evidence of a bifid canal.
In contrast, 110 patients (37.16%) had one
or more bifid canals. Of the 110 patients
demonstrating bifid canals, 56 (50.9%) had
Figure 3: 55% (61/110) of bifid canals were unilateral one bifid canal, 37 (33.6%) had two canals,
while nearly 46% (49/110) were identified bilaterally. The and 17 (15.45%) had three or more canals.
majority of unilateral canals were located on the right side
of the mandible (41/61).
Laterality
Slightly more than half (55.45%) of bifid canals
cessing center of a single dental radiologi- were unilateral. Two thirds (67%) of the unilat-
cal practice (i-dontics, llc., New York, N.Y.) eral bifid canals were on the right side of the
which is limited to taking and processing 3D mandible; one third (33%) of the unilateral bifid
CT images for the dental community. Scans canals were on the left side of the mandible.
were taken on either i-CAT scanners (8 cen-
ters) or on a (1) NewTom 3G scanner. All stud- Location of the Bifid Canal
ies were converted to SimPlant™ (Materialise, 9 bifid canals (8.18%) were located at the
Glen Burnie, MD). When not specified, the mental foramen, 94 (85.45%) were poste-
data was converted to SimPlant™ version 10. rior to the mental foramen, and 7 (6.36%)
In the current study, 296 of the 500 scans continued anterior to the mental foramen.
were of the mandible. These scans were eval-
uated for the following: the incidence of bifid DISCuSSIOn
branches of the inferior alveolar canal, the num- The incidence of bifid canals has been reported
ber of branches present when the IAN was at less than one percent3,4 and the split of the
observed to split, laterality of the bifid canals, and mandibular nerve may be of unequal sizes.1,2
the location of the bifid canal in relation to the Regardless of the frequency of identify-
mental foramen (anterior, equal to, or posterior). ing bifid canals, various authors have identi-
All CBCT studies were made into 1.0 fied the surgical risks and complications that
mm slides and viewed both in the coro- may be experienced when they are encoun-
nal and transaxial planes. To be counted as tered, including an inability to obtain pro-
a bifid canal, each offshoot had to be con- found anesthesia using a local anesthetic.5-9

Winter et al
Figure 4: The majority of the bifid canals (85%) ended posterior to the mental foramen, while 8 percent terminated at the
mental foramen, and 6% extended anterior the mental foramen.
In order to achieve standardization and con- were then verified by a second author (AW).
sistency, the authors agreed as to what consti- The significance of the findings in this study
tutes a bifid canal as identified on the 3D image: matters relative to the size and location of the
any branch that appeared as a continuous radio- bifid canals, and what clinical procedure is
lucent canal extending from the inferior alveolar anticipated. Concerning operative dentistry,
nerve. All slices were 1mm in thickness and all it has been postulated that bifid nerves may
bifid canals were viewed and appeared to ema- explain why anesthesia is not as profound as it
nate from the IAN in three planes: axial, coronal, should be when employing a local anesthetic.
and sagittal. Once the parameters were defined, When encountered, infiltration of the local anes-
one researcher (YK) examined and identified all thetic to anesthetize these extra branches of
of the bifid canals noted in this study, which the IAN may help achieve greater local anes-
80 • Vol. 1, No. 8 • November 2009

Winter et al
Figure 5: Arrow indicates a small bifid canal that starts and ends distal to tooth #31. A larger canal can be seen anterior to
tooth #18.
Figure 6: The left bifid canal is highlighted in red, illustrating 3 bifid canals.
thesia. When planning implant surgery, it is Note the arrow in Figure 5 that highlights a
helpful to identify if any bifid canals exist in the bifid canal. Careful inspection will note addi-
surgical site. Encountering these extra canals tional canals emanating from the right IAN.
may not only contribute to unwanted local par- Mention must be made of the value of 3D
esthesias, but may also explain unusual bleed- images identifying normal and abnormal struc-
ing that emanates from the alveolar bone.10-11 tures when compared to 2D images. Figure
Figures 5 and 6 illustrate an example of 7 is a panoramic image (formatted in a 15 mm
multiple canals as they were identified in this trough) taken on a patient that was referred
study. While the widest branch, which is ante- to the CT lab after an implant was inserted
rior to tooth #18, is evident on the panoramic that resulted in paresthesia in the patient.
slice, smaller canals are highlighted in Figure 6. Figure 8 highlights a bifid branch of the IAN

Winter et al
Figure 7: Patient presented after an implanted was inserted in the #30 site resulting in paresthesia.
Figure 8: A bifid nerve rises from the IAN and was traumatized by the implant insertion.
that was traumatized by an implant. This aber- implant insertion would have identified the bifid
rant branch was not evident in the panoramic (aberrant) branch and altered the surgical site.
view due to the dense cortical bone. Traditional
2D imaging, both panoramic and periapical film,
is limited in revealing key anatomic structures COnCLuSIOn
that are obscured by thick buccal and/or lingual The incidence of bifid mandibular canals (37%)
bone. In this example, using 3D imaging prior to from the current study was greater than that
82 • Vol. 1, No. 8 • November 2009

Winter et al
reported in other studies. Presurgical identifi-

cation of bifid canals reduces risk of damage
to vital structures and may explain difficulty in
obtaining local anesthesia in certain situations. ● The Journal of Implant & Advanced Clinical Dentistry
Correspondence:
Dr. Alan Winter
a.winter@i-dontics.com
ATTENTION
PROSPECTIVE
AUTHORS
Disclosure:
Support for this study was generously given by NobelBiocare, Mahwah, NJ
and Imaging Sciences Inc., Hatfield, PA.
References:
1. Mardini S, Gohel A. Exploring the Mandibular Canal in 3 Dimensions.
JIACD wants
An Overview of Frequently Encountered Variations in Canal Anatomy.
AADMRT Newsletter, Fall 2008.
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your article!
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regarding publication in
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JIACD, please refer
8. Auluck A, Ahsan A, Pai KM, Shetty C. Anatomical variations
in developing mandibular nerve canal: A report of three cases. to our author guidelines at
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the following link:
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Dent J 1980; 46:646.
or email us at:
editors@jicad.com

Gonshor et al
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Volume 1, No.

The Journal of Implant & Advanced Clinical Dentistry

Say Goodbye To Impression Copings

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13 Case of the Month

19 JIACD Continuing Education

29 Single Surgery Comprehensive

49 Maxillary Sinus Floor

The Journal of Implant & Advanced Clinical Dentistry • 3

59 Preservation of Buccal Bone

69 Subperiosteal Dental Implants:

77 Dental 3D Imaging Centers -

The Journal of Implant & Advanced Clinical Dentistry • 5

Publisher Copyright © 2009 by SpecOps Media, LLC. All rights

Internet Management Opinions expressed in JIACD articles and communications

The Journal of Implant & Advanced Clinical Dentistry • 7

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7. If insufficient keratinized tissue is present at

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of blood loss from a single surgical site.19,20 Blood

The Journal of Implant & Advanced Clinical Dentistry • 21

Table 1: Local Hemostatic aids

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Vasoconstrictor 1:100,000 Epinephrine Activation of a adrenergic

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Surgicel® Plant derived a-cellulose Occlusive matrix: activation

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22 • Vol. 1, No. 8 • November 2009

whole blood.32 Absorbable collagen sponges

Oxidized Regenerated Cellulose

The Journal of Implant & Advanced Clinical Dentistry • 23

24 • Vol. 1, No. 8 • November 2009

The Journal of Implant & Advanced Clinical Dentistry • 25

26 • Vol. 1, No. 8 • November 2009

Continuing Education JIACD Quiz #4

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The Journal of Implant & Advanced Clinical Dentistry • 27