Microscopic Periodontics & Advanced Dental Implants — Diplomate of the American Board of Periodontology

Alloderm Results

I would like to highlight a recent article in the Journal of Clinical Periodontology, entitled; *Acellular dermal matrix allograft (Alloderm) versus subepithelial connective tissue graft in treatment of gingival recessions: a 5 yr. randomized clinical study by Neda Moslemi.

There were 16 patients with Miller class I /II gingival recession (recession to the mucogingival junction). One side was treated with a subepithelial connective tissue graft (SECTG) and the other with Alloderm. Clinical parameters were measured at baseline, 6 months and 5 years post surgery.

At 6 months, all parameters showed significant improvement in both groups (root coverage, reduction of recession width, reduction of recession height). At 5 years, it was noted that compared to baseline, there was no difference in complete root coverage between the groups. The increase in gingival thickness in the SECTG sites was stable for the same period, but returned to pre surgical values in the Alloderm treated sites.

For the past 15 years I have treated at least one patient per day for gingival grafting. Over the years I also have noticed, when using Alloderm, the thickness of the graft is lost over time and less keratinized tissue is formed when compared to SECTG. The loss of gingival thickness is significant. Gingival thickness is important because the thicker the tissue, the more resistant it is to trauma and the less likely it is that recession will occur. For these reasons, my first choice is always a subepithelial connective tissue graft which utilizes the patients own tissue. There are times when the palatal anatomy is not conducive to harvesting a graft and in these cases I do recommend Alloderm.

Lecturers and clinicians are recommending Alloderm as the graft of first choice. I see no evidence to support Alloderm over SECTG. They claim Alloderm is easier to use, can treat many teeth at once and results in less discomfort because a palatal graft is not necessary. Using Alloderm will result in an easier procedure, but if microsurgical techniques are employed, many teeth can be treated and there will be little to no discomfort. Periodontal microsurgery affords the patient the best treatment modality with the finest results. The connective tissue graft will maintain tissue thickness, maximize keratinized tissue, provide root coverage and an esthetic result.

*Moslemi, Neda. Acellular dermal matrix allograft (Alloderm) versus subepithelial connective tissue graft in treatment of gingival recessions: a 5 yr. randomized clinical study. Journal of Clinical Periodontology. Volume 38. Issue 12. Pages 1122-1129. Online December 2011

SMILE Technique Implants

Simplified Microsurgical Implant

Lifelike Esthetics

The SMILE Technique is an immediate dental implant method performed directly following tooth removal as well as a temporary crown that emerges like a natural tooth. Promptly replacing the implant and tooth preserves the surrounding bone structure and maintains tissue height that would otherwise breakdown or reabsorb. Reabsorption can cause a collapsed jawline and gum-line, diminished lip support and increased wrinkles surrounding the mouth area.

After the SMILE technique has been integrated for approximately 4 months and a strong bond with the surrounding bone & gum has been established, a final & permanent crown is placed.

Before – Tooth #10 Fractured

1 Week Later – Temporary Tooth

16 Wks Later – Final Crown

Read on to find out more about SMILE Technique Advantages…

Abutment Surface

Recently, an article entitled Effect of Surface Topography of Implant Abutments on Retention of Cemented Single-tooth Crowns, by Tomie Nakakuki de Campos et al., for the International Journal of Periodontics and Restorative Dentistry, investigated whether surface topography affects the retentive strength of cemented full crowns, comparing the effects of standard machined, sandblasted (80µm aluminum oxide), and grooved implant abutments.

International Journal of Periodontics and Restorative Dentistry
July/August 2010
Volume 30 , Issue 4, Pages 409-413

Five metallic crowns per abutment type were cast and cemented with zinc phosphate. After 24 hours, the crowns were submitted to a tensile test. The retentive strength of the cemented crowns was significantly affected by abutment surface topography. The sandblasted and grooved surface groups had approximately 2.4 times greater mean uniaxial retentive strength than the machined surface group. This suggests that sandblasted and grooved surface groups may be helpful in retaining metal castings in cases where standard machined abutments have failed or a large amount of stress is expected.

	Surface Roughness parameters of the test abutments
Surface roughness Parameter	Standard machined abutment (µm)	Sandblasted abutment (µm)	Grooved abutment (µm)
Ra	.09	1.04	8.38
Rz	.63	6.00	29.16
Rq	.12	1.33	9.57

Descriptive statistics of the retentive strength (in Newtons)
Abutment type	Mean	Standard Deviation
Standard Machined	368.73	46.31
Sandblasted	821.79	164.30
Grooved	870.83	116.11

Implants Infected Sites

Another article in the Journal of Periodontology, Fresh-Socket Implants in Periapical Infected Sites in Humans, by Crespi, Roberto, deserves attention.

Journal of Periodontology

Mar 2010, Vol. 81, No. 3, Pages 378-383

The aim of this study is to compare outcome of the immediate placement of implants when used in the replacement of teeth with and without chronic periapical lesions.

Method: 30 patients requiring a single tooth extraction of a premolar tooth were selected. The control group included 15 patients without periapical lesions but with root caries and root fractures. The test group included 15 patients with periapical lesions, periapical radiolucencies and no signs of pain, fistulas,or suppuration. Thirty teeth were extracted, and implants were immediately positioned in fresh sockets dn loaded after 3 months in both groups.

Results: At 24 months a survival rate of 100% was reported for all implants. There were no significant difference in any clinical parameter between control and test group. There was an equally favorable soft and hard tissue integration of the implants, revealing a predictable outcome.

This study confirms previous studies by other authors confirming successful implant survival in periapical infected sites.

Piezoelectric Microsurgical Sinus Lift

Dental implant surgery in the posterior maxilla requires consideration of anatomic factors. Due to reduced bone quality of this region, tooth loss results in a resorbtion of bone and a pneumatized maxillary sinus. When <5mm of residual bone remains between the alveolar crest and maxillary sinus, often a lateral window sinus lift is warranted.

This approach to increasing bone available for placing implants uses a window in the lateral bony wall of the maxillary sinus to gain access to the underlying Schneiderian membrane. Although implant survival rates associated with this procedure routinely exceed 90%, the lateral window sinus lift remains a technique sensitive procedrue due to the high risk of Schneiderian membrane perforation (research shows 11-56%) and hemorrhagic complications, the latter of which is associated with the inadvertent laceration of the intrasosseous arterial supply to this region.

The recent incorporation of piezoelectric technology when performing a lateral window elevation is one way to potentially reduce or eliminate many of the complications associated with the procedure. In contrast to using burs to prepare the window, piezoelectric surgery does not cut soft tissues, and therefore reduces the risk of Schneiderian membrane perforation. It uses technology which produces microvibrations that cut bone while leaving soft tissue intact.

A recent article in the Journal of Periodontology, using piezoelectric technology for lateral window sinus lifts showed a perforation rate of 3.6%.

Piezoelectric technology, in combination with microscope enhanced vision, illumination and microsurgical techniques, leads to further reduction in perforation rates, surgical complications, pain and swelling.

The photographs show a patient of record who has severe pnematization of the maxillary sinus and little bone remaining for implant placement. There is also minimal interradicular space to create a window into the sinus cavity.

Lasers

Lasers

In the last decades, laser therapy has been proposed as an alternative to therapy, due to its capability to obtain tissue ablation, hemostatic, bactericidal and detoxification effects against periodontal pathogens. Lasers have been approved by the FDA but not endorsed by the American Academy of Periodontology. Among the different types of laser, Er:YAG (erbium-doped: yttrium-aluminum-garnet) appears to be the most suitable to be used for periodontal treatment.

Despite in vitro studies (Tweak et al. 1994, Wilder-Smith 1995, Israel 1997), that have demonstrated its ability to create a surface that suggests biocompatibility for soft tissue attachment, few clinical trials have been conducted until now evaluating the clinical outcomes of Er:YAG laser in mechanical periodontal treatment.

A recent systematic review (Schwartz 2008) suggests that the Er:YAG application in non-surgical periodontal therapy was comparable with non-surgical mechanical debridement. However due to the high heterogeneity of the studies, a meta-analysis could not be formed. Therefore their conclusions were based on a simple narrative synthesis.

Henceforth, The Sixth European Workshop on Periodontitis (Sanz 2008) highly recommended a well designed randomized controlled clinical trial with a large population design to further evaluate the efficacy of Er:YAG laser treatment compared with traditional mechanical debridement.

A recent article; Lack of adjunctive benefit of the Er:YAG laser in non-surgical periodontal treatment: a randomized split mouth clinical trial- Rotundo, R J Clin Perio 2010, took up such a task. This is the first study to evaluate Er:YAG laser treatment using the highest standard in study design. The CONSORT design (Consolidated Standards of Reporting Trials) was dictated due to the controversial results of laser treatment. This study design shows the greatest transparency in reporting randomized controlled studies.

The study compared four modalities of non surgical therapy: supra-gingival debridement, scaling and rooot planing (SRP) + Er:YAG laser, Er:YAG laser, and SRP. Clinical outcomes were evaluated at 3 and 6 months.

This study concluded that there are benefits and disadvantages of using the Er:YAG laser treatment. The main advantage is that it shows a similar clinical attachment gain value to the one reported by the SRP approach, it does not cause significant discomfort for the patient and it it is less time consuming than the other treatments.

However, Er:YAG laser efficacy was similar to the supra-gingival scaling, while the SRP approach resulted in a statistically greater efficacy than the supra-gingival scaling. This means when comparing the results from 3 to 6 months, the Er:YAG laser had an appreciable loss in attachment, similar to supra-gingival scaling, whereas SRP maintained the attachment gain. The results also show that when the laser is used along with SRP, it does not provide a further adjunctive benefit with respect to SRP alone.

Drug Allergies

Drug Allergies

Should all NSAIDS be avoided in patients with aspirin reactions?

Most aspirin and NSAID reactions AREN’T immune mediated or TRUE allergies. Most are sensitivities due to inhibition of COX-1 which triggers leukotriene productions…leading to bronchospasm, hives, etc.

Patients with aspirin sensitivity are usually also sensitive to NONselective NSAIDS such as ibuprofen, naproxen, ketorolac, etc. Avoid nonselective NSAIDS in these patients.Consider these alternatives for patients with aspirin sensitivity.

Acetaminophen or salsalate weakly inhibit COX-1 but cross-sensitivity with aspirin usually isn’t a problem at lower dose. Try up to 650mg/dose of acetaminophen and 1500mg/dose of salsalate for people with aspirin sensitivity.

Celecoxib (Celebrex) prescribing info discourages using it in patients with aspirin sensitivity. But cross – sensitivity is rare..because it’s COX-2 selective.

Meloxicam (Mobic,etc) is COX-2 selective at low doses but loses selectivity at high doses. Try up to 7.5 mg/day for meloxicam.

Consider giving the first dose of these alternatives in your office in case there’s a reaction or refer patients to an allergist.

Occasionally a reaction to aspirin is immune mediated. In this case, it’s usually okay to use an NSAID because its chemical structure is different than aspirin.

The problem is that it’s hard to distinguish between aspirin sensitivity and a true allergy. When in doubt, refer these patients to an allergist for evaluation.

Curr Allergy Asthma Rep 2009;9:155

Biotypes

Biotypes

The April 2010 edition of Journal of Periodontology had an article entitled “Tissue Biotype and Its Relation to the Underlying Bone Morphology”, authored by Jia-Hi Fu et al. In the article, Cliffy’s and Shanley’s tissue biotype definitions are referred to. They define thin tissue as a gingival thickness of <1.5 mm, and thick tissue as having a thickness of ≥ 2mm. In Jia-Haifa’s study, the mean buccal soft tissue and bone thickness of the maxillary anterior teeth at 2mm below the bone crest were respectively .5mm +/- .24mm and .83mm +/- .32mm. These results are in agreement with previous studies.

It is important to consider the tissue biotype before the start of treatment. The thickness of the gingival and bone tissues affects the treatment outcomes, perhaps because of a difference in the amount of blood supply to the underlying bone and the susceptibility to resorption. I have found that most maxillary and almost all mandibular anterior tissue biotypes can be considered thin and susceptible to recession. When performing orthodontic tooth movement, restorative dentistry, implant treatment or periodontal care, the clinician must consider the possibility that recession can occur during or shortly after treatment. A periodontal consult to evaluate the need for gingival augmentation should be considered.

The most minimally invasive treatment for recession and inadequate attached gingiva is the subepithelial connective tissue graft from the palate. This graft will provide a sustained increase in gingival thickness, keratinized tissue, and root coverage. No other treatment can make such a claim. The best graft material is the patient’s own tissue.

The photos below show a patient who had orthodontic care with an excellent final orthodontic result. Shortly after completion of orthodontics, severe recession occurred on tooth # 24. This case shows a very common finding; a thin periodontium where root form is visible through the gingival tissue. The gingival tissue was less than 1 mm in thickness so careful manipulation and suturing was necessary. Traditional techniques would require raising a flap with vertical release incisions over the adjacent teeth. Using a microsurgical approach was instrumental in treating this patient. The tissues were gently handled; sutured using 7-0/9-0 sutures and no flap was reflected. Wound healing was greatly enhanced by not raising a flap; circulation was minimally compromised and the forces from lip movement were significantly reduced. Each of these microsurgical steps leads to a finer surgical result, greater predictability and an easy post operative recovery for the patient.

Kissel October Biotypes 1

Kissel_Biotypes_October 1

Kissel October Biotypes 2

Kissel October Biotypes 3

Keratinized Mucosa

Keratinized Mucosa

In the November issue of Journal of Periodontology an article entitled, A 4-year evaluation of the peri-implant parameters of immediately loaded implants placed in fresh extraction sockets authored by Roberto Crespi, considered the correction between the meaning of keratinized mucosa(KM) and the long-term maintenance of implants placed in fresh sockets and immediately loaded.

Methods: Twenty-nine patients requiring extractions of ≥2 teeth in the maxilla and mandible were selected. One-hundred thirty-two maxillary and 32 mandibular teeth, in the incisor, canine, and premolar regions, were extracted. Implants were positioned in fresh sockets and immediately loaded. Based on the amounts of KM, implants were categorized as follows: KM ≥2 mm (group A) and KM <2 mm (group B). Clinical parameters (probing depth, modified plaque index, modified bleeding index, and gingival index) and marginal bone levels were followed at 4 years after implant placement. Comparisons between group A and B values were performed by the Student two-tailed t test.

Results: At 4-year follow-up, a survival rate of 100% was reported for all implants. The mean values of group B were significantly higher (P <0.05) than group A for the following parameters: gingival index (group A, 0.67 – 0.09; group B, 1.01 – 0.11); modified plaque index (group A, 1.18 – 0.09; group B, 1.71 – 0.12); and modified bleeding index (group A, 0.35 – 0.05; group B, 0.78 – 0.05). Gingival recession was significantly elevated in group B. In both group A and group B, up to 60% of gingival recession occurred within the first 6 months. For mean bone loss values, statistically nonsignificant differences were reported between groups.

Conclusions: At 4-year follow-up, the results suggested that the presence of mid-buccal KM is not a critical factor in the maintenance of interproximal bone level around fresh socket implants immediately loaded. Conversely, less width of KM is significantly associated with more gingival inflammation, more plaque accumulation, and more gingival recession.

Office Technology

Office Technology

Over the past year I have incorporated the use of resonance frequency analysis (RFA) to help determine when an implant is ready for loading. I wanted to prevent the infrequent situation where the restorative dentist and patient have invested much time and expense in creating a final abutment and crown, to unfortunately find a non-integrated implant during abutment screw tightening.

The first FRA device clinically available was the Osstell. It has undergone many changes over the past several years and now is very user friendly.

The RFA is a bending test of the implant-bone interface, where a transducer applies an extremely small bending force that is transmitted as a lateral force to the implant and then its displacement is measured.

The most recent device is wireless, where a metal rod (peg) is connected to the implant by means of a screw and it is excited by magnetic pulses elicited from a handheld computer. This diagnostic device has been extensively used in experimental and clinical research for the last 10 years and has demonstrated a good correlation between the obtained ISQ (implant stability quotient) values and the degree of stiffness between the implant and the bone.

It is great to have an objective way to assist in determining osseointegration and when to load an implant. You can be assured that when I send a patient back for restorative procedures the implant ISQ value will indicate a high level of implant rigidity. Most well integrated implant have a value about 70 or greater.

← Previous Entries