Specops Jiacd 200903

Volume 1, No.
1 m arch 2009
The Journal of Implant & Advanced Clinical Dentistry
The Agony and Ecstasy of

Buying Cone Beam Technology
Part 1: The Ecstasy | Dale A. Miles
Case of the Month:

A New Smile Utilizing an
Pr Implant and Ten All Ceramic
em
ie Restorations | Ross W. Nash
re
Iss
ue
shaping the future
of Bone Repair
Exactech is shaping the future of bone and predictable results to dental

repair with Regenaform® and Regenafil® professionals around the world.
allograft. For nearly a
Clinically proven in dental
decade, Exactech has been
practices for a variety of
a leader in orthopaedic
applications, Regenaform
bone regeneration. Now,
and Regenafil are the natural
Regenaform and Regenafil
choices for biological bone
©2008 Exactech, Inc.
materials offer simple

regeneration.
Pericardium also
available.
1-866-284-9690
www.exac.com
Regenaform® and Regenafil® are processed by RTI Biologics, Inc. and distributed by Exactech, Inc.
$:501-"45¥40$,&5(3"'5*/(
8IZJT4PDLFU(SBGUJOH4P6OQSFEJDUBCMF
.Ð£JÐîÚb¬ÓåÐvÚÓÚ¬Üv¨ÚJÐlÚÜ¬Ú¬XÜJ¨ÚJ¨lÚ£J¨ÜJ¨Úìv¨ÚÐJÜ¨ÚÐvÓÚvíÜÐJbÜ¬¨ÚÓÜvÓÀÚ3vvJÓ¨Ú¨bÓ¬¨ÓÚJÐvÚ
¬Üv¨ÚÐvÅåÐvliÚb¬£»Ð¬£Ó¨ÚÜvÚX¬¬lÚÓå»»îÚÜ¬ÚÜvÚJ»iÚlÓÐå»Ü¨ÚÜvÚÓ¬ÜÚÜÓÓåvÚJÐbÜvbÜåÐvÚJ¨lÚÐvlåb¨Ú
ÜvÚ vÐJÜ¨òvlÚ ÜÓÓåvÚ ìlÜÀÚ llÜ¬¨JîiÚ £¬ÓÜÚ £v£XÐJ¨vÓÚ JÐvÚ ¨¬ÜÚ lvÓ¨vlÚ Ü¬Ú XvÚ vÜÚ ví»¬ÓvliÚ ÐvÓåÜ¨Ú ¨Ú
»Ðv£JÜåÐvÚÐvÓ¬Ð»Ü¬ïÚ¨vbÜ¬¨ÚJ¨lÚJåÐvÚ¬ÚÐJÜ¨Ú»Ð¬bvlåÐvÓÚìv¨Úví»¬ÓvlÀÚ;¨ÜÚ¨¬ìÚ
.JÜv¨ÜvlÚ3vv¨ÜvíÑÚÓåÐJbvÚ
v»ÓÚÓÜJXòvÚÜvÚ£v£XÐJ¨vÚ
J¨lÚÜvÚÓ¬ÜÚÜÓÓåvÚJ»À
îÜ¬»JÓÜÑÚ7C7ãôôÚ4¨vÓÚJÐvÚ
JbÜåJîÚ4#ÚÜ¬ÚXvÚvÜÚví»¬ÓvlÚ 4£»viÚ¨¬¨ÓåÐbJÚÐv£¬ëJ
ìÜ¬åÜÚÐÓÚ¬Ú¨vbÜ¬¨À l¬vÓÚ¨¬ÜÚÐvÅåÐvÚ¬bJÚJ¨vÓÜvÓJÀ
¬£J¨¨Ú%iÚ JÐÜvvÚ iÚ vJå£¬¨ÜÚ
iÚJÓJÚiÚvÚiÚ
HJÐ¬»¬å¬ÓÚhÚëv¬JÐÚ ¬¨vÚ.ÐvÓvÐëJÜ¬¨Ú¨ÚíÜÐJbÜ¬¨Ú
4¬bvÜÓÚ;Ó¨Ú#¬¨3vÓ¬ÐXJXvÚl.7Ú"v£XÐJ¨vÓhÚ
Ú3vÜÐ¬Ó»vbÜëvÚ#¬¨3J¨l¬£òvlÚ
4ÜålîÀÚÚÚ.vÐ¬l¬¨Ü¬iÚãôô{Ö
×©h³Þ³ÞØ©À
;ÓvÚ¬ÚÜvÚv¨ÓvÚ.7
BÜÚJÚ»¬Ð¬ÓÜîÚ¬Ú £v£XÐJ¨vÚvÜÚví»¬Óvl
ôÀÞ¦£iÚv¨ÓvÚ ÐvÓåÜÓÚ¨ÚJÚ³¿Ú¨bÐvJÓv
.7ÚÓÚ£»vÐë¬åÓÚ ¨ÚvÐJÜ¨òvlÚÜÓÓåvÚìlÜ
Ü¬ÚXJbÜvÐJÀÚ ëÓÀÚåÓ¨Ú¨¬
U¨lv»v¨lv¨ÜÚJXÚÜvÓÜÚ £v£XÐJ¨vÀ
ÐvÓåÜÓÚ¬¨ÚvÀ
JÐX¬òJÚ.i
ÐJ¨bÓb¬Ú 4i
vÐÐvÐJÚAÀ
4¬ÜÚÜÓÓåv
v¨J¨bv£v¨Ü
åÓ¨Ú¨¬¨
ví»J¨lvlÚ.7
£v£XÐJ¨vÓ
ìÜ¬åÜÚ»Ð£JÐî
b¬ÓåÐvÚ]JXÓÜÐJbÜ^À
Ú.vÐ¬l¬¨Ü¬Úãôô{
4v»ÜÖ×©½©¾h³{³ãôÀ
ÚbÜåJÚÓòvÀ
$ZUPQMBTU¥5954JOHMFT
4QFDJBM0GGFS.FOUJPO0GGFS$PEF+*"$% #POVT '3&& 4FDPOE

UISPVHI "QSJM BOE 3FDFJWF 0'' %BZ4IJQQJOHUPGJSTU
FBDICPYPG5954JOHMFT 3FHVMBSMZ#090'
+JBDE 3FBEFST XIP PSEFS

JÚ7¬ÐvvÚ ÚÜ¬Ú%ÐlvÐÚ#¬ì
Volume 1, No. 1 • m arch 2009
Table of Contents
11 Case of the Month: A New Smile Utilizing an 65 A Novel Dehydrated Amnion Allograft for
Implant and Ten All Ceramic Restorations use in the Treatment of Gingival Recession:
Ross W. Nash, Robert Passaro An Observational Case Series
Brian Gurinsky
19 The Agony and Ecstasy of Buying Cone
Beam Technology, Part 1: The Ecstasy
Dale A. Miles
33 The Use of Cone Beam Computerized

Tomography Generated Surgical Template in
the Mandibular Molar Region: A Case Report
Ilser Turkyilmaz, Jose Carlos Suarez 75 Crestal Sinus Lift: A Minimally Invasive and
Systematic Approach to Sinus Grafting
Samuel Lee, Grace Kang Lee, Kwang-bum Park
Thomas Han
91 Comparative Analysis of Interleukin-1 Beta

Concentrations and Crestal Bone Loss in
Patients Treated with Conventional Versus
41 American Academy of Oral and Maxillofacial Osteotome Expansion Techniques for Dental
Radiology Executive Opinion Statement on Implant Delivery: A Pilot Study
Performing and Interpreting Diagnostic Thallum Padmanabhan, Nandhini Unnikrishnan
Cone Beam Computed Tomography
Laurie Carter, Allan G. Farman, James Geist,
101 Current Clinical Review
William C. Scarfe, Christos Angelopoulos,
2007 American Heart Association
Madhu K. Nair, Charles F. Hildebolt, Donald Tyndall, Guidelines for Prevention of Infective
Michael Shrout Endocarditis (IE)
Gregory D. Naylor
45 The Periodontally “Accelerated Osteogenic
Orthodontics”™ (PAOO™) Technique:
Efficient Space Closing With either
Orthopedic or Orthodontic Forces
M. Thomas Wilcko, William M. Wilcko,
Karen Breindel Omniewski, Jerry Bouquot,
James M. Wilcko
The Journal of Implant & Advanced Clinical Dentistry • 3

Publisher Copyright © 2008 by SpecOps Media, LLC. All rights

SpecOps Media, LLC reserved under United States and International Copyright
Conventions. No part of this journal may be reproduced
Design or transmitted in any form or by any means, electronic or
Jimmydog Design Group mechanical, including photocopying or any other information
retrieval system, without prior written permission from the
Production Manager publisher.
Stephanie Belcher
Disclaimer: Reading an article in JIACD does not qualify
Copy Editor the reader to incorporate new techniques or procedures
discussed in JIACD into their scope of practice. JIACD
Bryant Duhon
readers should exercise judgment according to their
Digital Conversion educational training, clinical experience, and professional
expertise when attempting new procedures. JIACD, its
NxtBook Media
staff, and parent company SpecOps Media, LLC (hereinafter
referred to as JIACD-SOM) assume no responsibility or
Internet Management
liability for the actions of its readers.
InfoSwell Media
Opinions expressed in JIACD articles and communications
Spanish Translation
are those of the authors and not necessarily those of JIACD-
Gustavo Fra SOM. JIACD-SOM disclaims any responsibility or liability
for such material and does not guarantee, warrant, nor
Subscription Information: Annual rates as follows:
endorse any product, procedure, or technique discussed in
Non-qualified individual: $99(USD) Institutional: $99(USD).
JIACD, its affiliated websites, or affiliated communications.
For more information regarding subscriptions,
Additionally, JIACD-SOM does not guarantee any claims
contact info@jiacd.com or 1-888-923-0002.
made by manufact-urers of products advertised in JIACD, its
affiliated websites, or affiliated communications.
Advertising Policy: All advertisements appearing in the
Journal of Implant and Advanced Clinical Dentistry (JIACD)
Conflicts of Interest: Authors submitting articles to JIACD
must be approved by the editorial staff which has the right
must declare, in writing, any potential conflicts of interest,
to reject or request changes to submitted advertisements.
monetary or otherwise, that may exist with the article.
The publication of an advertisement in JIACD does not
Failure to submit a conflict of interest declaration will result
constitute an endorsement by the publisher. Additionally,
in suspension of manuscript peer review.
the publisher does not guarantee or warrant any claims
made by JIACD advertisers.
Erratum: Please notify JIACD of article discrepancies or
errors by contacting editors@JIACD.com
For advertising information, please contact:
info@JIACD.com or 1-888-923-0002
JIACD (ISSN pending) is published on a monthly basis by
SpecOps Media, LLC, Saint James, New York, USA.
Manuscript Submission: JIACD publishing guidelines
can be found at http://www.jiacd.com/author-guidelines
or by calling 1-888-923-0002.

Astra Tech
BioManagement
Complex™
—function, beauty and biology
in perfect harmony
The success of an implant system cannot be determined by one

single feature alone. Just as with all natural systems, the delicate
balance is maintained by the interaction of different but equally
important features.
The Astra Tech BioManagement Complex™ is a unique
combination of interdependent features that helps to support the
natural balance, and ensures long-term clinical success by
stimulating bone growth, providing bone preservation, soft tissue
health and architecture. To put it simply: function, beauty and
biology in perfect harmony.
OsseoSpeed™
— more bone, more rapidly
MicroThread™
— biomechanical bone stimulation
Conical Seal Design™

— a strong and stable fit
Connective Contour™
— increased soft tissue contact zone and volume
800-531-3481. www.astratechdental.com
Founder, Co-Editor in Chief Founder, Co-Editor in Chief
Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS
Editorial Advisory Board

Tara Aghaloo, DDS, MD Richard Hughes, DDS Israel Puterman, DMD
Faizan Alawi, DDS Anil Idiculla, DMD Giulio Rasperini, DDS
Michael Apa, DDS Tassos Irinakis, DDS, MSc Michele Ravenel, DMD, MS
Alan M. Atlas, DMD James Jacobs, DMD Terry Rees, DDS
Charles Babbush, DMD, MS Ziad Jalbout, DDS Laurence Rifkin, DDS
Thomas Balshi, DDS John Johnson, DDS, MS Paul Rosen, DMD, MS
Barry Bartee, DDS, MD John Kois, DMD, MSD Joel Rosenlicht, DMD
Lorin Berland, DDS Joseph Kravitz, DDS, MS Larry Rosenthal, DDS
Peter Bertrand, DDS Aldo Leopardi, DDS, MS Steven Roser, DMD, MD
Michael Block, DMD Carlo Maiorana, MD, DDS Salvatore Ruggiero, DMD, MD
Chris Bonacci, DDS, MD Jay P. Malmquist, DMD Anthony Sclar, DMD
Ronald Brown, DDS, MS Louis Mandel, DDS Maurizio Silvestri, DDS, MD
Bobby Butler, DDS Michael Martin, DDS, PhD Dennis Smiler, DDS, MScD
Donald Callan, DDS Ziv Mazor, DMD Muna Soltan, DDS
Nicholas Caplanis, DMD, MS Dale Miles, DDS, MS Michael Sonick, DMD
Daniele Cardaropoli, DDS Robert Miller, DDS Ahmad Soolari, DMD
John Cavallaro, DDS John Minichetti, DMD Christian Stappert, DDS, PhD
Stepehn Chu, DMD, MSD Uwe Mohr, MDT Eric Stoopler, DMD
David Clark, DDS Jaimee Morgan, DDS Scott Synnott, DMD
Charles Cobb, DDS, PhD Dwight Moss, DMD, MS Haim Tal, DMD, PhD
Spyridon Condos, DDS Peter K. Moy, DMD Gregory Tarantola, DDS
Massimo Del Fabbro, PhD Mel Mupparapu, DMD Dennis Tarnow, DDS
Douglas Deporter, DDS, PhD Ross Nash, DDS Geza Terezhalmy, DDS, MA
Alex Ehrlich, DDS, MS Gregory Naylor, DDS Tiziano Testori, MD, DDS
Nicolas Elian, DDS Marcel Noujeim, DDS, MS Michael Tischler, DDS
Paul Fugazzotto, DDS Sammy Noumbissi, DDS, MS Tolga Tozum, DDS, PhD
Scott Ganz, DMD Arthur Novaes, DDS, MS Isler Turkyilmaz, DDS, PhD
Arun K. Garg, DMD Charles Orth, DDS Dean Vafiadis, DDS
David Guichet, DDS Thallum Padmanabhan, MDS Hom-Lay Wang, DDS, PhD
Kenneth Hamlett, DDS Jacinthe Paquette, DDS Tom Wilcko, DDS
Istvan Hargitai, DDS, MS Adriano Piattelli MD, DDS William Wilcko DMD, MS
Michael Herndon, DDS Stan Presley, DDS Alan Winter, DDS
Robert Horowitz, DDS George Priest, DMD Glenn Wolfinger, DDS, FACP
Michael Huber, DDS Richard K. Yoon, DDS

Follow the new leader
in bone regeneration: Cerasorb ®
For all your bone grafting needs

• ridge augmentation
• extraction sites
• sinus floor elevation
888-237-2767
www.riemserdental.com
Editorial Commentary
Welcome to the evolution of dental literature
I
f you take a dental journal and break it down of technology. Email and online chat sessions
to its lowest common denominator, its purpose are quickly replacing land based paper mail for
is simple: the transfer of knowledge from the personal and business communiqués. Internet
author to the reader. Throughout human history, blogs and newsgroups are causing the agonizing
the transfer of knowledge has occurred through an demise of traditional print based newspapers.
ever changing cycle of communicatory evolution. In dentistry, we are not immune to this shift in
Prior to the introduction of written language, communication. Paper records are being replaced
ancient cultures preserved knowledge and customs by digital records. Paper bills are being replaced
through communication such as song and dance. by electronic invoices. The time has come for paper
Societal progression eventually rendered the based dental literature to follow suit and step into
spoken word ineffective as a means of information the digital age.
preservation, so this method of communication The Journal of Implant and Advanced Clinical
gave way to writing around the 4th millennia BC. Dentistry (JIACD) is the dental profession’s first
As different cultures began to exchange and trade completely paperless interactive journal. This format
goods, written communication was developed to allows for options not available in traditional print
document complex financial transactions and keep based media. Flash animation, audio, video, unlimited
track of inventories. It was nearly 5,000 years use of photographs, and hyperlinks to external
before the next breakthrough would dethrone the information are just a few of the features exclusive
hand written word as the most effective means of to JIACD’s revolutionary online format. Additionally,
communication. In 1439, Johannes Gutenberg’s JIACD’s elimination of physical print allows for rapid
invention of the mechanical printing press allowed manuscript review and article publication. With
for the mass production of movable type and JIACD, authors will no longer need to wait up to
spurred the great advances of the European sixteen months to see their article in print. While
Renaissance. To this day, variations of printed JIACD is pushing dental literature into the future, its
type continue to remain an important method of focus remains on the traditional pillar of the dental
communication. profession: the actively practicing clinician.
Some say that “the printed word is timeless”, The future of dental literature is here. The future
but in all reality, the time of the printed word as is JIACD. ●
the predominant form of communication may be
coming to an end. The development of computers
and our movement into the digital age has
facilitated yet another advance in communication:
virtual communication. By its very nature, virtual
communication is paperless. Improved efficiency,
immediate access, and worldwide availability Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS
are just a few of the benefits of this new form Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief

Nash et al
where future meets practice
UNPARALLELED
Superior continuing education in an extraordinary teaching center,
abounding with ultimate technologies. Experience begins at
www.vizstaraPROFESSIONAL.com
300 Sylvan Avenue | Englewood Cliffs, NJ 07632 | 201-816-4000
Nash et al
Case of the Month:
A New Smile Utilizing
an Implant and Ten All
Ceramic Restorations
Ross W. Nash, DDS1 • Robert Passaro, CDT2

Abstract
Background: This case report documents were restored with a combination of all ceramic
maxillary arch rehabilitation for a young female crowns, onlays, and veneers.
patient. The patient suffered from internal
resorption of her left maxillary central incisor and Results: A total of 10 all ceramic restorations
was not satisfied with the state of her maxillary were delivered, restoring the patient with a
dentition. harmonious and highly aesthetic maxillary arch.
Methods: The patient’s left maxillary central Conclusion: Multidisciplinary treatment of the
incisor was atraumatically extracted and replaced maxillary arch with all-ceramic restorations can
with a single staged dental implant. Teeth 3-14 establish superior aesthetics and functionality.
KEY WORDS: Dental implants, dental crowns, dental veneers, dental onlays
1. Private practice, Huntersville, NC. The Nash Institute for Dental Learning, Charlotte, NC, USA
2. Center for Ceramics, The Nash Institute for Dental Learning, Charlotte, NC, USA
A
n attractive young woman suffered from first molars were prepared to receive onlays, while
internal resorption of her maxillary left the premolars, canines, and incisors were prepared
central incisor and was unhappy with the to receive a combination of full coverage crowns
current state of her smile. Prognosis for the central and laminate veneers. Bisacrylic provisional
incisor was poor, so the patient was referred to a restorations were fabricated after final polyvinyl-
Periodontist for atraumatic extraction of tooth #9 siloxane impressions and occlusal registration were
and replacement with a dental implant. A provisional taken. All ceramic crowns and porcelain veneers
fixed partial denture was used to temporize site were fabricated by the dental laboratory in the
#9 during implant osseointegration in lieu of a Center for Ceramics at the Nash Institute, Charlotte,
removable temporary partial denture. N.C. In total, 10 all ceramic restorations were used
Following implant integration, final preparations to restore functionality to the maxillary arch and
of teeth 3-14 were accomplished. The maxillary establish superior aesthetics.
Note: Implant #9 was restored with the Vericore System (Whip Mix, Louisville, KY).

Nash et al
12 • Vol. 1, No. 1 • March 2009

Nash et al

Nash et al
14 • Vol. 1, No. 1 • March 2009

Nash
Nash et
et al

Nash et al
16 • Vol. 1, No. 1 • March 2009

Nash et al

Miles
The Agony and
Ecstasy of Buying
Cone Beam Technology
Part 1: The Ecstasy
Dale A. Miles, DDS, MS1
Abstract
Background: Since Methods: The author
arriving in North America reviews a number of CBCT
in 2001, cone beam articles published in dental
computed tomography literature and draws upon
(CBCT) has been rapidly his personal experience
and enthusiastically from analysis of over 3,700
embraced by the dental CBCT cases.
profession. With nearly
two dozen CBCT systems Results: CBCT
currently available, dental applications, image
providers are faced outputs and decision
with a number of options when they consider points for purchase are discussed. 5 cases
purchasing this new technology. This aim of with various CBCT applications are discussed.
this article is to present introductory information
on cone beam machines, the wide array of Conclusion: Use of CBCT technology
applications made possible by the incredible provides unique and valuable information
variety of image output choices, and decision that is unobtainable in any other format. This
points to aid the reader in their decision making information can benefit practitioners in all
process for purchasing CBCT systems. aspects of dental treatment.
KEY WORDS: Cone beam computed tomography, digital radiography,

radiographic image enhancemnet
1. Arizona School of Dentistry and Oral Health; Private Practice Fountain Hills, AZ, USA

Miles
Miles
Introduction The Ecstasy of CBCT:

Cone Beam Computed Tomography (CBCT) has Applications, Image Output and
been rapidly and enthusiastically embraced by the Decision Points for Purchase
dental profession in a much more dramatic way Many recent articles on CBCT have reported quite
than “digital x-ray imaging”. Introduced in 1988, a number of applications.3-8 While these current
it has taken our profession over 20 years to reach applications may change somewhat over time,
a 40% adoption level with digital x-ray systems. table 1 presents what I feel will be the primary
In contrast, since arriving in North America in applications that may become the “standard of
20011, cone beam manufacturers have gone care” or commonplace for particular dental tasks.9
from one available system, the NewTom (initially
QR Systems, Verona, Italy – acquired by AFP Table 1
Imaging Corporation, Elmsford, NY), to over 13 Clinician Task(s)
currently available systems. This does not count General Dentist Implant site assessment
companies making more than one version of their TMJ evaluation
machine. A previous publication by Cattaneo and Paranasal sinus evaluation
Melsen2, to which the reader is referred for an Airway analysis (sleep disorders)
excellent CBCT resource, gives a more complete Endodontist Root form, pulp canal assessment
description of machine parameters such as scan Periapical lesion assessment
size, voxel size, kilovoltage, and milliamperage. Implant site assessment
Because of the rapid introduction and “Re-treatment”
adoption of CBCT technology, dentists and Orthodontist Space analysis
dental specialists have been offered so many Impactions
choices that the decision making process is as Treatment “records”
complex and difficult as it was for digital x-ray Craniofacial anomaly assessment
adoption. The primary difference, however, is TMJ evaluation
the huge cost of cone beam machines which Supernumerary tooth assessment
can range in price from $120,000 to $350,000! Oral and Third molar assessment
Despite this enormous investment, dentists Maxillofacial Orthognathic surgery
are discovering the advantages of cone beam Surgeon Pre-surgical planning for lesions
imaging and taking the plunge. Paranasal sinus evaluation
In the first part of this article, “the Ecstasy”, I TMJ evaluation
present introductory information on cone beam Pediatric Dentist Tooth development
machines, the wide array of applications made
Periodontist Bone grafting
possible by the incredible variety of image output
Implant site assessment
choices, and some decision points to help you TMJ evaluation
decide which cone beam device might best suit
Prosthodontist Implant site assessment
your practice.
20 • Vol. 1, No. 1 • March 2009

Miles
Miles
Figure 1a: A reconstructed panoramic image, simulating a Figure 1c: A 3D reconstructed color image reveals that
conventional panoramic, showing the impaction of tooth the cuspid crown is palatal to the lateral incisor. Note the
#6. From this image, the clinician cannot determine if the complete lack of space clinically for this tooth.
tooth is impacted facially or palatally.
1e and 2a-2d, show 2 patients with different

permanent tooth impactions and the advantage
of having CBCT information for the surgeon and
orthodontist.
Case 1: A fifteen year-old white female with an

Figure 1b: A reconstructed MIP (Maximum Intensity Profile) impacted maxillary right cuspid and developing
image provides improved clarity, but is still inadequate
third molars.
for determining tooth position. Note the complete root
formation and the developing third molar follicle positions.
Case 2: A fifteen year-old white female with an
The cases below graphically illustrate the impacted maxillary right cuspid and developing
impact of CBCT on the assessment of various third molars.
relatively common patient problems encountered
by dentists. Case 3: Pre-surgical
Implant Imaging
Cases 1 and 2: Impacted Teeth in Perhaps the most widely adopted application for
the Mixed Dentition CBCT to date is implant site assessment. Images
One of the more common problems for dentists, from any cone beam machine are rendered in
orthodontists, and oral & maxillofacial surgeons a precise 1:1 ratio in reconstruction software
is to assess the position of impacted permanent provided by the vendor. Dentistry has never
teeth for exposure and repositioning into the had this capability before. All of our previous
correct occlusal position. We have all suffered image applications (periapical, panoramic, and
through and continue to use the “Buccal Object cephalometric) have been magnified and distorted
Rule” or “SLOB (Same on Lingual, Opposite because of the nature of the image capture. The
on Buccal) Rule” to determine the position of precise 1:1 ratio of CBCT images allows the
impacted teeth.11 The cases below, Figures 1a- clinician to have very large and accurate implant

Miles
Miles
Figure 1d: (left) Axial image showing the crown position of tooth #6. (right) Sagittal view showing the crown position of
tooth #6 and its follicular space palatal to tooth #7.
site images rather than the older “life size” images

displayed in medical CAT scan software of the
past. The width and height of the proposed site
are also measured with an accuracy of 0.1 mm.
Figure 3a illustrates this concept.
Image 3d depicts some of the ways to display
implant information available in this third party
software (OnDemand 3D, CyberMed International,
Seoul, Korea).
Cases 4-5: Assessment of

the Temporomandibular Joint
Complex
Until now, dentists have had to rely on 2D grayscale
images and radiographic interpretations of condylar
changes to determine the severity of a condylar
Figure 1e: A 3D reconstructed color image reveals the
problem and how it should be managed. To visualize
“true” position of the impacted cuspid. This image and
disc displacement problems, we still have to rely on
related CBCT images allow for improved surgical planning
in comparison to standard digital images. magnetic resonance imaging or arthroscopy to see
22 • Vol. 1, No. 1 • March 2009

Miles
Miles
the “soft tissues” to the TMJ complex. Bony changes,

however, are easily and completely imaged by CBCT.
Conditions such as osteoarthritic changes, synovial
chondromatosis, and rheumatoid arthritis can be seen
in color in three dimensions. Additionally, it is simple
to correlate vertebral body changes in the cervical
spine with condylar and articular eminence changes.
The cases below demonstrate this capability.
Figure 2a: A reconstructed panoramic image reveals
normal tooth development except for tooth #9. In this
image the tooth almost appears deformed or even Case 4
replaced by an odontogenic malformation such as an This 59 year-old white female was referred for
odontoma. evaluation of tooth site #14 for implant placement.
In addition to chronic sinus changes and a failing
implant at another site, the following images depict
osteoarthritic changes of the right TMJ condyle and
certain vertebral bodies.
Osteoarthritis (OA) is a common finding
in adults and clinicians placing implants and
possibly altering the patient’s occlusion should
always image the TMJ complexes to rule out pre-
existing problems like OA to ensure success of
their case restoratively. In addition, orthodontists
are justifying scanning patients in “adult
orthodontic cases” to assess any joint problems
which could alter the progress of their case.
Case 5
This 68 year-old white female was referred for a
preliminary assessment for orthodontic treatment.
This case demonstrates a bilateral occurrence of
Figure 2b: A sagittal view of this tooth shows normal “loose bodies” or synovial chondromatosis.
development of the crown and root, but a very unique
horizontal impaction. This image and related CBCT images
allow for improved surgical planning in comparison to
standard digital images.

Miles
Miles
Figure 2c: (left) 3D color reconstruction using a “Cube” tool in OnDemand 3D third party software (CyberMed International,
Seoul, Korea) shows the sub-mucosal position of developing teeth #6, 9, and 11.
(right) The same image made “transparent” to remove the thin bone and allow better visualization of the dentition.
Figure 2d: A 3D color panoramic reconstruction shows all

tooth relationships and root development.
Figure 2e:
A 3D color skull
reconstruction of the
potential problems.
24 • Vol. 1, No. 1 • March 2009

Miles
Miles
Figure 3a: (left) Multiple views of a proposed implant site. (right) View captured directly in the software, enlarged for
planning and displaying to the patient in practice management software. Since image reconstruction is 1:1, the image may be
displayed at any size on the monitor or if printed. The measurements depicted are accurate to within 0.1 mm.
Figure 3b: (left) A 3D color reconstruction of the patient rotated to show left mandible. Note the detail of the bony anatomy.
(right) This slice pseudopanoramic used to “paint” the inferior alveolar nerve canal, allows reconstruction of the anterior
implant site showing the canal painted in red exiting the mental foramen.

Miles
Miles
Figure 3c: (top) This slice pseudopanoramic reconstructed at 1.0 mm thickness showing location and path of inferior alveolar
nerve canal. (bottom) color rendition thickened to about 10mm.
Figure 3d: (left) Selected “mini-implant” placed by operator into site for visualization. (right) A “Verification” tool allows
precise adjustments to show an implant can be placed, verified in the axial and sagittal views.
Conclusion dental practice. Each picture is, for the most part,
In Part I of this article I’ve briefly discussed some worth 1000 words. In part II of this series, I will
current machines and common applications of present the downside of this technology: “The
CBCT. This part, called “the Ecstasy”, used many Agony.” That is, the need for additional education
cases to illustrate the power of these images for if you’re going to adopt cone beam imaging and
clinical decision making. The reader simply needs to the absolute need for a formal radiographic report
look at the axial views and 3D color reconstructions from an oral & maxillofacial radiologist or medical
to know that this technology will help them in their radiologist with most cases. ●
26 • Vol. 1, No. 1 • March 2009

Miles
Miles
Figure 4a: Axial “slice” through the mid-condyle region

showing a “cystic lesion” on the lateral pole of the right Figure 4b: 3D color reconstruction of the right TMJ condyle
condylar head (blue arrow). and related bony elements showing the osteophyte
formation and subchondral cyst on the lateral pole as well
as some osteophyte formation on the anterior surface (blue
arrows).
Figure 4c1: 3D color reconstruction of right TMJ complex.

Miles
Figure 4c2: The same process applied to the left TMJ complex for comparison showing a normal condylar head.
Figure 4d: Midline sagittal view of the vertebral column showing

osteophyte formation, subchondral sclerosis and subchondral cyst
formation on C4 and C5. These images confirm osteoarthritis of the
C-spine and TMJ condyles.
28 • Vol. 1, No. 1 • March 2009

Miles
Figure 5a: A-P (top) and sagittal (bottom) image 3D color reconstructions of the right TMJ complex showing the “loose body”
anterior to the lateral pole of the condyle.

Miles
Figure 5b: A-P (top) and sagittal (bottom) 3D color reconstructions of the left TMJ complex showing the “loose body”
anterior to the lateral pole of the condyle (white arrow, top image and blue arrow, bottom image).
30 • Vol. 1, No. 1 • March 2009

Miles
Disclosure
The author reports no conflicts of interest with any
products mentioned in this article.
References
1. Danforth R, Mah J. 3-D Volume for Dentistry: A New
Dimension. CDA Journal 2003; 31(11): 817-823.
2. Cattaneo PM, Melsen B. The use of cone-beam

computed tomography in an orthodontic department
in between research and daily clinic. World J Orthod
2008; 9(3): 269-82.
Figure 5c: A-P 3D color reconstructions of the right and 3. Miles D, Danforth R. A Clinician’s Guide to
left TMJ complexes showing the “loose body” anterior to Understanding Cone Beam Volumetric Imaging.
the lateral pole of the condyle (blue arrows). Note also the Academy of Dental Therapeutics and Stomatology
calcified elongated stylohyoid ligaments. Special Issue 2007; 1-13.
4. Nakajima A, Sameshima G, Arai Y, et al. Two and

three-dimensional orthodontic imaging using limited
cone-beam computed tomography; Angle Orthod
2005; 75: 895–903.
5. Scarfe W, Farman A, Sukovic P. Clinical applications

of cone-beam computed tomography in dental
practice. J Canadian Dent Assoc 2006; 72: 75–80.
6. Bourjeois M, Sikorski P, Taylor S. Cone Beam

Volumetric Tomography. Oral Health 2007; 6: 14-16.
7. Miles D. Clinical Experience with Cone-Beam

Volumetric Imaging – Report of Findings in 381
cases. US Dentistry 2006; 1(1): 39-42.
8. Danforth R, Miles D. Irish Dentist 2007; 10(9):

14-18.
Figure 5d: Side-by-side comparison of the right and left 9. Miles D: Color Atlas of Cone Beam Volumetric
condyles in the “TMJ” program showing subchondral cyst Imaging for Dental Applications. Quintessence.
formation in the condylar heads. 2008: 47-303.
10. Miles D. The Future of Dental and Maxillofacial

Imaging. Dent Clin N Am 2008; 52(4): 917–928.
11. Miles D, VanDis M, Williamson G, Jensen C.

Radiographic Imaging for the Dental Team.
SAUNDERS Elsevier, 4th Ed. 2008: 17-18.

Unparalled Image Quality
Turkyilmaz et al
Imagine the Possibilities

The PreXion 3D Dental Cone Beam Scanner
processes images in only 30 seconds.
Additional benefits include:
• Highest resolution of any Cone Beam System
• More detail through proprietary
XTrillion Processor
• Powerful Diagnostic 3D Planning Tools
• NEW Four different scanning modes
• NEW Automatic Panoramic View
• Ideal for Implant Planning
• Available FOV 8cm x 8cm or 5cm x 5cm
• Small Foot Print of only 39˝ x 59˝ fits anywhere
• Fully Networkable
Please ask us about

Below Prime Financing or
6 Month No Payments
Call us to today for an in-office

demonstration at (650) 212-0300
info@prexion3d.com • www.prexion3d.com
Turkyilmaz et al
The Use of Cone Beam
Computerized Tomography
Generated Surgical Template
in the Mandibular Molar
Region: A Case Report
Ilser Turkyilmaz, DDS, PhD1 • Jose Carlos Suarez, DDS, MS2
Abstract
Background: Pre-surgical planning is crucial to software. A CBCT generated surgical template
achieve favorable clinical outcomes with implant was then fabricated using this same software.
therapy. Because pre-operative assessment All implants were placed after flap elevation
of the jaw using traditional radiographic and insertion of the CBCT generated surgical
methods has some drawbacks, cone beam template. After a healing period of 2 months, a
computerized tomography (CBCT), which definitive fixed dental prosthesis was delivered to
provides 3-dimensional views and more accurate the patient.
detection of anatomic landmarks, has recently
been introduced. The aim of this report was to Results: All implants were placed uneventfully.
present a patient restored with 3 implants in the The patient was recalled 2 weeks, 3, 6, and
posterior mandible using a CBCT generated 12 months after the implant placement. At the
surgical template. 1-year recall appointment, no implants were lost
and 0.2mm (±0.1) mean marginal bone loss
Methods: A 51-year-old male with three missing was noted.
molars and a considerable lingual concavity in
the posterior mandible was treated with three Conclusion: This case report demonstates how
implants and an implant supported screw- a CBCT generated surgical template may be a
retained fixed dental prosthesis. After obtaining safer method for implant placement, especially in
3-dimensional CBCT scans, all three implants the posterior mandible where mandibular canal
were virtually placed using implant planning presents and lingual concavity is more likely.
KEY WORDS: Dental implants, surgical template, computerized tomography, CBCT, mandible
1. Assistant Professor, Department of Prosthodontics, Dental School,

University of Texas Health Science Center at San Antonio, Texas.
2. Implant Surgical Fellow, Department of Oral and Maxillofacial Surgery, College of Dentistry,
The Ohio State University, Columbus, Ohio.

Turkyilmaz et al
INTRODUCTION generated surgical templates are manufactured in

Clinical reports have indicated promising results such a way that they match the location, trajectory,
with dental implants.1 However, unfavorable and depth of the planned implant with a high
positioning of implants may compromise esthetic degree of precision.8 As the dental practitioner
outcome of implant-supported prostheses.2,3 places the implants, the guides stabilize drilling by
Therefore, presurgical planning is vital to attain restricting degrees of freedom for drill trajectory
optimum esthetic and functional outcomes and depth. Earlier studies have concluded that
with dental implants. Dental practitioners have utilization of 3D implant planning software resulted
commonly used traditional dental radiographs in implant positioning with improved biomechanics
(panoramic and periapical radiographs)4 and and esthetics.10 Use of CBCT scans, implant
conventionally fabricated surgical templates for planning software, and CBCT generated surgical
implant placement.5 A panoramic radiograph templates usually extinguishes complications such
is a two-dimensional image providing little as mandibular nerve damage, sinus perforations,
information about the buccal-lingual width of fenestrations, or dehiscences.11
the jawbones.6 Surgical guides conventionally The aim of this clinical report was to present
fabricated on diagnostic stone casts have a a patient with a significant lingual concavity in
number of shortcomings. In addition to stability the posterior mandible, who was restored with
issues following surgical flap reflection, they do not three implants using a CBCT generated surgical
provide information about the varying thicknesses template.
of the mucosa, topography of underlying bone,
or anatomical structures such as the mandibular CLINICAL REPORT
canal, maxillary sinus.5 A 51-year-old male with three missing mandibular
CBCT has recently been introduced for molars was referred to the Implant Clinic,
pre-surgical implant planning as a means to Department of Restorative and Prosthetic Dentistry,
eliminate the concerns raised by the panaromic College of Dentistry, The Ohio State University
or periapical radiographs.6,7 CBCT scans allow in 2008. Clinical examination revealed a non-
dental practitioners to visualize cross-sectional, contributory medical history and a significant lingual
axial, and panoramic views of the patient’s jaws concavity and lingually angulated edentulous area
for more precise planning of implant therapy. The in the posterior mandible. Because the patient
pre-surgical CBCT scan is often used for implant was seeking an implant-supported fixed dental
selection and exact implant positioning. prosthesis, he was sent to the Department of
With CBCT scans, dental practitioners can Radiology for a CBCT scan (iCAT, Imaging
virtually place dental implants in optimum positions Sciences International, Hatfield, PA) to determine
and finalize treatment planning regarding precise if available bone was present to place implants and
implant size, depth, and angulation. Currently, a also identify the amount of the lingual concavity.
small number of implant planning software systems An implant-supported fixed dental prosthesis
utilize CBCT scans to facilitate the creation supported by three implants placed using CBCT
of surgical drilling templates.8,9 These CBCT generated surgical template was planned.
34 • Vol. 1, No. 1 • March 2009

Turkyilmaz
Turkyilmaz et
et al
Figures 1a, 1b: Treatment planning and implant selection using 3D computer simulation software and CBCT scans. Please
notice the lingual concavity.
Maxillary and mandibular preliminary proceeded to the next while the images of the
impressions were made using irreversible previously planned implant remained on the axial
hydrocolloid and then poured in stone. After slices. If necessary, implant position was adjusted
obtaining the CBCT data, these data were in order to achieve an optimum outcome. The
imported to the 3D implant planning software oral surgeon also used the 3D-view showing the
(Facilitate, Materialise Dental Inc, Glen Burnie, shape of the jaw, the ideal prosthetic axis, and the
MD) allowing both oral surgeon and restorative implants to improve the position of each implant.
dentist to simulate implant placement on the 3D Thus, the implants were accurately positioned in
model. Taking into consideration the anatomic the 3D volume (figures 1a and 1b).
structures, the dental team interactively simulated After virtual implant placement was completed,
the position of the dental implants on each plane. data for the final plan and a preliminary stone
The oral surgeon worked on one implant and then case were used to fabricate a tooth-supported

Turkyilmaz et al
Figure 2: The design of the CBCT generated surgical

template.
Figure 4: Guide pin confirmation following dental implant

osteotomy preparation.
Figure 5: All three implants were uneventfully placed.
Figure 3: Placement of tooth-supported CBCT generated SLA consists of a vat containing a liquid photo-
surgical template to guide the drilling procedure. polymerized resin and a laser mounted on top of the
vat moves in sequential cross-sectional increments
CBCT generated surgical template (figure 2). A of 1 mm, corresponding to the slice intervals
rapid prototyping machine using the principle of specified during the CT formatting procedure. The
stereolithography (SLA) was utilized to fabricate laser polymerizes the surface layer of the resin
the CBCT generated surgical template. Briefly, the on contact. Once the first slice is completed, a
36 • Vol. 1, No. 1 • March 2009

Turkyilmaz
Turkyilmaz et
et al
Figure 7: Periapical radiograph of the implants one year

after the implant placement.
were attached to the implant body. After 2 weeks,

Figure 6: Delivery of the screw-retained fixed dental the final impression was made and, subsequently,
prosthesis. Access holes were covered with temporary the definitive implant-supported screw-retained
composite material. fixed dental prosthesis was delivered to the
patient (figure 6).
mechanical table immediately below the surface Patients were recalled 2 weeks, 3 months, 6
moves down 1 mm, carrying with it the previously months, and 12 months after implant placement.
polymerized resin layer of the model. The laser Implant success was based on the following
subsequently polymerizes the next layer adjacent criteria, which were suggested by Albrektsson
to the previously polymerized layer. In this manner, and Zarb; absence of mobility, painful symptoms,
a CBCT generated surgical template with periapical radiolucencies and less than 1 mm of
stainless steel tubes attached into the cylindrical marginal bone resorption after a one-year period.
guide was fabricated (figure 3). At one year following implant placement, all
After flap elevation, all three dental implants implants were present and the mean marginal bone
were placed using the tooth-supported CBCT loss was 0.2mm (± 0.1) (figure 7). No periapical
generated surgical template under local anesthesia radiolucencies, bleeding on probing, or pathologic
with intra-venous sedation (figures 4,5). The drilling probing depths were recorded at these recalls.
procedures were performed using appropriate Thus, all implants were considered successful.
drills for each corresponding implant according to
the manufacturer’s instructions. Following implant DISCUSSION
placement and cover screw delivery, the mucosa In contrast to conventional CT scanners, which are
was sutured. At the second stage surgery, which large and expensive to purchase/maintain, CBCT
was 2 months after implant placement, the cover is suited for use in dental clinics where cost and
screws were removed and healing abutments dose considerations are important, space is usually

Turkyilmaz et al
limited, and scanning requirements are limited to They concluded that SLA surgical guides using CT
the head.7 When compared to conventional CT, data might be reliable in implant placement.
the advantages of the use of CBCT for maxillofacial Van Steenberghe et al.,15 evaluated a concept
imaging in clinical practice can be considered as including a treatment planning procedure based
follows: a reduction in the number of radiographic on CT scan images and a prefabricated fixed
images, image accuracy, rapid scanning time, prosthetic reconstruction for immediate function
dose reduction, and reduced image artifacts.7 in upper jaws using a flapless surgical technique.
In addition, the introduction of computer-aided They placed 184 implants in 27 consecutive
manufacturing (CAM) of anatomic models and patients with edentulous maxillae. Treatments were
surgical templates generated from computer-aided performed according to the Teeth-in-an-Hour™
design (CAD) images has accurately allowed the concept (Nobel Biocare AB, Göteborg, Sweden)
transfer of planning information to implant placement. including a CT scan–derived customized surgical
For implant planning and placement, the association template for flapless surgery and a prefabricated
of CAD/CAM techniques presents advantages prosthetic suprastructure. All patients received
regarding 3D determination of the patient’s jaw their final prosthetic restorations immediately
anatomy and fabrication of both anatomical models (approximately 1 hour) after implant placement.
and surgical templates. Rapid prototyping using They concluded that the prefabrication of both
stereolithographic modelling, which is a fast and surgical templates derived from 3D implant
highly accurate CAM method, is used to produce planning software for flapless surgery and dental
prototypes in various manufacturing industries.13,14 prostheses for immediate loading was a very
Earlier studies concluded that CAD/CAM software reliable treatment option.
may enhance the association between dental
implant planning and insertion.13,14 CONCLUSION
Ersoy et al.,14 evaluated the match between the This case report suggests that the use of a tooth-
positions and axes of planned and placed implants supported CBCT generated surgical template may
using stereolithographic surgical guides. They be a more predictable way to place implants in the
placed a total of 94 implants using SLA surgical posterior mandible where surgical complications
guides generated from computed tomography. such as mandibular nerve damage, fenestrations, or
All patients used radiographic templates during dehiscences are more likely. ●
CT imaging and a new CT scan was taken for
Correspondance:
each patient following implant placement. Special
Dr. Ilser Turkyilmaz
software was used to fuse the images of both the Department of Prosthodontics.
planned and placed implants and the locations and Dental School, University of Texas,
axes were compared. They found that the placed Health Science Center at San Antonio,
implants showed angular deviation of 4.9 degrees 7703 Floyd Curl Drive, MSC 7912,
(±2.36), while mean linear deviation was 1.22mm San Antonio, Texas 78229-3900.
(±0.85) at the implant neck and 1.51mm (±1.0) at Phone: 210-567-6450 • Fax: 210-567-6376,
email: turkyilmaz@uthscsa.edu
the implant apex compared to the planned implants.
38 • Vol. 1, No. 1 • March 2009

Turkyilmaz
Turkyilmaz et
et al
Disclosure 7. Scarfe WC, Farman AG, Sukovic 12. Albrektsson T, Zarb GA.
The authors report no conflicts of P. Clinical applications of cone- Determinants of correct clinical
interest with anything mentioned in beam computed tomography in reporting. Int J Prosthodont
this article. dental practice J Can Dent Assoc. 1998;11(5):517-521.
2006;72(1):75-80.
References 13. Sarment DP, Sukovic P,
1. Turkyilmaz I. Clinical and 8. Kupeyan HK, Shaffner M, Clinthorne N. Accuracy of
radiological results of patients Armstrong J. Definitive CAD/CAM- implant placement with a
treated with two loading protocols guided prosthesis for immediate stereolithographic surgical guide.
for mandibular overdentures loading of bone-grafted maxilla: Int J Oral Maxillofac Implants
on Brånemark implants. J Clin a case report. Clin Implant Dent 2003;18(4):571-577.
Periodontol 2006;33(3):233-238. Relat Res. 2006;8(3):161-167.
14. Ersoy AE, Turkyilmaz I, Ozan
2. el Askary AS, Meffert RM, Griffin T. 9. Almog DM, LaMar J, LaMar O, McGlumphy EA. Reliability
Why do dental implants fail? Part I. FR, LaMar F. Cone beam of implant placement with
Implant Dent 1999;8(2):173-185. computerized tomography- stereolithographic surgical
based dental imaging for implant guides generated from computed
3. el Askary AS, Meffert RM, Griffin
planning and surgical guidance, tomography: clinical data from
T. Why do implants fail? Part II.
Part 1: Single implant in the 94 implants. J Periodontol.
Implant Dent 1999;8(3):265-277.
mandibular molar region. J Oral 2008;79(8):1339-1345.
4. Gahleitner A, Watzek G, Imhof Implantol. 2006;32(2):77-81.
15. van Steenberghe D, Glauser
H. Dental CT: imaging technique,
10. Sanna AM, Molly L, van R, Blombäck U, Andersson
anatomy, and pathologic
Steenberghe D. Immediately M, Schutyser F, Pettersson
conditions of the jaws. Eur Radiol
loaded CAD-CAM manufactured A, Wendelhag I. A computed
2003;13(2):366-376.
fixed complete dentures using tomographic scan-derived
5. Lal K, White GS, Morea flapless implant placement customized surgical template
DN, Wright R. Use of procedures: a cohort study of and fixed prosthesis for flapless
stereolithographic templates consecutive patients. J Prosthet surgery and immediate loading
for surgical and prosthodontic Dent 2007;97(6):331-339. of implants in fully edentulous
implant planning and placement. maxillae: a prospective
11. Nickenig HJ, Eitner S. Reliability
Part I. The concept. J Prosthodont multicenter study. Clin Implant
of implant placement after virtual
2006;15(1):51-58. Dent Relat Res. 2005;7 Suppl
planning of implant positions
6. Angelopoulos C, Thomas SL, 1:S111-120.
using cone beam CT data and
Hechler S, Parissis N, Hlavacek surgical (guide) templates.
M. Comparison between digital J Craniomaxillofac Surg
panoramic radiography and cone- 2007;35(4-5):207-211.
beam computed tomography for
the identification of the mandibular
canal as part of presurgical
dental implant assessment.
J Oral Maxillofac Surg.
2008;66(10):2130-2135.

Miles
American Academy of
Oral and Maxillofacial
Radiology Executive Opinion
Statement on Performing and
Interpreting Diagnostic Cone
Beam Computed Tomography
T
he American Academy of Oral and criteria, dose optimization, technical proficiency,
Maxillofacial Radiology (AAOMR) is the and assessed diagnostic or treatment needs.
professional organization representing oral The following guidelines have been formulated to
and maxillofacial radiologists in the United States. assist practitioners in providing appropriate CBCT
The Academy is a nonprofit professional society radiologic care. These guidelines are not inflexible
the primary purposes of which are to advance rules or requirements of practice and are not
the science of radiology, improve the quality and intended, nor should they be used, to establish a
access of radiologic services to the patient, and legal standard of care.
encourage continuing education for oral and
maxillofacial radiologists, dentists, and persons 1. Use of CBCT
practicing oral and maxillofacial imaging in allied CBCT imaging involves exposure of the patient
professional fields. The AAOMR embraces the to ionizing radiation. CBCT should be performed
introduction of cone beam computed tomography only by an appropriately licensed practitioner or
(CBCT) as a major advancement in the imaging certified radiologic operator under supervision of
armamentarium available to the dental profession. a licensed practitioner with the necessary training.
The AAOMR is currently in the process of CBCT examinations should be performed only for
developing a position paper on appropriate valid diagnostic or treatment reasons and with the
application of CBCT to provide evidence-based minimum exposure necessary for adequate image
guidelines. In the interim, the Executive Committee quality.
(EC) of the AAOMR considers it necessary to
provide an opinion document addressing the 2. Practitioner responsibilities
principles of application of CBCT as it relates A practitioner who performs or supervises
to acquisition and interpretation of maxillofacial CBCT examinations must hold a valid license.
imaging in dental practice. Dentists using CBCT should be held to the same
standards as board certified oral and maxillofacial
Recommendations radiologists (OMFRs), just as dentists excising
The AAOMR EC believes that the practitioner oral and maxillofacial lesions are held to the same
should apply imaging procedures based on standards as OMF surgeons. It is the responsibility
considerations of patient radiograph selection of the practitioner obtaining the CBCT images to

Scarfe
Miles et al
interpret the findings of the examination. responsibility for radiologic findings beyond those
Just as a pathology report accompanies a needed for a specific task (e.g., implant treatment
biopsy, an imaging report must accompany a planning). This assumption is erroneous.
CBCT scan. CBCT operators should only be individuals
Practitioners who operate a CBCT unit, or who are legally permitted to perform CBCT
request CBCT imaging, should have thorough procedures prescribed by a licensed dental
understanding of the indications for CBCT practitioner. Such individuals may be employed
as well as a familiarity with the basic physical by the dental practitioner or may perform CBCT
principles and limitations of the technology. procedures in an independent facility pursuant to
Practitioners should be familiar with alternative all pertaining regulations. The CBCT operator must
and complementary imaging and diagnostic have a thorough understanding of the operating
procedures and should be capable of correlating parameters of the CBCT system and the effects
the results of these with CBCT findings. of these parameters on image quality and radiation
Practitioners using CBCT must have a thorough safety. The CBCT operator has the responsibility
understanding of the operational parameters and for patient comfort, preparing and positioning
the effects of these parameters on image quality the patient for the CBCT procedure examination,
and radiation safety. monitoring the patient during the examination, and
It is desirable for practitioners to undergo obtaining the image data in a manner prescribed
specific training to perform CBCT examinations by the referring practitioner. The CBCT operator
successfully. The practitioner who operates should also perform calibration and the regular
a CBCT unit, or requests a CBCT study, quality control testing.
must examine the entire image dataset. This Before delegating the operation of CBCT
is predicated on a thorough knowledge of units, the dental practitioner must confirm the
CT anatomy for the entire acquired image legal authority for technical performance of CBCT
volume, anatomic variations, and observation imaging in his or her specific locality. As the CBCT
of abnormalities. It is imperative that all image system is considered to be a medical device
data be systematically reviewed for disease. The in some localities, a dental auxiliary certified to
field of view will vary with the system employed, perform dental radiographic procedures might not
positioning, and collimation, and can include be qualified to perform CBCT.
intracranial structures, the base of the skull,
the paranasal sinuses, the cervical spine, the 3. Documentation
neck, and the airway spaces. Qualified specialist Documentary evidence should be provided to
OMFRs may be able to assist diagnostically demonstrate the diagnostic or treatment guidance
when practitioners are unwilling to accept the need of the CBCT examination. Appropriate
responsibility to review the whole exposed tissue demographic, clinical, and case history information
volume. should be available to permit the proper performance
There may be a misconception on the part and interpretation of the CBCT examination.
of some practitioners that the user has no To support the diagnostic necessity of the
42 • Vol. 1, No. 1 • March 2009

Scarfe et al
Miles
procedure and facilitate patient understanding, responsible for the development of the program.
it is desirable that a separate patient consent be The program should include documentation of the
obtained for the CBCT procedure before imaging. performance of calibration tests, a log of the results
To facilitate image retrieval, the dataset itself should of equipment performance monitoring, facility
be stored in compliance with relevant legal and dosimetry results, and a legible chart of patient-
regional stipulations and should be exportable in a and task-specific technique exposure parameters.
format compatible with the International Standards The AAOMR EC encourages the use of CBCT
Organization (ISO)-referenced Digital Imaging technology within the practice of dentistry where
and Communications in Medicine (DICOM) this results in health care benefits for the patient.
Standard. Distributed images are a component of The above represents the collective statement of
the permanent record and should be stored in a the AAOMR EC as approved without dissent. Dr.
suitable archival format. An interpretation report of William. ●
the imaging findings should also be included in the
patient’s record. William C. Scarfe was assigned the role of
primary editor and coordinator for development of
4. Radiation safety and quality assurance this statement.
Facilities operating CBCT should have specific
Laurie Carter, DDS, MA, PhD
policies and procedures for dose optimization.
These include, but are not limited to, custom Allan G. Farman, BDS, PhD, EdS, MBA, DSc,
examination exposure protocols taking into DDS, MS
account patient body size, field limitation to the James Geist, DDS
region of interest, and use of personal protective
William C. Scarfe, DDS
devices such as a lead torso apron and, where
appropriate, a thyroid collar. Procedures should Christos Angelopoulos, DDS
follow all pertaining regulations. Madhu K. Nair, BDS, DMD, MS, Lic.Odont., PhD
The purpose of a quality control program is to
Charles F. Hildebolt, DDS, PhD
minimize radiation risk to the patient, personnel, and
public, while sustaining adequacy of the diagnostic Donald Tyndall, DDS, MSPH, PhD
information obtained. The dental practitioner is Michael Shrout, DMD, FAGD
American Academy of Oral and Maxillofacial Radiology

Executive Committee
P.O. Box 1010
Evans, GA 30809-1010

The Periodontally “Accelerated Osteogenic
Orthodontics”™ (PAOO™) Technique: Efficient Space
Closing With Either Orthopedic or Orthodontic Forces
M. Thomas Wilcko, DMD1 • William M. Wilcko, DMD, MS2

Karen Breindel Omniewski, RDH, BSed3 • Jerry Bouquot, DDA, MSD4
James M. Wilcko, DMD5
Abstract
Background: For more than 50 years, the Methods: Three cases are presented in which
mechanical mindset of “bony block movement” PAOO was utilized to accomplish complete
has prevailed in the literature to erroneously orthodontic treatment. In all cases, orthodontics
describe the rapid tooth movement associated were combined with full thickness flap reflection,
with corticotomy facilitated orthodontics. Modern selective ostectomies, and bone grafting
computerized tomography (CT) imaging and according to the PAOO protocol.
histologic evaluation have revealed that it is the
demineralization of the alveolar housing consistent Results: All cases demonstrated rapid tooth
with the regional acceleratory phenomenon movement and stability up to 11.5 years after
(RAP) process that provides the environment of treatment.
decreased mineral content and increased bone
turnover that is responsible for the facilitated tooth Conclusion: PAOO is a method that produces
movement. This case series presents 3 cases efficient and stable orthodontic tooth movement.
in which periodontally accelerated osteogenic Oftentimes, teeth can be moved 2 to 3 times
orthodontics (PAOO) were utilized to treat dental further in 1/3 to 1/4 the time required for
malocclusions. traditional orthodontic therapy alone. The basis
. of these movements is physiologically based on
principles of RAP.
KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft
1. Private practice limited to Periodontics, Erie, PA. Associate Professor Periodontics,

Case School of Dental Medicine, Cleveland, OH
2. Private practice limited to Orthodontics, Erie, PA
3. Private practice, Erie, PA
4. Chairman Department of Diagnostic Science, University of Texas Dental Branch Houston, Houston, TX
5. Private practice limited to Endodontics, Erie, PA

Wilcko et al
Introduction/Background housing even though lingual full thickness flaps

In describing periodontally accelerated osteogenic had been reflected. Corticotomy cuts can result in
orthodontics (PAOO), Wilcko et al1 were the first significant demineralization of the alveolar housing,
to attribute rapid tooth movement post-corticotomy but only in close approximation of the osseous insult.
surgery to “bone matrix transportation” rather During retention, the demineralized collagenous
than to the previously long-held notion of “bony soft tissue matrix of the bone was found to
block movement.”2-4 Utilizing hospital based high remineralize, albeit to a much lesser degree in the
resolution computed tomographic (CT) scanning, adult patient than in the adolescent patient. We
analyses of the alveolar housing were performed would attribute this discrepancy in remineralization
on both adolescents and adults. Wilcko et al to the increased vitality and recuperative potential
in 2001 reported that rapid tooth movement of adolescent tissues versus adult tissues.
in decrowding was the result of the apparent The rapid tooth movement was thus not the result
demineralization of a relatively thin layer of bone of “bony block movement” as previously thought,
over the root prominences in the direction of the but rather to a demineralization-remineralization
intended tooth movement.6,7 They suggested that phenomenon within the alveolar housing consistent
the demineralized collagenous soft tissue matrix of with the wound healing pattern of regional
bone and islands of osteoid that remained following acceleratory phenomenon (RAP) as described
the demineralization process could then be by Frost8 in long bones and by Yaffe et al9 in the
rapidly transported with the root surfaces into the alveolus. Wilcko et al have also shown that it
desired positioning, hence the term “bone matrix is not the design of the “bone activation” that is
transportation.” At the time of the corticotomy responsible for the rapid tooth movement, but rather
surgery, full thickness mucoperiosteal flaps were the intensity and proximity to the osseous insult.7
reflected both facially and lingually around all teeth Ferguson et al10, Sebaoun et al11, Lee et al12, and
in each surgerized arch, regardless of whether or Wilcko et al13 have provided histologic and systemic
not the teeth would be corticotomized (activated). evidence to support the hypothesis proposed by
That is to say that the full thickness flaps were Wilcko et al1,6,7 that the facilitated tooth movement
reflected around not only the teeth that would subsequent to corticotomy surgery is attributable
be activated, but also around the teeth that were to a demineralization/remineralization phenomenon
designated for anchorage. Interestingly, it was rather than “bony block movement.” Sebaoun and
observed that even though there was pervasive coworkers reported that in a rat model, selective
demineralization of the thin layer of alveolar housing alveolar decortication resulted in a 3-fold increase
over the root prominences in close approximation to in the catabolic response (osteoclastic count)
the corticotomy cuts that even one tooth removed and anabolic process (formation response)
from the corticotomy cuts there was no apparent at 3 weeks post surgery that dissipated to
demineralization of the alveolar bone over the root normal steady state by 11 weeks post surgery.11
prominences. Additionally, when corticotomy cuts In this paper we would like to pay special
were made facially, but not lingually, there was no attention to space closure of the extraction sites
apparent demineralization of the lingual alveolar of the upper and lower first bicuspids. The most
46 • Vol. 1, No. 1 • March 2009

Wilcko et al
crucial point in being able to optimize space apices of the canine and second bicuspid or the
closure at the first bicuspid sites is to remember wall of the maxillary sinus, whichever comes first.
that the most optimal scenario following bone The ostectomy preparation is very similar to that
activation is to have a relatively thin layer of bone described by Köle.2 Köle reportedly retracted the
(in close approximation to the osseous insult) over canines with heavy orthodontic forces delivered
the root surface in the direction of the intended through removable appliances and claimed to be
tooth movement. Rapid tooth movement cannot able to complete all major movements in 6 – 12
be sustained through a large amount of bone in weeks. Even though Köle talked in terms of “bony
a mesiodistal orientation of the alveolus. If one block movement”, his osseous preparations also
attempts to move a tooth through a large volume included alveolar thinning. This was especially
of bone, the osteopenic effect at a distance from evident in the uprighting of lingually tipped lower
the periodontal ligament (PDL) will resolve and posterior teeth where he removed the entire
return to a regular rate of tooth movement before buccal cortical plate of bone. Liou also employed
1/2 of the bicuspid space can be closed. Space the thinning of interseptal bone on the distal of
closure should be initiated 2 to 4 weeks following the canine prior to retraction, but this was done
the PAOO surgery. This will provide an adequate in the absence of flap reflection and the buccal
amount of time for the thin layer of bone over and lingual cortical plates over the extraction
the root surface to demineralize. The resulting socket were not removed.14 Liou accomplished
collagenous soft tissue matrix of the bone and space closure in three weeks by retracting the
the islands of osteoid can then be rapidly carried canines with fixed orthopedic devices and the
with the root surface into the desired positioning. adjustments beginning immediately post surgery.
In order to provide for a very thin layer of bone Three case reports will be presented to
over the root surface in the direction of the intended demonstrate the most efficient manner in which
tooth movement an ostectomy is performed at the to accomplish rapid space closure following
bicuspid extraction site. The buccal and lingual first bicuspid removal utilizing either orthopedic
cortical plates and the interspersed medullary or orthodontic forces. A careful review of these
bone are removed at the extraction site. Bone cases should aid in dispelling much of the
thinning is then performed on what would have confusion associated with surgically assisted rapid
been the interseptal bone on the distal of the space closure utilizing the PAOO technique.
canine. Typically, the canine is being retracted into
the ostectomy site of the extracted first bicuspid. Case Reports
It is very important to assure that there is only an Materials and Methods
extremely thin layer of bone on the distal of the Three cases are presented that include
canine from mid-facial to mid-lingual, extending extraction of the first bicuspids and retraction
to the apex of the canine if possible. In the lower of the canines to close space. Adequate
arch, care must be taken to stay coronal to the and inadequate surgical preparation of the
inferior alveolar nerve and in the upper arch one extraction sites will be demonstrated. There
should stop at an imaginary line connecting the was absolutely no luxation of any of the teeth or

Wilcko et al
any outline blocks of bone. The surgeries were

performed under intravenous sedation and
local anesthesia and orthodontic adjustments
were performed at strict 2-week intervals.
Case #1
A 29 year old female patient presented with a Class
I molar relationship, moderate upper crowding,
severe lower crowding, anterior openbite, and an
8-millimeter anterior overjet (figures 1a, 2a, and 3a).
The patient previously had traditional free gingival
grafting done in the lower anterior/bicuspid areas Fig. 1a Patient 1, pre-treatment, right lateral view.
because of gingival recession. The orthodontic

treatment plan included the removal of the upper
first bicuspids and lower canines. Fortunately, the
roots of her teeth, including the roots of the lower
incisors and lower bicuspids, were relatively long,.
The patient was bracketed and very light wires
were placed in the week preceding PAOO surgery.
Full thickness flaps were reflected both facially
and lingually around all of the remaining upper
and lower teeth except for the lingual aspects of
the interdental papilla between teeth #8 and #9.
Sulcular releasing incisions were employed. The
Fig. 1d Post suturing.
orthodontist determined that ostectomies would
be performed at the extraction sites of the upper
first bicuspids (figure 1b). Care was taken to lower canines (figures 3b, 3c). Ostectomies are
ensure that only a very thin layer of bone remained generally not needed to accomplish space closure
over the distal aspect of the roots of the upper in the upper and lower anterior areas due to the
canines extending to the apices of these two teeth. sparseness of bone in these areas. The orthodontist
This would facilitate the closure of the upper first also determined that bone activation should be
bicuspid extraction sites. Additionally, the bone accomplished in the manner of circumscribing
was thinned on the linguals of the upper canines corticotomy cuts and intramarrow penetrations
and upper incisors leaving only a thin layer of both facially and lingually around all of the remaining
bone on the linguals of these teeth. This would upper and lower teeth. Approximately 9 ccs of
facilitate tipping the upper anterior teeth lingually particulate bone grafting material consisting of
to resolve the severe proclination. Ostectomies demineralized cortical powder (2 parts) and bovine
were not performed at the extraction sites of the bone (1 part) was then layered over the activated
48 • Vol. 1, No. 1 • March 2009

Wilcko et al
Fig. 1b Post bone activation and ostectomy, right lateral Fig. 1c Post bone grafting.
view.
Fig. 1e 1 month post-op, post insertion of the 0-0™ Fig. 1f 1.5 months post-op, extraction space about 50%
retractor. closed.
bone both facially and lingually and placed in the per the instruction of the orthodontist, the 0-0™
ostectomies (figure 1c). This bone grafting mixture retractors were inserted approximately 1 month
was hydrated with a clindamycin phosphate/ after the PAOO surgery (figures 1e and 2b). The
bacteriostatic water solution, approximately 5mgs/ 0-0™ retractors were adjusted on a daily basis
ml. The full thickness flaps were coronally advanced by the patient as instructed by the orthodontist.
to cover the grafting material and sutured with After 2 weeks of adjusting the 0-0™ retractors,
interrupted loop 5-0 Gortex sutures (figure 1d). the upper first bicuspid spaces were about 50%
The lower canine spaces were closed by the closed (figure 1f) and after an additional two
decrowding of the lower incisors (figures 3d and weeks of home adjustments, the spaces were
3e). The extraction spaces of the first bicuspids in almost completely closed (figure 1g). The 0-0™
the upper arch were closed with 0-0™ orthopedic retractors were removed approximately 5 weeks
retractors (Wilckodontics Inc., Erie, PA, USA). As after insertion (figure 2c). The active orthodontic

Wilcko et al
Fig. 1g 2 months post-op, extraction space almost closed. Fig. 1h 9 months post-op, active orthodontic work
completed 0-0™ retractor removed 1 week later.
Fig. 1i Day of debracketing, 11 months post-op. Fig. 1j 2.5 years retention.
treatment was completed at 9 months post in a much improved chin profile (figures 4a and 4b)
PAOO surgery (figures 1h and 2d). The patient was .
scheduled to be debracketed during the following Case #2
month. Unfortunately, the patient was in a fairly serious A 30 year old male presented with bi-maxillary
automobile accident and it was almost two additional protrusion, an eight millimeter anterior open
months before she could be debracketed (figures 1i bite, and moderate upper and lower anterior
and 2e). Fortunately, the patient’s dentition was not crowding (figure 5a). In centric occlusion,
damaged as a result of the automobile accident. The the patient occluded only on his molars and
patient’s case has remained stable at 1-year retention second bicuspids. The orthodontist designated
(figures 2f and 3f) and at 2.5 years retention (figure 1j). that all four upper and lower first bicuspids be
Additionally, increasing the alveolar volume at B-point removed, and that the upper and lower second
by filling in the dentoalveolar deficiency has resulted bicuspids and molars be used for anchorage.
50 • Vol. 1, No. 1 • March 2009

Wilcko et al
The case was bracketed and light wires placed canines were closed with T-loops. Lingual chain
during the week preceding PAOO surgery. Full elastics were also utilized to lessen rotation of the
thickness facial and lingual flaps were reflected canines. The T-loops were inserted one month
around all of the remaining upper and lower teeth after the PAOO surgery (figure 5g) and removed six
utilizing sulcular-releasing incisions. The lingual of weeks later. One month after the insertion of the
the interdental papilla between teeth #8 and #9 T-loops and 2 months following the PAOO surgery,
was not reflected, but all of the other upper and the extraction spaces were about 50% closed
lower interdental papillae were reflected with the (figure 5h). The T-loops had been removed two
facial and lingual flaps. The orthodontist determined weeks later for a total time of six weeks of space
that ostectomies would be performed at all four closing. At three months following the PAOO
upper and lower first bicuspid sites and that bone surgery and two weeks after the T-loops were
activation would be performed in the manner of removed, the incisors are seen being retracted
circumscribing corticotomy cuts and intramarrow (figure 5i). Even though T-loops deliver typical
penetrations both facially and lingually around the orthodontic forces, the extraction site spaces
upper and lower anterior teeth (figures 5b and 5c). closed remarkably quickly. The canines were
Since the upper and lower molars and second tipped into position and root paralleling followed.
bicuspids would be used for anchorage, no bone Total PAOO treatment time from bracketing
activation was performed around these teeth. Care to debracketing was nine months (figure 5j). At
was taken to extend the ostectomies as close to the three years retention, this case has remained
apices of the upper and lower canines as possible stable with no re-opening of the first bicuspid
without encroaching on the lining of the maxillary extraction site spaces and no re-opening of the
sinuses or the inferior alveolar nerves. Extensive anterior open bite. Since there was no significant
bone thinning was performed on the distals of the horizontal bone loss prior to the PAOO treatment,
canines leaving little more than the PDLs, lamina the dark triangle found between teeth #26 and
dura, and the thinnest layer of medullary bone #27 at debracketing (figure 5j) self-corrected
possible. The bone was also thinned on the linguals over the following three years (figure 5k).
of the upper and lower anterior teeth. A mixture of
demineralized cortical powder (3 parts) and bovine Case #3
bone (1 part) was then spread over the activated A 37 year old male presented with Class II molar
bone both facially and lingually, and placed in the and canine relationships, severe upper crowding,
ostectomy sites (figures 5d and 5e). This bone moderate lower crowding, a moderately deep
grafting mixture was hydrated with a solution bite, and a three to four mm anterior overjet. The
of clindamycin phosphate/bacteriostatic water upper first bicuspids were designated for removal
solution, approximately 5mgs/ml. The full thickness which was accomplished approximately one month
flaps were then coronally repositioned to cover the prior to PAOO surgery. The upper and lower
bone grafting mixture and sutured into place with molars were designated as the anchorage teeth.
interrupted loop 5-0 Gortex sutures (figure 5f). At the PAOO surgery, full thickness flaps were
The extraction spaces of the upper and lower reflected both facially and lingually around all

Wilcko et al
Fig. 2a Patient 1, pre-treatment, palatal view. Fig. 2b 1 month post-op, post insertion of 0-0™ retractors.
Fig. 2d 9 months post-op, active orthodontic work almost Fig. 2e Post debracketing, 11 months post-op.
complete.
of the remaining upper and lower teeth. Limited and lower anterior teeth, lower bicuspids, and upper
ostectomies were performed at the extraction sites second bicuspids (figure 6b). No bone activation
of the upper first bicuspids and bone activation was was performed around the upper and lower molars.
performed both facially and lingually in the manner of The ostectomies eliminated the buccal and lingual
circumscribing corticotomy cuts around the upper cortical plates and any interspersed medullary
52 • Vol. 1, No. 1 • March 2009

Wilcko et al
the linguals of the upper anterior teeth. Since

the roots of the upper canines were much longer
than the roots of the upper first bicuspids and
since the medullary bone in the apical one-third
of the extraction sites was left in place, there was
a substantial thickness of the medullary bone
remaining over the apical one-half of the distal root
surfaces of the upper canines. A 50/50 mixture
of demineralized cortical powder and bovine bone
was then placed over the activated bone and into
the ostectomy sites. The full thickness flaps were
returned to their original positioning and sutured.
Space closure at the upper first bicuspid
extraction sites was accomplished with facially
positioned space closing coils and chain elastics.
Fig. 2c 9 weeks post-op, 0-0™ retractors removed.
Unfortunately, due to the substantial thickness of
the medullary bone over the apical one-half of the
distal root surfaces of the upper canines, space
closure progressed very slowly. At four months
post PAOO surgery, the extraction site spaces
were only 50% closed (figure 6d) and space
closure was not complete until eight months post
PAOO surgery (figure 6e). From bracketing to
debracketing, the total treatment time for this
case was approximately 12 months (figure 6f).
Even though only orthodontic forces
were utilized, had the extraction sites been
surgerized properly, space closure could have
been accomplished in six to eight weeks and
completed within two to three months following
PAOO surgery. The total treatment time for this
Fig. 2f 1-year retention.
particular case could have been reduced to eight
to nine months. In order to sustain rapid tooth
bone in the coronal two-thirds of the extraction site movement, there can only be a very thin layer
sockets with only the buccal and lingual cortical of bone over the root surface in the direction of
plates being removed over the apical one-third. the intended tooth movement. Unfortunately,
In the apical one-third, the medullary bone was in this case, we failed to create this situation
left in place and the bone was not thinned on on the distals of the upper canines. This case

Wilcko et al
Fig. 3b Post extractions and bone activation, lower

anterior area, facial view.
Figs. 3a Patient 1, pretreatment, lower occlusal view.
Fig. 3d 2 weeks post-op, lower occlusal view. Fig. 3e 4 months post-op.
has remained stable at 6-months retention would maintain their structural integrity and could
(figure 6g) and 11.5-years retention (figure 6h) be moved rapidly due to the decreased resistance
offered by the less dense connecting medullary
Discussion bone. Modern CT imagery and re-entry surgeries
For the latter half of the 20th century, the rapid tooth have revealed that the structural integrity of these
movement subsequent to one-stage (reflection of small blocks of bone is not maintained following
both facial and lingual flaps) corticotomy surgery the corticotomy surgery.1 The rapid movement is
was attributed to “bony block movement.”2-5 It was more likely attributable to a transient reversible
widely believed that the small outline blocks of bone demineralization of the alveolar bone consistent
54 • Vol. 1, No. 1 • March 2009

Wilcko et al
Fig. 3c Post extractions and bone activation, lower

anterior area, lingual view.
Fig. 4a Patient 1, pre treatment, chin profile.
Fig. 3f 1-year retention.
with a RAP-like physiologic process.6,7,10,13 The

remineralization process would appear to be
almost complete in the adolescent, but much less
complete in the adult. We would attribute this to
the increased vitality and recuperative potential
Fig. 4b Patient 1, post treatment, chin profile.
of adolescent tissues versus adult tissues.
Ferguson has further defined this demineralization/
remineralization to be an osteopenic process.10
The degrees of the osteopenic response is

Wilcko et al
Fig. 5a Patient 2, pre-treatment, right lateral view. Fig. 5b Post bone activation and ostectomy, upper arch,
right lateral view.
Fig. 5e Post bone grafting, lower arch, right lateral view. Fig. 5f Post suturing, right lateral view.
Fig. 5i 3 months post-op, The T-loops and lingual chain Fig. 5j Post Debracketing, total treatment time 9 months.
elastics were removed 2 weeks earlier. The extraction site
space closing was accomplished in 6 weeks.
56 • Vol. 1, No. 1 • March 2009

Wilcko et al
Fig. 5c Post bone activation and ostectomy, lower arch, Fig. 5d Post bone grafting, upper arch, right lateral view.
right lateral view.
Fig. 5g 1-month post-op, post insertion of T-loops and Fig. 5h 2 months post-op, 1-month post insertion of
lingual chain elastics, right lateral view. T-loops and lingual chain elastics, extraction site spaces
about 50% closed.
directly related to the intensity of the surgical

wounding.11,12 Goldie and King have demonstrated
increased tooth movement and decreased
root resorption in an experimentally induced
osteoporotic condition in calcium deficient lactating
rats.15 It would appear that under the conditions
of increased osseous turnover, calcium depletion,
and diminished bone density, tooth movement will
occur in preference to root resorption. Perhaps
Fig. 5k 3 years retention. the ability of the bone to more readily respond

Wilcko et al
Fig. 6a Patient 3, pre-treatment, right lateral view. Fig. 6b Incorrect preparation of the extraction site for
space closure.
Fig. 6e 8 months post-op, extraction site space closed. Fig. 6f Post debracketing, approximately 1 year post-op.
to the forces applied to the teeth lessens the alveolus. Lino et al have clearly shown that the insult
likelihood of PDL over compression that can result of circumscribing corticotomy cuts alone will not
in hyalinization necrosis. Hyalinization of the PDL produce an osseous response that is sustainable
has been shown to precede root resorption during enough to permit movement of tooth roots through
orthodontic treatment and can be seen adjacent large amount of bone in the mesiodistal orientation
to this process.16,17 Machado has reported of the alveolus.19 Tooth movement can only
significantly less apical root resorption (1.1 mm) be sustained post-corticotomy surgery if a thin
of the maxillary central incisors in corticotomy- layer of bone is present over the root surface in
facilitated non-extraction orthodontic patients.18 the direction of the intended tooth movement.1
Closing spaces in posterior areas requires Additionally, continued tooth movement prevents
moving teeth in the mesiodistal orientation of the tissues immediately adjacent to the root from
58 • Vol. 1, No. 1 • March 2009

Wilcko et al
Fig. 6c 1 month post-op, facial space closing coil and chain Fig. 6d 4 months post-op, extraction site space about 50%
elastic used for space closure. closed.
Fig. 6g 6 months retention. Fig. 6h 11.5 years retention.
remineralizing. Conversely, alveolar bone further is the reason that the surgical preparation is these
away from the root will remineralize quickly. This areas (bone activation) for decrowding is generally
becomes readily apparent upon close comparison rather minimal, consisting of osseous insult in the
of the case reports that have been presented. manner of circumscribing corticotomy cuts and/or
The movement following bone activation is intramarrow penetrations. In all three cass in this
tipping followed by uprighting for parallelism. The report, this is the manner in which bone activation
situation that is most conducive to this is one in was accomplished on the facials of the upper and
which there is a very thin layer of bone over the entire lower anterior teeth. If, however, there are facial
length of the root in the direction of the intended exostoses in an area in which the teeth need to
tooth movement. This is typically what one finds on be decrowded, these thick dense areas of bone
the facials of the upper and lower anterior teeth and need to be reduced leaving only a thin layer of bone.

Wilcko et al
Likewise, if there is a thick layer of bone over the ostectomies have been performed. In a situation
roots on the linguals of the teeth, and the teeth need like this, simply removing the buccal and lingual
to be tipped lingually then this thick layer of bone cortical plates over the first bicuspid sockets will not
must be thinned. The upper anterior teeth in case 1 suffice. After ostectomies, one must specifically
are severely proclined and needed to be uprighted perform additional thinning of the bone on the
by tipping them lingually. Generally speaking there is distal of the canines over the entire length of the
a fairly substantial thickness of bone on the linguals roots, extending as close to the apices as is possible.
of the upper anterior teeth, especially if the palatal If ostectomy site preparation is performed
vault is shallow. Thinning the palatal bone over properly leaving a very thin layer of bone left
the lingual root surfaces in these areas will greatly remaining over the entire length of the distal canine
facilitate tipping the proclined upper anterior teeth root, the canine can readily be retracted to close
lingually, and this is exactly what was done in case 1. the extraction site space of the first bicuspid in
The more difficult situation is not when teeth are less then two months. If orthopedic forces are used
being moved faciolingually, but rather when they to retract the canines, space closure can generally
need to be moved mesiodistally through the long be accomplished in four to six weeks as was
axis (mesiodistal orientation) of the alveolus. This is demonstrated in case 1. If orthodontic forces are
a situation that often needs to be addressed in molar utilized, space closure can typically be accomplished
uprighting. If the most distally positioned molars are in six to eight weeks as was demonstrated in case 2
tipped mesially then removing a wedge-shaped where space closure was accomplished in about six
piece of bone distally and leaving only a very thin layer of weeks. It appears that the amount of utilized force is
bone over the distal surface of the distal root will greatly not as critical as is assuring there is only the thinnest
facilitate the molar uprighting. Another situation layer of bone possible left remaining on the distal
in which teeth need to be moved in a mesiodistal aspect of the root of the canine. Orthopedic forces
orientation is, of course, in posterior space closure. are generally more efficient than orthodontic forces,
In situations where first bicuspid removal and but both will suffice if the bone thinning is adequate.
space closure is deemed advisable, the canines Case 3 is an example of inadequate preparation
are more often than not retracted. Accomplishing of the extraction sites and space closure in this
this retraction movement in the most efficient case was not complete until eight months following
manner possible will require a considerable amount surgery. The ostectomies only extended about half
of alveolar preparation at the extraction site space. the distance to the apices of the canines leaving
To provide for a very thin layer of bone over the entire the alveolar medullary bone covering the apical half
length of the distal root surface of the canine requires of the distal root surfaces. There was no way to
ostectomy in the area previously occupied by the establish the “bone matrix transportation” scenario
root of the first bicuspid. Even this, however, may since the bone over the apical half of the roots
not necessarily be sufficient. Generally, the roots on the distal of the canines was much too thick.
of the canines are longer than the roots of the first Again note, that a thin layer of demineralized bone
bicuspids and if these roots are divergent, there can matrix adjacent to a root will remain demineralized
be a substantial amount of bone remaining after if the tooth movement is not interrupted, but that
60 • Vol. 1, No. 1 • March 2009

Wilcko et al
demineralized bone further away from the root will being able to move the teeth two to three times
remineralize quickly. Even when an ideal surgical further than traditional orthodontics alone.1
preparation is achieved, the initiation of the space The inclusion of the bone augmentation makes
closure should be delayed for at least two weeks it possible to provide for an increase in the alveolar
and preferably up to four weeks to allow the thin volume post treatment. If the alveolar augmentation
layer of bone to demineralize. This will then leave is not included for adult patients, the result will be
only the collagenous soft tissue matrix of the bone less alveolar housing supporting the roots of the
and islands of osteoid to be transported with the teeth than was present at pretreatment. The alveolar
root of the canine, thus providing an environment augmentation also makes it possible to cover pre-
favorable for “bone matrix transportation.” existing bony dehiscences and fenestrations over
Truly ankylosed teeth are not amenable to vital root prominences. We can thus provide for
PAOO treatment. A PDL is absolutely necessary a more intact periodontium with greater alveolar
for the facilitated tooth movement subsequent to volume to help support the teeth during retention.
the bone activation. The increase in the osseous A thin layer of bone is preferable in accomplishing
turnover in conjunction with the diminished bone tooth movement post bone activation, but a thicker
density creates an environment in which the layer of bone is preferable in helping provide for
PDL mediation process occurs more readily, but stability during retention. In a study on mandibular
a healthy PDL must be present. In a one-stage relapse, Rothe and coworkers have reported that
corticotomy based procedure such as this, the patients with thinner mandibular cortices after
teeth or outline blocks of bone must never be debanding were at greater risk for dental relapse.21
luxated. Luxation can lead to a disruption of In all three case reports presented in this paper, the
the osseous blood supply which is needed to results have remained stable during retention; 2.5
support this physiologically driven process.20 years, 3 years and 11.5 years respectively. This
Since the tooth movement post bone activation is consistent with stability findings post PAOO
is accomplished through tipping followed by treatment in non-extraction cases.13 In an evaluation
uprighting, the pretreatment angulations of the of stability in non-extraction therapy, immediate
teeth will play an important role in determining the post orthodontic treatment results were statistically
amount of tooth movement that can be expected. the same with or without PAOO treatment. During
If, at pretreatment, a tooth is tipped in the opposite retention, however, the clinical outcomes of the
direction of the intended movement then one would PAOO patients improved and did not demonstrate
anticipate being able to accomplish a substantial relapse. We would suggest that the improved
amount of tooth movement with the tipping post treatment stability is not only attributable to
followed by uprighting. If, however, at pretreatment an increased thickness of the alveolar housing
the tooth is already tipped in the same direction of supporting the roots of the teeth, but also to
the intended tooth movement, considerably less “memory loss” resulting from the demineralization/
correction can be anticipated. With the PAOO remineralization of the original alveolus.1,10,13
technique, if pretreatment angulations of the teeth In case 1, the alveolar augmentation on the facial
will accommodate, we can generally anticipate aspect of the lower anterior teeth not only corrected

Wilcko et al
the bony dehiscences (figure 3b), but by filling in the With the PAOO technique, teeth can be moved
dentoalveolar deficiency at B-point, the chin profile 2 to 3 times further in 1/3 to 1/4 the time required
was greatly improved (figures 4a, 4b). Additionally, for traditional orthodontic therapy alone. Moderate
placement of the bone grafting material into the to severe malocclusions are amenable to treatment
ostectomy sites helps consolidate space closure in both healthy adolescents and adults. The PAOO
and lessens the likelihood of any significant residual treatment can be used in place of selected orthognathic
alveolar clefting. In all three of the cases that have surgeries, but is not appropriate for the treatment of
been presented in this series, various mixtures of substantial anterior/posterior discrepancies such as
demineralized cortical powder and bovine bone severe Class III skeletal malocclusions. The alveolar
were utilized. Our preference is to use resorbable augmentation makes it possible to complete treatment
bone grafting materials that will eventually be with an increased net alveolar volume. Even though
replaced by the patient’s own natural bone. the chin prominence cannot be advanced, the chin
The rapid tooth movement stimulated by bone profile can be rounded out dramatically by filling
activation is facilitated by increased bone turnover the dentoalveolar deficiency at B-point. The ability
and calcium depletion. Medications that reduce to increase alveolar volume can also provide for a
the rate of bone turnover and increase calcium significantreductionintheneedforbicuspidextractions.
uptake, such as bisphosphonates, could potentially CT scan analyses in decrowding cases have
be problematic. Long-term corticosteroid therapy indicated that a thin layer of bone over the root
can lead to areas of devitalized bone through which prominences in the direction of the intended tooth
teeth cannot be moved. We also strongly suspect movement is preferable in facilitating tooth movement.
the osteopenia that facilitates this tooth movement This thin layer of bone will demineralize subsequent
is a sterile inflammatory process and certain to the bone activation leaving the collagenous soft
medications such as non-steroidal anti-inflammatory tissue matrix of the bone and islands of osteoid
drugs (NSAIDs) could counteract this process. that can readily be carried with the root surfaces
into the desired positioning hence “bone matrix
Conclusion transportation”. There are, of course, situations where
The PAOO technique is an in-office outpatient bicuspid extractions cannot be avoided and such
treatment that combines both periodontal surgery cases require ostectomy at the extraction sites. Bone
and orthodontics. The development and refinement thinning is imperative to assure the thinnest layer of
of the PAOO technique over the past 15 years has bone possible over the root surface in the direction
attempted not only to engineer an “optimal response” of the intended tooth movement. When surgerized
of the alveolar bone to the applied “optimal force”, properly, most bicuspid extraction sites can be readily
but to also provide an increased alveolar volume and closed in four to eight weeks with either orthopedic or
more intact periodontium to support the teeth and orthodontic force levels. Orthopedic forces are more
overlying soft tissues following treatment. PAOO efficient than orthodontic forces, but the thinness
can also provide for the reduction of undesirable of the bone is the more critical factor for efficient
side effects such as root resorption, relapse, and space closing. The bone grafting at the ostectomy
bacterial time/load factors, caries and infections. sites lessens the likelihood of alveolar clefting
62 • Vol. 1, No. 1 • March 2009

Wilcko et al
and assists in consolidating the closed spaces. preparation must reflect the physiologic realities
Luxation is absolutely contraindicated and can and not the misconceptions of the past 50 years. ●
only lead to possible devitalization of the teeth and
ligamental damage. The rapid tooth movement Correspondance:
subsequent to corticotomy surgery is not due to M. Thomas Wilcko, DMD
“bony block movement as previously believed. 6074 Peach Street, Erie, PA 16509
Because of the demineralization that ensues following Phone: (814) 868-3669
the corticotomy surgery, any outlined blocks of Fax: (814) 864-1368.
bone quickly lose their structural integrity. It is not E-mail: wilcko@velocity.ne
the design of the corticotomies that is important, Website: www.fastortho.com
but rather the physiologic response. The osseous
References 8. Frost HA. The regional acceleratory 15. Goldie R, King G. Root
1. Wilcko MT, Wilcko WM, Bissada phenomena: a review. Henry Ford resorption and tooth movement in
NF. An evidence-based analysis of Hosp Med 1983; 31: 3-9. orthodontically treated, calcium-
periodontally accelerated orthodontic 9. Yaffe A, Fine N, Bindermen I. deficient, and lactating rats. Am J
and osteogenic techniques: a Regional accelerated phenomenon in Ortho 1984; 83: 424-430.
synthesis of scientific perspectives. the mandible following mucoperiosteal 16. Brudvik P, Rygh P. The initial phase
Seminars in Orthodontics 2008; flap surgery. J Periodontol 1994; 65: of orthodontic root resorption
21(4): 305-316. 79-83. incident to local compression of
2. Köle H. Surgical operations of the 10. Ferguson DJ, Wilcko WM, Wilcko periodontal ligament. Eur J Orthod
alveolar ridge to correct occlusal MT. Selective alveolar decortication 11993; 14: 249-263.
abnormalities. Oral Surg Oral Med for rapid surgical-orthodontic 17. Kurol J, Owman-Moll P. Hyalinization
Oral Pathol 1959; 12: 505-529. resolution of skeletal malocclusion and root resorption during early
3. Suya H. Corticotomy in orthodontics. treatment. Distraction Osteogenesis orthodontic tooth movement in
In: Hösl E, Baldauf A (eds). of the Facial Skeleton. Hamilton:BC adolescents. Angle Orthod 1998;
Mechanical and Biological Basics in Decker, 2006: 199-203. 68: 161-165.
Orthodontic Therapy. Heidelberg, 11. Sebaoun JD, Ferguson DJ, Kantarci 18. Machado IM, Ferguson DJ, Wilcko
Germany: Hütlig Buch, 1991:207- A, Carvalho RS, VanDyke TE. WM, Wilcko MT. Reabsorcion
226. Catabolic modeling of trabecular radicular despues del tratamiento
4. Anholm M, Crites D, Hoff R, bone following selective alveolar ortodontcico con o sin cortictomia
Rathbun E. Corticotomy-facilitated decortication. J Periodontol 2008; alveolar. Rev Ven Ort. 2002; 19;
orthodontics. Calif Dent Assoc J 79: 1679-1688. 647-653.
1986; 7: 8-11. 12. Lee W, Karapetyan G, Moats R, 19. Lino S, Sakoda S, Ito G, Nishimori
5. Gantes B, Rathbun E, Anholm M. Yuamashita D, Moon H, Ferguson T, Ikeda T, Ikyawaki S. Acceleration
Effects on the periodontium following D, Yen S. Corticotomy-/osteotomy- of orthodontic tooth movement by
corticotomy-facilitated orthodontics. J assisted tooth movement micro-CTs alveolar corticotomy in the dog. Am
Periodontol 1990; 61: 234-238. differ. J Dent Res 2008; 87: 861- J Orthod Dentofacial Orthop 2007;
6. Wilcko WM, Wilcko MT, Bouquot JE, 867. 131: 448.e l-8.
Ferguson DJ. Rapid orthodontics with 13. Wilcko MT, Wilcko MW, Marquez 20. Bell WH, Levy BM.
alveolar reshaping: Two case reports MG, Ferguson DJ. Chapter 4. The Revascularization and bone healing
of decrowding. Int J Periodontics contribution of periodontics to after maxillary corticotomies. J. Oral
Restorative Dent 2001; 21: 9-19. orthodontic therapy. In: Practical Surg 1972; 30: 640-648.
7. Wilcko Wm, Ferguson DJ, Bouquot Advanced Periodontal Surgery. 21. Rothe LE, Bollen RM, Herring SW.
JE, Wilcko MT. Rapid orthodontic Wiley Blackwell 2007: 23-50. Trabecular and cortical bone as risk
decrowding with alveolar 14. Liou E, Shing Huang C. Rapid factors for orthodontic relapse. Am
augmentation: case report. World J canine retraction through distraction J Orthod Dentofacial Orthop 2006;
Orthodont 2003; 4: 197-505 of the periodontal ligament. Am J 130: 476-484.=
Orthod Dentofacial Orthop 1998;
114(4):372-382.

A Novel Dehydrated
Amnion Allograft for use
in the Treatment of
Gingival Recession:
An Observational Case Series
Brian Gurinsky, DDS, MS1
Abstract
Background: Autograft Results: The average age
tissue currently remains the of the five patients was 46
“gold standard” of periodontal years with the youngest
plastic surgery. It provides being 30 and the oldest 65
excellent predictability, years of age. The average
improved long-term root mucogingival defect size was
coverage, and superior 3.3mm (±0.84). At three
esthetics over other treatment months after surgery, there
options. Unfortunately, was an average increase of
autogenous graft tissue 3.2mm (±1.71) of new gingival
is limited in supply and significantly increases tissue representing 97% (±0.5) defect coverage.
patient morbidity. For these reasons, the dental
profession continues to search for an effective Conclusion: Based on the data collected in
and easy to use alternative. this cases series, processed dehydrated allograft
amnion may provide an effective alternative to
Methods: A novel allograft composed of autograft tissue in the treatment of shallow-
amnion tissue has recently been introduced for to-moderate Miller Class I and II recession
use in periodontal plastic surgery. The aim of defects. Additionally, the self-adherent nature
this five patient observational case series was of the amnion allograft significantly reduces
to document the use of allograft amnion in the surgical time and makes the procedure easier to
treatment of shallow-to-moderate recession perform relative to techniques involving the use of
defects at three months. autograft or allograft dermis tissue.
KEY WORDS: Gingival recession, gingiva/surgery, allograft, amnion
1.. Private practice, Denver, CO, USA. Assistant clinical professor Periodontics,
University of Colorado Denver School of Dental Medicine

Gurinsky
Background patient morbidity while also lengthening the

Approximately one-quarter of the United States duration of surgery. Considering these pitfalls,
adult population possesses gingival recession many patients have an aversion to periodontal
defects.1 This loss of gingival tissue can result plastic procedures and delay or completely forgo
in dental hypersensitivity, difficult plaque control, treatment. Ultimately, this may cause the condition
root caries, bone loss, and impaired aesthetics. to worsen and possibly decrease the probability of
From a scientific and clinical perspective, covering successful outcomes when eventually treated. For
an exposed root surface with new gingival tissue these reasons, the dental profession has continued
presents one of the most challenging scenarios for to search for an alternative soft tissue graft material
regeneration of new tissue in the entire body. The that is effective and easy to use.
avascular and microbiologically affected nature of Recently, allograft alternatives to autogenous
the root surface acts as a barrier to regenerative tissue grafts have been introduced in the form of
efforts. Additionally, newly formed tissue must allograft dermis tissue products (Puros® Dermis,
withstand the physical forces of mastication, Zimmer Dental, Warsaw, IN, USA and Alloderm®,
speaking, and oral hygiene. LifeCell Corporation, Branchburg, NJ, USA). An
Various surgical approaches and materials additional allograft of alternative origin is derived
have been employed for the treatment of gingival from human amnion tissue (BioCover™, Snoasis
recession.2-8 In most of these approaches, the Medical, Denver, CO, USA). This novel soft
exposed root surface is cleansed of bacterial tissue allograft is composed of multiple layers of
endotoxins and regenerative material is placed dehydrated human amnion tissue processed via
over the defect. The materials used in these Purion™, a proprietary tissue processing technology
procedures include autogenous free gingival that preserves the inherent structure of amnion
grafts,9 autogenous connective tissue grafts,6 and while cleansing and fusing its layers together.
allograft dermis tissue.10 Additionally, biologic To demonstrate the viability this allograft for the
mediators such as enamel matrix derivative, treatment of mucogingival defects, the aim of this
platelet-rich plasma, and recombinant platelet five patient observational case series was to record
derived growth factor have been introduced into the use of processed dehydrated allograft amnion
surgical protocols with the intent of accelerating in the treatment of shallow-to-moderate gingival
and directing the wound healing.11-13 Despite the recession defects.
introduction of allograft dermis tissue products
and biologic mediators, autograft tissue remains Materials and Methods
the “gold standard” of periodontal plastic surgery The aim of this five patient observational case series
as it provides excellent predictability, improved was to record the use of processed dehydrated
long-term root coverage, and superior esthetics allograft amnion in the treatment of shallow-to-
over other treatment options.14 Despite these moderate recession defects defined as ≤3 mm of
clinical outcomes, the use of autograft tissue has recession when there was no attached gingiva and
drawbacks. Autogenous graft tissue is limited in or a lack of keratinized tissue around the defect and ≥
supply and its procurement significantly increases 3 mm of recession when the defect was surrounded
66 • Vol. 1, No. 1 • March 2009

Gurinsky
Figure 1: Amnion allograft being placed over the defect site. Figure 2: Rehydrated allograft secured over the defect site.
by healthy tissue. In all cases, only one tooth was flap. 7) De-epithelialization of adjacent papilla. 8)
treated and all patients met the inclusion and The processed dehydrated allograft was placed
exclusion criteria. All patients were treated using onto the exposed root surface and proximal bone
the following surgical protocol: 1) 60-second pre- with the embossed side facing outward away
operative rinse with 0.12% Chlorhexidine and local from the tooth (figure 1). Upon placement, the
administration of 2% xylocaine with epinephrine, processed dehydrated amnion allograft becomes
1:100,000. 2) Measurement of gingival recession hydrated and self-adheres to the exposed root
defect. A standard periodontal probe was used to and proximal bone, thus eliminating the need
measure from the cementoenamel junction (CEJ) for suture techniques (figure 2). 9) Immediately
to the apical extent of the gingival margin in the after placing the membrane, the reflected flap
recession defect. 3) Preparation of exposed root was coronally positioned over the processed
surfaces which involved minimal flattening with dehydrated amnion allograft and secured with
hand instrumentation. 4) 2-minute application of either an interrupted or sling suture technique.
tetracycline solution followed by saline rinse. 5) Care was taken not to move the allograft after
Intrasulcular incisions at the buccal margin of placement and during flap closure.
treated tooth and extending to the adjacent tooth All patients were prescribed Lortab 5.0 and
to include the papillae with horizontal incisions over-the-counter ibuprofen pain medication. Oral
made at right angles to the adjacent interdental hygiene instructions included discontinuing tooth
papillae, at the level of the CEJ. Two oblique brushing near the surgical site and to use a 0.12%
vertical incisions along the adjacent teeth were Chlorhexidine rinse twice a day until instructed
extended beyond the mucogingival junction by the clinician to do otherwise. Sutures were
(MGJ) and a trapezoidal mucoperiosteal flap was removed at two weeks after surgery. Patients
raised to the point of the MGJ. 6) Split thickness were seen two, four, and twelve weeks following
dissection allowing for coronal positioning of the surgery. At 12 weeks, grafted defect sites were

Gurinsky
Figure 3: Patient 1 before treatment. Figure 4: Patient 1 three months after treatment.
re-measured with a standard periodontal probe photos. Patient 3 was a 65 year old male, non-
from the CEJ to the apical extent of the gingival smoker with a 3 mm recession defect on tooth
margin. Gingivoplasty was not utilized in any case #22. Figures 7 and 8, respectively, show the pre
to smooth newly formed tissue. and post operative (3 months) photos. Patient 4
was 52 year old male, non-smoker with a 3 mm
Results recession defect on tooth #6. Figures 9 and 10,
Patient 1 was a 34 year old female, non-smoker respectively, show the pre and post operative (3
with a 2 mm recession defect on tooth #11 with months). Patient 5 was a 49 year old female, non-
no attached gingiva present. Figures 3 and 4, smoker, with a 3.5 mm recession defect on tooth
respectively, show the pre and post operative #5. Figures 11 and 12, respectively, show the
(3 months) photos. Patient 2 was a 30 year old pre and post operative (3 months) photos.
female, non-smoker with a 4 mm recession defect The average age of the five patients was 46
on tooth #27. Figures 5 and 6, respectively, years with the youngest being 30 and the oldest
show the pre and post operative (3 months) 65 years of age. The average defect size treated
was 3.3mm (±0.84). At three month there was an
Table 1: Summary of defect coverage average increase of 3.2mm (±1.71) of new gingival
Patient Defect Residual Percent tissue representing 97% (±0.5) root coverage. A
Size Defect Coverage summary of the results in terms of root coverage
1 2mm 0mm 100% is provided in Table 1.
2 4mm 0mm 100%
3 3mm 0mm 100% Discussion
The amniotic sac encloses the developing fetus
4 4mm 0mm 100%
through gestation and is composed of amnion and
5 3.5mm 0.5mm 88%
chorion tissue. Amnion lines the inner most portion
68 • Vol. 1, No. 1 • March 2009

Gurinsky
Figure 5: Patient 2 before treatment. . Figure 6: Patient 2 three months after treatment.
of the amniotic sac and consists of a single layer collagen types III, IV, and V and cell-adhesion bioactive
of epithelium cells, thin reticular fibers (basement factors including fibronectin and laminins.
membrane), a thick compact layer, and a fibroblast Data suggests the amnion basement membrane
layer (figure 13). The basement membrane contains closely mimics the basement membrane of human

Gurinsky
oral mucosa.15 Of particular interest is the fact that bacterial contamination19 and multiple studies
this amnion layer possesses several types of laminins, support amnion’s ability to decrease the host
with Laminin-5 being the most prevalent. Laminin-5 immunologic response via mechanisms such as
plays a role in the cellular adhesion of gingival cells localized suppression of polymorphonuclear cell
and concentrations of this glycoprotein in amniotic migration.20
allograft may be useful for periodontal grafting Amniotic tissue has been used since the early
procedures.16 1900s for skin grafts, treatment of burns, and
Amnion tissue contains growth factors treatment of ulcerated skin conditions. More recently
that may aid in the formation of granulation it has been used for temporary biologic dressings for
tissue by stimulating fibroblast growth and full-thickness wounds,21 reconstruction of damaged
neovascularization.17 Additionally, the cells found or malformed organs,22 and prevention of tissue
within tissue exhibit characteristics associated with adhesion.23 Additionally, use of amniotic tissue has
stem cells and may enhance clinical outcomes.18 been reported to decrease post-operative pain when
Amnion has shown an ability to form an early used as a wound dressing.21 Amnion tissue grafts
physiologic “seal” with the host tissue precluding have also been routinely used for the past decade
70 • Vol. 1, No. 1 • March 2009

Gurinsky
Figure 12: Patient 5 three months after treatment.
Figure 11: Patient 5 before treatment.
in ophthalmologic surgery. Cryo-preserved amnion24

and dehydrated amnion25 have demonstrated
equivalent results to conjunctive autograft tissue in
ocular reconstruction procedures.
In the production of the amnion allograft used in
this study, pre-screened, consenting mothers donate
the amnion and associated tissues during elective
cesarean section surgery. All donated tissue follows
strict guidelines for procurement, processing, and Figure 13: The structure of amnion tissue.
distribution, as dictated by the United States Food
and Drug Administration (FDA) and the American
Association of Tissue Banks (AATB). These safety
measures include testing for serological infectious
diseases such as human immunodeficiency virus
(HIV) type 1 and 2 antibodies, human T-lymphotropic
virus (HTLV) type 1 and 2 antibodies, Hepatitis C
antibody, Hepatitis B surface antigen, Hepatitis B
core total antibody, serological test for Syphilis, HIV
type 1 nucleic acid test, and Hepatitis C virus nucleic
acid test. Upon collection of the maternal tissue, the
amnion and chorion tissues are carefully separated
and the amnion is cleansed prior to processing. Figure 14: Amniotic allograft with embossed markings.
The allograft is terminally sterilized, dehydrated and Note processed perforations for improved vascularization.

Gurinsky
Figure 15: Amnion and chorion tissues being separated. Figure 16: Amnion tissue is cleansed before processing.
embossed with the letters “SM” to allow for proper demanding and significantly decreases surgical
orientation during placement (figure 14), perforated, time. The ability to self-adhere makes processed
and terminally sterilized (SAL 10-6). Figure 15 shows dehydrated allograft amnion an attractive option
separation of the amnion from the chorion while figure for multi-teeth procedures and recession defects
16 demonstrates amnion tissue prior to processing. in particularly hard to reach areas such as the
The aim of this observational case series was molar region.
to document the use of processed dehydrated
allograft amnion in the treatment of shallow- Conclusion
to-moderate mucogingival recession defects. Based on the data collected in this cases series,
Collected data and subjective observation by processed dehydrated allograft amnion may
the authors indicates that the use of processed provide an effective alternative to autograft tissue
dehydrated allograft amnion provides good in the treatment of shallow-to-moderate Miller
results in terms of root coverage, increased tissue Class I and II recession defects. Additionally,
thickness, and increased attached gingival tissue. the self-adherent nature of the amnion allograft
Although not specifically recorded during this significantly reduced surgical time and made the
study, processed dehydrated allograft amnion procedure easier to perform relative to techniques
demonstrated excellent esthetic results in terms of
texture and color match. There were no adverse
Correspondance:
reactions during the course of this study and
Brian Gurinsky, DDS, MS
patients reported relatively little post-operative
1141 18th Street • Denver, CO 80202
discomfort. The ability of processed dehydrated
303-296-8527 (office)
allograft amnion to self-adhere eliminates the need
BGurinsky@Hotmail.com
for sutures, making the procedure less technically
72 • Vol. 1, No. 1 • March 2009

Gurinsky
involving the use of autograft or allograft dermis mucogingival defects, the limited number of
tissue. Although this case series provides initially patients, lack of controls, and short duration of this
promising results for utilization of processed study warrants additional research be conducted
dehydrated allograft amnion in particular to confirm the results of this study. ●
Disclosure 10. Harris R.J. Root coverage with 17. Koizumi N, Inatomi T, Sotozono
Dr. Gurinsky serves on the Clinical a connective tissue with partial C, Fullwood N J., Quantock A J.,
Advisory Board for Snoasis Medical, thickness double pedicle graft and Kinoshita S. Growth factor mRNA
Inc. and has a financial interest in the an acellular dermal matrix graft: a and protein in preserved human
company. clinical and histological evaluation of amniotic membrane. Current Eye
a case report. J. Periodontol 1998; Research 2000; 20(3): 173-77.
References 69(11): 1305-11.
1. Albandar J.M., Kingman A. Gingival 18. Toda A, Okabe M, Yoshida T,
recession, gingival bleeding and 11. Hagewald S, Spahr A, Rompola E, Nikaido T. The Potential of Amniotic
dental calculus in adults 30 years of Haller B, Heijl L, Bernimoulin J.P. Membrane/ Amnion-Derived Cells for
age and older in the United States. J. Comparative study of emdogain and Regeneration of Various Tissues. J.
Periodontol 1999; 70(1): 30-43. coronally advanced flap technique Pharmacol Sci 2007; 105: 215-28.
in the treatment of human gingival 19. Talmi Y P., Sigler L, Inge E, Finkelstein
2. Grupe H.E. Acrute necrotizing recessions. A prospective controlled
gingivitis. Med. Bulletin U.S. Army Eur. Y, Zohar Y. Antibacterial Properties
clinical study. J. Clin. Periodontol of Human Amniotic Membranes.
1956; 13(8): 187-9. 2002; 29(1): 35-41. Placenta 1991; (12): 285-88.
3. Nabers, J.M. Free Gingival Grafts. 12. Huang L.H., Neiva R.E., Soehren
Periodontics 1966 Sept-Oct; 4(5): 20. Hao Y, Hui-Kang D, Hwang D G.,
S.E., Giannobile W.V., Wang H.L. Kim W, Zhang F. Identification of Anti-
243-5. The effect of platelet-rich plasma angiogenic and Anti-inflammatory
4. Cohen D.W., Ross S.E. The on the coronally advanced flap root Proteins in Human Amniotic
double papillae repositioned flap in coverage procedure: a pilot human Membrane. Cornea 2000; 19(3):
periodontal therapy. J. Periodontol trial. J. Periodontol 2005; 76(10): 348-52.
1968; 39(2): 65-70. 1768-77.
21. Robson M.C., Krizek T.J. The effect
5. Bernimoulin J.P., Luscher B, 13. Nevins, M.L. Aesthetic and of human amniotic membranes on
Muhlemann H.R. Coronally regenerative oral plastic surgery: the bacteria population of infected
repositioned periodontal flap. Clinical clinical applications in tissue rat burns. Ann. Surg. 1973; 177(2):
evaluations after 1 year. J. Clin. engineering. Dentistry Today 2006; 144-9.
Periodontol 1975; 2(1): 1-13. 25(10): 142, 144-6.
22. Morton K.E., Dewhurst C.J. Human
6. Langer B, Langer L. Subepithelial 14. Harris R.J. Gingival augmentation amnion in the treatment of vaginal
connective tissue graft technique for with an acellular dermal matrix: malformations. Br. J. Obstet.
root coverage. J. Periodontol 1985; human histologic evaluation of a Gynaecol. 1986; 93(1):50-4.
56(12): 715-20. case – placement of the graft on
periosteum. International Journal 23. Muralidharan S, Gu J, Laub G.W.,
7. Raetzke P.B. Covering localized Cichon R, Daloisio C, McGrath
Periodontics Rest. Dent. 2004;
areas of root exposure employing the L.B. A new biological membrane for
24(4): 378-85.
“envelope” technique. J. Periodontol pericardial closure. J. Biomed. Mater.
1985 Jul; 56(7): 397-402. 15. Takashima S, Yasuo M, Sanzen N, Res. 1991; 25(10): 1201-9.
Sekiguchi K, Okabe M, Yoshida T,
8. Tarnow D, Stahl S.S., Magner A, 24. Luanratanakorn P, Ratanapakorn
Toda A, Nikaido T. Characterization
Zamzok J. Human gingival attachment T, Suwan-Apichon O, Chuck R.S.
of laminin isoforms in human amnion.
reponses to subgingival crown Randomised controlled study of
Tissue and Cell 2008; 40: 75-81.
placement. Marginal remodeling. J. conjunctival autograft versus amniotic
Clin. Periodontology 1986; 13(6): 16. Pakkala T, Virtanen I, Oksanen J, membrane graft in pterygium excision.
563-9. Jones J C.R., Hormia M. Function British Journal of Ophthalmology
of Laminins and Laminin-Binding 2007; 90(12): 1476-1480.
9. Miller PD Jr. The frenectomy
Integrins in Gingival Epithelial Cell
combined with a laterally positioned 25. Memarzadeh F, Fahd A.K., Shamie
Adhesion. J. Periodontol 2002; 40:
pedicle graft. Functional and esthetic N, Chuck R.S. Comparison of de-
709-19.
consideratons. J. Periodontol 1985; epithelialized amniotic membrane
56(2): 102-6. transplantation and conjunctival
autograft after primary pterygium
excision. Eye 2008; 22(1): 107-12.

Lee et al
Crestal Sinus Lift: Lee et al
A Minimally Invasive
and Systematic
Approach to
Sinus Grafting
Samuel Lee1, Grace Kang Lee1, Kwang-bum Park2, Thomas Han3
Abstract
Background: The placement of dental implants crestal window maxillary sinus augmentation
in the posterior maxilla is often a challenge due approach. Preoperative radiograph and
to pneumatization of the maxillary sinus. Dental CT scan analyses were performed on all patients.
surgeons have predictably overcome this obstacle A combination of specialized trephines was used
by performing bone grafting procedures such at slow speeds (40-50 RPM) to access the
as lateral window maxillary sinus augmentation maxillary sinus. Multiple specialized elevators
(modified Caldwell-Luc). Although predictable, were then used to elevate the Schneiderian
this technique produces patient morbidity membrane via the crestal window and particulate
including postoperative bruising, pain, and graft was added to the sinus. Dental implants
swelling. To reduce such morbidity, many internal were placed, typically in a single staged approach.
(crestal) approaches to sinus grafting have
been introduced using a variety of specialized Results: All 5 cases in this series resulted in
instruments. One problem associated with such successful clinical outcomes with adequate sinus
techniques is lack of visibility when opening augmentation and implant survival. The patients
the sinus floor and manipulating Schneiderian experienced minimal morbidity associated with
membrane. This case series reports on a new the crestal window approach to maxillary sinus
crestal approach to maxillary sinus augmentation augmentation.
that results in reduced patient morbidity and
improved intrasurgical visualization. Conclusion: The crestal window approach
to maxillary sinus augmentation is a simple,
Methods: 5 patients were treated with the predictable technique with low patient morbidity.
KEY WORDS: Sinus lift, maxillary sinus, dental implants
1. Private practice, First Choice Dental Group, Buena Park, CA, USA.
2. Private practice, Mir Dental Hospital, Dae Gu, Republic of Korea
3. Private practice, Los Angeles, CA, USA, Department of Periodontics UCLA.

Lee et al
Introduction may overcome poor bone quality by increasing bone

Due to pneumatization of the maxillary sinus, poor to implant surface contact in addition to producing
bone quality and quantity, treatment of posterior superior emergence profile.21 Use of such implants
edentulism has been and continues to remain a in molar areas may also decrease fracture risk,
challenge for dental physicians. Traditionally, these crestal bone stress, and allows fabrication of a
obstacles are overcome by bone condensing natural occlusal table.20 The purpose of this paper
and grafting into the maxillary sinus beneath is to describe an innovative surgical technique that
the Schneiderian membrane.1-18 Bone grafting combines a crestal internal sinus lift with use of
into the sinus has produced predictable results wide diameter implants.
enabling clinicians to place longer implants for
more stable prostheses and better long term Description of Surgical Technique
outcomes.3 Although final outcomes have proved Flap Elevation
satisfactory, sinus augmentation via lateral window Incision design that is at least 2 mm palatal to
grafting procedures produces substantial patient desired implant position and flap elevation that
morbidity.5-7, 15, 17, 18 Because this technique does not extend beyond the mucogingival junction
involves flap elevation beyond the mucogingival is recommended (figure 1). This incision design
junction, bruising, swelling, and pain are common allows for minimal pain, unilateral flap retraction, the
postoperative complications.5-7, 15, 17, 18 An additional option of doing one or two stage implant placement
intraoperative complication associated with this without losing keratinized tissue, and the ability to
procedure may arise from the laceration of the treat oral antral communications in case of excessive
intraosseous branch of posterior superior artery Schneiderian membrane perforation.
(branch of maxillary artery).15 Finally, the technique
sensitive nature of the lateral window approach Location of Crestal Window
carries a risk of Schneiderian membrane perforation When performing this technique, the lowest point
during window preparation and membrane of the maxillary sinus should be located by means
elevation. In an attempt to forgo the risks and of radiographic or cone-beam/ct options (see arrow
complications of lateral window sinus augmentation, in figure 2). It is most favorable when this position
a number of internal (crestal) approaches to have coincides with implant position. If implant placement
been introduced such as osteotome5-7, reamers17, at sites #2, 3, and 4 are anticipated with site #3
tapping drills18, piezoelectric, ISM17, and HSC.15 being the lowest point in the maxillary sinus floor, site
With most of these internal techniques for sinus #3 should be used to lift the sinus membrane.
augmentation, poor visibility during manipulation of
the Schneiderian membrane remains a problem. Crestal Window Preparation
While a great solution for the premolar region, and Membrane Lift
use of standard diameter implants (4.0mm) in To perform the crestal internal sinus lift, a round
the molar region has limitations such as poor window is made on the crestal bone with a set
emergence profile, implant fracture, and crestal of specially designed trephine burs that have a
bone strain.19-21 Large platform diameter implants diameter 1 mm less than the final implant size.
76 • Vol. 1, No. 1 • March 2009

Lee et al
Figure 1: Palatal incision design.
Figure 3: Pointed trephine used to mark precise location of

crestal window position.
Figure 2: Crestal sinus lift initiated from lowest point of

maxillary sinus (arrow).
Figure 4: Crestal marking after use of pointed trephine.
For example, if a 6mm implant is anticipated, a Conventional trephining with precision is

4.0mm (inner diameter) x 5.0mm (outer diameter) often challenging due to skipping or drifting of the
trephine is used. Unlike the conventional trephine trephine during initial bone cutting. To minimize
techniques that require 700-1000 rpm with ample this complication and maximize visualization and
irrigation, this technique utilizes lower speeds precision of the trephine bur, a “pointed trephine”
of 40-50 rpm without irrigation and is referred is used at a speed of 50 rpm without irrigation
to as a “Waterless technique.” The waterless (figure 3). The pointed trephine is used to mark the
technique has the advantage of not washing away location of the intended crestal window and only
autogenous bone filings during bone manipulation, penetrates the cortical crest (figure 4).
thus allowing the surgeon to collect an increased The second step in this technique utilizes a
amount of autogenous bone.18 trephine with an internal adjustable stopper (ASBE

Lee et al
Figure 5: Adjustable stopper and bone ejector (ASBE)

trephine used at 50 RPM to a point 1mm short of the sinus Figure 7: Specialized self-limiting diamond bur may be
floor. used to remove residual bone on sinus floor.
Figure 6: Sinus floor removed with trephine exposing Figure 8: Crestal window after use of specialized self-
Schneiderian membrane. limiting diamond bur.
trephine). Radiograph or cone-beam/CT is used to ASBE trephine is used to penetrate the ridge crest
measure the width of residual native bone from the and remove a bone core (figure 5). Although the
ridge crest to the floor of the sinus and 1 millimeter ASBE trephine is set to a length 1mm short of the
is subtracted from this distance. The adjustable sinus floor, bone core removal will often expose the
stopper within the ASBE trephine is then set to Schneiderian membrane (figure 6). In cases where
such a length to prevent perforation of the maxillary the sinus floor is extremely dense or on an inclined
sinus floor. For example, if 6mm of native residual plane, 1mm of cortical bone may remain at the floor
bone remains from the ridge crest to the floor of of the maxillary sinus. In the event that 1mm of
the maxillary sinus, the ASBE trephine adjustable residual bone remains at the sinus floor following
stopper is set to 5 mm. At a speed of 50 rpm, the use of the ASBE trephine, a specialized wide
78 • Vol. 1, No. 1 • March 2009

Lee et al
Figure 9: Mushroom elevator used to initiate Schneiderian Figure 10: Mushroom elevator may be used to remove
membrane elevation. residual bony ledges at crestal window.
diameter “sinus diamond bur” is used to expose

the Schneiderian membrane. The specialized
sinus diamond bur contains a shoulder stop that
prevents drilling into the Schneiderian membrane.
Additionally, as the sinus diamond bur grinds the
residual cortical bone, resultant fine bone particles
act as a buffer between sinus membrane and
diamond bur (figure 7).
With the third step in this technique, elevation
of the maxillary sinus Schneiderian membrane
is accomplished. Following preparation of the
crestal window, a “mushroom elevator” is used
as a probe for tactile feel of the sinus floor and
detection of membrane exposure. The maxillary Figure 11: Cobra elevator used to elevate Schneiderian
sinus floor is rarely perfectly flat, so it is common membrane mesially and distally.
to find initial sinus membrane exposure at the
corner of the osteotomy rather than at the center osteotomy site that interfere with sinus membrane
(figure 8). Once the mushroom elevator slightly elevation (figure 10). After initial Schneiderian
drops into the maxillary sinus and the Schneiderian membrane elevation, the “Cobra sinus elevator”
membrane is felt, membrane elevation is initiated is used to further elevate the sinus membrane and
(figure 9). This same elevator is also used to scrape the bony sinus floor to promote bleeding
break away any remaining ledges of bone in the in the sinus cavity (figures 11 and 12).

Lee et al
Figure 12: Cobra elevator further elevates Schneiderian Figure 13: Bone graft added to prepared maxillary sinus.
membrane and may be used to scrape sinus floor
to induce bleeding.
to augment the sinus and produce additional lift

of the Schneiderian membrane (figures 13 and
14). Lateral bone graft condensation is critical to
reducing pressure on the Schneiderian membrane
and, thus, reducing the risk of perforation. This
method facilitates healing by increasing blood
supply from the lateral and medial wall. Under-
preparing the diameter of the osteotomy in relation
to the implant is recommended to achieve bone
compaction and improve initial fixture stabilization
(figure 15).
Case 1
Figure 16: Case 1 presurgical radiograph of left maxillary
A 29 year old non-smoking Asian female with a
sinus.
noncontributory medical history had extraction of
Bone Condensing and Implant Insertion tooth #14 three months prior to implant surgery
To accommodate a wide diameter implant of and site #15 edentulism for 5 years. Preoperative
sufficient length, bone graft is added to the radiographs showed 4-6 mm of residual bone height
maxillary sinus. A combination of lateral and between the ridge crest and the maxillary sinus floor
vertical condensation of particulate bone is used (figure 16). Cross sectional CT revealed no signs
80 • Vol. 1, No. 1 • March 2009

Lee et al
Figure 14: Lateral condensation of bone graft into Figure 15: Implant insertion into prepared maxillary sinus.
prepared maxillary sinus.
of sinusitis, ostium patency, and a thin Schneiderian

membrane (figure 17). Coincidentally, the patient
also had a very thin gingival biotype. There is
no known study correlating gingival biotype with
Schneiderian membrane thickness, but through the
author’s clinical experience it has been observed
that patients with a thin gingival biotype tend to
have thinner sinus membranes (unless he/she is a
smoker).
The patient’s sinus floor was relatively flat, thus it
was expected that the sinus floor could be removed
with the bone core after use of ASBE trephine (figure Figure 17: Case 1 cross sectional CT images.
18). Trephine with the Waterless technique was
used to remove the crestal bone core. Rotation of of the Schneiderian membrane with the mushroom
the bone core within the trephine is an indication and cobra elevators, slow bone compaction was
that the sinus floor is broken and no further apical accomplished by inserting the condenser no more
pressure of the trephine is recommended to avoid than initial height of residual bone (figure 19). Next,
cutting sinus membrane. Autogenous bone collected lateral condensation was achieved by the use of a
from the trephine was made into particulate graft and “sinus spreader” instrument (figure 20).
condensed into the maxillary sinus. After initial elevation To allow for single stage implant surgery, the

Lee et al
Figure 20: Case 1 lateral condensation of bone into

maxillary sinus.
Figure 18: Case 1 left maxillary ridge following use of ASBE

trephine. Note exposure of intact Schneiderian membrane.
Figure 19: Case 1 vertical condensation of bone into

maxillary sinus.
Figure 21: Case 1 closure. Note preservation of buccal

keratinized gingiva due to palatal incision design.
82 • Vol. 1, No. 1 • March 2009

Lee et al
Figure 22: Case 1 postsurgical radiograph and CT image.
Figure 24: Case 2 postsurgical radiograph.
Case 2
A 53 year old non-smoking Asian male with a
noncontributory medical history presented for
implant placement. Preoperative radiographic and
CT scan evaluation revealed a patent ostium and no
signs of sinusitis. The lowest point of the maxillary
sinus floor was located at site #3 with residual
bone height of 6.5mm. In this case, due to the high
density of the sinus floor, removal of the trephine
core left approximately 1mm of residual bone on the
Figure 23: Case 2 maxillary ridge following use of ASBE sinus floor. The self-limiting sinus diamond bur was
trephine. Note exposure of intact Schneiderian membrane used to safely expose the Schneiderian membrane
(figure 23). Next, the Schneiderian membrane was
elevated with the aforementioned elevators and
implant osteotomy was under-prepared in diameter bone grafting was achieved using demineralized
to achieve good initial stability through compaction freeze dried bone allograft (DFDBA) mixed with
of porous quality bone during implant placement. A autogenous bone graft (figure 24).
palatal incision design allowed for preservation of
keratinized tissue following placement of the healing Case 3
abutments. (figure 21). Panoramic and CT scans A 60 year old Asian patient with a non-
were accomplished after surgery to verify proper contributory medical history and current
grafting of the maxillary sinus without perforation smoking status presented for implant treatment.
and to note horizontal compaction of bone graft Radiographic and CT scan evaluation revealed
touching the medial and lateral walls (figure 22). residual bone height of only 1.5mm at site #14.

Lee et al
Figure 25: Case 3 maxillary ridge following preparation with Figure 27: Case 3 crestal osteotomy following ledge
specialized self-limiting diamond bur. Note sinus membrane removal.
at center of preparation.
Figure 28: Case 3 post surgical radiograph. Note 12mm

elevation at site #14.
Figure 26: Case 3 membrane elevation with mushroom
elevator.
As this site was the lowest point of the maxillary used to penetrate to the bone directly instead
sinus in relation to the residual ridge, site #14 of using trephine bur because the residual bone
was used to lift the Schneiderian membrane height was only 1.5mm (figure 25). After visual
and an implant was placed at sites #13 and confirmation of sinus membrane exposure,
#14 after grafting. The sinus diamond bur was membrane elevation was accomplished with the
84 • Vol. 1, No. 1 • March 2009

Lee et al
Figure 29: Case 3 cross sectional CT image. Note excellent

lateral condensation.
Figure 31: Case 4 cross sectional CT image of initial bone

condensation.
Figure 30: Case 4 presurgical radiographic image of left

maxillary sinus.
mushroom elevator (figure 26). A remaining ledge

of bone in the osteotomy was removed with an
implant osteotomy drill at low speed using the
waterless technique (figure 27). After bony ledge
removal, introduction of “cobra elevator” was Figure 32: Case 4 radiographic image following additional
implant placement.
possible to further elevate the sinus membrane in
all directions. Bone was then condensed into the of 4.6 mm drill for 5.1 mm implant). Good primary
sinus and the implant was inserted, skipping the stabilization of the implant was achieved and
last drill sequence (4.3 mm diameter drill instead a postoperative radiograph revealed adequate

Lee et al
Figure 35: Case 5 membrane insertion into prepared

maxillary sinus.
Figure 33: Case 4 two year postsurgical radiograph. smoker, the membrane is exceptionally thick.
Case 4
A 53 year old patient with a non-contributory
medical history and current heavy smoking status
presented for implant treatment. As was the
case with the patient in Case 3 of this series, the
patient’s smoking history resulted in a Schneiderian
membrane that was very thick. Radiographic
and CT scans revealed a patent ostium, no signs
of sinusitis, and 2mm of residual bone height
at site #15 (figure 30). The lowest point of the
maxillary sinus (site #15) was used to elevate the
Schneiderian membrane. Sinus augmentation was
achieved with DFDBA using mostly with lateral
Figure 34: Case 5 presurgical radiographic image of left condensation rather than vertical condensation
maxillary sinus. (figure 31). Implants were placed at sites #13, #14,
sinus augmentation (figure 28). Cross section and #15 (figure 32). One mistake that the author
from a CT scan showed the medial and lateral made was not overgrafting with DFDBA. It is the
wall fully elevated to maximize blood supply to author’s experience that DFDBA tends to resorb
the graft (figure 29). Note the thickness of the faster and have more shrinkage than other bone
Schneiderian membrane on the unelevated lateral graft materials. However, one advantage is that it
and medial walls. Because this patient was a is not too radiopaque. Therefore, when DFDBA
86 • Vol. 1, No. 1 • March 2009

Lee et al
implant osteotomy is crucial in this case to make

initial stabilization successful. As discussed above,
the crestal window approach is easier if residual
bone height is thin as in this case. To avoid bone
shrinkage as observed in case 4, the author used
a long lasting resorbable membrane under the
Schneiderian membrane.
The crestal window in this case was only 4mm
in diameter. Therefore, insertion of the resorbable
membrane was achieved by rolling the membrane
Figure 36: Case 5 postsurgical CT image. Note excellent after soaking in saline with tetracycline (figure 35).
lateral bone condensation and resorbable membrane (arrow).
Lambone has excellent plasticity, so once inserted
into sinus cavity via crestal window it will open
and return to its original shape (see arrow in figure
36). Postoperative radiograph evaluation revealed
an adequate sinus augmentation housing implants
at sites #13-15 (figure 37).
Discussion
The morbidity associated with lateral window
sinus augmentation and the “blind” nature of
closed sinus lifts necessitated the need for an
alternative to these techniques. As shown in the
many clinical cases of this series, the “Crestal
Window Technique” predictably allows for
Figure 37: Case 5 post surgical radiograph. elevation of the Schneiderian membrane without
the morbidity associated with lateral window
is replaced by host bone, the clinician can have technique. With proper sinus instrumentation
visual confirmation by observing radiopacity from (mushroom, cobra, bone carrier, vertical
new bone as well and new cortical bone formation condenser, lateral condenser) and bony cutting
on the new sinus floor (figure 33). tools (pointed trephine, ASBE trephine, sinus
diamond bur), the crestal window approach is
Case 5 predictable and results in similar outcomes to
A 39 year old non-smoking Asian patient presented lateral window techniques in terms of membrane
for implant treatment. Radiographic and CT scans elevation and bone condensing.
revealed a patent ostium, no signs of sinusitis, and Indications for the crestal window technique
a residual bone height only about 2mm at sites are an edentulous maxillary posterior site with
#14 and #15 (figure 34). Under preparing the residual native bone height of 1-7mm. It is

Lee et al
the author’s experience that elevation of the prior to bone grafting, the author recommends the
Schneiderian membrane with the cobra elevator is cobra elevator be used to induce bleeding inside
easiest when there is less residual bone height as the sinus by scraping the bony floor.
this reduces interference of bone on the instrument
during membrane elevation. In cases of extremely Conclusion
thin residual bone, the author recommends that The crestal window technique is an alternative to
the sinus diamond bur be used to penetrate to conventional lateral window and closed maxillary
the bone directly instead of using the trephine. sinus augmentation techniques. This technique
This will reduce the likelihood of Schneiderian requires the use of specialized instrumentation that
membrane laceration. Finally, as a terminal step is unique to the procedure. ●
Disclosure 7. Summers R. A new concept in 14. Soltan M, Smiler D. Antral

* Dr. Samuel Lee is the inventor of, maxillary implant surgery: The membrane balloon elevation.
and has a financial interest in, the osteotome technique. Compendium J Oral Implantol 2005; 31: 85-90.
instrumentation kit described in this 1994; 15: 152-158. 15. Chen L, Cha J. An 8-year
article. 8. Bori J. A new sinus lift procedure: retrospective study: 1,100 patients
** All instrumentation used in this article Sa-4/”O”. Dent Implantology receiving 1,557 implants using
manufactured by MegaGen Co., LTD Update 1991; 2: 33-37. the minimally invasive hydraulic sinus
9. Smiler D. The sinus lift graft: condensing technique. J Periodontol
References 2005; 76: 482-491.
basic technique and variations.
1. Tatum H. Maxillary and sinus implant
Pract Periodontics Aesthet Dent 16. Wallace S, Froum S. Effect of
reconstruction. Den Clin North Am
1997; 9: 885-893. maxillary sinus augmentation on
1986; 30: 207-229.
10. Bruschi G. Scipioni A, Calesini G, the survival of endosseous dental
2. Boyne P, James R. Grafting of the implants. A systematic review.
Bruschi E. Localized management
maxillary sinus floor with autogenous Ann Periodontol 2003; 8: 328-343.
of the sinus floor with simultaneous
marrow and bone. J Oral Surg 1980;
implant placement: a clinical report. 17. Yamada J, Park H. Internal sinus
38:613-616.
Int J Oral Maxillofac Implants manipulation (ISM) procedure:
3. Misch C. Maxillary sinus augmentation 1998;13: 219-226. A technical report. Clin Implant
for endosteal implants: organized Dent Relat Res 2007;9: 128-135.
11. Toffler M. Site development
alternative treatment plans.
in the posterior maxilla using 18. Lee S, Lee G. Minimally invasive
Int J Oral Implant 1987; 4: 49-58.
osteocompression and apical sinus grafting with autogenous bone.
4. Garg J, Quinones C. Augmentation alveolar displacement. Implant Trib 2008;3: 8-10.
of the maxillary sinus. A surgical Compend Contin Educ Dent 19. Petrie C, et al. Increasing implant
technique. Pract Periodontics 2001;22: 775-784. diameter resulted in 3.5-fold
Aesthet Dent 1997; 9: 211-219.
12. Fugazzotto P, De P. Sinus floor reduction in crestal strain. Clin Oral
5. Summers R. The osteotome augmentation at the time of maxillary Impl Res 2005;16: 486-494.
technique: part 3 – less invasive molar extraction: success and failure 20. Davarpanah M, et al. Wide diameter
methods of the elevating the sinus rates of 137 implants in function implants: New concepts. Int J
floors. Compendium 1994; for up to 3 years. J Periodontol Periodontics Restorative Dent
15: 698-704. 2002; 73: 39-44. 2001;21: 149-159
6. Summers R. The osteotome 13. Winter A, Pollack A, Odrich R. 21. Degidi M, Piatelli A, Iezzi G, Carinci
technique: part 2 – the ridge Placement of implants in the F. Wide diameter implant: Analysis
expansion osteotomy (REO) severely atrophic posterior maxilla of clinical outcome of 304 fixtures.
procedure. Compendium 1994; using localized management of the J Periodontol 2007;78: 52-58
15 :422-426. sinus floor: a preliminary study. Int J
Oral Maxillofac Implants 2002; 17:
687-695.
88 • Vol. 1, No. 1 • March 2009

Lee et al
Padmanabhan et al
Padmanabhan et al
Comparative Analysis of Interleukin-1 Beta
Concentrations and Crestal Bone Loss in
Patients Treated with Conventional Versus
Osteotome Expansion Techniques for
Dental Implant Delivery: A Pilot Study
Thallum Padmanabhan, MDS1 • Nandhini Unnikrishnan, MDS1

Abstract
Background: Crevicular fluid analysis of various surgery and on the 60th day, radiovisuography was
inflammatory mediators has been investigated as accomplished to measure the crestal bone loss.
a means of providing objective criteria of gingival
health. The measurement of interleukin-1 beta (IL-1β) Results: Results indicate that inflammation was
may be an important supplement to clinical findings present in all patients after implant placement
in establishing a diagnosis of peri-implantitis. The and highest in cases of the osteotome expansion
aim of this pilot study is to measure and compare technique. Both implant delivery techniques showed
concentrations of the inflammatory marker IL-1β increased levels of IL-1β in comparison to healthy
and crestal peri-implant bone loss for two different controls, with the osteotome expansion technique
techniques of implant placement: the conventional showing statistically significant elevations of IL-1β in
technique utilizing twist drills and the osteotome comparison to the conventional technique. Crestal
expansion technique. bone loss and BOP were also elevated in the
osteotome group.
Methods: 5 subjects were selected with a minimum
of two teeth missing in the anterior sextant. 2 dental Conclusion: This two month pilot study showed
implants were placed: the 1st site treated with the that dental implants delivered with the osteotome
conventional twist drill technique and the second expansion technique have elevated levels of the
site with the osteotome expansion technique. pro-inflammatory cytokine IL-1β in comparison to
Patients were recalled after an interval of 4 days for traditionally treated sites during the first 60 days of
removal of sutures, enzyme linked immunosorbent healing. While the cytokine findings of this study
assay (ELISA) sampling, bleeding on probing (BOP) are a convenient explanation for the elevated crestal
scoring, and prosthesis insertion. ELISA sampling bone loss and gingival bleeding seen with the
was accomplished on the 4th, 20th, 40th and 60th osteotome expansion technique, this was a short
day after placement of implants. On the day of the term clinical trial with few subjects.
KEY WORDS: Dental implants, interleukin-1 beta, enzyme-linked immunosorbent assay
1. Sri Ramachandra Dental College and Hospital, Sri Ramachandra University, Porur, Chennai, India

Padmanabhan
Padmanabhanetetalal
INTRODUCTION high speed rotating drills suggests a reduced

The loss of crestal bone associated with dental inflammatory response and corresponding level of
implants is a significant clinical phenomenon. inflammatory mediators may occur. To investigate
Several investigators have indicated this to be this assumption, the present pilot study was
a normal occurrence as it eventually exhibits a conducted to compare levels of the inflammatory
steady state when an adequate mucosal barrier is marker IL-1β and crestal bone loss between
formed by peri-implant epithelial connective tissue conventionally delivered dental implants and dental
attachment. However, other views suggest that implants delivered by an osteotome expansion
crestal bone loss may result from surgical trauma, technique.
occlusal trauma, apical migration of crevicular
epithelium to establish a biologic width, interruption MATERIALS AND METHODS
of the blood supply when implants and abutments The study population consisted of 5 adults (2
are placed transmucosally, or development of a females and 3 males) aged 20-50 years from the
pathogenic bacterial biofilm.1 Sri Ramachandra Medical College and Research
A technique to counteract the surgical trauma Institute, Chennai, India. Inclusion criteria were
aspect of crestal bone loss during implant a minimum of two missing teeth in the maxillary
placement is said to be based on the principle of anterior sextant, a normal overjet/overbite occlusal
ridge expansion osteotomy (Summers osteotome relationship, and a minimum of 5mm bone width
technique) introduced by Summers in 1994.2 It and 7mm mesiodistal length at the edentulous
has been suggested that the osteotome expansion site. Patients with systemic medical conditions
technique improves recipient bone quality and were excluded from the study. A written informed
causes no bone overheating. However, histological consent was obtained from all patients prior to
evaluation shows that fractured trabeculae in the study commencement.
condensed peri-implant bone results in an increase Screw tapered self threaded implants 3.7mm
of pro-inflammatory and inflammatory mediators
around the implant during the first 2 to 3 weeks
after implant placement.3
During the initial stages of healing following
implant placement, clinical signs commonly
associated with periodontal disease are present in
peri-implant tissues.4 The presence of the potent
pro-inflammatory mediator interleukin-1 beta (IL-
1β) is inevitable following conventional implant
delivery due to the initial inflammatory reaction
associated with high speed rotating drills used
during implant placement. With the osteotome
expansion technique, gradual osteotome bone Figure 1: Full thickness flap elevation following crestal
expansion and elimination of heat associated with incision.
92 • Vol. 1, No. 1 • March 2009

Padmanabhan et
Padmanabhan et al
Figure 2: Conventional dental implant delivery.
in diameter and 13mm in length (Equinox Medical

Technologies, Zeist, Holland) were used throughout Figure 3: Osteotomy preparation with threaded
osteotomes.
this study. Preoperative antibiotics (Amoxicillin
500 mg) and local anaesthesia (Lignocaine with The dental implant was then inserted to full depth
1:100,000 epinephrine) were administered prior (figure 2). In the second site, which was treated
to surgery. One site was selected for placement with the osteotome expansion technique, a 2mm
of implants in the conventional manner while pilot drill was used to create the initial osteotomy.
the second site was treated with the osteotome A threaded osteotome (MIS Implants Technologies
expansion technique for implant placement. Crestal Ltd, Shlomi, Israel) was placed into the pilot
incisions followed by full thickness mucoperiosteal osteotomy with finger pressure and then rotated
flap reflection were accomplished in all surgical with the help of a hand wrench (figure 3). The hand
areas (figure 1). wrench, unlike the conventional implant wrench,
In the area of conventional implant placement, allows only a half a rotation at a time. It has to be
pilot and twist drills were utilized according to the disengaged, removed from the holder and then re
manufacturer instructions. A 2mm pilot drill was engaged into position for the next half rotation. After
used to create an initial osteotomy and followed each rotation, an interval of 20–30 seconds was
by successive increased diameter twist drills. maintained to allow gradual expansion of the bone

Padmanabhan
Padmanabhanetetalal
Figure 4: Final position of dental implants. Figure 5: Closure with impression posts in place.
Figure 6: Prepared abutments after 4 days of healing. Figure 7: Final prosthesis.
in an attempt to avoid fracture of the labial plate. loading, impressions were made with impression
After the first osteotome was placed to a depth of posts after placement of sutures (figure 5). Patients
13 mm (laser marks are present on the threaded were dismissed with placement of gingival formers
osteotome which indicate depths of 8, 10, and or healing abutments. Post-operative instructions
13mm), a second larger diameter osteotome was were provided and the patient was prescribed
utilized following the same principle. a course of antibiotics, non-steroidal anti-
Once the required depth and width was inflammatory medication, and 0.2 % Chlorhexidine
achieved with the threaded osteotomes, the oral mouth rinse. Patients were initially recalled
dental implant was placed (figure 4). Since the after an interval of 4 days for suture removal and
suggested protocol was for early non-functional prosthesis insertion (figures 6,7).
94 • Vol. 1, No. 1 • March 2009

Padmanabhanet
Padmanabhan etal
al
Cytokine Assay
On days 4, 20, 40, and 60 following surgery,
enzyme linked immunosorbent assay (ELISA)
sampling was accomplished. The peri-implant
crevicular fluid was examined for plaque and was
air dried. Sterile paper points were placed in the
peri-implant sulcus for an interval of 20 seconds
(figure 8). Care was taken to avoid contamination
of the paper points by collecting crevicular fluid
samples before measurement of probing depth.
Salivary contamination of the paper points was
avoided by isolating sampled sites with cotton rolls.
Paper points containing peri-implant crevicular
fluid were transferred to a vial containing 700μl
of Phosphate buffered saline. Within 24 hours of
sampling, the samples were centrifuged and ELISA
was performed according to the manufacturer’s
directions (Abcam ltd, USA). For a comparative
control, identical ELISA sampling and processing
were also performed on healthy teeth in the same
patient on day 4.
Bleeding on Probing
On days 4, 20, 40, and 60 following surgery,
bleeding on probing (BOP) was used to assess
peri-implant tissue conditions. The periodontal
probe was inserted into the peri-implant sulcus with
a pressure of 0.25 N and readings were recorded.
Radiographic Monitoring
Radiographic examination was carried out with
standardized radiograph directional holders
(RINN Corp, Dentsply, Elgin, IL, USA) using a Figure 8: Paper point sampling for ELISA.
paralleling long cone technique (figure 9). These
examinations were accomplished on the day of
implant placement and 6 months after the surgical
procedure. The radiopaque implant length, implant
shoulder, and alveolar crest were used as reference

Padmanabhan
Padmanabhanetetalal
Figure 11: Boxplot diagram illustrating bleeding score

index findings.
points. The distance between the implant shoulder

and alveolar crest were digitally measured on the
mesial and distal aspects, thrice for each implant,
using SOPRO digital imaging software (SOPIX,
La Ciotat, France) (figure 10). Mean measurement
values were calculated and recorded for each
implant. Crestal bone loss was analyzed by
calculating the difference between measured bone
Figure 9: Radiographic examination. levels in radiographs on the day of surgery and
180 days post operatively. Original implant length
was used as a standard to calculate distortion of
radiographs using the formula [x/x’ = y/y’] where “x”
equals original implant height, “x’” equals apparent
implant height, “y” equals original bone level, and
“y’” equals apparent bone level.
Statistical Analysis
The IL–1β concentrations, BOP, and crestal bone
loss data were analyzed using statistical packages
(SPSS for Windows). Means, standard deviations,
and ranges were calculated from the quantitative
data. Paired t-tests were performed to discern
the difference in IL–1β concentrations, BOP, and
Figure 10: Measurements of digital radiographs with
crestal bone loss between the conventional and
SOPRO digital imaging software.
96 • Vol. 1, No. 1 • March 2009

Padmanabhan et
Padmanabhan et al
Figure 12: Boxplot diagram illustrating IL-1β Figure 13: Boxplot diagram illustrating crestal bone loss
concentrations determined by ELISA. findings as determined by SOPRO imaging software.
osteotome expansion techniques. P–values less statistical significance for bleeding was seen at
than 0.05 were considered statistically significant. day 20 (p = 0.034).
IL–1β concentrations determined by ELISA
RESULTS are provided in table 2. In all patients, IL–1β
Bleeding index scores are reported in table 1. ELISA findings were elevated at treatment sites
Bleeding index scores for conventionally placed in comparison to healthy site controls (p < 0.05).
implants averaged 1.2mm (± 0.69) versus 1.9mm When comparing conventional implant placement
(± 0.55) for osteotome expansion delivered dental to the osteotome expansion technique, the latter
implants. For all patients in this case series, consistently resulted in higher IL–1β concentrations
bleeding index scores were highest in sites treated (figure 12). Statistical significance for these
with the osteotome expansion technique (figure comparisons was seen at all measured time
11). When comparing the osteotome expansion intervals: Day 4 (p = 0.042), Day 20 (p = 0.004),
and conventional implant placement techniques, Day 40 (p = 0.011), Day 60 (p = 0.010).
Table 1: Bleeding Index Scores

Patient A Patient B Patient C Patient D Patient E
Conv Osteo Conv Osteo Conv Osteo Conv Osteo Conv Osteo
Tech Tech Tech Tech Tech Tech Tech Tech Tech Tech
4th day 2 2 2 2 2 2 2 2 2 3
20th day 2 2 1 2 1 3 1 2 1 2
40th day 1 2 1 1 0 2 1 2 2 2
60th day 1 2 0 1 0 2 1 1 1 1

Padmanabhan et al
Table 2: ELISA Findings

Patient A Patient B Patient C Patient D Patient E
Conv Osteo Conv Osteo Conv Osteo Conv Osteo Conv Osteo
Tech Tech Tech Tech Tech Tech Tech Tech Tech Tech
4th day 72 85 88 86 76 84 62 76 76 85
20th day 72 82 84 88 76 82 62 72 73 84
40th day 62 77 83 87 73 82 64 70 72 80
60th day 62 79 77 86 79 83 62 70 68 78
Crestal bone loss findings as measured with In this study, IL–1β was detected in all
SOPRO imaging software averaged 1.0mm (± samples, including those from natural control teeth
0.035) for conventionally placed implants and and all dental implant sites. These findings are
1.194mm (± 0.068) for osteotome expansion in agreement with previous studies in regards to
delivered implants (figure 13). With all patients, peri-implant sampling,15,16 but differ from others in
the osteotome expansion technique resulted in a regards to healthy controls.13,14 In comparison to
statistically significant greater amount of crestal conventional twist drill techniques, implant sites
bone loss in comparison to the conventional implant treated with the osteotome expansion technique
delivery technique (p = 0.0001). displayed statistically significant elevated levels of
IL-1β at all analysis intervals.
DISCUSSION Several studies have evaluated the osteotome
The clinical aspects of peri-implant inflammation expansion method for dental implant delivery, but
are similar to those seen with natural teeth and none have examined the host inflammatory response
bone loss is one of the most common features.5-8 in relation to traditional twist drill techniques. Sites
Tissue destruction in periodontal disease is the treated with osteotome expansion may contain
net result of the host’s inflammatory reaction with higher levels of IL-1β due to bony trabeculae fracture
periopathogenic bacteria.9,10 A principle mediator of induced by the osteotome. Wound healing studies
this response, detectable in gingival crevicular fluid, for bone have shown that IL-1β significantly increases
is the cytokine IL–1β.11-14 The Summers osteotome the number of osteoblasts at the site of bone
technique, or osteotome expansion technique, was injury.17 While IL-1β may increase the recruitment
introduced as a way to improve recipient bone of osteoblasts to the site of bony injury, this cytokine
quality and reduce bone heating.2 The authors of also possesses pro-inflammatory properties and has
the present pilot study hypothesized that the level been implicated as a key factor in the development
of inflammatory response would be less at sites of periodontal disease.18-20 Elevated IL-1β levels
treated in this manner versus those treated with the may explain secondary findings of this study in
conventional method employing twist drills. which sites treated with the osteotome expansion
98 • Vol. 1, No. 1 • March 2009

Padmanabhan et al
technique consistently showed increased crestal to traditionally treated sites during the first 60
bone loss and gingival bleeding in comparison to days of healing. While the cytokine findings of
traditionally treated sites. this study are a convenient explanation for the
elevated crestal bone loss and gingival bleeding
CONCLUSION seen with the osteotome expansion technique,
In contrast to the authors’ study hypothesis, this was a short term clinical trial with few subjects.
the results of this pilot study show that dental Accordingly, additional studies evaluating the
implant sites treated with the osteotome host inflammatory response to conventionally
expansion technique have elevated levels of and osteotome expansion delivered implants
the pro-inflammatory cytokine IL-1β in relation may be warranted. ●
Disclosure ankylosed teeth : Stereologic and periodontitis. A cross sectional study.

The authors report no conflicts of interest histologic observations in cynomolgus J Clin Periodontol 1992; 19: 53–7.
with anything mentioned in this article. monkeys (Macaca fascicularis). J 15. Panagakos F, Aboyoussef H,
Periodontol 1993; 64(6): 529–37. Dondero R, Jandinski Jj. Detection
References
8. Schou S, Holmstrup P, Stoltze K, and measurement of inflammatory
1. Callan D, O’Mahony C, Cobb C. Loss
Hjorting–Hansen E, Kornmann K. cytokines in implant crevicular fluid:
of crestal bone around dental implants:
Ligature induced marginal inflammation a pilot study. Int J Oral Maxillofac
A retrospective study. Implant Dent
around osseointegrated implants and Implants 1996; 11(6): 794-9.
1998, 7(4): 258– 66.
ankylosed teeth: Stereologic and 16. Salcetti J, Moriarty J, Cooper L,
2. Summers R. A new concept histologic observations in cynomolgus Smith F, Collins J, et al. The clinical,
in maxillary implant surgery: the monkeys (Macaca fascicularis). Clin microbial, and host response
osteotome technique. Compendium Oral Implants Res 1993; 4(1): 12–22. characteristics of the failing implant.
1994;15(2):152-8.
9. Neiders M, Chen P, Suido H. Int J Oral Maxillofac Implants 1997;
3. Leblebicioglu B, Ersanli S, Karabuda Heterogenity of virulence among 12: 32–42.
C, Tosun T, Gokdeniz H. Radiographic strains of Bacteriodes gingivalis. 17. Olmedo M, Landry P, Sadasivan
Evaluation of Dental Implants Placed Journal of Periodontal Research, 1989, K, Albright J, Meek W, et al.
Using an Osteotome Technique. 24(3): 192- 98. Regulation of osteoblast levels during
Journal of Periodontology 2005, 76 :
10. Genco R. Host responses in bone healing. J Orthop Trauma
385-90.
periodontal diseases: Current 1999;13(5):356-62.
4. Lamster I. Evaluation of components of concepts. J Periodontol 1992; 63(4): 18. Tobón-Arroyave S, Jaramillo-González
gingival crevicular fluid as diagnostic 338-55. P, Isaza-Guzmán D. Correlation
tests. Ann Periodontol 1997; 2(1):
11. Dinarello C. Interleukin-1. Dig Dis Sci between salivary IL-1beta levels and
123-37.
1988; 33(3 Suppl): 25S-35S. periodontal clinical status. Arch Oral
5. Lang N, Bragger U, Walther D, Beamer Biol 2008; 53(4):346-52.
12. Charon J, Luger T, Mergenhagen S,
B, Kornmam K. Ligature – induced
Oppenheim J. Increased thymocyte- 19. Duarte P, de Oliveira M, Tambeli
peri implant infection in cynomolgus
activating factor in human gingival C, Parada C, Casati M, Nociti
monkeys. I. Clinical and radiographic
fluid during gingival inflammation. F. Overexpression of interleukin-
findings. Clinical Oral Implants Res
Infect Immun1982; 38(3):1190-5. 1beta and interleukin-6 may play
1993; 4(1): 2–11.
13. Masada M, Persson R, Kenney J, Lee an important role in periodontal
6. Lindhe J, Berglundh T, Ericsson I, breakdown in type 2 diabetic
S, Page R, Allison R. Measurement of
Liljenberg B, Marinello C. Experimental patients. J Periodontal Res 2007;
interleukin–1 A and interleukin–1 B in
breakdown of peri implant and 42(4):377-81.
gingival crevicular fluid: implications
periodontal tissues. A study in the
for the pathogenesis of periodontal 20. Orozco A, Gemmell E, Bickel M,
beagle dog. Clin Oral Implants Res
disease. J Periodontal Res 1990; 25: Seymour GJ. Interleukin-1beta,
1992; 3(1): 9–16.
156-63. interleukin-12 and interleukin-18
7. Schou S, Holmstrup P, Reibel j, Juhl levels in gingival fluid and serum
14. Wilton J, Bampton J, Griffith G.
M, Hjorting–Hansen E, Kornmann K. of patients with gingivitis and
Interleukin–1 beta levels in gingival
Ligature induced marginal inflammation periodontitis. Oral Microbiol Immunol
crevicular fluid from adults with
around osseointegrated implants and 2006; 21(4):256-60.
previous evidence of destructive

Are your sinus membranes
still getting ruptured?
STOP SWITCH
TO THE NEW
USING OLD
METHODS SOLUTION
Sinu-Lift™ System - The safest way to lift the sinus membrane.

A minimally invasive, non-traumatic approach that yields predictable results.
INTRODUCING THE COMPLETE SINUS LIFT PROCEDURE OFFER

From lifting to grafting
SINU-LIFT SYSTEM + 3.2mm DRILL + GENMATRIX BONE GRAFT
Retail $297 Retail $127.50 Retail $79
ALL FOR $297 A savings of $206.50 from retail price
To order call 1.866.944.1118 or go to www.iitweb.com

Current Clinical Review
2007 American Heart Association

Guidelines for Prevention of
Infective Endocarditis (IE)
Gregory D. Naylor, DDS, ABOM1
T
he American Heart Association (AHA) has body of literature and clinical evidence
made recommendations for the prevention concerning IE following dental procedures and
of infective endocarditis (IE) since 1955 removed from the list many heart conditions
and the March 2007 AHA guidelines represent previously thought to put patients at high risk for
the 10th iteration. The primary reasons for IE. The current cardiac conditions associated
this revision include: (1) IE is much more likely with high risk for IE are listed in Table 1.
to result from frequent exposure to random The goal of the AHA committee was to
bacteremias associated with daily activities than provide prophylaxis for high risk patients and to
from bacteremia caused by a dental procedure; decrease the incidence of antibiotic-associated
(2) Prophylaxis may prevent an exceedingly adverse events and the development of drug
small number of cases of IE, if any, in individuals resistant organisms.
who undergo a dental procedure; (3) The risk The AHA Committee reviewed the literature
of antibiotic-associated adverse events exceeds and the data suggest that transient streptococcal
the benefit, if any, from prophylactic antibiotic bacteremia may result from dental procedures
therapy; (4) Maintenance of optimal oral health that involve perforation of the oral mucosa, the
and hygiene may reduce the incidence of manipulation of gingival tissue, or manipulation
bacteremia from daily activities and is more of the periapical region of teeth. Therefore,
important than using prophylactic antibiotics for antibiotic prophylaxis is recommended for
reducing the risk of IE from a dental procedure. patients listed in Table 1 who undergo a dental
The AHA Committee reviewed the existing procedure as described above. The following
1. Dental Consultant, Metropolitan Life Insurance Company

procedures and events do not need prophylaxis: is another treatment alternative.

routine anesthetic injections through non-infected In order to decrease the incidence of
tissue, taking dental radiographs, placement of prosthetic valve endocarditis, it is highly
removable prosthetic or orthodontic appliances, recommended that a preoperative dental
adjustment of orthodontic appliances, placement evaluation be performed and necessary treatment
of orthodontic brackets, shedding of deciduous provided prior to any cardiac valve surgery or
teeth, and bleeding from trauma to the lips or repair of congenital heart disease.
oral mucosa. Patients on anticoagulant therapy should
Antibiotic prophylaxis should be administered not be given intramuscular (IM) injections for IE
in a single dose 30 to 60 minutes prior to dental prophylaxis. Whenever possible, an oral regimen
procedures. If the antibiotic is inadvertently not should be administered for these patients.
administered prior to the procedure, the dosage There is no evidence that coronary bypass
may be taken up to 2 hours after the procedure. graft surgery is associated with long-term risk
The antibiotics of choice for dental procedures for infection. Therefore, antibiotic prophylaxis
are directed against the viridans group of for dental procedures is not needed for these
streptococci. It is extremely important to be patients.
aware of the possibility of cross-allergenicity, so
the use of cephalosporins is not recommended Conclusion
for patients that have a history of anaphylaxis, Dentists play a critical role in patient education
angioedema, or urticaria as the result of the concerning the current AHA IE prophylaxis
administration of a penicillin derivative. It is also guidelines since many patients will no longer
very important to understand that the use of require coverage prior to dental treatment. With
antibiotics is not risk free and may be associated these new guidelines, fewer patients will need
with allergic reactions, adverse drug effects, and prophylaxis. This will result in fewer adverse
promotion of antibiotic resistance. events and decreased antibiotic resistance. ●
The current antibiotic regimens recommended
by the AHA for IE prophylaxis for dental
procedures are provided as Table 2.
Correspondence
gnaylor@comcast.net
Special Situations
References
Patients already taking a penicillin derivative
Prevention of infective endocarditis: guidelines from the Ameri-
for another illness should be administered an can Heart Association: a guideline from the American Heart
alternate antibiotic due to the development of Association Rheumatic Fever, Endocarditis, and Kawasaki
Disease Committee, Council on Cardiovascular Disease in
antibiotic resistance. Cephalosporins should
the Young, and the Council on Clinical Cardiology, Council
not be used in these instances due to their cross on Cardiovascular Surgery and Anesthesia, and the Quality
resistance with penicillin. Also, waiting at least of Care and Outcomes Research Interdisciplinary Working
Group. Wilson W, Taubert K, Gewitz M, et al. Circulation.
10 days after completion of the antibiotic therapy
2007; 116(15): 1736-54.
before administering the prophylactic antibiotics
102 • Vol. 1, No. 1 • March 2009

2007 American Heart Association Guidelines for Prevention of Infective Endocarditis (IE)
Gregory D. Naylor, DDS, ABOM
Table 1: Cardiac Conditions Associated With High Risk of IE

● Prosthetic cardiac valve ● Repaired CHD with residual defects at the
site or adjacent to the site of a prosthetic
● Previous IE
patch or prosthetic device which inhibits
● Congenital heart disease (CHD)* endothelialization
● Unrepaired cyanotic CHD, including those ● Cardiac transplantation recipients who
with palliative shunts and conduits develop cardiac valvulopathy
● Completely repaired CHD with prosthetic *Except for conditions listed above, antibiotic prophylaxis is
material or device by surgery or catheter no longer recommended for any other form of CHD
intervention during the first 6 months after **Prophylaxis is recommended because endothelialization of
the procedure** prosthetic material occurs within 6 months of procedure
Table 2: Regimens for a Dental Procedure

Situation Agent Regimen
Single Dose 30-60 minutes before procedure
Adults Children
Oral Amoxicillin 2gm 50 mg / kg
Ampicillin 2 gm IM or IV 50 mg / kg IM or IV
Unable to take
OR
oral medication
Cefazolin or Ceftriaxone 1 gm IM or IV 50 mg / kg IM or IV
Cephalexin**^ 2 gm 50 mg / kg
Oral
OR
(Allergic to
Clindamycin 600 mg 20 mg / kg
penicillins or
OR
ampicillin)
Azithromycin or 500 mg 15 mg / kg
Clarithromycin
Cefazolin or Ceftriaxone^ 1 gm IM or IV 50 mg / kg IM or IV
Allergic to penicillins or
OR
ampicillin and unable to
Clindamycin 600 mg IM or IV 20 mg / kg IM or IV
take oral medication
* IM – intramuscular, IV - intravenous ^ Cephalosporins should not be used in an individual with

** or other first or second generation oral cephalosporin in a history of anaphylaxis, angioedema, or urticaria with
equivalent adult or pediatric dosage penicillins or ampicillin

The Future is NOW
Join the 21ST century
with the only lab prepared
to take on the ever-evolving
technologies of the future.
Are you able to offer your patients the latest

dental restorations and systems?
Is your lab up to date with new technology?
For more than 35 years, Marotta Dental Studio has been working
with the restorative dentist, prosthodontist, periodontist and oral
surgeon as a team, providing precision-crafted prosthetics, superb
esthetics and personalized service.
We have been and still are the Beta lab for new technologies and
concepts for every branch of dentistry. We were instrumental in the
development of the Procera® implant bridge, Encode, NobelGuide™,
Procera®, Lava™, CAM StructSURE®, Implant restorations, Easy Guide,
Inter oral scanning and digital impression taking, digital shade taking,
custom surgical drill guides, bonding cements for zirconia, blasting
compounds on zirconia, frames designs for implants and esthetics
restorations, a line of patented implant components sold through various
suppliers, Zirconia innovations, Pressed-to ceramics, Simplant surgical guides,
Synthetic porcelain, Nitrogen processed provisional, immediate load technologies,
milled titanium, cast titanium Cad/Cam technologies such as Stereolithography,
wax printing and milling, as well as many more research projects and case
studies too numerous to mention and all made in America.
Our goal is to produce the finest quality dental prosthetics while maintaining a
supportive environment for both our employees and our clients. We promote a
family atmosphere that includes an emphasis on service, support, and education.
We have the best trained, most reliable, most experienced, elite team of
Dental technicians in the world. All performed in The U.S.A.
MarottaDental.com
Where Dentistry is Art 1-866-Marotta (627-6882)
ATTENTION PROSPECTIVE
AUTHORS
JIACD wants to publish your article!
D
o you have an article ready for up to 20 high quality color photos and a short
publication? If so, consider submitting description of the case. Please note any specific
your manuscript to The Journal of Implant products that were used during the case.
and Advanced Clinical Dentistry (JIACD). All articles submitted to JIACD are peer
JIACD welcomes original, unpublished articles reviewed by the editor-in-chief, executive editor,
that focus on implant and advanced clinical and members of the JIACD manuscript review
dentistry topics including: dental implants, esthetic panel. Manuscript review commences once
restorative dentistry, endodontics, periodontics, JIACD receives all text files, photographs,
prosthodontics, oral & maxillofacial surgery, oral & pictographs, fully signed (all authors) conflict
maxillofacial radiology, oral medicine, orthodontics, disclosure form, and fully signed (all authors)
orofacial pain management, sedation management, transfer of copyright form associated with the
CAD/CAM dental technology, and dental laboratory submitted manuscript. The JIACD manuscript
technology. JIACD articles emphasize clinical review process typically takes thirty (30) days
techniques, critical reviews, case reports, and from the date of complete submission. Upon
topics that can immediately benefit the modern manuscript review completion, the author will
actively practicing dental professional. receive communication from JIACD regarding
The JIACD “Case of the Month” is a unique acceptance or rejection of the submitted
picture based article format that should include manuscript.
For complete details regarding publication in JIACD, please refer

to our author guidelines at the following link:
http://www.jiacd.com/authorinfo/author-guidelines.pdf
or email us at: editors@jicad.com

Are you getting what
you need from your current
allograft implant provider?
www.OraGraft.com
LifeNet Health
BIO-IMPLANTS DIVISON
October 2008 Review | Oral Implications of Cancer Cheomotherapy
ADVERTISE
ADVERTISE WITH
TODAY!
Reach more customers with the dental
profession’s first truly interactive
paperless journal!
Using revolutionary online

technology, JIACD provides its
readers with an experience that is
simply not available with traditional
hard copy paper journals.
WWW.JIACD.COM
24 The Journal of Implant & Advanced Clinical Dentistry JIACD
e p a ration
Pr
. Highest torque of any micro motor on the market .

.. Widest speed range on the market .. Selective cutting for preservation of soft tissue
Accurate irrigation for prevention of bone overheating
Handpiece does not overheat and is vibration free
Compatible will all contra-angles
.. Carbon fiber tips for safe maintenance of implants

. Diamond coated and bladed curette tips for perio treatments
Color coding system for easy tip and power selection
124 Gaither Drive, Suite 140 . Mount Laurel, NJ 08054 . Tel: (800) 289-6367 . Fax: (856) 222-4726 . info@us.acteongroup.com . acteongroup.com
The Standard of Care for Implant Supported Overdentures
2.2 mm 3.25 mm 3.25 mm

0˚ 0˚ angled
✦ Approved for Permanent Application

✦ True Vertical Resiliency
✦ Corrects Misalignment of Implants
✦ 20 Years of ERA Clinical Success
✦ Mentor Program Available
✦ Educational Opportunities
Mention Ad #530
and receive
$100 Off
Marketing Kit
ÓÎÊÀ>ÊÃÃLiÀ}ÊÀÛiÊUÊÌÌiLÀ]ÊÊÊäÓÇäÎäÈÇ
nääÓ{Î{ÓÊUÊxänÓÓÈxÈÈä
"ÀìÀÊiÊ>ÌÊwww.sterngold.com ERA Marketing Kit

Specops Jiacd 200903

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Specops Jiacd 200903

Uploaded by

Copyright:

Available Formats

Volume 1, No.

The Journal of Implant & Advanced Clinical Dentistry

The Agony and Ecstasy of

Case of the Month:

Exactech is shaping the future of bone and predictable results to dental

materials offer simple

4QFDJBM0GGFS.FOUJPO0GGFS$PEF+*"$% #POVT '3&& 4FDPOE

33 The Use of Cone Beam Computerized

91 Comparative Analysis of Interleukin-1 Beta

The Journal of Implant & Advanced Clinical Dentistry • 3

Publisher Copyright © 2008 by SpecOps Media, LLC. All rights

The Journal of Implant & Advanced Clinical Dentistry • 5

The success of an implant system cannot be determined by one

Conical Seal Design™

Editorial Advisory Board

The Journal of Implant & Advanced Clinical Dentistry • 7

For all your bone grafting needs

Welcome to the evolution of dental literature

The Journal of Implant & Advanced Clinical Dentistry • 9

where future meets practice

Ross W. Nash, DDS1 • Robert Passaro, CDT2

The Journal of Implant & Advanced Clinical Dentistry • 11

12 • Vol. 1, No. 1 • March 2009

The Journal of Implant & Advanced Clinical Dentistry • 13

14 • Vol. 1, No. 1 • March 2009

The Journal of Implant & Advanced Clinical Dentistry • 15

16 • Vol. 1, No. 1 • March 2009

The Journal of Implant & Advanced Clinical Dentistry • 17

Dale A. Miles, DDS, MS1

KEY WORDS: Cone beam computed tomography, digital radiography,

The Journal of Implant & Advanced Clinical Dentistry • 19

Introduction The Ecstasy of CBCT:

20 • Vol. 1, No. 1 • March 2009

1e and 2a-2d, show 2 patients with different

Case 1: A fifteen year-old white female with an

The Journal of Implant & Advanced Clinical Dentistry • 21

site images rather than the older “life size” images

Cases 4-5: Assessment of

22 • Vol. 1, No. 1 • March 2009

the “soft tissues” to the TMJ complex. Bony changes,

The Journal of Implant & Advanced Clinical Dentistry • 23

Figure 2d: A 3D color panoramic reconstruction shows all

24 • Vol. 1, No. 1 • March 2009

The Journal of Implant & Advanced Clinical Dentistry • 25

26 • Vol. 1, No. 1 • March 2009

Figure 4a: Axial “slice” through the mid-condyle region

Figure 4c1: 3D color reconstruction of right TMJ complex.

The Journal of Implant & Advanced Clinical Dentistry • 27

Figure 4d: Midline sagittal view of the vertebral column showing

28 • Vol. 1, No. 1 • March 2009

The Journal of Implant & Advanced Clinical Dentistry • 29

30 • Vol. 1, No. 1 • March 2009

2. Cattaneo PM, Melsen B. The use of cone-beam

4. Nakajima A, Sameshima G, Arai Y, et al. Two and

5. Scarfe W, Farman A, Sukovic P. Clinical applications

6. Bourjeois M, Sikorski P, Taylor S. Cone Beam

7. Miles D. Clinical Experience with Cone-Beam

8. Danforth R, Miles D. Irish Dentist 2007; 10(9):

10. Miles D. The Future of Dental and Maxillofacial

11. Miles D, VanDis M, Williamson G, Jensen C.

The Journal of Implant & Advanced Clinical Dentistry • 31

Imagine the Possibilities

Please ask us about

4QFDJBM0GGFS.FOUJPO0GGFS$PEF+*"$% #POVT '3&& 4FDPOE