Specops Jiacd 200905

Volume 1, No.
3 M ay 2009
The Journal of Implant & Advanced Clinical Dentistry
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Sandwich Technique
Treatment of
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Volume 1, No. 3 • M ay 2009
Table of Contents
11 Prosthetic Case of the Month 41 T reatments and Treatment Outcomes in
Customized Implant Abutment Patients with Oral Lichen Planus
with Titanium Laser Welding Abigail Soto, Celeste M. Abraham, Terry D. Rees
Miguel A. Iglesia
55 C lassification of Single Tooth

Edentulous Ridges with Augmentation
17 P iezoelectric Sandwich Vertical Recommendations for Dental
Augmentation: A Series of Case Reports
Implant Treatment
Dong-Seok Sohn, Won-Hyuk Lee,, Jeung-Uk Heo
Masana Suzuki. Yorimasa Ogata
31 M
odified Palatal Papilla Construction Flap
for Aesthetic Second Stage Implant Surgery
GD Rachlin, MN Pratt, JF Koubi
63 F actors Driving Peri-implant Crestal Bone

Loss - Literature Review and Discussion:
Part 2 of 4
Mohammad Ketabi, Robert Pilliar, Douglas Deporter
73 R eview of the Seventh Report of the

Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of
High Blood Pressure (JNC 7)
Gregory D. Naylor
The Journal of Implant & Advanced Clinical Dentistry • 3

Volume 1, No. 3 • M ay 2009
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Founder, Co-Editor in Chief Founder, Co-Editor in Chief

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

Editorial Commentary
Giving Dental Implants the “Mickey Mouse” Treatment
F
or this year’s spring break, my family and location? Are we using implant planning software
I spent a week at the imagination mecca to simulate optimal fixture placement? Are we
Walt Disney World in Orlando, Florida. using traditional technology such as diagnostic
Now, I have been to Walt Disney World about a wax-ups and jaw relation records? Are we using
half dozen times before, but this trip was different. the most advanced technology of all…our peers
During our stay, I picked up a copy of Walt in the form of consults and referrals? The time
Disney’s biography and a book chronicling the to consult is before treatment begins, not after
efforts of Disney “imagineers” in their design and problems arise.
construction of the Magic Kingdom. I must say Finally, are we treatment planning with
that I was thoroughly impressed by the content of attention to detail? Are we evaluating the gingival
these texts and I now view the Walt Disney World tissue for thickness and margin location prior to
complex with a newfound sense of awe and implant placement? Are we evaluating anticipated
wonderment. The vision, foresight, and attention residual thickness of the buccal plate after
to detail that went into the planning of this resort implant placement? Are we planning for papilla
paradise are simply amazing. maintenance with interim restorations during the
With a humbling respect for the men and healing phase? Although they may seem of minor
women that devised this exquisite marvel of importance to some, little nuances such as these
engineering and efficiency, I wondered if we could can be the determining factor as to whether an
improve implant dentistry by employing some of implant case is a success or failure.
the same practices that went into the planning of It is true that just about anyone can be trained
Walt Disney World. to place a dental implant. Heck, if you operate a
For starters, are we using vision in the field of dental drill and parallel a tooth, you can place a
implant dentistry? To this, I would say “yes.” On dental implant. The question isn’t whether or not
the manufacturing front, industry is continually you can place a dental implant, the question is if
researching new and improved physical aspects you can think three steps ahead and anticipate
of implant design such as surface modifications, what is needed for optimal implant restorability,
thread pitch variations, abutment interface esthetics, and long term maintenance. To do
connections, etc. On the surgical front, we so, one must have vision, foresight, and exacting
are constantly developing new and improved attention to detail when planning and delivering
techniques such as ridge splitting and application dental implant treatment. ●
of growth factors to aid implant success.
Concerning foresight, are we being thorough
in our treatment planning of implant cases? To
answer in the affirmative, we must consider
whether we are using the vast array of technology
currently at our disposal. Are we using cone
beam computed tomography (CBCT) when there Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS
are questions about bone morphology or nerve Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief

Iglesia
Iglesia
Prosthetic Case of the Month
Customized Implant Abutment
with Titanium Laser Welding
Miguel A. Iglesia, DDS, MS1
Abstract
Background: Customized dental implant abut- wax when necessary to provide for optimal res-
ments provide the restoring dentist and lab- toration placement and maximum porcelain sup-
oratory technician an opportunity to make port. This waxed structure was cast in grade-2
subtle changes to the final implant resto- titanium and laser welded to the abutment
ration position. Such modifications assist at the apical joint prior to porcelain stacking.
in the achievement of maximum aesthetics.
Results: The final implant restoration achieved
Methods: A customized dental implant abut- superior aesthetics while retaining maxi-
ment was fabricated for mum porcelain support.
replacement of a con-
genitally missing maxil- Conclusion: Customized
lary lateral incisor. An implant abutments with
abutment designed for titanium laser welding pro-
cementation was tight- vide exceptional porcelain
ened in a working model, support while still achiev-
reducing it or adding ing superior aesthetics.
KEY WORDS: Dental implant abutment, dental implant, dental prosthetics
1. Private practice, Zaragoza, Spain

Iglesia
F
ollowing orthodontic treatment, an 18-year
old female patient presented with a con- Correspondence:
genitally missing left maxillary lateral incisor Miguel A Iglesia, DDS MS
and requested a single fixed implant-supported Residencial Paraíso 1, esc B, 1ºC
restoration. The implant was placed during orth- 50008 ZARAGOZA
odontic treatment with a surgical template and Spain
osteotomes. Plasma rich in growth factors with Telephone: 34 976 233 448
calcium sulphate was added to the buccal plate driglesia@clinicamaip.net
in order to achieve more bone volume. A provi-
sional restoration was screwed directly to the
implant after 4 months. When orthodontic space Disclosure
The author reports no conflicts of interest with anything mentioned in this article.
closure was finished achieving an adequate Acknowledgement
mesio-distal width for the final restoration, the The author mentions his gratitude to Pedro Lorente, DDS for the orthodontic
treatment depicted, and to Pedro Moreno CDT and Nuria Pérez CDT for their
provisional restoration was modified in order to technical assistance.
achieve aesthetics that closely mimicked that of

the planned final restoration in regard to emer-
gence profile, interdental contours, contact
points, and gingival contour at the facial margin.
After 4 months, these goals were achieved
and a fixture-level impression was taken. A lat-
eral incisor was waxed-up on the master cast and
a facial/lingual index of the expected final resto-
ration was created. An abutment designed for
cementation was tightened in the working model,
reducing it or adding wax when necessary to
provide enough metal to support porcelain. A
silicone index was utilized to verify that enough
space for aesthetic porcelain was allowed. This
waxed structure was cast in grade-2 titanium
and laser welded to the abutment at the api-
cal joint. After confirming clinically the precise
and correct form of the customized metal abut-
ment, special porcelain for titanium was applied.
The final aesthetics of the restoration demon-
strated improved integration, shape and shade.
12 • Vol. 1, No. 1 • May 2009

Iglesia

Iglesia
14 • Vol. 1, No. 3 • May 2009

Iglesia
Products used for this case

● Biomet-3i ™ Osseotite MicroMiniplant
● Lifecore Biomedical Inc, Calmatrix
calcium sulphate
● Biomet-3i ™ GingiHue abutment
● Orotig grade 2 titanium
● Orotig Titec 60L laser welder
● Orotig TiKron porcelain

Who says you can’t
Sohn et al
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www.exac.com/dental
Sohn et al
Piezoelectric Sandwich
Vertical Augmentation:
A Series of Case Reports
Dong-Seok Sohn1 • Won-Hyuk Lee2 • Jeung-Uk Heo3
Abstract
Background: Variations of pedicled and inter- repositioned. Residual gaps between the
positional bone grafts for dentistry have been mobilized bony segment and the basal bone
in use for over 30 years. This case series were grafted with a variety of materials.
reports on three cases in which a piezoelec-
tric “sandwich” variation of the previously men- Results: Vertical gains of up to 6mm of new
tioned grafting techniques was employed. bone were achieved with this technique. His-
tologic analysis of bone core biopsy samples
Methods: Three patients with significant from grafted sites demonstrated vital bone.
alveolar ridge deficiencies were treated with
piezoelectric sandwich augmentation. At Conclusions: The piezoelectric sandwich aug-
edentulous sites requir- mentation technique pro-
ing augmentation, a piezo- vides the ability to achieve
electric surgery unit was significant gains in verti-
used to create alveolar seg- cal bone without the need
ments which were vertically for a secondary donor site.
KEY WORDS: Alveolar ridge augmentation, dental implants, grafts, bone
1. Professor and Chair, Dept. of Dentistry and Oral and Maxillofacial Surgery, Daegu Catholic University Hospital,
Daegu, Republic of Korea
2. Clinical instructor, Dept. of Dentistry and Oral and Maxillofacial Surgery, Daegu Catholic University Hospital, Daegu,
Republic of Korea
3. Private Practice, Goodwill Dental Hospital, Pusan, Republic of Korea

Sohn et al
Introduction
The atrophic alveolar ridge is a challenging site for
dental implant placement and a variety of surgical
techniques have been developed to reconstruct
such areas. Guided bone regeneration, alveolar
distraction osteogenesis, pedicled grafts, interpo-
sition alveolar bone grafts, and onlay block grafting
have been used to overcome bone deficiency.1-4
The “sandwich technique” with interposi-
tional bone grafting is the vertical bone augmen-
tation procedure using a pedicled bony segment
moved crestally following osteotomies. In addi- Figure 1: Initial panoramic view showing severe
mandibular vertical deficiencies.
tion to eliminating the need for a secondary sur-
gical donor site, this technique preserves the
lingual or palatal periosteum which maintains the mandible and maxilla (figure 1). Under gen-
vascular supply to the segmented bone. Accord- eral anesthesia, ridge augmentations of the man-
ingly, it leads to minimal resorption of the trans- dible and maxilla were performed on July 23,
positioned bony segment and has led to gains 2004. Sinus augmentation was performed in
of up to 6mm in new vertical bone height. When the pneumatized right maxillary sinus while inter-
performing sandwich ostetomies, piezoelectric nal (crestal) elevation and simultaneous implant
surgery is recommended to preserve the lingual placement was accomplished in the left sinus.
periosteum, soft tissue, and ancillary nerves. The Titanium plate assisted horizontal ridge augmen-
specialized piezoelectric surgical properties cut tation was performed to augment the severely
hard tissue while sparing soft tissue and, thus, is atrophic anterior maxilla. Titanium mesh (Jaeil
able to preserve the periosteal blood supply to Co, Seoul, Korea) assisted ridge augmentation
segmented alveolar bone during osteotomies.5-8 using allograft (OrthoBlast II®, IsoTis OrthoBilog-
This series of case reports evaluates the efficacy ics Inc. Califonia, USA) was performed in the right
of vertical sandwich augmentation using piezo- and left atrophic posterior mandible (figures 2, 3).
electric bone surgery and interpositional allograft After 2 weeks of healing, exposure of the tita-
by means of radiographic and histologic analysis. nium mesh on the left side occurred secondary
to occlusion from the opposing premolars. The
CASE REPORTS mesh was later removed and failure of the verti-
Case Report 1 cal augmentation was revealed due to premature
A 63 year old woman visited our department with exposure (figures 4, 5). After 4 months of heal-
the complaint of mobility of her upper and lower ing, sandwich augmentation using piezoelectric
removable dentures. Plain panoramic and com- bone surgery (Piezosurgery®, Mectron, Genova,
puted tomographic radiogram showed severe Italy) was performed. Two vertical osteotomies
horizontal and vertical bony deficiencies in both and one apical horizontal osteotomy were per-
18 • Vol. 1, No. 3 • May 2009

Sohn et al
Figure 2: Titanium mesh assisted ridge augmentation. Figure 4: Premature titanium mesh exposure.
Figure 3: Postoperative panoramic view showing alveolar Figure 5: Panoramic view showing initial failure of vertical
ridge augmentations. augmentation.
formed until penetrating the lingual cortex of man-

dible (figure 6). Segmented bone was elevated
vertically 6mm with an elevator and allograft
(OrthoBlast II®) was compacted into the space
between the elevated bony segment and basal
bone (figure 7). The surgical site was then cov-
ered with a resorbable membrane (Pericardium®
Zimmer Dental Inc, Carlsbad, USA) (figure 8).
Immediate postsurgical radiographs demonstrate
the elevated bony segment (figure 9). The aug-
mented ridge was exposed after 7 months of heal- Figure 6: Sandwich osteotomies performed with
ing and favorable bone density and volume was piezosurgery.

Sohn et al
Figure 7: Segmented alveolar bone was elevated 6mm Figure 10: After 7 months of healing, 2 implants were
and gel conditioned allograft was grafted into the space placed in the augmented ridge.
between segmented bone and basal bone.
Figure 11: Panoramic view showing augmented ridge and

Figure 8: Resorbable membrane covers the graft. implant placement in the left posterior mandible.
Figure 9: Note vertical elevation of segmented bone in the Figure 12: Panoramic view of final restoration.
left posterior mandible.
20 • Vol. 1, No. 3 • May 2009

Sohn et al
Figure 14: Panoramic view showing moderate atrophy in

the right posterior mandible.
Figure 13: Stable marginal bone after 2 years in function.
observed. Two hydroxylapatite implants (TSV®,

Zimmer Dental Inc, Carlsbad, USA) were placed
and healing abutments were seated as a single
stage technique (figures 10,11). Final prosthet-
ics were delivered by the patient’s referring den-
tist after 6 months of implant healing (figure 12).
Stable bone height was demonstrated radio-
graphically after 2 years in function (figure 13). Figure 15: Sandwich osteotomies were performed with
piezoelectric surgery.
Case Report 2
A 25 year old male visited our department with
a chief complaint of mastication difficulty. Teeth
28-31 were missing and he expressed a desire
for an implant supported prosthesis. Clinical and
radiographic evaluation revealed atrophic alveolar
bone in the right posterior mandible and extru-
sion of opposing dentition (figure 14). To cor-
rect extrusion of the opposing teeth, the patient
was referred to the department of orthodontics
before performing bone augmentation. A ves-
tibular incision was made by diode laser (Lambda
Scientifica SpA, Italy) and sandwich osteotomies
were made with the piezoelectric device (Sur- Figure 16: Segmented alveolar bone elevated 6mm and
gyBone®, Silfradent srl, Sofia, Italy) under local fixed with microplate/microscrew.

Sohn et al
Figure 17: Postoperative radiograph showing vertical

elevation of segmented bone. Orthodontic implants were
placed to correct the extrusion of opposing teeth. Figure 20: Radiographic view after implant placement.
Figure 18: After six months of healing, four implants were

placed into the augmented bone. Figure 21: Hematoxyline and eosin stain of bone core
biopsy. Arrow head indicates bone graft and arrow
indicates newly formed bone.
anesthesia with 2% lidocaine 1:100,000 epi-

nephrine (figure 15). The segmented alveolar
bone was elevated up to 6mm high and fixed
with microplate and microscrew (Jaeil Co.
Seoul, Korea) (figure 16). The space between
segmented bone and basal bone was grafted
with mineral allograft (OrthoBlast II®) and cov-
ered with collagen membrane (figure 17). After
Figure 19: Allograft and collagen membrane used to 6 months of uneventful healing, the microplate
augment dehiscence defects around implants. was removed and a bone biopsy was taken
22 • Vol. 1, No. 3 • May 2009

Sohn et al
Figure 22: Uncovering of implants after four months of Figure 24: Temporary prosthesis was cemented on the
healing. Note the favorably augmented ridge. implants.
Figure 23: F ree gingival graft to augment keratinized Figure 25: Note stable marginal bone after fourteen
gingiva. months in function.
from the graft site to evaluate new bone forma- able vertical augmentation was observed (fig-
tion. Four 4.3mm wide and 11mm high implants ure 22). At this time, a free gingival graft was
(Endure implant, IMTEC Co, Ardmore, USA) performed to increase the amount of keratinized
were placed (figure 18). Allograft (OrthoBlast gingiva around the implants (figure 23). After
II®) was used to augment dehiscence defects 5 weeks of healing, a temporary prosthesis was
around the implants and collagen membrane cemented onto the implants (figure 24). Deliv-
was used to cover over the graft (figures 19, ery of the final prosthesis will be delayed until
20). The bone biopsy specimen showed active completion of orthodontic treatment. Stable
new bone formation (figure 21). Implants were bone height was observed radiographically
uncovered after four months healing and favor- after fourteen months in function (figure 25).

Sohn et al
Figure 28: Grafted gap between the elevated bone

Figure 26: 4mm vertical defect in the anterior maxilla. and basal bone after fixation of elevated segment with
microplate/microscrews.
Figure 27: 6mm vertical elevation was achieved after Figure 29: Resorbable membrane was used to cover the
piezoelectric sandwich osteotomies. graft.
Case report 3 A vestibular incision was made to expose the

A 48 year old male patient was referred to the labial surface of atrophic anterior maxilla. Two verti-
Department of Oral and Maxillofacial Surgery at cal and one horizontal complete osteotomies were
Catholic University Medical Center, Daegu, Korea created using a piezoelectric saw with minimal
for reconstruction of an atrophic alveolar ridge in injury of the palatal periosteum. The newly seg-
the anterior maxilla. The patient presented with sig- mented alveolar bone was then moved crestally to
nificant vertical alveolar deficiency (figure 26) and the bone level of adjacent teeth. The segmented
was treatment planned for a vertical ridge augmen- bone was secured with a microplate and screws
tation with our piezoelectric sandwich technique. (Jaeil Co, Seoul, Korea) (figure 27). Final position-
24 • Vol. 1, No. 3 • May 2009

Sohn et al
Figure 30: Note the favorable vertical augmentation after

5 months of healing.
Figure 32: Hematoxyline and eosin stain of bone core
biopsy. Note new bone formation.
Figure 31: Healing at 5 months. Note bone regeneration

in the graft site.
Figure 33: Grafting of exposed implant threads.
ing of the mobilized segment achieved 7mm of able temporary prosthesis was delivered and mod-
vertical gain. A mixture of allograft (Orthoclase® ified to avoid placing pressure on the healing graft.
II) and Ca-P nano-coated xenograft (BioCera TM, After 5 months of uneventful healing, the
Oscotec, Chunan, Korea) was condensed into the augmented ridge was reopened and the fixa-
gap between mobilized bone and the basal bone tion hardware was removed (figures 30, 31). A
(figure 28). A resorbable pericardium membrane biopsy specimen which was taken from the site
was then utilized to cover the entire graft and the of the sandwiched bone graft showed favorable
surgical site was sutured primarily with layered new bone formation (figure 32). Two conven-
sutures. (figure 29). After site closure, a remov- tional implants (Scewplant implant, ImplantDi-

Sohn et al
Figure 36: Removal of the mini-dental implant.
Figure 34: Radiograph of implants and graft.
Figure 37: Temporary prosthesis on the conventional

implants after four months of healing.
rect Co, USA) and one provisional mini-implant

(Mini-implant, Cowellmedi Co, Busan, Korea)
were placed into the grafted site. Although sig-
nificant vertical improvement of the augmented
site was achieved, some exposure of the buc-
cal implant threads remained. Bovine xenograft
mixed with centrifuge concentrated growth fac-
Figure 35: Immediate temporization using mini implant. tors to accelerate bone formation was grafted
as a first layer over the exposed implant threads
and gel conditioned allograft was grafted on top
of the first layer (figures 33, 34). Following pri-
26 • Vol. 1, No. 3 • May 2009

Sohn et al
mary closure, an immediate temporary fixed pros- of handling and showed extensive new bone
thesis was cemented on the provisional mini- bone formation.14,15 OrthoBlast II® contains
implant (figure 35). After an additional 4 months DBM, known for its ability to stimulate new
healing, the provisional mini-implant was removed bone formation and cancellous bone which is
(figure 36) and a temporary fixed prosthesis was known to provide an osteoconductive scaffold
seated on the conventional implants (figure 37). for bone deposition and remodeling. Further-
more, OrthoBlast II® incorporates DBM with a
Discussion reverse thermal poloxamer carrier. When dis-
Many clinicians have modified and further devel- solved in water at low ambient temperatures,
oped pedicled and interpositional bone grafts poloxamer is a fluid liquid. The retention and
since the late 1970s.9-12 Harle first reported the slow release of DBM and growth factors at the
use of the visor osteotomy to augment the atro- surgical site could enhance osteoinduction.16,17
phic mandible in 1975.9 He sectioned the man- The poloxamer is malleable at operating room
dible sagittally between the mental foramens temperatures, but hardens when placed in
and the pedicled bone segment was fixed with the operative site. Therefore, the graft shows
wires in a lifted position. Peterson et al modi- minimal loss through irrigation and suction.
fied Harle’s description of the visor in 1977.10 Sandwich osteotomy has been shown to
Stoelinga et al reported on the combination of be less subject to resorption than that of onlay
the visor osteotomy with the sandwich osteot- grafts by providing a greater vascular supply
omy interpositional bone grafting of the eden- to the inlay graft.18 The sandwich technique
tulous mandible in 1978.12 This study used is a simpler technique than distraction osteo-
autogenous iliac crest corticocancellous grafts genesis, but is advocated only when the mag-
placed in a subcortical position in the mandible. nitude of correction is small, in the order of 3
When grafting the space between elevated to 6 mm of vertical movement.19 Exceptional
bone segment and basal bone, various types of results of up to 10mm of vertical gain, how-
bone graft may be utilized. Both the mineralized ever, have been demonstrated in the ante-
allograft and the mineralized allograft mixed with rior mandible with sandwich augmentation.20
bovine bone used in this report showed favor- Complications such as nerve damage may
able new bone formation histologically after the occur as a result of the sandwich osteotomy
healing. Sohn et al reported on the efficacy procedure. Egbert and colleagues reported
of OrthoBlast II®, a synergistic combination of that the inferior alveolar nerve was located lin-
demineralized bone matrix (DBM) and can- gually in many atrophic mandibles and there
cellous bone in a reverse phase medium, and was insufficient space to make a sandwich
Tutoplast® cancellous microchips with sand- osteotomy lingual to the foramen without dam-
wich augmentation.13 This study reported an aging the nerve.21 Jensen noted that many
average of 20.6% new bone formation after patients may have some transient paresthesia
a short healing period. Other studies evaluat- post-surgically, the longest lasting six weeks
ing putty or gel conditioned allograft note ease and that the paresthesia was likely related to

Sohn et al
flap retraction of the mental nerve.3 Paresthe- Conclusion

sia can occurred by nerve trauma during tis- In this report, the sandwich technique with an
sue distraction and osteotomy. In this study, a interpositional mineralized allograft was a suc-
piezoelectric device was used for osteotomy in cessful procedure to augment vertical bony
order to reduce trauma to nerve and soft tissue. defects in the atrophic mandible and maxilla
Piezoelectric surgery makes highly controlled prior to the placement of implants. Piezoelectric
osteotomies and reduces damage to soft tissue osteotomy offered highly controlled osteotomies
and neurovascular bundle during osteotomy.5, 7-8, and preserved the lingual periosteum and soft
22
Nevertheless, temporary neurosensory distur- tissue during the procedure. Segmental bone
bance did occur in one patient from this study. segments demonstrated favorable bone regen-
Previous studies have clearly demonstrated eration whether fixed or not, but fixation cases
that fixation cases have shown less relapse showed less relapse of elevated alveolar bone
of the elevated bone than non-ficxtion case.13 than non-fixation cases. Additional studies with
Accordingly, fixation of the elevated alveo- long term follow up observation are warranted to
lar bony segement with microplates is recom- further evaluate the efficacy of this technique. ●
mended to prevent relapse of the elevated bone.
Disclosure 9. Harle F. Visor osteotomy to increase the absolute 17. Cheung S, Westerheide K, Ziran B. Efficacy of
The authors report no conflicts of interest with height of the atrophied mandible. J Maxillofac contained metaphyseal and periarticular defects
anything mentioned in this paper. Surg 1975 Dec; 3: 257. treated with two different demineralized bone
matrix allografts, Int Orthop 2003; 27: 56-59.
References 10. Peterson LJ, Slade E. Mandibular ridge
1. Jensen OT, Greer RO Jr, Johnson L, Kassebaum augmentation by a modified visor osteotomy: a 18. Massimo P, Massimo R. Localized alveolar
D. Vertical guided bone-graft augmentation preliminary report. J Oral Surg 1977; 35: 999- sandwich osteotomy for vertical augmentation of
in a new canine mandibular model. Int J Oral 1004. the anterior maxilla. J Oral Maxillofac Surg 1999;
Maxillofac Implants 1995 May-Jun; 10(3):335-44. 57: 1380-1382.
11. Harle F. A follow up investigation of surgical
2. Jensen OT. Distraction osteogenesis and its use correction of the atrophied alveolar ridge with 19. Jensen OT, Kuhlke L, Bedard JF, White D.
with dental implants. Dent Implant. 1999 May; visor osteotomy. J Maxillofac Surg 1979; 7: Alveolar segmental sandwich osteotomy for
10(5):33-36. 283-293. anterior maxillary vertical augmentation prior to
implant placement. J Oral Maxillofac Surg 2006;
3. Jensen OT. Alveolar segmental “Sandwich” 12. Stoelinga P, Tideman H, Beger J, de Koomen
64: 290-296.
osteotomies for posterior edentulous mandibular HA. Interpositional bone graft augmentation of
sites for dental implants. J Oral Maxillofac Surg the atrophic mandible: A preliminary report. J 20. Moon JW, Choi BJ, Lee WH, An KM. Sohn DS.
2006; 64(3): 471-475. Oral Surg 1978; 36:30-2. Reconstruction of atrophic anterior mandible
using piezoelectric sandwich osteotomy : A case
4. Misch CM. et al. Reconstruction of maxillary 13. Sohn DS, Shin HI, Ahn MR, Lee JS. Piezoelectric
report. Implant Dent; In press.
alveolar defects with mandibular symphysis grafts vertical bone augmentation using the
for dental implants; a preliminary procedural sandwich technique in an atrophic mandible 21. Egbert M, Stoelinga PJ, Blijdorp PA, de
report. Int J Oral Maxillofac Implants 1992; 7(3): and histomorphometric analysis of mineral Koomen HA. The “Three-piece” osteotomy and
360-366. allografts: Case reports series. Int J Periodontics interpositional bone graft for augmentation of the
Restorative Dent; In press. atrophic mandible. J Oral and Maxillofac Surg
5. Vercellotti T. Technological characteristics and
1986; 44: 680-687.
clinical indications of piezoelectric bone surgery. 14. Callan DP, Salkeld SL, Scarborough N.
Minerva Stomatol 2004; 53(5): 207-214. Histologic analysis of implant sites after grafting 22. Eggers G, Klein J, Blank J, Hassfeld S.
with demineralized bone matrix putty and sheets. Piezosurgery: an ultrasound device for cutting
6. Sohn DS. Sinus bone graft using piezoelectric
Implant Dent 2000; 9(1): 36-44. bone and its use and limitations in maxillofacial
surgery. J Oral & Maxillofacial Implantology 2003;
surgery, British J Oral and Maxillofac Surg 2004;
7(1): 48-55. 15. Babbush CA. Histologic evaluation of human
42(5): 451-453.
biopsies after dental augmentation with a
7. Sohn DS. Ahn MR, Lee WH, Lee JS. Piezoelectric
demineralized bone matrix putty. Implant Dent
osteotomy for intraoral harvesting of block bone.
2003; 4: 325-332.
Int J Periodontics Restorative Dent 2007; 27(2):
127-31. 16. Ziran B, Cheung S, Smith W, Westerheide
K. Comparative Efficacy of 2 different
8. Sohn DS. Color atlas, Clinical applications of
demineralized bone matrix allografts in treating
piezoelectric bone surgery, Koonja Publishing Co
long-bone nonunions in heavy tobacco smokers,
2008; 456-501.
Am J Orthop 2005; 34(7): 329-332.
28 • Vol. 1, No. 3 • May 2009

Sohn et al
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Rachlin et al
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BIO-IMPLANTS DIVISON
Rachlin et al
Modified Palatal Papilla
Construction Flap for
Aesthetic Second Stage
Implant Surgery
GD Rachlin, DDS1 • MN Pratt, DDS2 • JF Koubi, DDS3
Abstract
Background: The aim Papilla Index Score (PIS)
of this clinical case included: 1) Presence or
series is to describe lack of the papillae at
a surgical technique the time of the second
to create “papillae” stage surgery; 2) Pres-
around dental implants ence or lack of the papil-
when they are missing lae at delivery of the final
or when the initial hori- prosthetic restoration.
zontal ridge covering
the implant site is flat. Results: This surgi-
cal technique allows to
Methods: The described surgical technique uses obtain interdental-interimplant or interimplant tissue
the thick palatal connective tissue to recreate the looking like papillae in area where they are missing.
interdental papilla. 3 patients completed this case
series. One presented with a single tooth replace- Conclusions: Primary used for single tooth
ment while 2 other patients had two missing max- replacement, the technique is also predict-
illary anterior teeth. Recorded data based on able in the cases of multiple teeth replacement.
KEY WORDS: Dental implant, papilla, periodontal plastic surgery
1. Periodontist in private practice, Toulon, France

2. Periodontist in private practice, Toulon, France
3. Professor, Marseille University, Marseille, France

Rachlin et al
INTRODUCTION
Initially, implant treatment was a matter of func-
tion.1,2 As time went on, aesthetics became
equally important.3-5 In the anterior maxilla, the
aesthetic component of implant treatment is
often considered the most important criteria
for success.6 Many parameters are involved in
achieving this success: the residual bone quan-
tity, the first stage surgery, the second stage
surgery, and the final prosthetic restoration.
The purpose of this case reports is to
describe a second stage surgical technique for Figure 1: Frontal view of the 1st case at the second stage
surgery.
management of the interproximal soft tissue and
create, when necessary, interdental papillae.
The Papilla Index Score (PIS) used to measure
papillae was originally described by Jemt.7 This
technique can be used for single tooth replace-
ment as well as for multiple teeth replacement.
CASE 1: Technique for a

single implant
A 42-year-old male patient was referred for
implant surgery to replace a first right maxillary
incisor which was extracted due to root fracture.
The residual bone volume was adequate to place Figure 2: Occlusal view of the case at the second stage
the implant in a desirable position without using surgery.
regeneration techniques. After 6 months of fol-

low up, the second stage surgery was planned. and to create the papillae, two “S-shaped” pal-
At that time, the clinical observation revealed a atal incisions were developed and turned buc-
flat area between the 2 adjacent teeth and the cally (Figure 3). The cover screw was retrieved
mesial and distal PIS were 0 (Figures 1, 2). and healing abutment placed. The two rotated
palatal pieces of tissue were adjusted to fit
Surgical Procedure around the healing abutment and secured
A sulcular incision was made from the distal to by two mattress sutures to the buccal flap
the mesial aspect of the adjacent teeth and then which was apically positioned (Figures 4, 5).
crossed the edentulous ridge so that the buccal
part of the cover screw was uncovered when Results
the flap was raised. To retrieve the cover screw Healing was uneventful and a provisional resto-
32 • Vol. 1, No. 3 • May 2009

Rachlin et al
Figure 3: The buccal flap is open and the 2 S-shaped Figure 6: Frontal view of the provisional reconstruction.
palatal incisions developed.
Figure 4: The healing abutments positioning the 2 palatal

Figure 7: Final Implant-supported reconstruction. Note
pieces of tissue.
good topography of the papillae.
ration was rapidly made for patient convenience

(Figure 6). Upon delivery of the final implant-sup-
ported prosthesis, the mesial and distal papillae
were classified as PIS 3 respectively (Figure 7).
Figure 5: Mattress sutures are securing the buccal flap and

the palatal pieces of tissue.

Rachlin et al
CASE 2: Technique for Surgical procedure

adjacent implants The same incision was made as in the first
A 58-year-old female patient was referred for clinical case to uncover the buccal half of
implant surgery to replace 2 Maxillary incisors the cover screws (Figure 9). The mesial
which were lost secondary to periodontal prob- “S-shaped” incisions were rotated to form papil-
lems. In spite of this, the residual bone volume lae between the teeth and the implants while
was enough to place the implants in a good posi- the distal “S-shaped” incisions were sutured
tion without regeneration techniques. After 6 together, as in the double papilla technique,
months follow up, the second stage surgery was and rotated between the two implants. The
planned. At that time, the clinical observation flaps and the surgically created papillae were
showed a relatively flat ridge and the PIS Mesial secured by mattress sutures (Figures 10, 11).
to the adjacent teeth and at the inter-implant
site in the middle of the ridge were 0 (Figure 8).
Figure 8: Frontal view of the 2nd case at the second stage Figure 10: Healing abutments with the palatal pieces of
surgery. Note the flat ridge at the surgical site. tissue in place.
Figure 9: Buccal flap uncovering half of the cover screw. Figure 11: Notice the palatal tissue miming papillae
between the healing abutments.
34 • Vol. 1, No. 3 • May 2009

Rachlin et al
Results
Healing was uneventful and, as in the first
case, a provisional prosthesis was rap-
idly placed (Figure 12). Upon delivery of the
final implant-supported prosthesis, the papil-
lae were respectively classified as PIS 3.
Figure 13: The case at the second stage surgery.
Figure 12: Frontal view of the provisional restoration.

Interdental papilla is present between the 2 teeth.
CASE 3: Technique for

adjacent implants
A 25 year-old female patient was referred for
replacement of the two central maxillary inci- Figure 14: The buccal flap is open and the 2 palatal
sors which were lost due to trauma many years S-shape pieces of tissue are prepared to be sutured
ago. Upon referral presentation, she was wear- altogether.
ing a partial denture and the bone volume was
just enough to obtain a primary fixation of the ure 14), adapted to the healing abutments (Figure
implants. To resolve the buccal depression, an 15), and secured by mattress sutures. The buc-
autogenous bone graft obtained with a coagulum cal flap was apically positioned to give more thick-
trap was placed without a membrane and the sur- ness to the tissue around the implants (Figure 16).
gical area was gently closed with sutures. At the
second stage surgery the PIS were 0 (Figure 13). Results
Healing was uneventful and the final prosthetic
Surgical procedure reconstructions were made during the first month
After the intra sulcular buccal incision, papillae following surgery. The PIS between the two adja-
were created from the palatal aspect using the cent implants was 3, whereas the PIS was 2
previously described double papilla technique (Fig- between the implants and the teeth (Figure 17).

Rachlin et al
DISCUSSION
This second stage surgical technique allowed
aesthetic results with PIS generally higher than it
was recorded pre-operatively (Table 1). The ability
to regenerate or augment gingival tissue in a coro-
nal direction is difficult to perform successfully,8
although some authors have reported that without
reconstructive surgery there is interproximal tissue
redevelopment after 1 to 3 years.9 Unfortunately,
such long term results are unpredictable and are
the impetus for a number of surgical techniques
Figure 15: The 2 sutured pieces of tissue and healing for papillae reconstruction. Previously published
abutments in place. techniques for papillae reconstruction developed
papillae-like formations using the buccal flap.10, 11
In the present surgical technique, the buccal flap
was not split through its full thickness to create
the mesial and the distal papillae. Papillary recon-
struction tissue came from the thick palatal tissue
to reduce aesthetic risks to the buccal tissue. An
added benefit of this technique is peri-implant bone
coverage with soft tissue during the healing phase.
The papillae reconstructions presented in
the 3 clinical cases of this paper were achieved
no matter what the quality of the soft tissue pres-
Figure 16: Occlusal view of the sutures. ent. It seemed more difficult to gain soft tissue
and papilla-like formations between a tooth and
an implant than between two implants (Table
1). It was important to keep in mind that the
presence of the papillae is a function of the dis-
tance between bone and crown contact point.12
CONCLUSION
When flapless implant placement or single stage
implant placement is not possible, the technique
described in this paper allows: 1) preservation of
buccal keratinized tissue during the second stage
Figure 17: Frontal view of the interdental new Papilla.
surgery; 2) creation of papillae-like tissue origi-
nating from the palate to reduce the risk of buc-
36 • Vol. 1, No. 3 • May 2009

Rachlin et al
Table 1: Comparison of papilla index scores pre and post operatively.

(0: no papilla, 1: less than half a papilla, 2: half a papilla at least, 3: papilla)
Pre-Op Post-Op
Mesial Inter Implant Distal Mesial Inter Implant Distal
P nº1 0 - 0 3 - 3
P nº2 0 0 0 3 3 3
P nº3 0 0 0 2 3 2
cal tissue necrosis; 3) improved coverage of bone

surrounding the implant. This technique may be
used for either single or multiple implants. Dia-
grammatic depictions of the techniques described
in this paper are provided in figures 18-25. ●
Correspondence:
GD Rachlin, DDS
Phone: 04 94 92 21 11
e-mail: georges.rachlin@wanadoo.fr
Figure 19: Buccal flap open (technique for 2 implants).
Figure 18: Occlusal view of the incision (technique for 2

implants). Figure 20: Palatal flap positioning before suturing
(technique for 2 implants).

Rachlin et al
Figure 21: Occlusal view of the incision (technique for 1

implant).
Figure 24: Palatal mesial and distal positioning (technique
for 1 implant).
Figure 22: Buccal flap open (technique for 1 implant).
Figure 25: Papillae reconstructed before suturing

(technique for 1 implant).
Disclosure
The authors report no conflicts of interest with anything mentioned in this article.
Acknowledgement
The authors would like to thank Dr Guy Mouren for the drawings he provided for
this paper.
References
1. Adell R, Erikson B, Lekholm U, Branemark P, Jemt T. Long term follow-up study
of osseointegrated implants in the treatment of totally edentulous jaws. Int J
Oral Maxillofac Implants 1990; 5(4): 347-359.
2. Albreksson T, Senerby L. State of the Art in oral implants. J Clin Periodontol
1990; 18: 474-481.
3. Laney W, Jemt T, Harris D, Henry P, Krogh P, et al. Osseointegrated implants
for single tooth replacement: progress report from a multicenter prospective
study after 3 years. Int J Oral Maxillofac Implants 1994; 9(1): 49-54.
Figure 23: Palatal mesial laps positioning (technique for 1 4. Lazzara R. Managing the soft tissue margin: The key to implant esthetics. Pract
Periodontics Aesthet Dent 1993; 5(5): 81-87.
implant). 5. Garber D. The esthetic dental implant: Letting restoration be the guide. J Am
Dent Assoc 1995, 126(3): 319-325.
6. Reikie D. Restoring gingival harmony around single tooth implants. J Prosthet
Dent 1995; 74(1): 47-50.
7. Nemcovsky C, Moses O, Artzi Z. Interproximal papillae reconstruction in
maxillary implants. J Periodontol 2000; 71(2): 308-314.
8. Sullivan D, Kay H, Schwarz M, Gelb D. Esthetic problems in the anterior
maxilla. Int J Oral Maxillofac Implants 1994; 9: 64-74.
9. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J
Periodontics Restorative Dent 1997; 17(4): 327-333.
10. Palacci P. Peri-implant soft tissue management: Papilla regeneration
technique. In : Palacci P, Ericsson I, Engstrand P, Ranger B. eds. Optimal
implant positioning and soft tissue management for the Branemark system.
Chicago : Quintessence; 1995; 59-70.
11. Adriaenssens P, Hermans M, Ingber A et al. Palatal sliding stip flap soft tissue
management to restore maxillary anterior esthetics at stage 2 surgery: A
clinical report. Inter J Oral Maxillofac Implants 1999, 14 30-36.
12. Tarnow D, Magner AW, Fletcher P. The effect of the distance from the contact
38 • Vol. 1, No. 3 • May 2009 point to the crest of the bone on the presence or absence of the interproximal
dental papilla. J. Periodontol 1992, 63: 995-996.
Rachlin et al
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Soto et al
Preliminary List of Invited Speakers

Dr Paulo Coelho, USA Dr Michael Pikos, USA
Dr Matteo Danza, Italy Dr Paul Rosen, USA
Dr Scott Ganz, USA Dr Philippe Russe, France
Dr Robert Horowitz, USA Dr Maurice Salama, USA
Dr Jack Krauser, USA Dr Marius Steigmann,Germany
Dr Ziv Mazor, Israel Dr Tiziano Testori, Italy
Prof Adriano Piattelli, Italy Dr Tomaso Vercellotti, Italy
Secretariat
Paragon Conventions
18 Avenue Louis-Casai, 1209 Geneva, Switzerland
Tel: +41-(0)-22-5330-948, Fax: +41-(0)-22-5802-953
Email: fti@ftidental.com
Soto et al
Treatments and Treatment
Outcomes in Patients
with Oral Lichen Planus
Abigail Soto1• Celeste M. Abraham DDS, MS2 • Terry D. Rees DDS, MSD3
Abstract
Background: The aim of this study was to review ment options. Other topical agents included retin-
the clinical characteristics of biopsy proven oral oids, tacrolimus and pimecrolimus. Fluocinonide
lichen planus (OLP), the therapeutic methods used gel was most often prescribed followed by clobeta-
and treatment outcomes achieved in 100 individu- sol gel. Complete resolution occurred in 5 patients,
als referred to a tertiary care center and followed complete resolution followed by recurrence in 10
for up to 4 and one-half years after diagnosis. patients, partial remission in 52 patients and no
change in 4 patients. No clinical information was
Methods: Retrospective data were collected available on the rest. Partial remission and complete
from records of patients with biopsy proven OLP. resolution were achieved most often using topical
Records were consecutively selected from indi- corticosteroids. Twenty-five percent of patients
viduals who received diagnosis and treatment developed oral candidiasis in association with topi-
for OLP between Jan 2004 and July 2008 in the cal therapy. Twelve percent of patients had concom-
Stomatology Center, Baylor College of Dentistry. itant LP lesions on either skin, genitalia, or scalp.
Collected data was recorded in a standardized
table and included: Patient record number, location Conclusion: Topical corticosteroid therapy
of OLP lesion(s), type of OLP, other oral mucosal is usually successful in achieving satisfactory
diseases, concomitant lesions in other parts of the results in OLP patients who comply with rec-
body, treatment(s) used, and treatment results. ommended treatment regimens and clinical
follow-up. Some individuals using topical corti-
Results: Reticular OLP lesions were most fre- costeroids intraorally develop secondary oral can-
quently observed, usually occurring concomitantly didiasis and prophylactic antifungal therapy may
with erosive lesions. Treatment most commonly be indicated. Finally, lack of patient compliance
used was topical corticosteroids (89 times) often in is a deterrent to long-term treatment success.
conjunction with palliative treatment or other treat-
KEY WORDS: Lichen planus
1. Student Dentist, Baylor College of Dentistry, Texas A&M Health Science Center
2. Assistant Professor, Periodontics, Baylor College of Dentistry, Texas A&M Health Science Center
3. Director of Stomatology, Baylor College of Dentistry, Texas A&M Health Science Center

Soto et al
Introduction
Oral Lichen Planus (OLP) is a chronic inflam-
matory disease that affects the oral mucous
membranes and gingiva. The etiology of OLP is
unknown, however it has been associated with
several systemic diseases including hypertension,
diabetes mellitus, and hepatitis B, but no constant
relationship has been found.1 In some parts of the
world (Italy, southern Europe, Japan, and other
countries) OLP is relatively strongly associated
with chronic hepatitis C infection.2 There are also
well recognized oral lichenoid reactions that clini- Figure 1: Reticular pattern of oral lichen planus on
cally, histologically, and by direct immunofluores- dorsum of tongue.
cence resemble idiopathic OLP. They result from
hypersensitivity to dental materials or initiated by
exposure to a wide range of identified drugs most
commonly, anti-malarials, non-steroidal anti-inflam-
matory agents, or antihypertension mediciments.3,4
OLP is a relatively common disease, seen
in about 2% of the general population.5 It may
present in several forms as classified by Andrea-
son. Among them are reticular, papular, plaque-
like, atrophic, bullous, and ulcerative.6 The
atrophic, ulcerative, and bullous forms feature tis- Figure 2: Non-elevated, painless plaque-like oral lichen
sue destruction and pain and are often grouped planus of lower labial mucosa.
together as erosive lichen planus.7 Conversely
the reticular, plaque-like, and papular forms may represent transition from the reticular to one of the
be asymptomatic.8 Reticular OLP is the most erosive forms (figure 3).10 Bullous OLP is rare; it
common clinical presentation. It is easily diag- presents with vesicles or bullae that may range
nosed because it consists of raised, thin, white in size from 4mm to 2cm.10 The blisters may rup-
lines connected in arcuate patterns with a lace- ture fairly quickly, leaving a painful atrophic or
work appearance against an erythematous back- ulcerative lesion. The ulcerative form of OLP fea-
ground (figure 1).9,10 These interconnected white tures painful, irregular and persistent ulcerations
lines are known as Wickham’s striae.9,10 Papular (figure 4). On many occasions multiple forms of
OLP presents as white painless papules without OLP may be present simultaneously (figure 5).
Wickham’s striae, while the plaque-like form is a A variety of treatment modalities have been
white raised or flattened leukoplakia-like lesion described for management of OLP. The most
(figure 2). Atrophic LP is erythematous and may frequently used options are topical steroids, local-
42 • Vol. 1, No. 3 • May 2009

Soto et al
Figure 5: Combined ulcerative, atrophic and plaque-like

forms of OLP on dorsum of tongue.
Figure 3: Atrophic (erythematous) lichen planus lesion of cal corticosteroids such as triamcinolone, potent
right cheek mucosa. fluorinated steroids such as fluocinonide, and
superpotent halogenated steroids such as clo-
betasol, betamethasone, or halobetasol.11-13 Other
topical therapies that have been recommended
include, cyclosporine, Dapsone, griseofulvin, tac-
rolimus, pimecrolimus, immunosupressants, immu-
nomodulatory agents, or retinoids.11 It is probable
that topical corticosteroids are most often pre-
scribed to treat OLP. The drugs are relatively
safe, although an observed side affect of topical
steroid use has been development of secondary
oral candidiasis.14,15 Therefore it is sometimes
recommended that clinicians also prescribe an
anti-fungal medicament when treating with topi-
Figure 4: Ulcerative OLP lesion on right corner of mouth. cal corticosteroids.15 Systemic corticosteroids
such as Prednisone® are frequently prescribed
ized injectable steroids, and systemic steroids. when topical steroids have failed.11 Since sys-
Topicals range in potency and are available as temic corticosteroids can have adverse side
ointments, creams, gels, sprays, rinses, or other effects, they are usually prescribed at low doses
forms.11-13 For example, there are midpotency topi- and for short periods of time. Localized inject-

Soto et al
Table 1: Data Collection Form

Record # Location Other Oral Concomitant Treatment Results Type of
Diseases LP Lesions OLP
able steroids such as triamcinolone acetonide number of studies and case reports have indicated
may be effective in managing localized erosive that individuals with OLP may be at slightly higher
lesions.16 They too are administered in small risk of developing squamous cell carcinoma.18
dosages and for short periods of time so they The aim of the present study was to review
will not cause an unwanted systemic response. therapeutic methods and treatment out-
OLP can be associated with extra-oral con- comes achieved in a group of 100 individu-
comitant lesions up to 15% of the time.17 Mucosal als with biopsy proven OLP patients who were
lesions are found throughout the oral cavity and followed for up to 4 years after diagnosis.
almost always have a bilateral symmetrical dis-
tribution. Different forms of OLP may co-exist.9 Methods
When OLP is not displayed in its clinical reticular Retrospective data were collected from patient
form, a histological confirmation may be needed records of 100 individuals with OLP who were
to establish diagnosis and direct immunofluores- diagnosed and treated in the Stomatology Cen-
cence studies may provide additional diagnostic ter, Department of Periodontics, Baylor College
information.7 A biopsy is also useful to identify of Dentistry TAMHSC, Dallas, Texas. Involved
dysplasia or malignancies that may have lichenoid patients had previously granted permission to use
features.8,9,11 Although the issue is controversial, a data relative to their clinical visits and treatment
44 • Vol. 1, No. 3 • May 2009

Soto et al
and no individuals were identified by name. Eli- Results

gibility was limited to those patients that did not Chart 1: Includes the compiled data and types
display other types of chronic autoimmune dis- of treatments used and their frequency of use.
ease of the lining of the mouth. The 100 records Therapies included topical, systemic, intra lesional
were consecutively selected from individuals who corticosteroid injection, laser treatment, retinoids,
had received diagnosis and treatment between and other treatment options such as diet modifica-
Jan 1, 2004 and July 29, 2008. All patients had tion .i.e. cinnamon free or sodium benzoate free
histopathologically confirmed OLP based on diets and changes in physician prescribed medi-
established histologic diagnostic criteria. The cation with medical approval. The chart also dis-
oral examinations were performed by Periodon- plays the number of times palliative treatments
tics residents/faculty and recorded in a specially were used (including changes in toothpaste and/
designed record used in the Stomatology Cen- or mouthrinses) in conjunction with the therapies
ter. After collection, the data was recorded in a listed above. The number of times other multiple
standardized table (table 1). Information gath- types of treatment were used simultaneously was
ered from patient records included the follow- also recorded. For example the simultaneous
ing: patient record number, location of the OLP use of a topical medication and an intra-lesional
lesion(s), type of OLP found, other oral diseases corticosteroid injection. Chart 2 shows the num-
such as oral candidiasis, concomitant lesions of ber and types of topical agents that were used
LP in other parts of the body, treatment(s) used, to treat OLP. These include Temovate®, Lidex®,
and results of the treatment. Therapeutic out- Diprolene®, Protopic®, Elidel®, Dexamethasone
comes were assessed by the following criteria: Elixir®, DesOwen® and their generic forms. Chart
● CR (complete resolution): Patient 3: Displays the type and number of times pallia-
records showed no signs or symptoms tive treatment was used in conjunction with the
of OLP lesions at follow up visits. main treatment for OLP. Chart 4: Shows the cli-
● PR (partial remission): Patient records nician determined treatment outcome. Graph
showed a reduction in the symptoms 1 shows treatment used and drug used to treat
and/or improvement in the lesions. the patient and reach a partial remission of OLP.
● NC (no change): Patient records showed no Graph 2 shows the number of cases determined
improvement or worsening of the lesions. to have had complete resolution and the agents
● R EC (recurrent): Patient records showed used to reach this outcome. In 35 patients no
lesions that disappeared for a period of treatment results were available because the
time but subsequently returned with same patient did not return for follow up. Attempts were
intensity, higher intensity, or less inten- made to contact all 35 individuals to offer them the
sity than the first lesions treated. opportunity to return for an oral evaluation, how-
● N I (no information available): Patient records ever not all were reached. Six patients agreed to
did not show the results of treatment. return for evaluation, and ten of those contacted
The information on the table was then declined the opportunity to return. These ten
compiled into charts for comparison. patients reported their status over the telephone.

Soto et al
Chart 1: Treatments Used Chart 2: Topicals Prescribed
1% 1% 3%1% 2%
1% 5%
20%
30%
39%
6%
57%
28%
2%
1% 2%
Data representing the chart Data representing the chart
● Topical 89 ● Temovate® (clobetasol propionate) 34
● Systemic Steroid 6 ● Lidex® (flucinonide) 64
● Intralesional Corticosteroid 4 ● Diprolene® 2
injection (betamethasone dipropionate)
● Laser treatment 2 ● Protopic Ointment® (tacrolimus) 6
● Simultaneous treatments used 65 ● Elidel cream® (pimecrolimus) 3
● Other (diet mod. & Rx change) 13 ● Dexamethasone Elixir® 1
● Palliative 45 ● DesOwen® (desonide) 2
● Retinoids 2
Percent of times a particular topical medication was
● No Treatment 3
prescribed in patients who received topical treatment.
Percent of times the particular treatment was used in a Data includes patients treated with more than one topical
patient pool of 100. medication.
Nineteen patients were never reached. Graph 3 ment that was used for those particular patients.
shows the telephonic patient reported treatment Twenty-five percent of patients developed
outcome. Graphs 4-5 show more specifically the oral candidiasis in association with topical
patient reported outcomes and the type of treat- therapy, and 3% of patients were treated pro-
46 • Vol. 1, No. 3 • May 2009

Soto et al
Chart 3: Palliative Treatment Chart 4: Clinically Determined

Treatment Outcome
1%
4%
21%
45%
54%
11% 58%
6%
Number of times palliative Data representing the chart

treatment was prescribed ● Partial remission 52
● Chlorhexidine 30 ● Complete remission 5
● Biotene products 36 ● Recurrent 10
● Children’s toothpaste 1 ● No information available 19
● No change seen 4
Palliative treatment was used 45 times. Data includes those Note: The numbers do not add to 100 because 10
who were treated with more than one. patients reported their treatment outcome over the
telephone and was not determined by a clinician.
phylactically with antifungals. Nystatin® was
prescribed 75% of the time, Diflucan® 21% of Treatment outcome in 100 patients.
the time, and Clotrimazole® 4% of the time.
Reticular OLP was the most commonly seen than one type of OLP was recorded as mixed
type (n=68). This was followed by the ulcer- (n=58) and not specified (n=4), Graph 6.
ative form (n=39) and the erythematous/atro-
phic form (n=39). The plaque like form (n=16) Discussion:
and the papular form (n=4) were less com- In this study 82 out of 100 patients were
mon and no patient presented with the bullous females with an average age of 54. 12% of
form. The number of patients that had more the patients reported concomitant LP lesions

Soto et al
Graph 1: Clincally Diagnosed Partial Remission and Treatment Method

50
31
9
2 1 2
Topical Diet/Rx Palliative Laser Intralesional Systemic
modification
These numbers are based on the 52 patients with clinician reported Partial Remission (PR). The
numbers are based on all the treatments options. Some patients utilized more than one treatment
method. Palliative treatment was never used alone to reach PR, it was always used in conjunction
with another treatment method.
Graph 2: Clincally Diagnosed Complete Resolution and Treatment Type Used

5 2
1
Topical Intralesional Palliative
Five patients were reported by dental professionals to have complete resolution (CR) on follow-up
examinations greater than 3 weeks from previous examination. The numbers are based on all treatment
options. Some patients utilized more than one treatment method. Palliative treatment was never used
alone to reach CR.
on skin (n=26), genitalia (n=3), combination Additionally, prescription drug changes were also
of skin and genitalia (n=3), and scalp (n=1). sometimes recommended and changed by the
As defined in the exclusion criteria, none of patient’s physician. More than one treatment was
the patients suffered from other chronic auto- used more than half the time, usually by combining
immune diseases of the lining of the mouth. topical or systemic or intra-lesional injection with
The most common treatment used in this palliative or diet modifications. On three occa-
patient population was topical corticosteroid. It sions, patients did not receive any treatment as
was frequently used in conjunction with a palliative shown in Chart 1. These 3 patients did not return
treatment and, at times, with diet modification such after the initial appointment during which a biopsy
as a cinnamon free or a sodium benzoate free diet. was performed and diagnosis established. Chart
48 • Vol. 1, No. 3 • May 2009

Soto et al
Graph 3: Patient Reported Treatment Outcome
3 5 2
No change seen Complete Resolution Partial
Remission
Efforts were made by telephone to contact 35 patients who had not been seen recently. 10 of the 35
who could not return for evaluation were reached and asked to rate their degree of improvement
since their last treatment visit. Responses were recorded.
Graph 4: Patient Reported Partial Remission and Treatment Used
2 1
Topical Palliative
Two individuals reached by telephone reported only partial remission. One patient used a topical
only and the other used a topical in conjunction with a palliative treatment which included
Biotene toothpaste.
2 shows Lidex® (fluocinonide gel) as the most noted at follow-up appointments. One patient
commonly prescribed topical agent in our clinic, had not used any treatment since her last recall
followed by Temovate® (clobetasol). There were visit, while a second patient showed no change
five instances in which Lidex® was changed to a but was asymptomatic. This second patient was
more potent corticosteroid such as Temovate®. followed from November 15, 2003 until May 1,
However, in one particular case, a patient asked 2008. He never experienced ulcerations and
for the change because she disliked the flavor he showed no discomfort although lesions con-
of the topical Lidex®. In another case, a change tinued to be present. A third patient was not
was made from Dexamethasone Elixir® to Temo- compliant with the prescribed treatment as she
vate®. Palliative treatments (Chart 3) were never reported using the topical medicament one to
used as the primary means of treatment. Many two times weekly instead of daily; she reported
times a specially prepared 0.2% chlorhexidine in no discomfort and no erosions. The fourth patient
water mouthrinse was prescribed along with bland attended only two appointments and at her
toothpaste such as Biotene. On occasion, other request, was referred to her dentist for follow up.
alcohol-free mouthrinses were recommended. Partial remission was most often seen in this
In 4 patients, no change in OLP status was study mainly after use of a topical agent which

Soto et al
was often accompanied by palliative treatment. could have played a role since occasional lichenoid
Partial remission was also seen after other types drug reactions have been reported among indi-
of treatments such as diet modification, prescrip- viduals using a number of different medications.3
tion drug changes, laser treatment, intra-lesional Our data affirms that reticular OLP is the
injections, and systemic corticosteroids as seen most common single type of OLP, although
in Graph 1. On the other hand, complete reso- it often is present in conjunction with vari-
lution was also seen most often with the use of ous other types. Most OLP lesions observed
a topical agent. Patients in this group also may were ulcerative or atrophic compared to white
have received more than one type of treatment lesions (reticular, plaque like, papular). Only
such as topical, palliative and/or local injection. 28 patients exclusively displayed white lesions.
Among the 10 patients that gave their sta- However, it should be noted that the Stomatol-
tus over the telephone (Graph 3) 5 stated that ogy Center is a referral center and it is probable
they did not return because they had completely that patients with severe discomfort or severe
healed, 3 said they noticed no change in their lesions are most likely to be scheduled. Conse-
lesions, and 2 reported partial remission. It is quently, the disease types described here do not
not known why the remaining 19 patients did not necessarily represent a true picture of the oral
return for follow up after diagnosis of OLP and we manifestations of patients with lichen planus.
have no information for this group. The patients The patient records reviewed in this paper
that reported partial remission and complete res- document outcome findings for up to 4½ years
olution over the telephone were also treated by after the original histologically confirmed diag-
topical agents in conjunction with other, mostly nosis of OLP. Overall, only 5% of patients were
palliative treatments. The patients that reported confirmed to have complete remission at the time
complete resolution over the telephone had ero- of data collection while 10% had remission fol-
sive LP (n=2), ulcerative LP (n=1), and mixed lowed by recurrent lesions. No information was
LP (n=2). Those that reported partial remis- available on 19% of study participants. In con-
sion had reticular LP (n=1) and mixed LP (n=1). trast, a previous record review conducted in the
In a 1988 report on long term treatment out- Stomatology Center (Stomatology Center, Baylor
comes among 611 OLP patients, Thorn et al19 College of Dentistry Unreported data 1989) eval-
described a small percentage of patients who uated treatment outcomes in 282 patients with
apparently experienced spontaneous remission OLP who were followed for less than 1 year. A
of OLP, however for the most part, we did not much higher percentage (49%) of those patients
observe this in our patients. There was one patient achieved complete remission of erosive lesions at
who returned to our clinic after 4 years and was some point in their therapy while under intensive
free of lesions. He stated he hadn’t returned previ- care. In this intensive care approach, treatment
ously because he had healed within a month after was modified as necessary and compliance was
sparingly using a topical medicament and after stressed during frequent recall appointments and
stopping the use of Vioxx®. Vioxx® discontinuation therapy was usually continued until success was
50 • Vol. 1, No. 3 • May 2009

Soto et al
Graph 5: Patient Reported Complete Resolution and Treatment Used
5 4
1
Topical Palliative Diet
Modification
Five individuals reached by telephone reported complete remission. All five patients used some type
of topical, 4 used a palliative treatment in conjunction with the topical and one patient also used a
cinnamon free diet thereby eliminating a contact OLP.
Graph 6: OLP Type

69
58
39 39
16
4 4
Ulcers Reticular Plaque Atrophic Papular Mixed Not
Specified
Four records out of 100 did not clearly specify what type of LP was present. The term Erosive was
occasionally used as a generalization of atrophic and/or ulcerative LP.
achieved or patients declined to return. Com- in the current study. Current study data also
parison of data from the two reviews suggest that suggests that patients who do not comply with
patients with chronic persistent mucosal diseases long-term (6 month to 1 year) maintenance care
such as OLP may lose motivation to perform sin- experience less satisfactory therapeutic outcomes.
gle or multiple daily treatment procedures over The data also indicates that the majority of
time and that they tire of keeping frequent recall patients with OLP do not achieve complete remis-
appointments. They tend to discontinue therapy sion. Because we don’t know the exact cause of
once a satisfactory level of comfort has been OLP, it is imperative that we help reduce the symp-
achieved. It should be noted, however, that recall toms of this disease to help improve the quality of
visit fees were markedly increased during the life of these patients. Therefore, the patient must
years between the two reviews and it is probable be educated on the treatment and advised on how
that financial concerns may have negatively influ- to regularly carry out their treatment regimen. The
enced recall compliance among patients included resolution or remission of OLP heavily depends on

Soto et al
the instructions given to the patient and carried out part, those who were compliant and returned
by them. The patient should be advised that OLP for follow-ups reached partial remission. It was
can recur and/or may persist for many years.20 also seen that when treating OLP, a palliative
treatment in conjunction with a topical corticos-
ConclusioN teroid may help alleviate pain and improve the
This study gives some evidence that topical quality of life for the patient. The study finds
corticosteroid therapy is usually successful in evidence that reticular LP is the single most
achieving satisfactory treatment results, how- common type of OLP, however it is often seen
ever no single treatment should be expected to along with other LP types. Our numbers were
be successful in all OLP patients. OLP patients also small for complete remission and no com-
should return for follow ups when lesions are plete remission was seen without treatment. ●
painful and the clinician should modify therapy
as necessary. When applying therapy, it is unre- Correspondence:
alistic to believe complete long-term remission
Dr. Celeste Abraham
will be achieved. The patient should be taught
Baylor College of Dentistry, Texas
that any completely or partially successful treat-
ment modality may be followed by recurrences A&M Health Science Center
and that they should seek treatment for manage- 3302 Gaston Ave. Dallas TX 75246
ment of recurrent lesions. It is also seen that Telephone: 214-828-8467
patients are often not fully compliant and com- FAX: 214-874-4563
pliance may depend on the degree of patient e-mail: cabraham@bcd.tamhsc.edu
discomfort being experienced. For the most
Disclosure 8. A nonymous. Oral Features of Mucocutaneous 15. Jainkittivong A, Kuvatanasuchati J, Pipattanagovit

The authors report no conflicts of interest disorders. J Periodontol. 2003 Oct;74(10): P, Sinheng W. Candida in oral lichen planus
with anything mentioned in this paper. 1545-56. patients undergoing topical steroid therapy. Oral
9. Al-Hashimi I, Schifter M, Lockhart PB, et al. Surg Oral Med Oral Pathol Oral Radiol Endod.
References:
Oral lichen planus and oral lichenoid lesions: 2007 Jul;104(1): 61-6. Epub 2007 Jan 29.
1. Kirtak N, Inalöz HS, Ozgöztasi , Erbağci Z. The
diagnostic and therapeutic considerations. Oral 16. J. Philip Sapp, Lewis R. Eversole, George P.
prevalence of hepatitis C virus infection in patients
Surg Oral Med Oral Pathol Oral Radiol Endod. Wysocki, Contermporary Oral and Maxillofacial
with lichen planus in Gaziantep region of Turkey.
2007 Mar;103 Suppl:S25.e1-12. Epub 2007 Pathology (St. Louis, Missouri: Mosby, 1997),
Eur J Epidemiol. 2000;16(12): 1159-61.
Jan 29. 258-259.
2. Carrozzo M. Oral diseases associated with
10. J. Philip Sapp, Lewis R. Eversole, George P. 17. Eisen D. The evaluation of cutaneous, genital,
hepatitis C virus infection. Part 2: lichen planus
Wysocki, Contermporary Oral and Maxillofacial scalp, nail, esophageal, and ocular involvement
and other diseases. Oral Dis. 2008 Apr;14(3):
Pathology (St. Louis, Missouri: Mosby, 1997), in patients with oral lichen planus. Oral Surg
217-28. Epub 2008 Jan 22.
258-259. Oral Med Oral Pathol Oral Radiol Endod. 1999
3. Wright JM. Oral manifestations of drug reactions.
11.Scully C, Carrozzo M. Oral mucosal disease: Oct;88(4): 431-6.
Dent Clin North Am 1984 Jul;28(3): 529-43.
Lichen planus. Br J Oral Maxillofac Surg. 2008 18. S. Gandolfo, L. Richiardi, M. Carrozo, R.
4. Eversole LR, Ringer M. The role of dental
Jan;46(1): 15-21. Epub 2007 Sep 5. Broccoletti, M. Carbone, M. Pagano, C. Vestita,
restorative metals in the pathogenesis of oral
12. Lozada-Nur F, Miranda C, Maliksi R. Double- S. Rossso, F. Merleti, Risk of squamous cell
lichen planus. Oral Surg Oral Med Oral Pathol.
blind clinical trial of 0.05% clobetasol propionate carcinoma in 402 patients with oral lichen
1984 Apr;57(4): 383-7.
(corrected from proprionate) ointment in planus: a follow-up in an Italian population ral
5. Axéll T, Rundquist L. Oral lichen planus a
orabase and 0.05% fluocinonide ointment in Oncology (2004) 40: 77-83. Oral Oncol. 2004
demographic study. Community Dent Oral
orabase in the treatment of patients with oral Oct;40(9): 964.
Epidemiol. 1987 Feb;15(1): 52-6
vesiculoerosive diseases. Oral Surg Oral Med 19. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ.
6.Andreason JO. Oral lichen planus: a clinical
Oral Pathol. 1994 Jun;77(6): 598-604. Course of various clinical forms of oral lichen
evaluation of 115 cases. Oral Surg 1968;25:
13. Thongprasom K, Luengvisut P, Wongwatanakij planus. A prospective follow-up study of 611
31-41.
A, Boonjatturus C. Clinical evaluation in patients. J Oral Pathol. 1988 May;17(5): 213-8.
7. Toscano NJ, Holtzclaw DJ, Shumaker ND,
treatment of oral lichen planus with topical 20. Vincent SD, Fotos PG, Baker KA, Williams TP.
Stokes SM, Meehan SC, Rees TD. Sugical
fluocinolone acetonide: a 2-year follow-up. J Oral Oral lichen planus: the clinical, historical, and
Considerations and Management of Patients with
Pathol Med. 2003 Jul;32(6): 315-22. therapeutic features of 100 cases. Oral Surg
Mucocutaneous Diseases.In Press. Compend
14. T. Lehner and C. Lyne, Adrenal function during Oral Med Oral Pathol. 1990 Aug;70(2): 165-71.
Cont Ed Dent. 2009
topical oral corticosteroid treatment, Br Med J 4
(1969), pp.138-141. View Record in Scopus ,
Cited By in Scopus (11).
52 • Vol. 1, No. 3 • May 2009

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Suzuki et al
Suzuki et al
Classification of Single Tooth
Edentulous Ridges with Augmentation
Recommendations for Dental
Implant Treatment
Masana Suzuki1,2 • Yorimasa Ogata2
Abstract
Background: The goal of implant therapy is to Results: The morphology of soft tissues of eden-
achieve both functional and cosmetic improve- tulous ridges is closely related with cosmetic
ments. Dental implantation into defective alveo- conditions. If alveolar ridges are horizontally or
lar ridges should be performed with more caution perpendicularly below level lines, soft tissue aug-
than treatment using a fixed partial denture or mentation will be necessary. If implantation into
bridge. To prepare dental implants with biologi- alveolar ridges with more than 2 mm of bone on
cal stability and optimal function, it is necessary the buccal is considered as the standard, bone
not only to establish appropriate conditions for augmentation is necessary in edentulous front
prostheses but also to consider how they blend in teeth. Hard tissue augmentation is performed
with surrounding periodontal tissues. There have when bone defects are large from the level line.
been several studies on the classification of par-
tially edentulous alveolar ridges, but most of them Conclusions: In this study, we propose
reported simple ridge-defect patterns alone. Such new classification for single-tooth edentu-
classifications may not provide enough informa- lous ridges clinically, which include treat-
tion for making dental implant treatment plans. ment procedures of ridge augmentation for
dental implant treatment in such regions.
Methods: To prepare a classification includ-
ing treatment methods of single-tooth eden-
tulous ridges, we evaluated the shape of
alveolar ridges according to a combination of
the horizontal and perpendicular conditions.
KEY WORDS: Dental implant, edentulous, alveolar ridge augmentation, classification
1. Suzuki Dental Clinic, private practice, Tokyo, Japan

2. Department of Periodontology, Nihon University School of Dentistry at Matsudo, Matsudo, Chiba, 271-8587, Japan.

Suzuki et al
Introduction alveolar ridges with implant treatment. Seib-

Recently, dental implant treatment has become ert classified partially edentulous ridges into 3
clinically indispensable and this method is groups: horizontal, perpendicular and mixed
applied to patients with various complicated defects.1 Allen et al divided partially edentu-
dental conditions. Unfortunately, however, there lous ridges, in addition to Seibert’s classifica-
are patients in whom functional and cosmetic tion, into mild (< 3 mm), moderate (3-6 mm) and
failures result. Such failures are generally con- severe (> 6 mm) groups, based on the sever-
sidered to be caused by technical insufficiency ity of defects for the reconstruction of partially
and a lack of experience. Perhaps these cases edentulous ridges using soft tissues.2 While
would not have been attempted had there there are several reports for the classification of
been an appropriate classification system that edentulous ridges, treatment methods accord-
combines description of partially edentulous ing to the classification are not indicated.3-5
Figure1: Horizontal and perpendicular conditions of single-tooth edentulous ridge.
56 • Vol. 1, No. 3 • May 2009

Suzuki et al
Table 1: Augmentation for Ridge Type

Convex Level Concave
No Augmentation Soft Tissue or
Hill No Augmentation or Hard Tissue or
Hard Tissues Soft & Hard Tissues
No Augmentation Soft Tissue Soft Tissue
Level or or or
Soft Tissue Soft & Hard Tissues Soft & Hard Tissues
Soft Tissue
Valley Soft & Hard Tissues or Soft & Hard Tissues
Soft & Hard Tissues
With the development of dental implants, the ing to the combination of horizontal and perpen-
classification of alveolar ridges without soft tissues dicular conditions. The line between the existing
has been reported.6,7 From the same viewpoint bilateral teeth adjacent to an edentulous site
as Seibert, Wang and Al-Shammari proposed a was defined as the “level line” and single-tooth
clearer classification of alveolar ridges as the hori- edentulous ridges were classified accord-
zontal, vertical and combination (HVC) classifica- ing to horizontal and perpendicular conditions.
tion, and indicated surgical methods appropriate
for the classes.8 In this classification, implants Classification methods
and fixed partial dentures are individually divided, In the horizontal condition, the line between the
indicating the usefulness for the determination of labial necks of the existing bilateral teeth adja-
treatment strategies. However, there have been cent to an edentulous site was defined as the
no classifications that show methods for the mea- level line, as shown in figure 1a. Alveolar ridges
surement of defects. It is considered necessary were defined as “Convex type” when they were
to change the evaluation methods depending on positioned on the labial side from the level line
single and multiple-tooth defects. In this study, and “Concave type” when they were positioned
we propose a new method for the classification on the lingual side from the level line. In the
of single tooth edentulous ridges and evaluate vertical condition, the line between the lowest
treatment methods based on this classification. points of the gingival scallop by clinical obser-
vation of the existing bilateral teeth adjacent to
Material and Methods an edentulous site was defined as the level line,
Level line as shown in figure 1b. Alveolar ridges were
To prepare a classification including treatment defined as “Hill type” when their lowest points
methods of single-tooth edentulous ridges, we were positioned on the coronal side from the
evaluated the shape of alveolar ridges accord- level line and “Valley type” when they were posi-

Suzuki et al
Concave-H Concave-L tioned on the apical side from the level line. We
summarized the several methods for treatment of
edentulous ridges according to the combination
of the horizontal and perpendicular conditions.
Results
To indicate appropriate surgical methods
according to the horizontal and perpendicular
conditions, we summarized the results in Table
1. For example, edentulous ridges are class
Convex-H if they are Convex and Hill types
and class Concave-H or Concave-L if they are
Concave and Hill or Concave and Level types
(figure 2). If edentulous ridges are classified
into the level types by both horizontal and per-
pendicular conditions, they are class Level-L.
Treatment methods are determined
according to classification. Table 1 sug-
gests treatment methods according to the
horizontal and perpendicular conditions. In
other words, there are several methods for
the implant treatment of edentulous ridges.
No ridge augmentation
In alveolar ridges with a sufficient width and
height, which are generally included in class
Convex-H, implant treatment is possible without
ridge augmentation. However, since bone con-
ditions cannot be evaluated by observing soft
tissues, ridge augmentation may be required
in class Convex-H ridges, and if marked bone
defects are detected, hard tissue ridge augmen-
tation is performed. Naturally, there is a differ-
ence in the level of defects estimated from the
Figure 2: After the implant placement (teeth numbers
level line between front tooth and molar regions.
7 and 9). These edentulous ridges were classified into
Concave-H and Concave-L. Therefore, even if the maxillary canine tooth
region is class Convex-H, it is important to suf-
ficiently evaluate the necessity of augmentation.
58 • Vol. 1, No. 3 • May 2009

Suzuki et al
Figure 3: (above) Connective tissue graft using pouch

technique.
Figure 4: (right) After the final restoration. Notice the

healthy band of keratinized attached gingiva around the
implants.
Soft tissue augmentation tion techniques are not described in this paper,
For cosmetic implant treatment, soft tissue aug- treatment is performed by the combination of
mentation may be performed in many patients. roll, pouch, inlay, and onlay graft methods.1,2,9-11
This is because the morphology of soft tis- An example of a connective tissue graft using
sues of edentulous ridges is closely related the pouch technique for augmentation of
with cosmetic conditions and varies with mor- an implant site is shown in figures 3 and 4.
phologically small changes. However, soft tis-
sue augmentation is not recommended for all Hard tissue augmentation
patients, as shown in Table 1. When implanta- For hard tissue augmentation, the criteria for
tion can be performed into the predetermined application, methods and prognoses have not
site, the management of soft tissues in classes been established.12-19 If implantation into alve-
Convex-H and L is generally possible by simple olar ridges with more than 2 mm of bone on
surgical techniques. However, if alveolar ridges the buccal side is considered as the standard,
are horizontally or perpendicularly below the as reported by Glunder et al, bone augmenta-
level lines, soft tissue augmentation will likely tion is necessary in almost all patients with
be necessary. Although soft tissue augmenta- edentulous front teeth.20 However, in implan-

Suzuki et al
tation into single-tooth edentulous ridges, if an the basis of our classification, which is related
implant can be inserted into bone, the implant to the concept that the appearance can be
will be stably maintained, even when part of the maintained without bone augmentation by the
tissue on the buccal side of the implant is soft thickness of soft tissues, as long as an implant
tissue. Hard tissue augmentation is performed is inserted into bone. When implant treatment
when bone defects are large from the level line. is performed according to the classification of
this study, in class Concave-H, for example,
Hard and soft tissue augmentation the bone on the labial side has been absorbed,
Generally, hard and soft tissue augmenta- and the residual alveolar ridge is often narrow.
tion is necessary if bone defects extend However, if the width of the edentulous ridge is
horizontally and perpendicularly beyond sufficient for implantation, soft tissue augmenta-
the level line, as described above. In many tion alone is generally performed without bone
cases requiring hard tissue augmentation, augmentation (figures 2, 3 and 4). Implanta-
soft tissue augmentation is also necessary. tion is performed on the lingual side as much
as possible, so that thick gingiva is obtained on
Discussion the labial side. In single-tooth defects, if gin-
In dental implant treatment for edentulous giva is thick on the labial side, gingival reces-
ridges, to obtain the same morphology as nat- sion does not readily occur, resulting in implant
ural teeth in multiple-teeth defects, many fac- treatment with cosmetic improvement.21,22
tors have to be taken into consideration. This When establishment of the level line as
makes the treatment complicated and measure- the basis of our classification is difficult due
ment of the level of defects is not easy. There- to teeth malalignment and marked gingival
fore, the classification of edentulous ridges and recession caused by periodontal disease, the
their treatment methods cannot be readily sum- level line must be modified based on the sur-
marized as a table. However, in single-tooth rounding conditions. This classification does
implantation, morphological analysis of defective not indicate defects on the lingual side. How-
alveolar ridges related to the existing bilateral ever, if there are large defects on the lin-
teeth adjacent to a defective tooth is relatively gual side, analysis is performed as same as
easy. In other words, the positions of the bone the labial side. Therefore, the classification
crests of the existing, bilaterally adjacent teeth proposed in this study is considered to be
and the interdental papilla, and the widths and important for single-tooth implant treatment.
heights of the edentulous gingiva and alveo- Single-tooth implantation is widely per-
lar bone can be sufficiently analyzed and diag- formed, but failures are sometimes observed.
nosed. In single-tooth edentulous ridges, the Such failures are not necessarily observed
interdental papilla and its surrounding soft tis- in patients with problematic conditions. In
sues are stably maintained by not only the bone the classification of single-tooth edentulous
around the implant, but also the soft tissues of ridges described in this study, the level line
the existing bilaterally adjacent teeth. This is can be easily evaluated, indicating that this
60 • Vol. 1, No. 3 • May 2009

Suzuki et al
method is clinically useful. Furthermore, the dif- Disclosure

ficulty level of implant treatment will become The authors report no conflicts with anything mentioned in this paper.
Acknowledgements
clear by evaluating this classification method. This work was supported in part by a Grant for Supporting Project for Strategic
Research by the Ministry of Education, Culture, Sports, Science, and Technology,
In conclusion, future implant treatment will 2008-2012.
References
become safer by performing single-tooth 1. Seibert F. Reconstruction of deformed, partially edentulous ridges, using
full thickness onlay grafts. Part II. Prosthetic/periodontal interrelationships.
implantation according to this classification. ● Compend Contin Educ Dent 1983; (4): 549-562.
2. Allen E, Gainza C, Farthing G, Newbold D. Improved technique for localized
ridge augmentation. A report of 21 cases. J Periodontol 1985; (56): 195-199.
3. Sposetti V, Young H, Collins J. A classification system of edentulous ridge
problems in prosthodontics. Gen Dent 1985; (33): 504-507.
Correspondence: 4. Glisić B, Stanisić D. Reconstruction of initial dimensions of the lower residual
Yorimasa Ogata, ridge and classification of reduction in vertical direction. Stomatol Glas Srb
1989; (36): 261-266.
Department of Periodontology, 5. Denissen H, Kalk W. Classification of edentulous mandibles in preventive
implantology. Ned Tijdsch Tandheelkd 1990; (97): 230-233.
Nihon University School of Dentistry at 6. Lekholm U, Zarb G. Patient selection and preparation. In: Brånemark P-I
Matsudo, ed. Tissue-Integrated Prostheses: Osseointegration Clin Dent Chicago:
Quintessence; 1985: 199-209.
2-870-1, Sakaecho-nishi, Matsudo, Chiba, 7. Misch C, Judy K. Classification of partially edentulous arches for implant
dentistry. Int J Oral Maxillofac Implantol 1987; (4): 7-13.
271-8587, Japan. 8. Wang H, Al-Shammari K. HVC ridge deficiency classification: a therapeutically
oriented classification. Int J Periodontics Restorative Dent 2002; (22): 335-
Phone & Fax: +81-47-360-9362. 343.
email: ogata.yorimasa@nihon-u.ac.jp 9. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed
prosthesis. Compend Contin Educ Dent 1980; (1): 205-213.
10. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthetic
Dent 1980; (44): 363-367.
11. Seibert J. Treatment of moderate localized alveolar ridge defects. Preventive
and reconstructive concepts in therapy. Dent Clin North Am 1993; (37):
265-280.
12. Buser D, Brägger U, Lang N, Nyman S. Regeneration and enlargement of
jaw bone using guided tissue regeneration. Clin Oral Implants Res 1990; (1):
22-32.
13. Buser D, Dula K, Belser U, Hirt H, Berthold H. Localized ridge augmentation
using guided bone regeneration. II. Surgical procedure in the mandible. I Int J
Periodontics Restorative Dent 1995; (15): 10-29.
14. Hermann J, Buser D. Guided bone regeneration for dental implants. Curr
Opin Periodontol 1996; (3): 168-177.
15. Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bone-
grafts and immediate endosseous implants. J Craniomaxillofac Surg 1992;
(20): 2-7.
16. Misch C. Comparison of intraoral donor sites for onlay grafting prior to
implant placement. Int J Oral Maxillofac Implants 1997; (12): 767-776.
17. Scipioni A, Bruschi G, Calesini G. The edentulous ridge expansion technique:
a five-year study. Int J Periodontics Restorative Dent 1994; (14): 451-459.
18. Simion M, Baldoni M and Zaffe D. Jawbone enlargement using immediate
implant placement associated with a split-crest technique and guided tissue
regeneration. Int J Periodontics Restorative Dent 1992; (12): 462-473.
19. Tinti C, Parma-Benfenati S. Vertical ridge augmentation: surgical protocol
and retrospective evaluation of 48 consecutively inserted implants. Int J
Periodontics Restorative Dent 1998; (18): 434-443.
20. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant
relationship on esthetics. Int J Periodontics Restorative Dent 2005; (25):113-
119.
21. García García A, Somoza Martin M, Gandara Vila P, Gandara Rey JM. A
preliminary morphologic classification of the alveolar ridge after distraction
osteogenesis. J Oral Maxillofac Surg 2004; (62): 563-566.
22. Winkler S. Implant site development and alveolar bone resorption patterns. J
Oral Implantol. 2002; (28): 226-229.

Ketabi et al
Ketabi et al
Factors Driving Peri-implant
Crestal Bone Loss - Literature
Review and Discussion:
Part 2 of 4
Mohammad Ketabi, DDS, MDS1 • Robert Pilliar BASc, PhD2

Douglas Deporter, DDS, PhD3
Abstract
Many factors contribute to the cumulative in English language refereed journals for the
crestal bone loss seen around endosseous decade preceding May 2008 and attempted to
dental implants. This can create confusion for identify the major factors associated with peri-
the practicing clinician and lead to undesirable implant bone loss. Part two of this article series
outcomes. In this four part review series, we examines patient and biologic width factors
have searched the literature for papers published associated with peri-implant crestal bone loss.
KEY WORDS: Crestal bone loss, dental implants, causative factors, biologic width
1. Dean, Professor and Chairman, Department of Periodontology, Faculty of Dentistry, Islamic Azad University
(Khorasgan Branch), Arghavanieh, Isfahan, Iran
2. Professor Emeritus, Faculty of Dentistry & Center for Biomaterials, University of Toronto
3. Professor, Discipline of Periodontology and Oral Reconstructive Center, Faculty of Dentistry,
University of Toronto

Ketabi et al
Introduction Discussion
Many factors, both biological and biomechani- A number of patient based and implant bio-
cal, will have a cumulative impact on the final logic width based factors may contrib-
amount of bone loss seen. It is important ute to peri-implant crestal bone loss. The
for clinicians to understand all of these fac- most common of such factors include:
tors in addition to their relative contributions
and interactions. This is the second install- Patient Factors in Crestal Bone Loss
ment of a four part series review of factors As is the case with periodontitis induced bone
driving peri-implant crestal bone loss. Part loss in the natural dentition, peri-implant crestal
one of this review examined surgical and ana- bone loss can be influenced by a plethora of
tomical factors associated with peri-implant host factors. Some of these factors include the
crestal bone loss. In the present review, patient host’s genetic profile, medical history, periodon-
and biologic width factors associated with tal status, oral hygiene, and smoking history.
peri-implant crestal bone loss are reviewed.
Genetic Profile
Materials and Methods Thus far, controlled clinical studies investigat-
A literature search of papers published in ref- ing an association between genetic profile and
ereed journals in the English language for the peri-implant crestal bone loss have focused on
decade preceding May 2008 was performed polymorphisms of the interleukin IL-1 gene. This
by computer using the National Library of Medi- same gene had earlier been linked to periodon-
cine and SCOPUS Cochrane Oral Health Group tal disease susceptibility.1 Investigators have
databases. Search strategy included a specific reported significantly greater (p < 0.05) early
series of terms and key words. The reference marginal bone loss (i.e. during initial site heal-
lists of identified publications, relevant textbooks ing) in patients with the IL-1B−511 2/2 genotype
and professional workshops also were scanned. receiving moderately rough (particle-blasted) or
As the first selection method, relevant refer- rough (TPS-coated) surfaced dental implants.2,3
ences were selected on the basis of their titles Genetic polymorphisms of other factors such as
and abstracts. As the final selection method, full the calcitonin receptor genotype and bone mor-
texts of publications identified as possibly relevant phogenic protein BMP-4 genotype4,5 also have
were reviewed for more detailed evaluation. Pub- been linked to early marginal bone loss with
lications reviewed included experimental animal particle-blasted dental implants. Likewise, links
studies, prospective and retrospective human clini- have been established between IL-1 genotype
cal studies, a few case reports and relevant review and late bone loss associated with peri-implan-
papers. Because of the limited numbers of avail- titis about a variety of dental implant systems.6,7
able studies for some factors and their heterogene-
ity, focusing on a specific pre-defined question to Oral Hygiene, Smoking and
be answered by a systematic review was not feasi- Alcohol Consumption
ble and therefore no meta-analysis was attempted. There is general agreement that patients with
64 • Vol. 1, No. 3 • May 2009

Ketabi et al
poor oral hygiene and/or existing periodontal dis- coated press-fit cylinder implants) in 421 partially
ease experience greater peri-implant crestal bone edentulous patients with similar oral hygiene sta-
loss than patients with good oral hygiene and a tus on regular recall. After 1 to 7 years of implant
stable periodontal status.8-10 Cigarette smoking function, smokers (quantity of cigarettes/day not
is a known health risk factor. Both current and reported) showed significantly (p < 0.01) greater
lifetime cigarette smoking are associated with (3.95mm vs 1.47mm) bone loss around maxil-
deterioration in bone quality and impaired wound lary implants than around mandibular implants.
healing.11,12 Smoking has been shown to be However, in contrast to Lindquist,16 no signifi-
one of the most significant factors predisposing cant (p > 0.05) difference was found for bone
to implant failure13-15 and a number of investiga- loss around mandibular implants between smok-
tors have reported a significant impact of ciga- ers and non-smokers. This differential impact of
rette smoking on marginal peri-implant bone loss. smoking in maxilla vs mandible may relate to the
Lindquist et al16 reported ten year follow-up data fact that maxillary bone is generally more cancel-
for marginal bone loss around machine-turned lous than mandibular bone. Nociti et al19 reported
implants placed in mandibular sites of edentulous animal findings documenting a greater effect of
patients and, using multivariate analysis, found intermittent cigarette smoke exposure on loss of
cigarette smoking to have a highly important influ- bone density in cancellous versus cortical bone.
ence (p < 0.001). Mean bone loss values were Similar outcomes to Haas18 were reported by
nearly twice as large for smokers as for non-smok- Nitzan et al.20 Their recorded mean bone loss
ers year following implant treatment and this differ- values generally appeared to be smaller, per-
ence remained throughout the observation period. haps because of implant type used and/or the
The mean difference between smokers and non- fact that orthopantographs were used exclu-
smokers had reached 0.6 mm after 10 years. Non- sively to record bone loss, this type of radiograph
smokers had less bone loss than both low (≤14 being considered inaccurate for the purpose.21
cigarettes/day) and high (≥14 cigarettes/day) Only one study was found where the effect
smokers while smokers with low cigarette con- of alcohol consumption on peri-implant mar-
sumption had less bone loss than those with high ginal bone loss was assessed.22 After 3 years of
consumption. Among smokers, those with poor implant function, significantly (p < 0.0008) higher
oral hygiene had significantly greater bone loss marginal bone loss (1.66mm vs 1.29mm) was
(p < 0.001) than those with good oral hygiene. detected in patients drinking >10g (gms alcohol
Implant surface roughness might modify = 0.8 x volume in mls) alcohol daily compared
crestal bone loss in smokers. Watzak et al17 to those who did not consume this level of alco-
reported that anodized implants used with man- hol. Other important factors were gingival index
dibular complete overdentures showed less and implant surface. Individuals who use alcohol
crestal bone loss than machine-turned implants to excess may have inadequate nutrition includ-
after a mean functional time of 33 months. ing vitamin deficits23 which may compromise ini-
Haas et al18 reported retrospective results tially site healing. Alcohol also is a liver toxin and
for 1366 implants (Branemark-Type® and TPS- can alter production of prothrombin and vitamin

Ketabi et al
K, both affecting coagulation,24 and therefore, implant bone loss. Implants in the periodontitis
early clot formation at the bone-implant interface. group suffered a mean bone loss of 2.2mm com-
pared to 1.7 mm in the non-periodontitis group.
History and Type of Periodontitis An important clinical factor often not
Several recent review articles have addressed the addressed in published papers on the effect of
possible effect of a history of treated periodontitis previous history of periodontitis, is the quality of
on the performance of dental implants in partially supportive periodontal maintenance treatment
edentulous patients.25-29 One of these papers27 (SPT) provided for patients during the period of
highlighted the limitations of evidence published implant function being studied. In a recent review
to date including failure to account for confound- of literature, Quirynen et al26 concluded that peri-
ing factors, especially smoking, and factors such odontally compromised patients can be success-
as variability in definitions used, outcome crite- fully treated with minimally or moderately rough
ria (e.g. what constitutes “excessive” bone loss) surfaced implants provided that regular SPT is
and quality of ongoing supportive periodontal included to keep periodontal disease at bay. Type
therapy. As is the case with smoking and kerati- of periodontitis also appears to be of significance
nized tissue, implant susceptibility in patients with with aggressive periodontitis (AP) having more
a history of periodontitis will likely be affected by impact on outcomes with dental implants than
implant type. In a small group of patients treated chronic periodontitis (CP). Mengel and Flores-
with TPS-coated threaded implants, Karoussis et de-Jacoby33 provided data on the performance
al30 reported different outcomes for patients with of Branemark-Type® or acid-washed threaded
or without a history of chronic periodontitis. Uti- implants in patients previously treated for AP or
lizing as success criteria, pocket probing depth CP compared to a non-periodontitis control group,
≤ 6mm and crestal bone loss < 0.2mm annually all patients being provided with SPT. In this 3-year
after year one, over a 10-year interval, 71.4% of prospective study, bone loss was greater for
implants were considered successful in patients implants than for teeth in all three patient groups.
with a history of periodontitis compared to 94.5% Implants and teeth in patients with a history of AP
of implants in the non-periodontitis group. At showed greater bone loss than in either of the
recall visits, implant complications were man- other two groups. This bone loss in AP patients
aged according to a defined interceptive support- was continuous over the study period, leading
ive therapy.31 Hardt et al32 determined marginal the investigators to suggest that implants in this
bone loss for Branemark-Type® implants placed patient group might be at greater risk to progres-
in posterior maxillary sites in patients for whom sive bone loss and complications in the long term.
an age-related bone loss score (ArB-score) for
remaining posterior maxillary teeth was used to Diabetes
categorize patients in regard to previous his- Several medical conditions, like diabetes, Crohn’s
tory of periodontitis. Over a 5-year follow-up disease and osteoporosis, and/or medications
period, they found a statistically significant (p < used to treat them have been implicated in the fail-
0.05) relationship between ArB-scores and peri- ure of dental implants,34 but published evidence
66 • Vol. 1, No. 3 • May 2009

Ketabi et al
of an effect on crestal bone loss about implants maxillary implants. Excessive alcohol consump-
appears to be limited to studies on diabetes. It tion may also play a role in promoting peri-implant
is well known that diabetics are at higher risk for bone loss but, further investigation is needed here.
developing periodontitis and are also more prone In patients with a history of treated periodonti-
to infection,35 making it highly likely that perfor- tis, higher levels of peri-implant marginal bone loss
mance of dental implants will be affected as well. can be expected than seen in control patients, at
Accursi36 examined retrospectively the effect of least where effective supportive periodontal treat-
diabetes on Branemark-Type® implants in fully ment was lacking or where very rough implant
and partially edentulous patients with 1 to 17 surfaces were used. Patients with a history of
year follow up. Fifteen (2 Type I, 13 Type II) con- treated aggressive periodontitis may be at par-
trolled diabetic patients had received 59 implants. ticular risk to continued peri-implant crestal bone
Each of these 15 patients was matched by strict loss over time as they are with their remaining nat-
criteria to two non-diabetic control patients, the ural teeth. Well-controlled diabetic patients may
latter having received in total 111 implants. Dia- suffer somewhat greater early peri-implant bone
betic patients exhibited greater crestal bone loss loss but, no significant differences in the long-
than controls during the first year of loading, but term are likely to occur compared to non-diabetic
this difference disappeared with function over control patients, assuming good homecare, regu-
time. All implant failures occurred in fully eden- lar SPT and a non-smoking lifestyle. Effects of
tulous patients and no differences in implant fail- other medical conditions and medications used
ure rates were seen between diabetic and control to treat them on marginal bone loss with den-
patients. Poor metabolic control in diabetic sub- tal implants have yet to be studied and reported.
jects does increase the risk of developing peri-
implantitis.10 A more extensive review of dental Biologic Width Factors in Crestal Bone Loss
implant performance in both diabetic animals and Remodeling of crestal bone to allow estab-
humans has been published by Kotsovilis et al.37 lishment of a “biologic width” or soft tissue
seal in peri-implant mucosal tissues is consid-
Summary of Patient Factors ered the central driving force in early crestal
As is the case with periodontitis, genetic factors, bone loss with all types of endosseous dental
including certain polymorphisms of IL-1, BMP-4, implants.39,40 Factors known to affect this bone
and calcitonin receptor may predispose affected loss include the level of the micro-gap in rela-
individuals to greater peri-implant bone loss so tion to bone crest, platform-switching achieved
that pre-treatment genetic testing may become either by implant body design and/or using an
widely used in future for patients seeking den- abutment smaller in diameter than the implant
tal implants.38 Significantly greater peri-implant body and, tooth-implant or inter-implant horizon-
crestal bone loss is expected to happen in patients tal distance. It has also been suggested that
who practice poor oral hygiene, have untreated repeated removal and replacement of abutments
periodontitis, and/or smoke cigarettes. The effects may have a deleterious effect on crestal bone
of smoking are dose-dependent and greater for because of disruption of the soft tissue seal.41

Ketabi et al
Level of the Micro-Gap mucosal collar. It was reported that one-piece

The connection between implant body and pros- implants placed with a 3mm long polished
thetic abutment is termed the “micro-gap” and is trans-mucosal collar and the collar-to-rough-
generally susceptible to microbial accumulation ened surface junction initially positioned at the
and micro-movements between the parts during level of bone crest suffered less crestal bone
clinical function. Both of which can lead to local- loss than 2-piece implants with 1.5mm long pol-
ized inflammation and associated bone loss if the ished collars and placed in either a submerged
micro-gap is within a minimum distance from the or non-submerged approach with the micro-gap
alveolar crest. Biologic width around the neck of positioned at the crestal level. Differences in
a tooth or a dental implant constitutes a mucosal bone loss were attributed to the level of micro-
seal intended to offer protection to underlying gap, establishment of biologic width apical to
bone. It is formed apical to the micro-gap and all micro-gaps and a greater inflammatory reac-
requires a minimum of about 1.5mm of fibrous tion seen with 2-piece implants.47 Piattelli et al48
connective tissue between bone and epithe- drew similar conclusions on the importance of
lial attachment of the gingival sulcus of tooth or the position of micro-gap from a study examin-
implant.39,40 With one-piece implants, the micro- ing primates and rough surfaced (TPS) implants.
gap is generally placed sufficiently proud of the
alveolar crest to have minimal impact on crestal Platform Switching
bone loss. As such, peri-implant crestal bone “Platform-switching” is defined as the inward
loss with these implants is primarily driven by horizontal repositioning of the implant-abut-
dimensions of biologic width and elements pre- ment interface (micro-gap).49 This design fea-
viously reviewed in part one of this series. With ture can be created in an implant body by the
2-piece implants, the micro-gap is generally ini- manufacturer or achieved by the clinician using
tially positioned at the level of the alveolar crest a compatible abutment of lesser diameter
and when biologic width is established in relation than the implant platform. The effect of plat-
to the micro-gap, there may be greater bone loss form-switching is to create a horizontal com-
because of the latter’s negative influences (i.e. ponent for the total linear distance between
bacteria and micro-movements).42-44 With 2-piece micro-gap and bone crest required for biologic
implants placed in dogs, whether with non-sub- width,50,51 and possibly to shift stress concen-
merged or submerged technique, the most coro- tration away from the cervical bone-implant
nal bone-to-implant contact was consistently interface.52 Generally the horizontal compo-
located about 2mm apical to the micro-gap.45 nent created by platform-switching is around
In another study in animals, Hermann et 0.5mm but, this is sufficient to result in signifi-
al46 compared soft and hard tissue dimensions cantly less radiographically detectable crestal
around one-piece and 2-piece implants both bone loss in humans.50,52,53 Not only does this
placed in either submerged or non-submerged situation reduce the risk of peri-implantitis in the
fashion. The implants had a moderately rough future but, also has the benefit in the aesthetic
surface and varying heights of polished trans- zone of providing better soft tissue support.54
68 • Vol. 1, No. 3 • May 2009

Ketabi et al
Implant-Tooth or Inter-Implant Distance implant distance would be incomplete papilla

For single tooth dental implants, provided that reformation and poor esthetics. Whether this
a minimum horizontal distance of approximately lateral component can be reduced or eliminated
2mm is left between the implant and the two by platform-switching remains to be shown.
approximating tooth root surfaces, after bio- For one-piece moderately rough implants, the
logic width accommodation crestal bone loss in amount of radiographically detectable bone loss
relation to the implant will be dependent upon will vary with the original positioning of the rough
height of periodontal bone support of the two surfaced segment of the implant body with respect
teeth.55-57 When two implants are placed side to alveolar crest. Implants with their rough sur-
by side, the bone loss that occurs between faced segment initially positioned below the crest,
them has a more complicated etiology. First and at 6 months showed greater vertical crestal bone
foremost, inter-implant crestal bone loss will be loss (average 1.72 mm) than those with the coro-
affected by the horizontal distance between the nal level of their rough surface segment placed at
two implants which, in the esthetic zone, should or near the crest (average 0.68 mm).61 The reason
be as close to 3mm as possible. Of course, it for greater bone loss with implants with submerged
will also be affected by the level of the micro- rough surfaces is likely disuse atrophy in relation
gap, biologic width, and whether or not platform- to the segment of submerged polished collar.62
switching has been employed. A clear tendency
for increased inter-implant vertical bone loss Summary of Biologic Width Factors
occurs as inter-implant distance decreases The positioning of both implant micro-gap and, in
below 3mm.58,59 Histological data from ani- the case of moderately rough implants, coronal-
mal experiments using 2-piece, moderately most level of rough surface in relation to the bone
rough submerged implants showed that verti- crest both will affect extent of peri-implant mar-
cal crestal inter-implant bone loss decreased ginal bone loss. Because one-piece implants are
from 1.98mm for a 2 mm inter-implant distance generally placed with the micro-gap well proud
to 0.23 mm for a 5 mm inter-implant distance.60 of the crest, they generally suffer less marginal
Tarnow et al58 also showed there to be a lat- bone loss than 2-piece implants which are usu-
eral component to this inter-implant bone loss ally placed with the micro-gap at the level of the
around minimally rough implants in humans in alveolar crest. Inter-implant horizontal distance
addition to the more commonly discussed ver- must be greater than 3mm in order to avoid exces-
tical component. Following re-entry of 2-piece sive inter-implant vertical bone loss and associ-
minimally rough implants and establishment of ated suboptimal regeneration of inter-implant
biologic width, approximately 1.4 mm of hori- soft tissue papillae. In some situations, use of
zontal marginal bone loss was seen in relation smaller diameter implants may assist with main-
to the implant surface. This lateral contribution taining the required inter-implant horizontal dis-
resulted in further vertical bone loss if the inter- tance >3mm. Features in implant body design
implant distance was not > 3mm. In the esthetic or use of under-sized abutments to achieve
zone, the overall effect of sub-optimal inter- platform-switching will reduce peri-implant and

Ketabi et al
most likely inter-implant vertical bone loss by

capturing a horizontal component that can con-
tribute to the overall linear length of implant sur-
face needed for biologic width accommodation.
Conclusion Correspondence:
A number of factors contribute to peri-implant Douglas Deporter, DDS, PhD
crestal bone loss. Patient and biologic width douglas.deporter@utoronto.ca
factors such as medical history, genetic profile,
oral hygiene status, smoking history, implant
microgap, platform switching, and inter-
implant distances are a few of these factors. ●
This is part 2 of a 4 part review series.

Parts 3 and 4 will appear in future issues of JIACD.
Disclosure: 7. Andreiotelli M, Koutayas S, Madianos P, Strub J. 14. Hinode D, Tanabe S-I, Yokoyama M, Fujisawa K,
The authors report no conflicts of interest with Relationship between interleukin-1 genotype and Yamauchi E, Miyamoto Y. Influence of smoking
anything mentioned within this article. peri-implantitis: A literature review. Quintess Inter on osseointegrated implant failure: A meta-
2008; 39: 289-298. analysis. Clin Oral Implants Res 2006; 17:
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76:791-802. Dent Res 1997; 76: 1667-1674.
3. Shimpuku H, Nosaka Y, Kawamura T, Tachi Y,
Shinohara M, Ohura K. Genetic polymorphisms 10. Ferreira S, Silva G, Cortelli J, Costa J, Costa F. 17. Watzak G, Zechner W, Busenlechner D, Arnhart
of the interleukin-1 gene and early marginal bone Prevalence and risk variables for peri-implant C, Gruber R, Watzek G. Radiological and clinical
loss around endosseous dental implants. Clin disease in Brazilian subjects. J Clin Periodontol follow-up of machined- and anodized-surface
Oral Impl Res 2003; 14: 423-429. 2006; 33:929–935. implants after mean functional loading for 33
months. Clin Oral Implants Res 2006 ; 17:651-
4. Nosaka Y,Tachi Y, Shimpuku H, Kawamura T, 11. Bernards C, Twisk J, Snel J, van Mechelen W,
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Ohura K. Association of calcitonin receptor gene Lips P, Kemper H. Smoking and quantitative
polymorphism with early marginal bone loss ultrasound parameters in the calcaneus in 18. Haas, R, Haimbock, W, Mailath, G, Watzek, G.
around endosseous implants. Int J Oral Maxillofac 36-year-old men and women. Osteoporos Int The relationship of smoking and peri-implant
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protein-4 gene polymorphism and early marginal Implant Dent 2005; 14:357-363. Bone density around titanium implants may
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346–352.

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24 The Journal of Implant & Advanced Clinical Dentistry JIACD
Current Clinical Review
Review of the Seventh Report of the Joint National

Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7)
Gregory D. Naylor, DDS, ABOM1
H
ypertension is a disease that affects ●P atients with a SBP of 120-139 mmHg or
approximately 50 to 60 million individuals a DBP of 80-89 mmHg are considered as
in the United States and over a billion prehypertensive, and require health-promoting
people worldwide. It is the most common lifestyle changes to prevent CVD.
primary medical diagnosis in the United States ● Thiazide-type diuretics should initially be
and represents approximately one third of used in the treatment for most patients with
the population. As the population ages, the uncomplicated HTN, either alone or combined
prevalence of hypertension (HTN) will continue with drugs from other classes.
to increase unless effective preventive measures ● Most patients will require two or more drugs
are implemented. The JNC 7 represents the to achieve the goal BP of less than 140/90
seventh iteration of hypertension guidelines. mmHg.
It was designed to provide a new, clear, and ● The most effective therapy prescribed by the
concise guideline for clinicians, and to simplify clinician will control HTN only if the patient is
the classification of blood pressure (BP). All motivated.
dentists and their staff need to be aware of these ● Refer to Table 1 for the updated classification
important changes and should be proactive in of HTN.
the measurement, detection, and treatment of
hypertension. Medical Management
Goals of therapy. The primary goal of
Significant JNC 7 Changes antihypertensive therapy is the reduction of
● In patients older than 50 years, systolic blood cardiovascular and renal disease. Patients
pressure (SBP) greater than 140 mmHg is a older than 50 years will reach the DBP goal
much more important cardiovascular disease once the SBP goal is maintained; therefore,
(CVD) risk factor than diastolic blood pressure the primary focus should be to attain the SBP
(DBP). goal. For patients younger than 50, the primary
1. Dental Consultant, Metropolitan Life Insurance Company

focus should be the DBP goal. A BP less than products with an overall emphasis on the
140/90 mmHg is associated with a decrease in reduction of saturated and total fat. Dietary
CVD complications. For patients with diabetes sodium should be reduced to no more than 6
or renal disease, the goal BP is set at less than grams of sodium chloride. Engaging in regular
130/80 mmHg. aerobic physical activity, such as a brisk walk
for 30 minutes, for most days of the week
Lifestyle Modifications. Adoption of is also indicated. Consumption of alcohol
healthy lifestyles by all patients is critical for should be limited to no more than 24 ounces
the prevention of HTN. A number of lifestyle of beer, 10 ounces of wine, or 3 ounces of
modifications have been shown to lower BP. whiskey as a daily guideline. Adoption of these
Weight reduction in those individuals who are lifestyle modifications will reduce BP, enhance
overweight or obese can significantly lower antihypertensive drug efficacy, and decrease the
BP. Also, adoption of the Dietary Approaches patient’s CVD risk.
to Stop Hypertension (DASH) eating plan is
very important. The DASH eating plan consists Pharmacological Treatment. The following
of a diet rich in potassium and calcium found classes of drugs are used to lower BP:
primarily in fruits, vegetables, and low fat dairy angiotensin converting enzyme inhibitors,
Table 1: Classification of Blood Pressure for Adults

BP SBP* DBP* Lifestyle
Classifications mm of Hg mm of Hg Modification
Normal < 120 and < 80 Encourage
Prehypertension 120-139 or 80-89 Yes
Stage 1 140-159 or 90-99 Yes

Hypertension
Stage 2 ≥ 160 or ≥ 100 Yes

Hypertension
*SBP, systolic blood pressure; DBP, disatolic blood pressure

Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report, JAMA
2003; 289, 2560-2572
74 • Vol. 1, No. 3 • May 2009

angiotensin receptor blockers, beta-blockers, For patients with a BP over 180/110 mmHg,
calcium channel blockers, and thiazide-type dental treatment should be deferred and the
diuretics. patient should be referred immediately to their
physician.
Dental Management
Although HTN is the most common primary Vasoconstrictor use. The use of
medical diagnosis in the United States, 30 vasoconstrictors in local anesthetics for patients
percent of the people with HTN are unaware with CVD is debatable and is finally addressed
they have the condition, and of all the patients in the JNC 7 recommendations. A review
being treated for HTN, only 34 percent have of the literature dealing with the CV effects
their BP controlled at levels consistent with the of epinephrine on dental patients with HTN
current JNC 7 guidelines. As a result, practicing demonstrated that the use of epinephrine in
dentists encounter many patients on a daily local anesthetics resulted in infrequent adverse
basis with undetected or poorly controlled HTN outcomes. It has been concluded that the
that may require medical evaluation. Therefore, advantages of profound anesthesia far outweigh
the dentist and their staff should measure the any potential disadvantages or risks. However,
BP for all new patients and for all recall patients it is recommended that vasoconstrictor use be
on an annual basis. Patients with known HTN minimized in patients with increased CVD risks.
should have their BP measured at each visit in Although there is no official maximum ceiling
which significant procedures are planned. Also, dose for local anesthetics with vasoconstrictors,
regular BP measurements for patients with two to three carpules of lidocaine with
known HTN can determine their level of control. 1:100,000 epinephrine is considered safe
It is important to note that a distinctly elevated in patients with all but the most severe CVD.
BP measurement is an indication of poor control The use of gingival retraction cord containing
and increases the patient’s risk of experiencing epinephrine should be avoided due to the
a cardiovascular episode while undergoing availability of suitable alternatives.
dental treatment.
Patients with well controlled HTN or those Urgent dental care. Elevated BP in patients
with Stage 1 HTN are good candidates for all seeking urgent dental care is very common.
dental procedures. In fact, studies indicate This can be due to the patient’s chief complaint,
that patients with BP measurements less than previously undetected HTN, inadequate
180/110 mmHg can undergo any necessary treatment of HTN, or poor patient compliance.
dental treatment, both surgical and nonsurgical, There are no professionally recognized criteria to
with very little risk of an adverse outcome. determine when it is safe to treat patients with
However, patients with a BP over 160/100 an elevated BP that require urgent dental care.
mmHg should have their BP monitored during In the absence of such a guideline, a logical
surgical or prolonged procedures and then be ceiling for urgent care should be a SBP over
referred to their physician for timely reevaluation. 180 mmHg or a DBP over 110 mmHg. A BP

at either of these levels requires an immediate Oral Complications

referral. Xerostomia. Many antihypertensive medications
cause xerostomia and the likelihood of
Stress management. The dentist should symptoms increases with multiple medication
make every effort to reduce as much as possible use. Xerostomia increases the potential for
the stress and anxiety associated with dental caries; difficulty with mastication, swallowing,
treatment for all patients. Stress management and speech; candidiasis; and burning mouth. If
is very important in patients with HTN to prevent xerostomia is severe, relief can be provided with
the release of endogenous catecholamines the use of a parasympathetic stimulator such as
during a dental appointment. Long or pilocarpine, or by taking frequent sips of water,
stressful appointments should be avoided, using moisturizing gels, sucking on sugarless
and short morning appointments should be candy, chewing sugarless gum, and minimizing
implemented. Anxiety can be minimized by intake of caffeinated and alcoholic beverages.
using oral premedication with a short acting Due to the increase incidence of caries, custom
benzodiazepine at bedtime the night before the trays for fluoride delivery should be considered.
scheduled appointment followed by another
dose one hour before the dental appointment. Gingival overgrowth. Calcium channel
Nitrous oxide and oxygen inhalation sedation blockers may cause gingival overgrowth. This
is an excellent method to minimize anxiety gingival overgrowth can result in pain, gingival
during the dental procedure. For stage 2 HTN bleeding, and difficulty with mastication.
patients, it is advisable to monitor the BP during Excellent oral hygiene can reduce or minimize
the procedure and if the BP goes over 180/110 the overgrowth. Extensive gingival overgrowth
mmHg then treatment should be terminated as may require gingivectomy, gingivoplasty or
soon as possible. a combination of both. In these cases, the
patient’s physician should consider the use of
Orthostatic hypotension. A number another antihypertensive medication in order to
of antihypertensive medications produce reverse the gingival changes.
orthostatic hypertension. In order to prevent
an episode at the end of a dental appointment, Lichenoid drug reactions. A number of
the dental chair should be returned slowly to antihypertensive medications may cause what
the upright position. After a few minutes of is known as a lichenoid drug reaction, which
sitting in a normal position, the patient should are lesions clinically identical to lichen planus.
have adjusted and can be assisted while The best and easiest method to deal with this
getting out of the chair. If there is any problem complication is withdrawal of the offending drug
with lightheadedness or dizziness, the patient and to prescribe another medication. The drug
should sit back down until the postural change withdrawal will allow resolution of the lesions;
symptoms disappear. otherwise short term symptomatic management
with topical corticosteroids is indicated.
76 • Vol. 1, No. 3 • May 2009

Burning mouth symptoms. Angiotensin of blood pressure. Due to the increase in

converting enzyme (ACE) inhibitors have been the number of patients with hypertension
reported to be associated with oral burning. and the aging of the population, each dental
The use of an alternative antihypertensive practitioner will encounter more complications
medication and discontinuing the ACE inhibitor of antihypertensive therapy that will require
alleviates the burning mouth symptoms. ACE medical consultation. Dentists and their staff
inhibitors have also been implicated in loss of have an opportunity to play an important role
taste symptoms. in the treatment success of the patient with
hypertension by monitoring blood pressure,
Drug interactions. Drug interactions between detecting hypertension, and encouraging
antihypertensive medications and some of patients to develop a healthy lifestyle. ●
the therapeutic agents used in dentistry may
result in adverse effects for the patient. An Correspondence
interaction with nonselective beta blockers and gnaylor@comcast.net
epinephrine in local anesthetics can result in a References
1. Chobanian A, Bakris G, Black H, Cushman W, Green L, Izzo J, et al. The Seventh
reduction of cardiac output, an increase in BP, Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003 ;289
and a reduction in heart rate. However, with (19): 2560-2572.
careful administration of local anesthetic with

frequent aspiration will prevent this interaction.
Also epinephrine use with patients taking non-
potassium sparing diuretics, can decrease
potassium levels and increase the chance of
a dysrhythmia. Prolonged use of nonsteroidal
anti-inflammatory agents (NSAIDs) decreases
the antihypertensive effect of diuretics, beta
blockers, alpha blockers, ACE inhibitors,
vasodilators, and central agonists. Alternative
analgesics may be substituted to avoid this
interaction; fortunately short term use of
NSAIDs does not appear to produce a clinically
significant effect.
Summary
The goal of successful antihypertensive
therapy is the reduction of cardiovascular and
renal morbidity and mortality. The JNC 7 has
developed clear and concise prevention oriented
guidelines and simplified the classification

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Volume 1, No.

The Journal of Implant & Advanced Clinical Dentistry

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55 C lassification of Single Tooth

63 F actors Driving Peri-implant Crestal Bone

73 R eview of the Seventh Report of the

The Journal of Implant & Advanced Clinical Dentistry • 3

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

Internet Management Opinions expressed in JIACD articles and communications

The Journal of Implant & Advanced Clinical Dentistry • 5

Founder, Co-Editor in Chief Founder, Co-Editor in Chief

The Journal of Implant & Advanced Clinical Dentistry • 7

Giving Dental Implants the “Mickey Mouse” Treatment

The Journal of Implant & Advanced Clinical Dentistry • 9

Miguel A. Iglesia, DDS, MS1

KEY WORDS: Dental implant abutment, dental implant, dental prosthetics

1. Private practice, Zaragoza, Spain

The Journal of Implant & Advanced Clinical Dentistry • 11

achieve aesthetics that closely mimicked that of

12 • Vol. 1, No. 1 • May 2009

The Journal of Implant & Advanced Clinical Dentistry • 13

14 • Vol. 1, No. 3 • May 2009

Products used for this case

The Journal of Implant & Advanced Clinical Dentistry • 15

always get what

to get what you want when you want it. Pericardium

Pericardium is processed by RTI Biologics, Inc. and distributed by Exactech, Inc.

Dong-Seok Sohn1 • Won-Hyuk Lee2 • Jeung-Uk Heo3

KEY WORDS: Alveolar ridge augmentation, dental implants, grafts, bone

The Journal of Implant & Advanced Clinical Dentistry • 17

18 • Vol. 1, No. 3 • May 2009

formed until penetrating the lingual cortex of man-

The Journal of Implant & Advanced Clinical Dentistry • 19

Figure 11: Panoramic view showing augmented ridge and

20 • Vol. 1, No. 3 • May 2009

Figure 14: Panoramic view showing moderate atrophy in

Figure 13: Stable marginal bone after 2 years in function.

observed. Two hydroxylapatite implants (TSV®,

The Journal of Implant & Advanced Clinical Dentistry • 21

Figure 17: Postoperative radiograph showing vertical

Figure 18: After six months of healing, four implants were

anesthesia with 2% lidocaine 1:100,000 epi-

22 • Vol. 1, No. 3 • May 2009

The Journal of Implant & Advanced Clinical Dentistry • 23

Figure 28: Grafted gap between the elevated bone

Case report 3 A vestibular incision was made to expose the

24 • Vol. 1, No. 3 • May 2009

Figure 30: Note the favorable vertical augmentation after

Figure 31: Healing at 5 months. Note bone regeneration

The Journal of Implant & Advanced Clinical Dentistry • 25

Figure 36: Removal of the mini-dental implant.

Figure 34: Radiograph of implants and graft.

Figure 37: Temporary prosthesis on the conventional

rect Co, USA) and one provisional mini-implant

26 • Vol. 1, No. 3 • May 2009

The Journal of Implant & Advanced Clinical Dentistry • 27

flap retraction of the mental nerve.3 Paresthe- Conclusion

28 • Vol. 1, No. 3 • May 2009

55 C lassification of Single Tooth

63 F actors Driving Peri-implant Crestal Bone

73 R eview of the Seventh Report of the

Disclosure 8. A nonymous. Oral Features of Mucocutaneous 15. Jainkittivong A, Kuvatanasuchati J, Pipattanagovit