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The Journal of Implant & Advanced Clinical Dentistry

Volume 7, No. 4 April 2015

Dentin Autografts for Extraction Site Enhancement

Mandibular Reconstruction After Ossifying

Fibroma Removal

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The Journal of Implant & Advanced Clinical DentistryVolume 7, No. 4 • April 2015

Table of Contents

11 Mandibular Reconstruction and Oral Rehabilitation with Dental Implants by Sequel of Ossifying Fibroma with 8 Years of Evolution: A Clinical Report Luis Roberto Sanchez Garza, Brayann Oscar Aleman, Francisco José Carrillo Morales

33 Dentin Autografts Maintain Alveolar Width Following Tooth Extraction Thanhha Pham, James Rhett Baker, S. Craig Rhodes, David Horn, Paul D. Eleazer, Michael McCracken

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optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification



Table of Contents

For more information, contact BioHorizonsCustomer Care: 1.888.246.8338 or shop online at www.biohorizons.com

SPMP12245 REV A SEP 2012

make the switch

The Tapered Plus implant system offers all the great benefits of BioHorizons highly successful Tapered Internal system PLUS it features a Laser-Lok treated beveled-collar for bone and soft tissue attachment and platform switching designed for increased soft tissue volume.

Laser-Lok® zoneCreates a connective tissue seal and maintains crestal bone

platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

prosthetic indexingConical connection with internal hex; color-coded for easy identification

45 Complex Full arch Implant Impressions Simplified: A Clinical Tip for Accurate Predictable Impressions Dr. Anshul Khanna, Shantanu S Jambhekar, Dr.Jyoti Karani, Dr. Ashutosh Pai

51 Regeneration of the Deficient Alveolar Ridge with Utilization of “Tunnel Approach” to Guided Bone Regeneration. A Retrospective Study of the Outcomes Edward Ruvins, Mark Stein, Susanna Kayserman

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IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefNick Huang, MD

The Journal of Implant & Advanced Clinical Dentistry

IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!

Garza et al

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Garza et al

Background: Ossifying fibroma (osteo-genic fibroma, Cemento-ossifying fibroma) is a true neoplasm with significant growth poten-tial. When the lesion obtains a relevant scale, results in a substantial osteolytic reaction, being essential surgical resection followed by bone grafting for functional reconstruc-tion. The mandibular reconstruction in the head and neck surgery has been a topic dis-cussed throughout history, especially in the last 50 years. The use of iliac crest grafts fol-lowed by osseointegrated dental implants provides a valuable technique for the oral reha-bilitation in patients with this type of defects.

Methods: The presented case is a female patient 37 years-old with no medical history of impor-tance, under mandibular resection for ossifying fibroma in the symphysis, followed by reconstruc-

tion with autologous anterior iliac crest bony graft and subsequent rehabilitation by implant-sup-ported prosthesis. Follow up time was eight years.

Results: Through the therapy applied, were able to establish the functional parameters of chewing, swallowing, phonetics, and aesthet-ics; Resetting far as possible the anatomy, facial symmetry and appearance, resulting in physi-cal and psychological comfort of our patient.

Conclusions: A thorough evaluation, diag-nosis, treatment plan, the patient-physician communication and multidisciplinary action are essential to achieve the expected results.For perfect functional rehabilitation of patients we should resolve the problems that affect mastication, swallowing, salivation and the aesthetic results should be improved.

Mandibular Reconstruction and Oral Rehabilitation with Dental Implants by Sequel

of Ossifying Fibroma with 8 Years of Evolution: A Clinical Report

Luis Roberto Sanchez Garza, MCD1 • Brayann Oscar Aleman, CD2

Francisco José Carrillo Morales, CD3

1. Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery ISSSTE Monterrey, Nuevo León, México; Private Practice Monterrey, Nuevo León, Mexico.

2. Private Practice Monterrey, Nuevo León, Mexico.

3. Private Practice Monterrey, Nuevo León, Mexico.

Abstract

KEY WORDS: Ossifying fibroma, dental implants, iliac crest autograft, oral surgery


12 • Vol. 7, No. 4 • April 2015

INTRODUCTIONPatients treated for tumors of the maxillofacial region, are prone to suffer from a major deficit in the constitutive anatomical structures of the oral cavity, if these are not reconstructed adequately.1

The mandible plays an essential physiological oral function. The resection of a fragment could mean, in some of the cases, the necessary con-dition to eradicate the entire lesion, creating a defect of mandibular discontinuity that affects the support of the soft tissue and facial balance.1 From an aesthetic point of view, mandibular resec-tion produces a marked asymmetry of the lower

third of the face if not reconstructed.1 Function-ally, the most common aftermath characteris-tics are: labial incompetence, drooling, difficulty chewing and swallowing, and phonological disor-ders.1 If mandibular continuity is not conserved with the resection, an autologous or alloplastic bone graft will be required for the reconstruction.1

The ossifying fibroma (osteogenic fibroma, cemento-ossifying fibroma, or cementifying fibroma) is a true neoplasia with exponential potential growth; commonly associated with peo-ple in the third and fourth decade of life with a definite female predilection, involving the mandible

Figure 1: Initial Frontal Extraoral Photo. Figure 2: Initial Submandibular view.

Figure 3: Initial Intraoral view. Figure 4: Ortopantomography evaluation.

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Figure 5: CT transversal cuts. Figure 6: Submandibular incision, dissection by layers.

Figure 7: Lesion Approach.

Figure 8: Conformation of reconstruction plate following bending template pattern.

Figure 9: Reconstruction plate shaped. Figure10: Presentation of reconstruction plate and partial adjustment with fixing screws (2.7 x 11mm system), which indicate the benchmarks final set.

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more often than the maxilla. The mandibular pre-molar and molar area is the most common site.2,3,4

The OMS describes it as an encapsulated neoplasia, wrapped by fibrous tissue with vary-ing amounts of metaplasic bone and mineral-ized masses that resemble bone and/or cement. Small lesions are asymptomatic and only detected radiographically. However, larger lesions are able to expand and cause marked facial asym-metry; pain and paresthesia are infrequent and rarely associated with ossifying fibroma.2,3,4

Radiographically, the lesion is well defined and unilocular, it may appear completely radiolucent

or mixed radiopaque-radiolucent, depending on the amount of calcified material produced by the tumor. Root displacement or resorption of roots of the teeth may be associated with the tumor.3,4,5

Histologically, consists of a fibrous stroma tissue surrounding the short and thick bone trabeculae, varying in size and often show-ing a mixture of woven and lamellar bone; Displaying concentric basophilic struc-tures similar to cement, coupled with regions where it can penetrate with reactive bone.2,3,4

Although there are cases where small lesions of ossifying fibroma are successfully removed

Figure 11: Vertical Osteotomies with a reciprocating saw. Figure 12: Left Vertical osteotomy complete.

Figure 13: Immediate view after the resection. Figure 14: Resected bone block, posterior view.


Garza et al

Figure 15: Resected bone block, anterior view. Figure 16: Right bone edge lesion free.

Figure 17: Left bone edge lesion free.

Figure 18: Reconstruction plate fixation to the mandible with bicortical fixation screws (2.7 x 11mm system).

Figure 19: Floor mouth muscles suture to the Reconstruction plate with Nylon 1/0.

Figure 20: Oral mucosa suture with Vycril 4/0.

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by enucleation, some lesions have an expo-nential growth that leads to a substantial oste-olysis. In such circumstances, it is imperative to resort to surgical resection.2,3,4 The prognosis is favorable and recurrence is rare; There are no reported cases, or evidence showing an ossify-ing fibroma undergoing malignant change.2,3,4

Autologous iliac crest grafts offer a great volume of bone with progenitor cells, capa-ble of creating an enabling environment for the consolidation of the new bone.6,7,8

Dental implants are of great value in

functional rehabilitation and final aesthetic results on patients with mandibular recon-struction.1,9 Osseointegrated implants pro-vide the most rigid prosthetic stabilization to withstand the masticatory forces.1,9,10

CASE REPORTA female patient 37 years old with no significant medical history, came to our office in the Depart-ment of Oral and Maxillofacial Surgery at ISSSTE Constitution Hospital, Monterrey, Nuevo León, referring an asymptomatic gingival vestibular

Figure 21: Intradermal suture of submental approach and placement of Drenovac®

Figure 22: Postoperative control panoramic radiograph

Figure 23: Wound progress after 8 days. Figure 24: Occlusion assement.


Garza et al

Figure 25: Occlusion assessment after surgery event, Maxilla-Mandibular fixation remove.

Figure 26: Wound healing at 20th day

Figure 27: Provisional removable partial prosthesis installation.




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Figure 31: Control radiograph after 2 months of the surgery

Figure 32: Anterior Iliac Crest Surgical approach by trauma team.

Figure 33: Bone graft harvested. Figure 34: Pre-op Photograph of submandibular area.

swelling of several months of evolution; An his-topathology study document that she brought confirmed the lesion was an ossifying fibroma.

In the clinical extraoral evaluation, a moder-ate swelling in the lower facial third is observed at the mandibular right parasymphyseal region, causing facial asymmetry being painless, solid and immobile to digital palpation (Figures 1-2). Intraorally, a swelling of approximately 5 cm by 5 cm is seen in the gingival vestibular portion on the right parasymphyseal and body regions of the mandible which appears pink in color,

well delimited, asymptomatic to palpation, not ulcerated, which comprises from teeth 33 to 45 (FDI Numbering System) (Figure 3). In the pan-oramic imaging, a mixed radiopaque and radio-lucid multilobulated zone with sclerotic borders comprises from teeth 34 to 45. Displacement of the tooth involved without root resorption was observed (Figure 4). CT scan shows a mixed multilobulated lesion, well circumscribed, pres-ence of osteolysis, calcifications, and bone sequestra occupying the full thickness of the mandible with bicortical expansion (Figure 5).


Garza et al

Figure 35: Submandibular incision. Figure 36: Debridement by layers and approach to the reconstruction plate.

Figure 37: Preformation and adaptation of the bone graft. Figure 38: Presentation of bone blocks in the defect.

Figure 39: Corticocancellous graft blocks fixation to the reconstruction plate.

Figure 40: Autologous fibrin clot placement PRGF.

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Figure 41: Wound suture with intradermal technique. Figure 42: Panoramic Radiograph after 1 month.

Figure 43: Panoramic Radiograph after 2 months. Figure 44: Panoramic Radiograph after 5 months.

SURGICAL TREATMENT PLANPhase 1: Partial mandibulectomy from mesial of teeth 34 to distal of 45; place-ment of the locking reconstruction plate with and intra and extraoral approach.

Phase 2: Two months later, delayed reconstruction. Getting a bone graft from the anterior iliac crest, adapting it to the mandibu-lar defect using an extraoral approach.11,12

Phase 3: Six months later, once the graft is positioned, BIOMET 3i Osseotite Certain® (Biomet 3i México, México, D.F.) dental implants are placed, of internal con-

nection of 4 x 15mm, over the new bone.Phase 4: Three months later: Dis-

covering the dental implants and place-ment of gingival healing screws.

PROSTHETIC TREATMENT PLANPhase 1: Once achieved the healing of the soft tissues involved, manufacture of provisional prosthesis posterior to mandibular resection.

Phase 2: Manufacture of surgical guide.Phase 3: Having osseointegrated

dental implants and well adapted peri-implant tissues; passive occlusal load-


Garza et al

Figure 45: CBCT using prosthesis with barium sulphate teeth and implant planning.

Figure 46: Osseous assessment of 46 zone. Figure 47: Osseous assessment of 43 zone.

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Figure 48: Osseous assessment of 31 zone. Figure 49: Osseous assessment of 33 zone.

Figure 50: Full thickness flap elevation and placement of surgical guide.

Figure 51: Parallelism pins.

ing with provisional prosthesis begins.Phase 4: Manufacture Hader type

bar, cast in gold, and fabricate remov-able implant supported prosthesis

SURGICAL TREATMENT PHASE 1

The patient was assessed for general anes-thesia and was determined to be ASA-1.

The patient is placed in a supine posi-tion, under general anesthesia through fiber-

scopic nasal intubation, with prior preparation of the surgical field with povidone iodine solu-tion 10%; Infiltration of local anesthesia (Lido-caine Hydrochloride 2% with Epinephrine 1:100,000) in the submental region and sub-labial mucosa is performed. One submandibu-lar incision of 8cm of length is performed with a No. 15 scalpel blade and subsequent dis-section of planes is completed. Then, a sec-ond sublabial intraoral approach that extends from mesial of teeth 46 to distal of the 36


Garza et al

Figure 52: Implants in position.

Figure 53: Radiographic control of the bone graft and dental implants.

Figure 54: Clinical appearance before implants discovery. Figure 55: Full thickness flap elevation and dental implants exposure.

Figure 56: Full thickness flap elevation and dental implants exposure.

Figure 57: Full thickness flap elevation and dental implants exposure.

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Figure 58: Second phase gingival healing screws placement with 8mm high.

Figure 59: Wound closure.

Figure 60: Clinical appearance at 10 days, suture material removal.

Figure 61: Provisional prosthesis installation and initiation of occlusal passive load.

in the buccal oral mucosa is performed, fol-lowed by dissection of planes (Figure 6).

Once exposed the area of the lesion, the bend-ing template is superimposed to the mandible and the reconstruction 13-hole plate ThreadLock TS® Reconstruction Module, (KLS Martin L.P., Jacksonville, FL) is conformed; the reconstruction plate is placed on the jaw and bicortical screws (2.7 x 11mm) are partially adjusted, 3 of them dis-tal to the lesion and 3 mesial to it. Then, the plate and screws are removed to perform the osteot-

omy; in this way the position of the condyle would be preserved, in order to ensure stable postopera-tive intermaxillary relationship and occlusion. Ver-tical mandibular osteotomies were performed by a reciprocating saw, both in bone free of lesion, mesial to teeth 45 and distal to 34. Once estab-lished the correct condylar position in the glenoid fossa, the reconstruction plate is fixed in the previ-ously set in position. The muscles of the floor of the mouth are attached to the reconstruction plate by simple interrupted suturing with nylon 1-0 to


Garza et al

Figure 62: Radiograph checkup of overdenture bar seating.

Figure 63: Occlusal view of mounted teeth on wax.

Figure 64: Front view and occlusion verification of the unfinished prosthesis.

Figure 65: Occlusal view of final prosthesis with forged hooks.

Figure 66: Hader type bar installation and approach points sealing with cotton.

Figure 67: Placement of attachment clips in the final prosthesis.

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Figure 68: Anterior view of the final prosthesis. Figure 69: Radiograph control after 3 years.

Figure 70: Clinical appearance of submandibular scar after 3 years.

Figure 71: Frontal extraoral appearance at 3 years.

prevent muscle collapse, followed by a contin-uous locked suture with vicryl 4-0 to close the edges of oral mucosa. Placement of Ivy loops for intermaxillary fixation is performed (Fig-ures 7-20).3,14,15,16 A Drenovac® surgical drain (Drenovac S.A. de C.V., San Andrés Cholula, Puebla) is placed for 48 hours (Figure 21). The resected block is sent to the Department of Pathology in order to confirm the accuracy of the histopathological diagnosis and to verify that the edges of the resection are free of lesion.

Next, a clinical and radiographic post-operative control is performed at 48 hours;

the closure of wounds showed good evo-lution, and the Drenovac surgical drain was removed (Figure 23) Eight days after surgery, the wounds are reevaluated; it is then, when intermaxillary fixation and suture material is removed (Figures 22-25).

PROSTHETIC TREATMENT PHASE 1

Twenty days after surgery provisional prosthe-sis are manufactured, returning the support to the perioral soft tissues, improving facial aes-thetics and masticatory function (Figures 26-30).


Garza et al

Figure 72: Submandibular scar aspect at 5 years. Figure 73: Facial symmetry assessment at 5 years.

Figure 74: Radiograph control after 5 years.

Figure 75: Frontal Hader type bar appearance and periimplant tissues after 8 years.

Figure 76: Occlusal Hader type bar appearance and periimplant tissues after 8 years.

Figure 77: Final prosthesis clinical aspect after 8 years.

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SURGICAL TREATMENT PHASE 2

Ilium is the preferred donor site for bone grafting as it resembles the shape and structure of man-dibular bone. The bone graft can be obtained from either the anterior or posterior portions of the ilium, as it contains the greatest and most abundant volume of cancellous and cortico-can-cellous bone.17,18 Furthermore, the bone graft needs to be broad enough in size, to provide adequate resistance to functional loads.18,19

Two months after the first surgical interven-tion, the panoramic radiograph shows the bone tissue without evidence of recurrence and good stability of the mandibular segments (Figure 31).

The trauma and oral and maxillofacial surgery team assessed the second surgical procedure: the trauma team approached the anterior por-tion of the ilium from which the cortico-cancel-lous bone graft was removed (Figures 32, 33).

The oral and maxillofacial surgery team mod-eled and adapted the bone graft to the man-dibular defect by an strictly extraoral approach; for such procedure, the graft was fixed to the Reconstruction Plate Threadlock TS® Recon-struction Module (KLS Martin LP, Jackson-ville, FL) with bicortical screws 2.7 x 13mm, which provide immobilization to ensure opti-mal osseointegration. Also, an autologous fibrin clot (PRGF) was incorporated to accel-erate the bone regeneration process (Figures 34-41). After 10 postoperative days, an optimal clinical outcome was observed and the sutur-ing material was removed. Radiologic controls where made at the first, second and fifth month, which confirmed bone stability (Figures 42-44).

SURGICAL PHASE 3 AND PROSTHETIC PHASE 2

Six months after the mandibular reconstruc-tion, the placement of biphasic dental implants was performed.20,21,22,23,24 A CBCT study was used for planning the position, angle and depth of the dental implants in the mandibu-lar arch. It should be emphasized, that the denture with barium sulfate teeth was previ-ously made to the tomographic study.25 The following aspects were evaluated in a 3D software before the implant placement: 1) Bone quantity; 2) Bone quality; 3) Number of implants; 4) Position of implants in the den-tal arch; 5) Implants axis; 6) Implant depth.

The evaluation demonstrated adequate bone quality and quantity for the place-ment of dental implants. We decided to palce four hybrid biphasic Biomet 3i (4mm x 15mm) dental implants in the 31, 33, 43 and 46 regions (Figures 45-49).

Under local and infiltrative anesthe-sia (mepivacaine 2% and epinephrine 1: 100,000) an incision in the oral mucosa is performed, and a full thickness flap is ele-vated. The surgical guide is placed in position to lead dental implants by means of osteot-omy depth, confirming its correct positioning by parallel pins and periapical radiographs.

After obtaining the desired parallelism, sequential osteotomies where performed to the diameter of 4mm (as indicated by the supplier), placing the implants with an insertion torque to achieve primary stabil-ity. The wound was closed by simple inter-rupted suturing with silk 3-0 (Figures 50-52).

After 10 postoperative days, a clinical and radiographical control was performed, show-


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ing good evolution and stability of the den-tal implants. Good healing of the wound was observed and the suture material was removed. The patient was examined a week later show-ing complete closure of the wound (Figure 53).

SURGICAL PHASE 4Three months after implants osseointegration, second phase gingival screws (8mm high) were placed on labial mucosa and its proper position was confirmed by periapical radiographs. Ten days later, the sorrounding tissue of the implants were evaluated showing good healing and the suture material was removed (Figures 54-60)

PROSTHETIC PHASE 3Once the soft tissue healing and adecuate osseointegration was observed, a temporary partial denture was manufactured to provide a passive occlusal load to the implants (Figure 61)

.

PROSTHETIC PHASE 4Three weeks after the discovery of dental implants, we decided to take an impression with drag tech-nique using Biomet 3i posts and a personalized tray manufactured with Triad® system (Dentsply, Mexico, DF). Impression posts were installed, rec-tifying their settlement by periapical radiographs.

Impression were performed with heavy

Figure 78: Radiograph control after 8 years. Figure 79: Clinical appearance of submandibular scar after 8 years.

Figure 80: Frontal extraoral photo at 8 years, harmony and facial symmetry are stable.

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and light body silicone swiss type A TEC HydroXtreme® (ColtreneGroup, Cuyahoga Falls, OH) to proceed to the manufac-ture of implant-supported hybrid prosthesis.

BAR OVERDENTURE AND FINAL PROSTHESIS INSTALLATION

Having concluded the manufacture of the bar and the final prosthesis, the Hader type bar was settled and fixed with a single screw. Pan-oramic and periapical radiographs were taken to document the passive settlement of the bar. Once corroborated this information, a second impression was taken, teeth were mounted in the second dental cast and occlusion was veri-fied. The final prosthesis was acrylated and the hooks were adapted to improve stability (Fig-ures 62-65). The bar was positioned in the mouth, fixation screws were placed in the cor-responding implants and 32 N torque (torque indicated by the supplier) was performed. Tak-ing into account functional and aesthetic param-eters, fixing clips were assembled and the final prosthesis was settled in place (Figures 66-68).

RESULTSFacial balance, symmetry and masticatory functionality was achieved. After multiple sur-gical events, only a palpable but discreet cutaneous scar remained. A dental prophy-laxis as well as both clinical and radiologic check-ups have been performed annualy, observing stability and proper functionality of both prostheses and implants for 8 years in a row. To date, the patient has not pre-sented signs or symptoms of recurrence of the lesion or peri-implant disease (Figures 69-80).

DISCUSSIONMultiple studies demonstrate the stability and longevity of the cortico-cancellous grafts from the iliac crest. The functional requirements of reconstruction includes: 1) The restoration of the continuity of the mandible; 2) Adequate bone height and width to allow functional res-toration and occlusion; 3) The restoration of mandibular morphology for aesthetic and func-tional requirements; 4) The criterion of success of dental implants is based on the absence of bone loss, stability of the peri-implant tissues and proper function; 5) The implant-supported dental prosthetic rehabilitation provides a defini-tive solution to the recovery of masticatory function and improvement of other sequelae.

CONCLUSIONSImmediate reconstruction with iliac crest avas-cular grafts after resection of the tumor, proves to be a viable alternative for patients with par-tial mandibulectomies treatment. Iliac bone resorption is minimal after periods of 6 to 9 months of consolidation. Thanks to the tech-nological evolution of surgical and prosthetic techniques, guided tissue regeneration and biological engineering, the degree of improve-ment in complex surgical treatments has shown that oral implantology is primarily the treat-ment of choice for restoration of functional oral abilities, and for the restitution of lost teeth.

In addition to demonstrating the stability of autogenous grafts, this case with an evolution of 8 years underpins the viability of rehabilitat-ing patients who have undergone radical surgery due to diseases or traumas. It also offers the possibility to return cosmetic and functional-ity to the stomatognathic system, by the place-ment of dental implants in autogenous grafts. ●


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CorrespondenceDr. Luis Roberto Sanchez GarzaGómez Morín 2003 L-9, Col. Carrizalejo, San Pedro Garza García, Zip Code: 66254, Phone: 044-818-280-8992, Office: 83461176 email: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Rehabilitación implantosoportada en el colgajo libre de peroné C.

Navarro Cuéllar1, S. Ochandiano Caicoya, F. Riba Garcia1, F.J. Lopez de Atalaya, J. Acero Sanz2, M. Cuesta Gil, C. Navarro Vila.

2. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofa-cial Pathology. 2nd ed. Philadelphia: Saunders; 2002: 563-6.

3. Eversole LR. Patología Bucal. Ed. Panamericana. México. 1983. Sapp JP, Eversole L, Wysocki G. Patología oral y max-ilofacial contemporanea. Ed.Harcourt, Barcelona. 1998.

4. W.G.Shafer , B.M. Levy. Tratado de patología bucal Edi-torial. Interamericana. 4 Ed. 1986. Mexico D.F.

5. Eversole LR, Merrell PW, Strub D. Radiographic characteristics of central ossifying fibroma. Oral Surgery Oral Med Oral Pathol 1985;59:7-522.

6. Principles of Oral and Maxilofacial Surgery. pg 267-269; pg 789-795;1.

7. Lawson W. Biller HF. Reconstruction of the Mandibule In: Mc. Carthy Plastic Surgery 1990:2069

8. Adamo AK, Szal RL. Timing, results, and complications of mandibular reconstructive surgery: report of 32 cases. J Oral Surg 1979;37:755–60.

9. Andersson B, Odman P, Lindvall AM, Lithner B. Single-tooth restorations sup-ported by osseointegrated implants: Results and experiences from a prospec-tive study after 2 to 3 years. Int J Oral Maxillofac Impl 1995;10(6):702-11.

10. Garber DA. The esthetic dental implant: Letting restora-tion be the guide. J Am Dent Assoc 1995;126(3):319-25.

11. Enneking WF, Eady JL, Burchard H. Autogenous cortical bone grafts in the construction of segmental skeletal defects. J Bone Joint Surg 1980;62:1039–58.

12. Kurz LT, Garfin SR, Booth RE. Harvesting autogenous iliac crest bone grafts: a review of complications. Spine 1989;14:1324–31.

13. Söderholm A-L, Lindqvist C, Skutnabb K, Rahn B. Bridging of man-dibular defects with two different reconstruction systems: an experi-mental study. J Oral Maxillofac Surg 1991;49:1098–105.

14. May M, Tucker HM, Ogura IH. Closed management of man-dibular fractures. Arch Otolaryngol 1972;95:53–7.

15. Uniper RP, Awty MD. The immobilization period for fractures of the mandibular body. J Oral Surg 1973;36:157–63.

16 Amaratunga NA. The relation of age to the immobilization period required for healing of mandibular fractures. J Oral Maxillofac Surg 1987;45:111–3.

17. Westrich GH, Geller DS, O’Malley MJ, et al. Anterior iliac crest harvesting using the corticocancellous reamer system. J Orthop Trauma 2001;15:500–6.

18. Ahlmann E, Patzakis M, Roidis N, et al. Comparison of anterior and posterior iliac crest bone harvest in terms of harvest site morbid-ity and functional outcomes. J Bone Joint Surg 2002;84:716–20.

19. Callan DP, Salkeld SL, Scarborough N. Histologic analy-sis of implant sites after grafting with demineralized bone matrix putty and sheets. Implant Dent 2000;9:36–44.

20. Lekholm U, Wannfors K, Isaksson S, Adielsson B. Oral implants in com-bination with bone grafts. Int J Oral Maxillofac Surg. 1999;28:181–187.

21. Stoler A, Hill T. Part 1. Reconstruction after total mandibulectomy with free cranial and micro-vascular iliac crest grafts as preparation for implants. J Oral Implantol. 1992;18:36–44.

22. Keller EF, Van Rockel NB, Desjardins RP, Tolman DE. Prosthetic-surgical reconstruction of the severely resorbed maxilla with iliac bone grafting and tissue-integrated prosthesis. Int J Maxillofac Implants. 1987;2:155–156.

23. Sailer HF. A new method of inserting endoosseous implants in totally atrophic maxillae. J Craniomaxillofac Surg. 1989;17:299–305.

24. Frodel JL Jr, Funk GF, Capper DT, et al. Osseointegrated implants: a comparative study of bone thickness in four vascularized bone flaps. Plast Reconstr Surg. Sep 1993;92(3):449-55; discussion 456-8.

25. Saadoun AP, LeGall M, Touati B. Selection and ideal three-dimensional implant position for soft tissue aesthetic. Pract Periodontics Aesthet Dent 1999;11(9):1063-72.

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Pham et al

Background: The aim of this study was to preserve alveolus by maintaining natu-ral PDL with a buccal dentin autograft.

Methods: Animal and clinical studies were used. Maxillary premolars in two dogs were sectioned and removed. Buccal dentin 1 mm thick, 120 degrees in circumference was replanted. After 50 and 98 days tis-sue blocks were examined microscopically.In the human model study, four patients with at least two single root extractions received either a bone allograft or an allograft along with den-tin root sliver. At six months models compared. In the human histology study, trephined cores

were evaluated at six weeks. Six dentin root sliver sites were compared to three controls.

Results: In the dog study, new cemen-tum was found over both the cut and pre-existing dentin. No inflammation was noted. Half of the human’s models dentin auto-grafts showed less resorption. One patient had equal resorption. Two slivers sloughed. In the second human study, all sites showed excellent healing. New periodontal ligament formed with new cementum over all autografts.

Conclusions: Retaining the buccal aspect of the root can aid retention of alveolar contours.

Dentin Autografts Maintain Alveolar Width Following Tooth Extraction

Thanhha Pham, DDS1 • James Rhett Baker, DMD2 S. Craig Rhodes, DDS3 • David Horn, DDS4

Paul D. Eleazer, DDS, MS5 • Michael McCracken, DDS, PhD6

1. Resident, Graduate Endodontics, Department of Endodontics, University of Alabama at Birmingham School of Dentistry, Birmingham, AL.

2. Private Practice, Orlando, FL

3. Associate Professor, Department of Endodontics, Texas A&M University Baylor College of Dentistry, Dallas, TX

4. Endodontist, VA Hospital, Atlanta, GA

5. Professor and Director of Graduate Endodontics, Graduate Endodontics, Department of Endodontics, University of Alabama at Birmingham School of Dentistry, Birmingham, AL.

6. Professor of General Dental Sciences, University of Alabama at Birmingham School of Dentistry, Birmingham, AL. Director of Foundry Dental Clinic, Bessemer, AL.

Abstract

KEY WORDS: Socket preservation, dentin autograft, tooth retention, alveolar ridge


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BACKGROUNDTooth extraction results in alveolar bone loss that leads to ridge atrophy.1 Significant resorp-tion of the alveolar ridge could influence the quality and prognosis of the implant place-ment and final restoration.2 The role of bun-dle bone in change of the alveolar ridge after extraction was investigated in several dog studies.1, 2 It has been observed that the crestal region of the buccal bone wall was made up exclusively of bundle bone, whereas the corresponding region of the lingual bone was made of a combination of bundle bone and lamellar bone.2 After the tooth has been extracted, the bundle bone quickly resorbs. At day 14 post-extraction, most of the bundle bone is gone, however, adjacent to the newly formed blood vessels, “woven bone” forms on socket walls inward, toward the center of the socket.3 This may explain the more pronounced resorption of the buccal than the lingual bone. Tan et al. 2012 evaluated the dimensional changes in the hard and soft tissues of the alve-olar process up to 12 months following tooth extraction1. They found that after 6 months of healing the vertical resorption of the alveo-lar bone was 11–22%, whereas the horizontal resorption of the alveolar bone was 29–63%.

Several studies have proposed various socket presentation techniques following extraction, including immediate implant place-ment, placement of different graft materials, use of membranes to cover the extraction socket, and retention of residual root tips in extrac-tion sites.1, 3 Grafting using xenograft has been shown to be a suitable technique to help main-tain the alveolar.4 Several studies showed that immediate implant placement does not prevent

resorption of the buccal crest.3, 5 Also the use of some grafting materials in extraction sockets may interfere with the healing process in the sockets.6 Coster et al 2009 evaluated BoneCe-ramic® as a grafting material in fresh extraction sockets.7 They found that at the time of implant surgery, bone at grafted sites was softer than in un-grafted controls, compromising initial implant stability. New bone formation at these allo-plast grafted sites was consistently poorer than controls, presenting with predominantly loose connective tissue and less woven bone. There-fore, BoneCeramic® in fresh extraction sockets appears to interfere with normal healing, and its use should be reconsidered.6,7 Clinical stud-ies on humans using demineralized freeze-dried bone allograft (DFDBA) and deproteinized natu-ral bovine bone mineral (Bio-Oss) have shown the presence of the grafted particles in the alve-olar socket 6 to 9 months following insertion.9

Ohayon 2014 studied the results of maxil-lary sinus floor augmentation using anorganic bovine bone (ABB) at 6-month and 5-year post surgery on the same human clinical case.14 Results at 6-months postoperative, the showed large remaining ABB particles integrated inside the newly formed bone architecture. At 5-years, small residual particles of ABB were sur-rounded by large areas of newly formed bone confirming the long-term ongoing resorption process of the ABB. Among the more impor-tant esthetic goals of socket grafting are the maintenance or enhancement of the facial and interproximal gingival contours and height of the interproximal papilla.8 Socket grafting minimizes residual ridge resorption, preserves crestal ridge volume after extraction, allows ideal implant placement in relation to bone and gingi-

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val tissues, reduces or eliminates ridge augmen-tation procedures during implant placement, and prevents loss of both hard and soft tissues, thus enhancing optimum esthetic outcomes.9

Grafting extraction sites with autogenous hard and soft tissue enables optimal preserva-tion of the ridge topography after tooth extrac-tion.10 Hanser et al evaluated alveolar ridge preservation and new bone formation through extraction site management in cases of buc-cal alveolar bone defects using autogenous hard and soft tissue grafts.5 Extraction sock-ets were completely filled with autogenous bone chips after tooth extraction and a free gingival-connective tissue graft from the pal-ate sealed the grafted extraction site. They judged that implants could be inserted into 81.0% of treated extraction sockets with-out additional grafting procedures after 10 to 12 weeks following socket augmentation.5

Landsberg investigated a minimally invasive socket grafting procedure immediately follow-ing tooth extraction known as socket-seal sur-gery.11 A soft-tissue graft harvested from the palate and placed on top of the bone graft in the socket produced optimal outcomes com-pared to control of grafting socket alone without soft-tissue graft. Currently, the most commonly used techniques for socket grafting are place-ment of the graft alone, placing a graft and cov-ering it with a membrane or collagen wound dressing, or placing a collagen sponge in the socket with or without any coverage. Ideally, all procedures concluded with flap advancement to achieve complete or partial primary closure.8

The majority of bone loss has been shown to be on the buccal aspect of the extraction socket.15 Studies reported that an immediate

implant with the retained buccal aspect of the root might be beneficial in preserving the alveo-lar ridge.20,24. Hurzeler et al. investigated plac-ing a buccal fragment of root approximately 1 mm coronal to the buccal bone plate in bea-gles.24 A titanium implant was placed lingual to that tooth fragment. Four months after implant placement, histological evaluation revealed that all four implants were osseointegrated with-out any histologic inflammatory reaction. The tooth fragment did not show any resorption and newly formed cementum was found directly on the implant surface adjacent to the fragment.

Various investigators have reported varying success rates for the outcome of intentional replantation (IR). Bender and Rossman evalu-ated 31 IR cases with an overall success rate of 80.6%.26 Nuzzolese et al. stated that the success rate of intentional replantation at five years reported in the literature ranges from 70 to 91%.28 In 1955, Hammer described the importance of leaving an intact PDL on intentionally replanted teeth.29 He believed that a healthy PDL is essential for reattach-ment and retention of replanted teeth. Conse-quently, ankylosis was not seen; however, all teeth showed resorption repaired with cemen-tum. These results were confirmed by Deeb in 1965 and Edwards in 1966.30, 31 The aim of this study is to evaluate alveolar ridge preser-vation and formation of new bone and cemen-tum using autogenous dentin sliver grafts.

METHODSThe research protocols were approved by the animal use committee (IACUC) and the insti-tutional review board (IRB) at the University of Alabama at Birmingham. Two healthy mon-

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grel dogs were used for the preliminary animal study using procedures described in a pre-vious report19. The maxillary premolars were hemisected and roots extracted individually. Crowns were removed by high-speed, water-cooled diamond and carbide burs and root slivers was fashioned by carving the majority of the root away to leave only a buccal sliver, approximately 1 mm thick about 120 degrees of the root’s circumference. The cementum-covered root surface was protected with a gauze sponge moistened with sterile saline. Longitudinally, the sliver reached from near the apex to 1 mm below the buccal bone crest. After 50 days and 98 days following surgery, animals were perfused with fixative and whole sections of the jaw were dissected

and processed for microscopic examination.Four patients with two single-rooted teeth

on either the mandible or maxilla that were treatment planned for routine extraction par-ticipated in first part of clinical study compar-ing ridge dimensions on dental stone models. All four participants were adults over the age of 30 with no major systemic and periodon-tal disease. Prior to their participation, a ver-bal description of the procedure was given to the patient followed by written consent. Stan-dardized volumetric measurements of the buc-cal alveolar contour were evaluated before tooth extraction using alginate impressions and stone casts. The patients were anesthetized using 2% lidocaine. The teeth were atraumati-cally extracted using an elevator and forceps.

Following the extraction, the socket was thoroughly curetted of all soft tissue debris. The tooth sliver was fashioned from the buc-cal root surface of the extracted tooth using a coarse-grit diamond in a water-cooled, high-speed handpiece. The carved dentin sliver was done chairside and the dimension of the sliver was approximately 1mm thick X 3mm X 5mm. The sliver was then placed back into the same site on the buccal aspect of the socket at least 1mm apical to the alveolar ridge crest (Figure 1). RegenerOss Allograft Putty (BIOMET, Palm Beach Gardens, FL, USA) was grafted to the site and a collagen mem-brane (ACE, Brockton, MA, USA) was placed over the grafted bone and dentin sliver. One or more sutures were used to hold the flap in place. The control site received the same treat-ment without the addition of the dentin sliver autogenous graft. After 6-7 months, the patients returned for a final alginate impression and

Figure 1: Graphic showing dentin sliver being placed at buccal aspect of extraction socket.


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stone casts, which were compared with the pre-treatment casts. Alveolar width resorption was evaluated between the two grafting methods.

Results showed that dentin sliver sites resorbed approxi-mately 18.6% less than controls (Table 1).

Six patients with 9 extraction sites partici-pated in the second aspect of the human study. The patients ranged in age from 20 to 70 years, the teeth were extracted due to non-restorable caries. All patients were physically healthy, with no underlying systemic disease. Periapi-cal radiographs were taken prior to the surgical procedure. Patients with significant periapical or periodontal pathosis were excluded. Patients were given 5 mL of a pre-operative chlorhexi-dine 0.12% rinse (Henry Schein, Chicago, IL, USA). The extraction sites were anesthetized with appropriate local anesthesia. The teeth were atraumatically removed and the socket

thoroughly curetted. The tooth sliver was fashioned from the buccal root aspect of the extracted teeth using a water-cooled, coarse-grit diamond bur. The dentin sliver consisted of approximately 1mm thickness of about 120º of the buccal circumference of the tooth. The sliver length was from about 1mm below the alveolar ridge crest to about 1mm short of the apex. It was then inserted back in its original position in the buccal aspect of the socket. The sock-ets were filled with RegenerOss Allograft Putty (BIOMET, Palm Beach Gardens, FL, USA), and covered with a collagen membrane (ACE, Brockton, MA, USA). The control site received the same graft and collagen membrane, with-out the addition of the dentin sliver autogenous graft. After surgery, an anti-inflammatory drug (ibuprofen 400mg) and 0.12% chlorhexidine rinse was prescribed twice per day for 7 days.

After 6 weeks, the patient’s bone samples

Table 1: Measurments of Ridge Dimensions

Patient Tooth # Site Pre-extraction 6 month % Decrease

8 Dentin Sliver+Allograft 10.42 6.92 33.6 1 11 Allograft only 10.57 5.57 47.6

27 Dentin Sliver+Allograft 9.03 8.19 9.3 2 22 Allograft only 9.54 8.02 15.9

26 Dentin Sliver+Allograft 8.88 4.1 53.8 3 23 Allograft 9.75 4.58 53.1

Note: Patient 4 sloughed the dentin sliver at 5 months post-op. Patient 1 #8 dentin sliver sloughed 1 month after the post-treatment impression was taken.

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were taken to histologically evaluate healing. Patients were given 5mL chlorhexidine 0.12% as a preoperative rinse. The grafted sites were anesthetized with appropriate local anesthetic. A small incision was made and a full-thickness flap reflected at the grafted site. A small 2mm diameter sample of bone and graft material was taken with a 2mm diameter trephine drill, hori-zontally placed in a buccal-lingual direction. The trephine containing the sampled bone and graft material was fixed in 10mL of 10% buffered formalin solution. In the histology laboratory, the bone core was removed from trephine bur and demineralized by alcohol and 0.1 M ethyl-ene diamine tetra-acetic acid (EDTA) at 42ºC.

Histological ProcedureThe specimens were cut longitudinally in

the bucco-lingual direction through the cen-tral axis of the dentin sliver. The specimens were embedded following complete dehy-dration in ascending grades of ethanol and EDTA in a light-curing one-component resin (Technovit 7200 VLC, Kulzers, Wehrheim, Ger-many) according to the standardized histol-ogy laboratory protocol. The specimens were cut into 8 micron sections and stained using hematoxylin-eosin, Masson’s trichrome, or Tartrate-resistant acid phosphatase (TRAP).

RESULTSDog specimens from both 50 and 98 days showed no inflammation as well as new cemen-tum and PDL on both sides of the dentin sliver (Figure 2) A few resorption lacunae were noted. These were no more than 20 um in depth,

Figure 2: Dog Study - new cementum and periodontal ligament observed on both side of the dentin sliver. “A” shows pre-existing cementum with thin layer of new cementum. “B” shows lingual aspect of sliver that was cut following extraction. Note new cementum formation and normal PDL. Normal bone is appreciated on the lingual aspect of the sliver, replacing the allograft.

Figure 3: Human Study - the buccal side of the dentin sliver revealed a normal and intact periodontal ligament. Note the absence of either osteoclasts adjacent to cementum or multinucleated cells within the resorption lacuna (Masson’s trichrome stain). Original magnification 20X.


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were free of osteoclasts, and new cementum could be appreciated within these. No inflam-matory cells were seen in these sites, or else-where in the microscopic examination. The bone grafts were almost completely replaced by new bone in the longer-term specimens.

In first part of the clinical study, the mea-sured widths and net changes of the pretreat-ment and post-treatment casts were recorded (Table I). Three patients’ casts were compared: two showed a decrease in net change with the experimental tooth sliver. Patient 3 showed an equal net change with both sites. Results were not statistically significant due to the small sam-ple size. The fourth patient sloughed the tooth sliver which was extracted before the 6 month recall. The first patient also sloughed the tooth sliver one month after the post-treatment cast

was taken and it had to be removed as well. In the histology part of the human study, all

nine of the extraction sites showed uncompli-cated healing with normal coverage by soft tis-sue. Some sections showed that the specimen separated during removal from the trephine bur. In two cases the trephine missed the den-tin sliver or the sliver was lost post-operatively. All intact sections of the dentin sliver revealed a normal, uninflamed periodontal ligament (Fig-ure 3). Where tissue separations occurred, no inflammation was seen on either side of the separation. No active resorption was observed on either the unaltered dentin or the cut den-tin surfaces. TRAP and trichrome stains con-firmed the impression from H&E sections that no active osteoclastic resorption was present (Figure 4). New formation of woven bone was

Figure 4: Sequential section of image in Figure 3. The buccal side of the dentin sliver revealed a normal and intact periodontal ligament. TRAP stain shows no osteoclastic activity in the old resorption lacuna. Original magnification 20X.

Figure 5: Human- at six weeks. A thin layer of newly-formed cementum covered the surface of the cut dentin sliver. Original magnification 100X.

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observed in all the graft sites. The cut surface of the sliver was partially covered by a thin layer of newly-formed cementum (Figure 5) in one specimen, but the PDL was damaged dur-ing processing. The newly-formed cementum demonstrated its firm attachment to the dentin.

DISCUSSIONIn the preliminary dog study, healthy tooth sliv-ers showed excellent healing in the healthy animals. Arguably, this might not be the case with dentin from diseased teeth or in humans.

Chronic inflammation in the peri-radicular region, or the presence of bacteria peri-radicu-larly or within the dentinal tubules could account for problems seen in some of the human cases. A history of tobacco smoking was unknown and may have been a factor in the overall heal-ing outcome. Patient behaviors could have played a role in cases where the dentin sliver was lost. An example of such behaviors could have been vigorous debridement of the exist-ing bone which resulted in increased gap formation between the graft and the socket wall, leading to its eventual dislodgement.

Casey and Lauciello in 1980 reviewed the submerged-root concept and concluded that it could be a safe technique for socket preservation.6 Hurzeler et al. in 2010 placed four implants in a beagle dog leaving the buc-cal part of the extracted tooth root and supra-periosteal attachment to help preserve the alveolar ridge.24 Histologically, they noted new cementum and new periodontal attach-ment on both side of the buccal dentin as well as on the surface of the implant at 4 months.

Wang & Lang showed that applying guided bone regeneration principles using

bone allografts together with a collagen membrane has positive effects on preserv-ing alveolar ridge height as well as ridge width, yet this augmentation regresses after 7 months.19 They also noted improved ridge preservation using human demineralized bone matrix irrespective of the particle sizes.8,19

Histologically, the dentin sliver revealed a normally appearing and intact periodon-tal ligament without inflammatory activity or resorption on both the unaltered dentin as well as on the cut dentin surfaces. No sign of active tooth resorption was seen, and new cementum and reformation of the PDL were visible on both dentin sides. These results appear to be promising regard-ing this future socket preservation method.

It is well known that dental replantation fol-lowing traumatic avulsion is successful if cel-lular vitality and the periodontal ligament are retained. The rate of endodontic success for replanted teeth at five years ranges between 70% and 91%.28 Differing prognoses exist for intentional dental replantation and trauma-related replantation due to such important variables as the level of cellular vitality in the periodontal ligament, the degree of trauma to surrounding tissues, and the degree of asepsis when a tooth is removed.26,28

In the ridge measurement clinical study, it was observed that the net bone width loss was reduced with the experimental dentin sliver used for socket preservation. Also, two of the four patients eventually sloughed the tooth sliver due to unknown reasons. We sus-pect that residual bacteria contained within the tooth sliver may be responsible, despite stud-ies by Love et al. who reported seeing canal


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bacteria penetrating only a portion of the den-tin tubules immediately adjacent to the canal.32

In the trephine study, two specimens failed to contain the dentin sliver. Perhaps this was due to the trephine missing the dentin sliver. Perhaps the sliver had been resorbed, or per-haps the sliver was sloughed without the patient’s knowledge or recollection. Regard-less, this observational study produced eigh-teen good sections of the dentin sliver, all with excellent healing, including new cemen-tum present on the cut surface. The presence of newly-formed cementum means that pre-cementum must also be present. Precemen-tum (and predentin) are well known to prevent osteoclast invasion in the absence of long term inflammation.26,28 It is our conclusion that long term maintenance of the dentin sliver, with concomitant retention of the specialized bone unique to the alveolus will preserve ridge width and height, thus helping to stabilize bone and soft tissue levels around dental implants.

Future studies might include utilizing micro-biology, and a disinfectant or antibiotic on the dentin sliver or socket to address recalcitrant bacteria. Different membranes or more effec-tive debridement of the socket may also be investigated. All the allografts observed his-tologically in the present study showed excel-lent healing, with replacement by normal host bone. The replacement in humans was nearly complete at six weeks. In this study, the buc-cal dentin sliver autograft healed well and appears to act as a durable means of pre-serving the labile buccal bone and associated soft tissue. Future studies on longer follow up of sockets preserved with the buccal tooth sliver and with immediate implant placement

are needed to further evaluate this method.

CONCLUSIONApplying guided bone regeneration principles using bone allograft, membrane, and a den-tin autograft has shown promising effects on preserving alveolar ridge height and width. Including a dentin buccal root autograft in the socket grafting procedure resulted in nor-mal healing, and may be beneficial in pre-serving the buccal bone for future implant placement and restorative purposes. ●

Correspondence:

Dr. Paul D. Eleazer

Department of Endodontics

University of Alabama at Birmingham

School of Dentistry

1919 Seventh Avenue South, SDB 417

Birmingham, AL 35294

Phone: 205-934-5373

Fax: 205-975-9197

E-mail: [email protected]

42 • Vol. 7, No. 4 • April 2015

Pham et al

DisclosureThis project was supported by DENTSPLY-Tulsa fund for the animal study and by the Department of Endodontics Research Endowment, University of Alabama at Birmingham and The Foundry Dental Clinic fund for the human study.

References1. Tan WL, Wong TL, Wong MC, et al. A systematic

review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res. 2012;23(5):1-21.

2. Vignoletti F, Matesanz P, Rodrigo D, et al. Surgical protocols for ridge preservation after tooth extrac-tion. A systematic review. Clin Oral Implants Res. 2012;23(5):22-38.

3. Wang RE, Lang NP. Ridge preservation after tooth extraction. Clin Oral Implants Res. 2012;23(6):147-56.

4. Araujo M, Linder E, Lindhe J. Effect of a xenograft on early bone formation in extraction sockets: an experimental study in dog. Clin Oral Implants Res. 2009;20:1-6.

5. Hanser T, Khoury F. Extraction site management in the esthetic zone using autogenous hard and soft tissue grafts: a 5-year consecutive clini-cal study. Int J Periodontics Restorative Dent. 2014;34(3):305-12.

6. Casey DM, Lauciello FR. A review of the submerged-root concept. J Prosthet Dent. 1980;43:128-32.

7. De Coster P, Browaeys H, De Bruyn H. Healing of extraction sockets filled with BoneCeramic® prior to implant placement: Preliminary histo-logical findings. Clin Implant Dent Relat Res. 2011;13:34–45.

8. Darby I, Chen S, De Poi R. Ridge preservation: what is it and when should it be considered. Aust Dent J. 2008;53(1):11-21.

9. Camargo PM, Lekovic V, Weinlaender M. Influence of bioactive glass changes in alveolar process dimensions after exodontia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(5):581-6.

10. Houston F, Sarhed G, Nyman S, et al. Healing after root reimplantation in the monkey. J Clin Periodontol. 1985;12(9):716-27.

11. Landsberg CJ. Implementing socket seal surgery as a socket preservation technique for pontic site development: Surgical steps revisited. A report of two cases. J Periodontol. 2008;79(5):945-54.

12. Gound T, O’Neal RB, del Rio CE, et al. Submer-gence of roots for alveolar bone preservation. II. Reimplanted endodontically treated roots. Oral Surg Oral Med Oral Pathol. 1978;46(1):114-22.

13. Plata RL, Kelln EE, Linda L. Intentional retention of vital submerged roots in dogs. Oral Surg Oral Med Oral Pathol. 1976;42(1):100-8.

14. Ohayon L. Histological and histomorphometric evaluation of anorganic bovine bone used for maxillary sinus floor augmentation: a six-month and five-year follow-up of one clinical case. Implant Dent. 2014;23(3):239-44.

15. Pietrokovski J, Massler M. Alveolar ridge resorp-tion following tooth extraction. J Prosthet Dent. 1967;17:21-7.

16. Fickl S, Zuhr O, Wachtel H. Hard tissue altera-tions after various socket preservation tech-niques – an experimental study in the beagle dog. Clin Oral Implants Res. 2008;19:1111-8.

17. Vina-Almunia J, Candel-Marti M, Cervera-Balles-ter J. Buccal bone crest dynamics after immedi-ate implant placement and ridge preservation techniques: review of morphometric studies in animals. Implant Dent. 2013;22:155-60.

18. Araùjo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol. 2005;32:212–8.

19. Eleazer PD, Rhodes CS, Horn DM, DeVilliers P, Wei S, Novak L, Dohm ED, Weems RA, Litaker MS. In vivo evaluation of an experimental root-end filling material versus MTA. Open J Anim Sci. 2013;3(3A):19-23.

20. Kassim B, Ivanovski S, Mattheos N. Current perspectives on the role of ridge (socket) preservation procedures in dental implant treatment in the aesthetic zone. Aust Dent J. 2014;59(1):48-56

21. Agarwal G, Thomas R, Mehta D. Postextraction Maintenance of the Alveolar Ridge: Rationale and Review. Compend Contin Educ Dent. 2012;33(5):320-4

22. Oghli A, Steveling H. Ridge preservation fol-lowing tooth extraction: A comparison between atraumatic extraction and socket seal surgery. Quintessence Int. 2010;41(7):605-609.

23. Reames RL, Nickel JS, Patterson SS, Boone M, el-Kafrawy AH. Clinical, radiographic, and histological study of endodontically treated re-tained roots to preserve alveolar bone. J Endod. 1975;1(11):367-73

24. Hurzeler MB, Zuhr O, Schupbach. The socket shield technique: a proof-of-principle report. J Clin Periodontol. 2010;37:855-62.

25. O’Neal RB, Gound T, Levin MP, del Rio CE. Submergence of roots for alveolar bone preser-vation. I. Endodontically treated roots. Oral Surg Oral Med Oral Pathol. 1978;45(5):803-10.

26. Bender IB, Rossman LE. Intentional replantation of endodontically treated teeth. Oral Surg Oral Med Oral Pathol. 1993;76(5):623-30.

27. Rouhani A, Javidi B, Habibi M, Jafarzadeh H. Intentional replantation: a procedure as a last re-sort. J Contemp Dent Pract. 2011;12(6):486-92.

28. Nuzzolese E, Cirulli N, Lepore MM, D’Amore A. Intentional dental reimplantation: a case report. J Contemp Dent Pract. 2004;5(3):121-30.

29. Hammer H. Reimplantation of teeth and implan-tation of foreign substances. Osterr Z Stomatol. 1955;52(7):357-8.

30. Deeb E, Prietto PP, McKenna RC. Reimplanta-tion of luxated teeth in humans. J South Calif Dent Assoc. 1965;33(4):194-206

31. Edwards TS. Treatment of pulpal and peri-apical disease by replantation. Br Dent J. 1966;121(4):159-66.

32. Love RM, Jenkinson HF. Invasion of dentinal tubules by oral bacteria. Crit Rev Oral Biol Med. 2002;13(2):171-83.

Pham et al

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Khanna et al

Khanna et al

Treating full arch multiple implant supported complex cases is clinically and techni-cally challenging. To obtain precise and

accurate impressions is critical to minimize the laboratory errors and prevent prosthesis misfit. Splinting of implant impression copings has been recommended when fabricating prostheses sup-ported by multiple implants. Various techniques

have been reported in the past for complex mul-tiple abutment impressions like using acrylic resin using dental floss or orthodontic wires are time-consuming and add to the complexity of the pro-cedure. This article presents a convenient, cost effective technique which simplifies the complex full arch multi implant impression procedures to obtain accurate and predictable impressions.

Complex Full arch Implant Impressions Simplified: A Clinical Tip for

Accurate Predictable Impressions

Dr. Anshul Khanna, MDS1 • Shantanu S Jambhekar, MDS2 Dr. Jyoti Karani3 • Dr. Ashutosh Pai4

1. Department of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai.

2. Department of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai and Former ITI Scholar, Department of Reconstructive Sciences (Division of Prosthodontics) University of Connecticut,

School of Dental Medicine, Farmington, CT, USA

3. Professor and Head, Department of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai.

4. Department of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai. Department(s) and institution(s): Department of Prosthodontics, Terna Dental College, Nerul, Navi Mumbai.

Abstract

KEY WORDS: Implant impressions, light cured acrylic resins, impression material


46 • Vol. 7, No. 4 • April 2015

BACKGROUNDThe introduction of osseointegrated implants in the early 1980’s altered the way in which partially and fully edentulous patients are treated prostheti-cally.1 The prosthetic rehabilitation of the edentu-lous maxilla and mandible can be achieved using removable implant retained, implant-supported, or fixed implant-supported prostheses. Several long-term prospective and retrospective stud-ies reported high survival and success rates for implant-supported prosthesis for full-arch reha-bilitations.2-4 These treatment options have been shown to provide patients with a high degree of satisfaction and to have a positive effect on their quality of life.5 Treating full arch multiple implant supported complex cases is clinically and tech-nically challenging, yet highly rewarding to both patient and clinician when successfully completed. The most challenging and critical aspect of an ideal impression is to precisely and accurately record the correct three dimensional position-ing of the implant in the apicocoronal, mesiodis-tal and buccolingual dimensions to minimize the laboratory errors and produce prosthesis mis-fit. Various techniques have been reported in the past for complex multiple abutment impressions like using acrylic resin using dental floss, prefab-ricated acrylic resin bars, stainless steel burs, and orthodontic wires as a scaffold.6-8 However these methods besides being time-consuming add to the complexity of the procedure. The large amount of acrylic resin is required to splint the impression copings and its resultant shrinkage increases the inaccuracies. This article presents a convenient, cost effective technique which simplifies the com-plex full arch multi implant impression procedures to obtain accurate and predictable impressions.

PROCEDURE1. At the definitive impression appointment, the

healing abutments are removed. Direct impres-sion copings are then screwed in and the seat-ing/ fit is verified radiographically (Figures 1, 2).

2. Light cure for record base is taken and rolled into string (Figure).

3. These strings are adapted along grooves in the body of the impression copings on both the buccal and lingual/palatal aspects. Apply finger pressure to ensure the impres-sion copings are locked (Figure 3).

4. After ensuring the close adaptation of the material to the impression copings, it is light cured with a light cure gun.

5. Definitive impression can be made in medium bodied polyether elastomeric impression material (Figure4).

DISCUSSIONInaccuracies during impressions inevitably lead to laboratory errors resulting in lack of preci-sion and misfit of prostheses, particularly in fixed and implant-supported prosthodontics.9-11

Literature has reported that prosthetic misfit is likely to increase the incidence of mechanical complications like occlusal discrepancies, screw, and abutment loosening and fracture of the pros-thetic or implant components.12-17 Marginal dis-crepancies caused by the misfit enhance plaque accumulation, thus affecting peri-implant hard and soft tissues.18,19 Making accurate impressions is the first step in achieving an accurate, passively fitting prosthesis.13-15 For implant impression making, transfer techniques such as the different direct or indirect impression techniques, the use of different impression materials, splinting or sur-face treatment of impression copings, the relative

Khanna et al


implant angulation, the die material accuracy, and master cast realization have a decisive influence on the fabrication of accurate working casts.20-30

Most of the researchers reported the open-tray pick-up technique to be more precise and predict-able than the closed tray technique using repo-sitionable copings.31-33 Literature has reported based on clinical and laboratory studies that the splinted impression technique generates more accurate implant impressions and master casts than the non splinted technique for complete-arch

multiple implant supported prostheses.6-8, 34 The light cure resin allows fast and simple modality to rigidly splint the direct impression copings intra-orally. Thus saving valuable clinical time. Since material is completely cured chairside curing unit, there is minimum dimensional changes. Further rigidity of the material minimizes/prevents distor-tion /deformation on removal of the impression.

Figure 1: Dental implant healing abutments prior to removal.

Figure 2: Open tray impression copings screwed into place and fit verified with radiograph.

Figure 3: Light cured resin used to connect all impression copings.

Figure 4: Definitive impression with medium bodied polyether elastomeric impression material.

Khanna et al

48 • Vol. 7, No. 4 • April 2015

Khanna et al

CONCLUSIONThe technique discussed above is a pre-cise and simple way of making complex full arch multi implant impressions. Thus the technique described here simplifies the complexity of full arch impressions involv-ing multiple implants and helps obtain accurate and predictable impressions. ■

Correspondence:Dr. Anshul Khanna,A, 203 Safal Park, Plot No. 3 And 12,Sector 25, Nerul East,Navi Mumbai. - 400706.Tel: 09323727089Email: [email protected]


References1. Jambhekar S, Kheur M, Jothavade M, Dugal R.

Occlusion and Occlusal Considerations in Implan-tology. Indian J Dent Adv 2010:1(2):125-130.

2. R. Adell, B. Eriksson, U. Lekholm, P. I. Bråne-mark, and T. Jemt, “Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws,” The International Journal of Oral & Maxillofacial Implants, vol. 5, no. 4, pp. 347–359, 1990.

3. T. Jemt and J. Johansson, “Implant treatment in the edentulous maxillae: a 15-year follow-up study on 76 consecutive patients provided with fixed prostheses,” Clinical Implant Dentistry and Related Research, vol. 8, no. 2, pp. 61–69, 2006.

4. P. Åstrand, J. Ahlqvist, J. Gunne, and H. Nilson, “Implant treatment of patients with edentulous jaws: a 20-year follow-up,” Clinical Implant Dentistry and Related Research, vol. 10, no. 4, pp. 207–217, 2008

5. ld intro ref 6

6. Inturregui JA, Aquilino SA, Ryther JS, Lund PS. Evaluation of three impression techniques for osseointegrated oral implants. J Prosthet Dent 1993; 69:503–509.

7. Phillips KM,Nicholls JI,Ma T, Rubenstein J. The accuracy of three implant techniques: a three dimensional analysis. Int J Oral Maxillofac Implants 1994; 9:533–540.

8. Dumbrigue HB, Gurun DC, Javid NS. Prefabricat-ed acrylic resin bars for splinting implant transfer coping. J Prosthet Dent 2000; 84:108–110

9. Lee H, Ercoli C, Funkenbusch PD, Feng C. Effect of subgingival depth of implant placement on the dimensional accuracy of the implant impres-sion: an in vitro study. J Prosthet Dent 2008; 99:107–113.

10. Jemt T. In vivo measurements of precision of fit involving implant-supported prostheses in the edentulous jaw. Int J Oral Maxillofac Implants 1996; 11:151–158.

11. Jemt T, Rubenstein JE, Carlsson L, Lang BR.Measuring fit at the implant prosthodontic interface. J Prosthet Dent 1996;75:314–325.

12. Tan KB, Rubenstein JE, Nicholls JI, Yuodelis RA. Threedimensional analysis of the casting accuracy of one-piece, osseointegrated implant-retained prostheses. Int J Prosthodont 1993; 6:346–363.

13. Phillips KM, Nicholls JI,Ma T, Rubenstein JE. The accuracy of three implant impression techniques: a 3-dimensional analysis. Int J Oral Maxillofac Implants 1994; 9:533–540.

14. Sahin S, Cehreli MC. The significance of passive framework fit in implant prosthodontics: current status. Implant Dent 2001; 10:85–92.

15. Heckmann SM, KarlM,Wichmann MG,Winter W, Graef F, Taylor TD. Cement fixation and screw retention: parameters of passive fit. An in vitro study of three-unit implant supported fixed partial dentures. Clin Oral Implants Res 2004; 15:466–473.

16. Wee AG, Aquilino SA, Schneider RL. Strate-gies to achieve fit in implant prosthodontics: a review of the literature. Int JProsthodont 1999; 12:167–178.

17. Jemt T, Book K. Prosthesis misfit and marginal bone loss inedentulous implant patients. Int J Oral Maxillofac Implants 1996; 11:620–625.

18. Ericsson I, Persson LG, Berglundh T,Marinello CP, Lindhe J, Klinge B. Different types of inflam-matory reactions in periimplant soft tissues. J Clin Periodontol 1995; 22:255–261.

19. Leonhardt A, Renvert S, Dahlen G. Microbial findings at failing implants. Clin Oral Implants Res 1999; 10:339–345.

20. Carr AB,Master J. The accuracy of implant verification casts compared with casts produced from a rigid transfer coping technique. J Prostho-dont 1996; 5:248–252.

21. Assif D, Nissan J, Varsano I, Singer A. Accuracy of implant impression splinted techniques: effect of splinting material. Int J Oral Maxillofac Implants 1999; 14:885–888.

22. Vigolo P, Majzoub Z, Cordioli G. In vitro com-parison of master cast accuracy for single-tooth implant replacement. J Prosthet Dent 2000; 83:562–566.

23. Daoudi MF, Setchell DJ, Searson LJ. A laboratory investigation of the accuracy of two impres-sion techniques for single-tooth implants. Int J Prosthodont 2001; 14:152–158.

24. Vigolo P,Majzoub Z, Cordioli G. Evaluation of the accuracy of three techniques used for multiple implant abutment impressions. J Prosthet Dent 2003; 89:186–192.

25. Akca K, Cehreli MC. Accuracy of 2 impression techniques for ITI implants. Int J Oral Maxillofac Implants 2004; 19:517–523.

26. Assuncao WG, Filho HG, Zaniquelli O. Evalua-tion of transfer impressions for osseointegrated implants at various angulations. Implant Dent 2004; 13:358–366.

27. Naconecy MM, Teixeira ER, Shinkai RS, Frasca LC, Cervieri A. Evaluation of the accuracy of 3 transfer techniques for implant-supported prostheses with multiple abutments. Int J Oral Maxillofac Implants 2004; 19:192–198.

28. Vigolo P, Fonzi F, Majzoub Z, Cordioli G. An evaluation of impression techniques for multiple internal connection implant prostheses. J Pros-thet Dent 2004; 92:470–476.

29. Vigolo P, Fonzi F, Majzoub Z, Cordioli G. Master cast accuracy in single-tooth implant replace-ment cases: an in vitro comparison.A technical note. Int J OralMaxillofac Implants 2005; 20:455–460.

30. Cehreli MC, Akca K. Impression techniques and misfitinduced strains on implant-supported su-perstructures: an in vitro study. Int J Periodontics Restorative Dent 2006; 26:379–385.

31. Hsu CC,Millstein PL, Stein RS.A comparative analysis of the accuracy of implant transfer tech-niques. J Prosthet Dent 1993; 69:588–593.

32. Humphries RM , Yaman P, Bloem TJ. The ac-curacy of implant master casts constructed from transfer impressions. Int J Oral Maxillofac Implants 1990; 5:331–336.

33. Wostmann B,Rehamann P,Balkenhol M.Influence of impression technique and material on the accuracy of multiple implant impressions Int J Prosthodont 2008;21:299-301.

34. 9. Assif D, Nissan J, Varsano I, Singer A. Accu-racy of implant impression splinted techniques: effect of splinting material.Int J Oral Maxillofac Implants 1999; 14: 885-888

Khanna et al

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The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

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Wilcko et al

A number of clinical factors like trauma, past surgical procedures and various pathologic conditions cause substan-

tial alteration of normal bone structure requir-ing osteoregenerative procedures to restore an adequate volume and architecture of alveo-lar structure needed for implant placement.

Background: The objective of this retrospec-tive study was to analyze clinical benefits gained by a completion of guided osseous tis-sue regeneration treatment with the utilization of a “tunnel approach.” Additionally, this ret-rospective in-office study compares statisti-cal quantitative postoperative values obtained and assessed in association with this modified guided tissue regeneration therapy to the out-comes of comparative published clinical studies.

Methods: The study included 16 patients diagnosed with alveolar ridge deficiency impeding adequate implant placement. Lat-eral ridge augmentation with plans for delayed

implant placement was completed on 39 sur-gical sites, of which 28 were maxillary and 11 mandibular. All 39 surgical sites were eval-uated at 6 months after the surgical ridge reconstruction using the “tunnel approach”.

Results: Notwithstanding the differences in clinical techniques, “tunnel approach” to the guided tissue regeneration of hori-zontal of the alveolar ridge has proven to predictably produce statistically similar suc-cess rates and measurable volumes of alve-olar bone in the areas of bony defects as other scientific studies published in the pro-fessional literature. Success rate reported in this study was determined at 97.2%.

Conclusions: This analysis established a statistically significant similarity between the results obtained after lateral alveolus “tunnel approach” guided bone regeneration and the outcomes of lateral ridge augmentation com-pleted by means of other clinical techniques.

Regeneration of the Deficient Alveolar Ridge with Utilization of “Tunnel Approach” to Guided Bone

Regeneration. A Retrospective Study of the Outcomes

Edward Ruvins, DDS, MS, MBA1 • Mark Stein, DDS, MD2 Susanna Kayserman, DDS3

1. Private Practice, Denver, Colorado, USA

2. Board Certified Oral & Maxillofacial Surgeon, Private Practice, New York City, New York

3. Private Practice, Warren, New Jersey

Abstract

KEY WORDS: Dental implants, guided bone regeneration, tunnel technique, bone


52 • Vol. 4, No. 15 • April 2015

Ruvins et al

INTRODUCTIONImproved clinical standards in the field of restor-ative dentistry have significantly changed the sur-gical treatment planning approach to the majority of the dental implant cases. From the routine placement of single unit fixtures to the complex restorations of severely compromised clinical cases, the demands for a predictable surgical, restorative and esthetic outcome caused a para-digm shift in our approach to case planning, goal establishment and standards of quality assess-ment. The challenges of many clinical cases lie in difficulties of management of severely compromised ridge defects to maximize suc-cessful surgical and restorative outcomes.

Guided bone regeneration (GBR) has been historically indicated for correction of vol-ume deficiency of the residual alveolar ridge limiting implantation and optimal esthetic and functional outcomes. The “tunnel approach” tech-nique to bone grafting is well known and was developed as an alternative modification to the traditional open flap surgical approach to con-

ventional guided tissue regeneration technique. The research method used in this study

was designed to quantitatively assess the suc-cess rates of the “tunnel approach” technique of guided tissue regeneration and compare the out-comes with data published in scientific clinical literature relating to guided tissue regeneration of lateral ridge accomplished by other tech-niques. Computation of cumulative success rate data available in current scientific publications was also compared to the findings in this study.

METHODSThe study of 16 patients and 39 surgi-cal sites was conducted between Jan-uary 2008 and February of 2013.

Patient SelectionThe subjects for this study were screened and selected according to the inclusion and exclusion criteria listed below. All selected patients were informed on the nature of the study, presented with alternatives and had consented to the treat-

Figure 1: Visual Assessment of the Maxillary Ridge Deficiency

Figure 2: Clinical Measurements of the Ridge at the Reference Points with Ridge Caliper.


Ruvins et al

ment and postoperative follow up protocol. Prior to surgery, in attempt to achieve optimal oral health, all patients (excluding fully edentulous sub-jects) underwent a pre-treatment phase consisting of dental prophylaxis, limited or complete scal-ing and root planning (when needed) and post-operative oral hygiene instructions. All subjects included in this study demonstrated adequate abilities to maintain sufficient level of oral health.

Inclusion Criteria ● Manageable medical conditions● Controlled oral hygiene● Absence of non-healing oral lesions● Horizontal bone deficiency preventing implant

placement without bone grafting● Adequate vertical dimension of alveoli to sub-

sequently place at least 8mm implant fixtures● Adequate volume of soft tissue to complete

flapless approach to the recipient site in attempt to preserve crestal bone-gingival seal and facilitate an adequate clinical and esthetic integration.

Exclusion CriteriaFollowing exclusion criteria were imposed:● Active smoking (more than 3 cigarettes per day)● History of both oral and IV bisphosphonates

intake ● Active chemo- or radiation therapy● Inflammatory intraoral conditions● Chronic xerostomia● Acute or chronic kidney, liver, hematologic and

immune diseases● Pregnancy● Poor oral hygiene● Acute or chronic periodontal conditions● Autoimmune diseases ● History of neoplasm within 10 yr. prior to the

study participation ● Rheumatic or degenerative diseases● Chronic or acute systemic infections

(HIV, HBV, HCV, STD) ● Failure on the part of the patient to follow up

with the treatment.Exclusion criteria, when applied, resulted in elimination of eight subjects with acceptable ridge defects from the study.

Figure 3: Initial Vertical Incision and Gingival Tissue Elevation.

Figure 4: Decortication of the Recipient Site with Bone Scraper.

54 • Vol. 4, No. 15 • April 2015

Ruvins et al

Study ProtocolInitially, 16 patients were selected for the study regardless of the extent of the edentulism. All patients consented to the procedure and were aware of the participation in the study. The extent of the horizontal ridge atrophy was uniformly advanced enough to directly limit the prospec-tive patient of adequate implant site preparation and necessitated delayed implant placement. All subjects had guided tissue regeneration pro-cedure with the “tunnel approach” (Figures 1-7) completed at least 24 weeks (6 months) prior to the implant placement, to repair deficient bone configuration and facilitate appropriate implant positioning and osseous coverage. Guided tis-sue regeneration in both methods discussed was completed under local anesthesia in an office set-ting. Pre-operative work up included initial diag-nostic preoperative radiographs, ridge mapping and preoperative cone beam CT scan. All surgical procedures were completed by the same surgeon under local anesthesia. Initial one week follow up appointments were followed by monitoring

appointments scheduled at one, three, five and six month’s intervals. Exclusion criteria, when applied, resulted in elimination of eight subjects from the study. Even though the eliminated subjects had ridge defects that qualified for the study, they possessed one or more of the exclusion criteria.

Data Collections and MethodsInitial measurement data was collected on the day of the surgery under local anesthesia (Figure 1.) Three referenced dimensional points were estab-lished and used for all measurements. Three refer-ence points were established at three (3), six (6) and nine (9) mm apically from the tip of the crestal bone respectively. Reference points were desig-nated as A, B and C. The limitations of the caliper design forced the measurements to be rounded to the closest of 0.5mm value, for accuracy. The reference point of the crestal bone tip was established with trans-gingival application of periodontal probe under local anesthesia. Crestal bone reference point was desig-nated as [T]. Prefabricated surgical guides were used to establish initial reference point T and reli-

Figure 5: Strap Suture Preparation for Membrane Placement.

Figure 6: Membrane Placement and Fixation.


Ruvins et al

ably used the same position at the crest of alveolar bone for the 6 months of follow up measurements. Data collected was assembled in a summary table (Table 1). Respective designations were assigned: [a], [b] and [c] for presurgical measure-ments at reference points; [A], [B] and [C] for postsurgical measurements at reference points. Postoperative control measurements were con-ducted utilizing the same measurement protocol at six months. Data collected was also assembled in a summary table. Assessment and analysis of com-bined data was conducted with utilization of Microsoft Office 2007 Excel (Microsoft©, Inc.) statistical functions.

It is important to state that even though in all of the cases utilized for this study, a preop-erative CT scan was obtained as a part of the clinical protocol, it was clinically unfounded to expose all of the patients involved in this study to the additional radiation of a postoperative CT scan. The actual preoperative and postopera-tive measurements were conducted manually by the clinician conducting the study to preserve consistency of the statistical values. Addition-

ally, postoperative measurements were con-ducted as close as possible to the 6 month time line established by a clinical protocol to, again, preserve an adequate accuracy of the data.

Statistical AnalysisStatistical analysis was used to interpret the results of this study. Mean and median statistical values were calculated and used for visual recon-struction of the ridge map based on the statisti-cal mean of collected data. Data comparison was designed as a pair comparison of a mathematical difference between the values designated as D ([A – a=D(A)], [B - b=D(B)] and [C – c=D(C)]). Additionally, the final value of D was calculated as a mathematic mean of D(A), D(B) and D(C). Statistical Methods For the purpose of statistical accuracy, numerical tests utilized in this study are based on the prin-ciple that each subject and each measurement was sampled independently of the rest. Any pos-sible random factor in this study protocol could not affect more than one value preserving data independency. Statistical outcome of the research would not be compromised if any random factor would cause a value of numerical measurement obtained during the study to be too high or too low and consequently affect the rest of the values.

RESULTSThe final census of the study was established at 16 patients (10 men and 6 women). Lateral ridge augmentation was completed on 39 sur-gical sites that were augmented with plans for delayed implant placement. All 39 surgical sites were evaluated at 6 months after the surgical ridge reconstruction. Out of 39 sites included in this

Figure 7: Postoperative View.

56 • Vol. 4, No. 15 • April 2015

Ruvins et al

study there were 28 maxillary and 11 mandibular. Secondary to one incidence of a postopera-

tive infection, the success rate was determined to be at 97.2%. Even though it was treated suc-cessfully with 0.12% Chlorhexidine Gluco-nate / Doxycycline lavage and no recurrence or a need for an additional surgical revision, it affected the cumulative success rate of this study.

Analysis of Measurements Analysis of two independent samples deliv-ered the following results: D value was calcu-lated as a mathematic mean of D(A), D(B) and D(C) and is a mathematical mean of

values ([A–a=D(A)], [B-b=D(B)] and [C – c=D(C)]) and was established at 2.1mm with standard deviation value of 1.175mm. The summary of initial mean values for pre-operative, postoperative, maxillary, mandibu-lar and mean values presented in Table 1.

Clinical analysis of the data based on pre-augmentation and post-augmentation mea-surements established that in all augmented sites a consistent and statistically measurable increase of the bone volume was achieved. The data collected from the clinical group of patients involved in this study demonstrated 2.1mm +/- 1.18 mm (32.6%) gain with a larg-

Table 1: Summary of Preoperative (a, b, c) and Postoperative (A, B, C) Site Specific Measurement Values (Mean)

Mean (mm) St. Deviation Maxilla (mm) Mandible (mm)

D(A) Value

Preoperative Measurements (a) 5.2 2.2 1.9 1.4

Postoperative Measurements (A) 7.2 1.8 2.7 1.9

Gain/Loss 2.0 0.8 0.5

D(B) Value

Preoperative Measurements (b) 6.1 2.1 2.2 1.7

Postoperative Measurements (B) 8.2 1.3 3.1 2.2

Gain/Loss 2.1 0.9 0.5

D(C) Value

Preoperative Measurements (c) 7.4 2.2 2.8 2.0

Postoperative Measurements (C) 9.4 1.5 3.5 2.5

Gain/Loss 2.0 0.7 0.5


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est amount of linear gain at 2.6mm. Maxil-lary augmentation demonstrated an average of 2.1mm gain, while mandibular average gain was 1.2mm of newly formed bone at the recipi-ent sites. A general summary of pre- and post-operative means was compiled in the Table 2.

DISCUSSIONA variety of available bone grafting tech-niques present many possibilities for surgical practitioners expecting a successful outcome. The gold standard approach to alveolar ridge deficiency regeneration was using monocor-tical grafts harvested from various autoge-nous donor sites. Buser et al. (1993)1, Mahn (2010)2 and Aghaloo and Moy (2007)3 reported successful bone regeneration with Guided Tissue Regeneration (GTR). Significant con-tributions by Pikos (1995, 1996, 1999)4,5,6

in many clinical reports presented a success-ful series of cases utilizing autograft blocks harvested from the chin and posterior man-dible for localized mandibular and maxillary ridge augmentations with superior results.

Regeneration of the deficient alveolar ridge with “Tunnel Approach” guided tissue regen-eration technique produces predictable and statistically measurable outcomes that are com-parable to other clinical techniques of guided tissue regeneration reported in the published clinical research literature. This approach also presents important clinical benefits.

The “Tunnel Approach” to GBR is con-servative. An attractive feature of the “tunnel approach” has been its conservatism to soft tissue management in an attempt to prevent dehiscence and gingival recession. Toscano et al. (2010)7 who presented works by Gapski

et al. (2001)8 summarizing analysis of several surgical incision techniques such as sulcu-lar, attached gingiva and vestibular incisions focused on the common disadvantages of those surgical approaches. In 2007 Kfir et al.9 presented “tunnel approach” to Guided Bone Regeneration (GBR) as “minimally invasive.” In addition to Kfir et al. (2007)9 other clinicians like Azzi et al. (2009)10 and Lee et al. (2000)11 emphasized the conservative nature of the “tun-nel approach” to guided tissue regeneration or connective tissue grafting. Work of Heller AL and, Heller RL (2010)12 provided a well-developed rationale for tissue management protocols in cases utilizing “tunnel approach.”

The surgical technique is versatile. “Tunnel approach” also affords the clinician with sig-nificant clinical versatility and has been shown to work well even if modified by different clini-cians. While techniques used by Mazzocco et al. (2008)13 advocated elimination of the need

Table 2: Summary of Measurements

Mean Initial Measurements/Total Value 4.7

Mean Final Measurements/Total Value 7.3

Gain/Loss 2.6

Mean Initial Measurements/Maxilla 2.3

Mean Final Measurements/Maxilla 7.3

Gain/Loss 2.6

Mean Initial Measurements/Mandible 1.7

Mean Final Measurements/Mandible 2.9

Gain/Loss 1.2

58 • Vol. 4, No. 15 • April 2015

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Table 3: Summary of Published Data in Reference to GBR Success Rate Outcomes

# of Implant Success Ref. # Reference Approach Membrane Sites Survival Rate Rate

30 Clin Oral impl Research, Full/Split Thickness Flap PTFE/Removed 12 100% 75% 1990 Dec, 1 (1);22-32

41 J Oral Maxillofacial Surg., Full/Split Thickness Flap PTFE/Removed 63 100% 98.80% 1994 Feb, 5 2(2);106-12

42 J Oral Maxillofacial Surg., Full/Split Thickness Flap e-PTFE/Removed 40 100% 100% 1996 April, 5 4(4);420-32

43 J Prosthet Dent, Full/Split Thickness Flap Collagen/Resorbed 7 100% 100% 2003 Dec, 9 0(6);530-8

44 Int J Oral Maxillofac Impl, Full/Split Thickness Flap e-PTFE/Removed 82 100% 94.70% 2009 May, 24 (3);502-10

45 Int J Oral Maxillofac Impl, Full/Split Thickness Flap Glycolide/Resorbed 58 100% 100% 2011 March, 26 (2);404-14

46 Clin Oral impl Research, Full/Split Thickness Flap None 72 96% 95.80% 2012 Oct, 23 (10);1232-7

47 J Oral Implantol, Tunnel None 11 Not 100% 2007; 33 (4);205-210 reported

48 Int J Periodontics Rest Tunnel None 10 Not 100% Den, 2013 Sep; 33 (5);651-9 reported

Mean 96% Standard Deviation 8%

n/a Results of this study Tunnel Collagen/Resorbed 79 100% 97.20%

for a barrier membrane due to a complete pres-ervation of the integrity of the periosteum, Kfir et al. (2007)14 advocated application of the bar-rier membrane as well as bone decortication and grafting with substitute bone and platelet rich fibrin (PRF) filling. In contrast to Lee et al. (2000)15 who discussed a vertical approach to vestibular incisions and a supraperiosteal tunnel

access for connective tissue grafts and Kfir et al. (2007)16 presented a subperiosteal access for osseous grafts emphasizing again the “mini-mally invasive” nature of the technique. Apart from the fact that “tunnel approach” to guided bone regeneration (GBR) was developed in attempt to address a volume deficiency of the residual ridge that limits implantation or optimal


Ruvins et al

implant installation for esthetic and functional needs, some studies reported similar surgical approach for treatment of gingival recession. While direct statistical relationship of “tunnel approach” to the reduction of postoperative incidence of dehiscence was not established in recent scientific literature, it was collectively recognized by the scientific community that this modification to soft tissue management and bone regeneration in a one-wall osseous defects warrants further evaluation (Azzi et al., 2009).17 The technique is adaptable to the sur-geon’s preferences of the materials. The utili-zation of the “tunnel approach” does not limit the surgeon to the utilization of particular graft material. Since many different types of grafts are used for osseous regeneration, the tech-niques of the grafting vary. While Mazzocco et al. (2008)18 presented a series of success-ful “tunnel“ alveolar ridge augmentations with use of bone blocks many clinicians still prefer particulate grafts. Even though grafting mate-rials vary in their capacity to promote osseo-integration, the autogenous bone grafts and grafting techniques involving autolo-gous bone demonstrated many advantages when compared with other graft composi-tions and surgical methods. Studies con-ducted by many researches (Da Costa et al. (2011)19 Lundgren et al. (1997)20, Block et al. (1997)21) established that an autologous component of the traditional allograft signifi-cantly increases the regenerative potential of cortico-cancellous allogenic bone grafts.

Surgical TechniqueThe following surgical principals were applied and followed in the course of the study:● Minimal surgical incision associated with

“tunnel approach” in the immediate proximity of the grafting site

● Preservation of critical gingival - cortical bone seal

● Partial decortications with micro osseous scraper

● Thorough and diligent isolation of the grafting site with resorbable collagen membrane and fixation of the latter with resorbable sutures.

● Strategic placement of allograft bone par-ticles in a mixture with autogenous bone and adequate saturation of the graft with blood

● Maintenance of the space above basal cortical level to allow for bone recontouring and healing. Special emphasis in application of the tech-

nique was placed on use of barrier membrane in combination with bone reconstruction and regeneration. Multiple research sources advo-cate the use of barrier membranes stating superior osseous healing process facilitated by mechanical obstruction preventing fibro-blasts and other connective tissue elements from entering the bone reconstruction and regeneration site. This mechanical hindrance creates a setting allowing “presumably slower-migrating cells with osteogenic potential … to repopulate the defect” (Dahlin et al. (1988)22, Dahlin et al. (1990)23, Barbossa (1999)24).

Use of the tunnel technique with utilization of an acellular dermal matrix was advocated by Mahn in 201025 as well as in 200126 with utili-zation of an acellular dermal connective tissue allograft. Experimental studies by Lundgren et

60 • Vol. 4, No. 15 • April 2015

al. (1997)27 established that “the coverage of particulate autologous bone grafts with a biore-sorbable barrier resulted in a larger volume of augmented bone than the use of bone grafts not covered with a barrier.”27 Furthermore, stud-ies evaluating regeneration and enlargement of the bone in the recipient site conducted by Buser et al. (1990)28 reported a gain in new bone formation ranging from 1.5mm to 5.5mm and concluded that “the biological principle of GTR is highly predictable for ridge enlarge-ment or defect regeneration under the pre-requisite of a complication-free healing.”28

Specific stress in the design of this clinical method was placed on adequate vascularization of the surgical recipient site. Preservation of blood clot has been considered an essential ele-ment by many clinicians for many years. Earlier studies emphasizing protection of blood clots were published by Melcher and Dryer back in 1962.29 Additional researchers adapted clinical techniques surgically creating artificial condi-tions for the blood clot to form and survive adja-cent to the recipient site. Buser, Brägger and Lang (1990)30 discussed benefits of perforation of “cortical bone to create a bleeding bone sur-face”30 and adjustment to membrane placed at the surgical site to create “a secluded space….between the membrane and the subjacent bone surface in order to increase the width of the ridge or to regenerate bony defects present.”30

CONCLUSIONSThis analysis of clinical results establishes a statistically significant similarity between the results obtained after lateral alveolus “tun-nel approach” guided tissue regeneration and the outcomes of lateral ridge augmentation

completed by means of other clinical tech-niques reported in modern clinical literature. Additionally, the results of the study proved that the regeneration of the deficient alveo-lar ridge with “Tunnel Approach” guided tis-sue regeneration technique generally produces statistically measurable positive outcomes.

As many retrospective studies, this study has inherent limitations and disadvantages. A certain degree of variability may be present within the data due to the nature of data col-lection procedure especially in comparison to measurements on the CT Scan images. Fur-thermore, the subjective imperfections may, to a certain degree affect the data collected. Utilization of prefabricated intraoral surgical stent minimizes inaccuracies of the final mea-surements by re-establishing a reference posi-tion at the point of secondary measurement. ●

Correspondence:

Edward Ruvins

9450 East Mississippi Avenue

Suite #A

Denver CO 80247

303-368-0777

Fax: 303-484-4024

Email: [email protected]

Ruvins et al



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Using GBR, I. Surgical Procedures in the Maxilla. International Journal of Periodontics and Restorative Dentistry 1993; 29-45.

2. Mahn DH. Use of the tunnel technique and an acellular dermal matrix in the treatment of multiple adjacent teeth with gingival recession in the esthetic zone. International Journal of Periodontics and Restorative Dentistry. 2010 Dec;30(6):593-9.

3. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques are the most successful in furnishing bony support for implant placement? International Journal of Oral Maxillofacial Implants. 2007;22:49-66.

4. Pikos MA. Facilitating implant placement with chin grafts as donor sites for maxillary bone augmentation--Part I. Dental Implantology Update. 1995 Dec;6(12):89-92

5. Pikos MA. Facilitating implant placement with chin grafts as donor sites for maxillary bone augmentation-Part II. Dental Implantology 1996; 7:1-4

6. Pikos MA. Block autografts for localized ridge augmentation; Part I. The posterior maxilla. Implant Dentistry 1999; 8:279-284.

7. Toscano N. Shumaker N. Holtzclaw D. The Art of Block Grafting. A Review of the Surgical Protocol for Reconstruction of Alveolar Ridge Deficiency. The Journal of Implant & Advanced Clinical Dentistry 2010;Mar; 2(2):45-66

8. Gapski R, Wang HL, Misch CE. Management of incision design in symphysis graft procedures: A review of the literature. Journal of Oral Implantology 2001;27(3):134-142.

9. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive guided bone regeneration. Journal of Oral Implantology 2007;33(4):205-10.

10. Azzi R, Etienne D, Takei H, Carranza F. Bone regeneration using the pouch-and-tunnel technique. International Journal of Periodontics and Restorative Dentistry 2009; Oct;29(5):515-21.

11. Lee CT, Hamalian T, Schulze-Späte U.Minimally invasive treatment of soft tissue deficiency around an implant-supported restoration in the esthetic zone: Modified VISTA technique: Case report. International Journal of Periodontics and Restorative Dentistry. 2000 Oct;20(5):510-9.

12. Heller AL, Heller RL. Tissue management protocol: “tunnel bone graft” technique. Dentistry Today 2010; Nov;29(11):120-124.

13. Mazzocco C, Buda S, De Paoli S. The tunnel technique: a different approach to block grafting procedures. International Journal of Periodontics and Restorative Dentistry 2008 Feb;28(1):45-53.

14. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive guided bone regeneration. Journal of Oral Implantology 2007;33(4):205-10.Lee CT, Hamalian T, Schulze-Späte U.Minimally invasive treatment of soft tissue deficiency around an implant-supported restoration in the esthetic zone: Modified VISTA technique: Case report. International Journal of Periodontics and Restorative Dentistry. 2000 Oct;20(5):510-9.

15. Kfir E, Kfir V, Eliav E, Kaluski E. Minimally invasive guided bone regeneration. Journal of Oral Implantology 2007;33(4):205-10.

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17. Mazzocco C, Buda S, De Paoli S. The tunnel technique: a different approach to block grafting procedures. International Journal of Periodontics and Restorative Dentistry 2008 Feb;28(1):45-53.

18. Da Costa CE, Pelegrine AA, Fagundles DJ, Simoes Mde J, Taha MO. Use of corticocancellous allogenic bone blocks impregnated with bone marrow aspirate: a clinical, tomographic, and histomorphometric study. General Dentistry 2011; 59(5):e200-5.

19. Lundgren AK, Sennerby L, LundgrenD, Taylor A, Gottlow J, Nyman S. Bone augmentation at titanium implants using autologous bone grafts and bioresorbable barrier. An experimental study in the rabbit tibia. Clinical Oral Implants Research 1997;8:82-89.

20. Block MS, Kent JN. Sinus augmentation for dental implants: The use of autogenous bone. Journal of Oral Maxillofacial Surgery 1997;55:281-286.

21. Dahlin C, Linde A, Gottlow J, et al. Healing of bone defects by guided tissue regeneration. Plastic Reconstructive Surgery. 1988;81:672-676.

22. Dahlin C, Gottlow J, Linde A, et al. Healing of maxillary and mandibular bone defects using a membrane technique. An experimental study in monkeys. Scandinavian Journal of Plastic Reconstructive Surgery Hand Surgery. 1990;24:13-19.

23. Barossa EP. Localized ridge maintenance using bone membrane. Implant Dentistry. 1999;8:167-172.

24. Mahn DH. Use of the tunnel technique and an acellular dermal matrix in the treatment of multiple adjacent teeth with gingival recession in the esthetic zone. International Journal of Periodontics and Restorative Dentistry. 2010 Dec;30(6):593-9.

25. Mahn DH. Treatment of gingival recession with a modified “tunnel” technique and an acellular dermal connective tissue allograft. Practical Procedures and Aesthetic Dentistry. 2001 Jan-Feb;13(1):69-74.

26. Lundgren AK, Sennerby L, LundgrenD, Taylor A, Gottlow J, Nyman S. Bone augmentation at titanium implants using autologous bone grafts and bioresorbable barrier. An experimental study in the rabbit tibia. Clinical Oral Implants Research 1997;8:82-89.

27. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clinical Oral Implants Research. 1990;1:22-32.

28. Melcher A. Dreyer C. Protection of the blood clot in healing circumscribed bone defects. Journal of Bone Joint Surgery Br. 1962;44:424-430.

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