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                    D e n t a l    F o l l i c l e               

             The        Monthly     E-newsletter                   Vol - I I      Number-  I          June  2007

In this Issue:

  • Editorial

  • News

  • Laughter - The best Medicine

  • Achieve self reliance in dental health care: President APJ Abdul Kalam

  • Breakthrough technology to hit the detection of Dental Caries

  • Usage of nanocrystalline Hydroxylapatite in paste form to preserve post–extractive sites. A one–case report.- Dr.Marco Iorio

  • Brush, Floss ... and Rinse?

     

Editorial :

      Dear Fellow Dentist,

                          Its 1 year and 1 month since we started Dental Follicle . We thank the support recieved by all of you. Today Dental Follicle reaches the mail boxes of morethan 30K dentists across the globe.We would like to introduce more and more features which would be of immense use to you .Please send in your suggestions so that we make "Dental Follicle" more interesting & informative.

                       I hope you enjoy every bit of the present issue.

 

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Yours truly

Dr. S . Nabeel

Editor of Dental Follicle & WebMaster www.DentistryUnited.com

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News :

         

                       

Laughter - The Best Medicine :

Man: "Darling, your teeth remind me of the stars"
Woman: "Because they gleam and sparkle"
Man: "No, because they come out at night!"

                                         

 Achieve self reliance in dental health care: President APJ Abdul Kalam

          President A P J Abdul Kalam today ,the 29th of June ,called on the medical practitioners and R and D centres to achieve 'self reliance' in dental healthcare, as the country was lagging behind many others in providing quality dental care.

                  Inagurating Implantology at Army College of Dental Sciences (ACDS) herein Hyderabad, Kalam said ''there is a need to network the Dental centres located in different parts of the country to generate clinical database which will be useful for research.'' He also said ''Better use of tele-medicine for the dental care in the remote villages will enable the doctors to examine the patients using intra oral X-rays through digital sensors and consult through 'Virtual Dental Clinics' which can provide knowledge to the field centres,''

             The President said a case study should be conducted about the use of Neem tree material as a cost effective solution for promoting dental care in the villages.
 

                Nanotechnology Dental Implants

                       Dental implant company BIOMET 3i™ has just introduced a new dental implant using nanotechnology. The NanoTite Implant adds deposits of nanoscale calcium phosphate crystals to approximately 50% of the surface. These nanoscale deposits create a complex surface on the implant that, according to pre-clinical studies, appears to play a key role in how the implant bonds with the bone. Human bone recognizes calcium phosphate as being biologically natural, allowing the bone and implant to bond during healing.Patient applications and benefits of the NanoTite Implant include use to replace single or multiple missing teeth due to cavities, decay, trauma or disease. The NanoTite Implant, like all dental implants, is designed to help preserve bone structure and natural facial contours.

Usage of nanocrystalline Hydroxylapatite in paste form to preserve post–extractive sites. A one–case report.

 

Marco Iorio

DMD, DDS, private practice in Castelletto Ticino (NO) Italy

Via G.Barberis 1

28053 Castelletto Ticino (NO)

Italy

Tel. +39–0331–973311+39–0331–973311

Fax +39–0331–971729

iorio.marco@libero.it

 

ABSTRACT

This article proposes a technique to preserve post–extractive sites in order to simplify prosthetically-guided insertion of  osseointegrated dental implants. 

KEY WORDS

Nanocrystalline hydroxylapatite, dental implants, extraction sockets, bone regeneration.

INTRODUCTION

The healing process following tooth extraction often leads to a partial filling of the empty socket1,2, together with  3–4mm ridge resorption both in transversal and vertical direction1,3. The result of these processes is a narrow and reduced ridge, with inadequate bone volume to support soft tissue or to permit implant placement in an ideal position.

Applying GBR principles to post–extractive sockets significantly reduces the amount of bone resorption3.

To make GBR effective, it is mandatory to obtain and maintain soft tissue coverage over the augmented site4,5 by elevating and advancing a wide mucoperiosteal flap. This inevitably leads to a modification of  normal mucoginigival anatomy of the augmented site, with a subsequent esthetic alteration. Full thickness flap elevation interrupts periosteal vascularization of buccal bony plate, thus inducing a partial resorption.

Recently a technique to preserve post–extractive site was propose (Bio–Col technique, Sclar 20036). The tooth has to be extracted without causing trauma to the neighboring tissue, the empty socket has to be filled with bovine bone mineral — a slow–resorbing osteconductive material — and the site has to be sealed with resorbable collagen sponge and cyanoacrylate.

This combination, according to the Author, leads to a good re generation of alveolar bone, without the problems caused by the need to obtain primary wound closure.

One big problem with this technique is the long resorbtion time of bovine Hydroxylapatite.

Nanocrystalline hydroxylapatite in paste form (Ostim®, Heraeus–Kulzer GmbH, Hanau, Germania) is a pure, unsintered hydroxylapatite material, made of crystals of hydroxylapatite (average dimension 18 μm) in 35% water suspension. The nanocrystalline structure of the biomaterial allows a quick vascularization of the graft, with a wide contact surface between the graft and the osteoblasts (106 m2/g, vs 50–90 m2/g of bovine bone mineral). This characteristic makes hydroxylapatite in paste form a very quick resorbing biomaterial. A recent animal study reports a 53,9% average percentage of mineralization of a defect filled with Ostim® at 12 weeks; this data is not statistically different from the percentage of mineralization of a similar defect filled with autogenous bone7.

Another characteristic of  nanocrystalline hydroxylapatite in paste form is its complete radiolucency, which allows for a radiographical evaluation of bone regeneration process. 

                                                               

CASE REPORT

A 37 years old, Caucasian male man presented at my office requesting the substitution of the ill–fitting gold–acrylic veneer crown on tooth 2.4. Radiological examination (Fig. 1) revealed very deep caries on 2.5 and external root resorption on 2.4.

Text Box: Fig. 1: Diagnostic film: very deep caries on tooth 2.5 and external root resorption on tooth 2.4.
 

The proposed treatment plan was, after full mouth scaling and root planing, to perform endodontic therapy of 2.5, to place a cast gold post and core restoration on 2.5; 2.4 had to be extracted and a technique of socket preservation was applied before placing an osseointegrated implant.

The tooth 2.4 was extracted by means of periotomes and thin elevators, an envelope flap was raised, performing intrasulcular incisions on 2.3 and 2.5 and a limited exposition of buccal and palatal bony margins of the socket were exposed (Fig. 2).

Text Box: Fig. 2: Extraction of tooth 2.4, with maximum preservation of surrounding soft and hard tissues.
 
 

 

The empty socket was carefully debrided and rinsed with sterile saline, then it was filled with Ostim® up to the level of the surrounding bone (Fig. 3). The material, extruded from the syringe, was adapted to the bone cavity, then stabilized with a PLA mesh (Vicryl VM302, Ethicon inc., Cornelia GA, USA) (Fig. 4). The mesh was covered with a resorbable collagen sponge (Hémocollagène, Septodont, Saint-Maur-des-Fossés Cedex, Francia).

Text Box: Fig. 3: Socket filled with nanocrystalline hydroxylapatite in paste form (Ostim®).
 
 

 

Text Box: Fig. 4: A PLA mesh is placed over the graft material.
 
 

 

The flap was sutured with a 4–0 resorbable PLA thread  (FS–3 Vicryl JV394, Ethicon inc., Cornelia GA, USA), applying two single sutures on the papillae and a cross suture over the collagen sponge (Fig. 5–6).

Text Box: Fig. 5: The mesh is covered with a collagen sponge stabilized by a cross suture.
 
 

 

Text Box: Fig. 6: Post–op radiogram: the grafting material is completely radiolucent, the amount of the ongoing re generation can be easily evaluated by means of radiograms.
 
 

 

To further protect the grafted site a fixed provisional restoration (crown on 2.5 and mesial cantilever ovate pontic on 2.4) was placed (Fig. 7); no occlusal contacts, neither in centric occlusion, nor in lateral excursions, were present on the pontic.

Text Box: Fig. 7: A provisional acrylic bridge with an ovate cantilever pontic is placed to further protect the grafted site.
 

 

Three months after the extraction good bone regeneration is evident at the grafted site (Fig. 8); after flap elevation it is not possible to notice any difference between native and regenerated bone (Fig. 9). One single self–tapping, external hex, rough surface, 4mm in diameter and 15mm in length implant was placed (OSS415, 3i Implant Innovations, West Palm Beach FL, USA) (Fig. 10).

 Text Box: Fig. 8: Control radiogram 3 months after the grafting procedure.
 

 

Text Box: Fig. 9: The amount of obtained bone regeneration is evident.

Text Box: Fig. 10: Insertion of an implant in the ideal position for the final prosthesis

 

After 6 months of healing (Fig. 11), there’s still a deficiency in tissue volume below th mucogingival junction (Fig. 12), a roll technique was performed, at the same time the healing abutment was connected (Fig. 13–14). Overcorrection of the defect was necessary to compensate for the subsequent graft contraction.

Text Box: Fig. 11: Control radiogram of the inserted implant.

 

 

Text Box: Fig. 12: Six months after implant placement a vestibular defect is present.

 

 

Text Box: Fig. 13: Together with stage 2 implant surgery a “roll technique” is performed to increase the volume of soft tissue buccal to the implant.

 

 

Text Box: Fig. 14: A slight overcorrection of the defect is performed to compensate for the subsequent graft contraction
 
 

 

After 3 months of soft tissue healing, the final impression was taken (Fig. 15) using a polyether material (Permadyne H/Permadyne L, 3M Espe AG, Seefeld, Germania) (Fig. 16). Prosthetic rehabilitation was carried out using a UCLA cast–on abutment on the implant (SGUCA1C, 3i Implant Innovations, West Palm Beach FL, USA) and two single ceramometal crowns (Fig. 17).

Text Box: Fig. 15: Three months after stage 2 surgery a pick–up transfer is connected to the implant and retraction cords are placed around the prepared abutment tooth.
 

 

 

Text Box: Fig. 16: A polyether material impression is taken. The small air bubble doesn’t affect impression accuracy, since it’s past finishing line.
 
 

 

Text Box: Fig. 17: Metal–ceramic crowns, the custom cast abutment and the gold retaining screw.
 
 

 

 

 

The position of 2.4 and 2.5 interproximal contact points, in a apico–coronal direction, was placed — according to Tarnow’s investigations8 — at less than 5mm from the crest of the ridge to predictably obtain a papilla both in the interproximal space in between the crowns and between each crown and neighboring natural teeth (Fig. 18–19).

Text Box: Fig. 18: Intraoral image of the crowns the day they were delivered.
 
 

 

 

Text Box: Fig. 19: Control radiogram of the definitive prostheses.
  

 

 

DISCUSSION AND CONCLUSIONS

The usage of the socket preservation technique allowed for an ideal implant placement, avoiding the use of more complex techniques such as sagittal osteotomies (“split crest”), guided bone regeneration or onlay block graft.

The subsequent soft tissue augmentation and the placement of interproximal contact point following well–documented scientific criteria permitted, after only three months from final prostheses delivery, to obtain a natural looking esthetic result with a complete filling of the interproximal spaces by papillary tissue (Fig. 20).

Text Box: Fig. 20: Clinical control after three months. Interproximal spaces are almost completely filled by interproximal papillae.
 
 

 

 

 

ACKNOWLEDGEMENTS

The Author would like to thank his office team: Dr. Mario Iorio MD, DMD, DDS (thank you dad!), Dr. Rossana Repossi RDH, Dr. Silvia Terazzi DMD, Mr. Luca Varalli and Mr. Marco Brignoli MDT, Ms. Patrizia Losi, Ms. Erica Bagaini, Ms. Alice Guerini dental assistants for the invaluable help in treating this patient and many others.

 

BIBLIOGRAPHY

1.      Lekovic V, Kenney EB, Weinlaender M, et al. A bone regeneration approach to alveolar ridge maintenance following tooth extraction: Report od 10 cases. J Periodontol 1997; 68:563–570

2.      Lang N, Becker W, Karring T. Alveolar bone formation. In Lindhe J (ed). Textbook of clinical periodontology and implant dentistry, ed 3. Copenhagen: Munksgaard, 1998:906–932.

3.      Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol 1998; 69:1044–1049.

4.      Warrer K, Gotfredsen K, Hjorting–Hansen E, Karring T. Guided tissue regeneration ensures osseointegration of dental implants into extraction sockets. An experimental study in monkeys. Clin Oral Implants Res 1991;2:166–171.

5.      Becker W, Becker B, Handelsman M, Ochsenbein C, Albrektsson T. Guided tissue regeneration for implants placed into extraction sockets: A study in dogs. J Periodontol 1991;62:703–709.

6.      Sclar AG. The Bio–Col Method. In: Sclar AG (ed.). Soft Tissue and Esthetic Considerations in Implant Therapy. Carol Stream: Quintessence Publishing Co, Inc., 2003:75–112

7.      Thornwarth WM, Schlegel KA, Srour S, Schultze–Mosgau S, Wiltfang J. Untersuchung zur knöchernen Regeneration ossärer Defekte unter Anwendung eines nanopartikulären Hydroxylapatitis (Ostim®). Implantologie 2004;12:21–32.

8.      Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Periodontol. 2001;72:1364-71.

 

 

Brush, Floss ... and Rinse?

        Cliff Whall, director of the ADA Seal of Acceptance program, agrees that adding "rinse" to the mantra of "Brush twice" would probably be a good move for most everyone as well, as antimicrobial mouthwashes have been shown in clinical studies to prevent the  gingivitis.Listerine , chlorhexidine and Flouride containing mouthwashes have carried the ADA Seal of Acceptance for two decades now for this very reason.

   

A December 2002 article in the American Journal of Dentistry suggested that in combination with brushing, rinsing with an antimicrobial mouth rinse is actually more effective than flossing when it comes to preventing gingivitis. Follow-up studies published in the Journal of the American Dental association in 2003 and 2004 further solidify the effectiveness of adding antimicrobial mouth rinses to the medicine cabinet.