3

Clinical Advances
in Periodontics
I N THI S I SSUE:
An Online Journal of the American Academy of Periodontology
www.clinicalperio.org
Stem Cell Allograft and
Titanium Mesh Augmentation
Regenerative Treatment of
EndodonticPeriodontic
Lesion
Extracellular Matrix
Membrane for Root Coverage
Periodontal Regeneration
and Orthodontic Treatment in
Infrabony Defects
Effect of a Root-Like Structure
on Periodontitis
Pharmacovigilance in
Dentistry
Oral Granulomatosis With
Polyangiitis
Sonic Handpiece in Implant
Dentistry
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VOLUME 3 | NUMBER 1 | FEBRUARY 2013
Clinical Advances in Periodontics
TABLE OF CONTENTS
CASE-BASED LEARNING
1 Alveolar Ridge Augmentation With Allograft Stem CellBased Matrix and
Titanium Mesh
Bradley S. McAllister, V. Thomas Eshraghi
Substantial increase in horizontal and vertical bone dimension was achieved following treatment with stem
cell ll based graft, allowing for implant placement and restoration with a milled bar rr supported locking denture.
10 Use of Guided Tissue Regeneration in the Treatment of a Severe
EndodonticPeriodontic Lesion: A 15-Year Follow-Up Case Report
Ronaldo B. Santana, Carolina M. Mattos Santana
In this case report, a severe combined endodontic cc periodontic lesion was successfully treated with guided tissue
regeneration and clinical improvements were preserved for several years after treatment.
16 Use of an Extracellular Matrix Membrane for Root Coverage: Case Series
and Review of the Literature
Monish Bhola, Shayna Sanchez, Shilpa Kolhatkar
An extracellular matrix membrane was successfully used for root coverage and soft tissue augmentation in Miller
Class II and III defects in six patients.
24 Orthodontic Treatment After Induced Periodontal Regeneration in Deep
Infrabony Defects
Carlo Ghezzi, Valeria M. Vigan, Paola Francinetti, Gianfranco Zanotti, Silvia Masiero
Aregenerative procedure that combinedenamel matrix derivate and collagen bone bovine mineral as a periodontal
preorthodontic procedure provided excellent clinical results in this case series.
33 The Possible Effect of an Accessory Root-Like Structure on Periodontitis:
A Clinical and Histologic Case Report
Jianxin Du, Xiaoying Wang, Jin Zhang, Shiguo Yan, Li Wang, Pishan Yang
An accessory root-like structure found on a patients left maxillary central incisor might have accelerated the
progression of periodontitis in this case report.
(continued on page iii )
ON THE COVER:
Preoperative view of gingival
recession on tooth #6 and 15
months after treatment with
extracellular matrix membrane.
(Bhola et al.)
40 Medical Histories: A Case Report of Pharmacovigilance in Supporting
Dentists and Participation in a Drug-Safety Program
Edward H. Karl, Frederick A. Curro
This case involves an adverse event following routine medication and demonstrates the importance of medical
histories taken by dentists as a source of information that can often be of value in assessing treatment regimens.
45 Rare Manifestation of Granulomatosis With Polyangiitis
Manoj Bhattarai, Weijia Yuan, Paul Fletcher, AdamGersten, Anthony Chang, Robert Spiera,
Anne Bass, Doruk Erkan, Dennis Tarnow
In this case report, a 76-year-oldwoman presenting with dental implant failure was diagnosed with granulomatosis
with polyangiitis.
52 Applications of a Newly Developed Sonic Surgical Handpiece in Implant
Dentistry
Erich C. Schmidt, Dimitrios E. Papadimitriou, Jack G. Caton, Georgios E. Romanos
In this case series, a recently developed sonic handpiece using oscillating technology had various clinical
applications in implant dentistry.
T A B L E O F C O N T E N T S
Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013
IMPORTANT SAFETY INFORMATION
GEM 21S
Growth-factor Enhanced Matrix is intended for use by

cllnlclans famlllar wlLh perlodonLal surglcal graflng Lechnlques. lL should
noL be used ln Lhe presence of unLreaLed acuLe lnfecuons or mallgnanL neoplasm(s)
aL Lhe surglcal slLe, where lnLra-operauve sof ussue coverage ls noL posslble, where bone
graflng ls noL advlsable or ln pauenLs wlLh a known hypersensluvlLy Lo one of lLs componenLs. lL musL
noL be ln[ecLed sysLemlcally. 1he safeLy and eecuveness of CLM 21S
has not been established in other non-

perlodonLal bony locauons, ln pauenLs less Lhan 18 years old, ln pregnanL or nurslng women, ln pauenLs wlLh frequenL/excesslve
Lobacco use (e.g. smoklng more Lhan one pack per day) and ln pauenLs wlLh Class lll furcauons or wlLh LeeLh exhlblung moblllLy greaLer
Lhan Crade ll. ln a 180 pauenL cllnlcal Lrlal, Lhere were no serlous adverse evenLs relaLed Lo CLM 21S
, adverse evenLs LhaL occurred were

consldered normal sequelae followlng any perlodonLal surglcal procedure (swelllng, paln).
www.oosteeooheeaalth.coom | 1-8880000-888744-23344
GEM 21S
Growth-factor Enhanced Matrix

Caution: Federal Law restricts this device to sale by or on the order of a dentist
or physician.
GEM 21S
is composed of two sterile components:

s]nthetic oeta-tricalcium phosphate (-TCPj [Ca
3
(P0
4
j| is a highl] porous,
resorbable osteoconductive scaffold or matrix that provides a framework
for oone ingrowth, aids in preventing the collapse of the soft tissues and
promotes staoilization of the olood clot. Pore diameters of the scaffold are
specifcall] designed for oone ingrowth and range from 1 to 5OO m. The
particle size ranges from O.25 to 1.O mm and
highl] purifed, recomoinant human platelet-derived growth factor-BB
(rhPD0F-BBj. PD0F is a native protein constituent of olood platelets. lt is a
tissue growth factor that is released at sites of injur] during olood clotting. ln
vitro and animal studies have demonstrated its potent mitogenic (proliferativej, o
angiogenic (neovascularizationj and chemotactic (directed cell migrationj
effects on oone and periodontal ligament derived cells. Animal studies have
shown PD0F to promote the regeneration of periodontal tissues including
oone, cementum, and periodontal ligament (PDlj.
The contents of the cup of -TCP are supplied sterile o] gamma irradiation.
8terile rhPD0F-BB is asepticall] processed and flled into the s]ringe in which
it is supplied. All of these components are for single use onl].
lhDlCATl0h8.
GEM 21S
is indicated to treat the following periodontall] related defects.

lntraoon] periodontal defects,
Furcation periodontal defects, and
0ingival recession associated with periodontal defects.
C0hTRAlhDlCATl0h8.
As with an] periodontal procedure where oone grafting material is used, 0EN
21S
is C0hTRAlhDlCATED in the presence of one or more of the following

clinical situations:
Untreated acute infections at the surgical site,
Untreated malignant neoplasm(sj at the surgical site,
Patients with a known h]persensitivit] to an] product component (-TCP or
rhPD0F-BBj,
lntraoperative soft tissue coverage is required for a given surgical procedure
out such coverage is not possiole, or
Conditions in which general oone grafting is not advisaole.
wARhlh08.
The exterior of the cup and s]ringe are h0T h0T 00T sterile. See directions for use.
lt is not known if 0EN 218
interacts with other medications. The use of

0EN 218 with other drugs has not oeen studied. Carcinogenesis and
reproductive toxicity studies have not been conducted.
The safet] and effectiveness of 0EN 218
has not been established:

ln other non-periodontal oon] locations, including other tissues of the
oral and craniofacial region such as oone graft sites, tooth extraction sites,
oone cavities after c]stectom], and oone defects resulting from traumatic or
pathological origin. 0EN 218
has also not been studied in situations where it

would oe augmenting autogenous oone and other oone grafting materials.
ln pregnant and nursing women. lt is not known whether rhPD0F-BB is
excreted in the milk of nursing women.
ln pediatric patients oelow the age of 18 ]ears.
ln patients with teeth exhioiting mooilit] of greater than 0rade ll or a
Class lll furcation.
ln patients with frequent or excessive use of tooacco products.
Careful consideration should oe given to alternative therapies prior to perform-
ing oone grafting in patients.
who have severe endocrine-induced oone diseases (e.g. h]perparath]roidismj,
who are receiving immunosuppressive therap], or
who have known conditions that ma] lead to oleeding complications (e.g.
hemophiliaj.
The 0EN 218 Thee 0EN 218 218
grafting material is intended to oe placed into periodontall] ggraf aaft fti ft ngg maateeriaal is inteended to oe placed into pe nddeedd too ooee pplaaceedd intoo ppeeriodont riooddoontall aall]]
related defects. lt must not oe injected s]stemicall]. reelaateedd ddeefeects. lt must not oe injected s]stemi cts. lt must noot ooee injeecteedd s]steemicall]. caall].
The radiopacit] of 0EN 218
is comparable to that of bone and diminishes

as GEM 21S
is resoroed. The radiopacit] of 0EN 218
must be considered
when evaluating radiographs as it ma] mask underl]ing pathological condi-
tions.
PRECAUTl0h8.
GEM 21S
is intended for use o] clinicians familiar with periodontal surgical

grafting techniques. 0EN 218
is supplied in a single use kit. An] unopened

unused material must be discarded and components of this system should not
be used separately.
ADVER8E EVEhT8.
Although no serious adverse reactions attrioutaole to 0EN 218
were reported
in a 18O patient clinical trial, patients oeing treated with 0EN 218
may
experience an] of the following adverse events that have oeen reported in the
literature with regard to periodontal surgical grafting procedures. swelling,
pain, oleeding, hematoma, dizziness, fainting, diffcult] oreathing, eating, or
speaking, sinusitis, headaches, increased tooth mooilit], superfcial or deep
wound infection, cellulitis, wound dehiscence, neuralgia and loss of sensation
locall] and peripherall], and, anaph]laxis.
0ccurrence of one or more of these conditions ma] require an additional
surgical procedure and ma] also require removal of the grafting material.
8T0RA0E C0hDlTl0h8.
The 0EN 218
kit must oe refrigerated at 2-8 C (8G-4G Fj. Do not freeze.

Th i di id l hPD0F BB t t o f i t d t 2 8 C (8G
CPu 2S7 lss. 11/2012
VOLUME 3 | NUMBER 1 | FEBRUARY 2013
Clinical Advances in Periodontics
Co-Editors
Dr. Kenneth S. Kornman
Interleukin Genetics
Waltham, MA
Dr. Michael S. Reddy
University of Alabama at Birmingham
Birmingham, AL
Associate Editors
Dr. Anna Dongari-Bagtzoglou
University of Connecticut
Farmington, CT
Dr. Steven P. Engebretson
New York University
New York, NY
Dr. David W. Paquette
Stony Brook University
Stony Brook, NY
Dr. Frank A. Scannapieco
University at Buffalo
Buffalo, NY
2012-2013 Ofcers of the AAP
President
Dr. Nancy L. Newhouse
Independence, MO
President Elect
Dr. Stuart J. Froum
New York, NY
Vice President
Dr. Joan Otomo-Corgel
Los Angeles, CA
Secretary/Treasurer
Dr. Wayne A. Aldredge
Hazlet, NJ
Past President
Dr. Pamela K. McClain
Aurora, CO
Founding Editorial Board
Dr. Richard T. Kao
Private practice
Cupertino, CA
Dr. Paul S. Rosen
Private practice
Yardley, PA
Dr. Hom-Lay Wang
University of Michigan
Ann Arbor, MI
Dr. Thomas G. Wilson Jr.
Private practice
Dallas, TX
Editorial Advisory Board
Dr. Edward P. Allen
Dr. Steven B. Blanchard
Dr. Daniel Buser
Dr. Joseph V. Califano
Dr. Jack G. Caton
Dr. David L. Cochran
Dr. Manuel De La Rosa Jr.
Dr. Joseph P. Fiorellini
Dr. Paul A. Fugazzotto
Dr. Nicolaas C. Geurs
Dr. Henry Greenwell
Dr. Dan J. Holtzclaw
Dr. T. Howard Howell
Dr. Vincent J. Iacono
Dr. Georgia K. Johnson
Dr. Niklaus P. Lang
Dr. Samuel B. Low
Dr. Angelo Mariotti
Dr. Pamela K. McClain
Dr. Michael K. McGuire
Dr. Brian L. Mealey
Dr. Michael P. Mills
Dr. Dean Morton
Dr. Francisco H. Nociti
Dr. Terry D. Rees
Dr. Mark A. Reynolds
Dr. Louis F. Rose
Dr. Mariano Sanz
Dr. Robert G. Schallhorn
Dr. Anton Sculean
Dr. Thomas C. Waldrop
Dr. Hans-Peter Weber
Dr. Jan L. Wennstrm
Dr. Ray C. Williams
Dr. Hiromasa Yoshie
The American Academy of Periodontology
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Publications Director, Katie Goss
Managing Editor, Julie Daw
Production Manager, Bethanne Wilson
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members.
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CASE REPORT
Alveolar Ridge Augmentation With Allograft Stem CellBased
Matrix and Titanium Mesh
Bradley S. McAllister*
and V. Thomas Eshraghi*
Introduction: When bone surrounding a proposed implant site is deficient in both a vertical and horizontal dimension,
bone augmentation procedures using titanium mesh can be used. Although there are multiple reports of titanium mesh use
with a variety of graft materials, to our knowledge, this presentation is the first to show use of a stem cellbased titanium
mesh augmentation.
Case Presentation: After the removal of a failing maxillary subperiosteal implant, significant atrophy of the maxillary al-
veolus was evident. After bilateral sinus augmentation with an allograft-derived stem cellbased matrix (cellular allograft), four
posterior implants were placed. In preparation for future anterior maxillary ridge augmentation, an interimdenture supported by
the posterior implants and O-ring attachments was fabricated. The anterior titanium mesh-supported cellular allograft was
placed and allowed to heal for 4 months, followed by placement of four additional implants. After 4 months of integration,
the patient was restored with a locking milled bar denture.
Conclusion: The use of a cellular allograft with titanium mesh for stabilization can result in significant horizontal and ver-
tical augmentation for implant reconstruction. Clin Adv Periodontics 2013;3:1-7.
Key Words: Allograft; bone screws; dental implants; stem cells; surgical mesh; titanium.
Background
The restoration of oral hard- and soft-tissue contours are
vital to function, esthetics, and phonetics. Well-established
research has been performed regarding bone defect re-
generation for future implant placement.
1
Osseous re-
generation, although possible, remains challenging in many
implant reconstructive situations. Extraoral autogenous
bone has long been regarded as the gold standard of bone
regeneration because of its inherent osteoconductive,
osteoinductive, and osteogenic potential.
2
Although effica-
cious in use, autogenous bone is not without significant
shortcomings. Harvests of intraoral bone and bone marrow
aspirates have varying cellular concentrations and often
have limited numbers of mesenchymal stem cells (MSCs)
and osteoprogenitor cells.
3
Such variation may be related to
harvest location, age, sex, and genotype.
4
There are also
great technical challenges related to the addition of a second
surgical site, extended operation time, limited supply of
intraoral bone harvesting, donor-site morbidity, infection,
and bleeding risks.
5
Many replacements for autogenous bone have been ex-
amined, ranging from processed allografts and xenografts
to synthetic and syntheticbiologic composites.
2
Varying
success has beenachievedwitheachinalveolar ridge defects.
Freeze-dried bone, xenografts, and demineralized free-dried
bone allografts workindifferent ways.
2
Demineralizedbone
allografts offer varying osteoinductive potential, whereas
mineralized bone allografts, xenografts, and alloplasts pri-
marily provide an osteoconductive scaffold.
2
Furthermore,
some alloplasts heal ecapsulated within a connective tissue
infiltrate with little to no bone formation.
2
When such bone replacement materials are used, there is
usually sufficient regenerative capacity in the surrounding
bone bed to allow bone formation. MSCs and osteopro-
genitor cells can migrate into the graft, proliferate and
* Department of Periodontology, Oregon Health Sciences University,
Portland, OR.
Private practice, Portland, OR.

Submitted October 18, 2011; accepted for publication March 16, 2012
doi: 10.1902/cap.2012.110094
Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 1
differentiate into osteoblasts, and form bone. However,
when the size of a defect encroaches a threshold in which
cell proliferation from the lateral wound borders is re-
duced, a significant reduction in ossification and turnover
of grafting materials occurs. When appropriate cell popu-
lations do not exist in the bone graft or the adjacent boney
borders, limited bone formation will occur and the central
region of the graft will be the slowest to heal.
6
Thus, it
would be prudent to consider grafting with a material that
has the appropriate cellular constituents.
3,7
MSCs are unique cells that, when activated, can undergo
asymmetric division leading to an identical daughter cell
(self-renewal) and a cell that can go on to additional pro-
liferation and differentiation to become the needed spe-
cialized cell.
8
Embryonic stem cells are undifferentiated
pluripotent cells derived fromthe inner cell mass of the em-
bryo during the blastocyst stage.
9
The embryonic stem cell
can differentiate into cells for ectodermal, mesodermal,
and endodermal tissue development. Fetal stem cells are
found in great concentration during early developing tis-
sues, such as the placenta, amniotic fluid, the developing
fetal organs, and marrow.
10
Embryonic and fetal stemcells
have enjoyed research success; however, ethical concerns
leading to political considerations have slowed their devel-
opment and pushed science to evaluate adult stem cells.
10
Adult stemcells are multipotent, meaning that they have an
ability to differentiate into one of a variety of similar cell
lineages (i.e., hematopoietic stem cells, MSCs) but cannot
developintoevery cell type. Cell-type differentiation canbe
provoked by multiple routes, including signals from solu-
ble growth and differentiation factors, extracellular matrix
contact, mechanical stimuli, and cell-to-cell interactions.
11
Of particular interest to the periodontist, MSCs have the
capacity to develop into bone, muscle, ligament, cartilage,
tendon, and adipose cells, which indicates the potential ap-
plication for periodontal and implant surgery.
12
Histori-
cally, the majority of efforts for bone grafting with
MSCs have focused on the concept of harvesting cells, fol-
lowed by in vitro culture expansion for later implanta-
tion.
13-15
MSCs have also been shown by investigators to
be hypoimmunogenic, opening the potential for allogenic
MSCs for bone grafting applications.
9
The cellular allograft bone matrix used is commercially
prepared from cadavers recovered by a licensed tissue pro-
curement agency.
Cadavers are processed within 24 hours

postmortem. In parallel rigorous safety testing, donor
screening and evaluation for bacterial, fungal, and spore
contamination begins. Screening measures consist of phys-
ical examination and evaluation of both medical and social
history, including a next of kin interview. Comprehensive
serologic and microbial testing is also performed.
Cortical bone fromthe cadaver is separated fromthe cel-
lular cancellous bone and processed into demineralized
bone particles, which are added back to the cellular cancel-
lous graft component after all processing is complete. The
cellular component processing includes a selective immu-
nodepletion that involves several wash steps to remove
cells, such as red blood cells and lymphocytes, that can
provoke an immune response. This cellular cancellous
bone component containing the native MSCs and osteopro-
genitor cells then undergoes a broad-spectrumantimicrobial
treatment designed to eliminate potential contamination but
preserve the viability of the cells. These remaining viable
MSCs and osteoprogenitor cells remain attached to the can-
cellous bone matrix as demonstrated previously in scanning
electron microscopic images.
16
A cryopreservation solution
is added and the product is stored at 80 5C, permitting
a 5-year shelf life.
The depletion approach that leaves the native MSCs
and osteoprogenitor cells found within allogenic bone
marrow and substantially reduces unwanted cells, like
those of hematopoietic lineage, has been studied pre-
viously
6,7
and is demonstrated in the case presentation
below.
Clinical Presentation and Case
Management
A 71-year-old female presented to the private clinic of the
authors in Portland, Oregon on March 4, 2009 with a fail-
ing subperiosteal implant extending bilaterally from the
right and left tuberosity areas (Fig. 1). Previously, the sub-
periosteal implant had been partially removed. Full-thick-
ness flap elevation was completed, and the subperiosteal
implant was removed. Simultaneously, a classic lateral wall
sinus elevation procedure was performed bilaterally. The
cellular allograft
x
was placed bilaterally, and no mem-
branes were placed over the access windows and bone
grafts. A 4-month healing period was used based on pub-
lished histology at the time.
6
After 4 months of healing,
four implants were placed in the sinus lift areas (Fig. 2). Af-
ter a 4-month integration period, a complete maxillary
denture was fabricated using O-ring attachments on the
posterior implants for retention. The ridge deficit in the an-
terior maxilla contained a significant vertical and horizon-
tal component. Residual bone in the anterior maxilla was
seen to be only 2 to 3 mmin thickness (Figs. 3 and 4). After
a palatal displaced incision a full-thickness flap was
FIGURE 1 Preoperative CBCT scan with panoramic view of failing
subperiosteal implant.
AlloSource, Centennial, CO.

x
Osteocel, ACE Surgical Supply, Brockton, MA.
C A S E R E P O R T
2 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Stem Cell Allograft and Titanium Mesh Augmentation
elevated and cortical penetrations were completed in an
effort to improve vascularity to the cellular allograft
(Fig. 4). Titanium mesh was adapted to the ridge (Fig. 5),
followed by placement of the cellular allograft.
Final
fixation of the titaniummesh was achieved by using screws
{
(Fig. 6). Tension-free primary closure of soft tissues was
achieved using periosteal releasing incisions, horizontal
mattress, and simple interrupted 4-0 sutures
#
(Fig. 7). The
FIGURE 2 Cross-sectional CBCT scan of the cellular allograft sinus
augmentation.
FIGURE 3 Preoperative CBCT scan. A sagittal slice of the premaxilla
showing only a 2- to 3-mm vertical bone height from the floor of the nose to
the alveolar crest. Anterior is to the left.
FIGURE 4 Mucoperiosteal elevation with cortical penetrations before bone
grafting.
FIGURE 5 Initial fixation of titanium mesh and placement of the cellular
allograft.
FIGURE 6 Final fixation of titanium mesh and cellular allograft.
FIGURE 7 Primary closure of surgical site using polyglactin sutures.
Osteocel, ACE Surgical Supply.

{
ACE Bone Screw, ACE Surgical Supply.
#
VICRYL Sutures, Ethicon, Johnson & Johnson, San Angelo, TX.
C A S E R E P O R T
McAllister, Eshraghi Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 3
maxillary prosthesis was cut back in the anterior (Fig. 8),
and the patient was instructed to wear the prosthesis for so-
cial occasions only and to ensure that no food pressure was
applied. This essentially necessitated a liquid diet for the 4-
month healing period. Primary closure of tissues was main-
tained throughout the healing process.
Clinical Outcomes
After 4 months of healing, the titanium mesh (Fig. 9) was
removed and bone fill was noted in a horizontal and
vertical dimension, filling the space maintained by the
mesh. Four bone level implants** of 4.1 mmdiameter were
successfully placed into the graft site, which appeared to be
type III bone quality (Fig. 10). Soft-tissue healing was un-
eventful, with adequate bands of keratinized tissue present
around all healing abutments (Fig. 11). Placement of four
bone level and four 4.1 mmdiameter tissue level implants
with good anteroposterior spread is demonstrated on

the axial slice shown in Figure 12 from the final cone-
beam computerized tomography (CBCT) scan. After the
FIGURE 8 Complete denture with four O-ring attachments and anterior
relief to eliminate tissue contact.
FIGURE 9 Four-month reentry of graft site and titanium mesh removal.
FIGURE 10 Placement of four implants.
FIGURE 11 Soft-tissue healing around transmucosal abutments.
FIGURE 12 Post-restoration CBCT scan. Axial slice view and panoramic
view of implants and grafted bone.
**SLA Surface RC and RN Implants, Straumann, Andover, MA.
SLA Surface RC and RN Implants, Straumann.

C A S E R E P O R T
4-monthintegration period, the final milled bar restoration
with locking denture was fabricated (Figs. 13 through 15).
Excellent stability and retention of final prosthesis was
noted.
Discussion
It is apparent fromthe presented case and multiple publica-
tions
6,7
that cellular allografts containing MSCs and osteo-
progenitor cells can be used to treat challenging implant
reconstructions. It is also important to note that titanium
mesh is very technique sensitive, with exposure rates re-
ported from 20% to 40%.
2
Because of the porosity of tita-
niummesh, the rate of revascularization is likely more rapid
compared to more conventional techniques, such as tita-
nium-reinforced polytetrafluoroethylene or collagen mem-
branes. In addition, mesh exposure complications can often
be managed without a significant impact on the results. For
example, a small exposure of the mesh can usually be man-
aged with plaque removal at the exposed portion of the mesh
and local application of 0.12%chlorohexidine. As long as no
obvious infection is present, the mesh removal can be delayed
until the originally planned time.
Additionally, the literature has demonstrated successful
use of autogenous-derived stem cells for implant recon-
struction.
15
The future holds promise for improved predict-
ability in the area of large implant reconstruction as studies
are performedtoevaluate the long-termsuccess of cell-based
treatment modalities. n
FIGURE 13 Milled bar fixed in place.
FIGURE 14 Occlusal view of the locking denture in place.
FIGURE 15 Facial view of the denture in place.
C A S E R E P O R T
Summary
Why is this case new information?
j
To the best of our knowledge, this is the first case report using a stem
cellbased allograft matrix and titanium mesh for horizontal and
vertical bone augmentation.
What are the keys to successful
management of this case?
j Tension-free primary soft-tissue closure
j Appropriate temporization
j Vascular supply for maintaining viability of implanted allogenic MSCs
and osteoprogenitor cells
j
Space maintenance and immobility of the bone graft matrix
j
Case selection and management of patient expectations during the
healing process
What are the primary limitations to
success in this case?
j
Limited prospective clinical trials of short- and long-term efficacy of
stem cellbased cellular allograft matrix grafting supported by
titanium mesh
j Titanium mesh can be very difficult to manage clinically
Acknowledgments
Dr. McAllister has received financial support for research
and lecture fees from ACE Surgical Supply, Brockton,
Massachusetts. The excellent prosthesis fabrication was
placed by Dr. Alberto Ambard (private practice, Portland,
Oregon). Dr. Eshraghi reports no conflicts of interest re-
lated to this case report.
CORRESPONDENCE:
Dr. Brad McAllister, Periodontal Associates, 11525 S.W. Durham Rd.,
#D-6, Tigard, OR 97224. E-mail: Mcallister@portlandimplantdentistry.
com.
C A S E R E P O R T
References
1. Fiorellini JP, Nevins ML. Localized ridge augmentation/preservation. A
systematic review. Ann Periodontol 2003;8:321-327.
2. McAllister BS, Haghighat K. Bone augmentation techniques. J Peri-
odontol 2007;78:377-396.
3. Gonshor A, McAllister BS, Wallace SS, Prasad H. Histologic and
histomorphometric evaluation of an allograft stem cell-based matrix sinus
augmentation procedure. Int J Oral Maxillofac Implants 2011;26:123-131.
4. Muschler GF, Nitto H, Boehm CA, Easley KA. Age- and gender-related
changes in the cellularity of human bone marrow and the prevalence of
osteoblastic progenitors. J Orthop Res 2001;19:117-125.
5. Nkenke E, Weisbach V, Winckler E, et al. Morbidity of harvesting of bone
grafts from the iliac crest for preprosthetic augmentation procedures: A
prospective study. Int J Oral Maxillofac Surg 2004;33:157-163.
6. McAllister BS, Margolin MD, Cogan AG, Buck D, Hollinger JO, Lynch
SE. Eighteen-month radiographic and histologic evaluation of sinus
grafting with anorganic bovine bone in the chimpanzee. Int J Oral
Maxillofac Implants 1999;14:361-368.
7. McAllister BS, Haghighat K. Clinical applications of a stem cell based
therapy for oral bone reconstruction. In: Elisseeff J, Li S, LHeureux N,
eds. Stem Cells and Tissue Engineering. Hackensack, NJ: World
Scientific Publishing; 2011:14.
8. Muschler GF, Nakamoto C, Griffith LG. Engineering principles of clinical
cell-based tissue engineering. J Bone Joint Surg Am 2004;86-A:1541-1558.
9. Ryan JM, Barry FP, Murphy JM, Mahon BP. Mesenchymal stem cells
avoid allogeneic rejection. J Inflamm (Lond) 2005;2:8.
10. Barry FP, Murphy JM. Mesenchymal stem cells: Clinical applications
and biological characterization. Int J Biochem Cell Biol 2004;36:568-
584.
11. Brafman DA, Willert K, Chien S. High-throughput systems for stem cell
engineering. In: Elisseeff J, Li S, LHeureux N, eds. Stem Cells and
Tissue Engineering. Hackensack, NJ: World Scientific Publishing;
2011:17.
12. Chamberlain G, Fox J, Ashton B, Middleton J. Concise review:
Mesenchymal stem cells: Their phenotype, differentiation capacity,
immunological features, and potential for homing. Stem Cells 2007;25:
2739-2749.
13. Kadiyala S, Young RG, Thiede MA, Bruder SP. Culture expanded
canine mesenchymal stem cells possess osteochondrogenic potential
in vivo and in vitro. Cell Transplant 1997;6:125-134.
14. Malekzadeh R, Hollinger JO, Buck D, Adams DF, McAllister BS.
Isolation of human osteoblast-like cells and in vitro amplification for
tissue engineering. J Periodontol 1998;69:1256-1262.
15. Kaigler D, Pagni G, Park CH, Tarle SA, Bartel RL, Giannobile WV.
Angiogenic and osteogenic potential of bone repair cells for craniofacial
regeneration. Tissue Eng Part A 2010;16:2809-2820.
16. McAllister BS, Haghighat K, Gonshor A. Histologic evaluation of
a stem cell-based sinus-augmentation procedure. J Periodontol 2009;
80:679-686.
indicates key references.
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CASE REPORT
Use of Guided Tissue Regeneration in the Treatment
of a Severe EndodonticPeriodontic Lesion:
A 15-Year Follow-Up Case Report
Ronaldo B. Santana* and Carolina M. Mattos Santana*
Introduction: Treatment of combined endodonticperiodontic lesions remains a considerable challenge in clinical
practice. The degree of success in the management of these lesions is related to the efficacy of both periodontal and end-
odontic treatments and is influenced by specific anatomic characteristics of the lesion. This report presents the long-term
clinical outcomes of a severe endodonticperiodontic lesion treated by guided tissue regeneration (GTR) and documented
over a 15-year period.
Case Presentation: A non-smoking, 42-year-old female presented with a combined endodonticperiodontic lesion
consisting of a large through-and-through apical lesion communicating with the marginal periodontium as a result of the
complete loss of the facial bone plate. Treatment consisted of GTRand grafting with absorbable hydroxyapatite. The clinical
variables evaluated were plaque, bleeding on probing (BOP), gingival recession, probing depth (PD), and clinical attachment
level (CAL). Reevaluation was performed 1 year and 15 years after the surgical procedure. Healing was uneventful. Measure-
ments revealed that PD was reduced by 17 mm, a 16-mm CAL gain was recorded, and no BOP was detected at any tooth
aspect. CAL gains were maintained up to the 15-year recall. Radiographic evaluation demonstrated a complete resolution of
the bony lesion at both 1 year and 15 years after surgery.
Conclusion: Severe combined endodonticperiodontic lesions can be successfully treated via regenerative tech-
niques, and the resultant bone and CAL gains are preserved for several years after the active treatment. Clin Adv Periodon-
tics 2013;3:10-13.
Key Words: Guided tissue regeneration, periodontal; root canal obturation.
Background
When periapical and periodontal diseases simultaneously
affect the same tooth and are merged in a single lesion
communicating the apical and marginal tissues, a com-
bined endodonticperiodontic lesion is established.
1
The
presence of apical pathology or inadequately filled root
canal systems has been associated with increased probing
depth (PD), increased loss of clinical attachment level
(CAL), and reduced response to conventional and surgical
periodontal therapy.
2-4
Advances in surgical management
of periradicular pathosis, with particular emphasis on
guided tissue regeneration (GTR) techniques, may improve
success rates
5
and are used for the treatment of combined
endodonticperiodontic lesions.
5-10
The severe bone de-
struction characteristic of the combined endodontic
periodontic lesions is a major therapeutic challenge. This
report presents the long-term clinical outcomes of a severe
endodonticperiodontic lesion treated by GTR and docu-
mented over a 15-year period.
* Department of Periodontology, Fluminense Federal University, Dental
School, Niteroi, Rio de Janeiro, Brazil.
Submitted November 1, 2011; accepted for publication February 12,
2012
doi: 10.1902/cap.2012.110098
10 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013
Clinical Presentation
Clinical parameters (bleeding on probing [BOP], PD, reces-
sion [REC], and CAL), were assessed as described previ-
ously
11
at baseline and repeated 12 months and 15 years
after the initial surgery. BOP was recorded dichotomously
as the percentage of total surfaces (six sites per tooth).
A non-smoking, 42-year-old female was treated from
March 1994 to May 2009 at the Periodontology Clinic of
Fluminense Federal University (Rio de Janeiro, Brazil). The
patient reported diffuse, spontaneous pain in the region rel-
ative to the maxillary right central and lateral incisors (teeth
#7and#8) andmentionedthat these teethhadbeenendodon-
tically treated several years before her first appointment.
Teeth #7 and #8 presented localized redness in the oral
mucosa and pain after vertical percussion and palpation
on the buccal alveolar mucosa adjacent to the apexes of
both teeth. Periodontal probing revealed PD and CAL >15
mm (z21 mm) in the buccal aspect of tooth #8, followed
by drainage of bloody purulent exudate. No REC was
noted. Millers Class III mobility was noted in tooth #8,
and Class II mobility was noted for tooth #7. The baseline
radiographic image (Fig. 1a) revealed an extensive radiolu-
cent image in the periapical area of teeth #7 and #8 that was
continuous with the radiolucency in the interproximal
crestal bone walls of tooth #8. Radiopaque deposits, sug-
gestive of dental calculus, were observed on the root sur-
faces of tooth #8. The root canals of both teeth were
filled with a radiopaque material, which was overextended
and overfilled to the canal spaces of teeth #7 and #8.
In tooth #7, the lamina dura seemed to be intact except
for discontinuity in the apical portion. A diagnosis of si-
multaneous combined endodonticperiodontic lesion and
through-and-through periapical lesion was formulated.
Written informed consent was obtained from the patient
after comprehensive explanation of available treatment
options.
Case Management
Local anesthesia was obtained, and a facial trapezoidal
mucoperiosteal flap and a palatal envelope flap were ele-
vated. Bone defect debridement and root planing were
thoroughly performed. Tooth #8 exhibited an extensive
apical osseous defect associated with the complete loss
of the buccal alveolar bone wall. An extensive through-
and-through lesion involving the buccal and palatal apical
osseous walls of tooth #7 was also observed (Fig. 1d).
The root apexes of teeth#7 and #8 were resected, andthe
neo apexes were rounded, retro-prepared, and retro-filled
with amalgam. A double-layered collagen membrane
was
adjusted in the palatal aspect of the osseous crypt. The os-
seous lesion and the lateral and facial aspects of tooth #8
were completely filled with a resorbable microparticulate
hydroxyapatite,
and then a polytetrafluoroethylene mem-

brane
x
was positioned buccally over the borders of the le-
sion (Fig. 1e). The flap was split at its apical extent and
coronally advanced. Primary closure was obtained with
sling and interrupted single sutures. Postoperative recom-
mendations and maintenance schedule were performed as
described previously
11
in the first year and then repeated
once annually for 14 years.
FIGURE 1 Clinical and radiographic findings. 1a
Radiographic view at baseline. 1b Radiographic
view 1 year after treatment. 1c Radiographic
view 15 years after treatment. 1d Trans-surgical
view after mucoperiosteal flap reflection and
defect debridement. 1e Trans-surgical view of
membrane placement. 1f Trans-surgical view
after flap reflection and membrane removal.
CollaTape, Zimmer Dental, Carlsbad, CA.
Biohapatita, Dentoflex, So Paulo, Brazil.

x
Dentoflex.
C A S E R E P O R T
Santana, Santana Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 11
Clinical Outcomes
Healing was uneventful and, 12 months after surgery, re-
opening surgery was performed to remove the barrier
membrane. Visual and clinical inspection revealed a com-
pletely repaired apical bone defect and facial alveolar bone
plate (Fig. 1f). A 0.5-mm-thick superficial soft-tissue layer
was also found covering the facial bone plate. The flaps
were coronally positioned to completely cover the newly
formed tissues. Six months after membrane removal, prob-
ing measurements were repeated. Midfacial measurements
at tooth #8 revealed that PD reduced to 4 mm. REC mea-
surements were equal to 1 mm, and a total 16-mm CAL
gain was recorded. At the 15-year recall, PD was 2 mm,
REC was 3 mm, and 16-mm CAL gain was documented.
Measurements at other aspects of teeth #7 and #8 demon-
strated PD<3 mm, and noRECor BOP was detectedafter 1
and 15 years. Radiographic follow-up revealed increased
radiographic density in the periapical area of teeth #7
and #8 continuous with restored mesial and distal crestal
bone walls of tooth #8 1 year after treatment (Fig. 1b). Sim-
ilarly, improved radiographic results were seen 15 years
after treatment (Fig. 1c), both classified as Class 1D ac-
cording to Molven et al.s
12
radiographic classification
of healing after endodontic surgery.
Discussion
Treatment of teeth with advanced combined endodontic
periodontic lesions is a complex clinical challenge that
requires the elimination of the apical and marginal compo-
nents of the pathologic process.
1-4,8
Endodontic factors, in-
cluding the diameter of the apical lesion
6,13-15
and absence
of facial or lingual/palatal bone plate in conjunction with
a periapical lesion,
13,14
directly influence periodontal heal-
ing. In perforating through-and-through lesions, healing is
<25%.
7
Thus, the presence of a large through-and-through
apical lesion communicating with the marginal periodon-
tium as a result of the complete absence of the facial bone
plate, as observed in the case presented, is a clinical chal-
lenge because of the presence of significant negative prog-
nostic factors.
7,13-15
Positive clinical responses have been
documented for the treatment of human furcation defects
11
with the regenerative approach used in the present case.
Clinical and radiographic follow-up of the present case re-
vealed sustained bone and CAL gains for 15 years after ac-
tive treatment. To the best of our knowledge, this is the first
long-term report of successful treatment and maintenance
of regenerative therapyof advancedendodonticperiodontic
lesions followed for >2 years. Considering the important
technical developments in surgical endodontic retreat-
ment that occurred in the past decade (use of microscope,
microinstruments, absorbable membranes, and biocom-
patible filling materials, such as super ethoxybenzoic
acid or mineral trioxide aggregate),
8-10
we speculate that
procedures performed with state-of-the-art materials and
techniques may result in significantly improved and pre-
dictable outcomes. n
Summary
Why is this case new information? j This case demonstrates that short-term clinical benefits of combined
surgical endodonticperiodontic therapy can be longitudinally stable
for a long time in severe lesions treated by a regenerative approach.
j
Adequate case selection, use of regenerative materials, elimination of
both the apical and marginal components of the pathologic process,
and careful longitudinal supportive periodontal therapy are mandatory
for successful outcomes.
j The degree of success in the management of these lesions is
influenced by specific anatomic characteristics of the lesion.
Acknowledgment
The authors report no conflicts of interest related to this
case report.
CORRESPONDENCE:
Dr. Ronaldo B. Santana, Department of Periodontology, Dental School,
Fluminense Federal University, Rua Sao Paulo 28, Niteroi, Rio de
Janeiro 24040 115, Brazil. E-mail: rbarsantana@ig.com.br.
C A S E R E P O R T
12 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Regenerative Treatment of EndodonticPeriodontic Lesion
References
1. Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal
and periodontal tissues. J Clin Periodontol 2002;29:663-671.
2. Jansson L, Ehnevid H, Blomlof L, Weintraub A, Lindskog S. Endodon-
tic pathogens in periodontal disease augmentation. J Clin Periodontol
1995;22:598-602.
3. Ehnevid H, Jansson LE, Lindskog SF, Blomlof LB. Periodontal healing
in relation to radiographic attachment and endodontic infection.
J Periodontol 1993;64:1199-1204.
4. Ehnevid H, Jansson LE, Lindskog SF, Blomlof LB. Periodontal healing
in teeth with periapical lesions. A clinical retrospective study. J Clin
Periodontol 1993;20:254-258.
5. Rankow HJ, Krasner PR. Endodontic applications of guided tissue
regeneration in endodontic surgery. J Endod 1996;22:34-43.
6. Pecora G, Kim S, Celletti R, Davarpanah M. The guided tissue
regeneration principle in endodontic surgery: One-year postoperative
results of large periapical lesions. Int Endod J 1995;28:41-46.
7. Brugnami F, Mellonig JT. Treatment of a large periapical lesion with
loss of labial cortical plate using GTR: A case report. Int J Periodontics
Restorative Dent 1999;19:243-249.
8. Karabucak B, Setzer FC. Conventional and surgical retreatment of
complex periradicular lesions with periodontal involvement. J Endod
2009;35:1310-1315.
9. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical study
evaluating endodontic microsurgery outcomes for cases with lesions
of endodontic origin compared with cases with lesions of combined
periodontal-endodontic origin. J Endod 2008;34:546-551.
10. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of
endodontic surgery: A meta-analysis of the literature Part 1:
Comparison of traditional root-end surgery and endodontic microsur-
gery. J Endod 2010;36:1757-1765.
11. Santana RB, de Mattos CM, Van Dyke TE. Efficacy of combined
regenerative treatments in human mandibular Class II furcation defects.
J Periodontol 2009;80:1756-1764.
12. Molven O, Halse A, Grung B. Observer strategy and the radiographic
classification of healing after endodontic surgery. Int J Oral Maxillofac
Surg 1987;16:432-439.
13. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting the
long-term results of endodontic treatment. J Endod 1990;16:498-
504.
14. Skoglund A, Persson G. A follow-up study of apicoectomized teeth with
total loss of the buccal bone plate. Oral Surg Oral Med Oral Pathol
1985;59:78-81.
15. Danin J, Stromberg T, Forsgren H, Linder LE, Ramskold LO. Clinical
management of nonhealing periradicular pathosis. Surgery versus
endodontic retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1996;82:213-217.
C A S E R E P O R T
Santana, Santana Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 13
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CASE SERIES
Use of an Extracellular Matrix Membrane for Root Coverage: Case Series
and Review of the Literature
Monish Bhola,* Shayna Sanchez,* and Shilpa Kolhatkar*
Introduction: The treatment of gingival recession (GR) is a growing need in patients as a result of functional, esthetic,
and preprosthetic demands. Techniques that primarily use autogenous grafts, although well established, often require a re-
mote second surgical site. Clinicians have attemptedto achieve comparable results without a donor site by using substitutes
for autogenous grafts, such as allografts. Recently, the efficacy and predictability of an extracellular matrix (ECM) membrane
for root coverage procedures has received close attention. This case series investigates whether the use of an ECM mem-
brane for root coverage procedures achieves objectives, such as complete root coverage (CRC), stable results, and good
esthetics in the form of uniform gingival color and contour. The results of six such cases in a variety of clinical situations are
presented.
Case Series: Six cases of Miller Class II and III GR defects were treated using an ECM membrane. The flap oper-
ation was conducted with a trapezoidal or sulcular flap, followed by placement of the ECM over the GR defect. A follow-
up range of 15 months showed complete (two cases) to partial (four cases) root coverage and an increase in tissue
thickness.
Conclusion: These results suggest that the use of an ECMmembrane is a viable alternative to the use of autogenous
grafts when treating GR defects or for soft-tissue thickness augmentation. Clin Adv Periodontics 2013;3:16-21.
Key Words: Extracellular matrix; gingival recession.
Background
Gingival recession (GR) is a common finding in the adult
population in the United States.
1
Treatment of GRis needed
in an increasing number of individuals, primarily for
functional and esthetic needs. Although many oral plastic
treatment modalities
2
have been available to treat GR, the
need for a secondary surgical site frequently adds discom-
fort and longer chair time and increases the likelihood of
tissue morbidity and intraoperative and/or postoperative
complications.
3
An added concern is the limited thickness
of autogenous grafts in the presence of thin palatal tissue.
Additionally, in patients with shallowpalates, the size of the
autogenous graft that can be harvested at a single time is
limited. All of this makes the treatment of multiple GR
defects difficult and may contribute to reduced patient
acceptance. Acellular dermal matrix grafts have been
offered as a substitute for autogenous grafts, but the
resulting root coverage was not stable over time.
4
Recently, an extracellular matrix (ECM) membrane has
received close attention for use in root coverage procedures
as a result of favorable clinical outcomes. A split-mouth
study was performed to evaluate the safety, feasibility,
and efficacy of an ECM for gingival augmentation.
5
That
* Department of Periodontology and Dental Hygiene, University of Detroit
Mercy, School of Dentistry, Detroit, MI.
Submitted October 29, 2011; accepted for publication December 12,
2011
doi: 10.1902/cap.2012.110096
study compared the clinical and histologic results of ECM
versus an autogenous gingival graft in augmenting kerati-
nized tissue. The authors concluded that ECM was effec-
tive in increasing the zone of keratinized tissue and
seemed to have a more esthetically pleasing outcome.
The newly formed tissue resembled the original gingival
color and texture more closely compared to the autoge-
nous graft. The advantages of using ECM included the
elimination of a secondary surgical site, unlimited graft
supply, and a natural esthetic appearance.
The current case series investigates whether the use of an
ECM for root coverage procedures achieves objectives
such as complete root coverage (CRC), stable results,
and good esthetics, such as uniformgingival color and con-
tour. The results of six such cases in a range of clinical sit-
uations are presented.
Six non-smoking patients (one male and five females, aged 39
to 63 years) presented to private practice (Detroit, Michigan)
fromJanuary 2009 to July 2011, for evaluation of GRthat re-
quired root coverage and/or soft-tissue augmentation for bio-
type modification (Table 1). The cases treated had GR
depths ranging from slight (2 mm) to severe (9 mm) and were
present on both anterior and posterior teeth (Figs. 1a, 2a, 3a,
and 4a). A presurgical evaluation was completed on each pa-
tient, includingadetailedoral examandnecessaryradiographs.
Medical history of all patients was non-contributory. Oral pro-
phylaxis or scaling and root planing were completed and cari-
ous lesions, if any, were treatedbefore soft-tissue augmentation.
Case Management
The recommended treatment was thoroughly explained to
each patient, and written informed consent was obtained.
The material usedinthis case series is anECM
derivedfrom
the small intestinal submucosa (SIS) of pigs from qualified
animal production facilities. SIS is obtained from the intes-
tine using a process that retains the natural composition of
matrix molecules, such as collagen (types I, III, VI), glycos-
aminoglycans (hyaluronic acid, chondroitin sulfate Aand B,
heparin, and heparan sulfate), proteoglycans, growth factors
(fibroblast growth factor-2, transforming growth factor-
b), and fibronectin.
6,7
All procedures were performed under profound local
anesthesia.
Site preparation was accomplished using the

following techniques: diverging trapezoidal incisions (Figs.
1b and 2b) and sulcular incisions followed by reflection of
a mucoperiosteal flap. Root surface debridement was ac-
complished using hand instruments and flame-shaped ro-
tary instruments
x
and chemically treated
for 2 minutes.
The membrane
{
was then appropriately trimmed and su-
tured using resorbable sling suture
#
(Fig. 4b) and placed
over the root surface. A sling suture** was used to coro-
nally advance the facial flap by using periosteal releasing
incisions (Fig. 1c). The vertical incisions were secured with
interrupted sutures
(Figs. 1d, 2b, and 3b). Detailed writ-

ten and verbal postoperative instructions were given. Each
patient was placed on 250 mg amoxicillin every 8 hours for
5 days, 800 mg ibuprofen every 6 hours as needed, and
0.12% chlorhexidine gluconate mouthrinse
twice daily
for 30 seconds.
Clinical Outcomes
For all patients, healing of the surgical site was uneventful,
and no intraoperative/postoperative complications oc-
curred. All GRdefects were stable after a follow-up period
of 15 months (Figs. 1e, 2c, 3c, and 4c). Table 1 illustrates
preoperative GR and total root coverage (in millimeters
and percentage) obtained. Two of the six defects treated
(cases 1 and 3) obtained 100% root coverage. A severe
GRdefect (case 2) gained 67%root coverage, and multiple
adjacent GRdefects (case 4) gained 50%root coverage and
successful biotype conversion from thin to thick gingival
biotype as assessed through visual examination. The color
of the gingiva closely matched the adjacent teeth and
TABLE 1 Case Descriptions
Case Age, Sex Tooth #
Initial GR
Depth (mm)
Miller
Classification
9
Medical History
Root Coverage
Obtained (mm)
Root Coverage
Obtained (%) Figure
1 55, Female 6 4 II Non-contributory 4 100 1
2 60, Male 14 9 III Reynaud syndrome 6 67 2
3 50, Female 6 5 III Non-contributory 5 100 3
4 63, Female 23 through 26 2 to 4 III Mitral valve prolapse 1 to 2 50 4
5 41, Female 24 3 III Non-contributory 1.5 50 N/A
6 39, Female 24 5 II Non-contributory 4 80 N/A
DynaMatrix Plus, Keystone Dental, Burlington, MA.
Septodont, Lancaster, PA.

x
7406, Brasseler USA, Savannah, GA.
PrefGel, Straumann, Andover, MA.

{
DynaMatrix Plus, Keystone Dental.
#
Ethicon, Johnson & Johnson, Somerville, NJ.
**Ethicon, Johnson & Johnson.
Ethicon, Johnson & Johnson.
3M ESPE, St. Paul, MN.

C A S E S E R I E S
Bhola, Sanchez, Kolhatkar Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 17
provided harmonious blend of the treated area. Case 3
demonstrated a reduced concentration of physiologic
pigmentation.
Discussion
When considering treatment of GR, the option of soft-tis-
sue autogenous grafting requires two surgical sites, donor
and recipient site. Since the introduction of tissue-engi-
neeredsoft-tissue graft substitutes, harvesting a donor graft
from a secondary surgical site may no longer be required.
5
The success of using ECM for gingival augmentation has
been reported previously.
5,8
Saroff
8
conducted an investi-
gation to assess use of ECM for guided tissue regeneration
for root coverage. Seven patients with varying degrees of
GRand bone loss were treated using ECMand bone grafts,
with successful tissue remodeling and enhanced root cov-
erage in areas of localized GR. All of our cases presented
achieved similar results in the form of partial or complete
FIGURE 1 Case 1. 1a Preoperative view of tooth #6. 1b A trapezoidal flap
was raised, and the root surface was prepared. 1c ECM placed and
secured with sutures. 1d Flap coronally advanced and sutured. 1e Follow-
up at 15 months.
C A S E S E R I E S
18 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Extracellular Matrix Membrane for Root Coverage
root coverage. These results maintained stability for a
follow-up duration of 15 months.
This case series presents results of root coverage using
ECM for root coverage in varying and complex clinical cir-
cumstances. The results are favorable and have maintained
stability up to a 15-month observation period. In this case se-
ries, we present six cases that were treated using ECM as an
alternative toharvestinganautogenous graft, for treatment of
GR. In all cases, we were able to obtain an increased width of
keratinized tissue and partial-to-complete root coverage. n
Summary
Why are these cases new
information?
j
ECM eliminates the need for an autogenous graft.
j
The root coverage obtained is comparable to that seen in connective
tissue graft with good color match.
management of these cases?
j
It is important to ensure thorough debridement and preparation of the
root surface, tension-free closure, and immaculate oral hygiene.
j Complete coverage of the ECM with the flap is also necessary.
success in these cases?
j The maximum time of observation is 15 months, and a clinical trial of
longer duration with a larger sample size is needed to assess
long-term results.
Acknowledgments
Dr. Bhola is a consultant for Keystone Dental (Burlington,
Massachusetts) and has given lectures sponsored or co-
sponsored by the company. Drs. Sanchez and Kolhatkar
report no conflicts of interest related to this case series.
CORRESPONDENCE:
Dr. Shayna Sanchez, 2700 Martin Luther King Jr. Blvd., Detroit, MI 48208-
2576. E-mail: shayna729@gmail.com.
FIGURE 2 Case 2. 2a Preoperative view of tooth #14. 2b ECM was placed and pedicle was flap secured over membrane and GR defect. 2c Follow-up at 3
months.
C A S E S E R I E S
FIGURE 3 Case 3. 3a Preoperative view of tooth #6. 3b After the ECM was
placed, the flap was coronally advanced and sutured. 3c Follow-up at 1
year.
FIGURE 4 Case 4. 4a Preoperative view of teeth #23 through #26. 4b ECM
was sutured into place. 4c Follow-up at 3 months.
C A S E S E R I E S
20 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Extracellular Matrix Membrane for Root Coverage
References
1. Albandar JM, Kingman A. Gingival recession, gingival bleeding, and
dental calculus in adults 30 years of age and older in the United States,
1988-1994. J Periodontol 1999;70:30-43.
2. Chambrone L, Pannuti CM, Tu YK, Chambrone LA. Evidence-based
periodontal plastic surgery. II. An individual data meta-analysis for
evaluating factors in achieving complete root coverage. J Periodontol
2012;83:477-490.
3. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative
complications following gingival augmentation procedures. J Periodontol
2006;77:2070-2079.
4. Harris RJ. A short-term and long-term comparison of root coverage
with an acellular dermal matrix and a subepithelial graft. J Periodontol
2004;75:734-743.
5. Nevins M, Nevins ML, Camelo M, Camelo JM, Schupbach P, Kim DM.
The clinical efficacy of DynaMatrix extracellular membrane in aug-
menting keratinized tissue. Int J Periodontics Restorative Dent 2010;
30:151-161.
6. Hodde J, Janis A, Ernst D, Zopf D, Sherman D, Johnson C. Effects of
sterilization on an extracellular matrix scaffold: Part I. Composition
and matrix architecture. J Mater Sci Mater Med 2007;18:537-543.
7. Hodde JP, Badylak SF, Brightman AO, Voytik-Harbin SL. Glycosaminoglycan
content of small intestinal submucosa: A bioscaffold for tissue replacement.
Tissue Eng 1996;2:209-217.
8. Saroff S. The use of DynaMatrix extracellular membrane for gingival
augmentation and root coverage: A case series. J Implant Adv Clin
Dent 2011;3:19-30.
9. Miller PD Jr. A classification of marginal tissue recession. Int J
Periodontics Restorative Dent 1985;5(2):8-13.
C A S E S E R I E S
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CREDITS
CASE SERIES
Orthodontic Treatment After Induced Periodontal Regeneration
in Deep Infrabony Defects
Carlo Ghezzi,* Valeria M. Vigan,* Paola Francinetti,* Gianfranco Zanotti,
and Silvia Masiero
Introduction: Limited studies investigated whether orthodontic movement should be performed in patients with peri-
odontal disease and severe intrabony defects. The purpose of this study is to assess the stability of the periodontal complex
combining regeneration treatment with enamel matrix derivative (EMD) and collagen bovine mineral bone, followed by early
orthodontic movement.
Case Series: In a prospective case series, 10 patients with radiographic vertical defects with probing depths (PDs) 6
mmand pathologic tooth migration were enrolled. Each patient contributed one infrabony defect treated with a combination
of EMD and collagen bovine mineral bone. All patients started the alignment stage 1 month after periodontal surgery with
0.014 nickeltitanium wires, and the treatment lasted a mean time of 9 3.2 months. Clinical measurements (PD, clinical
attachment level [CAL], and gingival recession) were calculated from baseline to the end of orthodontic treatment. Mean
PD reduction was 3.7 1.77 mm, with an average residual PD of 4 1.05 mm; mean CAL gain was 4.4 1.71 mm, with
a residual CAL of 5.5 1.72 mm. Both differences are statistically significant (P (( <0.001).
Conclusions: Areconstructive procedure that combines EMDandcollagen bovine mineral bone as a periodontal pre-
orthodontic procedure seem to provide excellent clinical results. In this clinical case series, early orthodontic movement,
even if it takes place in immature bone during the healing time, has not adversely affected the maturation process of the
entire periodontal apparatus. Clin Adv Periodontics 2013;3:24-31.
Key Words: Enamel matrix proteins; intrabony defects; orthodontics; periodontal regeneration; regenerative medicine.
Background
Patients with periodontal disease can present pathologic
tooth migration (PTM), often combined with severe
intrabony defects. Periodontal bone reabsorption seems
to be one of the main agents in the etiology of PTM, along
with changes in occlusion caused by several factors,
including the pressure produced by inflamed tissues within
the periodontal pockets.
1
PTM causes an esthetic and
functional problem that is also reflected in the social
relationship of the patient.
The orthodontic movement of teeth, with reduced but
healthy periodontal tissue, has been investigated in several
studies on both humans and animals.
2-4
These studies have
confirmed that orthodontic treatment does not damage the
periodontal attachment if the level of gingival inflammation
is kept under control. However, the combination of ortho-
dontic forces andinflammationsustainedfromplaque cause
the uncontrolled breakdown of periodontal attachment.
5
Several histologic studies in animals
6,7
investigated the
effects of periodontal therapy combined with orthodontic
* Private practice, Milan, Italy.
Private practice, Pessano, Italy.
Private practice, Saronno, Italy.

Submitted September 19, 2011; accepted for publication December 23,
2011
doi: 10.1902/cap.2012.110085
treatment. Polson et al.
6
in 1984 showed that orthodontic
movement in defects previously treated with scaling and
root planing did not lead to any increase in periodontal at-
tachment level. Instead, Diedrich et al.
7
treated intrabony
defects with enamel matrix derivative (EMD) and resorb-
able membranes, with subsequent orthodontic movement
1 month after surgery. This study
7
found that all treated
sites showed regeneration of the periodontal apparatus.
Data fromtwo other histologic studies in animals
8,9
indi-
cate that regeneration can be achieved in sites treated with
open-flapdebridement (OFD) combinedwithimmediate or-
thodontic treatment. Both confirmed the regenerative ca-
pacity of OFD associated with orthodontic treatment in
terms of both bodily and intrusive movement.
Despite these results, there is no histologic evidence of re-
generation association with OFD in humans, whereas sev-
eral histologic studies have confirmed the benefits of the
treatment withguidedtissue regeneration(GTR).
10-13
More-
over, some reviews have shown that GTR produces better
results in terms of probing depth (PD) reduction and clinical
attachment level (CAL) gaincomparedtoOFDalone.
14-18
In
a recent review, Esposito et al.
19
compared EMDwith GTR
and various bone grafting procedures in intrabony defects.
Although this review
19
confirms the actual regenerative po-
tential of EMDcompared to OFD, the comparison between
EMD and GTR did not lead to a significant conclusion.
Fromthe clinical point of view, the use of OFDto control
infrabony defects before the application of orthodontic
forces was indicated in some clinical case reports.
20-22
Statis-
tical significance in terms of CAL gain and PD reduction was
found in each study. However, other cases series
23-26
studied
the effects of regenerative procedures before orthodontic
movement. Ghezzi et al.
23
applied orthodontic forces 1 year
after regeneration procedures with EMD or collagen mem-
brane plus collagen bovine bone mineral and found signi-
ficant improvement in CAL and PD after maturation of
tissues. The subsequent orthodontic treatment was not dam-
aging toregenerated periodontal tissues, giving a general en-
hancement of the esthetic parameters calculated with the
papillae presence index.
27
To the best of our knowledge,
there has been no randomized clinical trial that has assessed
the results of one method compared to the other.
Moreover, the literature revealed that light continuous
forces (5 to 15 g) were recommended in a compromised pe-
riodontum, and the range of the commencement of tooth
movement after periodontal surgery ranged from 7 days to
1 year.
20-29
Lack of information about the effective and safe
timing in which to start the movement probably justified this
huge range; in fact, severe root and bone resorption could be
the major negative effects of moving teeth in immature bone.
Orthodontics are not used before regeneration because
of the residual attachment and the subsequent difficulty
in controlling the infection in the selected sites.
Taking into account the histologic results of Diedrich
et al.
7
and the excellent clinical data on reconstructive peri-
odontal therapy indeepintrabony defects, the purpose of our
study is to assess the stability of the final results on the peri-
odontal complex when combining periodontal regeneration
with EMD and collagen bovine mineral bone and subsequent
orthodontic movement starting 4 weeks after surgery.
Ten adult patients (four males and six females) were in-
volved in this case series from 2009 to 2011. Two patients
had severe generalized aggressive periodontitis, and the re-
maining eight had severe generalized chronic periodontitis.
All patients were >21 years of age, in good general health,
and without systemic disease. Patients were treated in a
private office by the same operator (CG) after signing in-
formed consent before each procedure.
The clinical inclusion criteria were the presence of PTM
and diastema after periodontal disease and completion of
the initial etiologic phase of therapy, reaching a full-mouth
plaque score and full-mouth bleeding score
30
<25% in the
presence of radiographic vertical defect with PD 6 mm.
Smokers were included in the study only if they smoked
<10 cigarettes per day.
Teeth that needed orthodontic extrusion movement and
teeth with furcation involvement were excluded from the
study. Table 1 shows both individual clinical data of the
patients and the type of infrabony defect. The prevalence
of wall defects is 50% for three walls, 30% for one wall,
and 20% for two walls.
Case Management
After causal therapy, all patients enlisted received a com-
plete periodontal reexamination and reinstruction of oral
hygiene procedures. Intraoral radiographs were subse-
quently taken, and data were collected for PD, CAL, and
gingival recession (GR). Each patient had an infrabony de-
fect that was treated with a combination of EMD and col-
lagen bovine bone mineral
x
(Figs. 1 and 2a).
TABLE 1 Demographic and Defect Information of Patients
Patient Tooth Infrabony Defect Walls Age (years)
F.M. 8 3 55
A.B. 22 3 44
A.R. 27 1 31
C.Z. 8 2 33
B.S. 6 3 41
C.D. 8 3 48
G.E. 9 3 53
M.L. 9 1 52
D.M. 8 1 53
G.S. 9 2 59
x
Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland.
C A S E S E R I E S
Ghezzi, Vigan, Francinetti, Zanotti, Masiero Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 25
The modified papilla preservation technique was used
when the interdental space was >2 mm, whereas when
the space was 2 mm, a simplified papilla preservation flap
was performed
31,32
(Fig. 3). A full-thickness flap was ele-
vated to allow an adequate visualization of the site, and
the absence of tension was reached to allow primary clo-
sure of the flap (Fig. 4). In each case, after infrabony defect
debridement, the sites were treated with a combination of
EMD and collagen bovine bone mineral (Figs. 5 and 6).
The combination of mattress and single suture was done
for complete primary closure (Fig. 7).
Patients received antibiotic therapy (3 g amoxicillin
k
daily for 6 days) and rinsed with 0.2%chlorhexidine twice
daily for 15 days, and then with 0.12% chlorhexidine for
an additional 2 weeks. Sutures were completely removed
between the first and second weeks, and patients were
placed in a monthly program of hygiene and remotivation
throughout the period of the orthodontic therapy.
Orthodontic treatment was started 1 month after sur-
gery, and all teeth needed a combination of bodily and in-
trusive movement (Fig. 8). Patients received different types
of orthodontic movement (mostly intrusion and displace-
ment body), according to their clinical needs in terms of
dental arch realignment: intrusion and bodily movement
(Fig. 9). A low-friction biomechanical system was used to
develop light and continuous forces (10 to 15 g/tooth) to
obtain a space closure of the migrated teeth.
All patients started the alignment stage with 0.014 nickel
titanium (NITI) wires, and the treatment lasted a mean time
of 9 3.2 months. The alignment was performed with this se-
quence of arches: 0.014NITI, 0.0140.025NITI, 0.018
0.025 NITI, and 0.019 0.025 titaniummolybdenum. At
theendof thetreatment period, all patients receivedpermanent
retention to avoid orthodontic relapse, to reduce tooth mobil-
ity, and to improve comfort during mastication (Figs. 10 and
11a). After orthodontics, no patients reported abnormal pain.
With the current information, it is not possible to deter-
mine whether a longer period of orthodontic therapy would
be negative on the final result. A hypothesis could be that,
with no inflammation, a correct control of both orthodontic
andocclusal traumas is not detrimental tothe overall therapy,
even in situations of poor residual periodontal support.
2-4
Clinical and radiologic measurements (PD, CAL, and
GR) were calculated at baseline (T.0) and at the end of or-
thodontic treatment (T.END) with mean values and stan-
dard deviation. A single trained operator (CG) did the T.0
and T.END measurements with a periodontal probe
{
to
minimize bias. The differences were statistically analyzed
FIGURE 1 PTM in maxillary central incisors.
FIGURE 2a Bone defect before initial phase of treatment. 2b PD of 8 mm.
k
Augmentin, GlaxoSmithKline, Milan, Italy.
{
UNC-15 probe, Hu-Friedy, Chicago, IL.
C A S E S E R I E S
26 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Periodontal Regeneration and Orthodontic Treatment in Infrabony Defects
by a Student t test, and the level of significance was assessed
at 5% (P 0.05).
Clinical Outcomes
In Table 2, the intrasurgical measurements of infrabony de-
fects are reported (mean SD, 5.5 1.1 mm). Tables 2 and
3 show individual clinical data of a single tooth, including
mean values and standard deviations at both T.0 and T.
END. The mean baseline PD was 7.7 1.2, with an initial
mean CALof 10 1.05. Mean PDreduction was 3.7 1.77
mm, with an average residual PD of 4 1.05 mm; mean
CAL gain was 4.4 1.71 mm, with a residual CAL of
5.5 1.72 mm. Both differences are statistically significant
(P <0.001) (Table 3). There was a reduction in GR, but it
was not statistically significant (gain of 0.8 mm).
FIGURE 6 The defect filled with EMD after the bone graft was added.
FIGURE 7 The combination of mattress and single suture was done to
complete the primary closure.
FIGURE 8 Clinical view at the start of the orthodontic treatment (1 month).
FIGURE 3 Modified papilla preservation technique.
FIGURE 4 Intrasurgical view exhibiting an infraosseus component of
5 mm.
FIGURE 5 The defect filled with EMD before the bone graft was added.
C A S E S E R I E S
Discussion
Today, esthetics are becoming the key objective when final-
izing a treatment plan. In patients with periodontal disease,
the presence of deep intrabony defects is often associated
with pathologic migration of teeth. Clinicians, in these
cases, consider treatment planning to be satisfactory only
when inflammatory periodontal control, esthetic goals,
and full-time supportive professional care are thoroughly
taken into account.
Several studies have demonstrated that teeth with re-
duced but healthy periodontium can be moved without
attachment loss, whereas both intrusion and bodily move-
ment may cause conversion of supragingival plaque into
subgingival plaque, resulting in intrabony pocket forma-
tion in cases of uncontrolled periodontal inflammation
or in the absence of good patient compliance.
2-5
In the presence of deep infrabony defects, periodontal re-
generation seems to be the only way to recreate new peri-
odontal support, as shown from clinical, histologic, and
long-term survival studies.
11,18,19,33
Despite this evidence,
some clinical studies
20,22
show that it is possible to treat
deep infrabony defects with both OFD and orthodontic
treatment. Animal studies on cell kinetics of periodontal
ligament during orthodontic treatment seem to indicate
only osteogenesis induction, which could confirm the
inability to recreate a new attachment without regenera-
tion procedures.
34-36
However, the histologic studies of
Melsen et al.
9
and Geraci et al.
8
have shown that it is pos-
sible to reconstruct lost attachment only by combining
OFDand orthodontic movement, but results have not been
FIGURE 9 Clinical view after 6 months of orthodontic treatment.
FIGURE 10 Clinical view at the end of orthodontic treatment. Note the
esthetic improvement resulting from the realignment and the enhancement
of the gingival contour.
FIGURE 11a The final radiograph shows complete defect fill after
orthodontic treatment. 11b The residual PD is 3 mm after orthodontic
treatment.
C A S E S E R I E S
confirmed by similar research. In any case, to our knowl-
edge, no histologic regeneration has been demonstrated
using OFD in humans, whereas several studies have shown
the histologic and clinical benefits of regenerative treat-
ments. It has also been histologically demonstrated
6,7,10,12,13
that GTRappears to be the only way to recreate periodontal
tissue in the presence of deep intrabony defects.
14,18
The rationale of our study was to use a well-known re-
constructive procedure that combines EMD and collagen
bone bovine mineral as a periodontal pre-orthodontic pro-
cedure to have a standardization on the surgical phase and
to start the movement after 4 weeks. Therefore, the ortho-
dontic movement occurred in immature bone, although
this timing has had no adverse effects on the maturation
of the tissues.
20-22
In fact, in an animal model, Diedrich
et al.
7
started tooth movement 1 month after regenerative
periodontal surgery in both bodily movement (tension or
pressure side) and intrusion, demonstrating the formation
of new periodontal apparatus.
However, according to Diedrich et al.,
7
osteogenesis was
reduced in all pressure sites in which polylactic membranes
were used, and this observation could be explained by con-
sidering how membrane degradation affects the remodel-
ing phase of bone graft during the healing period. This
consideration, together with a lack of information on this
topic, lead us to follow the possibility of reaching a good
result using a regenerative procedure, such as the use of
EMDrather than OFDas a periodontal pre-orthodontic ap-
proach to the treatment of intrabony defects. Furthermore,
the movement was started 1 month after surgery, the time
at which soft tissue was microscopically stable and oral hy-
giene was easily maintained by the patients.
37
n
TABLE 2 Individual Clinical Measurements at Baseline and After Orthodontic Treatment
Patient Tooth
Infrabony Defects
Surgical
Measurement
T.0 PD
(mm)
T.END
PD
(mm)
Difference
(mm)
T.0
CAL
(mm)
T.END
CAL
(mm)
Difference
(mm)
T.0
GR
(mm)
T.END
GR
(mm)
Difference
(mm)
F.M. 8 5 8 3 5 10 4 6 2 1 1
A.B. 22 4 6 4 2 11 9 2 5 5 0
A.R. 27 7 9 3 6 11 5 6 2 2 0
C.Z. 8 6 9 6 3 9 7 2 0 1 1
B.S. 6 6 9 4 5 10 6 4 1 2 1
C.D. 8 6 9 3 6 9 3 6 0 0 0
G.E. 9 4 7 3 4 11 4 7 4 1 3
M.L. 9 5 7 4 3 11 6 5 4 2 2
D.M. 8 4 6 5 1 8 5 3 2 0 2
G.S. 9 4 7 5 2 10 6 4 3 1 2
TABLE 3 Clinical Measurements at Baseline and After
Orthodontic Treatment
Parameter Mean SD P value
PD
T.0 PD (mm) 7.7 1.252
T.END PD (mm) 4 1.054 9.60e-05 <0.001
Reduction (mm) 3.7 1.77
CAL
T.0 CAL (mm) 10 1.054
T.END CAL (mm) 5.5 1.716 2.22e-0.5 <0.001
Gain (mm) 4.4 1.71
GR
T.0 GR (mm) 2.3 1.703
T.END GR (mm) 1.5 1.434 0.104
Gain (mm) 0.8 1.4
C A S E S E R I E S
Summary
information?
j
Follows a multidisciplinary treatment to define a new clinical approach
in periodontal patients
j
Shows that early orthodontic movement after regenerative surgery is
a great possibility in periodontal patients
j Lack of information in literature about the relationship between
periodontics and orthodontics
j
Patient compliance
j
Financial resources
j
High-level experience in periodontal surgery
j
Communication between different specialties
j
Patient compliance and motivation
j The multidisciplinary treatment approach
j Lack of follow-up
Acknowledgments
The authors thank Prof. Giampietro Farronato of the Uni-
versity of Milan (Milan, Italy) for his contributions to this
case series. The authors report no conflicts of interest
related to this case series.
CORRESPONDENCE:
Dr. Valeria Maria Vigan, Via S. Pellico, 26/2, I-20019 Milan, Italy. E-mail:
valeria.vigano@gmail.com.
C A S E S E R I E S
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16. Trombelli L, Heitz-Mayfield LJ, Needleman I, Moles D, Scabbia A. A
systematic review of graft materials and biological agents for peri-
odontal intraosseous defects. J Clin Periodontol 2002;29(Suppl. 3):
117-135.
17. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley
JC. The efficacy of bone replacement grafts in the treatment of peri-
odontal osseous defects. A systematic review. Ann Periodontol 2003;8:
227-265.
18. Esposito M, Coulthard P, Thomsen P, Worthington HV. Enamel matrix
derivative for periodontal tissue regeneration in treatment of intrabony
defects: A Cochrane systematic review. J Dent Educ 2004;68:834-844.
19. Esposito M, Grusovin MG, Papanikolaou N, Coulthard P, Worthington
HV. Enamel matrix derivative (Emdogain(R)) for periodontal tissue
regeneration in intrabony defects. Cochrane Database Syst Rev 2009;7:
CD003875.
20. Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G.
Orthodontic movement into infrabony defects in patients with ad-
vanced periodontal disease: A clinical and radiological study. J
Periodontol 2003;74:1104-1109.
21. Cirelli JA, Cirelli CC, Holzhausen M, Martins LP, Brandao CH.
Combined periodontal, orthodontic, and restorative treatment of
pathologic migration of anterior teeth. A case report. Int J Periodontics
22. Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the
maxillary midline papilla following a combined orthodonticperiodon-
tic treatment in adult periodontal patients. J Clin Periodontol 2004;31:
79-84.
23. Ghezzi C, Masiero S, Silvestri M, Zanotti G, Rasperini G. Orthodontic
treatment of periodontally involved teeth after tissue regeneration. Int J
Periodontics Restorative Dent 2008;28:559-567.
24. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Bio-Oss
collagen and orthodontic movement for the treatment of infrabony
defects in the esthetic zone. Int J Periodontics Restorative Dent 2006;
26:553-559.
25. Diedrich PR. Guided tissue regeneration associated with orthodontic
therapy. Semin Orthod 1996;2:39-45.
26. Schneider B, Wehrbein H, Meyer R, Diedrich P. Intrusion of peri-
odontally affected teeth using a polyglactin-910-membrane (Vicryl) (in
German). Dtsch Zahnarztl Z 1990;45:171-175.
27. Cardaropoli D, Re S, Corrente G. The Papilla Presence Index (PPI): A
new system to assess interproximal papillary levels. Int J Periodontics
28. Reichert C, Deschner J, Kasaj A, Jager A. Guided tissue regeneration
and orthodontics. A review of the literature. J Orofac Orthop 2009;70:
6-19.
29. Gkantidis N, Christou P, Topouzelis N. The orthodontic-periodontic
interrelationship in integrated treatment challenges: A systematic
review. J Oral Rehabil 2010;37:377-390.
30. OLeary TJ, Drake RB, Naylor JE. The plaque control record. J
Periodontol 1972;43:38.
31. Cortellini P, Prato GP, Tonetti MS. The modified papilla preservation
technique. A new surgical approach for interproximal regenerative
procedures. J Periodontol 1995;66:261-266.
32. Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservation
flap. A novel surgical approach for the management of soft tissues in
regenerative procedures. Int J Periodontics Restorative Dent 1999;19:
589-599.
33. Tu YK, Woolston A, Faggion CM Jr. Do bone grafts or barrier
membranes provide additional treatment effects for infrabony lesions
treated with enamel matrix derivatives? A network meta-analysis of
randomized-controlled trials. J Clin Periodontol 2010;37:59-79.
34. Roberts WE, Goodwin WC Jr, Heiner SR. Cellular response to
orthodontic force. Dent Clin North Am 1981;25:3-17.
35. Nemcovsky CE, Sasson M, Beny L, Weinreb M, Vardimon AD.
Periodontal healing following orthodontic movement of rat molars
with intact versus damaged periodontia towards a bony defect. Eur J
Orthod 2007;29:338-344.
36. Nemcovsky CE, Beny L, Shanberger S, Feldman-Herman S, Vardimon
A. Bone apposition in surgical bony defects following orthodontic
movement: A comparative histomorphometric study between root- and
periodontal ligament-damaged and periodontally intact rat molars.
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cepts and practical advice. Am J Orthod 1974;66:487-497.
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CASE REPORT
The Possible Effect of an Accessory Root-Like Structure on Periodontitis:
A Clinical and Histologic Case Report
Jianxin Du,* Xiaoying Wang,* Jin Zhang,* Shiguo Yan,* Li Wang,* and Pishan Yang*
Introduction: Tooth-related factors, such as cemento-enamel projections and furcations, are contributing factors to
periodontal disease. Tooth morphologic variations in the anterior teeth are less frequently reported.
Case Presentation: A 25-year-old female patient was referred to our clinic with generalized severe aggressive peri-
odontitis. An accessory root-like structure on the mesio-labial surface of the root of tooth #9 was identified. This root-like
structure was z7 mm long and had a sharp tip. Clinical examination revealed tooth #9 had Miller Class III mobility, a
7-mm-deep periodontal pocket on the mesio-labial aspect of the tooth, and a clinical attachment loss of 12 mm. Although
periodontal destruction could also be observed at other tooth sites, the destruction on tooth #9 was more prominent. After
initial periodontal treatment, tooth #9 was deemed hopeless, extracted, and then replaced with a provisional removable
partial denture.
Conclusions: Although developmental dental anomalies are important contributing factors for the development and
progression of periodontitis, they are frequently undiagnosed. Therefore, early recognition of the abnormal dental morphol-
ogy is of great clinical significance in effectively treating periodontitis. Clin Adv Periodontics 2013;3:33-38.
Key Words: Developmental biology; histology; periodontitis; risk factors.
Background
Some anatomic abnormalities are considered as contributing
factors for periodontal diseases because of their association
with the retention of dental plaque.
1,2
The anatomic structure of the maxillary central incisor
most likely presents with a single root and root canal.
3
How-
ever, developmental root anomalies have been reported.
Most cases reported two roots and/or two root canals.
4,5
In 1992, a cervical enamel projection on the facial aspect
of a maxillary central incisor was reported as being associ-
ated with gingival fenestration.
6
In the current case report,
we report an unusual accessory root-like structure on the
mesio-labial aspect of the root of the left maxillary central
incisor tooth (tooth #9). How this morphologic variation
might have contributed to the development and progres-
sion of periodontitis is also discussed.
This study was approved by the Institutional ReviewBoard
of Shandong University, Jinan, Shandong, China, and writ-
ten informed consent was obtained fromthe patient. On Feb-
ruary 11, 2011, a 25-year-old female patient was referred for
periodontal treatment with the complaint of mobility of
tooth #9 for 1 year. During clinical examination, an acces-
sory root-like structure on the mesio-labial aspect of the
root of tooth #9 (Fig. 1a) was identified. The probing depth
at this site was 7 mm, and the clinical attachment loss was 12
mm(Fig. 1b). The mobility of tooth #9 was assessed as Class
III using Millers mobility index.
7
Periodontal destruction
could also be observed at other teeth with a lesser degree
of destruction, as shown in the panoramic radiograph.
* Shandong Provincial Key Laboratory of Oral Biomedicine, School and
Hospital of Stomatology, Shandong University, Jinan, Shandong, China.
Submitted November 24, 2011; accepted for publication February 16,
2012
doi: 10.1902/cap.2012.110105
The location of the vertical bone resorption on tooth #9 cor-
responded to where the accessory root-like structure was
found, whereas the other teeth sites only showed horizontal
alveolar bone resorption to the middle third of the roots
(Fig. 1c). No morphologic variations were found on the con-
tralateral tooth. No similar abnormalities were found on the
teeth of her family members. The patient did not take any
medications and no systemic diseases or trauma history were
reported.
Case Management
Initial periodontal treatment was performed, including
oral hygiene instructions and scaling and root planing.
At the following appointment, a general improvement was
noted at most tooth sites. However, tooth #9 failed to show
an obvious positive response and still represented severe
mobility. Therefore, extraction was recommended.
Clinical Outcomes
After the extraction of tooth #9, the patient received a pro-
visional removable partial denture (Fig. 2). The patient was
placed on a 3-month periodontal maintenance program,
and dental implantation was scheduled.
The accessory root-like structure was z7 mm long with
a sharp tip, and originated from the cemento-enamel junc-
tion. Pointing apically, the accessory root-like structure
was separated from the middle third of the main root at an
angle of 45 (Fig. 3).
Histologic Analyses
The ground section of the extracted tooth was prepared
for investigation of its microstructure. The tooth was sec-
tioned longitudinally through the central part of the root-
like structure and fixed in 4% paraformaldehyde for 48
hours at 4C. After being thoroughly rinsed in phosphate-
buffered saline, the specimenwas thenslicedverticallyalong
the longitudinal axis using a high-precision diamond disk to
expose the dental pulp tissue, which was subsequently re-
moved. The specimen was ground to z100-mm thick with
grinding lap and 75-mm thick with frosted glass, then pol-
ished, demineralized in 1% hydrochloride alcohol, and de-
hydrated through a graded alcohol series. Under a light
microscope, we observed that the accessory root-like struc-
ture was composed of dentin covered with a thin layer of
cementum. No obvious root canal formation was observed
FIGURE 1a An accessory root-like structure
was identified on the mesio-labial aspect of the
root of tooth #9. 1b A deep probing depth was
observed at the corresponding site. 1c The
alveolar bone loss of tooth #9 extended to the
apex (black arrow).
FIGURE 2 The patient received a provisional removable partial denture.
C A S E R E P O R T
34 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Effect of a Root-Like Structure on Periodontitis
in this accessory root-like structure (Fig. 4a). In the coronal
two thirds of the accessory root, the dentinal tubules were
arranged to form an organized, radial structure (Figs. 4b
through 4d). In contrast, the dentinal tubules in the apical
third of the accessory root showed a disordered orientation
and a vortex-like structure (Figs. 4e and 4f).
Discussion
This case reports an unusual accessory root-like structure
on the root of tooth #9. Clinical and histologic examina-
tions showedthat this structure was sharp, pointed apically
at anangle of 45, andconsistedof dentincovered witha thin
layer of cementum. No root canal formation was detected.
An extensive literature review identified only two other pa-
pers reporting similar structures on the roots of the lower
central incisors. In 1984, Kogon
8
reported an accessory root
extending from the root of the lower central incisor. An
accessory lateral canal 1 mm below the cemento-enamel
junction was also observed in this accessory root. Kocsis
and Marcsik
9
reported another accessory root formation.
Similar to the current case, the researchers did not find
any radicular canals in this accessory root. The cellular
and histologic mechanisms underlying the accessory root
formation are still unclear. Kocsis and Marcsik
9
sug-
gested that, during the period of root morphogenesis,
the Hertwigs epithelial root sheath suffered fromcertain
traumatic injuries, resulting inthe formation of an accessory
root-like structure. Similar accessory structure was formed
by the changes in the function of odontoblasts during root
formation.
Bacterial plaque is the primary etiologic factor for the
initiation and progression of periodontal diseases. Ana-
tomic factors, such as enamel pearls,
10
cervical enamel pro-
jections,
11,12
cemental tears,
13,14
andradicular grooves,
15
are
often associated with advanced localized periodontal de-
struction and considered as the coetiologic factors. In the
present case report, the accessory root-like structure was
sharp, small in size, and located in the coronal half of
the root, which resulted in early exposure of this abnormal
structure into the periodontal pocket when the patient de-
veloped periodontal disease. Through accelerating the ac-
cumulation of dental plaques and subgingival calculus, the
exposed accessory root-like structure considerably pro-
moted the progression of periodontal disease. As a result,
the affected tooth demonstrated more severe periodontal
destruction. Therefore, the present study suggests that
a thorough examination of the root morphology is an es-
sential prerequisite for the success of periodontal therapy,
especially for those with advanced localized periodontal
diseases.
Considering that many abnormal morphologic struc-
tures are hereditary, family members should be examined
for similar conditions. Contralateral teeth of the patient
should be thoroughly examined to rule out the presence
of similar anatomic variations. Once identified, these ab-
normal structures should be monitored frequently and early
intervention should be executed when indicated to decrease
periodontal destruction.
This case report shows an unusual root-like structure on
tooth #9, which contributed to severe periodontal destruc-
tion and eventual loss of that tooth. Therefore, careful di-
agnosis of local contributing factors is warranted. n
FIGURE 3a The accessory root-like structure was sharp, z7 mm long,
and originated from the cemento-enamel junction. 3b Pointing apically, the
accessory root-like structure was separated from the middle third of the
main root at an angle of 45.
C A S E R E P O R T
Du, Wang, Zhang, Yan, Wang, Yang Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 35
FIGURE 4 Ground secti on resul ts of the
accessory root-like structure. 4a The acces-
sory root-like structure was composed of dentin
covered with a thin layer of cementum. No
obvious root canal formation was observed. 4b
through 4d In the coronal two thirds of the
accessory root, the dentinal tubules were
arranged to form an organized, radial structure
(white arrow) and covered with a thin layer of
cementum (black arrow). 4e and 4f The dentinal
tubules in the apical third of the accessory root
showed a disordered orientation and a vortex-
like structure. C cellular cementum; D dentin;
E enamel; T translucent zone; AC acellular
cementum. 4a, 4c, 4e, scale bars 200 mm; 4b,
4d, 4f, scale bars 100 mm. 4b, 4d, and 4f are
larger magnifications of the white frames in 4a, 4c,
and 4e, ee respectively.
C A S E R E P O R T
Summary
j
The accessory root-like structure reported in this case report serves
as an important coetiologic factor for the breakdown of the supporting
tooth structures.
j This morphologic anomaly is rarely seen and frequently missed by
periodontists.
j Our study suggests that a thorough examination of the root
morphology is an essential prerequisite for the success of periodontal
therapy, especially for those with advanced localized periodontal
disease.
j
Careful periodontal probing and radiographic examination may be of
great help in the early recognition of the abnormal root structures.
j The accessory root-like structure may be difficult to identify and is
frequently missed during clinical diagnosis and periodontal treatment.
Acknowledgments
Drs. Jianxin Du and Xiaoying Wang contributed equally to
this case report. The authors report no conflicts of interest
related to this case report.
CORRESPONDENCE:
Dr. PishanYang, School of Stomatology, ShandongUniversity. 44-1Wenhuaxi
Rd., Jinan, Shandong 250012, China. E-mail: yangps@sdu.edu.cn.
C A S E R E P O R T
Du, Wang, Zhang, Yan, Wang, Yang Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 37
References
1. Gher ME, Vernino AR. Root morphology Clinical significance in
pathogenesis and treatment of periodontal disease. J Am Dent Assoc
1980;101:627-633.
2. Olsson M, Lindhe J. Periodontal characteristics in individuals with varying
form of the upper central incisors. J Clin Periodontol 1991;18:78-82.
3. Kerekes K, Tronstad L. Morphometric observations on root canals of
human anterior teeth. J Endod 1977;3:24-29.
4. Benenati FW. Endodontic treatment of a maxillary central incisor with
two separate roots: Case report. Gen Dent 2006;54:265-266.
5. Ghoddusi J, Zarei M, Vatanpour M. Endodontic treatment of maxillary
central incisor with two roots. Acase report. NYState Dent J 2007;73:46-47.
6. Askenas BG, Fry HR, Davis JW. Cervical enamel projection with
gingival fenestration in a maxillary central incisor: Report of a case.
Quintessence Int 1992;23:103-107.
7. Miller SC. Textbook of Periodontia. Philadelphia: Blakiston Company;1938;
91.
8. Kogon S. Unusual malformed root. Oral Surg Oral Med Oral Pathol
1984;57:580.
9. Kocsis GS, Marcsik A. Accessory root formation on a lower medial
incisor. Oral Surg Oral Med Oral Pathol 1989;68:644-645.
10. Goldstein AR. Enamel pearls as contributing factor in periodontal
breakdown. J Am Dent Assoc 1979;99:210-211.
11. Chan HL, Oh TJ, Bashutski J, Fu JH, Wang HL. Cervical enamel
projections in unusual locations: A case report and mini-review.
J Periodontol 2010;81:789-795.
12. Blanchard SB, Derderian GM, Averitt TR, John V, Newell DH. Cervical
enamel projections and associated pouch-like opening in mandibular
furcations. J Periodontol 2012;83:198-203.
13. Lin HJ, Chan CP, Yang CY, et al. Cemental tear: Clinical character-
istics and its predisposing factors. J Endod 2011;37:611-618.
14. Ishikawa I, Oda S, Hayashi J, Arakawa S. Cervical cemental tears in
older patients with adult periodontitis. Case reports. J Periodontol
1996;67:15-20.
15. Wei PC, Geivelis M, Chan CP, Ju YR. Successful treatment of pulpal-
periodontal combined lesion in a birooted maxillary lateral incisor with
concomitant palato-radicular groove. A case report. J Periodontol 1999;
70:1540-1546.
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CASE REPORT
Medical Histories: A Case Report of Pharmacovigilance in Supporting
Dentists and Participation in a Drug-Safety Program
Edward H. Karl* and Frederick A. Curro
Introduction: Antibiotics are a class of medications widely used by dentists. The class of agents has a number of
listed side effects. This case report details an unusual adverse effect of tetracycline-induced psychosis recognized due
to the diligence of a practitioner. To our knowledge, this is the first reported case by a dentist.
Case Presentation: A 44-year-old patient was started on tetracycline therapy for prophylaxis before a periodontal
procedure. The patient began having paranoid and psychotic experiences. The patient sought psychiatric medical care and
was diagnosed with tetracycline-induced psychosis. He was treated with an antipsychotic drug, which resolved his
symptoms.
Conclusion: Dental medical histories are a resource that is underused and can often be of value in the continual
assessment of drug safety and pharmacovigilance. Clin Adv Periodontics 2013;3:40-43.
Key Words: Drug toxicity; pharmacovigilance; psychotic disorders; safety; tetracycline.
Background
The Food and Drug Administration (FDA) constantly tries
to balance the promotion of greater drug safety with
a quicker drug-review process. The director of the Center
for Drug Evaluation and Research, which now includes
the Center for Biologics Evaluation and Research, oversees
the balance of drug safety versus innovation through
science. Dentists have traditionally not been included in
this process. Drug utilization by dentists has not been
determined by the pharmaceutical industry. However, the
recent FDA opioid drug-safety initiative program
1
has
shown that dentists contribute to the overprescribing of
opioids, which led to stricter prescription patterns already
in place in some states. The majority of dentists are not
aware, nor do they participate in the FDAs MedWatch
program
2
directed at drug safety. As more targeted drugs
aimed at reducing drug-adverse effects are developed, the
US drug safety net would require the participation of all
prescribers, especially for the completeness of all elec-
tronic medical records. One example of dentists partici-
pating in this process was the reporting of osteonecrosis of
the jaw.
3
The medical histories dentists take are, for the
most part, isolated and remain in their offices. Electronic
dental records as part of the patients electronic health
record or electronic medical record under the broader
banner of the electronic medical home will forever change
howdentists record medical histories. An electronic dental
record will be integrated into the patients record and
therefore require oversight or some level of quality assurance,
much like a hospital record. This case report describes
a dentists (EHK) initiative to substantiate a medical
finding before and during periodontal treatment.
Pharmacotherapy is playing an increasing role in the
treatment and therapy for the management of oral condi-
tions, notably periodontal disease. Although the dental
pharmaceutical armamentarium is increasing, there is a
concomitant wider use of conventional drugs, such as tet-
racycline. The tetracycline family of drugs consists of a num-
ber of altered chemical modifications to increase efficacy,
distribution, and substantivity. As newer chemically-modi-
fied drugs become more specific for targeted therapy, the
adverse effects become more subtle and more difficult to
recognize unless further training in pharmacology is re-
quired.
3
The current case report documents a case of tetra-
cycline-induced psychosis observed by a periodontist during
treatment of a patient andas followedusing drug-safety pro-
cedures of pharmacovigilance. The patient was receiving
routine treatment for chronic periodontal disease.
It is well documented that several classes of antibiotics
have psychiatric adverse effects that range fromminor con-
fusion to psychosis.
4
These classes include antibacterials,
antimycobacterials, and antifungals. The termHoigne syn-
drome
5
is used to describe an acute non-allergic reaction to
procaine penicillin, with predominant acute psychiatric
symptomatology. The onset of symptoms in this syndrome
can be abrupt. Typical disturbances of perception are audi-
tory, visual, olfactory, gustatory, and/or somatosensory
pseudohallucinations recognized by the patient as being
unreal perceptions.
6
The experience of anxiety parallels
* Private practice, West Hartford and Glastonbury, CT.
PEARL (Practitioners Engaged in Applied Research and Learning)

Practice-Based Research Network, New York University, College of
Dentistry, New York, NY.
Submitted January 25, 2011; accepted for publication February 21, 2012
doi: 10.1902/cap.2012.110007
the onset of perceptual disturbances or may be conceived as
a reaction to their extraordinary and dreadful nature.
6
Per-
ceptual disturbances and anxiety are accompanied by
tachycardia, increase in blood pressure, feeling of breath-
lessness, numbness in the extremities, and psychomotor
agitation.
6
Occasionally, these symptoms may progress
into a full-blown psychosis or delirium, with disorienta-
tion, true hallucinations (mostly visual), and, in rare cases,
delusions.
6
Tetracyclines have the ability to distribute widely through-
out the body and into tissues and secretions.
5
Inflammation
of the meninges is not required for the passage of tetracy-
clines into the cerebrospinal fluid. Tetracyclines have also
been reported to cause neuropsychiatric toxicity. The in-
tent of this case report is to describe an actual delusion or
psychotic event of a patient who was diagnosed with
tetracycline-induced psychosis by a hospital known for
its professional expertise in mental illness.
A 44-year-old male patient presented to a private practice
(EK), inGlastonbury, Connecticut, andwas startedonatet-
racycline antibiotic for prophylaxis before a periodontal
procedure. The patient had been on the tetracycline for
z1 or 2 weeks before periodontal surgery. The patient
did not have any previous documented psychiatric epi-
sodes. The case as described by the patient and recorded
in his psychiatrists medical record (psychiatrist unknown,
The Institute of Living, West Hartford, Connecticut) was
provided to the periodontist (EK). This is similar to a pre-
viously reported medical case
5
in which a patient was being
treated with amoxicillin.
Case Management
The psychiatrist reported that, before the event, the patient
had been removing snowwith a plowuntil z1:00 am. The
patient reported to the psychiatrist that the next day, when
he was driving his car, he began to have experiences that
were paranoid and psychotic in nature. The patient re-
ported that he thought his wife was standing on a corner
with another guy, which was unexpected. He never had
a thought like this previously and had a very visceral emo-
tional reaction to it. He felt as though his heart dropped
into his stomach. The psychiatrists medical record re-
ports that, while still driving home, the patient heard
a voice that he thought might be that of God telling him
that he should move to Arizona, that there would be a spin
out on an exit ramp, and that there was a dead animal be-
low an underpass. He had irrational thoughts, such as
thinking of the number three, which was confirmed by
the configuration of certain light posts. These thoughts
continued until he arrived home, at which time he saw
that his wife was there. He tried to fight the thoughts
but could not resist asking his wife about his suspicions.
His wife became quite concerned and felt as if he were
a different person, and, although he was not overtly
threatening to her, she felt concerned for her safety. He
did not utter or speak any spontaneous noises. However,
he did hear a voice telling himthat, if his suspicions turned
out to be true, he should hit himself in the head with
a hammer. He did not act on any of these thoughts.
Clinical Outcomes
The patient reported to the psychiatrist that he reconciled
with his wife that night. The next day he and his wife
sought professional help. A counselor immediately said
the patient should go to the hospital, where he was admit-
ted for 2 days at a local institution (The Institute of Living,
West Hartford, Connecticut), and was evaluated, diag-
nosed, and treated by a psychiatrist with the antipsychotic
drug risperidone. His symptoms then resolved. He was
diagnosed with a tetracycline-induced psychosis.
Discussion
Antibiotics, from penicillin to tetracycline, have been as-
sociated with neuropsychiatric toxicity ranging from 1%
to 5%.
5
Depression, insomnia, and irritability may
emerge at higher doses of tetracycline, but the frequency
of sudden events in the adult population taking any tetra-
cycline is likely to be 1%.
7
Minocycline is most often
implicated in the genesis of tetracycline-induced neuro-
psychiatric toxicity. Tetracyclines have been reported to
produce a neuromuscular blockade as a result of postsyn-
aptic antagonism of acetylcholine.
7
Because the symp-
toms can be abrupt, it has been suggested that the
phenomenon of kindling may be the basis of the mecha-
nism. Kindling has been defined as the appearance of phys-
iologic and behavioral responses to repetition over time
of a stimulus initially without effect.
6
The administration
of some pharmacologic agents may serve as a stimulus
for the development of pharmacologic-induced kindling.
8
Neurotransmitter processes associated with the mechanism
of kindling may include the facilitation of excitatory
N-methyl-D-asparate receptors and a reduction in the in-
hibitory activity of g-aminobutyric acid transmission.
9
Drug safety is an ongoing concern for as long as the
drug is on the market. The responses to a drug range from
the complexity of pharmacogenetics to a simple food
effect response. The difficulty may be in identifying the
cause of a side effect. That is the basis for pharmacovigi-
lance of a drug, and it is the responsibility of every pre-
scriber to note and report any unusual drug response.
This case report is an example of post-marketing drug sur-
veillance and pharmacovigilance of a widely used anti-
biotic through which the drug-safety database can be
updated to educate and alert subsequent prescribers as
to the potential effect. Patient histories can be viewed
as vital statistics and, when incorporated into the elec-
tronic health record, can be cost effective as the nation
struggles to contain health care costs. Dentists are a na-
tional resource to expand the drug safety net to monitor
and report drug side effects. n
C A S E R E P O R T
Karl, Curro Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 41
Summary
j
To the best of our knowledge, this is the first reported case by
a dentist of unusual side effects of an antibiotic.
j
Demonstration of a dentists awareness of psychiatric conditions
j Demonstrates that dentists can participate in pharmacovigilance and/
or drug-safety programs
j Comprehensive patient medical history
j
Dentists knowledge of their patients medical history
j
Dentists follow-up on patients medication history
j
Lack of patient follow-up
j
Lack of patient motivation and compliance
j Lack of financial resources
Acknowledgments
Dr. Curro is the director of PEARL and a member of the
working group of the Food and Drug Administration opi-
oid drug safety initiative program. The authors report no
conflicts of interest related to this case report.
CORRESPONDENCE:
Dr. Edward Karl, 836 Farmington Ave., Suite 131, West Harford, CT 06119.
E-mail: dredwardkarl@gmail.com.
C A S E R E P O R T
42 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Pharmacovigilance in Dentistry
References
1. US Food and Drug Administration. Safe use initiative. Available at:
http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/default.htm.
Accessed January 25, 2011.
2. US Food and Drug Administration. Medical product safety information.
Available at: http://www.fda.gov/Safety/MedWatch/default.htm. Accessed
January 25, 2011.
3. Ruggiero SL, Mehrotra B, Rosenberg TJ, Engroff SL. Osteonecrosis of
the jaws associated with the use of bisphosphonates: A review of 63
cases. J Oral Maxillofac Surg 2004;62:527-534.
4. Murphy MB, Alcera L, Gill JK, Dunn J. The inexplicably suicidal
patient. Curr Psychiatr 2008;7:73-74, 80-82.
5. Turjanski N, Lloyd GG. Psychiatric side-effects of medications: Recent
developments. Adv Psychiatr Treat 2005;11:58-70.
6. Hoigne R, Schoch K. Anaphylactic shock and acute nonallergic
reactions following procaine-penicillin (in German). Schweiz Med
Wochenschr 1959;89:1350-1356.
7. Araszkiewicz A, Rybakowski JK. Hoignes syndrome, kindling, and
panic disorder. Depress Anxiety 1996-1997;4:139-143.
8. MacDougall C, Chambers H. Protein synthesis inhibitors and mis-
cellaneous antibacterial agents. In: Brunton LL, Chabner BA, Knollman
BC eds. Goodman & Gilmans The Pharmacological Basis of Thera-
peutics, 12th ed. Columbus, OH: McGraw-Hill; 2011:1521-1547.
9. Mori N, Wada JA. Bidirectional transfer between kindling induced by
excitatory amino acids and electrical stimulation. Brain Res 1987;425:45-48.
C A S E R E P O R T
Karl, Curro Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 43
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CASE REPORT
Rare Manifestation of Granulomatosis With Polyangiitis
Manoj Bhattarai,* Weijia Yuan,
Paul Fletcher,
Adam Gersten,
x
Anthony Chang,
Robert Spiera,
Anne Bass,
Doruk Erkan,
and Dennis Tarnow

{
Introduction: Granulomatosis with polyangiitis (GPA), formerly known as Wegener granulomatosis, is a multisystem
disorder that mainly involves airways and kidneys. Oral GPA may present as ulcerations or strawberry gingivitis. Early diag-
nosis and intervention are crucial for overall prognosis.
Case Presentation: An unusual case of oral GPA manifested by chronic localized inflammation, leading to failure of
dental implants in an elderly woman, is presented. Diagnosis was based on antineutrophil cytoplasmic testing and histo-
pathologic evidence of necrotizing vasculitis. Disease remission was achieved with cyclophosphamide and steroids.
Conclusion: Familiarity with oral manifestations of GPA will help dentists and oral surgeons diagnose and treat early
or incipient GPA without delay. Clin Adv Periodontics 2013;3:45-50.
Key Words: Antineutrophil cytoplasmic antibodies; cocaine; cyclophosphamide; gingivitis; proteinase 3; Wegener
granulomatosis.
Background
Granulomatosis with polyangiitis (GPA)
1
usually presents
with unexplained constitutional symptoms. Oral manifes-
tation is relatively uncommon and often misdiagnosed or
is diagnosed late. Disease progression could be fatal
without appropriate intervention.
A76-year-oldwhite woman with past medical history of peri-
odontal disease, osteoporosis treated with bisphosphonates,
hypertension, and osteoarthritis presented to the New York
Presbyterian Hospital in 2008 with a left-sided neck mass
that had been enlarging over 1 month.
The patients periodontal disease started 9 years before
presentation, manifesting as discomfort on the left side of
her mouth when biting. She had poorly fitting crowns on
two implants in the left maxillary first and second molar
positions, which were subsequently replaced. During this
period she developed intermittent gingival inflammation
around the implants and increased periodontal pocketing
on the palatal aspect of the implants indicating 6-mmbone
loss (Fig. 1). The affected area was debrided multiple times
without remarkable improvement. These implants were
eventually removed and primary closure was obtained.
Despite antibiotic therapy (amoxicillin for five days) the
patient developed a yellow mucus draining ulcer near the
removed implants. She returned with a non-healing surgi-
cal site and firm swelling at the left angle of the mandible
that did not respond to clindamycin. She was a retired
pharmacist with no history of tobacco, alcohol, or recreational
drug use.
* Department of Internal Medicine, Memorial Hospital of Rhode Island,
Pawtucket, RI.
Department of Rheumatology, Hospital for Special Surgery, New York,

NY.
Division of Periodontics, Columbia University College of Dental Medicine,

New York, NY.
x
Department of Pathology, New York Presbyterian Hospital/Weill Cornell
Medical Center, New York, NY.
Department of Radiology, Hospital for Special Surgery.

{
Department of Dental and Oral Surgery, Columbia University College of
Dental Medicine.
Submitted November 29, 2011; accepted for publication March 4, 2012
doi: 10.1902/cap.2012.110107
Onintraoral examination, anulcerative lesionof the left pos-
terior hard palate was observed. The previously approximated
surgical flaps had opened, leaving exposed bone and necrotic
tissue at the surgical site (Fig. 2b). Additionally, there was gen-
eralized gingival inflammation along with discrete areas of in-
tensely red patches appearing as granular strawberry gingivitis
(Fig. 2a). The left submandibular area had a non-tender 6- to
8-cm ulcerated mass, draining purulent material.
Cardiopulmonary, abdominal, neurologic, and muscu-
loskeletal examinations were unremarkable.
Case Management
The patient was admitted for additional workup of mandib-
ular swelling. Her basic laboratory tests, including urinalysis,
were unremarkable and urine for toxicology was negative.
Signedconsent was obtainedprior toadmissionof treatment.
Computed tomographic axial imaging of the head and
neck exhibited bilateral maxillary sinusitis (Fig. 3a), a het-
erogeneously enhancing left submandibular mass (Fig. 3b)
measuring 3.9 2.9 4.1 cm, and fistula at the left maxilla
connecting to the failed implant site. Incidentally, a spicu-
latedright apical mass (Fig. 4a) measuring 4.32.5cmwith
the central hypoattenuation abutting the superior mediasti-
num was identified. Small foci of air were noted within the
mass reflecting cavitation or small airways passing through
the lesion. Multiple spiculated masses were seen in bilateral
lungs (Fig. 4b); the largest was located on the left upper lobe
and measured 1.3 0.9 cm.
Biopsy of ulcerated squamous mucosa from palate and
right maxillary gingiva under high-power viewdemonstrated
dying neutrophils (leukocytoclastic response) (Fig. 5a) and
lymphocytes infiltrating smaller and larger vessels (Fig. 5b),
which suggested focal fibrinoid necrosis/vasculitis. Well-
formed granulomas and giant cells were not seen.
Biopsy of the left submandibular andright apical lung mass
was consistent with acute inflammation. The right lower lobe
wedge biopsy, observedviavideo-assistedthoracoscopy, dem-
onstrated necrotizing granulomatous inflammation (Fig. 6a)
and vasculitis (Fig. 6b). Stains for acid-fast bacilli and fungi
were negative. The routine cultures of right lower lobe wedge
tissue and right lung fine-needle aspirate were negative.
Rheumatologic workup demonstrated positive antineu-
trophil cytoplasmic auto-antibodies and elevated proteinase
3 (PR3), at 700 IU/mL(normal <19 IU/mL). The presence of
a non-healing surgical woundaroundthe dental implant site,
lung nodules with necrotizing granuloma, cytoplasmic anti-
neutrophil cytoplasmic antibody (c-ANCA), and an elevated
PR3 level supported the diagnosis of oral GPA.
Clinical Outcomes
Cyclophosphamide (2 mg/kg daily) was started in combi-
nationwith prednisone (60 mg daily), resulting in a marked
decrease of the left neck mass and gingival inflammation
after 6 weeks (Fig. 7). Eventually both medications were
stopped and the patient was asymptomatic during her fol-
low-up three years after presentation.
Discussion
A 76-year-old woman presented with an oral ulcer after
dental implant removal, friable gingiva, neck and right
lung apical mass, multiple lung nodules, positive c-ANCA,
elevated PR3 level, and necrotizing granulomatous vascu-
litis of lung tissue.
GPA is a chronic, relapsing necrotizing granulomatous
vasculitis primarily limited to upper and lower respiratory
FIGURE 1 X-ray of left upper dental implants with evidence of bone loss
(arrow).
FIGURE 2 Before treatment. 2a Buccal surface of gingiva. 2b Palatal
surface.
C A S E R E P O R T
46 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Oral Granulomatosis With Polyangiitis
tracts as well as kidneys. However, GPA can affect any or-
gan system, such as heart, nerves, and skin.
2,3
Unusual oral
presentations of GPA include: 1) palatal osteonecrosis; 2)
palatal and lingual ulcerations; 3) oroantral fistulae; 4)
postextraction poor wound healing; 5) labial mucosal nod-
ules; 6) salivary gland swelling; 7) cranial nerve palsies; and
8) friable-granular gingivitis with tooth mobility.
4-9
Ap-
proximately 20%of patients with GPAdevelop oral ulcers
and oral lesions can be a presenting feature in 2% of
cases.
10,11
Hyperplastic gingivitis (dark red to purple in
color with a granular surface), also known as strawberry
gingivitis, is a rare manifestation of GPA but is considered
pathognomonic.
12
The patient had long-term peri-implant
disease, but because she was on bisphosphonates for >3
years, it cannot be discounted that the rapid bone destruc-
tion and subsequent loss of the implants was not ultimately
attributable to bone necrosis secondary to long-term bis-
phosphonate therapy. Leukemia may present with gingival
manifestations but with much smoother gingival surfaces.
13
Pyostomatitis vegetans commonly results in bumpiness on
FIGURE 3 Coronal computerized tomography of head and neck. 3a Air
fluid level (arrow). 3b Left submandibular mass (arrow).
FIGURE 4 Coronal computerized tomography of chest. 4a Spiculated
mass (arrow). 4b Satellite nodules (arrow).
C A S E R E P O R T
Bhattarai, Yuan, Fletcher, et al. Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 47
gingival surfaces but extends beyond gingiva to oral
mucosa.
14
Pemphigus exhibits superficial non-granulo-
matous ulcerations with erythematous non-swollen gin-
gival, starts from oropharynx or soft palate, and moves
forward in the mouth (Nikolskys sign is present, in
which horizontal pressure to mucosa results in peeling
away of blisters).
15
Kaposi sarcoma, although rare, is pri-
marily seen in human immunodeficiency virus (HIV) and
involves the entire gingiva, palate, and maxilla.
16
Behcet
diseaserelated ulcers are flat and resemble aphthous ul-
cers, and sarcoidosis involves oral mucosa, including
periodontium.
17
The mortality rate in untreated generalized GPA is 82%
in 1 year, with a mean survival of 5 months.
18
Timely diag-
nosis is crucial, which was challenging in this patient be-
cause of the atypical presentation. The incidental finding
of lung mass led to additional investigation, and she met
three of the four diagnostic criteria for GPA(Table 1) based
on the American College of Rheumatology.
19
Noteworthy,
the specificity and sensitivity of c-ANCA are 96% and
92%, respectively, for patients with generalized disease,
which is also helpful in measuring disease activity and
possible relapse, but it is often negative in the limited or
early disease.
20,21
False-positive c-ANCA test results have
been reported in patients with tuberculosis, Hodgkin lym-
phoma, HIVinfection, nasal septal perforation, monoclonal
gammopathies, and drug-induced GPA-like disease.
22-27
Rachapalli and Kiely
28
yy have reported two cases of cocaine-
induced midline destructive lesions (CIMDLs) mimicking
ear, nose, and throat-limited GPA that presented with ele-
vatederythrocyte sedimentationrate andC-reactive protein,
positive perinuclear antineutrophil cytoplasmic antibody,
negative myeloperoxidase and PR3 antibodies, and incon-
clusive histology. Human neutrophil elastase ANCA is fre-
quently detected in these patient populations as opposed
to other autoimmune disease patients; hence, it can help
to distinguish CIMDL from GPA.
29
Approximately 90% of GPA cases receiving cyclophos-
phamide achieve remission; rituximab is as effective as cy-
clophosphamide for induction therapy.
30,31
Methotrexate
or azathioprine are used for maintenance therapy. Trimeth-
oprim/sulfamethoxazole canalsobe usedtoprevent relapses
and has been used by clinicians as a remission-inducing
agent in limited disease. n
FIGURE 5a Focus of neutrophilic micro-abscesses in squamous epithe-
lium (arrow). 5b Fibrinoid necrosis of the underlying small vessels, gingival
(arrow). Hematoxylin and eosin; original magnification, 40.
FIGURE 6 Focus of granulomatous inflammation (arrow) (6a) and vasculitis
(arrow) (6b), right lung lower lobe. Hematoxylin and eosin; original
magnification, 20.
C A S E R E P O R T
Summary
Why is this case new information? j This case is an atypical manifestation of GPA.
j
The incidental finding of lung and neck mass led to additional
investigation and final diagnosis.
j
Appropriate diagnosis was delayed as a result of unusual
manifestations.
Acknowledgment
Dr. Spiera has received financial support for research and
lecture fees from Genentech, South San Francisco, Califor-
nia; all other authors report no conflicts of interest related
to this case report.
CORRESPONDENCE:
Dr. Manoj Bhattarai, 111 Brewster St., Pawtucket, RI 02860. E-mail:
manoj_bhattarai@brown.edu.
FIGURE 7 After treatment. 7a Buccal surface of
gingiva. 7b Palatal surface.
TABLE 1 The American College of Rheumatology 1990 Criteria for the Diagnosis of GPA
Criteria Definition
Oral or nasal manifestations Oral ulcers or purulent/bloody nasal discharge
Abnormal findings on chest radiograph or hemoptysis during illness Nodules, cavities, or fixed infiltrates in chest x-ray
Abnormal urinary sediment Red cell casts or >5 red blood cells per high-power field
Granulomatosis Granulomatous inflammation on biopsy of small arteries, affecting the perivascular
or extravascular wall
At least two of four criteria must be met for the diagnosis. The presence of 2 criteria is associated with a sensitivity of 88.2% and specificity of 92.0%.
Adapted from Leavitt et al.
19
C A S E R E P O R T
Bhattarai, Yuan, Fletcher, et al. Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 49
References
1. Falk RJ, Gross WL, Guillevin L, et al; American College of Rheuma-
tology; American Society of Nephrology; European League Against
Rheumatism. Granulomatosis with polyangiitis (Wegeners): An alter-
native name for Wegeners granulomatosis. Arthritis Rheum 2011;63:
863-864.
2. DeRemee RA, McDonald TJ, Harrison EG Jr, Coles DT. Wegeners
granulomatosis. Anatomic correlates, a proposed classification. Mayo
Clin Proc 1976;51:777-781.
3. Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener granulomatosis: An
analysis of 158 patients. Ann Intern Med 1992;116:488-498.
4. Seyer BA, Grist W, Muller S. Aggressive destructive midfacial lesion
from cocaine abuse. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2002;94:465-470.
5. Bachmeyer C, Petitjean B, Testart F, Richecoeur J, Ammouri W, Blum L.
Lingual necrosis as the presenting sign of Wegeners granulomatosis.
Clin Exp Dermatol 2006;31:321-322.
6. Edwards MB, Buckerfield JP: Wegeners granulomatosis. A case with
primary mucocutaneous lesions. Oral Surg Oral Med Oral Pathol
1978,46:53-63.
7. Crean SJ, Adams R, Bennett J. Sublingual gland involvement in
systemic Wegeners granulomatosis: A case report. Int J Oral Max-
illofac Surg 2002;31:104-106.
8. Berge S, Niederhagen B, von Lindern JJ, Appel T, Reich RH. Salivary
gland involvement as an initial presentation of Wegeners disease. A
case report. Int J Oral Maxillofac Surg 2000;29:450-452.
9. Glass EG, Lawton LR, Truelove EL. Oral presentation of Wegener
granulomatosis. J Am Dent Assoc 1990;120:523-525.
10. Frances C, Du LT, Piette JC, et al. Wegeners granulomatosis.
Dermatological manifestations in 75 cases with clinicopathologic
correlation. Arch Dermatol 1994;130:861-867.
11. Fauci AS, Haynes BF, Katz P, Wolff SM. Wegeners granulomatosis:
Prospective clinical and therapeutic experience with 85 patients for 21
years. Ann Intern Med 1983;98:76-85.
12. Knight JM, Hayduk MJ, Summerlin DJ, Mirowski GW. Strawberry
gingival hyperplasia: A pathognomonic mucocutaneous finding in
Wegener granulomatosis. Arch Dermatol 2000;136:171-173.
13. Takahashi H, Tezuka F, Fujita S, Okabe H. Primary extranodal non-
Hodgkins malignant lymphoma of the oral region: Analysis of 11
autopsy cases. J Oral Pathol 1987;16:241-250.
14. Hegarty AM, Barrett AW, Scully C. Pyostomatitis Vegetans. Clin Exp
Dermatol 2004 Jan;29:1-7.
15. Sirois DA, Fatahzadeh M, Roth R, Ettlin D. Diagnostic patterns and
delays in pemphigus vulgaris: Experience with 99 patients. Arch
Dermatol 2000;136:1569-1570.
16. Greenspan JS, Greenspan D. The epidemiology of the oral lesions of
HIVinfection in the developed world. Oral Dis 2002;8 (Suppl. 2):34-39.
17. Suresh L, Aguirre A, Buhite RJ, Radfar L. Intraosseous sarcoidosis of
the jaws mimicking aggressive periodontitis: A case report and literature
review. J Periodontol 2004;75:478-482.
18. Walton EW. Giant-cell granuloma of the respiratory tract (Wegeners
granulomatosis). Br Med J (Clin Res Ed) 1958;2:265-270.
19. Leavitt RY, Fauci AS, Bloch DA, et al. The American College of
Rheumatology 1990 criteria for the classification of Wegeners gran-
ulomatosis. Arthritis Rheum 1990;33:1101-1107.
20. Sproson EL, Jones NS, Al-Deiri M, Lanyon P. Lessons learnt in the
management of Wegeners Granulomatosis: long-term follow-up of 60
patients. Rhinology 2007;45:63-67.
21. van der Woude FJ, Rasmussen N, Lobatto S, et al. Autoantibodies
against neutrophils and monocytes: Tool for diagnosis and marker of
disease activity in Wegeners granulomatosis. Lancet 1985;1:425-429.
22. De Clerck LS, Van Offel JF, Smolders WA, et al. Pitfalls with anti-
neutrophil cytoplasmic antibodies (ANCA). Clin Rheumatol 1989;8:
512-516.
23. Mains B. Wegeners granulomatosis: False positive anti-neutrophil
cytoplasmic antibody test. J Laryngol Otol 1989;103:524-525.
24. Koderisch J, Andrassy K, Rasmussen N, Hartmann M, Tilgen W.
False-positive anti-neutrophil cytoplasmic antibodies in HIV infec-
tion. Lancet 1990;335:1227-1228.
25. Esnault VL, Jayne DR, Keogan MT, et al. Anti-neutrophil cytoplasm
antibodies in patients with monoclonal gammopathies. J Clin Lab
Immunol 1990;32:153-159.
26. Alon U, Hellerstein S, Warady BA. Anti-neutrophil cytoplasmic
antibodies in drug-induced Wegener-like disease. Pediatr Nephrol
1990;4:299-300.
27. Zuckerman KK, Leventhal L, Wynne C. Positive c-ANCA in a patient
with lymphoma and without vasculitis. J Clin Rheumatol 1997;3:279-
281.
28. Rachapalli SM, Kiely PD. Cocaine-induced midline destructive lesions
mimicking ENT-limited Wegeners granulomatosis. Scand J Rheumatol
2008;37:477-480.
29. Wiesner O, Russell KA, Lee AS, et al. Antineutrophil cytoplasmic
antibodies reacting with human neutrophil elastase as a diagnostic
marker for cocaine-induced midline destructive lesions but not auto-
immune vasculitis. Arthritis Rheum 2004;50:2954-2965.
30. Stone JH, Merkel PA, Spiera R, et al; RAVE-ITN Research Group.
Rituximab versus cyclophosphamide for ANCA-associated vasculitis.
N Engl J Med 2010;363:221-232.
31. Jones RB, Tervaert JW, Hauser T, et al; European Vasculitis Study
Group. Rituximab versus cyclophosphamide in ANCA-associated renal
vasculitis. N Engl J Med 2010;363:211-220.
C A S E R E P O R T
Th iti ll f h th h ll i t hi P i d ti d h d bl t b ild d d i d
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full-time, clinician educator track position available at the Assistant Professor, Associate Professor level.
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CASE SERIES
Applications of a Newly Developed Sonic Surgical
Handpiece in Implant Dentistry
Erich C. Schmidt,* Dimitrios E. Papadimitriou,* Jack G. Caton,* and Georgios E. Romanos
Introduction: Lack of adequate alveolar bone width or height for proper implant placement is a common clinical situ-
ation that clinicians have to overcome in implant dentistry. A new sonic surgical handpiece (SSH) has been developed that
uses high-oscillation amplitude to produce precise bony incisions. In combination with the surgical tips, this device can be
used in many clinical situations.
Case Series: In this case series, we present various clinical applications of the SSHin implant dentistry. The handpiece
and the tips were evaluated in various procedures. These included: 1) ridge augmentation; 2) maxillary sinus augmentation; 3)
atraumatic tooth extraction; and 4) autogenous bone harvesting. The SSH was able to make very precise incisions through
bone and atraumatically separate teeth from their periodontal ligaments. All of these cases healed uneventfully and success-
fully. Advantages and disadvantages of this new innovative device are illustrated with the clinical cases, including postoper-
ative clinical outcomes.
Conclusions: The SSH was able to produce precise atraumatic bony incisions. With the variety of procedures the de-
vice can perform, it should be of value to any clinician performing surgical implant dentistry. Clin Adv Periodontics 2013;3:52-
57.
Key Words: Alveolar ridge augmentation; piezosurgery; sinus floor augmentation; tooth extraction.
Background
In implant dentistry, areas lacking sufficient bone for proper
implant placement are commonly encountered. Therefore,
bone grafting is routinely used to fill these osseous defects
around teeth and implants
1,2
and for implant site prepara-
tion procedures
3,4
in combination with the techniques of
guided tissue and guided bone regeneration. Different bone
grafts have been proposed, such as autografts, allografts,
xenografts, and alloplasts.
2
Autogenous bone grafts have the
unique characteristics that combine osteogenic, osteoinduc-
tive, and osteoconductive properties.
5-7
Ideally, because of
the benefits of autogenous bone grafts, there is a need
in implant dentistry for a device that would allow for
harvesting autogenous bone in conjunction with implant
surgical procedures. A recently developed sonic surgical
handpiece (SSH)
including surgical tips

x
(Fig. 1) has been
introduced for different surgical interventions. Because of
its precision, this device has clinical applications, such as
sinus floor access and elevation, atraumatic tooth extrac-
tion, ridge augmentation and ridge splitting, as well as the
harvesting of autogenous bone. Piezoelectric bone surgery
devices have been used for many years in similar clinical
indications.
8,9
* Division of Periodontology, Eastman Institute for Oral Health, University of
Rochester, Rochester, NY.
Currently, School of Dental Medicine, Stony Brook University, Stony

Brook, NY; previously, Division of Periodontology, Eastman Institute for
Oral Health, University of Rochester.
Submitted December 9, 2011; accepted for publication March 17, 2012
doi: 10.1902/cap.2012.110109
SONICflex 2008L, KaVo, Biberach, Germany.

x
SONICflex bone, KaVo.
More specifically, the SSH uses high-oscillation ampli-
tude to produce precise bony incisions. Sonic instruments
attach to a dental chair because they need compressed air;
they work at a frequency of 2,000 to 6,500 cycles per sec-
ond. The characteristics of the SSH include amplitude of
120 to 240 mm and frequency of 6,500 Hz.
In combination with the surgical tips, this device can be
used in many clinical situations. The aim of this case series
is to present a series of clinical applications in which the
SSH and its specifically designed tips are used to manage
common procedures encountered in implant dentistry.
Clinical Presentations And Case
Management
The SSHhas settings of 120, 160, and 240 mm. During use,
the amplitude setting is determinedby the clinician depend-
ing on the bone quality observed during the osteotomy pro-
cedure. In most cases, the device was set on the highest
amplitude.
The procedures performed included: 1) atraumatic tooth
extraction (Fig. 2); 2) sinus augmentation (Fig. 3); 3) site
development (Fig 4); and 4) autogenous bone harvesting.
More specifically, 35 extractions, 10 sinus lifts, five ridge
augmentations (one was alveolar ridge expansion), and
five autogenous bone harvesting cases were performed.
Clinical Outcomes
The SSH was able to make very precise incisions through
bone and atraumatically separate teeth from their peri-
odontal ligament. Minimal trauma was noted inall cases us-
ing the handpiece. All of these cases healed uneventfully and
successfully. The SSH was easy to use and simplified many
complex aspects of implant dentistry. The advantages and
disadvantages of this new device are described in Table 1
comparing them to conventional techniques. Intraopera-
tively, the time needed to perform these procedures was
twice that needed when conventional rotary instruments
are used and similar to the time when using piezosurgery.
No complications were present intraoperatively or post-
operatively and no sinus perforations were evident, which
was verified with high-magnification loops (2), strong
light, and the Valsalva maneuver. The Schneiderian mem-
brane was not perforated even when the SSH tips were in
contact with it during the lateral window preparation. All
implants were checked for osseointegration after healing.
Although osseointegration is an histologic phenomenon,
the following methods were used: 1) absence of radiolucent
areas around the implant; 2) absence of deep probing
depths and bleeding or purulence after probing; and 3) ab-
sence of fixture mobility and the presence of a character-
istic dull sound after percussion.
The number of cases was not large enough to generate
quantitative comparisons or draw statistically valid con-
clusions for individual procedures. For that reason, pro-
spective clinical trials evaluating implant success rates
and complications for each one of the procedures, while
comparing them to instruments available on the market,
should be performed. Finally, histologic comparisons
should be done with core biopsy studies to evaluate the bi-
ologic effect of this instrument.
Discussion
Ultrasonic vibrations have been used to cut tissues for 20
years.
10
Only in the past several years has this technology
found an application in clinical dentistry. In implant dentistry,
the importance of precision and minimal trauma is critical. It
has been shown that bone harvesting with piezosurgery
shows positive results histologically.
11
Furthermore, in a re-
cent study, particulated bone grafts harvested with the SSH
in vitro provided homogeneous graft size, in contrast to three
other conventional techniques (Papadimitriou DE, Romanos
GE. Morphology of bone particles after harvesting with four
different devices. unpublished data; University of Rochester,
Rochester, NY). In addition, a study by Heinemann et al.,
12
reported that the average heat generated by the SSHwas close
to that obtained using a conventional rotary bur (1.54C to
2.29C), whereas piezosurgery produced a greater rise in
temperature (18.17C). Histologic investigations of the bone
matrix adjacent to the defect radius showed intact osteocytes
with all three instruments and a similar wide damage diam-
eter at the bottomregion. Finally, the SSHshowed smooth
cutting surfaces with minimal damage in the upper defect
zone. Together, the SSH and the specifically designed tips
were found to be very effective in reducing the surgical
trauma for osteotomies similar to that of piezotome de-
vices. This may have the effect of reducing subsequent
bone resorption.
Sinus lift procedures have become common in implant
surgical therapy. The intraoperative complication most of-
ten seen is perforation of the Schneiderian membrane,
whichhas beenreportedtooccur in14%to56%of cases.
13
Many of these perforations occur during the initial access
window preparation procedure, performed with a
FIGURE 1a The SSH.1b The SSH bone tips. Note the different styles of
tips for different applications.
C A S E S E R I E S
Schmidt, Papadimitriou, Caton, Romanos Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 53
FIGURE 2a Perioperative: use of the SSH for atraumatic tooth extraction of teeth #8 and #9 that presented with failing endodontic treatment. 2b
Postoperative extraction sockets after the use of the SSH. 2c Immediate implant placement for teeth #8 and #9 after the use of the SSH. Primary stability
was achieved.
FIGURE 3a Window preparation with the SSH tips. 3b Perioperative: initial elevation of the sinus membrane using the special tip of the SSH. 3c Perioperative:
elevation of the sinus membrane was completed without perforation.
FIGURE 4a Site development before implant placement. Note the reduced width of the alveolar ridge (3 mm) with a buccal concavity. 4b SSH preparation with
special tips for ridge splitting. 4c Ridge splitting with the SSH tips in 3-mm depth. 4d Implant placement after ridge splitting with excellent primary stability.
C A S E S E R I E S
54 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Sonic Handpiece in Implant Dentistry
high-speed rotary device. With the use of piezotome de-
vices, the perforation rates are much lower (7%).
13
The
use of the SSH provided lateral window osteotomies with
no perforations present during the preparation.
Atraumatic tooth extractions have become essential in
treatment, especially in the esthetic zone. However, the
exact method to remove teeth atraumatically can vary. Pre-
viously, teeth would be extracted with techniques that
would apply force or trauma to the tooth, as well as vigor-
ously and uncontrollably tearing periodontal ligament
fibers.
14
In that study,
14
using piezosurgery for tooth ex-
traction and immediate implant placement showed very
good results regarding the atraumatic tooth extraction tech-
nique, the osteotomysite preparation, andsubsequent implant
osseointegration. It is known that, when full-thickness
flaps are raised, bone resorption is to be expected.
15
When
ultrasonic surgery is used for atraumatic tooth extraction,
the need for flaps and the necessity to cause trauma are
reduced. The oscillating technologyusedwiththe SSHseems
to provide clinically atraumatic results, similar to the use of
ultrasonic devices.
Considering the advantages and disadvantages of this
newtechnology, the oscillating technology allows clinicians
to perform atraumatic bony surgery in operator-sensitive
cases, improving the clinical outcome in challenging
cases in implant therapy. Similar results to that of piezo-
electric bone surgery devices were found in all clinical
cases.
The oscillating technology facilitates precise atraumatic
bony incisions. With the variety of procedures the device
can perform, it should be of value to any clinician perform-
ing surgical implant dentistry. n
TABLE 1 Advantages and Disadvantages of the SSH Compared to Conventional Surgical Techniques
Clinical Procedures Advantages Disadvantages
Extraction
Standard elevator and forceps Speed and cost Trauma, including fracturing of buccal bone
Periotomes Minimal trauma Time
SSH Minimal trauma, efficient Cost
Sinus lift
Standard high speed with
diamond bur
Efficiency and cost Perforation risk is high and does not aid in elevating
the membrane
SSH Little risk of membrane perforation, different tip also aids in
membrane elevation
Time
Alveolar ridge expansion
High speed and spreaders Efficient Lack of precision and excessive bone removal
SSH Efficient and precise bony incisions More time required compared to high speed
C A S E S E R I E S
Summary
information?
j
The SSH was developed recently.
j
In combination with the surgical tips, this device can be used in many
clinical situations.
j Recently, it was introduced for different surgical interventions.
j The clinician has to be familiar with the sonic technology.
j Minimal training is necessary for the clinician to become familiar with
the different tips.
j
This device can be used by any clinician who wants to perform fast
atraumatic extractions.
j
For the advanced surgical cases, advanced surgical training and
experience is necessary.
j This device is slower than conventional rotary burs.
j Patients are sometimes non-compliant of required surgical
procedures.
Acknowledgment
KaVo (Biberach, Germany) provided the handpiece used
in this study. The authors received no money from KaVo
for research, lecturing, or consulting and report no con-
flicts of interest related to this case series.
CORRESPONDENCE:
Dr. G. E. Romanos, School of Dental Medicine, Stony Brook University,
184C Sullivan Hall, Stony Brook, NY 11794-8705. E-mail: georgios.
romanos@stonybrook.edu.
C A S E S E R I E S
56 Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013 Sonic Handpiece in Implant Dentistry
References
1. Hammerle CH, Lang NP. Single stage surgery combining transmucosal
implant placement with guided bone regeneration and bioresorbable
materials. Clin Oral Implants Res 2001;12:9-18.
2. Hanes PJ. Bone replacement grafts for the treatment of periodontal
intrabony defects. Oral Maxillofac Surg Clin North Am 2007;19:499-
512, vi.
3. Buser D, Dula K, Hess D, Hirt HP, Belser UC. Localized ridge
augmentation with autografts and barrier membranes. Periodontol
2000 1999;19:151-163.
4. Buser D, Dula K, Hirt HP, Schenk RK. Lateral ridge augmentation
using autografts and barrier membranes: A clinical study with 40
partially edentulous patients. J Oral Maxillofac Surg 1996;54:420-432,
discussion 432-433.
5. Springer IN, Terheyden H, Geiss S, Harle F, Hedderich J, Acil Y.
Particulated bone graftseffectiveness of bone cell supply. Clin Oral
Implants Res 2004;15:205-212.
6. Schlegel KA, Fichtner G, Schultze-Mosgau S, Wiltfang J. Histologic
findings in sinus augmentation with autogenous bone chips versus
a bovine bone substitute. Int J Oral Maxillofac Implants 2003;18:53-58.
7. Misch CM. Autogenous bone: Is it still the gold standard? Implant
Dent 2010;19:361.
8. Vercellotti T. Technological characteristics and clinical indications of
piezoelectric bone surgery. Minerva Stomatol 2004;53:207-214.
9. Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony window
osteotomy and sinus membrane elevation: Introduction of a new
technique for simplification of the sinus augmentation procedure. Int
J Periodontics Restorative Dent 2001;21:561-567.
10. Horton JE, Tarpley TM Jr, Wood LD. The healing of surgical defects in
alveolar bone produced with ultrasonic instrumentation, chisel, and
rotary bur. Oral Surg Oral Med Oral Pathol 1975;39:536-546.
11. Chiriac G, Herten M, Schwarz F, Rothamel D, Becker J. Autogenous
bone chips: Influence of a new piezoelectric device (Piezosurgery) on
chip morphology, cell viability and differentiation. J Clin Periodontol
2005;32:994-999.
12. Heinemann F, Hasan I, Kunert-Keil C, et al. Experimental and
histological investigations of the bone using two different oscillating
osteotomy techniques compared with conventional rotary osteotomy.
Ann Anat 2012;194:165-170.
13. Wallace SS, Mazor Z, Froum SJ, Cho SC, Tarnow DP. Schneiderian
membrane perforation rate during sinus elevation using piezosurgery:
Clinical results of 100 consecutive cases. Int J Periodontics Restorative
Dent 2007;27:413-419.
14. Blus C, Szmukler-Moncler S. Atraumatic tooth extraction and imme-
diate implant placement with Piezosurgery: Evaluation of 40 sites after
at least 1 year of loading. Int J Periodontics Restorative Dent 2010;30:
355-363.
15. Wilderman MN, Wentz FM, Orban BJ. Histogenesis of repair after
mucogingival surgery. J Periodontol 1960;31:283-299.
C A S E S E R I E S
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Clinical Advances

Growth-factor Enhanced Matrix is intended for use by

has not been established in other non-

, adverse evenLs LhaL occurred were

Growth-factor Enhanced Matrix

is composed of two sterile components:

is indicated to treat the following periodontall] related defects.

is C0hTRAlhDlCATED in the presence of one or more of the following

interacts with other medications. The use of

has not been established:

has also not been studied in situations where it

is comparable to that of bone and diminishes

is resoroed. The radiopacit] of 0EN 218

is intended for use o] clinicians familiar with periodontal surgical

is supplied in a single use kit. An] unopened

kit must oe refrigerated at 2-8 C (8G-4G Fj. Do not freeze.

is a registered trademark of Straumann AG, Nobel and NobelReplace

are registered trademarks of Nobel Biocare.

is a registered trademark of Zimmer Dental and Astra

is a registered trademark of Astra Tech Inc.

Surface for faster bone apposition*

and V. Thomas Eshraghi*

Private practice, Portland, OR.

Cadavers are processed within 24 hours

AlloSource, Centennial, CO.

Osteocel, ACE Surgical Supply.

with good anteroposterior spread is demonstrated on

SLA Surface RC and RN Implants, Straumann.

Overdenture Implant System (LODI), featuring

and then a polytetrafluoroethylene mem-

CollaTape, Zimmer Dental, Carlsbad, CA.

Biohapatita, Dentoflex, So Paulo, Brazil.

Site preparation was accomplished using the

(Figs. 1d, 2b, and 3b). Detailed writ-

DynaMatrix Plus, Keystone Dental, Burlington, MA.

Septodont, Lancaster, PA.

PrefGel, Straumann, Andover, MA.

Ethicon, Johnson & Johnson.

3M ESPE, St. Paul, MN.

and Silvia Masiero

Private practice, Pessano, Italy.

Private practice, Saronno, Italy.

PEARL (Practitioners Engaged in Applied Research and Learning)

and Dennis Tarnow

Department of Rheumatology, Hospital for Special Surgery, New York,

Division of Periodontics, Columbia University College of Dental Medicine,

Department of Radiology, Hospital for Special Surgery.

including surgical tips

Currently, School of Dental Medicine, Stony Brook University, Stony

SONICflex 2008L, KaVo, Biberach, Germany.

3D: The Most Efcient

3D is the only system that

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