Volume 11, Number 2

February 2000

EDITOR
Arun K. Garg, DMD Associate Professor of Surgery Director, Center for Dental Implants Division of Oral/Maxillofacial Surgery University of Miami School of Medicine

Regenerating the Ridge: Performance of the Grafton Allograft

The popularity of endosseous dental implants for prosthodontic restorations continues to grow. In addition to supporting freestanding permanent restorations, implants are increasingly used to support hybrid and removable dentures or are being requested by long-term edentulous patients who have little bony support. In the presence of insufficient ridge height or width, ideal positioning of the implant cannot be achieved. As a result, bone-grafting procedures are frequently called upon to fill osseous voids and reproducibly regenerate bone geometry and quality sufficient for implant osseointegration. Autogenous bone is considered by many to be the gold standard graft material due to its osteogenic, osteoinductive, and osteoconductive properties. However, possible complications, pain, morbidity, and concern with excessive resorption limit the acceptability of autografts to both the patient and the surgeon. The development of bone graft substitutes has focused on either allografts or synthetic materials (tricalcium phosphate, hydroxyapatite [HA], bioglass, and anorganic bovine bone matrix solutions). These synthetic and ceramic particulates are typically osteoconductive and serve primarily as fillers of defects or voids. Historically, allografts have been used to overcome the limited supply and the prerequisite harvest of autogenous bone. Donor bone that has been properly screened, processed by a series of cleaning or sterilizing procedures, and then lyophilized has been shown to effectively produce a graft that is safe and sterile. Allograft-derived demineralized bone matrix (DBM) is produced by processing bone in dilute acid solutions. The resulting material contains little residual bone mineral and consists of collagen, noncollagens bone matrix proteins, and bone growth factors. Since the pioneering work of Urist, it is generally understood that DBM is both osteoinductive and osteoconductive. Recent studies have demonstrated that proper

EDITORIAL ADVISORS
Editor Emeritus: Morton L. Perel, DDS, MScD Charles A. Babbush, DDS, MScD Head, Section of Dental Implant Reconstructive Surgery Mt. Sinai Medical Center Cleveland Thomas J. Balshi, DDS, FACP Private Practice, Implant Prosthodontics Prosthodontics Intermedica Institute for Facial Esthetics Fort Washington, PA Anita Daniels, RDH Clinical Instructor Center for Dental Implants University of Miami School of Medicine Miami Charles E. English, DDS Staff Prosthodontist Veterans Affairs Medical Center Augusta, GA Jack A. Hahn, DDS Private Practice Cincinnati Kenneth W.M. Judy, DDS Clinical Professor Department of Prosthodontics University of Pittsburgh School of Dental Medicine Jack T. Krauser, DMD Private Practice, Periodontics and Implantology Boca Raton, FL Department of Periodontics Nova Southeastern College of Dental Medicine Davie, FL Richard J. Lazzarra, DMD, MScD Associate Clinical Professor Periodontal and Implant Regenerative Center University of Maryland Private Practice West Palm Beach, FL Robert E. Marx, DDS Professor and Chief Division of Oral/Maxillofacial Surgery University of Miami School of Medicine Carl E. Misch, DDS, MDS Co-Director, Oral Implantology University of Pittsburgh School of Dental Medicine Daniel Y. Sullivan, DDS Private Practice, Implant Prosthodontics McLean, VA; Washington, DC

This Month Inside

Clinically significant abstract ......14

NOW AVAILABLE ON-LINE! Go to www.ahcpub.com/online.html for access.

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processing techniques preserve osteoinductivity and render the material safe. Traditionally, DBM is supplied in freeze-dried powder form, although handling characteristics of DBM powder can be problematic. In particular, containment of DBM powder or a particulate ceramic material in a bleeding surgical bed can be difficult and can lead to loss or improper positioning of the graft material. New forms of DBM materials address both osteoinductive quality and handling characteristics. Grafton (Osteotech, Eatontown, NJ) is a commercially available allograft DBM available in three forms; a flowable gel (Gel DBM), a moldable putty (Putty DBM), and a flexible sheet (Flex DBM) that can be cut intraoperatively. Putty DBM resists migration while conforming to and filling irregular osseous defects of cavities. Flex DBM material is semi-rigid and is capable of maintaining volume and height, serving as the ideal onlay graft material capable of building alveolar ridge width and height. The process by which DBM is produced and its final form vary by source. Putty and Flex DBM are produced by the D-Min process (Osteotech). Briefly, appropriately screened cadaveric donor bone is meticulously cleaned to remove cellular, marrow,

CASE 1 The patient is a 50-year-old male with a history of periodontal disease. Tooth No. 14 was deemed periodontally hopeless. The patient chose to have the tooth extracted and a root-form implant placed.

Figure 1. A scanning electron microscope image of the elongated bone fibers used in Grafton Putty and Flex DBM.

Figure 2. Lateral view of the extraction socket, revealing little bone buccally and lingually.

Dental Implantology Update (ISSN 1062-0346) is published monthly by American Health Consultants, a unit of Medical Economics, 3525 Piedmont Road NE, Building Six, Suite 400, Atlanta, GA 30305. Telephone: (404) 262-7436. Periodical postage paid at Atlanta, GA 30374. POSTMASTER: Send address changes to Dental Implantology Update, P.O. Box 740059, Atlanta, GA 30374. American Health Consultants, in affiliation with Boston University Goldman School of Graduate Dentistry, offers continuing dental education to subscribers. Each issue of Dental Implantology Update qualifies for 1.5 continuing education units. Customer Service: (800) 688-2421. Fax: (800) 284-3291. Hours of operation: 8:30 a.m. - 6:00 p.m. Monday - Thursday; 8:30 a.m. - 4:30 p.m. Friday EST. E-mail: customerservice@ahcpub.com. World Wide Web: www.ahcpub.com. Subscription rates: U.S.A., $449 per year. Students, $200 per year. To receive student/resident rate, order must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the regular rate until proof of student status is received. Outside U.S., add $30 per year, total prepaid in U.S. funds. One to nine additional copies, $269 per year; 10 to 20 additional copies, $180. Missing issues will be fulfilled by customer service free of charge when contacted within 1 month of the missing issue date. Back issues, when available, are $75 each. For 18 continuing education units, add $96 per year. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. Clinical, legal, tax and other comments are offered for general guidance only; professional counsel should be sought for specific situations. Copyright 2000 by American Health Consultants. Dental Implantology Update is a trademark of American Health Consultants. The trademark Dental Implantology Update is used herein under license. All rights reserved. Reproduction, distribution, or translation of this newsletter in any form or incorporation into any information retrieval system is strictly prohibited without express written permission. For reprint permission, please contact American Health Consultants. Address: P.O. Box 740056, Atlanta, GA 30374. Telephone: (800) 688-2421. Group Publisher: Brenda Mooney, (404) 262-5403, (brenda.mooney@medec.com). Executive Editor: Susan Hasty, (404) 262-5456, (susan.hasty@medec.com). Managing Editor: Kevin New, (404) 262-5467, (kevin.new@medec.com). Senior Production Editor: Brent Winter, (404) 262-5401.

Dental Implantology Update

February 2000

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and blood components. Then the of dental implant design or meticuThe particles are often present in bone is milled to produce elongated lous surgical technique, subsequent the surrounding mucoperiosteal fibers (see Figure 1). The bone fibers success of the implant is at risk if it is and mucogingival tissue, even after are demineralized, rinsed in deionplaced in inadequate or poor-quality a healing period of six months. ized water, and soaked in 70% bone. Defects grafted with ceramic particethanol. To make Putty DBM, the Ceramics and synthetic particuulates often feel less dense on probfibers are combined with glycerol to lates undergo limited remodeling ing compared to defects grafted obtain the desired handling characand have only osteoconductive with Putty and Flex DBM. teristics. Alternatively, the DBM properties. Essentially, the ceramic With the goal of alveolar ridge fibers are formed into flexible sheets regeneration and expedient bone particles act only as a scaffold, supto fabricate Flex DBM. repair of socket defects, the bone porting new bone that originates Bone grafting with Putty and Flex graft material used must be reprofrom the adjacent host bone. Putty DBM can be used routinely to restore ducibly osteoinductive. Clinical and Flex DBM demonstrate excellent the required bone quality and geomexperience has shown that regardless new bone formation via osteoinducetry within a relatively tion within the material short healing time. (See itself. Figure 2.) Putty and Flex In addition, Putty and DBM are completely Flex DBM extensively incorporated within the remodel and quickly new bone by four to five incorporate. Because of months post-grafting, DBMs ability to form with little remaining new bone, numerous DBM matrix. (See Figure studies also have shown it 3.) to be effective in regenerThe restored ridge typiating periodontal bone cally is firm upon palpaloss and in the repair of tion at re-entry for implant fenestration defects or placement. In contrast, other osseous voids surwhen grafting with rounding endosseous ceramic particulates, it is implants (see Related common to be able to Readings). clearly recognize the HA The technique for the Figure 3. The osseous defect was grafted and the ridge was particles within the graft use of Putty DBM in recontoured with Putty DBM. site at re-entry. extraction socket grafting

Figure 4. Approximately 5 months after grafting with Putty DBM, the ridge appears well-formed, and complete bony fill of the lateral wall and the extraction socket is complete.

Figure 5. An implant of 5 mm diameter and 13 mm length was then easily placed.

February 2000

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is the same as with other convenwidth and height are essential to the When a narrow and/or shallow tional bone graft materials: success of the bone graft procedure. ridge is encountered, Flex DBM is Following standard anesthetic It also is important to note that the ideal material to build out width and aseptic surgical techniques, a both Putty and Flex DBM are initially and can be used to gain millimeters midcrestal mucoperiosteal flap is radiolucent on radiographs. With of height. The surgical protocol for raised at the site, and the extraction healing, the radiodensity of the graft the use of Flex DBM is similar to the is performed. site gradually increases as new bone protocol for the performance of an Any granulation tissue is careformation, ossification, and finally onlay autogenous graft: fully debrided. The osseous defects maturation occurs. (See Figure 4.) Flex DBM is rehydrated prior to are then filled with Putty use. Scissor or scalpel easDBM, slightly overfilling ily cuts the Flex DBM to the site with gentle comthe shape required. After CASE 2 The patient is a 77-year-old female with an atrophic edenpression of the graft careful flap elevation, the tulous region of the posterior mandible and a failed endomaterial. onlay graft(s) of Flex DBM dontically treated first bicuspid. The supporting ridge has Additional Putty DBM is placed, decorticating atrophied and requires bone grafting to facilitate implant placement. can be used to build out the cortical wall to assure the ridge contours. A a well-vascularized bone resorbable membrane bed. barrier material is used to Putty DBM should be cover the graft sites if priused to fill out any irregumary closure is not possilar contours that may be ble without displacing the troublesome at implant graft. Because bone forms placement. At closure, a where the graft is placed, resorbable membrane barit is imperative that care rier material is used if priis taken to avoid commary closure is not paction or movement of possible. the graft material during The full-thickness flaps the postoperative course. are then reapproximated. The use of protective Again, it is emphasized temporary bridges or that care be taken to proappliances made with tect the graft material Figure 6. Lateral view of the failed first bicuspid and edenspecific allowances for tulous area to be grafted to receive dental implants. (Continued on page 14) the newly grafted ridge

Figure 7. Surgical view of the narrow ridge and the osseous defect after extraction of the bicuspid.

Figure 8. Lateral surgical view of the same, revealing the large dehiscence in the area of the first bicuspid.

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Figures 9-11. A 1.5 sq. cm piece of Flex DBM was cut in half for use as an onlay along the narrow ridge. Both Putty and Flex DBM were used in this case.

Figure 10.

Figure 11.

Figure 12. The Flex DBM was placed along the lateral aspect of the ridge. Putty DBM was used to fill out the irregularly shaped extraction socket.

Figure 13. At approximately three and a half months after grafting, the ridge width was restored and the extraction socket and dehiscence defects were solved.

Figure 14. Three 4.3 mm diameter (10-13 mm length) implants were placed within the newly formed bone.

February 2000

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from movement or compression through the postoperative healing period. (See Figure 5.) An illustrative clinical case is shown on p. 13. (See Case 2, Figures 6 through 12.) Grafton DBM Putty and Flex offer an excellent option for the restoration of bone stock for the treatment of extraction sites and ridge augmentation procedures. These materials have clear advantages over other DBM materials and particulate synthetics in that Putty and Flex DBM are osteoinductive, easy to handle, and quickly remodeled into newly formed bone, and they allow the clinician to avoid autograft harvest.

Clinically Significant A B S T R A C T
Parodi R, Carusi G, Santarellil G, Nanni F. Implant placement in large edentulous ridges expanded by GBR using a bioresorbable collagen membrane. Int J Periodont Rest Dent 1998; 18:267-275. At times, the shape of the edentulous alveolar crest makes implant placement difficult, if not impossible. There may be anatomic defects in the height and/or width of the bone. Many techniques have been used to overcome these problems and make implant placement possible. A good rate of success has been reported with the use of a two-step guided bone regeneration (GBR) technique with nonresorbable membranes on small-sized edentulous ridges (the absence of one tooth), with or without bone grafting. In the authors experience, a high success rate has been achieved with single-tooth replacement using resorbable collagen membranes with or without filling material. However, in larger areas, the success rate is limited because the size of the membrane is directly proportional to the possibility of early exposure. Also, the size of the defect appears to have a great influence on the percentage of bone regeneration that is achieved. The authors conducted a study on implant placement in narrow edentulous ridges spanning two or more teeth after expansion using the GBR technique with a bioresorbable collagen membrane that uses resorbable collagen sponges placed under the membrane to maintain a tent effect. Sixteen patients with alveolar ridges of insufficient width for implant placement were included in this study. Screw-type implants were placed in 4 mandibles and 12 maxillae. Only one ridge augmentation was performed in each patient.

Related Readings
Callan DP. Use of human freezedried demineralized bone prior to implantation. Part I. Pract Perio Aesth Dent 1990; 2:14-18. Callan DP. Guided tissue regeneration without a second procedure. Int J Perio Rest Dent 1993; 13:173-179. Levin SS, Prewett AB, Cook SD. The use of a new form of allograft bone in implantation of osseointegrated dental implants a preliminary report. J Oral Implantol 1992; 18:366-371. Mellonig JT. Decalcified freezedried bone allograft as an implant material in human periodontal defects. Int J Perio Rest Dent 1984; 6:41-55. Neigel JM, Ruzicka PO. Use of demineralized bone implants in orbital and craniofacial reconstruction and a review of the literature. Ophthal Plast Reconstr Surg 1996; 12:108-120. Scarborough NL, White EM, Hughes JV, et al. Allograft safety: viral inactivation with bone demineralization. Contemp Orthop 1995; 31:257-260. Contact: Donald P. Callan, DDS, 10319 West Markham, Suite 300, Little Rock, AR 72205. Telephone: (501) 224-1122. Fax: (501) 224-1990. E-mail: dcallan@doncallan.com. M Dental Implantology Update

If the width of the alveolar ridge was less than 5 mm, GBR procedures were performed as follows: The alveolar bone was decorticated, following by smoothing of the bony surface. Two or more native collagen sponges were placed buccally and lingually in the deficient areas of the alveolar ridge. The purpose of this was for these sponges to act as a template for clot formation and provide the support necessary for positioning of a bioresorbable collagen membrane. The membrane was shaped to completely cover the alveolar ridge and the sponges. After soaking the collagen sponges with blood, primary closure over the membrane was achieved by suturing the flaps. Postoperatively, patients were examined every two weeks for the first two months and then every month. Patients were instructed not to wear removable prostheses in the treated area during this period. Implants were placed seven to 12 months after the initial surgery. Results showed that the mean increase in the size of the crest indicates that in 75% of the cases (12 of 16), the crest became greater than or equal to 5 mm at the planned site of implant placement. As a result, it was possible to insert implants that were 3.3 or 4.1 mm in diameter completely into the bone.The bone that the implants were inserted into had good texture and thickness. The mean increase in the size of the crest was 2.49 mm, which was clinically and statistically significant. However, differences in the amount of bone regeneration between the cases were noted. This may be due to a difference in resorption rates for the membranes, a difference in patient response, differences in the pressure of the flap, and differences in fitting the membrane to the underlying bone. The implants were subsequently loaded eight to 40 months after placement. No complications were observed in any of the cases. M February 2000

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The Impulse Factor in Cosmetic Case Acceptance

The reason for the low acceptance rate for pure cosmetic dental cases (those not based on the repair or restoration of front teeth but for esthetic purposes only) is due to the methodology dentists use to present cases, writes Roger P. Levin, DDS, MBA. In an article in the Fall 1999 Journal of the American Academy of Cosmetic Dentistry, Levin notes that in his experience working with hundreds of practices, less than 10% of the pure cosmetic treatment plans are accepted. Levin says dentists have to provide their patients with two different types of services: need-based and want-based. He says the reason for low acceptance is that dentists use the same approach with the cosmetic patient as they do for a need-based case. Levin says dentists have been conditioned to present a need-based, logical explanation, including technical factors, instead of focusing on a wantbased explanation. According to Levin, when dentists convert to a non-logic, impulsive cosmetic presentation, acceptance rates can increase to as high as 80%. The average number of whitening, bonding, veneer, or posterior tooth-colored restoration cases is far below where it should be. He notes that statistics indicate that middle- to highend practices perform less than 7% of their monthly services in pure elective dentistry. To understand the relevance even further, Levin notes that an estimated 80% of the need-based cases performed are one-tooth treatments. One tooth at a time, he writes, is the least efficient type of dentistry. Levin recommends dentists examine these three areas of cosmetic case

presentation to insure for a higher acceptance rate of cosmetic dentistry: impulsivity; interpersonal likability; interpersonal enthusiasm. Building a cosmetic practice requires a much higher level of enthusiasm or excitement, Levin writes. Patients reject cosmetic dentistry not because of a lack of trust, but because of a lack of interest. Any dentist can increase the number of cosmetic cases performed by changing the way cosmetic presentations are made, Levin advises. M

Trigeminal Neuralgia in Dentistry

A patient who complains of toothache or sinusitis-like pain with no apparent dental cause may be suffering from a neurological condition known as trigeminal neuralgia (TN), according to an article in the May/June 1999 issue of Northwest Dentistry. The article by Claire W. Patterson, president of Trigeminal Neuralgia Association, and Judd S. Copeland, DDS, surveys the causes, symptoms, and treatment of the disorder. They write that the patient usually complains of a sharp, stabbing pain that is aggravated by chewing, drinking hot or cold liquids, brushing the teeth, or talking. Misdiagnosis of the condition can result in unnecessary dental therapies such as multiple extractions, endodontic procedures, and TMJ surgery, frequently with no effect on the patients discomfort, the authors write. Trigeminal neuralgia usually is caused by compression of a blood vessel at the trigeminal nerve root entry-exit zone, according to the article. It produces what many

physicians consider to be the most excruciating of all types of pain. The symptoms may be mild in the early stages, but can develop into recurring episodes of intense, electric shock-like pain in the distribution of one or more branches of the trigeminal nerve. The article notes the major diagnostic criterion is the presence of trigger points on the face. The slightest stimulation of any of these points results in an agonizing attack for the patient. About 25% of patients will respond to treatment with anticonvulsant drugs, but surgery is required for most. Classic TN has distinct symptoms that clearly separate it from other forms of facial pain: Pain is short, acute bursts rather than a dull, constant ache often described as electric shock-like in nature. Pain is usually triggered by light touch or sensitivity to vibrations, such as brushing ones teeth, a light breeze, shaving, or talking. Pain has a tendency to come and go, with periods of intense, sometimes totally debilitating pain, followed by completely pain-free periods of remission lasting from weeks to months or possibly longer. Most patients experience pain during the day while they are up and about and generally are free of pain while asleep unless it is triggered by the touch of bed linens or changes in position. The patient history and description of symptoms are the major aids in confirming the diagnosis of TN, the authors write. Most physicians will recommend a CAT scan or MRI along with other laboratory tests. These are intended mostly to rule out other causes of pain such as tumors or multiple sclerosis. There is no specific test to confirm the diagnosis of TN, according to the authors. M

February 2000

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New Product News

Separating/Lubricating Medium
Formerly available through Felix Dental Manufacturing, Petro-Sil separating medium combines petrolatum and silicone release agents to create a fine, repellent finish that allows ready separation of impression materials, stone, plaster, and epoxy. Suitable for use on virtually any surface, the odorless spray cures in seconds. The resulting film reportedly does not wash off with water and does not require reapplication for multiple releases. Formulated without solvents or chlorofluorocarbons, it can be sprayed or painted on impression trays to facilitate release of alginates and on impressions to create smooth models. Available individually or in sets of two, the 8-ounce bottles are supplied with a finger-pump spray designed to minimize waste. Contact: American Dental Supply, Inc. Telephone: (610) 252-1464.

Calendar
Academy of Osseointegration March 9-11, New Orleans. For more information, contact: AO, 401 N. Michigan Ave., Chicago, IL 60611-4267. Fax: (312) 245-1080. San Francisco Tenth Annual Implant Symposium March 911. For more information contact ICOI at (800) 442-0525 or (973) 783-6300. Fax: (973) 783-1175. Cutting Edge II: The Cruise April 2-9. For more information, contact: MECC. Telephone: (305) 663-1628. Fax: (305) 663-1644. Jubilee Congress of the German Society for Oral and Maxillofacial Surgery May 3-6, Berlin, Germany. For more information, contact: Prof. Dr. Jurgen Bier. Telephone: 030/45055055. Fax: 030/450-55901.

American Academy of Periodontology May 5-6, Washington, DC. For more information, contact: AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611. Fax: (312) 573-3225. American Academy of Periodontology Sept. 17-20, Honolulu. For more information, contact: AAP, 737 N. Michigan Ave., Suite 800, Chicago, IL 60611 Fax: (312) 573-3225. AAOMS 82nd Annual Meeting, Scientific Sessions and Exhibition Sept. 20-24, San Francisco. For more information, contact: AAOMS, 9700 W. Bryn Mawr Ave., Rosemont, IL 60018. Telephone: (800) 822-6637. Fax: (847) 678-6286. American College of Prosthodontists Nov. 15-18, Honolulu. For more information, contact: ACP, 211 E. Chicago Ave., Suite 1000, Chicago, IL 60611. M

Bone Graft Material

Designed to provide optimal vertical defect fill, clinical attachment gain, and pocket depth reduction, PepGen P-15 bone graft material facilitates bone repair in patients with moderate to severe periodontitis. The peptide-enhanced material is said to be exceptionally effective for treating periodontal osseous defects. The material uses a synthetic peptide that is irreversibly bound to anorganic bovine-derived material (OsteoGraf N-300), a natural material similar to that found in human bone. It promotes attachment of reparative cells from surrounding tissues and facilitates the biomimetic environment for bone growth. This action reportedly starts a sequence of events that Dental Implantology Update

ultimately leads to bone formation and repair of the periodontal osseous defect. Contact: CeraMed LLC. Telephone: (800) 426-7836. World Wide Web: www.ceramed.com.

Regenerative Membrane
The Gore Osseoquest regenerative, bioabsorbable membrane is said to maintain functional integrity for six months. Suitable for a wide range of applications and custom cutting because of its large size, the 100% synthetic membrane features a hexametric pattern with large, open-surface structure for optimal tissue integration. GORE-TEX suture for soft closure and a sterile template to facilitate trimming are included in each package. Contact: 3i/Implant Innovations. Telephone: (800) 443-8166. World Wide Web: www.3I-online.com. M

Endodontic Accessories
This full-color, fold-out flyer highlights the companys line of endodontic accessories. Featured are paper, gutta-percha, calcium hydroxide points, rubber dam, tray covers, the Surgitip sterile surgical aspirator tip, and RockoSeal Automix root canal sealer. Pricing, illustrations, ordering options, and descriptions accompany each product. Contact: Rocko USA. Telephone: (888) 665-0411. World Wide Web: www.rocko.com.

February 2000