Clinical Advance Perio Nov

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Clinical Advances

in Periodontics

IN THIS ISSUE:

An Online Journal of the American Academy of Periodontology

www.clinicalperio.org

Creeping Attachment in MillerClass III Recessions

Subepithelial ConnectiveTissue Graft for aMucogingival Defect

Titanium Particles inPeri-Implant Tissues

Implant Treatment for Root

Resorption in a Growing Child

Management of RetrogradePeri-Implantitis via Resection

Vitamin D Deficiency andPeriradicular Bone Loss

Computed TomographyGuided Implantology

Volume 2 Number 4 November 2012


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VOLUME 2 | NUMBER 4 | NOVEMBER 2012

Clinical Advances in Periodontics

TABLE OF CONTENTS

CASE-BASED LEARNING

217 Creeping Attachment in Miller Class III Recessions: A Report of Five Cases

Deepa Kochar, Satish arula, ajinder umar Sharma, Shikha ewari, eepa Chopra

Partial rootcoverage through creeping attachment was achieved in Miller Class IIIgingival recessionsafter gingival

augmentation by ree gingival graf apical o he recession area.

224 Clinical and Histologic Long-Term Evaluation of a Subepithelial Connective

Tissue Graft Used as Treatment for a Mucogingival Defect: A Case Report

oo Carnio, auo . Camargo

his case report escribes how sur ace keratinization may not occur when a subepithelial connective tissue gra t is

covere by mucosal issue.

232 Titanium Particles in Peri-Implant Tissues: Surface Analysis and Histologic

Responsen rew Tawse-Smith, Sunyoung Ma, Allau in Siddiqi, arwick . Duncan,

z Girvan, a z a . ussa n

xamination o peri-implan tissue samples rme the r o particles containing itanium.

241 Treatment Alternative for Root Resorption of an Avulsed Tooth in a Growing

Child: A Case Report With a 4-Year Follow-Up

Ping Mau, ok- hao ang, Chuen-Chy seng, ea-Huey Melody hen,

av . ochran

In this report, repositioning f avulsed tooth and conservative ndodontic treatment in growing child

reserved he adjacent support ing tissues for elayed im plant treatmen after growth was complete.

250 Management of Retrograde Peri-Implantitis by Apical Resection and Guided

Bone Regeneration in Adjacent Maxillary Implants

Tamika . hompson-Sloan, Shilpa olhatkar, Monis hola

A combination of resective and regenerative therapy was a viable treatment modality for retrograde peri-implantitis

RPI cases ranging in small o large reas o bone estruction, an his combination helpe salvage implants

a c e with in he anterior reas o he m outh withou compromising the coronal eri-implan esthetics.

continued n page iii)

ON THE COVER:

eeth #21 and #22 at baseline

showing mucogingival problems

and months a ter treatment with

a subepithelial connective tissue

graft. (Carnio and amargo

An Online Journal of the American Academy of Periodontology


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258 Vitamin D Deciency: A Cause of Periradicular Bone Loss

Praveen Sharma, Paul Weston, ain Chapple

atient with vitamin eciency presente ith multiple asymptomatic ra iolucencies associate with lower

anterior teeth, which resolved following vitamin D supplementation.

CLINICAL DECISION MAKING

263 A Logical and Progressive Approach to Computed

TomographyGuided Implantology

osep . Califano, an osen e , George an e ar s

A rogressive approach o incorporating computed tomographyguided implantology into clinical practice

involves gra ual increase in complexity while minimizing risk uring the learning urv .

T A B L E O F C O N T E N T S

Clinical Advances in Periodontics, Vol. 2, No. 4, November 2012


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VOLUME 2 | NUMBER 4 | NOVEMBER 20

Clinical Advances in PeriodonticsAn Online Journal of the American Academy of Periodontology

Co-Editors

r. Kenneth S. KornmanInterleukin Genetics

Waltham, MA

r. Michael S. ReddyUniversity of Alabama at BirminghamBirmingham, 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

tony Brook University

tony 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, NYVice President

Dr. Joan Otomo-Corgel

Los Angeles, CA

ecretary/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. RosenPrivate 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

r. Hiromasa Yoshie

The American Academy of Periodontology

xecutive Director, John M. Forbes

Publications Director, Katie Goss

Managing Editor, Julie Daw

Production Manager, Bethanne Wilson

737 N. Michigan Avenue, Suite 800

Chicago, IL 60611-6660

o ce: 12.787.551

Fax: 312.573.3225

E-Mail: [email protected]

Website: www.perio.org

ournal: www.clinicalperio.org

linical Advances in Periodontics is dedicated to advancing clinical management o patients by translating knowledge into practical therapy. It is an online publication o the American Academy oPeriodontology. The statements and opinions expressed in this publication reect the views of the author(s) and do not re ect the policy of the Academy unless so stated.

Clinical Advances in Periodontics ISSN 2163-0097) is published quarterly by the American Academy of Periodontology, 737 North Michigan Avenue, Suite 800, Chicago, Illinois 60611-6660. Manuscripts shouldbe submitted online at http://mc.manuscriptcentral.com/clinicalperio. For assistance with submissions, please contact Jerry Eberle (telephone: 312/573-3255; fax: 312/573-3225; e-mail: [email protected]).Inquiries relating to advertisements should be addressed to the Academys advertising agent Todd Goldman (telephone: 813/760-8633; e-mail: [email protected]). Inquiries relating to subscriptionsshould be addressed to Product Services (telephone: 312/787-5518; fax: 312/573-3225; e-mail: [email protected]). Inquiries relating to permissions should be requested by completing the Permissions Request

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Copyright 2012 by the American Academy of Periodontology; all rights reserved.

ll a vertising appearing inClinical Advances in Periodonticsmust be reviewed and accepted prior to publication. Advertisers should allow a minimum of six (6) weeks for the review process. The publication ofan advertisement in linical Advances in Periodonticsis not to be construed as constituting an endorsement or approval of the product or its claims by the American Academy of Periodontology or any of itsmembers.


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mandibular central incisor region in which FGG was use

for gingival augmentation apical to the recession. Oney ater, a equate eratinize t ssue a ong it partiaroot overage attri uta le o reeping attachment wasac ieve .

Clinical Presentation

Five patients ( our ma e an one ema e, age 27 to 30 years)iagnose wit Mi er C ass III recessions in 10 teet ( e t an

right mandibular central incisors, teeth #24 and 25), weretreate at t e Government Denta Co ege, Ro ta , Haryana,India, from October 2009 to November 2009. Clinical find-ings in allfive patients included:1) wide recessions andshallow

estibule with minimal or absence of keratinized gingiva (KG);

2) high frenalpull; 3) progressive GR;and4) difficulty in main-a n ng ora ygiene n a ecte r . A pat ents r n-

smokers. Phase herapy as provided. Recession deptRD (mi - acia ), pro ing ept PD , an i t o K

(WKG) were recorded immediately before surgery (baseline).A millimeter graded periodontal probe wit ru er stop-

er used for al measurements an etermine wita ca iperx to e nearest .1 mm. was wit in normalimits on the day of surgery.

TABLE 1 KG at Baseline and After 1 Year (mm)

Tooth #24 Tooth #25

Case Baseline 1 Year Change Baseline 1 Year Change

1 5.0 5.0 0 5.5 5.5

2 1.4 5.0 .6 1.5 5.5 .0

1.0 5.5 .5 1.0 5.5 .5

4 . . .5 . 5. 4.

. . 2.0 . .5

TABLE 2RD at Baseline and After 1 Year (mm)

Tooth #24 Tooth #25

Case Baseline 1 Year Change Baseline 1 Year Change

1 5.5 4.0 1.5 3.5 3.0 0.5

2 .0 2.3 .7 3.5 2.5 1.0

. . . . . .

2.5 1.5 1.0 2.5 2.0 .5

5 4.5 4.1 .4 2.0 1.6 .4

FIGURE 1 Surgical procedure. 1a Before

urgery. 1b Recipient bed preparation. 1c Donor

ite. 1d Graft sutured and stabilized. 1e One year

after surgery.

PCP-UNC 15, Hu-Friedy, Chicago, IL.

itutoyo merica orporation, urora, .

C A S E R E P O R T

218 linical vances in erio ontics, ol. , o. , ovember 1 reeping ttachment in iller lass III ecession


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Case ManagementPrior to t e proce ures, written in orme consent was o -taine rom a patients. Gingiva augmentation apica tothe recession with FGG was performed in all five patients.After obtaining anesthesia, the submarginal recipient bedwas prepared by a horizontal incision 1 mm apical to the

ase o t e su cus in t e a veo ar mucosa. Two vertica in-cisions were ma e at t e en o orizonta incision. T epartial-thickness flap was separated and a firm periostealbed was obtained. An approximately 1-mm-thick graftwas arveste rom t e premo ar region o t e pa ate.The graft was positioned and sutured on the periostea

bed (Fig. 1). A periodontal pack was applied. The patientsreceived routine postsurgical instructions and were advisednot to rus t e treate site or 4 wee s. T ey were pre-scri e 0.12% c or exi ine mout rinse twice ai y or4 weeks, systemic antibiotics (500 mg amoxicillin, every8 hours for 5 days), and analgesics (400 mg ibuprofen,every 8 ours or 5 ays). Sca ing, i nee e , was one 1month after surgery. PD, RD, and WKG were recordeat 1 year a ter surgery. PD was t e same preoperative yand after 1 year. There were increases in the WKG anddecreases in RD in all 10 teeth (Figs. 2 through 6; Tables1 an 2).

Clinical OutcomesThere was considerable improvement in the gingival statusafter gingival augmentation apical to recession. Increase inWKGwas 3.5 to5.5 mm (Ta e 1).Decreasein RDas a re-sult of creeping attachment was in range of 0.4 to 2.8 mm(Figs. 2 t roug 6; Ta e 2).

DiscussionTreatment of Miller Class III GR cases poses a challenge tothe periodontist in day-to-day practice because of loss ointerproxima one an so t tissues. T e amount o root

coverage in these situations depends primarily on inter-proximal attachment level. Gingival augmentation apicalto t e recession is equa y important an is more pre ict-able than root coverage in these cases.

War 3 o serve a ecrease in recession o 0.5 to 1.5 mmin two thirds of patients treated with FGG. Matter10 ob-serve creeping attac ment or 5 years an state t at itoccurre rom 1 mont to1 year a ter surgery an was neg-ligible after 1 year. On the contrary, Agudio et al.12,13 ob-serve t at creeping attac ment continue uring t eentire follow-up period of 10 to 25 years. Bell et al.11 e-termine t e extent an rate o creeping an oun

FIGURE 2 Case 1. 2a Before surgery. 2b One year after surgery.

FIGURE 3 Case 2. 3a Before surgery. 3bOne year after surgery.

C A S E R E P O R T

Kochar, Narula, Sharma, Tewari, Chopra linical Advances in Periodontics, Vol. 2, No. 4, November 2012 219


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a 0.89 0.46 mm average wit a range o 0.38 to 1.61 mmover 1 year. Matter and Cimasoni9 studied 20 cases ooca ize GR treate y FGGs an escri e ive actors

that influence creeping: 1) width of recession; 2) positionof the graft; 3) interproximal bone height; 4) position o

he tooth; and 5) patient oral hygiene. In our cases, FGGapica to recession area was success u in ac ieving a e-quate vestibular depth, halting progressive GR, and im-proving patients ora ygiene status. In a ition, partiaroot coverage as a result of creeping attachment was alsoobserved. n

FIGURE 4 Case 3. 4a Before surgery. 4b One year after surgery.

FIGURE 5 ase 4. 5a Before surgery. 5b ne year after surgery.

C A S E R E P O R T

220 linical Advances in Periodontics, Vol. 2, No. 4, November 2012 reeping Attachment in Miller lass III Recession


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Summary

Why is this case new information? j To the best of our knowledge, root coverage through creeping

attachment in Miller Class III recessions has not been previouslyreported.

What are the keys to successful

management of this case?

j FGG facilitated plaque control. It favored long-term creeping

attachment.

What are the primary limitations to

success in this case?

j Root coverage was not attempted because there was little difference

in the attachment levels on surfaces bearing the recession and

neighboring proximal surfaces.

AcknowledgmentsThe authors acknowledge Dr. Shikha Mukhija, Senior Res-i ent, epartment o Perio ontics, overnment DentaCollege, Postgraduate Institute Of ental Sciences, Roh-tak, Haryana, India, or er elp n manuscr pt re ara-tion. T e aut ors report no con icts o interest re ateto this case report.

CORRESPONDENCE:

Dr. Deepak Kochar, Department f Periodontics nd ral Implantology,Government Dental College, Postgraduate Institute of MedicalSciences, Rohtak 124001, Haryana, India. E-mail: [email protected].

FIGURE 6 Case . 6a Before surgery. 6b One ear after surgery.

C A S E R E P O R T

Kochar, arula, harma, Tewari, hopra linical dvances in eriodontics, ol. 2, o. 4, ovember 012 221


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References1. Rateitschak KH, Egli U, Fringeli G. Recession: A 4-year longitudinal

study after free gingival grafts. Clin Periodontol 1979;6:158-164.

2. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles ofsuccessful grafting. Periodontics 1968;6:121-129.

3. Ward VJ. A clinical assessment of the use of the free gingival graft fororrecting localized recession associated with frenal pull. J Periodontol

1974;45:78-83.

4. Vandersall DC. Management of gingival recession and a surgical

ehiscence with a soft tissue autograft: 4 year observation. J Peri-odontol 1974;45:274-278.

. Miller PD Jr. A classification of marginal tissue recession. ntPeriodontics Restorative Dent 1985;5(2):8-13.

6. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Rootoverage revisited. Periodontol 2000 2001;27:97-120.

7. Muller HP, Eger T, Schorb A. Gingival dimensions after root coveragewith free connective tissue grafts. J Clin Periodontol ; 5: - .

8. Goldman HM, Cohen DW. Periodontal Therapy, 5th ed. St. Louis: C.V. Mosby; 1973:715-758.

. Matter J, Cimasoni G. Creeping attachment after free gingival grafts.J Periodontol 1976;47:574-579.

. Matter J. Creeping attachment of free gingival grafts. A five-yearfollow-up study. J Periodontol ;5 : - 5.

1. Bell LA, Valluzzo TA, Garnick JJ, Pennel BM. The presence ofcreeping attachment in human gingiva. J Periodontol 1978;49:513-517.

12. Agudio G, Nieri M, Rotundo R, Cortellini P, Pini Prato G. Freegingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10 to 25 years) of outcomes. Periodontol2008;79:587-594.

13. Agudio G, Nieri M, Rotundo R, Franceschi D, Cortellini P, PiniPrato GP. Periodontal conditions of sites treated with gingival-augmentation surgery compared to untreated contralateral homolo-gous sites: A 10- to 27-year long-term study. J Periodontol2009;80:

- 5.

indicates key references.

C A S E R E P O R T

222 linical Advances in Periodontics, Vol. 2, No. 4, November 2012 reeping Attachment in Miller lass III Recession


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CASE REPORT

Clinical and Histologic Long-Term Evaluation of a SubepithelialConnective Tissue Graft Used as Treatment for a

Mucogingiva efect: Case epor

Joo Carnio* and Paulo M. Camargo

Introduction: The objective of this casereport is to examine the epithelial surface characteristics of a fully submergedsubepithelial onnective tissue graft (CTG) that was initially performed to treat a mucogingival problem seven years earlier.

Surface keratinization f a fully submerged CTG may be desirable, but its predictability is still subject to debate.

Case Presentation: Two adjacent lower teeth were treated for recession and minimal amount of keratinized tissue.The surgical technique included flap advancement and the CTG was completely covered with a flap that had mostly a non-

keratinized surface. At 18 months after surgery, the surface of the healed CTG showed mostly no clinical or histologic signs

f epithelial keratinization; at that point, the surface epithelium of the whole grafted area was surgically excised and allowed

o heal by secondary intention. The absence f keratinization persisted after the second surgical procedure.Conclusion: When fully submerged, a CTG may not induce keratinization of its overlying epithelial surface. Clin Adv

Periodontics2012;2:224-230.

Key Words: Connective tissue; ingivoplasty; periodontics.

BackgroundT e attac e gingiva p ays an important ro e in protectingt e perio ontium rom mec anica trauma in uce ytoothbrushing and in facilitating plaque control, thereforecontri uting to t e sta i ization o t e gingiva margin atthe level of the cemento-enamel junction (CEJ). The pres-ence o minima imensions o attac e gingiva or its com-p ete a sence constitutes a ris actor or t e eve opmentof he acquired deformity of gingival recession (GR).1-4

The subepithelial connective tissue graft (CTG), first de-scri e y Langeran Langerin 1985,5 is a wi e y use aneffective mucogingival surgical technique in correcting de-ficiencies n attached g ng va and cover ng enuded rootsur aces.6

Unlike the free ingival graft, the CTG should be par-tia y or tota y covere y t e pe ic e ap t at is e evatein the area receiving treatment. As such, the grafted tissue

as an increased chance of survivingbecause there is a max-ima oo supp y. T ere are c inica situationsinw ic t eflap covering the CTG is composed mostly or entirely ofnon-keratinize mucosa. oncerns ave een raise withrespect to t e nature ( eratinize versus non- eratinize )o the epithelial surface o he CTG after ealing.7,8

This case report presents the long-term clinical and his-tologic results of a CTG that was performed with flap ad-

ancement an , t ere ore, comp ete y covere wit

* epartment o erio ontics, tate niversity o on rina enter or he

Health Sciences, Londrina, Brazil.

Section of Periodontics, School of Dentistry, University of California, Los

Angeles, Los Angeles, CA.

Submitted June 25, 2011; accepted for publication October 4, 011

o : 10.1902/cap.2012.110064

224 l in ical v ances in erio o nt ics, o l . , o . , o vemb er 1


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a flap with a mostly non-keratinized surface. By followingt e case or 7 years, it was possi e to stu y w et er t eepithelial surface of the grafted area changed its character-istics over time.

Clinical PresentationA 37-year-o ema e was re erre toa private practice(JC)in Londrina, Brazil, for treatment of a mucogingival prob-

lem on the facial aspect of teeth #21 and #22 in October,2003. T e treatment o jectives inc u e an increase inthe apico-coronal dimension of the keratinized tissue, cre-ation o a zone o attac e gingiva, an possi e coverageo t e enu e roots on ot teet (Figs. 1 an 2). T e pa-tient provided oral consent before the procedures.

Case ManagementPreparation o t e recipient area or t e CTG use an en-velope technique9 (Fig. 3). The harvested CTG is shown inFigure 4. Care was exercised to stabilize the CTG at thelevel of the CEJ. The flap was then advanced to coverthe whole CTG and sutured (Fig. 5).

FIGURE 2 linical aspect of teeth #21 and #22 at baseline after application

of Schiller solution. Note the presence of minimal keratinized tissue.

FIGURE 3 plit-thickness flap preparation of the recipient site of the CTG.

FIGURE 1 Clinical aspect of teeth #21 and #22 at baseline, which

presented with mucogingival problems.

FIGURE 4 The subepithelial CTG was harvested from the upper left

posterior palate and shaped to the dimensions of the recipient site.

FIGURE 5The CTG was sutured at the CEJ of teeth #21 and #22. The flap

was advanced to completely cover the CTG and sutured with 6-0 plain gut.

C A S E R E P O R T

arnio, Camargo linical Advances in Periodontics, Vol. 2, No. 4, November 2012 225


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After a representative section of the specimen was se-ecte , igita images were o taine using a scanner sys-

temx at 200 magnification. The University California,Los Angeles Translational Pathology Core Laboratory per-orme t e igitization o t e isto ogic sections.

Histologic Findings

Figure 9 s ows t e w o e specimen, compose o a core odense well-organized, connective tissue covered by epithe-ium. T e arrow in Figure 10 enotes t e mucogingiva

junction, which is about 1 mm apical to the gingival mar-gin. Rete pegs are evident above the arrow. On the mostcorona aspect (1 mm) o t e specimen (Fig. 11), t e epit e-lium demonstrates morphologic characteristics of keratini-zation. T e epit e ia ce s on t e sur ace are most y atand do not present with nuclei. Examination of the speci-men farther than 1 mm apical from its coronal end revealst at t e connective tissue is covere y epit e ium t at oesnot show evidence of keratinization (Fig. 12). The epithelialcells are squamous in shape, as typical of the stratum spino-

sum in non- eratinize epit e ium (Fig. 12). T ere ore, t emicroscopic appearance of this epithelial tissue starting at 1mm apica rom t e gingiva margin is suggestive o non-

FIGURE 9 Histologic section of specimen retrieved at 18 months (refer to

Fig. 8). Magnification, 1; H&E. Tissue consisted of dense connective

tissue covered by epithelium.

FIGURE 11 Histologic section of the coronal area shown in Figure 10.

Magnification, 10; H&E. Epithelial cells are flat and lost their nuclei, which

is typical of a keratinized surface.

FIGURE 12 Histologic section of the apical area shown in Figure 10.

Magnification, 10; H&E. Squamous cells of the stratum spinosum are

present, which is typical of a non-keratinized epithelium.

FIGURE 10 Histologic section of the area correspondent to the mucogin-

gival junction in Figure 9. Magnification,3; H&E. Arrow denotes mucogin-

gival junction. Area coronal to the arrow shows flattened epithelial cells,

suggesting the formation of a stratum corneum. Area apical to the arrow

shows squamous cells, suggesting the absence of keratinization.

can cope XT ystem, Aperio Technologies, Vista, A.

C A S E R E P O R T

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eratinized mucosa. Thehistologicappearance of theepithe-ium in i erent areas o t e specimen, as escri e a ove,

corresponded to the clinical description of the area shown inFigure 7.

Final Clinical Outcome

At 7 years after treatment, another full clinical examina-tion o t e area was con ucte (Figs. 13 an 14; Ta e 1).

Discussion

This case report shows that epithelial surface keratiniza-tion may not occur w en a CTG is per orme in a su -merged manner. The periodontal flap appears to haveremaine via e uring ea ing an it con erre a non-

eratinize mucosa sur ace to t e gra te tissue. T issuggests that thecellsoriginally present on the flap surfaceretaine t eir p enotype an were not suscepti e to anymorphologic change that could be induced by the underly-ing cells from the CTG.12 he only area in which post-surgical epithelial keratinization was observed was on

t e most corona area o t e gra t, w ic correspon s tot e presurgica narrow an o eratinize epit e iumincluded on the flap.

Anot er possi e exp anation or t e a sence o epit e-lial keratinization in the treated area is the fact that the flaphat initially covered the CTG presented with a compo-

nent, albeit thin, of connective tissue. Therefore, it is possi-le that the epithelialmesenchymal interaction remaine

unc ange uring an a ter ea ing, espite t e act t atpa ata connective tissue was p ace in contact wit t e in-ernal aspect of the flap connective tissue. Conserving the

original epithelialmesenchymal interaction may haveonferred a non-keratinized surface to the grafted area.

This report also presents evidence contrary to the con-ept that surgical excision of the epithelial tissue present

over the healed CTG (epithelial abrasion) may result ine ormation o a eratinize sur ace.13 T is urt er sup-

ports the notion that the connective tissue cells from thera t o not p ay a ro e in etermining t e p enotype ohe epithelial tissue on its surface. Therefore, it can be as-

sumed that the tissue that first comes in contact with theCTG, w ic in t e case o a su merge CTG is primari ynon-keratinized mucosa, confers the surface characteristicsof the epithelial surface. This is in agreement with findingsreporte y Maurer et a .,14 who showed that treatment oa ea e CTG wit gingivop asty i not resu t in eratini-zation o non- eratinize epit e ium.

Carnio et al.2 showed that the apico-coronal dimensiono eratinize tissue can e augmente y t e mo i ieapically repositioned flap (MARF), which is a surgicatechnique that involves the simple apical positioning ofa narrow an o eratinize tissue an eaving t e un er-lying connective tissue exposed, in which healing by thesecon ary intention occurs. Wit t e MARF, eratinizetissue (and attached gingiva) can be created in an area thatpreviously presented with a non-keratinized mucosal sur-

ace. T e MARF surgica tec nique essentia y creates anisland of exposed connective tissue whose perimeter iscompletely occupied by keratinized epithelium. Presum-a y, ce migration starts on t e or ers o t e wounand continues toward the center, resulting in the formationo eratinize epit e ium. T is suggests t at w at con ersa keratinized nature to the epithelium developing on theconnective tissue surface is the type of epithelial cells thatare irst present in t e area. Wit t e MARF, t ese primarycolonizing cells are known to be keratinized based on theirorigin and location. Based on the MARF wound-healing

ynamics, it cou e specu ate t at a CTG nee s to eleft exposed if keratinization were to be expected on its sur-

ace. T is t oug t wou e in agreement wit t e sugges-tions made by Edel.11 Evi ent y, t is t eory nee s to econfirmed through in vivo experiments.

A t oug ucco- ingua (tissue t ic ness) measurementso t e treate area were not ma e, it is o vious t at t erewas an increase in tissue thickness after healing of the CTG(Fig. 9). T ere ore, t e c inica resu t o serve wit surgi-cal treatment was that of a thick, bound-down tissue, witha non- eratinize sur ace. T e e ectiveness o suc new yorme tissue in t e maintenance o attac ment eve s aningival health compared to the role exerted by keratinized

tissue is not nown. It as een suggeste t at treatment o

FIGURE 13 linical view of the surgical area 7 years after the CTG.

FIGURE 14 even-year postoperative view of teeth #21 and #22 after

application of Schillers solution. Note that some extra increase in the

apico-coronal dimension of the keratinized gingiva was achieved com-

pared to Figures 2 and 7.

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mucogingiva efects wit acellular ermal matrix resultsin e ormation o issue t at c inica y15 an isto ogi-cally16 resembles bound-down, non-keratinized mucosa,similar to that reported in this case report. The long-termsta i ity an e ectiveness n e ma ntenance o gingiva

ealth provided by tissue originated by grafting with acel-u ar erma matrix as not een etermine .

Based on the interpretation of the results described in

this case report, a fully submerged CTG results in he

formation o issue wit a non-keratinize epithelialsur ace. Su sequent surgica epit e ia remova romt e gra te area an ea ing o t at woun y secon aryintention does not induce the formation of keratinizedepit e ium. T ere ore, u y su merge manot e a re ia e tec nique to increase t e apico-corona

imension of keratinize tissue. These indings nee toe con irme y a case series wit a arger num er o

cases. n

Summary

Why is this case new information? jThis case suggests that a fully submerged CTG may not present withsurface keratinization after healing.



j Surgical removal of epithelium via gingivoplasty after treatment with

a CTG may not result in formation of keratinized epithelial surface.

What are the primary limitation to


jThe long-term clinical relevance of a thick, non-keratinized mucosa in

the long-term stability of the position of the gingival margin and overallgingival health in not known.

AcknowledgmentThe authors report no conflicts of interest related to thiscase report.

CORRESPONDENCE:

Dr. Paulo M. amargo, Periodontics, School f Dentistry, University ofCalifornia, os nge es, 1 e Conte ve., HS 4 , os nge es,CA 0095. E-mail: [email protected].

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References. ennstrom J, Lindhe J, Nyman S. Role of keratinized gingiva for

ingival health. Clinical and histologic study of normal and regeneratedingival tissue in dogs. J Clin Periodontol 1981;8:311-328.

2. Carnio J, Camargo PM, Passanezi E. Increasing the apico-coronaldimension of attached gingiva using the modified apically repositionedlap technique: A case series with a 6-month follow-up. J Periodontol

2007;78:1825-1830.

3. Wennstrom JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.

4. Pini Prato GP. Mucogingival deformities.Ann Periodontol 1999;4:98-.

5. Langer B, Langer L. Subepithelial connective tissue graft technique forroot coverage. Periodontol 1985;56:715-720.

6. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Rootoverage revisited. Periodontol 2000 2001;27:97-120.

7. Cordioli G, Mortarino C, Chierico A, Grusovin MG, Majzoub Z.Comparison of 2 techniques of subepithelial connective tissue graft inthe treatment of gingival recessions. J Periodontol 2001;72:1470-1476.

8. Han JS, John V, Blanchard SB, Kowolik MJ, Eckert GJ. Changes iningival dimensions following connective tissue grafts for root cover-

age: Comparison of two procedures. J Periodontol 2008;79:1346-1354.

9. Raetzke PB. Covering localized areas of root exposure employing theenvelope technique. J Periodontol 1985;56:397-402.

10. Edel A, Faccini JM. Histologic changes following the grafting ofconnective tissue into human gingiva.Oral Surg Oral Med Oral Pathol

77; : - 5.

11. Edel A. Clinical evaluation of free connective tissue grafts used toincrease the width of keratinised gingiva. J Clin Periodontol 1974;1:185-196.

12. Ouhayoun JP, Sawaf MH, Gofflaux JC, Etienne D, Forest N. Re-epithelialization of a palatal connective tissue graft transplanted in

a non-keratinized alveolar mucosa: A histological and biochemicalstudy in humans. J Periodontal Res 1988;23:127-133.

13. Levine RA. Covering denuded maxillary root surfaces with thesubepithelial connective tissue graft. Compendium 1991;12:568-578,

70, 572 pass m.

14. Maurer S, Hayes C, Leone C. Width of keratinized tissue aftergingivoplasty of healed subepithelial connective tissue grafts. Peri-odontol 2000;71:1729-1736.

15. Allen EP. AlloDerm: An effective alternative to palatal donor tissue fortreatment of gingival recession. Dent Today2006;25: 48, 50-52; quiz 52.

16. Cummings LC, Kaldahl WB, Allen EP. Histologic evaluation ofautogenous connective tissue and acellular dermal matrix grafts inhumans.J Periodontol 2005;76:178-186.


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CASE SERIES

Titanium Particles in Peri-Implant Tissues: Surface Analysis and HistologicResponse

Andrew Tawse-Smith,* Sunyoung Ma,* Allauddin Siddiqi,* Warwick J. Duncan,* Liz Girvan, and Haizal M. Hussaini*

Introduction:The role f bacteria in he tiology of peri-implantitis has been reported in the literature. However, theinfluence of confounding factors on the disease remains unclear. The following case series discusses the presence of metal

particles in iseased peri-implant mucosa.

Case Series: Four patients with peri-implantitis underwent surgical peri-implant herapy and diode laser surface de-ontamination procedures. Peri-implant mucosa was excised under local anesthesia and samples were prepared for histol-

gy, scanning lectron microscopy (SEM), and energy dispersive spectroscopy (EDS) to valuate peri-implant tissues and

identify eposits of foreign materials. Histologic xamination demonstrated cellular fibrous connective tissue, with or ith-

ut overlying stratified squamous epithelium. An inflammatory infiltrate consisting of a mixture of acute and chronic inflam-

matory cells was bserved. Numerous deposits of ranular foreign material were scattered within the connective tissue

immediately below the epithelium. The presence of metal particles as vident in the SEM and confirmed by EDS. Thesize f titanium particles ranged from to 15mm. Additional particles, such as aluminum, phosphorous, and sulfur, were

also found in some of the samples.

Conclusions: All four cases yielded peri-implant soft-tissue specimens containing particulate black foreign material.SEM and EDS examination of histologic specimens confirmed the presence titanium particles and ther elements in the

peri-implant tissues. hether the presence of titanium particles in the surrounding tissue constitutes a biocompatibility

issue is still a uestion that needs o be learly valuated. Clin Adv Periodontics 2012;2:232-238.

Key Words: Dental implants; microscopy, electron, scanning; peri-implantitis; titanium.

Backgroundn oral implantology, complications occur because oio ogic, mec anica , atrogenic, an ina equate patient

a aptation actors.1,2 Peri-imp antitis escri es any oca -

ized, inflammatory, and/or pathologic reaction that de-ve ops in ar tissues aroun a unctioning imp ant. t is

i icu t to estimate t e requency o peri-imp antitis ecausethere is a lac of consensus for its definition and, therefore,

i erent stu ies ave reporte various inci ence/preva encerates as high as 56%.3 The role of bacteria in the etiology ofperi-imp antitis as een iscusse ;4 t e ora oun in peri-imp ant esions resem e at associate wit perio onta yaffecte teeth.5 recent stu y exp ore our interre atemec anisms n t e causat on o peri-imp antitis an sug-

este that the initiation of the peri-implant lesion may emu ti actoria .2

* ral mplantology esearch roup, ir ohn alsh esearch nstitute,

School of Dentistry, University of Otago, Dunedin, Otago, New Zealand.

tago entre for Electron Microscopy, University of tago.

Department of Oral Pathology and Oral Medicine, Faculty of Dentistry,

National University of Malaysia, Bangi, Selangor, Malaysia.

Submitted September , 2011; accepted for publication October 7,

2011

doi: 10.1902/cap.2012.110081

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T e ora cavity is a ars environment wit unique c ar-acteristics. Oral implants are exposed to onstant electro-c emica attac y acteria pro ucts.2,6,7 Imp ant sur ace

eterioration or corrosion may a ect osseointegration;8,9 in-creased microbial biofilm accumulation on implant surfacest at ecome expose tot e ora environmentmaya so resu tin adverse clinical consequences.10 eri-implant bone losscan ea to imp ant insta i ity resu ting in imp ant ai ure.1

Irrespective of the etiology of peri-implant disease, the asso-

ciated inflammation and bone resorption may be similar.2T e mu ti actoria nature o peri-imp antitis ma es its man-agement ifficult, and, consequently, several reatmentmo a ities an protoco s ave een suggeste . ne o t etreatment objectives o bacterial-induced peri-implantitisis o control infection and prevent disease progression.Mec anica e ri ement in a ition to a junctive anti-infective therapy has been recommended to reduce the bi-ofilm formation on implant surfaces.11 The application ofasers as also been suggeste as an opt on or the treat-

ment o peri-imp antitis, ecause recent s ort-term ani-ma an uman stu ies ave s own prom s ng resu ts.12

T e o owing case series escri es patients re erre or

the treatment of peri-implantitis. Peri-implant soft-tissuespecimens underwent routine histologic examination, scan-ning e ectron microscopy (SEM), an energy ispersivespectroscopy (EDS).

Clinical Presentation and CaseManagement

our patients re erre to t e Perio onto ogy C inic o eFacu ty o Dentistry, University o Otago in 2010 were iag-nosed with peri-implantitis according to the following crite-ria: 1) ee ing onpro ing (BOP);2) pat o ogic peri-imp ant

probing depth (PD); and 3) radiographic bone loss (Table 1).Written informed consent was obtained from patients priorto ommenc ng treatment. Under local anesthesia, the af-fected implants were surgically exposed and theperi-implanttissue biopsied, before implant surface decontamination.Submarginal peri-implant incisions followed by horizontalincisions at the base of the bony defect and careful intracre-vicu ar incisions a owe t e care u remova o 1 to 2 mminflamed peri-implant soft tissue. Exposed implant surfaces

were then irradiated using a diode laserx set on a continuousmo e wit power output o 2.4 to 2.8 W. A junctive 0.2%chlorhexidine gluconate in aqueous solution was appliedtopica y tot e expose imp ant sur aces or1 minute e oresutur ng.

Specimen Preparation

For the histologic evaluation, tissue samples were fixed withorma in us ng stan ar t ssue processork an para inlocked. Sections were cut using a microtome at 3 to 5 mme section, mounte stan ar g ass s i es, an staine

with hematoxylin and eosin (H&E). Descriptive light micro-scopic (LM) examination{ was comp ete an p otomicro-

grap s# were taken at 10 and 20 magnifications.Peri-implant soft-tissue specimens an histologic sli es

were then analyzed using field SEM** and EDS. A back-scatter detector was used to identifyparticles of different den-sity it in eac tissue samp e. Any meta ic partic es weret en ana yze using EDS at an acce erating vo tage o 25 V.

TABLE 1Clinical, Histologic, and SEM Case Descriptions

Clinical Findings Histologic/SEM Findings

Case

Age

(years) Sex

Clinical

Condition and

History Implant

Smoking

Status

Implant

Function

(years)

PD and

Bleeding

Status

Connective

Tissue

Inflammatory

Infiltrate

Titanium

Particles

Size

ale Partially

edentulous andprevious

periodontitis

4.

15 mm*

Smoker . o 1

mm ndBOP

Mature Sparse r f

mainly hronicinfiltrate

o mm

Female Edentulous and

previous

periodontitis

. 3

12 mm

Non-

smoker

12 to

mm nd

BOP

Mixed

mature nd

immature

Intense mixture

of acute and

chronic infiltrate

to 1 mm

ema e entu ous an

previous

periodontitis

.7

15 mm*on-

smoker

to mm

nd BOP

ature ntense mxture

of acute and

chronic infiltrate

to m

4 73 Male Edentulous and

previous

periodontitis

4.3 3

13 mmNon-

Smoker

2 5 to 7 mm

and BOP

Matur e Sparse area f

mainly chronic

infiltrate

5 to 15 mm

External Hex-Enhanced surface, Southern Implants, Irvine, CA.Steri-Oss Acid-Etched PS External Hex, Nobel Biocare, othenburg, Sweden.

TiUnite Tapered Groovy, Nobel Biocare.

x Odyssey 2.4G, 81 , voclar iva ent, mherst, .

Citadel2000, Thermo Shandon, Runcorn, heshire, UK.

50, Olympus, okyo, apan.# DM5000B/DC50, eica, etzlar, Germany.

JEOL SM-6700F, JEOL, Tokyo, Japan.

JE L 2300 D ystem, JE L.

C A S E S E R I E S

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Clinical Outcomes

All affected implant sites showed the expected reduction in

BOP and PD after treatment. Of greater interest, however,

was the LM histologic identification of metallic particulate

foreign bodies within the peri-implant inflammatory tis-

sues of all four cases. This lead to the subsequent analyses

y SEM an EDS presente ere.

LM histologic examination of specimens showed cellu-lar fibrous connective tissue, with or without overlyingstratified squamous epithelium. Numerous deposits ofdark and granular foreign materials were seen scatteredwit in t e connective tissue imme iate y e ow t e epit e-ium and along collagen fibers, around small blood vessels

an nerves, wit areas o mo erate ymp o istiocytic or-eign o y reaction (Figs. 1 an 2). Partic e sizes range

FIGURE 1 ase 1. 1a Clinical view of the

implant with circumferential bone loss. 1b

Histology (20 magnification; H&E staining)

howing area of foreign material, some in thin-

alled blood vessels, with patches of lymphohis-

tiocytic granulomas surrounding smaller particles

m e e w t n t e connect v e t s su e. 1c EM

analysis showing a 11-mm particle surrounded by

cellular and fibrous components. 1d EDS analysis

confirming the presence of titanium in the sample.

FIGURE 2 ase 2. 2a Clinical view of theimplant with saucer-shaped peri-implant bone

loss. 2b Histology ( 0 magnification; H&E

taining) showing area of foreign material scat-

tered within the connective tissue close to the

covering epithelium, including patches of acute

and chronic inflammatory infiltrate (plasma cells,

lymphocytes, and histocytes) within the surround-

ing connective tissue. 2c EM analysis showing

a 8-mm particle surrounded by cellular and fibrous

componen s. 2d EDS analysis confirming the

presence of titanium in the sample.

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rom 2 to 15 m. T e isto ogic reports escri e a ym-p o istiocytic oreign o y reaction to oreign materiawithin the biopsied soft tissue.

SEM o t e cases i enti ie t e oreignmateria asmeta -lic particles surrounded by connective tissue and bloodcells. EDS confirmed the presence of titanium in all cases;

a itiona meta ic partic es o a uminum, p osp orous,an su ur were oun in cases 3 an 4 (Figs. 3 an 4).

Discussion

Titanium particles were found embedded in the peri-implantso t tissues o our c inica cases o peri-imp antitis. Ana ysis

FIGURE 3 Case 3. 3a linical view of the

implant with advanced buccal and interimplant

one loss. 3b Histology (20 magnification; H&

staining) showing fragments of dark foreign

materials scattered within a mixture of an acute

inflammatory infiltrate and necrotic debris.3c EM

analysis showing a 11- m particle surrounded by

cellular and ibrous components. 3d EDS analysis

confirming the titanium particle and other ele-

ments, such as aluminum, sulfur, and phosphorus

in the sample.

FIGURE 4 Case 4. 4a linical view of the

implant with horizontal peri-implant bone loss.

4b Histology (20 magnification; H&E staining)

showing numerous fragments of dark foreign

materials scattered within the connective tissue

and muscle fibers. An area of lymphohistiocytic

granuloma can be observed close to a vascular

channel. 4c SEM analysis showing a 8-

particle surrounded by cellular and fibrous

components. 4d EDS analysis confirming the

presence of titanium and phosphorus in the

sample.

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References1. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors

contributing to failures of osseointegrated oral implants. (II). Etiopa-thogenesis.Eur J Oral Sci 1998;106:721-764.

2. Mouhyi J, Dohan Ehrenfest DM, Albrektsson T. The peri-implantitis:Implant surfaces, microstructure, and physicochemical aspects. ClinImplant Dent Relat Res 2012;14:170-183.

3. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implantdiseases. Clin Periodontol2008;35(Suppl. 8):286-291.

4. Mombelli A, Marxer M, Gaberthuel T, Grunder U, Lang NP. Themicrobiota of osseointegrated implants in patients with a history ofperiodontal disease. J Clin Periodontol 1995;22:124-130.

5. Mombelli A, van Oosten MA, Schurch E Jr, Land NP. The microbiotaassociated with successful or failing osseointegrated titanium implants.Oral Microbiol Immunol 1987;2:145-151.

6. Videla HA, Herrera LK. Microbiologically influenced corrosion:Looking to the future. Int Microbiol2005;8:169-180.

7. Chaturvedi TP. An overview of the corrosion aspect of dental implants(titanium and its alloys). Indian J Dent Res 2009;20:91-98.

8. Olmedo DG, Duffo G, Cabrini RL, Guglielmotti MB. Local effect oftitanium implant corrosion: An experimental study in rats. Int J OralMaxillofac Surg ; 7: - .

9. Olmedo DG, Tasat DR, Duffo G, Guglielmotti MB, Cabrini RL. The issue ofcorrosion in dental implants: A review. Acta Odontol Latinoam 009;22:3-9.

10. Teughels W, Van Assche N, Sliepen I, Quirynen M. Effect of materialcharacteristics and/or surface topography on biofilm development.ClinOral Implants Res 2006;17(Suppl. 2):68-81.

11. Gosau M, Hahnel S, Schwarz F, Gerlach T, Reichert TE, Burgers .Effect of six different peri-implantitis disinfection methods on in vivohuman oral biofilm. Clin Oral Implants Res 2010;21:866-872.

12. Schwarz F, Aoki A, Sculean A, Becker J. The impact of laser applicationon periodontal and peri-implant wound healing. Periodontol 2000

;5 :7 - .13. Flateb RS, Hl PJ, Leknes KN, Kosler J, Lie SA, Gjerdet NR. Mapping

of titanium particles in peri-implant oral mucosa by laser ablationinductively coupled plasma mass spectrometry and high-resolutionoptical darkfield microscopy. J Oral Pathol Med 2011;40:412-420.

14. Jarmar T, Palmquist A, Bra emark R, Hermansson L, Engqvist H,Thomsen P. Characterization of the surface properties of commerciallyavailable dental implants using scanning electron microscopy, focusedion beam, and high-resolution transmission electron microscopy. ClinImplant Dent Relat Res ; : - .

15. Goodman SB, Ma T, Chiu R, Ramachandran R, Smith RL. Effects oforthopaedic wear particles on osteoprogenitor cells. Biomaterials2006;

: - .


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SOFT -T ISSUE

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ENHANCED

OSSEOINTEGRATION

CRESTAL BONE

PRESERVATION

The PREVAILImplant System

Please contact us at 561.776.6700 orvisit us online at www.biomet3i.com to learn more.

The key to achieving long-term sustainable aesthetic outcome

is preservation of hard and soft tissues. The PREVAIL Implant

Systems unique features are designed for preservation.


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CASE REPORT

Treatment Alternative for Root Resorption of an Avulsed Toothn a Growing Child: A Case Report With a 4-Year Follow-Up

Lian Ping Mau,* Iok-Chao Pang, Chuen-Chyi Tseng, Yea-Huey Melody Chen,x nd David L. Cochran*

ntroduction: Dental reatment is ifficult in young patients who present with a root-resorbed permanent tooth and arestill growing. The purpose of this case report is to present a treatment option to delay implant placement until the childs growth

has slowed and the tissues are fully eveloped so that an esthetic implant restoration an be achieved.

Case Presentation:A 9-year-old female patient presented to the clinic after a traffic accident. Avulsion of her maxillaryright central incisor had occurred and the tooth was repositioned uring that mergency visit. The tooth vitality was followed

regularly. Significant root resorption of the tooth was observed 4 years after the accident. The treatment strategy was to retain

the tooth as long as possible until her growth was completed. Root canal therapy was done, and the canal was sealed with cal-

ium hydroxide, mineral trioxide aggregate, and glass ionomer cement. Unfortunately, root resorption continued. When the pa-

tient was 22 years old, thetooth wasextracted, anda standard-sized implant was placedimmediatelywith a bone graft,collagen

membrane, and connective tissue raft augmentation. A temporary restoration was inserted 5 months after implantation. The

efinitive restoration was fabricated3 months afterthe provisional. The dentistsand patient were satisfied withthe final outcome.

Conclusion:Repositioning of an avulsed tooth and conservative endodontic treatment despite root resorption preservedthe adjacent bone in a young female until her growth was complete, allowing for the placement of a standard-sized dental

implant with a natural esthetic restoration. lin Adv Periodontics2012;2:241-247.

Key Words: Bone regeneration; connective tissue; dental implantation; immediate dental implant loading; root resorption; tooth

avulsion.

BackgroundMany studies have shown that toot avulsion s relativelyinfrequent, ranging from 0.5% to 3% of traumatic injuriesin t e permanent entition.1 T e maxi ary centra ncisorsare the most frequently avulsed teeth in both permanent andprimary dentitions.1 The most frequently involved age groupis 7 to 11 years, wit ma es experiencing avu sion t ree timesmore than females.2 Root resorption of an avulsed tooth is

one of the major complications of dental trauma. Endodon-tic therapy and replantation of the tooth into the socket have

a re ative y ow ong-term prognosis ecause o root re-sorption.3 C inica y, itis i icu t to ea wit a root-resor epermanent tooth hen the pat ent s stil grow ng. hepurpose o t is case report is to present a treatment optionof delaying dental implant placement, allowing for res-toration of tissues an post-adolescent growth.

Clinical Presentation

A 9-year-ol female presented to the enta clinic at Chie Me ica enter, ainan ity, aiwan, after traffic

acci ent n August, . Avu sion o er maxi ary rig tcentral incisor was found and the tooth was repositioned

uring t e initia emergency isit. T e toot was c ini-cally an radiographically examined y a general dentist(C-CT) on a regular basis.

Case ManagementSignificant root resorption was found 4 years after the ac-cident (Fig. 1). Therefore, the patient was referred o anen o ontist (Y-HMC) or a itiona treatment. Root cana

* Department of Periodontics, University of Texas Health Science enter

at San Antonio, San Antonio, TX.

Department ofPeriodontics, hiMei Medical enter,Tainan ity, Taiwan.

Center Union Dental Clinic, Tainan City, Taiwan.

x Department of Endodontics, Chi Mei Medical Center.

Submitted uly 14, 011; ccepted for publication November 17, 2011

o : 10.1902/cap.2012.110069

linical dvances in eriodontics, ol. 2, o. 4, ovember 012 241


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t erapy was per orme , an ca cium y roxi e (Ca(OH) )was used as intracanal medication (Fig. 2). The treatmento jective was to retain t e toot unti er growt was com-plete. The root canal was sealed with Ca(OH) , mineraltrioxi e aggregate (MTA),k an g ass ionomer cement(GIC){ (Fig. 3). T e rig t maxi ary centra incisor wasrestored with composite resin (Fig. 4). Unfortunately, rootresorption continue . W en t e patient was 22 years o ,the resorbed root was beginning to affect the gingiva(Fig. 5). A ter a t oroug examination, treatment p an

exp anation, an ora in orme consent, t e toot was re-moved, and a standard-sized dental implant (sand-blastedaci -etche 4.1 2 mm # was placed immediately int e extraction soc et. A V-s ape ucca e iscence e ectwas filled with deproteinized bovine bone mineral** andcovere wit a co agen mem rane. connective tissue

raft (CTG) harvested from the hard palate in the premolarregion was sutured onto the buccal flap and positioned to

FIGURE 1 our years after replantation of a right maxillary central incisor,

root resorption was noted on a periapical radiograph (August 1998).

FIGURE 2 Root resorption continued 6 years after replantation (August2000).

FIGURE 3Root canal sealed with Ca(OH)2, MTA, and GIC (October 2000).

FIGURE 4 Tooth #8 restored with composite resin (February 2001).

DENTSPLY Friadent Ceramed, Lakewood, CO.

Fuji K, GC, Tokyo, Japan.

Standard Plus implant, Straumann, Basel, Switzerland.

Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland.

Peri-Aid, ollagen Matrix, Franklin Lakes, NJ.

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242 linical Advances in Periodontics, Vol. 2, No. 4, November 2012 Implant Treatment for Root Resorption in a rowing hil


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increase the buccal gingival contour. Closure was achieve

with 4-0 sutures

and 5-0 nylon suturesxx

(Figs. 6 through10 .

Clinical Outcomes

Woun ea ing was unevent u an t e sutures were re-moved after 2 weeks. The implant was allowed to fully in-tegrate or 5 mont s. At t at time, a surgica a e (#15C)was used to remove soft tissue on the top of the implant toaccess the healing abutment. A preformed provisionaa utment was t en s ape an itte t roug t e gingivainto the top of the implant. A provisional restoration wasthen cemented on the provisional abutment to encourage

so t-tissue contouring (Fig. 11). T e so t-tissue contour ap-peared stable after 3 months (Fig. 12). Customized abutmentsand the definitive implant single crown were fabricated 3mont s a ter t e provisiona restoration (Fig. 13). T e c inicaresu ts o t e imp ant restoration a ter 4 years o o ow-upwas acceptable to the restoring dentist (I-CP) and patient. Im-portantly, the hard and soft tissues around the implant re-mained stable (Fig. 14).

FIGURE 5 The gingival contour around tooth #8 is affected, and the

periapical radiograph shows severe root resorption (January 2007).

FIGURE 6 Full-thickness flap elevation revealed a buccal dehiscence on

tooth #8.

FIGURE 7 IIP resulted in a buccal dehiscence bony defect.

FIGURE 8 A guided bone regeneration procedure was performed using

deproteinized bovine bone and a collagen membrane.

FIGURE 9 A CTG was sutured onto the buccal flap and positioned to

increase the buccal gingival contour.

FIGURE 10Primary wound closure was performed. Postoperative periapical

radiograph shows the implant location.

4-0 CV-5, Gore-Tex, W. L. Gore & Associates, Newark, DE.

Ethicon, Moore Medical, Farmington, T.

C A S E R E P O R T

au, Pang, Tseng, Chen, Cochran linical Advances in Periodontics, Vol. 2, No. 4, November 2012 243


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Discussion

Root resorption is one of the major complications of dentaltrauma. En o ontic t erapy an c emica con itioning othe root surface after an extended extraoral period has the po-tential to delay the resorptive processes of a replanted tooth.4

However, extraction is t e usua ina resu to root resorption.The treatment options when a tooth has root resorption

in a partia y e entu ous area inc u e: 1) imp ant, 2) ixe

partia enture (FPD), 3) remova e partia enture (RPD),or 4) do not replace the tooth. Longitudinal reports indi-

ate that prosthesis failure is more common and occursmore frequently with RPDs than with FPDs.5 Avivi-Arberan Zar 6 note t at ixe prost eses are associate witthe sacrifice of sound tooth tissue and inherent risks of pulpinjury. The most frequently reported complications inFPD a utment teet are caries (18%) an nee or en -odontic treatment (11%).7 A meta-analysis concerning im-

p ants in partia e entu ism an sing e-toot rep acementindicated survival rates of 93.6% and 97.5% after 6 to7 years, respectively.8 Lindquist and Karlsson9 indicateda mean success rate of traditionalFPDs at 8, 14, and 20 yearsas being 97%, 83%, and 65%, respectively.9 Imp ants o erconsiderable promise for reducing the disadvantages associ-ated with traditional prosthodontic techniques.6 As such,t ey provi e a means o support or enta prost eses wit -out re ying on t e remaining teet . Potentia a utment teetare not traumatized and endodontic intervention is unlikely.

Implant therapy was not considered in this case when theroot resorption was first detected, because the growth pro-cess was not comp ete. Cronin an Oester e10 reporte on

a single-tooth implant prosthesis performed after the trau-matic avu se maxi ary centra incisor in an 11-year-o

oy.10 W en t e oy reac e 16 years o age, an increaseingival incisal length of the implant prosthesis and irreg-

u arity o t e gingiva contour were note . Remo e ing as-sociated with skeletal growth in the region of the implantp acement site cou cause t e imp ant to eit er ecomeunsupporte y one or su merge wit in it.10 Implantsplaced after age 15 years in girls and 18 years in boys havet e most pre icta e prognosis.11

Ochoa and Nanda12 ompared the maxillary and man-i u ar growt in atera cep a ometric ra iograp s o 15

FIGURE 11 A provisional restoration was fabricated after 5 months. 11a

Five-month healing after implant placement. 11b oft tissue was removed

to access the top of the implant. 11c A preformed provisional abutment

was shaped and fit through the gingiva. 11d Provisional restoration was

then cemented on the provisional abutment.

FIGURE 12The gingival contour after 3 months of provisional restoration.

FIGURE 13 Definitive implant single-crown restoration.

FIGURE 14 linical 4-year follow-up and periapical radiograph of implant

tooth #8.

C A S E R E P O R T

244 linical Advances in Periodontics, Vol. 2, No. 4, November 2012 Implant Treatment for Root Resorption in a rowing hil


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females and 13 males. The SNA angle did not change signif-icant y wit age, ut t e SNB ang e increase signi icant y inthe males. The ANB angle decreased continuously until age14. The palatal plane descended significantly from the hor-izonta p ane. T e anterior an posterior nasa spines moveat approximately the same rate. The mandible grew inengt twice asmuc ast e maxi a rom ages6 to 20 years.

With growth, the facial profiles of the males became

straighter as the chin became more prominent. The femalesa ess incrementa growt an uration o growt o t e

mandible, so that the profiles remained more convex. Over-all, skeletal and chronologic ages did not differ significantly,except at ages 10 an 16 years in t e ema es.

Foley and Mamandras13 reporte ont e acia growt infemales 14 to 20 years of age. Overall mandibular growthas measure rom t e con y ion to t e gnat ion was ap-proximately twice that of the overall maxillary growthas measured from the condylion to the A point. The man-

i u argrowt ratewas oun to e twice asgreat rom 14to 16 years as from 16 to 20 years. Ligthelm-Bakker et al.14

reporte a negative corre ation etween t e averagegrowth rate of the upper and lower anterior facial heightin boys. Boys with a relatively large facial height exhibiteda ig er t an average growt rate o t e ower anteriorfacial height compared to the upper facial height. In girls,a simi ar tren was present. T e in ivi ua average growtrateo t e anterior upper an ower acia eig t maintainsor accentuates the early established facial form.

Rep acement o an avu se toot into a soc et in youngadolescents can preserve the alveolar ridge and gingivalcontour.15 Imp ant p acement as a treatment option is

contrain icate ecause su stantia growt wi occur. A -ter growth has predominantly occurred, however, dentalimp ants can provi e support an unction or missingteeth attributable to root resorption with excellent estheticresults and without preparation of adjacent natural teeth.16

In this case report, a one-staged immediate implant wasp ace . T e a vantages o imme iate imp ant p acement(IIP) are three-fold: 1) treatment time is significantly re-

duced; 2) ridge contour can be preserved; and 3) it is pos-sible to place the implant in a more ideal axial position,thus enhancing fabrication, esthetics, and biomechanicsof the subsequent restoration.17 Peri-implant hard and softtissue have been reported to remain stable after IIP whena toot wit a resor e root is remove .18 T e V-s apebuccal osseous defect found in this case has the minimaamount o gingiva recession compare to U- an UU-shaped type defects.19 Facial gingival recession of a thinperiodontal biotype has also been shown to be more pro-nounce t an t at o a t ic iotype.19 Because t is patientalso hadthin tissues, a techniquecombining a CTG with IIPwas use to ac ieve a more sta e peri-imp ant tissue.20

Furthermore, a review article concluded that there wasno signi icant i erence in t e success an surviva rates

etween imme iate an ear y imp ant p acement.21 T us,the IPP technique was chosen in this case report. Implantrestoration s ou not e per orme , owever, e ore com-pletion of most of the growth process in the adolescent pa-tient. This 4-year follow-up case report demonstrates thatan imp ant restoration o a maxi ary centra incisor re-moved as a result of root resorption caused by earliertrauma can e success u . n

C A S E R E P O R T



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Summary

Why is this case new information? j Treatment alternative for root resorption of an avulsed tooth in

a growing child



j Keep the avulsed tooth in position to maintain the alveolar bone aslong as possible while the patient was still growing

j

Timing for IIPjContour augmentation with bovine bone mineral, collagen membrane,

and CTG



j Length of time before the avulsed tooth is replacedj Malposition of the implantj Not augmenting soft tissues

AcknowledgmentThe authors report no onflicts of interest related o hiscase report.

ORRESPONDENCE:

Dr. Chuen-Chyi Tseng, Center Union Dental Clinic, 376 Gongyuan . Rd.,North District, ainan City, aiwan. E-mail: [email protected].

C A S E R E P O R T

246 linical vances in erio ontics, ol. , o. , ovember 1 Implant reatment or oot esorption in rowing hil


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References1. Andreasen JO, Andreasen FM. Avulsions. In: Andreasen JO, Andrea-

sen FM, Andresson L, eds. Textbook and Color Atlas of TraumaticInjuries of the Teeth, 4th ed. Copenhagen, Denmark: BlackwellMunksgaard; 2007:444.

2. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radio-graphic and clinical study of 110 human teeth replanted after accidentalloss.Acta Odontol Scand 1966;24:263-286.

3. Mentag PJ, Kosinski TF, Sowinski LL. Dental implant reconstructionafter endodontic failure: Report of case. Am Dent Assoc 1990;121:

241-244.4. American Association of Endodontists. Endodontic Considerations

in the Management of Traumatic Dental Injuries. Available at: http://www.aae.org/uploadedFiles/Publications_and_Research/Endodontics_Colleagues_for_Excellence_Newsletter/spring06ecfe.pdf. Accessed Sep-tember 6, 2011.

5. Priest GF. Failure rates of restorations for single-tooth replacement.IntJ Prosthodont 1996;9:38-45.

6. Avivi-Arber L, Zarb GA. Clinical effectiveness of implant-supportedsingle-tooth replacement: The Toronto Study. Int J Oral MaxillofacImplants 996;11:311-321.

7. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical compli-cations in fixed prosthodontics. J Prosthet Dent 2003;90:31-41.

8. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis of implants inpartial edentulism. Clin Oral Implants Res 1998;9:80-90.

9. Lindquist E, Karlsson S. Success rate and failures for fixed partial

dentures after 20 years of service: Part I. Int J Prosthodont 1998;11:133-138.

10. Cronin RJ Jr., Oesterle LJ. Implant use in growing patients. Treatmentplanning concerns. Dent Clin North Am 1998;42:1-34.

11. Cronin RJ Jr., Oesterle LJ, Ranly DM. Mandibular implants and thegrowing patient. Int J Oral Maxillofac Implants ; :55- .

12. Ochoa BK, Nanda RS. Comparison of maxillary and mandibulargrowth.Am J Orthod Dentofacial Orthop ; 5: - 5 .

13. Foley TF, Mamandras AH. Facial growth in females 14 to 20 years ofage.Am J Orthod Dentofacial Orthop 1992;101:248-254.

14. Ligthelm-Bakker AS, Wattel E, Uljee IH, Prahl-Andersen B. Verticalgrowth of the anterior face: A new approach. Am J Orthod DentofacialOrthop ; :5 -5 .

15. Shulman LB, Schnitman PA. Bone maintenance: Implant versus trans-

plant. Biomater Med Devices Artif Organs 979;7:333-338.

16. Zand C. Dental implant in resorbed root.J Oral Implantol 1993;19:152-156.

17. Novaes AB Jr., Novaes AB. Immediate implants placed into infectedsites: A clinical report. Int J Oral Maxillofac Implants 1995;10:609-613.

18. Kan JY, Rungcharassaeng K. Immediate placement and provisionaliza-tion of maxillary anterior single implants: A surgical and prosthodonticrationale.Pract Periodontics Aesthet Dent2000;12:817-824, quiz 826.

19. Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. Effects of the facialosseous defect morphology on gingival dynamics after immediate toothreplacement and guided bone regeneration: 1-year results. OralMaxillofac Surg2007;65(7, Suppl. 1):13-19.

. Kan JY, Rungcharassaeng K, Lozada JL. Bilaminar subepithelialconnective tissue grafts for immediate implant placement and provi-sionalization in the esthetic zone. J Calif Dent Assoc 5; : 5- 7 .

21. Chen ST, Wilson TG Jr., Hammerle CH. Immediate or early placementof implants following tooth extraction: Review of biologic basis,clinical procedures, and outcomes. Int J Oral Maxillofac Implants2004;19(Suppl.):12-25.


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CASE REPORT

Management of Retrograde Peri-Implantitis y Apical Resection and GuidedBone Regeneration n Adjacent Maxillary Implants

Tamika N. Thompson-Sloan,* Shilpa Kolhatkar,* nd Monish Bhola*

Introduction: Retrograde peri-implantitis (RPI) is defined as a linically symptomatic periapical lesion hat developsshortly after implant insertion hile the oronal portion of the implant sustains a normal bone-to-implant interface. The eti-

logy f RPI is unclear and may be attributed to several auses. Regardless of etiology, the management f RPI has been

attempted by either resective r regenerative techniques.Case Presentation:A 61-year-old male was screened and evaluated for three maxillary anterior implants placed 10

ears previously. Evaluation included a thorough periodontal and dental exam, radiographs, and cone-beam computed to-

mography. robing depths around all implants ranged from to 4 mm with no bleeding n probing/mobility. The apices f

implants #8 and #9 exhibited radiolucencies, and a draining fistula was associated with implant #8. Treatment onsisted of

sectioning and removal of the affected portion of the implants and collection of a specimen for histopathologic examination.

Demineralized bone matrix putty was placed in the residual bony efects and covered ith a collagen barrier. At 1 year, ra-

iographs revealed both lesions around implants 8 and 9 appeared o be resolving. The lesion associated with implant

9 had a more remarkable radiographic change, because it was smaller than the lesion around implant 8. Both implants

ontinued to unction with no recurrence f fistula formation. Histopathologic analysis was onsistent with the iagnosis

f a periapical ranuloma.

Conclusion: Resection f the apical portion f implants is a viable treatment modality in he management of RPI.Clin Adv Periodontics 2012;2:250-255.

Key Words: Bone regeneration; ental implants; infection; peri-implantitis.

Backgroundn entity separate rom peri-imp antitis was reporte in

the literature irst by McAllister et al.1 as retrograde peri-imp antitis (RPI). It is e ine as a c inica y symptomaticperiapica esion t at eve ops wit in t e irst ew mont safter implant insertion while the coronal portion of theimp ant sustains a norma one to imp ant inter ace.1 T e

* Department of Periodontology and Dental Hygiene, University of Detroit

Mercy, Detroit, MI.

Submitted November 29, 011; ccepted for publication anuary 4,

2012

doi: 10.1902/cap.2012.110106

250 l in ic al van ce s i n e ri o o nt ic s, o l. , o . , o ve mber 1


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incidence of RPI based on a handful of studies ranges from


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additional regenerative materials has also been docu-mente .8-10,14 Reports in t e iterature on t e managementof these lesions by antibiotics alone have had poor

outcomes.9,14

The other surgical option, which also focuses on retentionof the implant, is resection.4,10,14,15 Resective techniques fol-ow a similar protocol, with the primary difference being

the resection of the infected apical portion of the implant.Balshiet al.4 treated 39 cases with resective therapyand used

ovine bone to graft the defects. A collagen membrane wasp ace over t e arger e ects. T e o ow-up time average4.5 years, with 15 years being the longest follow-up. All

ut one of the 39 implants treated with this techniquewas successfully retained. The protocol of Dahlin et al.15 af-ter resection consisted of irrigation with saline and postop-erative systemic anti iotics. T e 3-year o ow-up o t e two

cases, with two implants total, revealed complete bone fillinto the resected area. The bone levels around the implantswere sta e, an t e patients remaine asymptomatic.

In our case report, after assimilating all diagnostic infor-mation, t e o owing treatment options were iscussewith the patient: 1) implant resection and GBR; 2) implantsurface decontamination and GBR; and 3) removal of im-p ants, GBR, an p acement o new imp ants in 6 mont s.Our clinical approach was similar to the above reports.4,15

A u - t ic n ess ucca an pa ata ap was e evate e-cause of the extensive nature of the lesion. Similar to theprotoco o Ba s i et a .,4 e size o t e ucca enestration

FIGURE 7Postoperative radiograph taken immediately after completion of

resection and placement of bone graft.

FIGURE 8 stopat o o g c ana ys s us ng ematoxy n an eos n stan

revealed predominately fibrovascular connective tissue and granulation

tissue. A dense infiltrate of both acute and chronic inflammatory cells was

seen embedded in the soft tissue. Vital lamellar bone and extravasated

erythrocytes were located at the periphery of the histologic specimen,

which was consistent with the diagnosis of a periapical granuloma. Original

magnification .

FIGURE 9 One-year postoperative periapical demonstrating increased

radiodensity and maturation of bone.

C A S E R E P O R T

Thompson-Sloan, Kolhatkar, Bhola linical Advances in Periodontics, Vol. 2, No. 4, November 2012 253


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a to e increase o provide access to the apical esion.A t oug on y two t ir s o t e imp ants t rea s were cov-ered with bone, both implants were immobile.The decisionto surgically access the implant apices and use resectivetec niques was ase primari y t e act t at comp etedebridement of the infected implant portions would be im-possi e given t e extent o e esions.

A combination of resective treatment, antibiotic decon-

tamination of the surgical sites, and regenerative therapy is

a viable treatment modality for the management of RPI.is o owe or 1 ear, an ot esions n

e areas o imp ants # an appeare o e reso vingwith no clinical symptoms. The lesion of implant #9 had

r remar a e ra iograp ic ange compare to t esize an extent o t e esion on imp ant #8. An a itionaregenerative procedure may be indicated at this site in theuture. Bot imp ants continue to unction wit no recur-

rence of fistula formation. n

Summary

Why is this case new information? jWe highlight the fact that a combination of resective and regenerativetherapy is a viable treatment modality for RPI cases that range in small

to large areas of bone destruction. This combination of treatment can

help salvage implants afflicted with RPI in the anterior areas of the

mouth without compromising the coronal peri-implant esthetics.



jWe achieved a favorable outcome in this case report because we were

able to remove the affected apical portion of the implant and accessand remove the surrounding pathology. The residual defects in bone

were augmented with a bone graft.



j For implant #8, the bucco-palatal extent of osseous destruction was

significant, with perforation of the palatal cortical plate. The lesion

completely enveloped the apical portion of the implant and extended

approximately half the length of the implant on the palatal aspect.

Implant #9 showed less osseous destruction in the form of a smaller

palatal and apical lesion.j At the 12-month postoperative visit, radiographically, the apex of

implant #8 appeared less radiodense compared to implant #9.

This was attributed to the size and extent of the lesion around implant

#8 along with the bicortical perforation.

AcknowledgmentsThe authors acknowledge Mr. Eric Jacobs, Media Special-ist, School of Dentistry, University of Detroit Mercy, e-tro t, Michigan, or his ass stance ith videotaping anphotography in this case report. rs. Thompson-Sloanan Ko at ar report no con ict o interest re ate to t iscase report. Dr. Bhola is a consultant for Keystone Dental,Burlington, Massachusetts, and Zimmer Dental, Carlsbad,Ca i ornia.

ORRESPONDENCE:

Dr.TamikaN. Thompson-Sloan, 2700 MartinLuther King Jr.Blvd., Detroit,MI 48208. E-mail: [email protected].

C A S E R E P O R T

254 linical vances in erio ontics, ol. , o. , ovember 1 anagement o etrogra e eri-Implantitis via esectio


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References1. McAllister BS, Masters D, Meffert RM. Treatment of implants

demonstrating periapical radiolucencies. Pract Periodontics AesthetDent 1992;4:37-41.

2. Reiser GM, Nevins M. The implant periapical lesion: Etiology, pre-vention, and treatment. Compend Contin Educ Dent 995;16: 768,770, 772 passim.

. Quirynen M, Vogels R, Alsaadi G, Naert I, Jacobs R, van SteenbergheD. Predisposing conditions for retrograde peri-implantitis, and treat-ment suggestions. Clin Oral Implants Res 2005;16:599-608.

. Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective evaluation ofa treatment protocol for dental implant periapical lesions: Long-termresults of 39 implant apicoectomies. Int J Oral Maxillofac Implants2007;22:267-272.

5. Piattelli A, Scarano A, Piattelli M, Podda G. Implant periapical lesions:Clinical, histologic, and histochemical aspects. A case report. Int JPeriodontics Restorative Dent 1998;18:181-187.

6. Scarano A, Di Domizio P, Petrone G, Iezzi G, Piattelli A. Implantperiapical lesion: A clinical and histologic case report. J Oral Implantol2000;26:109-113.

7. Chan HL, Wang HL, Bashutski JD, Edwards PC, Fu JH, Oh TJ.Retrograde peri-implantitis: A case report introducing an approach toits management. J Periodontol 2011;82:1080-1088.

8. Bretz WA, Matuck AN, de Oliveira G, Moretti AJ, Bretz WA.Treatment of retrograde peri-implantitis: Clinical report. Implant Dent1997;6:287-290.

9. Brisman DL, Brisman AS, Moses MS. Implant failures associated withasymptomatic endodontically treated teeth. J Am Dent Assoc 2001;132:191-195.

10. Jalbout ZN, Tarnow DP. The implant periapical lesion: Four casereports and review of the literature. Pract Proced Aesthet Dent 001;13:107-112, quiz 114.

11. Ataullah K, Chee LF, Peng LL, Lung HH. Management of retrograde peri-implantitis: A clinical case report. J Oral Implantol 2006;32:308-312.

12. Tozu m TF, Sencimen M, Ortakoglu K, Ozdemir A, Aydin OC, Keles M.Diagnosis and treatment of a large periapical implant lesion associated

with adjacent natural tooth: A case report. Oral Surg Oral Med OralPathol Oral Radiol Endod 2006;101:e132-e138.

13. Penarrocha-Diago M, Boronat-Lopez A, Garca-Mira B. Inflammatoryimplant periapical lesion: Etiology, diagnosis, and treatment d Pre-sentation of 7 cases. J Oral Maxillofac Surg ; 7: - 7 .

14. Shaffer MD, Juruaz DA, Haggerty PC. The effect of periradicularendodontic pathosis on the apical region of adjacent implants. OralSurg Oral Med Oral Pathol Oral Radiol Endod 1998;86:578-581.

15. Dahlin C, Nikfarid H, Alsen B, Kashani H. Apical peri-implantitis:Possible predisposing factors, case reports, and surgical treatmentsuggestions.Clin Implant Dent Relat Res 2009;11:222-227.

16. Ayangco L, Sheridan PJ. Development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic andapicoectomy procedures: A series of reports. Int J Oral MaxillofacImplan

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