The Journal of Implant & Advanced Clinical Dentistry ... Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 2 February 2014 Immediate Placement of Short Dental Implants

The Journal of Implant & Advanced Clinical Dentistry

Volume 6, No. 2 February 2014

Immediate Placement of Short Dental Implants

Dental Implant Mishaps and Failures

Built-in platform shiftingDual-function prosthetic connection

Bone-condensing property

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Built-in platform shiftingDual-function prosthetic connection

Bone-condensing property

Adjustable implant orientation for optimal final placement

High initial stability, even in compromised

bone situations

NobelActive™

A new direction for implants.

Nobel Biocare USA, LLC. 22715 Savi Ranch Parkway, Yorba Linda, CA 92887; Phone 714 282 4800; Toll free 800 993 8100; Tech. services 888 725 7100; Fax 714 282 9023Nobel Biocare Canada, Inc. 9133 Leslie Street, Unit 100, Richmond Hill, ON L4B 4N1; Phone 905 762 3500; Toll free 800 939 9394; Fax 800 900 4243Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare.

NobelActive equally satisfies surgical and restorative clinical goals. NobelActive thread design progressively condenses bone with each turn during insertion, which is designed to enhance initial stability. The sharp apex and cutting blades allow surgical clinicians to adjust implant orientation for optimal positioning of the prosthetic

connection. Restorative clinicians benefit by a versatile and secure internal conical prosthetic connec-tion with built-in platform shifting upon which they can produce excellent esthetic results. Based on customer feedback and market demands for NobelActive, theproduct assortment has been expanded – dental professionals will

now enjoy even greater flexi bility in prosthetic and implant selection. Nobel Biocare is the world leader in innovative evidence-based dental solutions. For more information, con-tact a Nobel Biocare Representative at 800 322 5001 or visit our website.

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 2 • February 2014

Table of Contents

11 The Use of a 6.5 mm Diameter Implant to Accomplish Successful Immediate Placement of Dental Implants: A Case Series Report Paul S. Rosen, Fredrik Engman, Neil Meredith, Adam D. Rosen

23 Pouch and Tunnel Technique for Augmentation of Gingival Recession: A Case Series Dr. Tarun Kumar, Dr. Triveni, Dr. V. Priyadharshini, Dr. Vinita Jain, Dr. DS Mehta


The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 2 • Febriary 2014

Table of Contents

35 Common Dental Implant Mishaps and Failures Dr. Shady A. M. Negm, Dr. Ahmed S. M. El-Mallah, Dr. Ahmed H. Ayoub

43 DenTack QUAD Dental Implant: A Preliminary Evaluation of a Novel Dental Implant and a 3 Year Follow-up Report (2010-2013) Dr. Nachum Samet

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The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 2 • February 2014

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platform switchingDesigned to increase soft tissue volume around the implant connection

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

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

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

Editorial Advisory Board

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

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS


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

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platform switchingDesigned to increase soft tissue volume around the implant connection

optimized threadformButtress thread for primary stability and maximum bone compression

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

Co-Editor in ChiefNick Huang, MD

Rosen et al

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Rosen et al

The similarity in success rate between implants placed immediately following tooth removal versus those placed after

a period of bone healing has been well docu-mented. It is not unreasonable to expect a suc-cess rate in the range of 95% or better for either approach. Whether an immediate or a delayed approach is selected, the inevitable success relies heavily on achieving primary stability at the time of implant placement which can be measured by insertion torque and/or resonance frequency analysis. Recently, an implant com-

pany has embarked on introducing a 6.5 mm diameter implant to facilitate immediate implant placement at wider extraction sites where more conventional sizes are less appropriate. This company’s surface has demonstrated that it is highly osteoconductive such that RFA values at early time points tend to remain stable or increase “bumped” up rather than show a dip due to temporary loss of primary stability. This case series reports on the initial experiences using a 6.5 mm wide implant to achieve suc-cessful outcomes for wider extraction sockets.

The Use of a 6.5 mm Diameter Implant to Accomplish Successful Immediate Placement

of Dental Implants: A Case Series Report

Paul S. Rosen, DMD, MS1 • Fredrik Engman, PhD2 Neil Meredith BDS, MSc, PhD3 • Adam D. Rosen4

1. Clinical Associate Professor of Periodontics, University of Maryland Dental School Baltimore, Maryland Private Practice: Yardley, Pennsylvania USA

2. NEOSS Co-Founder, Engineer

3. Acting Head of School, The University of Queensland School of Dentistry, Brisbane Australia

4. Dental Assistant, Private Practice Yardley, Pennsylvania USA

Abstract

KEY WORDS: Dental implants, short dental implant, stability


12 • Vol. 6, No. 2 • February 2014

Rosen et al

InTRODucTIOnThe similarity in success rate between implants placed immediately following tooth removal ver-sus those placed after a period of bone healing has been well documented.1,2 It is not unreason-able to expect a success rate in the range of 95% or better for either approach.3,4 Whether an immediate or a delayed approach is selected, the inevitable success relies heavily on achiev-ing primary stability at the time of implant place-ment which can be measured by insertion torque and/or resonance frequency analysis. The mac-rogeometry of the implant can certainly play a significant role in stability i.e. tapered ver-sus straight or selecting a greater diameter to engage more of the boney walls of the socket. Moreover, the advantage of a larger implant diameter for immediate placement could be the reduced need for more apical site prepara-tion which could introduce morbidities such as penetration into the maxillary sinus or encroach-ment on a nerve. Clearly patient acceptance from reducing the number of surgeries and treat-ment time is another advantage to this option.5

Another advantage of immediate implant placement is reliance on stabilizing the implant in host bone versus regenerated sites where there can be wide variation as to the amount of viable bone produced.6-8 Moreover, if the socket can have all attendant infection removed, the sourc-ing of progenitor cells from the surrounding blood supply and endosteal spaces may be enhanced.

Most recently, an implant company has embarked on introducing a 6.5 mm diameter implant to facilitate immediate implant placement at wider extraction sites where more conventional sizes are less appropriate. This company’s surface has demonstrated that it is highly osteoconductive

such that RFA values at early time points tend to remain stable or increase “bumped” up rather than show a dip due to temporary loss of primary sta-bility.9 This case series reports on the initial expe-riences using a 6.5 mm wide implant to achieve successful outcomes for wider extraction sockets.

MATERIAl AnD METhODS This reports the initial treatment of 10 patients who received 6.5 mm wide implants placed at the time of extraction of maxillary or mandibular premolars or molars. Extracted teeth were given a hopeless prognosis due to advanced caries, failed endodontics, horizontal/vertical fracture or advanced periodontitis. Local or block anesthesia were performed with articaine 4% with 1:100,000 epinephrine or articaine 4% with 1:200,000 epi-nephrine or carbocaine 2% with 1:20,000 levo-nordephrine or carbocaine 3%. Teeth were atraumatically extracted using a flapless approach. Sockets were mechanically debrided of any resid-ual granulomatous/granulation tissue and the walls of the socket were determined to be intact as assessed with a periodontal probe. Further decontamination was performed by irrigating the socket with povidone iodine solution for approxi-mately one minute followed by rinsing with sterile water. Implant site preparation followed accepted manufacturer’s protocol (Neoss, Harrogate, Eng-land) with progressive widening of the site where the final drill was 5.9 mm wide in diameter. All implants placed were either 9 or 11 millimeters in length. Patients were not included in this reported if bone quality was type 4, if insertion torque was less than 30 N/cm2, if RFA value failed to achieve a value of better than 60 or if the abut-ment could not be placed to allow for its trans-gingival exposure during the entire postoperative


Rosen et al

healing period. Following the placement of these electrowetted surface dental implants, resonance frequency analysis (RFA) (Osstell, Sweden) was recorded in two directions, buccal-lingual/palatal and mesial-distal with the lowest value recorded.

Postoperative management included the use of amoxicillin 875 mg twice daily for 7 days or 500 mg three times per day for seven days along with the use of either an essential oil, a botanical mouthrinse (PeriZone, Izun, Jerusa-lem, Israel) or 0.12% chlorhexidine gluconate mouthrinse. The chlorhexidine rinse was the only one strictlyapplied topically applied twice daily for at least the first 28 days. The others were used as both a rinse and a topical agent. If the patient was allergic to amoxicillin, then either clindamycin 150 mg taken four times daily for seven days or azithromycin 500 mg taken on the first day followed by 250 mg per day for the next four days was substituted. Pain manage-ment, consisted of ibuprofen 600-800 mg taken up to four times per day or acetaminophen with codeine # 3 taken every four-six hours if non-ste-roidal anti-inflammatory agents could not be used.

The first post-operative visit, where suture removal was performed if needed, occurred at 1-3 weeks post-implant placement and RFA was recorded again in two directions with the lowest value recorded. Lightly adherent plaque was removed by topical application of a 0.12% chlorhexidine mouth rinse. Subsequent post-operative visits were scheduled at 4-6 weeks when RFA was again repeated. If the values increased, remained stable or demonstrated less than a dip of 4 implant stability quotient (ISQ) units, the patient was sent to his/her restorative dentist for impressioning for the final restora-tion. Patients were seen within two months of

the final restoration to obtain a baseline radio-graph if none had been exposed, confirm crown fit, assure the absence of residual cement and to check occlusion. Subsequent follow-up was scheduled again at six months post-placement.

RESulTSThe patients in this case series consisted of 6 males and 4 females whose average age was 63.4 years (range 53-73). Table 1 summarizes the patient information. Generally this group of patients was in good health. There was one patient who was a smoker, one who was a well-controlled Type 2 diabetic based on hemoglobin A1c values and one patient who had a history of osteoporosis based on T-scan value. Two patients reported a history of penicillin allergy. Table 2 summarizes the specific site information. Implants were generally placed into Type 2 bone with one patient having Type 1 and another hav-ing Type 3. The extraction sockets were intact and the gap between the implants and socket walls was generally 1-2 mm. In one instance, the implant was immediately provisionalized but left out of function. Initial resonance frequency values (RFA) demonstrated high stability with the average buccal-lingual/palatal value being 76.7± 6.0 and the mesial-distal value being 77.8 ± 3.0. Readings taken at 1.5-3 weeks remained fairly consistent with those taken at time of initial placement. Buccal-lingual/palatal value slightly increased to 77.8 ± 5.2 and mesial-distal slightly increased to 78.6 ± 2.8. Second readings taken just prior to restoration (4-6 Weeks) continued this trend demonstrating values of 78.0 ± 6.9 and 79.3 ± 4.1 in the buccal-lingual/palatal and mesial-distal directions respectively. The implants have all been both restored and in function for

14 • Vol. 6, No. 2 • February 2014

Rosen et al

better than 6 months. The predominant design of the final crowns was a screw-retained res-toration in 8 of the 10 instances. Figures 1a-h and 2a-g demonstrate representative cases.

DIScuSSIOnThe current preliminary case series reports

suggests that this wide diameter implant can be effectively placed into larger extraction sock-ets. While the short term results displayed no complications, it remains to be seen whether this will carry forward into the future as any technique can have either immediate, early or delayed complications associated with it.10

The advantage of this wider diameter implant is its ability to be places at the time of extrac-

tion which may facilitate bone preservation11 and optimize implant positioning.1,12 Moreover, since there was little difference between socket width and implant diameter, graft materials were used in half of the patients to facilitate clot stabiliza-tion and osteoconduction. Utilizing graft materi-als to fill the gap between the socket and implant has been somewhat controversial as outstand-ing success has been seen both with and with-out their use.4,13,14 It could be argued that with so limited a space as the current case series demonstrated, there was no need to use a graft as a roughened surface implant with an elec-trowetted surface would stabilize the clot quite well. However, it is the comfort level of the clini-cian that will determine where such therapy may

Table 1: Summary of Patient Information

Penicillin Patient Gender Age Smoker Diabetes Osteoporosis Allergy

1 M 58 No No No No

2 M 73 No No No No

3 F 58 No No No No

4 M 68 No No No No

5 M 56 No No No Yes

6 M 71 No Type 2 No No

7 F 72 No No Yes No

8 F 60 Yes No No Yes

9 F 65 No No No No

10 M 53 No No No No

Averages 63.4


Rosen et al

be best implemented. Moreover, in sites where the labial plate may be thinner, it has been this clinician’s experience that bone width pres-ervation may be enhanced by using a graft.

The use of resonance frequency analysis has been quite helpful in clinical decision mak-ing with implant care. While insertion torque is an important piece of initial information,15 its subsequent use to give quantitative evidence is impossible. Moreover, the use of reverse torque in deciding to proceed has little relation to occlu-sal force and can be quite destructive to an implant if it is not completely osseointegrated. The information from this case series suggests that this 6.5 mm diameter implant had a high level of initial stability in both the buccal-lingual/

palatal and mesial-distal directions and remained stable throughout the entire healing period. This was in most probability related to engage-ment of the extraction socket/osteotomy’s lat-eral walls as the implants macrogeometry was straight wall in design. That a slight increase i.e. “bump” was seen at 1.5-3 weeks, quite prob-ably related to this same proximity of the implant to the socket walls combined with the highly osteoconductive nature of the implant surface.9

Bone levels of the implant remained stable at the flange area and this may have been related to the switched platform of this fixture and the lack of countersinking performed for implant place-ment. Preserving crestal bone is quite important for handling occlusal forces and may also have

Table 2: Summary of Implant Data

Implant Bone Gap Insertion ISQ ISQ ISQ Patient Length Type Width (mm) Torque (Placement) (1.5-3 weeks) (4-6 weeks)

1 9 2 2 30 64/76 67/79 62/76

2 11 2 0 32 75/78 77/77 80/80

3 11 2 2 32 82/81 82/82 84/84

4 11 2 1 32 75/75 75/74 77/75

5 9 2 2 32 80/80 80/83 82/84

6 9 2 1 32 84/83 83/80 83/83

7 9 3 1 32 78/74 79/78 80/79

8 9 1 1 32 82/80 83/78 80/78

9 9 2 2 32 71/75 72/75 70/72

10 11 2 1 32 76/76 80/80 82/82

Averages 76.7 ± 6.0 / 77.8 ± 5.2 / 78.0 ± 6.9/ 77.8 ± 3.0 78.6 ± 2.8 79.3 ± 4.1

16 • Vol. 6, No. 2 • February 2014

Rosen et al

Figure 1a: Preoperative buccal view of the maxillary right second premolar in a 58 year old Caucasian male who sustained a vertical root fracture just prior to a business trip.

Figure 1b: Radiograph of the area prior to implant surgery.

Figure 1c: Fragment removed from the buccal showing the extent of the vertical root fracture.

Figure 1d: The implant has been inserted and RFA values are taken. The buccal-palatal lowest reading was 76 while the mesial-distal low value was also 76.

further aided in maintaining the high RFA values demonstrated at the time of implant placement. Furthermore the surface roughness at the flange of this implant as measured by Sa and Sdr val-ues are quite similar to those of a machined sur-face. The thought process is that should some exposure of the flange occur following heal-

ing, there might be less concern for the initia-tion and/or progression of peri-implant disease.16

This also allows the collar to be left exposed should there be a limited amount of crestal bone height and a concern with whether vertical bone height can be achieved with regenerative efforts.

Some criticism might be given to the lack of


Rosen et al

Figure 1e: A 2 mm high and 4 mm wide polyethylether ketone (PEEK) healing abutment was placed and no grafting was performed at the site.

Figure 1f: Resonance frequency analysis was repeated at 2.5 weeks. Values now read 80 in both the buccal-palatal and mesial-distal directions.

Figure 1g: Clinical photo of the final screw-retained crown in place. Occlusion has been kept extremely light due to severe parafunction. (Prosthetics were performed by Philip Halper, DDS Yardley, Pennsylvania)

Figure 1h: Radiographic image exposed two months after the final restoration was placed. The platform-switched crown is screw retained and good maintenance of bone height is suggested.

standardization in this current case series. The intent of this retrospective was to report on how this wider diameter implant performed on ini-tial experiences in a private practice limited to periodontics and surgical implant placement. The protocol and follow-up has been one that has provided a high level of success in daily pri-

vate practice and was not specifically designed for a study. Hence, patients signed informed consents but were not given strict instructions on when they must return to remove sutures if needed, obtain RFA values, etc. While this may lead to some diminishment of the scien-tific value of the current work, it does give the

18 • Vol. 6, No. 2 • February 2014

Rosen et al

Figure 2a: Pretreatment radiograph of a retained deciduous molar in a healthy 58 year old female. There has been substantial resorbtion suggested at the distal of this tooth.

Figure 2b: Clinical view of the retained premolar suggests resorbtion based on the internal redness of this tooth and absence of decay.

Figure 2c: Upon extraction there is still some discrepancy between the socket size and the 6.5 mm diameter implant. RFA values were 82 in the buccal-lingual direction and 81 in the mesial distal direction.

Figure 2d: A wider diameter PEEK healing abutment was used to develop emergence profile. The site was grafted with freeze-dried bone allograft and recombinant platelet derived growth factor-BB (GEM21s, Osteohealth, Shirley, New York). Suturing was accomplished using 7-0 expanded polytetrafluoroethylene (Goretex, W.L. Gore & Associates, Flagstaff, Arizona).

clinician in private practice a good idea of how this implant performs under normal clinical cir-cumstances. Nevertheless, consideration was given to limiting such factors like penicillin allergy that might have an adverse effect on success.4

cOncluSIOnThis pilot case series reports on the initial experiences with a parallel wall 6.5 mm diam-eter implant used for immediate placement into extraction sockets. The consistently high


Rosen et al

Figure 2e: Sutures were removed at 3 weeks and RFA values remained stable at 82 for both the buccal-lingual and mesial-distal directions.

Figure 2f: Final crown has been placed and is cement retained. (Prosthetics were performed by Eric J. LePine, DMD Yardley, Pennsylvania)

Figure 2g: Final radiographic image suggests good amalgamation of the graft and bone height to approximate the platform.

level of RFA values throughout the observa-tion period suggests that this implant’s diam-eter will allow for its use at the time of tooth extraction in larger sockets as evidenced by both the initial and subsequently high RFA values. Further studies are needed to see if this implant design will translate to high suc-cess if used with a larger group of subjects

and surgeons Moreover, further evaluation is needed to see if the implant will perform simi-larly in wider ridges for delayed placement and for challenging circumstances such as sinus elevation and immediate provisionalization. ●

correspondence:

Dr. Paul Rosen

907 Floral Vale Blvd

Yardley, PA 19607

20 • Vol. 6, No. 2 • February 2014

Rosen et al

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References1. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate place-

ment of implplants into fresh extraction sites:a literature review. J Periodontol 1997;68:915-923.

2. Chen ST, Wilson TG Jr. Hammerle CF. Immediate or early placement of implants following tooth extraction. Consensus statement. Int J Oral Maxillofac Implants 2004;19(suppl):12-28.

3. Eckert SE, Choi YG, Sanchez AR, Koka S. Comparison of dental implant sys-tems: quality of clinical evidence and prediction of 5-year survival. Int J Oral Maxillofac Implants 2005;20:406-415.

4. Wagenberg B, Froum SJ. A retrospective study of 1925 consecutively placed immediate implants from 1988 to 2004. Int J Oral Maxillofac Implants 2006;21:71-80.

5. Rosenquist B, Grenthe B. Immediate placement of implants into extraction sock-ets: implant survival. Int J Oral Maxillofac Implants 1996;11:205-209.

6. Olson RA, Roberts DL, Osbon DB. A comparative study of polylactic acid, Gel-foam, and Surgicel in healing extraction sites. Oral Surg Oral Med Oral Pathol 1982; 53: 441–449.

7. Becker W, Clokie C, Sennerby L, Urist MR, Becker BE. Histologic findings after implantation and evaluation of different grafting materials and titanium micro screws into extraction sockets: case reports. J Periodontol 1998 ; 69(4): 414-421.

8. Horowitz R, Holtzclaw, Rosen PS. A review on alveolar ridge preservation follow-ing tooth extraction. J Evid Based Dent Pract 2012 Sep;12(3 Suppl):149-60.

9. Rosen PS, Meredith N, Reynolds MA. Case reports describing the “Bump”: a new phenomenon in implant healing. Journal of Implants and Advanced Clinical Dentistry. 2010;2(9):27-37.

10. Wagenberg B, Froum SJ. Implant complications related to immediate place-ment into extraction sites. Chapter from Dental Implant Complications Etiol-ogy Prevention Treatment. Editor: Stuart J. Froum. Wiley-Blackwell Publishing. 2010 Chapter 18 pp. 325-340.

11. Watzek G, Haider R, Mensdorff-Pouilly N, Haas R. Immediate and delayed im-plantation for complete restoration of the jaw following extraction of all residual teeth: a retrospective study comparing different types of serial immediate im-plantation. Int J Oral Maxillofac Implants 1995;105:561-567.

12. Shanaman RH. The use of guided tissue regeneration to facilitate ide-al prosthetic placement of implants. Int J Periodontics Restorative Dent 1992;124:256-265.

13. Becker W, Hujoel P, Becker BE. Effect of barrier membranes and autologous bone grafts on ridge width preservation around implants. Clin Implant Dent Relat Res 2002;4:143-149.

14. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immedi-ate implants: a 6-month study in the dog. Clin Oral Implants Res 2011;22:1-8.

15. Becker W, Sennerby L, Bedrossian E, Becker BE, Lucchini JP. Implant stability measurements for implants placed at the time of extraction: a cohort, prospec-tive clinical trial. J Periodontol 2005;76:391-397.116.

16. Albouy JP, Abrahamsson I, Persson LG, Berglundh T. Spontaneous progres-sion of peri-implantitis at different types of implants. An experimental study in dogs. I: clinical and radiographic observations. Clin Oral Implants Res

Rosen et al

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Kumar et al

Aim and Background: The correction of the gingival recession defects is becom-ing one of the most predominant concerns for the periodontist. The treatment modal-ity of Miller’s Class I and II defects is mainly based on the preservation of the interden-tal papilla with minimal surgical trauma at the recipient site for achieving predictable results.

Case Description: A series of 4 cases of Miller’s Class I gingival recession were treated with the pouch and tunnel technique. This technique along with the use of a sub-

epithelial connective graft has proven sev-eral benefits including early tissue healing, esthetic results and good patient cooperation.

Conclusion: This article emphasizes on the effectiveness of using this technique which improves the success rate up to 82% for treating gingival recession defects

Clinical Significance: This case series shows predictability of root coverage and esthetics when care is taken to ensure proper access through minimal releasing incisions.

Pouch and Tunnel Technique for Augmentation of Gingival Recession:

A Case Series

Dr. Tarun Kumar1 • Dr. Triveni2 • Dr. V. Priyadharshini3 Dr. Vinita Jain4 • Dr. DS Mehta5

1. Professor, Bapuji Dental College and Hospital, Davangere, Karnataka, India

2. Professor, Bapuji Dental College and Hospital, Davangere, Karnataka, India

3. Post-graduate student, Bapuji Dental College and Hospital, Davangere, Karnataka, India

4. Private practitioner, India

5. Professor and Department Head, Bapuji Dental College and Hospital, Davangere, Karnataka, India

Abstract

KEY WORDS: Gingival recession, root coverage, pouch and tunnel, connective tissue graft


24 • Vol. 6, No. 2 • February 2014

INTRODUCTIONRepairing mucogingival defects for achieving a good esthetic and functional tissue is a chal-lenge. Gingival recession is defined as the dis-placement of the gingival margin apical to the cementoenamel junction. It is characterized by the loss of periodontal connective tissue fibers, along with tooth cementum and alveolar bone. Gingival recession and inadequate attached gingiva have been considered precipitating fac-tors for root sensitivity, root caries, increased gingival inflammation and impaired esthetics. Various surgical procedures have been devel-oped to treat gingival recession including the pedicle flaps, free soft tissue grafts, tunnel tech-nique, guided tissue regeneration, allografts, or by combination techniques.1-6 Among these procedures, the subepithelial connective tissue graft has been the most reliable and it is con-sidered as the gold standard procedure in the treatment of recession type defects.3 The pro-

cedure originated in 1984 with an envelope design7 and a subepithelial connective tissue graft for single gingival recession defects and is used today for coverage of multiple adjacent gingival recession defects. This article focuses

Figure 1: Presurgical view of teeth #’ 23-26 with Miller’s Class I gingival recession.

Figure 2: Presurgical view of teeth #’ 23-26 with Miller’s Class I gingival recession.

Figure 3: Creation of pouch and tunnel without severing the interdental papilla.

Kumar et al


on the importance of connective tissue graft-ing, combined with a novel approach known as the tunnel procedure, in managing gingi-val recession defects with a single operation.

CASE REPORTA 30 year old male patient reported to the out-patient Department of Periodontology with a chief complaint of poor esthetics and sensitiv-ity with respect to the lower front tooth region. His anamnesis revealed no systemic health

Figure 4: Connective tissue graft harvested from the palate.

Figure 5: Graft secured with a 6-0 vicryl suture.

Figure 6: Post-operative healing after 2 months. Figure 7: Post-operative healing after 1 year.

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26 • Vol. 6, No. 2 • February 2014

problems and his family history was noncon-tributory. The personal history showed that patient was using horizontal scrub motion to brush teeth. After a detailed clinical exami-nation, the case was diagnosed as Miller’s class I gingival recession with respect to man-dibular central and lateral incisors (Figure 1).

Based on the clinical conditions, the fac-tors that affect the treatment and the com-pliance of the patient, a Pouch and Tunnel technique with connective tissue graft pro-cedure was considered to obtain both good esthetics and gingival recuperation.

Pre Surgical TherapyThe surgical procedure was explained to the patient and an informed consent was obtained. Prior to the surgery the patient was given oral hygiene instructions, supragingival scaling and root planing was done. Then the clinical parameters like probing depth, width of kera-tinized gingiva, recession depth were recorded before and after the surgery. Traumatic brush-ing habit was corrected before the treatment and care was given to the affected teeth.

Figure 8a: Miller’s Class I gingival recession in #24 and 25. Figure 8b: Postoperative healing of figure 8a after 1year.

Figure 9a: Miller’s Class I gingival recession in #24, 25. Figure 9b: Postoperative healing of figure 9a after 1 year.

Kumar et al


Figure 10a: Miller’s Class I gingival recession in #’s 7-10. Figure 10b: Postoperative healing of figure 10a after 1 year.

Surgical TreatmentPrior to administration of local anesthetic, the patient rinsed with 15 ml 0.12% chlorhexi-dine to reduce the bacterial load. The exposed roots of the recipient teeth were scaled and planed, and tooth convexities were reduced by using a smooth diamond bur and a high speed hand piece. The surgical site was anes-thetized using 2% xylocaine HCl with adrena-line (1:200,000). A sulcular partial thickness incision was made through the recession area using a no 15C scalpel blade, followed by additional incision performed with modi-fied Orban’s knife8 on labial aspect of incisors (Figure 2). A partial thickness dissection using Allen elevator from just below the cementoe-namel junction of incisors created a pouch undermining the tissue far beyond the muco-gingival junction so that there is enough relax-ation of this pedicle flap to allow the entrance of the connective tissue graft underneath (Fig-ure 3). Care was taken not to cut or perforate the flap or the interdental papilla in order to maintain blood supply and facilitate healing.

The connective tissue graft was harvested from the palate using single incision technique9

(Figure 4). After harvesting the graft, donor site was sutured with 4-0 vicryl suture. The graft that was procured was placed within the prepared pouch and finger pressure was applied to sta-bilize the graft until hemostasis was achieved. Later the graft was secured to mesial and dis-tal papilla of incisors with 6-0 vicryl suture (Figure 5). Application of an ice pack was rec-ommended to minimize postoperative swelling. The patient was instructed to take analgesic (paracetamol and ibuprofen) thrice daily and was advised not to brush in that area for a week but to rinse his mouth with 0.2% chlorhexi-dine twice daily. During the next 4 weeks, only gentle tooth brushing was permitted.

RESULTSHealing was uneventful. Patient was recalled every week for the first one month. The sutures placed in the palate were removed after one week and those placed in relation to the recipi-ent site were removed after 15 days. Oral hygiene instructions were reinforced at every appointment. Progressive adaptation of the edges of the graft to the surroundings and increased color matching were observed.

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28 • Vol. 6, No. 2 • February 2014

Postoperative healing after 2 months was sat-isfactory (Figure 6).Healing after 1 year revealed good amount of attached gingiva with 75% of recession coverage (Figure 7) and the position

of the mucogingival junction remained the same. The amount of keratinized gingiva on the inci-sors increased to 3.5 mm. Similar surgical pro-tocols were performed for the remaining 3 cases

Table 1: Clinical Parameters Pre-Operative

Pre-Operative

Cases PD(mm) KT RD DEF COV MES MID DIS (mm) (mm) (%)

Case 1 41 1.5 1.0 1.2 1.8 4.0 ––

42 1.4 0.8 1.3 2.3 3.8 ––

31 1.7 0.7 1.4 1.8 4.0 ––

32 1.5 0.9 1.2 2.1 4.5 ––

Case 2 31 1.1 0.5 1.3 2.2 5.0 ––

41 1.2 0.6 1.0 2.0 4.5 ––

Case 3 31 1.0 0.6 1.2 1.8 5.5 ––

41 1.1 0.7 1.1 1.7 5.3 ––

Case 4 12 1.0 0.6 1.2 3.5 3.0 ––

11 1.1 0.7 1.1 3.6 3.0 ––

21 1.2 0.9 1.8 3.8 3.5 ––

22 1.4 0.8 1.6 3.8 3.5 ––

PD = probing depth, KT=width of keratinized tissue, RD-recession depth, DEF COV=defect coverage

Kumar et al


Table 2: Clinical Parameters Post-Operative

Pre-Operative

Cases PD(mm) KT RD DEF COV MES MID DIS (mm) (mm) (%)

Case 1 41 1.4 0.8 1.2 3.8 0.6 85

42 1.3 1.1 1.2 3.7 1.1 65

31 1.7 0.6 1.0 3.7 0.5 87.5

32 1.5 0.6 0.8 3.1 1.5 66.6

Case 2 31 1.2 0.5 1.2 3.5 1.0 80

41 1.1 0.4 0.9 3.4 0.5 87.5

Case 3 31 0.9 0.5 1.1 3.9 0.0 100

41 1.2 0.7 1.0 3.8 0.9 83

Case 4 12 0.9 0.5 1.1 4.3 1.0 66.6

11 1.2 0.7 1.0 4.4 0.0 100

21 1.3 0.7 1.6 4.4 0.0 100

22 1.1 0.7 1.5 4.1 1.5 57.14


and satisfactory results were obtained after one year post-operatively (Figure 8a, 8b), (Figure 9a, 9b), (Figure 10a, 10b). The clinical parameters at baseline and one-year post-operative were

recorded (Table 1), (Table 2). The mean values of the clinical parameters at baseline and one-year post-operative were also calculated which showed significant increase in the keratinized

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30 • Vol. 6, No. 2 • February 2014

Table 3: Mean Values of Clinical Parameters at Baseline and 1 Year Post-Operative

Parameter Baseline 1 Year

PD-mesial (mm) 1.26 1.23

PD-mid (mm) 0.73 0.65

PD-distal (mm) 1.28 1.13

KT (mm) 2.53 3.84

RD (mm) 4.13 0.71

DEF COV (%) –– 81.52


tissue, reduction in the recession depth and a defect coverage of approximately 82% (Table 3).

DISCUSSIONGingival recession seems to be the most com-mon esthetic problem reported by periodontal patients. According to the glossary of periodon-tal terms, published by the American Academy of Periodontology, gingival recession is defined as the displacement of the soft tissue margin, apical to the cementoenamel junction,10 and its coverage is one of the most challenging procedures in periodontics. It is essential to carry out root coverage procedures whenever concerns of esthetics, sensitivity, susceptibil-ity to root caries, pulpal symptoms due to root exposure, food lodgment and plaque deposi-tion exist. The decision for the technique to be used requires careful evaluation of various parameters such as width and depth of reces-sion defect, number of recessions, width of attached gingiva present, surrounding inter-

dental papillae, and the thickness of the recipi-ent site tissue. According to Dembowska et al the most important factor in determining the treatment modality is the presence of appro-priate height and width of the gingival papil-lae, which ensures good blood supply to the graft and creates the possibility of its proper placement to the cementoenamel junction.11

Recession coverage procedure using sub-epithelial connective tissue graft was intro-duced by Langer and Langer in 1985.12

Thereafter several modifications of this proce-dure by Harris13, Allen14, Bruno15 were devel-oped which combined the advantages of pedicle flap procedure. The tunnel technique for recession coverage presented by Blanes and Allen16, Zabalequi et al17 and Santarelli et al4 is a modification of the envelope method described by Raetzke.7 This surgical proce-dure facilitates multiple recession defects to be treated simultaneously and successfully.

The advantages of the pouch and tunnel

Kumar et al


technique are those demonstrated by the con-nective tissue graft and the envelope tech-nique, with specific advantage of early healing as no external incisions are made on the sur-gical site. The subepithelial connective tissue graft is a predictable treatment modality with excellent results18 and it has the advantages of improved color blending, reduced morbidity in donor site and increased clinical success.13

The key to the pouch technique is that it preserves the lateral and apical blood supply of the flap by eliminating vertical release inci-sions. Mormann and colleagues demonstrated that the gingiva receive majority of their blood supply from an apical direction.19 Therefore, vertical incisions should not compromise this blood supply. However Tarnow demonstrated that lateral blood supply was more significant than previously assumed when tissues survived after severing the apicocoronal blood supply.20 This suggests vertical releases may compro-mise the lateral blood supply. Thus the advan-tage of using this technique is the preservation of lateral blood supply and also the intimate contact of the donor tissue to the donor site.

In all the cases presented above the inter-dental papilla of the teeth were maintained which minimized the trauma at the recipi-ent site, helped in the placement of the graft within the pouch, ameliorated the esthet-ics of the patient and rendered excellent adaptation of tissues on the recipient site. The gingival blood supply was preserved at the apical site which influenced early heal-ing. The overlying gingiva was also preserved which prevented it from becoming necrosed.

CONCLUSIONThe success of root coverage seems to be related to the transplanted graft and the proce-dure at the recipient site. Bouchard et al men-tioned that an increase in gingival width will occur as long as the connective tissue part of the graft survives.21 The flap design affects the initial healing and the amount of cover-age of the denuded roots during the follow-up period. The pouch and tunnel technique offers the advantage of a pedicle flap proce-dure and ensures double blood supply from both the overlying pedicle flap and the under-lying periosteum. The wound is sealed at the palatal donor site after harvesting the con-nective tissue graft.9 Hence this single-stage pouch and tunnel surgical technique is an ideal root coverage procedure for Miller’s Class I and II recession defects as its predictability is assured by enhanced graft healing, satis-factory esthetics and good functional results.

CLINICAL SIGNIFICANCEThis novel technique offers successful clini-cal results for both patients and clinicians. This minimally invasive gingival recession technique provides excellent root coverage with reduced trauma at the recipient site. ●

Correspondence:Dr. Priyadharshini V. Room no :5, Department of PeriodonticsBapuji Dental College and Hospital, Davangere, Karnataka, India.Phone: 07406064259Email: [email protected]

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33 • Vol. 6, No. 2 • February 2014

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DisclosureThe authors report no conflict of interest with anything reported in this manuscript.

References1. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of

gingival recession. A systematic review. Ann Periodontol 2003;8:303-320.2. Chambrone L, Lima LA, Pustiglioni FE, Chambrone LA. Systematic review of

periodontal plastic surgery in the treatment of multiple recession-type defects. J Can Dent Assoc 2009;75:203a-203f.

3. Chambrone L. Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. Can subepithelial connective tissue grafts be considered the gold standard procedure in the treatment of Miller Class I and II recession-type defects? J Dent 2008;36:659-671.

4. Santarelli GA, Ciancaglini R, Campanari F, Dinoi C, Ferraris S. Connective tissue grafting employing the tunnel technique: A case report of complete root coverage in the anterior maxilla. Int J Periodontics Restorative Dent 2001;21:77-83.

5. Greenwell H, Fiorellini J, Giannobile W, et al. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol 2005;76:1588-1600.

6. Mahajan A, Dixit J, Verma UP. A patient-centered clinical evaluation of acellular dermal matrix graft in the treatment of gingival recession defects. J Periodontol 2007;78:2348-2355.

7. Raetzke PB. Covering Localized Areas of Root Exposure Employing the “Envelope” technique. J Periodontol 1985;56:397-402.

8. Modaressi M, Wang HL. Tunneling procedure for root coverage using acellular dermal matrix: a case series. Int J Periodontics Restorative Dent. 2009;29(4):395-403

9. Hurzeler MB, Weng DA. Single incision technique to harvest subepithelial connective tissue graft from the palate. Int Periodontics Restorative Dent 1999;19:279-287.

10. Glossary of Periodontal Terms, ed 4, Chicago, American Academy of Periodontology, 2001:44

11. Dembowska E, Drozdzik A. Subepithelial connective tissue graft in the treatment of multiple gingival recession. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e1-7

12. Langer B, Langer L. The subepithelial connective tissue graft technique for root coverage. J Periodontol 1985; 56:715-720

13. Harris RJ. The connective tissue and partial thickness double pedicle graft : a predictable method of obtaining root coverage. J Periodontol 1992;63:477-486.

14. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. Rationale and Technique. Int J Periodontics Restorative Dent 1994;14:216-227.

15. Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14:126-137.

16. Blanes RJ, Allen EP. The bilateral pedicle flap-tunnel technique: a new approach to cover connective tissue grafts. Int J Periodontics Restorative Dent 1999;19:471-479.

17. Zabalequi I, Sicilia A, Combra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with tunnel subepithelial connective tissue graft: a clinical report. Int J Periodontics Restorative Dent 1999;19:199-206.

18. Langer B, Calagna LJ. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent 1982;2:22-33.

19. Mormann W, Meier C, Firestone A. Gingival blood circulation after experimental wounds in man. J Clin Periodontol 1979;6:417-424.

20. Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182-185.

21. Bouchard P, Etienne D, Ouhayoun JP, Nilvéus R. Subepithelial connective tissue grafts in the treatment of gingival recession. A comparative study of 2 procedures. J Periodontol 1994;65:929-936.

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Background: Depending on our long time prac-tice in the field of implant, We would give you some tips regarding implant failures and mistakes which might happen. The reason of develop-ing so many dental implant mistakes is because of implant dentistry was not a part of the dental school curriculum of the vast majority of den-tists in practice today. Only now are dental schools starting to incorporate adequate training in implantology. So that, there are many reasons that mistakes happen. Many dentists simply don’t possess the training or qualifications necessary to be successful. Sadly, these dentists are more concerned with saving money by cutting corners or performing a procedure too quickly. Below we have provided several factors that can contribute to dental implant mistakes. And we will illustrate the common reasons for dental implant failure. Methods: Many dentists use two-dimensional panoramic x-rays to place dental implants. Although this method works well for most dental surgeries, there is much more sophisticated tech-nology available for dental implants. So we have to use 3-D CT scans which give a much clearer Figure of the exact position of nerves and blood vessels present in the bone. These powerful CT scans combined with radiography techniques are

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Results: Many complications can result like infection, nerve damage that causes facial numbness and pain, or the implant can be misplaced into the sinus cavity Conclusions: The vast majority of complica-tions in implant surgery can be prevented by correctly selecting patients and treating dif-ficult cases in the most adequate way, while knowing the risks, trying to avoid them with the necessary information and having care-fully devised a specific plan for every patient.

Common Dental Implant Mishaps and Failures

Dr. Shady A. M. Negm1 • Dr. Ahmed S. M. El-Mallah2 • Dr. Ahmed H. Ayoub3

1. Dentist at Ministry of Health, Fellow of Alexandria Oral Implantology Association (A.O.I.A), Fellow of Egyptian Society of Oral Implantology (E.S.O.I)

2. Bachelor’s Degree School of Dentistry, Pharos University, Alexandria, Egypt. Diploma of Clinical Implant from Seville University, Spain

3. President of Egyptian Society of Oral Implantology, Seville University, Spain

Abstract

KEY WORDS: Dental implants, complications, failures


36 • Vol. 6, No. 2 • February 2014

IntRODuCtIOnImplant treatment is regarded as a safe tech-nique for restoring missing teeth, with high rates of success. Nevertheless, it has, as every surgical procedure does, several complications that can occur and must be known in order to prevent or solve them. Implantology is an ever growing field that is reaching the practice of general dentists due to the simplification of technical procedures. Specialists in oral sur-gery now perform more demanding proce-dures. Along with general dentists, they must pay special attention in order to avoid risks.

Nowadays, implants are considered as the first line of treatment almost all cases of com-plete or partial edentulous patients. Only by using a good work protocol, we can detect the local and systemic risk factors that could deter-mine the success of the treatment and allow us to implement preventive measures if needed. It is mandatory to know as many clinical complica-

tions as possible. The majority of problems that can arise in an implantology treatment include, but are not limited to, the following: a) poor quality or quantity of bone; b) erroneous surgi-cal technique; c) infection; d) poor oral hygiene; e) smoking; f) poorly controlled systemic dis-eases. Failures of implants normally occur once they are correctly osseointegrated, as the development of an acceptable masticatory function and the consequence of loss of bone support derived from a peri-implantitis pro-duced by the presence of bacterial plaque and/or overload. That was acceptable as normally the bone loss about 1 mm around the implant yearly. Early complications associated with dental implants often include, but are not lim-ited to the following: a) ecchymosis; b) edema; c) infection; d) hematoma; e) emphysema; f) bleeding; g) neurosensory issues. Late com-plications associated with dental implants often include, but are not limited to the following:

Figure 1: Although these two implants parallel their adjacent teeth, they do not parallel one another and complicate the prosthetic restoration process.

Figure 2: Poorly placed unparallel dental implants. Also note that one dental implant has an incompletely seated cover screw.

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a) maxillary sinusitis; b) pathologic bony frac-ture; c) formation of peri-implant bone defects; d) loss or failure to achieve osseointegration.

DISCuSSIOnWe prefer to describe these failures and mis-shapes as they arise in the course of the treatment, so we will divide them as follows:

Improper Implant AngulationIt is advisable to assess the characteristics of the edentulous zone clinically and by using and cone beam CT imaging before treatment. Improper planning that involves a malposition or an over-angulation, would represent an impossibility for carrying out the prosthetic restoration, while it also would deteriorate long-term implant viability. We should know that the angulation in the case of a single implant will increases tension forces between the implant and the bone. As a result

of negligence or bone deficit, an implant may have been placed with an angulation that makes it dysfunctional as seen in figures1-3. It is sug-gested that the use of a repositioning system that has yielded excellent results and which is based on the osteogenic distraction of a bone fragment containing the integrated implant. All of which improves esthetic effects, as well as the biome-chanical behavior of the implant by correcting crown-root proportion, contour of soft tissues and the relation with neighboring teeth. The distrac-tion rate is the usual value of 1mm per day and the suggested consolidation period is 8 weeks.1

Improper Distribution of Implants Along the ArchMany dental practitioners don’t make an ideal treatment plan nor do they use a surgical stent for proper implant placement. They depend on their imagination and illusion as we seen in

Figure 3: Poorly placed dental implants with one being too close to the adjacent tooth and others being unparallel to one another overall. This will result in a difficult final restoration.

Figure 4: Improper distribution of dental implants placed into the mandible. Also note that inferior alveolar nerve has been compromised.

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38 • Vol. 6, No. 2 • February 2014

Figure 4. These problems can be reduced with meticulous presurgical planning, often making use of the cone beam CT scan, and surgical stents.2

Improper number of ImplantsMany dental references prefer to place 6 Maxillary and 4 Mandibular implants but in a right angula-tion and distribution. But within our own studies we have found that 8 Maxillary implants and 6 Mandibular implants are more efficient and dura-ble in our hands. When more than these num-bers of dental implants are utilized, this may lead

to weakened mandibles or maxillae and possibly result in pathologic fractures as seen in figure 5.

Lesions of teeth Adjacent to Dental ImplantsThe malposition of an implant may sometimes lead to the lesion of an adjacent tooth. This involves a lesion on the radicular surface or the root apex and a subsequent post-operative pul-pitis or periodontitis that must be treated, in the majority of cases, by endodontic means. Some-times it involves the non-integration of the implant because of the inflammation. It is of the utmost interest to study the axis of those teeth delim-iting the edentulous space to be rehabilitated with implants to decide, before surgery, implant axis placement and thus choose the most con-venient one, or reduce its length to curb its con-vergence and thus prevent this type of dental iatrogenic lesions. On some other occasions, the inflammatory-infectious origin in the apical zone is a tooth adjacent to the implant and this is especially due to the proximity of the tooth to the implant and to the time elapsed since the endodontic procedure on the tooth was per-

Figure 5: Excessive placement of dental implants in the maxilla.

Figure 6: Dental implant placed too close to adjacent tooth resulting in pathologic apical lestion formation.

Figure 7: Failed dental implant at the site of a maxillary second molar. Low quality bone at this location places implants at higher risk of failure.

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Figure 8: Dental implant perforating the maxillary sinus. Figure 9: Dental implant perforating the maxillary sinus.

Figure 10: Dental implant perforating the maxillary sinus. Figure 11: Inferior alveolar nerve compromised by a dental implant.

formed, so the risk of a retrograde peri-implantitis increases when the distance between tooth and implant apexes is shorter and when the lapse of time between the endodontic procedure and the implantation is also shorter as seen in figure 6.3

Lack of Primary StabilityPrimary stability is determined by bone density and cortical bone thickness, a fact that explains why it is easier to obtain a better stability in man-dibular implants than in maxillary or in those cases in which the implant is immediately placed after an extraction procedure. A low insertion torque

value ( < 10Ncm) will determine a higher risk of osseointegration failure (type bone IV), whereas a too-high torque value ( > 45Ncm) could lead to a bone compression which would result in a bone necrosis (type bone I), and an osseointe-gration failure. Cooper described, in a study on 1084 implants, that there was a 6.43-fold lower risk of primary implant stability failure in the ante-rior mandible than in other locations.4 The max-illa had a 2.7-fold higher risk of primary stability failure versus the mandible. Females had a 1.54 higher risk of primary implant stability failure ver-sus men; implants less than 15 mm in length had

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40 • Vol. 6, No. 2 • February 2014

a 1.49-fold higher risk of primary implant stability failure versus longer implants as seen in figure 7.4

Implant Displacement into the Maxillary SinusThe invasion of the maxillary sinus by an implant can occur during or after the surgery as a result of insufficient primary stability. In cases of insuf-ficient primary stability when implants are placed in proximity to the maxillary sinus, it is advisable to simply place a cover screw and submerge the dental implant during the osseointegration period. Additionally, in cases with minimal max-illary bone existing at the maxillary sinus floor, augmentation procedures may be undertaken to avoid implant penetration into the sinus as seen in figures 8-10. In general, implant displacements

Table 1: Major Problems that can Arise in an Implantology Treatment

Be aware that the majority of problems that can arise in an implantology treatment are accidents, complications or iatrogenic errors, and are a consequence of an inadequate indication such as:

A: Poor quality or quantity of bone

B: An erroneous surgical technique

C: Infections

D: Lack of oral hygiene

E: Smoking habit

F: Systemic diseases that were poorly controlled, ect.

Table 2: Early Complications and Late Complications

We should know that early complications can be included in the following group: A: Infection

B: Edema

C: Ecchymosis

D: Hematoma

E : Emphysema

F: Bleeding

G: Dehiscence of the area

H: Sensitive alterations

While the group of late complications we can distinguish: A: Muco-periosteal flap perforations

B: Maxillary sinusitis

C: Mandibular fractures

D: Loss of Osseo integration

E: Bone defects

F: Peri-implant lesions

G: Infections.

Nevertheless, some of them, like bleeding, could appear at any moment during the treatment. We will not illustrate prosthetic complications or peri-implantitis because they will be explained in next review.

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into the maxillary sinus occur sometimes after implant placement because there is an absence or loss of osseointegration and, therefore, of sta-bility. Nevertheless, some authors report the dis-placement of implants into the maxillary sinus during their installation. When this happens, the implant remains, in almost all the cases, lodged inside the sinus, and can be removed a few days later by opening the lateral wall of the maxillary.

neurosensory ImpairmentNerve lesions are both an intraoperative accident and a postoperative complication that can affect the infra-orbital nerve, the inferior alveolar nerve and the lingual nerve. Neurosensory impairment may occur at any time during implant surgery including anesthesia administration, incision, rais-ing a flap, as well during drilling, bone augmen-tation, implant placement, suturing or any soft tissue swelling after surgery. Symptomatology is of a large variety and depends on the severity of the axonal damage. Several implants in contact with the inferior alveolar nerve can be seen in figure 11. Neurosensory complications could manifest as a paresthesia when the lesion is due to a nerve compression, or a minor stiffen-ing of nerve fibers, without sectioning any of them (neuropraxia). Dysesthesia may occur in cases of nerve compression, traction, partial crush or stretching (axonotmesis) of nerve fibers with different intensities. Hypoesthesia or hyper-esthesia may be caused by extreme stretch-ing, complete crush and direct trauma on nerve fibers (neurotmesis); anesthesia and pain appear as consequence of a complete nerve section. Treatment with corticosteroids and non-steroidal anti-inflammatory drugs are indicated to control inflammatory reactions that provoke nervous com-

pression. It seems that the topical application of dexamethasone (4 mg/ml) for 1 or 2 minutes enhances recovery, and when it is administered orally and in high doses within one week of injury, it has have shown to inhibit axon sprout-ing centrally and ectopic discharges from injured axons, and prevention of neuroma formation.5 ●

Correspondence:Dr. Shady A. M. Negm 15 Elahwazy st., Elwardian, Alexandria, Egypt [email protected]

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

References1. Abt E. Smoking increases denal implant failures and complications. Evid

Based Dent 2009; 10(3): 79-80.

2. Adell R, Eriksson B, Lekholm U, Branemark P. Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implant 1990; 5 (4): 347-359.

3. Al Jabbari YS, Fournelle R, Ziebert G, Toth J, Iacopino AM. Mechanical be-havior and failure analysis of prosthetic retaining screws after long-term use in vivo. Part 4: Failure analysis of 10 fractured retaining screws retrieved from three patients. J Prosthodont 2008; 17(3): 201-210.

4. Cooper LF. Factors influencing primary dental implant stability remain unclear.J Evid Based Dent Pract 2012; 12(3): 185-186.

5. Adell, R, Lekholm U, Rockler B, Brånemark P. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surgery 1981; 10 (6): 387-416.

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Dental implants are vastly used as replace-ments for natural dental roots. Over the last decades, dental implants have been

proven to provide excellent solutions for patients, whose other choices were either to use a remov-able denture or to prepare natural teeth as abut-ments for dental bridges. During this time, a few factors were determined as critical for long term success, mainly: materials, surface characteris-tics, and implant stability. Initial implant stability in particular is linked with short and long term suc-cess rates. With more and more publications demonstrating the long-term successes of short

implants, coupled with the inherent limitations of bone augmentation procedures, short implants are now acceptable as a valid treatment alternative. Based on current knowledge and understanding of bone biology and implant designs, DenTack aims to present a different solution. The inno-vative QUAD implant was developed to enable higher primary stability. This is gained by utilizing a unique expandable mechanism, which modifies the implant’s geometry after insertion. In order to evaluate the clinical performance of DenTack’s QUAD implants, a case series evaluation pro-cess was designed and reported on in this article.

DenTack QUAD Dental Implant: A Preliminary Evaluation of a Novel Dental Implant

and a 3 Year Follow-up Report (2010-2013)

Dr. Nachum Samet1

1. Harvard School of Dental Medicine, Boston, Massachusetts, USA

Abstract

KEY WORDS: Dental implants, short dental implant, initial stability


44 • Vol. 6, No. 2 • February 2014

INTRODUCTIONDental implants are vastly used as replacements for natural dental roots. Over the last decades, dental implants have been proven to provide excellent solutions for patients, whose other choices were either to use a removable den-ture or to prepare natural teeth as abutments for dental bridges.1,2 During this time, a few factors were determined as critical for long term suc-cess, mainly: materials, surface characteristics, and implant stability. Initial implant stability in particular is linked with short and long term suc-cess rates.3,4,5 Multiple implant designs are cur-rently available. These designs differ in implant’s body shape (cylindrical vs. conical), thread design; thread pitch and depth, and more. Aiming to provide designs that allow high initial stability through thread geometry, the industry changed from triangular, small pitch and small depth thread designs to more aggressive designs, with sharp and square shaped threads, and with higher pitch depth threads. However, these designs have inherent limitations when available bone height is less than 10 mm. Thus, close proximity to anatomic structure such as the inferior alveo-lar canal and maxillary sinus, often hinder the use of conventional length ( > 10mm) implants. Although some companies offer short implant ( ≤ 10mm), these are wide diam-eter implants ( > 5mm), which makes their use in narrow ridges impossible.

The other alternative, the use of augmentation procedures, is also far from being ideal. Vertical bone augmentation is still considered not to be a predictable procedure, and whenever augmenta-tion procedures are use, multiple additional factors need to be considered. These include additional

fees (sometime doubling the cost of treatment), additional healing time (up to 6 months or more), and of course other adverse effects such as swelling, pain, and discomfort that are commonly associated with bone grafting procedures.6,7

With more and more publications demonstrat-ing the long-term successes of short implants, coupled with the inherent limitations of bone aug-mentation procedures, short implants are now acceptable as a valid treatment alternative.8,9 These successes demonstrate clearly that some of the concepts, including the crown-to-root ratio concept work differently in teeth vs. implants.

Based on current knowledge and understand-ing of bone biology and implant designs,10,11,12,13 DenTack aims to present a different solution. The innovative QUAD implant was developed to enable higher primary stability. This is gained by utilizing a unique expandable mechanism, which modifies the implant’s geometry after insertion. (Figure 1) This unique pyramidal shape provides load-carrying capabilities, which are equivalent to that of conventional, 10-11.5 mm, implants.

ThE QUAD ImplANTThe QUAD implant was designed with biology in mind. The understanding that bone healing

Figure 1: The QUAD implant prior and post expansion.

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is different in cortical areas than in cancelous areas and with current understanding that under-sized osteotomy is beneficial; the QUAD implant utilizes a unique expandable mechanism that affect the cancelous bone only. Post inser-tion, the apical portion of the implant expands and implant’s geometry changes from cylindrical shape to a pyramid shape. There are significant benefits of this unique morphological change:

● Primary stability: Due to the change in geometry from a cylinder to a square based pyramid, rotational and horizon-tal stability are increased dramatically.

● Force distribution: like camera’s tripod and many other physical examples, the pyra-mid shape (post expansion) can handle forces better than cylindrical shapes, and is superior to tapered shapes.

● Enlargement of the circumference sur-face area: Four titanium membranes, which spread out during implant expan-sion, enlarge dramatically the contact area with the surrounding bone (Figure 2).

● The result is an implant that compensates for a short length with a morphological change.

ThE mEChANISmThe unique mechanism is a “push” mecha-nism. An internal element moves apically, creat-ing an outwards movement of four wing-shaped elements that create the desired geometrical change. The moving object is self-limiting by design, due to an innovative “snap back” mecha-nism, and locks upon full expansion. This fea-ture prevents over-expansion or extraction of the moving element out of the body of the implant. As a result, over expansion and over pressure are not possible, and complete control over the procedure is inherent in the mechanism.

There were two concerns related to the mechanism: 1) potential damage to bone around the expanded areas; and 2) potential leak-age through the mechanism to the apical area surrounding the implant. These issues were addressed in a series of preliminary, bench

Figure 2: An apical view of the implant. From left to right – a view of the implant at placement, a view of a partly expanded implant and a view of the fully expended implant.

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46 • Vol. 6, No. 2 • February 2014

and animal studies. These demonstrated no mechanical bone damage following expansion, and absolutely no leakage through the mecha-nism. These results were the background basis for this clinical evaluation, and for achieving the marketing approvals from the European Union.

ImplANT plACEmENT pROCEDURE

In principle, the only difference between con-ventional implant placement and the place-ment of QUAD implants is the expansion stage. Osteotomy is done utilizing straight forward drilling steps: including a mark-ing drill, a pilot drill and widening drills.

Expansion is achieved by use of a unique

device, which is attached to the implant once it is in its correct position in the bone (Fig-ure 3). Using torque ratchet set to 35Ncm, the upper component is screwed in, push-ing the expansion mechanism of the implant. The device has two clear rings that come into contact when expansion is completed, and used as a secondary safety tool to prevent over-expansion. At this point, the “snap back” mechanism locks. The placement procedure ends when the expansion tool is removed.

CASE SERIESIn order to evaluate the clinical performance of DenTack’s QUAD implants, a case series evalu-ation process was designed. A group of patients

Figure 3: The expansion process. A) Implant in place; B) Attachment of expansion tool; C) Use of a torque ratchet at 35Ncm for expansion; D) Radiograph of implant in place after expansion.

Figure 3a

Figure 3b Figure 3c

Figure 3d

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who had inadequate bone for conventional implant placement were identified in one clinic (Biodent, Elin-Pelin, Bulgaria). These patients preferred the DenTack implant solution over the alternative options, which included either bridges with no implants, or extensive bone augmenta-tion procedures. These patients gave consent for the use of QUAD implants, and to be evalu-ated every three to six months following implant placement for a period of up to three years.

GOAlTo evaluate the long-term success of QUAD implants in a variety of clinical scenarios, and to evaluate bone health at the expanded area and at the apical area of the implants.

pATIENT pOpUlATION Patients were offered treatment with Den-Tack implants only if an implant was a part of their original treatment plan. Patient popula-tion aimed to be random and as diverse as possible, in order to create a very hetero-geneous group; males and females, young and old patients, smokers and non-smokers. Exclusion criteria included patients who had specific contraindications for surgery or for implant placement. Number of patients and implants: One to three implants, in ten to fifteen patients. Placement protocol: Standard place-ment procedure into healed bone, adequate for a 7mm QUAD implant: at least 7mm bone height and at least 5mm bone width, or patients requiring simultaneous bone augmentation.

Loading protocol: Implants were loaded after three months of healing.

Restorations: Ceramo-metal restorations.

A SUmmARY Of ThE CASES● Patients: Implants were placed in thirteen

patients; eight males and five females. Age range was 27-59. Six patients were non-smokers. Some patients smoke more than 20 cigarettes per day.

● Implants: Twenty-three implants were placed. Twenty two of the implants were placed into healed bone. One was placed into an extraction socket.

● Data collection: Accumulated data included bleeding on probing, gingival recession or evident signs of gingival pathology, and radiographs utilizing a Kodak RVG sensor with a Dentsply Rinn Universal Sensor Holder.

● Follow-up time: Follow-up meetings were scheduled 3, 6, 13, 26 and 35 months after implant placement.

Twenty implants were followed for 13 months, nineteen were followed for 23-26 months, and eleven were fol-lowed for a period of 33-35 months.

● Implants survival: Two of the 23 implants failed within the first 4 months. All other implants are in function and with no evident pathology.

An Analysis of the Failures Reveals the Following ● One implant was restored as a single

molar crown. The crown was extremely wide and its occluso-gingival length was larger than that of the implant itself. It functioned as the only posterior sup-port in a patient weighing over 120Kg.

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48 • Vol. 6, No. 2 • February 2014

● The second implant was placed in a patient who is a heavy smoker. The patient wore a temporary denture that placed severe pressure on the area around the implant. Although there was a large sore spot in the area, the patient did not report of any problem and did not contact the clinic for help. By the time he came for a follow-up visit, the area was heavily inflamed, resulting in a clinical decision to remove the implant.

BONE EvAlUATION A qualitative measurement of bone changes around implants was performed by utiliz-ing digital periapical radiographs used with a designated sensor holder, and by using one specific panoramic radiograph machine.

RESUlTS ● Bone around the expanded area: None

of the implants showed bone changes or bone pathology around the expanded area.

● Bone around the apical area: None of the implants showed bone changes or bone pathology around the expanded area.

● Bone around the neck of implants: no or minor bone loss was observed around implant necks in fifteen of the nineteen surviving implants. In four of the implants a slight bone loss of 1-1.5mm was observed.

● Restorative phase evaluation: All implants were loaded for at least 3 months prior to final evaluation. No prosthetic complica-tions (such as screw loosening, fractures of porcelain or abutments etc.) were reported.

● Implant related complications: None of the implants was fractured during expansion or at any point later than that. No other implant related complications were reported.

DISCUSSION AND CONClUSION

Available bone height is often the limiting fac-tor when dental implants are considered. In many cases, the posterior areas of both maxilla and mandible have inadequate bone height due to either the maxillary sinus or the mandibular canal. In such cases, if implants are chosen as the restorative option, the clinical alternatives are either to utilize aug-mentation procedures, or short implants.

Short implants of 6 and 8mm are now considered a standard treatment modal-ity. However, their limited initial stability and wide diameter still prevent them from being used in a large group of people, who have both short and relatively short ridges.

Within the limitation of this case series it can be concluded that no bone changes and no bone pathologies were observed around the expanded areas or around the apex of any one of the QUAD implants that were followed for up to 26 months.

Based on that, and on the fact that there were no surgical or prosthetic com-plications, it can be concluded that:

1. DenTack expanding technology does not cause damage to bone surround-ing the expanded area of the implants.

2. Dentack’s expanding technology result in a tight seal and no leakage, resulting in no periapical pathologies.

3. DenTack’s QUAD expandable implants are a viable solution for a diverse range of clinical scenarios. ●

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Correspondence:Nachum Samet, DMDProsthodontist Department of Restorative Den-tistry and Biomaterials SciencesHarvard School of Dental Medicine188 Longwood Ave.Boston, MA 02115Tel: 617-432-1474Fax: [email protected]

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

References1. Cochran, D. L. State of the Art Review A Comparison of Endosseous

Dental Implant Surfaces * State of the Art Review. 1523–1539 (1999).2. Albrektsson, T., Zarb, G., Worthington, P. & Eriksson, a R. The long-term effi-

cacy of currently used dental implants: a review and proposed criteria of suc-cess. The International journal of oral & maxillofacial implants 1, 11–25 (1986).

3. Misch, C. E. et al. Implant success, survival, and failure: the Inter-national Congress of Oral Implantologists (ICOI) Pisa Con-sensus Conference. Implant dentistry 17, 5–15 (2008).

4. Oshida, Y., Tuna, E. B., Aktören, O. & Gençay, K. Dental implant systems. International journal of molecular sciences 11, 1580–678 (2010).

5. Papaspyridakos, P., Chen, C.-J., Singh, M., Weber, H.-P. & Gal-lucci, G. O. Success criteria in implant dentistry: a system-atic review. Journal of dental research 91, 242–8 (2012).

6. Nissan, J., Ghelfan, O., Mardinger, O., Calderon, S. & Chaushu, G. Efficacy of cancellous block allograft augmentation prior to implant placement in the posterior atrophic mandible. Clini-cal implant dentistry and related research 13, 279–85 (2011).

7. Esposito, M., Grusovin, M. G., Coulthard, P. & Worthington, H. V The efficacy of various bone augmentation procedures for dental implants: a Cochrane systematic review of randomized controlled clinical trials. The International journal of oral maxillofacial implants 21, 696–710 (2006).

8. Menchero-Cantalejo, E., Barona-Dorado, C., Cantero-Álvarez, M., Fernández-Cáliz, F. & Martínez-González, J.-M. Meta-analysis on the survival of short implants. Medicina oral, patología oral y cirugía bucal 16, e546–51 (2011).

9. Telleman, G. et al. A systematic review of the prognosis of short (<10 mm) dental implants placed in the partially edentulous patient. Journal of clinical periodontology 38, 667–76 (2011).

10. Park, J.-H., Lim, Y.-J., Kim, M.-J. & Kwon, H.-B. The effect of vari-ous thread designs on the initial stability of taper implants. The journal of advanced prosthodontics 1, 19–25 (2009).

11. Moon, S.-H., Um, H.-S., Lee, J.-K., Chang, B.-S. & Lee, M.-K. The effect of implant shape and bone preparation on primary stabil-ity. Journal of periodontal & implant science 40, 239–43 (2010).

12. Abuhussein, H., Pagni, G., Rebaudi, A. & Wang, H.-L. The effect of thread pattern upon implant osseointegration. Clini-cal oral implants research 21, 129–36 (2010).

13. Nedir, R., Bischof, M., Szmukler-Moncler, S., Bernard, J.-P. & Sam-son, J. Predicting osseointegration by means of implant primary stability. Clinical oral implants research 15, 520–8 (2004).

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The Journal of Implant & Advanced Clinical Dentistry ... Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 2 February 2014 Immediate Placement of Short Dental Implants