Custom Made Auricular Prosthesis

Volume 9, No. 3 April 2017

The Journal of Implant & Advanced Clinical Dentistry

GBR of Peri-Implantitis Defect

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Leon Chen MD, MS, Co-Editor-in-Chief | Dave Beller, Director |The JIACD Team The Journal of Implant & Advanced Clinical Dentistry Volume 9, No. 3 • April 2017 Table of Contents

6 A Custom Made Implant Supported Auricular Prosthesis Designed by Rapid Prototyping for Compromised Bone Support: A Case Report M. Lovely, Dinesh Gopal, Vinod Kumar, K. Chandrasekharan Nair, Biji.Thomas

12 Guided Bone Regeneration in Peri-Implantitis Bone Defect After Free Gingival Graft: A Case Report Daisuke Ueno, Tsuneaki Watanabe, Takatoshi Nagano

2 • Vol. 9, No. 3 • April 2017 The Journal of Implant & Advanced Clinical Dentistry Volume 9, No. 3 • April 2017 Table of Contents

20 Computer Based Textural Evaluation of Concentrated Growth Factors (CGF) in Osseointegration of Oral Implants in Dental Panoramic Radiography Francesco Inchingolo, Panagiotis G. Georgakopoulos, Gianna Dipalma, Stavros Tsantis, Tiziano Batani, Ezio Cheno, Ioannis P. Georgakopoulos

30 Extraction and Immediate Placement of Dental Implants in Mandibular Anterior Site with Delayed Prosthetic Loading Protocol in a Chronic Generalized Periodontitis Patient: A Case Report Dhaval Pandya

The Journal of Implant & Advanced Clinical Dentistry • 3 The Journal of Implant & Advanced Clinical Dentistry Volume 9, No. 3 • April 2017

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4 • Vol. 9, No. 3 • April 2017 The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Co-Editor in Chief Dan Holtzclaw, DDS, MS Leon Chen, DMD, MS, DICOI, DADIA

Tara Aghaloo, DDS, MD Michael Herndon, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDS Michael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MS Thomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Nicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Daniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDS Giuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMD John Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMD Jennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDS Leon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMD Stepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMD David Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhD Charles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDS Spyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDS Sally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Tomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDS Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Douglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhD Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhD Nicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhD Paul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDS David Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDS Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhD Ronald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS David Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDS Kenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDS Istvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS

The Journal of Implant & Advanced Clinical Dentistry • 5 Lovely et al A Custom Made Implant Supported Auricular Prosthesis Designed by Rapid Prototyping for Compromised Bone Support: A Case Report

M. Lovely, BDS, MDS, DipNb, PhD1 Dinesh Gopal, BDS, MDS, MOSRCS , FDS RCS (Edin)2 Vinod Kumar, M.B.B.S, M.S (Gen. Surgery), DipNb. (Plastic Surgery)3 K. Chandrasekharan Nair, BDS, MDS4 Biji.Thomas.George M.B.B.S, M.S (Gen Surgery), DipNb, FRCS (Glascow)5

Abstract

mplant supported auricular prosthesis requires case report in which rapid prototyping was used a minimum of 6mm bone depth in the tem- to build up the thickness and bone dimension Iporal bone area behind external auditory of the patient’s available bone depth to design meatus. Extra oral implants are available from a custom made single piece Titanium implant 4mm to 7mm length with 5 to 6mm diameter with superstructure attachment. The advantage flange. When the bone height is compromised of this new method was that it could copy the and when only few regions have favorable posi- available bone depth with the help of CT analy- tions which are not part of the slot area all the ses and design an implant as per the dimensions existing extra oral systems cannot be used. In obtained through the rapid prototyped model. cases with compromised bone condition, a cus- This new technique is economical and also tom made implant is the best choice that can offer offers the patient all the advantages and com- good prognosis. This article presents a unique fort of an implant retained auricular prosthesis.

KEY WORDS: Rapid prototyping, implant retained auricular prosthesis, custom made implant

1. 1. Asst.Prof Ras Alkhaimah College of Dental Sciences, RAK, UAE 2. 2. Consultant Oral and Maxillofacial surgeon, Trivandrum 3. 3. Consultant, Department of Plastic Surgery, Anandapuri Hospital, Trivandrum 4. 4. Professor Emeritus, Vishnu Dental College, Bhimavaram, Andhra Pradesh 5. 5. Consultant General surgeon SK Hospital Trivandrum

6 • Vol. 9, No. 3 • March 2017 Lovely et al

INTRODUCTION is only predictable after a CT of the tempo- The commonest reasons for auricular defects are ral bone is made to evaluate the thickness of congenital malformation, tumors or accidents. bone available for the type of implant that can If there is skin loss and scarring an autogenous be used. An axial CT enables to visualize the reconstruction is difficult and hence the only next distance from mastoid region to external audi- available option remains to be implant retained tory canal. If bone height is good in mastoid auricular prosthesis. Extraoral implant retained region the implant survival rate is the highest prosthesis have predictable results for maxillofa- when compared to all maxillofacial implants.8 cial rehabilitation.1,2 Amongst the implant retained The ideal location of the implant should be auricular prosthesis, the commonest ones used 20mm away from external acoustic meatus and are extra oral implants which can either be soli- with a space of 15mm between implants. 9 and tary or group implants. The most commonly used 11 clock positions are ideal for right side as the solitary implants are the Brånemark system, implants and the bar will be underneath antihe- ITI system by Straumann, IMZ by Friadent and lix ridge. Two stage procedure can result in scar Ankylosis by Dentsply. The implant dimen- tissue formation hence a single stage procedure sion for extra oral solitary implants vary from is preferred. Common type of super structure 3 to 5mm length with a diameter of 5.5mm. design is a metal bar as Dolder or Hader that is The grouped implants are Epitec and Epiplat- screwed onto the percutaneous posts which are ing systems which are subperiosteal implants parallel on which the prosthesis is clipped on.9,10 fixed with bone screws of 4, 5.5 and 7mm. Epitec was found to be flexible and hence pres- CASE REPORT ently not used but the epiplating system with A 30-year-old man, who lost his right ear due a plate thickness of 2mm with 4 thread turns to burn injury, who had undergone multiple are more reliable than the Epitec grid system. graft surgical procedures reported to the hos- Implant-retained auricular prosthesis provide pital with the chief complaint of wanting a per- convenience, consistent retention, eliminaties the manent replacement for his missing ear. Heavy need for adhesives, maintain marginal integrity scarring was observed with the missing right and longevity.3,4 These are two stage implants, ear. Due to scar formation, autogenous pro- later connected with a supra structure design cedures for ear reconstruction could not be like a metal bar or magnetic connection. Numer- done. The patient was young and wanted an ous attachments are available for the retention implant retained auricular prosthesis. The CT of implant-retained prosthesis. Implant-retained scan showed atrophied temporal bone with auricular prosthesis usually require a bar with the exception of a few areas with favorable clips or retentive elements in addition to the pros- bone depth but those areas were not ide- thetic ear.5,6,7 This article describes a new tech- ally located for a solitary implant. Hence after nique to make a custom made implant designed case history taking and treatment planning with the help of a rapid prototyped model. it was decided to do a custom made extra- The implant placement in mastoid region oral implant to retain the auricular prosthesis.

The Journal of Implant & Advanced Clinical Dentistry • 7 Lovely et al

Figure 1: Conversion of CT image for rapid prototyping. Figure 2: Rapid prototyped model.

Treatment plan: This was to help in designing the superstruc- To evaluate the areas of adequate bone depth a ture height from the base of the custom made CT of axial coronal and sagittal cuts of tempo- implant. The final design for the custom made ral bone up to mastoid process was taken. The implant was drawn on the model and the super- data was saved and transferred in DICOM (Digi- structure dimension was separately instructed tal Imaging and Communications in Medicine) to the lab via a lab authorization form which format for rapid prototyping. A 3D model was included the neck of the abutment superstruc- obtained from the data of computerized tomog- ture height and bar attachment design (Figure 3). raphy with the help of software Mimics, Materi- alise Inc (Figure. 1). The Proto typed model was Wax Pattern Trial for the Implant to be made of Polymethyl methacrylate (PMMA) indi- Custom Made cating the surface morphology of bone and the The replica of the custom made implant in wax varying bone depths available for implant screws. was tried in the patient to evaluate if the height of The exterior morphology of the bone was the supra structure was adequate. The position smooth with no depth or undercuts making it favor- of the bar superstructure was assessed to check able for a custom implant. Areas with adequate if the distance of the implant was 20mm away bone depth were marked in the PMMA model so from auditory canal and the single bar structure that screw slots could be made in those areas for with two abutment support were 15mm apart. the custom implant (Figure 2). Patient’s skin thick- The superstructure and the base of the implant ness was evaluated in the preauricular region after wax pattern were tentatively placed on skin in local anesthesia using needle prick technique. position to check if the bar will be underneath

8 • Vol. 9, No. 3 • April 2017 Lovely et al

Figure 3: Superstructure design. Figure 4: Wax pattern try in.

antihelix ridge. (Figure 4). The corrected pattern fixed in place. After the placement of the single was later casted in Titanium alloy superstructure. stage custom implant in ideal position, sutures were placed approximating the abutment super- Clinical Procedure structure. Every week patient was recalled to Marks were made with surgical ink and an inci- observe if any inflammation or skin pocket was sion line was made 7 mm behind the implant site seen. The implant was left for osseointegration for down to the periosteum. The procedure was done three months. On recall it was found tissues had under general anesthesia. The custom designed healed well with no post operative complications. Titanium frame work with multiple screw slots and A repeat CT showed good osseointegration and the superstructure bar design was slid into place adaptation of the custom made implant (Figure 6). within the temporal bone region as marked by areas of bone depth and multiple 1.5mm×4mm Prosthesis Fabrication titanium screws were used to hold the custom Hair adjacent to the ear was coated with petro- made implant in place (Figure 5). Before tighten- leum jelly and cotton was placed in the ear canal. ing the screw slot the implant position, superstruc- Impression of the superstructure design was ture position and the dimension of the abutment made with polyvinyl siloxane impression material neck height was rechecked. After confirming the (Elite H-D, Type 1, Zhermack). The impression was position along the axis with the other ear position boxed and poured in die stone. An ear pattern was using various facial plane measurements, the mul- created using the donor technique that matched tiple screws were tightened and the single stage closely to the patient’s ear in dimensions. The rest titanium implant with the bar superstructure was of the carving was perfected in the wax pattern

The Journal of Implant & Advanced Clinical Dentistry • 9 Lovely et al

Figure 5: Custom made implant in position. Figure 6: Post-operative CT image.

of ear to exactly match the opposite ear in size DISCUSSION and shape. The prepared wax pattern was then Maxillofacial defects can be restored by remov- adapted to the stone cast. Three retention clips able or fixed methods. Many patients with were positioned on the Ti bars, in a substruc- these defects have been rehabilitated suc- ture (Figure 7). The substructure along with cessfully with maxillofacial implants.2 The suc- the ear wax pattern was tried for accuracy of cess of implant retained prosthesis depended fit, orientation, and esthetics with the patient in on careful treatment planning.2,3 Advance- the physiologic rest position. Wax pattern was ments in computer technology to produce 3 placed into a flask and conventional procedures dimensional (3D) models by rapid prototyping for wax elimination of the mold were followed. technology (RP) perfects the final restoration. After the complete removal of wax, the silicon elastomer (A-RTV-30, Factor II) which was Rapid Prototyping (RP) colored intrinsically (Intrinsic Coloring Kit Fac- Advantages of CAD/CAM include elimi- tor II) was then bulk filled, and the material was nation of impression making, good posi- processed according to the manufacturer’s tive replica and ability to store the models directions. After processing, the prosthesis was in hard disks. In this case report rapid pro- removed from the mold; and extrinsic matching typed model has been used for accuracy of of the colour was completed. The final correc- bone depth to make a custom made implant. tions were made, and the silicon prosthesis’s was then adapted to the defect area (Figure 8).

10 • Vol. 9, No. 3 • April 2017 Lovely et al

Figure 7: Auricular prosthesis (tissue side). Figure 8: Final auricular prosthesis in place.

Disclosure CONCLUSION The authors report no conflicts of interest with anything mentioned in this article. This case report highlights the significance of References choices for patients with atrophied bone. A 1. Bulbulian AH. Facial Prosthesis. Springfield, IL: Charles C. Thomas; 1973. custom made implant enables the same com- 2. Beumer J, Curtis TA, Marunick MT. Maxillofacial rehabilitation: prosthodontic and surgical considerations. St. Louis: Medico Dental Media Intl; 1996. fort osseointegration success as that of a soli- 3. Tolman D, Desjardins R. Extraoral applications of osseointegrated implants. J tary implant retained auricular prosthesis with Oral Maxillofac Surg. 1991;49:33–45. 4. Parel S, Tjellstrom A. The United States and Swedish experience good prognosis. Rapid prototyping helps to with osseointegration and facial prostheses. Int J Oral Maxillofac Implants. 1991;6:75–79. clearly assess the varying bone depth avail- 5. Schaaf NG, Kielich M. Implant-retained facial prostheses. In: McKinstry RE, editor. able for screws making the procedure more Fundamentals of facial prosthetics. Arlington: ABI Professional Publications; 1995. pp. 169–179. precise. The recall appointments even after 6. Wolfaardt JF, Coss P. An impression and cast construction technique for implant- two years confirm high prognosis as there retained auricular prostheses. J Prosthet Dent. 1996;75:45–49. 7. Bergstrom K. Prosthetic techniques for orbital defects. Bone anchored was no postoperative complications and applications. In: Williams E, editor. Nobelpharma international updates. 93.2. 11,12 l Vol. 2. Goteborg: Nobelpharma; 1993. pp. 5–8. the patient is still comfortably using it. 8. Wang RR, Andres CJ. Hemifacial microsomia and treatment options for auricular replacement: a review of the literature. J Prosthet Dent. 1999;82:197–204. 9. Wright RF, Wazen JJ, Asher ES, Evans JH. Multidisciplinary treatment for Correspondence: an implant retained auricular prosthesis rehabilitation. N Y State Dent J. 1999;65:26–31.

Dr.Lovely M. BDS, MDS, DipNb, PhD. 10. Rubenstein JE. Attachments used for implant-supported facial prostheses: College of Dental Sciences, a survey of United States, Canadian, and Swedish centers. J Prosthet Dent. 1995;73:262–266 AlQuasidat, PO.Box 12973, RAK, UAE 11. Penkner K, Santler G, Mayer W, Pierer G, Lorenzoni M. Fabricating auricular prostheses using three-dimensional soft tissue models. J Prosthet Phone: +971508951751 Dent. 1999;82:482–484. Mail: [email protected] 12. Petzold R, Zeilhofer HF, Kalender WA. Rapid protyping technology in medicine- -basics and applications. Comput Med Imaging Graph. 1999;23:277–284.

The Journal of Implant & Advanced Clinical Dentistry • 11 Ueno et al Guided Bone Regeneration in Peri-Implantitis Bone Defect After Free Gingival Graft: A Case Report

Daisuke Ueno, DDS, PhD1 • Tsuneaki Watanabe, DMD2 Takatoshi Nagano, DDS, PhD3

Abstract

Background: Peri-implantitis is among the most submerged approach in peri-implantitis bone common pathological conditions encountered in defect (#31, 32) and the adjacent missing tooth the field of implant dentistry, where regenerative region with advanced bone resorption (#30). therapy, when possible to perform, is needed. One of the reasons why bone regeneration in peri-implan- Results: After a healing period of 5 months, an titis defects is difficult: due to prosthetic reasons, implant was placed in position #30 with fur- submerged healing is often not possible to per- ther bone augmentation. At 23 months after form. Another difficulty arises particularly in cases implant placement, the radiographic image of insufficient attached keratinized mucosa (KM), showed improvement of radiopacity in the graft- where the mobility of alveolar mucosa can increase ing area compared to the preoperative radiograph. leakage of grafting materials from the treated defect. Conclusions: Since lack of KM and narrowing of Methods: In this case report, a free gingival graft the oral vestibule promote effluence of bone graft- (FGG) was performed on the alveolar mucosa ing material in primary healing period, GBR after around peri-implantitis region of a 61-year-old acquisition of KM might be a potentially useful sur- male patient. Six months later, Guided bone gical technique for regenerative therapy with non- regeneration (GBR) was performed with a non- submerged procedure in peri-implantitis defect.

KEY WORDS: Guide bone regeneration, dental implants, bone grafting, gingival grafting

1. Division of Implantology and Periodontology, Kanagawa Dental University, Yokohama, Japan 2. Unit of Oral and Maxillofacial Implantology, Tsurumi University Dental Hospital, Yokohama, Japan 3. Department of Periodontology, Tsurumi University, School of Dental Medicine, Yokohama, Japan

12 • Vol. 9, No. 3 • April 2017 Ueno et al

INTRODUCTION Surgical regenerative therapy of peri-implantitis appears to be more predictable than any type of non-surgical treatment approach.1-3 Previ- ously, intrabony peri-implantitis defect has been tried to treated by regenerative therapy with several bone substitutes.3,4 Several studies, the majority of which involving deproteinzed bovine bone mineral (DBBM), have reported the efficacy of bone substitutes with gain in vertical bone level in intrabony peri-implantitis defect.1,2,5-7 One of the reasons why bone regeneration in peri-implantitis defects is difficult: submerged healing is often not possible to perform owing to prosthetic reasons. Particularly, insuf- Figure 1: Pre-operative radiographic image of advanced ficient attached keratinized mucosa (KM), periodontitis and peri-implantitis sites. where the mobility of alveolar mucosa probably increases leakage of grafting materials. To mucosa has healed. Due to lack of KM observed improve predictability in such cases, this case in the sites, Free gingival graft (FGG) harvested report demonstrates a novel strategy of bone from the light palatal mucosa was performed on augmentation in peri-implantitis bone defects. the buccal alveolar mucosa (Figures 2a-d). No complications occurred during healing period. CLINICAL PRESENTATION Since FGG was able to reduce the mobility of A 61-year-old male patient was referred to D.U at peri-implant mucosa, regenerative treatment was Tsurumi University Dental Hospital in April 2013 for performed in September 2013 (4 months later). chronic pain in tooth #30 and implant sites (#31, After administration of local anesthesia, a inci- 32). Diagnosis of Endo-Perio lesion was observed sion was performed from middle of alveolar crest around tooth #30 (Figure 1). In addition, diagnoses of the site #30 to the interproximal aspects of the of peri-implantitis was made; radiographic image #29, 31. The incision was extended intrasulcu- showed 2.4 and 1.8 mm vertical bone loss found larly, and vertical releasing incisions were made in respectively in mesial and distal aspects of the the mesial aspect of tooth #29 and distal aspect implant #32. 3.6 and 1.8 mm vertical bone loss were of implant #32. Full-thickness flaps were elevated found respectively in mesial and distal aspects of in the buccal and lingual aspects. The ridge was the implant #31. Since significant bone resorption resorbed in vertical dimension (Figure 3A). Granu- was observed after extraction of #30, bone aug- lation tissue was separated from implant and bone mentation was required for implant placement in site surfaces using hand curettes, and removed in a #30 and the proximal peri-implantitis bone defects. lump. The machined surface of the implant was Six weeks after extraction (in May 2013), the cleaned with saline soaked gauze. Then, the sur-

The Journal of Implant & Advanced Clinical Dentistry • 13 Ueno et al

Figure 2a: Pre-operatively a lack of keratinized mucosa Figure 2b: A free gingival graft (FGG) was performed on was observed in sites #30, 31. buccal alveolar mucosa.

Figure 2c: 10 days after free gingival graft. Figure 2d: 21 days after free gingival graft.

face was irradiated by Er:YAG laser (Morita Evo Biomaterials, Wolhuser, Switzerland): autogenous Yag laser, Morita, Tokyo, Japan) at 10PPS and bone particle = 80:20] (Figure 3C). Graft sites 30mJ (Figure 3B). Intra-marrow penetration of were covered with a collagen membrane (Figure the recipient site was achieved with a small round 3D). Finally, after periosteal-releasing incisions, bur. The peri-implantitis intrabony bone defect flaps were sutured with 4-0 nylon sutures with- was filled autogenous bone particle which was out flap tension. After the operation, antibiotics harvested from the buccal cortical bone of site (Cefdinir, a third-generation oral cephalosporin #30-32 by bone scraper. Then, the supracrestal antibiotic) were prescribed as 100mg, 3 times area of peri-implantitis bone defect and adjacent per day, for 3 days. Healing proceeded with- missing tooth region were filled with the grafting out any complications after bone augmentation. materials [ratio of DBBM (Bio-Oss®, Geistlich, Implant body was inserted 6 months (March

14 • Vol. 9, No. 3 • April 2017 Ueno et al

Figure 3a: Significant bone resorption was observed in site Figure 3b: Cleaning of implant surface with Er:YAG laser. #30-32.

Figure 3c: Bone augmentation with DBBM in the bone Figure 3d: The grafted sites were covered by collagen defects. membrane.

2014) after the grafting procedure. Significant tension. The post-surgical course was uneventful. augmentation of ridge height was achieved (Fig- At 4 months (September 2014) after implant ure 4). A 10-mm long, 4.1-mm diameter implant placement, the screw-retained temporary crown (Straumann® Standard plus Implant, Basel, Swit- was replaced by a cement-retained metal-ceramic zerland) was placed (30 Ncm) in site #30. Then, crown (Figures 5a,b). The radiographic image further bone augmentation using DBBM was showed significant fill around implants #30, 31 performed on the buccal aspect of the implant and 32. The vertical bone level had not changed (Figure 4C). The graft sites were covered with a at 23 months after implant placement (Figure 6). collagen membrane (BioMend absorbable col- Improvement of radiopacity in the grafting area lagen membrane, Zimmer Dental, CA, USA) and was observed on the radiograph, where the ver- the full thickness flaps were sutured without flap tical radiographic defect fill was 3.6 and 1.2mm

The Journal of Implant & Advanced Clinical Dentistry • 15 Ueno et al

Figure 4a: Occlusal view immediately after flap reflection. Figure 4b: Lateral view after flap reflection.

several researches have reported the efficacy of regenerative treatment in peri-implantitis intrabony defects has been supported by several articles.1,2,5-7 Matarasso et al. reported the possibility of GBR using DBBM and collagen membrane in peri-implantitis defects where 93% of intrabony defect fill was achieved.5 Roc- cuzzo et al. also reported GBR with DBBM in crater-like defect after treatment of implant surface by a 24% EDTA gel and a 1% chlorhexidine gel.6 Average of bone defect fill was 1.9mm. Figure 4c: Occlusal view after implant placement with From a biological point of view, the result of a addition bone augmentation. surgical regenerative treatment approach might also be influenced by the defect configuration of respectively in mesial and distal aspects of the the peri-implantitis lesion. Schwarz et al. demon- implant #31 compared to the preoperative radio- strated that defects with buccal bony dehiscence graph. In addition, 1.8 mm vertical defect fill was show a poorer prognosis as regards defect fill observed in the mesial aspect of implant #32. compared with circumferential bony defects.8 Also regarding bone augmentation in missing DISCUSSION teeth region, external bone augmentation remains In this case, GBR demonstrated vertical radio- more difficult than internal bone augmentation.9 graphic defect fill in the peri-implantitis bone Since the contact surface area between residual defect and the adjacent missing tooth region bone and graft material is small, particularly in with advanced bone resorption. Previously, cases which require more vertical bone regen-

16 • Vol. 9, No. 3 • April 2017 Ueno et al

Figure 5a: Intraoral view immediately after fixation of final Figure 5b: Radiographic view immediately after fixation of prosthesis. final prosthesis.

eration, this configuration limits the blood supply and cell supply from residual bone to graft material. In addition, external augmentation is suscep- tible to tissue pressure such as masticatory and tongue pressure, which may result in promot- ing bone resorption and morphological change. Therefore selection of bone grafting material with high osteoconductive and mechanical properties are important. Titanium reinforced non-resorbable membrane is useful for prevention of external pressure on grafting material in vertical ridge augmentation.10 However, membrane exposure Figure 6: Radiographic image at 23 months after implant is a frequent phenomenon, which is in agree- placement. ment with previous studies.11 Considering the promote soft tissue mobility around implants dur- lower risk of post-operative mucosal dehiscence, ing healing period, effluence of bone grafting the use of resorbable membranes is superior.12 material may be caused easily. Therefore, FGG Bone formation in submerged procedures is prior to regenerative treatment in peri-implanti- probably more reliable compared to that of non- tis defects seems to improve the biological seal submerged procedures, because in the former around implants and resistance to soft tissue there may be less bacterial contamination and mobility around implants, as well as avoids more less dislodgement of bone graft material. How- plaque accumulation and tissue inflammation.13 ever, owing to prosthetic reasons, submerged Surface decontamination is indispensable healing is often not possible to perform. Since for bone regeneration and re-osseointegration. lack of KM and narrowing of the oral vestibule Er:YAG laser having a sharpened irradiation tip

The Journal of Implant & Advanced Clinical Dentistry • 17 Ueno et al

is thought to be an ideal tool for decontamina- Disclosure tion of implant surface in narrow cleaning spaces. The authors report no conflicts of interest with anything mentioned in this article. Er:YAG laser has high absorption rate by water References 1. Schwarz F, Sahm N, Bieling K, Becker J. Surgical regenerative treatment of molecules with minimum temperature increase. peri-implantitis lesions using a nanocrystalline hydroxyapatite or a natural bone mineral in combination with a collagen membrane: a four-year clinical follow-up It leads to sterilization of the implant surface report. J Clin Periodontol. 2009;36:807-14. with less carbonization.14 An In vitro study con- 2. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Surgical treatment of peri-implantitis using a bone substitute with or without a resorbable membrane: cluded that Er:YAG irradiation at pulse energies a prospective cohort study. J Clin Periodontol. 2007;34:625-32. below 30 mJ/pulse and 30 Hz with water spray 3. Mombelli A, Moëne R, Décaillet F. Surgical treatments of peri-implantitis. Eur J Oral Implantol. 2012;5 Suppl:S61-70. in near-contact mode causes no damage and 4. Larsson L, Decker AM, Nibali L, Pilipchuk SP, Berglundh T, Giannobile WV. can be effective for debriding microstructured Regenerative Medicine for Periodontal and Peri-implant Diseases. J Dent Res. 2016;95:255-66. 15 surfaces. However, it is still unknown to what 5. Matarasso S, Iorio Siciliano V, Aglietta M, Andreuccetti G, Salvi GE. Clinical and radiographic outcomes of a combined resective and regenerative approach extent these contaminants have to be removed in the treatment of peri-implantitis: a prospective case series. Clin Oral Implants to achieve a successful treatment outcome.16 Res. 2014 ;25:761-7. 6. Roccuzzo M1, Bonino F, Bonino L, Dalmasso P. Surgical therapy of peri- Nonetheless, in this case report, the clini- implantitis lesions by means of a bovine-derived xenograft: comparative results of a prospective study on two different implant surfaces. J Clin Periodontol. cal outcome was carried out successfully with a 2011;38:738-45. regular implant placed in an augmented region 7. Romanos GE, Nentwig GH. Regenerative therapy of deep peri-implant infrabony defects after CO2 laser implant surface decontamination. Int J where peri-implantitis and severe bone resorp- Periodontics Restorative Dent. 2008;28:245-55. tion had taken place. After 23 months, the result 8. Schwarz F, Sahm N, Schwarz K, Becker J. Impact of defect configuration on the clinical outcome following surgical regenerative therapy of peri-implantitis. J seems quite promising, yet further prospec- Clin Periodontol. 2010;37:449-55. tive studies are needed to evaluate the use- 9. Pommer1 B, Zechner1 W, Watzek1 G and Palmer R. To Graft or Not to Graft? Evidence-Based Guide to Decision Making in Oral Bone Graft Surgery. In: fulness of this technique. In addition, defect Bone Grafting, ed by Alessandro Zorzi, In Tech Europe, Croatia, 2012, pp160- with bone substitute are hard to evaluate for 182. 10. Rakhmatia YD, Ayukawa Y, Furuhashi A, Koyano K. Current barrier new bone formation on radiographs.3 Evidence membranes: titanium mesh and other membranes for guided bone regeneration in dental applications. J Prosthodont Res. 2013;57:3-14. for re-osseointegration onto previously con- 11. Roos-Jansåker AM1, Renvert S, Egelberg J. Treatment of peri-implant taminated implant surface is nonexistent of infections: a literature review. J Clin Periodontol. 2003;30:467-85. 12. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of naturally occurring human peri-implantitis. l jaw bone using guided tissue regeneration. Clin Oral Implants Res. 1990;1: 22–32. 13. Ueno D, Nagano T, Watanabe T, Shirakawa S, Yashima A, Gomi K. Effect of Correspondence: keratinized mucosa width on the health status of periimplant and contralateral periodal tissue: a coress-sectional study. Implant Dentistry. 2016;25:1-6 Dr. Daisuke Ueno 14. Yoshino T, Aoki A, Oda S, Takasaki AA, Mizutani K, Sasaki KM, Kinoshita Division of Implantology and Periodontology, A, Watanabe H, Ishikawa I, Izumi Y. Long- term histologic analysis of bone tissue alteration and healing following Er:YAG laser irradiation compared to Graduate School of Dentistry, Kanagawa electrosur- gery. J Periodontol 2009;80:82–92. 15. Taniguchi Y, Aoki A, Mizutani K, Takeuchi Y, Ichinose S, Takasaki AA, Schwarz Dental University Yokohama Clinic, Yokohama, F, Izumi Y. Optimal Er:YAG laser irradiation parameters for debridement of Japan microstructured fixture surfaces of titanium dental implants. Lasers Med Sci. 2013;28:1057-68. 3-31-6 Tsuruya-cho, Kanagawa-ku, Yokohama, 16. Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Japan Periodontol 2000 2002;28:177–189. Fax: +81 -45-313-0007 E-mail: [email protected]

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Volume 8, No. 8 December 2016 Volume 8, No. 1 march 2016

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Modified Mandibular Implant Bar Implant-Supported Overdenture Milled Bar Overdenture

Full Mouth Rehabilitation Treatment of the Atrophic of Periodontitis Patient Maxilla with Autogenous Blocks

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Titanium Mesh Ridge Augmentation of Severe Augmentation for Dental Ridge Defect with rhBMP-2 Implant Placement and Titanium Mesh

Mandibular Overdentures Treatment of Mandibular with Mini-Implants Central Giant Cell Granuloma

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Start your FREE subscriptionThe today Journal of Implant at www.jiacd.com& Advanced Clinical Dentistry • XX InchingoloComputer et al Based Textural Evaluation of Concentrated Growth Factors (CGF) in Osseointegration of Oral Implants in Dental Panoramic Radiography

Francesco Inchingolo1,4 Panagiotis G. Georgakopoulos1,2,4 • Gianna Dipalma1,4 Stavros Tsantis3 • Tiziano Batani4 • Ezio Cheno1,4 Ioannis P. Georgakopoulos1,4

Abstract

Background: Concentrated growth factors tures were extracted so as to capture the textural (CGF) have positive impact in the field of regen- differentiation between radiographs that corre- erative medicine. The osseointegration proper- spond to immediate and after 8 months loading. ties of CGF around loaded oral implants were evaluated in this study by means of computer- Results: All selected features achieved Area- ized textural analysis in Panoramic Radiographs. Under-Curve (AUC) values within 0.77–0.81 range in the group with CGF employment Materials and Methods: Nineteen patients are and manage to capture the significant tem- randomly assigned to two groups. Test group poral textural differentiation that can be attrib- comprise patients that received CGF application uted to CGF properties. The control group, within osteotomy site and around new implants. exhibit poor AUC values within 0.51–0.68 Control group comprise patients with no CGF range, which in turn shows low osseointegra- employment. The region under textural evaluation activity in the bone-to-implant contact area. tion was the area between the implants in contact with the bone area. A clinical sample of 38 Digi- Conclusion: The positive results of CGF tized Panoramic Radiographs was analyzed, 19 employment have significant clinical inter- corresponding to immediate implant loading and est proving the increment of osteoregenera- 19 after an 8-month follow-up period. The con- tive potential of surrounding tissues after dental tact area was derived by means of a complicated implanting. Quantified evidence derived from segmentation algorithm. From each acquired the present study can orient the daily surgi- region from implant windings, 42 textural fea- cal procedure towards CGF employment.

KEY WORDS: Concentrated Growth Factors, Dental Implants, Texture Analysis, segmentation, Fuzzy C-means, Panoramic Radiography.

1. Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Italy 2. University Alfonso X El Sabio, Dental School, Madrid – Spain 3. Technological Education Institution of Athens, Department of Biomedical Engineering, Athens - Greece 4. World Academy of Growth Factors & Stem Cells in Dentistry

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BACKGROUND a valuable aid in the field of regenerative medi- Implantology plays a crucial role in dentistry effec- cine, to speed up the process of regeneration. tiveness throughout the last few decades. Given The main feature of the CGF resides in its con- the fact that a number of restorative options for sistency: it is an organic matrix rich in fibrin, able missing teeth treatment still exist, none have to “trap” platelets, leukocytes and growth factors. proven to be as functionally effective and robust Platelets comprise several growth factors, as implants. It has been proven that in most such as TGF-b1, VEGF and stem cells CD34+, cases, dental implants may be the only consis- that have been reported to enhance tissue regen- tent and successive choice for the teeth and sup- eration.3 CGF has also been reported to aid porting structures functionality restoration. Dental various healing situations such as filling of extrac- implants in use today are made primarily from tita- tion sockets4 and cavities after cystectomy,5 or nium or titanium alloy.1 Most studies have exhib- in sinus lifting procedures.6-8 Moreover, it has ited a five-year success rate of 95% for lower the capacity to be employed solely or combined jaw implants and a 90% success rate for upper with autologous bone particles or biomaterials.9 jaw implants. The lower success rate for upper Several studies that have evaluated the prop- jaw implants compared to the lower jaw is due to erties of CGF by means of Scanning Electron lower density in that region (especially the pos- Microscopy (SEM), have shown that the CGF terior section), constituting a successful implan- presents a fibrin network formed by thin and thick tation and osseointegration difficult to achieve.2 fibrillar elements.10 Histo-morphological studies11 Dental implants are until know the best pos- have allowed to see the fibrin network structure sible solution towards successful missing teeth and the distribution of blood cells (leukocytes, treatment. However, the surgical procedure is erythrocytes and platelets) in the CGF. Finally, highly affected by the osseoregenerative proper- in vitro studies using different human cell lines, ties of the surrounding tissues. In cases of poor have shown that the addition of the CGF to the properties, the surgical implant placement pro- culture medium, stimulated cell proliferation.11 cedure has decreased probability of success. In An experimental case control study, in terms addition, primary implant stability (high value of of a computerized texture analysis, that evalu- insertion torque) is considered of value for a suc- ated CGF osseoregeneration properties around cessful procedure.2 Another limitation is the pos- dental implants is carried out. The current study’s sibility that dental implants may break or become aim is to quantify any texture differentiation after infected (like natural teeth) and their crowns may CGF employment into the bone-to-implant con- become loose. The aforementioned limitations tact region, between a 0 and 8 month follow up have been generated several procedures in order period and to evaluate any difference between to aid implant and bone grafts healing. Strength- test and control groups (with and without CGF ening of the bone-to-implant contact area so as employment) that can be attributed to the CGF to accelerate the osseous healing has been the properties. The follow up period selected for the key factor towards a successful procedure. The purposes of this study has been considered ade- Concentrated Growth Factors (CGF) may be quate for CGF osseoregeneration properties eval-

The Journal of Implant & Advanced Clinical Dentistry • 21 Inchingolo et al

smoking and non-cancerous patients. All patients participating in the current study had maxillary and mandibular tooth loss and had chosen the surgical implant solution. All requirements for participation in the study have been given and every patient had a consent form signed. A follow up clinical sample for both groups of 38 digitized panoramic radiographs has been acquired and analyzed, corresponding to the 19 patients imaged immediately after implant loading and 8 months later.

SURGICAL PROCEDURES & Left Figure 1a: Phases of CGF. CGF PREPARATION Right Figure 1b: Tube for the creation of CGF. Surgical procedures towards surgical implant placement were performed under local anesthesia uation by the expert dentist conducted this study. (Ubistesin forte – 1.7 ml). An approximate number Texture analysis employed in panoramic radio- of 2 to 6 implants were placed in each selected graphs has been made by means of first order, co- patient. The bone surface area was exposed by occurrence and run length textural features along of type –H– Incision causing bone defects of with Receiver Operating Characteristic (ROC) approximately 3.60 mm. Specific Implants with curve analysis. To the best of our knowledge until 4 mm and 4.5 mm thickness, and 10 mm and now there has been no texture-based quantifica- 12 mm length and diameter dimensions were tion studies that investigate bone density altera- then placed (B&B Duravit EV Implants Italy) after tion around implants after CGF employment. been immersed in CGF-CD34+ matrix that was also placed within each osteotomy site before METHODS implant loading. CGF preparation involves ini- CLINICAL DATASET tially the patient’s blood centrifugation using eight A clinical dataset of 19 patients was selected sterile tubes (9 ml each) in a specific centrifuge for the study that was randomly assigned to two device (Medifuge, Silfradent srl, St. Sofia, Italy) for groups (test group–10 patients, control group–9 approximately 13 minutes in constant speed. For patients). The test group received CGF applica- optimum quality of CGF matrices the blood sam- tion around new implants and within the surgi- ples were centrifuged immediately after the blood cal site whereas in the control group the new was drawn. Following centrifugation, in each ster- implants were placed without CGF Employment. ile tube three layers can be seen from top to bot- Ages within the clinical dataset ranged from 29 – tom: (a) the upper layer, which is the liquid phase 61 years. Inclusion criteria for participating in to of plasma named platelet poor plasma (PPP); (b) the study were mainly the absence of diabetes, the middle layer, in which solid CGF lies with the osteoporosis, cardiac and thoracic diseases, non- following intermediate sublayers: the upper white

22 • Vol. 9, No. 3 • April 2017 Inchingolo et al

sublayer, the middle “buffy coat*” sublayer and the red sublayer which coincides with the lower layer, where red blood cells (RBC) are aggregated containing mainly erythrocytes; (Figures 1A,B). A large number of growth factors and stem cells CD34+ are aggregated in the middle sublayer (between the dense polymerized fibrin buffy coat and the upper 3-4 mm of red blood corpuscles mass of the bottom layer). This growth factors-rich segment is then separated from the rest of the red corpuscles using scissors (Figure 2A) in order to obtain the CGF-CD34+ matrix (Figure 2B). Povidine-iodine solution (Betadine) was at first employed extra-orally towards surgical site dis- infection. Infiltration was then performed using a 2% lidocaine solution containing a ratio of 1:100,000 epinephrine. A CGF-CD34+ matrix, derived from the aforementioned procedure, was then equally cut. The one half of the matrix after being mixed with Novocor alloplastic bone grafting material (Figure 2C) was inserted through the osteotomy site using the fibrin injector (B&B-Italy – Figure 2D). The other half of the CGF-CD34+ matrix was squeezed with the CGF-forceps (Silfradent, Italy – Figure 2E) deriving the Liq- uid Phase of the Concentrated Growth Factors (LPCGF) and collected in a sterilized container. Each implant was fully immersed into the LPCGF

Top left Figure 2a: Separation of the CGF matrix using scissors. Top right Figure 2b: The CGF-CD34+ matrix. Middle left Figure 2c: A mixture of highly concentrated Bottom left Figure 2e: Process of LPCGF with CD34+ growth factors, stem cells CD34+ and B&B Novocore bone production utilizing the CGF-forceps. grafting material. Bottom right Figure 2f: B&B Duravit EV Implant Middle right Figure 2d: Placement of the aforementioned immersions into LPCGF, towards the creation of a bioactive mixture in the osteotomy site. membrane around it.

The Journal of Implant & Advanced Clinical Dentistry • 23 Inchingolo et al

to form a “bioactive” membrane around it (Fig- ure 2e).12 Finally, all implants were then placed using a hand wrench and with insertion torque value between 20-25 N/cm2. Low insertion torque values are considered necessary due to the small bone heights at all implant sites. For each patient from both groups two panoramic radiographs were acquired. The first one (Class I, 54 implants) was taken immediately after implant placement (baseline panoramic radiograph) and the second one (Class II, 54 implants), eight months later leading to a total of 38 radiographs. All panoramic radiographs were taken by the same technician according to a standard- ized protocol for patient positioning and exposure parameter setting. To further ensure the reliabil- ity of the subsequent texture analysis results, an intensity based registration method that utilized the mean square error metric was employed so as to compensate any minor geometrical distortions between the two panoramic radiographs of each patient. As a result, all pair of radiographs had a one-to-one geometrical correlation. The panoramic x-ray equipment used within this study was the Orthophos C (Siemens co, AG Wittelsbacher- platz 2, 80333 Munich, Germany) with parameter settings selected at 66-69 kVp and 16 mA. The provided digitized images were in TIFF format.

Top left Figure 3a: Dental Implant. Top right Figure 3b: FCM clusters. Middle left Figure 3c: Implant outline derived from convex hull processing. Middle right Figure 3d: Areas of bone to implant contact. Bottom Figure 3e: Fitted ROIs (black color pointed with white arrows).

24 • Vol. 9, No. 3 • April 2017 Inchingolo et al

Figure 4: ROC analysis results for the CGF Group.

BONE-TO-IMPLANT CONTACT REGION and the already detected implant contour pro- (ROIs) EXTRACTION vides us with the ROIs from which the textural A complicated of bone to implant contact region features will be computed (Figure 3D, E). Two detection algorithm was designed for the pur- ROI classes for both groups were created corre- posed of this study. This particular region is sponding to the radiographs acquired immediately located both in between and adjacent to implant after the implant placement and 8 months later. windings, and is suitable for textural evaluation for any bone regeneration procedure. At first, TEXTURE AND STATISTICAL ANALYSIS the dental implant (Figure 3A) is extracted from From each ROI extracted from the previous seg- the surrounding tissue by means of the Fuzzy mentation procedure, first and second order tex- C-means (FCM) method13 (Figure 3B). After tural features derived from the gray-scale values the dental implant boundary extraction, the con- histogram, co-occurrence and run-length matrices vex-hull14 is computed so as to isolate the par- were computed in order to acquire any intensity ticular Regions of Interest (ROIs – Figure 3C). alteration that is indicative of CGF osseoregen- The subtraction between the convex-hull contour erative properties. In each ROI a normaliza-

The Journal of Implant & Advanced Clinical Dentistry • 25 Inchingolo et al

Table 1: Textural Features Employed Table 2: Subset of Features in the Texture-Based Evaluation Selected by SRA Analysis of Bone Formation Properties of CGF

Textural Feature a/a Feature Name Gray-Level Histogram Features 1 Mean value(m) 1 Mean value(m) 2 Angular Second Moment 2 Standard Deviation (std) 3 Inverse Different Moment 3 Skewness (sk) 4 Short Run Emphasis

4 Kurtosis (k) 5 Grey Level Non Uniformity 6 Run Length Non Uniformity Co-Occurrence Features (Mean & Range) 5 Angular Second Moment (ASM) 6 Contrast (CON) μ was the mean value of the gray levels inside 7 Inverse Different Moment (IDM) the ROI and σ the standard deviation. Any pixel 8 Entropy (ENT) values outside the range [μ–3σ, μ+3σ] were 9 Correlation (COR) excluded from the feature extraction procedure. 10 Sum of Squares (SSQ) All textural features computed for the purposes 11 Sum Average (SAV) of the current study are depicted in Table 1. 12 Sum Entropy (SENT) Minimum-redundancy-maximum-relevance 13 Sum Variance (SVAR) (mRMR) feature selection15 was utilized in the 14 Difference Variance (DVAR) initial dataset of 42 features to avoid any pos- 14 Different Entropy (DENT) sible feature redundancy leading to a reduced 16 Information Measure of Correlation (ICM1) feature subset (Table 2). The proposed fea- 17 Information Measure of Correlation (ICM2) ture selection algorithm employs mutual infor- Run-Length Features (Mean & Range) mation and distance/similarity scores so as to 18 Short Run Emphasis(SRE) rank a feature’s relevancy in a selected feature 19 Long Run Emphasis(LRE) set compared to its redundancy with the other 20 Grey Level Non Uniformity (GLNU) features. The reduced feature subset (Table 2) 21 Run Length Non Uniformity (RLNU) acquired from the feature selection procedure

22 Run Percentage (RP) is then analyzed by means of ROC analysis. The selected feature subset, captures valuable information, as regards any alteration tion procedure has been made in order to avoid within the bone-to-implant region throughout any pixels that belong to the dental implants the 8-month period that caused by the CGF that might create outliers. The normalization employment. Statistical differentiation for the was employed within the μ±3σ interval where selected subset was exploited by means of

26 • Vol. 9, No. 3 • April 2017 Inchingolo et al

Table 3: Subset of Textural Features Minimum-redundancy-Maximum-Revelance Analysis & ROC Analysis in the CGF & Control Groups

CGF Group Control Group Textural Feature AUC AUC (Lower-Upper 95.0% (Lower-Upper 95.0% Confidence Limit) Confidence Limit) Mean Value 0.82 0.66 (0,69 - 0,87) (0,55 - 0,69) Angular Second Moment 0.84 0.61 (mean) (0,74 - 0,88) (0,58 - 0,66) Inverse Different Moment 0.87 0.56 (mean) (0,78 - 0,93) (0,49 - 0,61) Short Run Emphasis 0.83 0.51 (mean) (0,78 - 0,93) (0,44 - 0,62) Grey Level Non Uniformity 0.89 0.55 (0,79 - 0,89) (0,49 - 0,60)

Run Length Non Uniformity 0.85 0.68 (0,79 - 0,89) (0,59 - 0,73)

ROC curve analysis. ROC analysis is con- ALGORITHM IMPLEMENTATION sidered a powerful statistical tool so as to Registration, segmentation Feature extrac- evaluate the discriminant attributes of each tion and selection were all implemented textural feature from the selected subset. in Matlab R2014b (MathWorks, 3 Apple Features with high values of Area Under the Hill Drive Natick, Massachusetts 01760, Curve (AUC) encode high separability prop- USA). ROC analysis was made by means erties between the two classes. The binormal of NCSS, PASS and GESS software pack- parametric method was chosen for the pur- age (NCSS, 329 North 1000 East, Kaysville, poses of this study to acquire the AUV values Utah84037, USA). The computer used for and graphs. This particular method is consid- processing had a Quad-Core Intel proces- ered as computationally more affordable and sor running at 4.2 GHz and 16 GB of RAM. robust in small sample size feature sets.16,17

The Journal of Implant & Advanced Clinical Dentistry • 27 Inchingolo et al

Figure 5: ROC analysis results for the Control Group.

RESULTS AND DISCUSSION employment group exhibit AUC values greater With regard to Bone-to-Implant contact region than 0.82, yielding increased differentiation capa- detection accuracy, the results provided by the bility between the two classes (0 and 8 month proposed segmentation algorithm were com- period) (Figure 4). The same feature subset in the pared with manual segmentations by an experi- control group with no CGF employment yields enced dentist in terms of overlap degree between smaller AUC values ranging from 0.51 – 0.68 the two sets. Very high correlation was found (Table 2). The latter results are indicative of the with little bias on inter-observer (r = 0.996 and poor discrimination between the two classes p < 0.0001) variability showing that manual ROI which in turn can be attributed to low osseoin- segmentation is reliable and can be regarded as tegration activity in the bone-to-implant regions the gold standard. The segmentation compara- compared with the CGF group (Figure 5). Com- tive study results demonstrated a high segmenta- puterized texture analysis performed within this tion accuracy, corresponding to overlap=0.934 ± study in the CGF group as regards the impact 0.010. The feature subset in the test with CGF CGF has in the osseointegration procedure

28 • Vol. 9, No. 3 • April 2017 Inchingolo et al

around dental implants has demonstrated a sig- tised panoramic radiographs acquired from a nificant difference in the selected texture sub- divided clinical dataset (CGF and Control group) set between the two groups (0 and 8 months). were utilised by means of several textural fea- On the contrary, in the test group the same features so as to capture any statistical differentia- ture subset has pinpointed the poor osseo- tion between immediate implant loading and after integration activity bilaterally dental implants. 8 month follow up period. This differentiation is The results derived from the current study investigated with ROC analysis which is con- are in total accordance with previous studies6-8 sidered as powerful measure of differentiation. in which the positive impact of the CGF in various dental cases has been reported. The six fea- CONCLUSION tures that comprise the selected subset: Mean The positive results as regards CGF employ- Value, Angular Second Moment, Inverse Differ- ment are considered of a significant clinical ent Moment, Short Run Emphasis, Grey Level interest proving the increment of osteoregenera- Non Uniformity and Run Length Non Uniformity tive potential of surrounding tissues after den- manage to capture in terms of texture differen- tal implanting. The latter can orient the daily tiation the increased bone remodeling around surgical procedure towards CGF employment. l implants after the CGF employment. The charac- teristics of the aforementioned features imply an Correspondence: active bone-regeneration procedure within the Dr. Stavros Tsantis implant windings be means of increased vari- Department of Biomedical Engineering, ability and high gray-level values (Table 3). For Technological Education Institution of Athens, the first time a fully automatic texture analysis Athens, Greece Email: [email protected], [email protected] aimed to evaluate the clinical impact of CGF Tel.: +30 6977635864 employment in dental implantology has been Fax: +30 2132028608 conducted for the purposes of the study. Digi-

Disclosure 7. Del Fabbro M, Bortolin M, Taschieri S, Weinstein 12. Georgakopoulos ΙG, Makris N, Almasri The authors declare that there is no conflict of RL. Effect of autologous growth factors in maxil- M, Tsantis S, Georgakopoulos IP (2016) interests regarding the publication of this article. lary sinus augmentation: a systematic review. Clin “IPG” DET Minimal Invasive Sinus Implant Implant Dent Relat Res 2013; 15: 205-216 Placement and Grafting without Sinus References 8. Sohn DS, Heo JU, Kwak DH, Kim DE, Kim JM, Floor Elevation – The Evolution of New 1. Arturo N. Natali. Dental Biomechanics. London/ Moon JW, Lee JH, Park IS. Bone regenera- Age Concepts. Dentistry 6: 375. 2016 New York: Taylor & Francis, 2003: 69-87. tion in the maxillary sinus using an autologous 13. J. C. Bezdek, R. Ehrlich and W. Full, “The 2. Esposito M., Grusovin M.G., Willings M., fibrin-rich block with concentrated growth fac- fuzzy c-means clustering algorithm,” Com- Coulthard P., Worthington H.V. ‘The effectiveness tors alone. Implant Dent 2011; 20: 389-395 put. Geosci. 10, 191-203 (1984). of immediate, early, and conventional loading of 9. Gheno E, Palermo A, Buffoli B, Rodella LF. 14. Andrew, A. M. (1979), “Another efficient algo- dental implants: a Cochrane systematic review The effectiveness of the use of xenoge- rithm for convex hulls in two dimensions”, Infor- of randomized controlled clinical trials’, Int. J. of neic bone blocks mixed with autologous mation Processing Letters, 9 (5): 216–219 Oral &Maxillofac Implants 2007:22(6):893–900 Concentrated Growth Factors (CGF) in 15. H.C., Long, F., and Ding, C., “Feature selec- 3.Sohn DS, Moon JW, Moon YS, Park JS, bone regeneration techniques: a case tion based on mutual information: criteria Jung HS. The use of concentrated growth series. J Osseointegr 2014; 6: 37-42 of max-dependency, max-relevance, and factors (CGF) for sinus augmentation. 10. Rodella LF, Favero G, Boninsegna R, Buf- min-redundancy,” IEEE Transactions on Pat- Implant Journal(Japan). 2009;38:25-35 foli B, Labanca M, Scarì G, Sacco L, tern Analysis and Machine Intelligence, 4. Tadić A, Puskar T, Petronijević B. Applica- Batani T, Rezzani R. Growth factors, CD34 Vol. 27, No. 8, pp. 1226–1238, 2005 tion of fibrin rich blocks with concentrated positive cells, and fibrin network analysis 16. Fawcett T. ‘An introduction to ROC analysis’, growth factors in pre-implant augmentation in concentrated growth factors fraction. Pattern Recognition Letters 2006:27:861–874 procedures. Med Pregl. 2014; 67:177-80. Microsc Res Tech. 2011; 74:772-7. 17. Lasko T.A., Bhagwat J.G., Zou K.H., and 5. Mirković S, Djurdjević-Mirković T, Pugkar T. 11. Borsani E., Bonazza V., Buffoli B, Cocchi M.A, Ohno-Machado L, ‘The use of receiver Application of concentrated growth fac- Castrezzati S., Scarì G., Baldi F., Pandini S., operating characteristic curves in bio- tors in reconstruction of bone defects after Licenziati S., Parolini S., Rezzani R., Rodella medical informatics,’ Journal of Biomedi- removal of large jaw cysts--the two cases L.F. Biological Characterization and In Vitro cal Informatics, 2005:38:404–415 report. Vojnosanit Pregl. 2015 72:368-71. Effects of Human Concentrated Growth Factor 6. Kim JM, Sohn DS, Bae MS, Moon JW, Lee JH, Preparation: An Innovative Approach to Tissue Park IS. Flapless transcrestal sinus augmentation Regeneration. Biol Med (Aligarh) 2015, 7:5. using hydrodynamic piezoelectric internal sinus elevation with autologous concentrated growth factors alone. Implant Dent 2014; 23: 168-174 The Journal of Implant & Advanced Clinical Dentistry • XX Pandya Extraction and Immediate Placement of Dental Implants in Mandibular Anterior Site with Delayed Prosthetic Loading Protocol in a Chronic Generalized Periodontitis Patient: A Case Report

Dhaval Pandya, MDS1

Abstract

n last few decades, implant dentistry has and treatment planning to achieve optimal func- emerged as a fully accepted discipline in tional and esthetic results. Most importantly, Identistry. During this period of development, patients must be at the heart of this process. its concepts, treatment modalities and material The clinical approach described, demonstrates science have undergone tremendous changes. points of consideration, when replacing a man- The key to successful restorative driven implant dibular anterior segment with immediate dental therapy is appropriate examination, diagnosis implants and delayed prosthetic loading protocol.

KEY WORDS: Dental implants, case report, prosthetics, periodontitis

1. Fellow International College Of Dentists (Section Vi India, Sri Lanka & Nepal), Diplomate International Congress Of Oral Implantologists

30 • Vol. 9, No. 3 • April 2017 Pandya

Figure 1: Pre-op clinical view. Figure 2: Pre-op OPG.

Figure 3: Cross section view of CBCT. Figure 4: Additional cross section view of CBCT.

INTRODUCTION odontally compromised patients has been Implant dentistry has experienced dramatic suggested to have a different outcome when changes in past few decades.1 Newer implant compared with patients without periodonti- designs, surface technologies allow for much tis.3 Long term survival rates varies according to faster osseointegration and modulation of bone the surgical technique used (78% for 1 stage reaction to the implant.2 Implant therapy in peri- technique versus 94% for 2 stage technique.4

The Journal of Implant & Advanced Clinical Dentistry • 31 Pandya

Figure 5: Minimally invasive extractions with periotomes. Figure 6: Extracted teeth.

Figure 7: Paralleling pins placed. Figure 8: Implant placement.

CASE REPORT A 54 year old woman presented to a general dentist with complaints of bleeding and swol- len gums (Figure 1) in her mouth with loosen- ing of her lower anterior teeth as well as her lower posterior teeth since a few weeks. The general dentist requested her to be seen by a periodontist. A detailed dental history taken by the periodontist revealed oral prophylaxis done by the patient intermittently and upper molar extractions carried out few years back because of advanced mobility. Routine medical and drug history revealed nothing significant. A cone beam CT scan along with routine hae- matological investigations were requested from the patient to further co- relate the clinical find- Figure 9: Torque achieved with implants. ings. Evaluation of the cone beam CT (Figures 2, 3 and 4) revealed advanced bone loss with

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Figure 10: Model with abutments. Figure 11: Occlusal adjustment.

Figure 12: Occlusal adjustment. Figure 13: Occlusal adjustment. respect to the patients mandibular four incisors dibular lateral incisors and further prosthetic and mandibular left and right second and third implant supported bridge over the two implants. molars. A decision was made to extract all the The patient was pre medicated with amoxi- mentioned teeth based on the CBCT examina- cillin and clavulanic acid 625mg (Cap Augmen- tion co relating with the degree of mobility clini- tin ) and Chlorhexidine gluconate mouthwash cally. Furthermore in mandibular anterior socket (Perioguard 0.12%). On the day of the pro- sites were studied in detail on the CBCT to cedure, local infilteration anaesthesia was consider a possibility of placing two implants administered with lignocaine hydrochloride immediately to reduce the appointments for (Xylocaine) at the lower mandibular anterior the patient. Immediate extraction implants with site and atraumatic extraction of lower four inci- a tapered design and oxidised surface treat- sors with periotomes was carried out (Figures ment (Nobel Biocare Replace select tapered 5 and 6) The extraction sockets were thor- Narrow platform) was decided to replace man- oughly debrided to remove granulation tissue

The Journal of Implant & Advanced Clinical Dentistry • 33 Pandya

Figure 13: Post-op OPG. Figure 14: Soft tissue after 4 months. and bleeding created to start with osteotomies carried out and laboratory poured the models. for the implant placements. Initial drilling was Straight profiled prosthetic abutments (Nobel checked with the parallel pin positioning (Figure snappy) were requested (Figure 10) by the 7) to verify the 3 D positioning and two implants lab technician and the subsequent coping try were placed in the lateral incisor sockets (Fig- ins, shade selection, and final prosthetic try in ure 8) Implant – tooth distance, buccolingual were done to adjust the occlusion (Figures 11, axial drilling final prosthetic emergence was 12 and 13) The final abutments were torqued taken into consideration at the drilling stage according to the manufacturer’s instructions itself to achieve optimum prosthetic outcomes. (15 Ncms) and they were sealed with a Teflon The implants showed a final torque which tape and the final prosthesis (porcelain fused to was less than 35 Ncms (Figure 9). Hence, metal implant supported bridge) was cemented a decision to do a delayed prosthetic load- using a provisional implant cement (Tempbond). ing was taken and the patient was informed of the same. The lower second and third molars CONCLUSION were extracted and the remaining salvageable The above case report demonstrates the effi- teeth were subjected to periodontal flap sur- cacy of minimally invasive extractions of peri- gery. A post-op panoramic x-ray was advised odontally compromised teeth, with Type I timing to check for implant positions (Figure 14) Fol- of implant placements according to Hammerle low up of 3 weeks and four months (Figure 15) et al.5 The advantage of this over the staged revealed a healthy soft tissue healing around approach is fewer appointments for the patient the implants and a decision to proceed with and the dental team. However, in periodon- the prosthetic phase was carried out with sup- tally affected sockets, if the primary stability is porting intra oral radiographs which revealed not adequately achieved like in this case less complete osseointegration of the two implants. than 35Ncms, then a decision may be taken to Closed tray implant level impressions were defer the loading of the implants and not jeop-

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ardise the osseointegration process. Proper case selection, technique used, material selection, and a good laboratory support will result in optimum functional and esthetic results. l The Journal of Implant & Advanced Clinical Dentistry

Correspondence: Dr. Dhaval Pandya Email: drdhavalpandya @yahoo.com ATTENTION [email protected] Contact no: +91-9930998282 PROSPECTIVE

Disclosure The author reports no conflicts of interest with anything in this article. AUTHORS

References 1. Immediate loading of dental implants: Theory and and clinical practice Mithridade Davarpannah and Serge Szmukler Moncler Quintessence 2008. 2. 4D implant therapy: Esthetic considerations for soft tissue management JIACD wants Akiyashi Funato and Tomohiro Ishikawa Quintessence 2008. 3. Van der weijden GA, Van Bemmel KM, Renvert S. J Clin Periodontol 2005; 32: 506-511 4. Baelum V, Ellegaard B. J Periodontol 2004; 75:1404-12. to publish 5. Hammerle CH, Chen ST, Wilson TG Jr. Int J Oral Maxillofac Implants 2004;19 (Suppl) 26-28. 6. Paolantonio M, Dolci M, Scarano A, et al. J Periodontol 2001;72: 1560-1571 your article! 7. Lazzara RJ. Int J Periodontics Restorative Dent 1989 ; 9:332-343. 8. Araujo MG, Lindhe J. J Clin Periodontol 2005 ;32: 212- 218. 9. Garber DA. J Am Dent Assoc 1995 ; 126:319-325. 10. Funato A, Salama MA, Ishiakawa T, Garber DA, Salama H. Int J Periodontics Restorative Dent 2007; 27: 313-323. For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: jiacd.com/ author-guidelines or email us at: [email protected]

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