All-On-4TM Success Rates with Different Implant Systems

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Volume 7, No. 5 May/June 2015

The Journal of Implant & Advanced Clinical Dentistry

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The Journal of Implant & Advanced Clinical Dentistry Volume 7, No. 5 • May/June 2015 Table of Contents

11 A Retrospective Analysis of Patients Treated with the All-On-4 Treatment Concept using a Variety of Different Dental Implant Systems Dan Holtzclaw, Nicholas Toscano, Joseph Yang

21 Mandibular Reconstruction and Full Arch Rehabilitation with Dental Implants Following a Gunshot Injury: A Clinical Report Luis Roberto Sanchez Garza, Brayann Oscar Aleman, Francisco José Carrillo Morales, Luis Roberto Sanchez Ramirez

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The Journal of Implant & Advanced Clinical Dentistry Volume 7, No. 5 • May/June 2015 switch Table of Contents 47 Current CAD/CAM Materials and Systems for All Ceramic Restorations: A Review of the Literature Christian Brenes, Ibrahim Duqum, Gustavo Mendoza, Lyndon Cooper

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64_NA2010_8125x10875.indd 1 8/1/11 1:37:30 PM The Journal of Implant & Advanced Clinical Dentistry Volume 7, No. 5 • May/June 2015

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The Journal of Implant & Advanced Clinical Dentistry • 7 DID YOU KNOW? Roxolid implants deliver more treatment options

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

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

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ACTEON North America . 124 Gaither Drive, Suite 140 Mount Laurel, NJ 08054 Tel - (800) 289 6367 . F ax - (856) 222 4726 www.us.acteongroup.com . E-mail: [email protected] Holtzclaw et al A Retrospective Analysis of Patients Treated with the All-On-4 Treatment Concept using a Variety of Different Dental Implant Systems

Dan Holtzclaw, DDS, MS1 • Nicholas Toscano, DDS, MS2 Joseph Yang, DDS, MS3 Abstract

Introduction: To date, no study has com- Discussion: A total of 384 arches were treated, pared success rates between different dental utilizing 1,704 dental implants from 4 different implant systems when utilized for the All-On-4 dental implant systems in 289 patients. Cumu- treatment concept. The aim of this retrospec- lative dental implant survival rate was 99.00% tive analysis is to evaluate the outcomes of with an overall prosthetic survival rate of 100%. patients treated with the All-On-4 concept using a variety of dental implant systems. Conclusion: The All-On-4 treatment concept allows for predictable immediate full Materials and Methods: A retrospective chart arch function and can be accomplished review encompassing the dates July 2009 to with a variety of dental implant systems. January 2015 was performed in three private periodontal offices to assess the results of patients treated with the All-On-4 treatment concept.

KEY WORDS: Dental implants, all-on-4, survival rate, immediate load

1. Consultant Faculty at US Navy Postgraduate Dental School, Department of Periodontics, Bethesda, Maryland, USA. Private Practice, Round Rock, Texas, USA.

2. Private Practice, New York, New York, USA.

3. Private Practice, San Diego, California, USA

The Journal of Implant & Advanced Clinical Dentistry • 11 Holtzclaw et al

INTRODUCTION tems for use with the All-On-4 treatment con- The All-on-4 treatment concept involves restor- cept. The goal of retrospective observational ing an arch with at least 4 dental implants, the study, therefore, is to document success rates distal of which are tilted up to 45 degrees, and and ease of restoration for the All-on-4 treat- immediately loading the transitional prosthesis.1 ment concept in both the mandible and maxilla This concept was originally documented over when utilizing a variety of dental implant sys- 10 years ago as an immediately loaded treat- tems in the hands of experienced clinicians. ment option for resorbed mandibles that could not be treated in the traditional manner.2 Biome- MATERIALS AND METHODS chanically, tilting the posterior dental implants A retrospective chart review was performed offers a number of benefits over axially inclined for all patients treated in private periodontal implants including increased anterior-poste- practices (DH in Texas, NT in New York, and rior spread, reduction of prosthetic cantilever JY in California) between July 2009 and Janu- length, and increased bone-to-implant contact.3 ary 2015 with the All-On-4 treatment concept. Anatomically, benefits of tilted implants include As this was a retrospective chart review, there avoidance of the inferior alveolar nerve and were no exclusion criteria. All patients in each mental foramen bundle,4 elimination of the need practice were treated in a similar fashion. Prior for maxillary sinus augmentation,5 elimination to surgery, medical histories were obtained of bone grafting procedures,6 and improved and clinical/radiographic examinations were implant anchorage in dense anterior alveolar performed. One day prior to surgery, patients bone.6,7 A number of articles have documented were instructed to begin antibiotic treatment the success of the All-on-4 treatment concept with Amoxicillin 500mg three times per day, and full-arch immediately loaded implant con- which would then continue for an additional cepts in both the mandible and the maxilla nine days after surgery. On the day of sur- using a variety of dental implant systems includ- gery, patients were consented for treatment ing Astra Tech,8 Biohorizons,9 Straumann,10 and then received local anesthesia in the con- and BioMet 3i.11-14 Most studies document- ventional fashion in addition to intravenous ing the success of the All-On-4 treatment con- sedation unless medically contraindicated. Full cept, however, have focused on Nobel Biocare thickness flaps were elevated in the standard dental implant systems.1,2,4-7,15-23 Each dental fashion. If dentate, all teeth were extracted implant system has specific design features and extractions sockets degranulated. Bone that may or may not make them ideally suited reduction was then performed with a high for the unique idiosyncrasies associated with speed surgical drill (Osteomed, Addison, Texas) the All-On-4 treatment concept. Addition- under irrigation. The amount of bone reduc- ally, the restorative components associated tion was determined by utilization of clear sur- with these dental implant systems differ sig- gical stents or bone reduction rulers to create nificantly. To date, there is no known study at least 12mm or vertical restorative space. that compares different dental implant sys- The surgical phase of treatment was similar

12 • Vol. 7, No. 5 • May/June 2015 Holtzclaw et al

Figure 1: Maxillary All-On-4 patient prior to treatment. Figure 2: Maxillary All-On-4 patient with transitional restoration. for both the maxilla and mandible. In the max- fashion, typically in the area of the lateral inci- illa, minor access to the maxillary sinus was sor with care being taken to avoid perforation obtained through the lateral sinus wall and a of the nasal cavity. Dental implants placed in periodontal probe was inserted to locate the the maxilla routinely achieved torque values mesial extent of the sinus cavity. Care was of 32-75 Ncm. In select cases with individual taken to avoid perforation of the Schneiderian dental implant torque values less than 32 Ncm, membrane. After locating the anterior wall of additional dental implants were placed adjacent the maxillary sinus, posterior dental implant to the low torque implant. Following the place- osteotomies were performed with all sites ment of all maxillary dental implants, straight or being underprepared and angled to accom- angulated multi-unit abutments were secured modate the anterior sinus wall. Osteotomy to each dental implant according to manufac- underpreparation was performed to improve turer’s directions, typically with torque values of the chance of obtaining higher torque val- 15 Ncm. When placing multi-unit abutments, ues during dental implant placement. Tilted transitional prostheses with restorative access posterior dental implant placement typically windows were placed to evaluate transitional occurred in the location of the first or second coping access points. Screw access holes premolar. The mesial angulation of the poste- were always placed palatally to the teeth in the rior tilted dental implants usually resulted in anterior region and in the occlusal surface or subcrestal submergence of the distal aspect of slightly palatal in the posterior region. Follow- the implant platform. Accordingly, high speed ing the placement of multiunit abutments with hand pieces and hand instruments were used proper angulation, healing caps were secured to reshape this bone to allow full access to to the abutments and the mucogingival flaps the dental implant platform. Anteriorly located were recontoured with scalpels and biopsy dental implants were then placed in an axial punches to reduce bulk and allow for better tis-

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

sue adaptation around the multi-unit abutments. able composite. Occlusion was verified with bilat- Prior to flap replacement and suturing with eral balanced posterior contacts and light anterior resorbable 4-0 chromic gut suture, exposed contacts prior to the dismissal of each patient. dental implant threads and residual extraction Post-surgically, patients were provided with sockets were grafted with a combination of ibuprofen 800mg and tramadol 50mg for pain mineralized/demineralized bone allograft (Maxx- control. Patients also continued their antibiotic eus, Community Tissue Services, Dayton OH). therapy in addition to taking a methylpredniso- Surgical treatment in the mandible was sim- lone dose pack. Follow-up visits were typically ilar to that of the maxilla with a few minor differ- performed at 7, 14, 42, and 90 days after surgery. ences. In the mandible, the mental foramen was Between 3 to 4 months after the initial surgery, visually identified and dental implants were placed patients began the final prosthetic phase of treat- at a 45° angle posteriorly. As in the maxilla, all ment. The transitional prostheses were removed dental implants were placed to achieve torque and all multi-unit abutments were retorqued to 15 values of at least 32 Ncm. Mucogingival tissue Ncm. In the event that multi-unit abutment plat- recontouring in the mandible was typically less forms were obscured with excess gingival tis- involved than that of the maxilla due to the fact sue, a diode laser (Biolase, Irvine, California) was that mandibular mucogingival tissue is less bulky utilized to fully expose the platform edges. Final and less keratinized than its maxillary counterpart. restorations (Fig. 3) were then fabricated with Upon completion of all surgeries, immedi- either hybrid milled titanium frames wrapped ate chairside conversion of provisional pros- in acrylic or full zirconia and were delivered, on theses was achieved (Figs. 1, 2). Healing caps average, between 6 to 7 months after the ini- were removed and multi-unit transitional posts tial surgery. Following final prosthesis delivery, were hand tightened on the multi-unit abutments. patients were seen yearly for clinical exams, pros- Custom premade conventional dentures were thesis prophylaxis, and radiographic evaluation. adjusted to allow the multi-unit transitional posts Dental implant survival was graded accord- to cleanly exit in occlusal or lingual positions. ing to the Malo Clinic survival criteria1: 1) the Rubber dam material was placed around all tran- implant fulfilled its purported function as sup- sitional posts and hand mixed acrylic was injected port for reconstruction; 2) the implant was sta- between the restorations and the posts. Once ble when individually and manually tested; 3) the acrylic was set to a hard consistency, the tran- no signs of infection were observed around the sitional restoration was removed by unscrewing implant; 4) no radiolucent areas were observed the transitional posts. Healing caps were then around the implant; 5) the implant demon- replaced onto the multi-unit abutments and the strated good esthetic outcome of rehabilitation; transitional restoration was refined to completion, 6) the implant allowed for construction of the typically within two hours. All transitional restora- implant supported fixed prosthesis, which pro- tions were torqued onto the multi-unit abutments vided patient comfort and good hygiene main- at 15 Ncm and screw access holes were filled tenance. Dental implants that were removed for with Teflon tape and sealed with light cured flow- any reason at any time were considered failures.

14 • Vol. 7, No. 5 • May/June 2015 Holtzclaw et al

Table 1: Implant Systems Data

# Patients # Arches # Implants # Implants # Prosthesis Implant System Treated Treated Placed Failures Failures Nobel Biocare 269 384 1,624 17 0 MIS 11 11 44 0 0 Zimmer 6 6 24 0 0

Biomet-3i 3 3 12 0 0 Total 289 404 1,704 17 0

DISCUSSION tal implants, 2.08% were treated with Zimmer Two hundred eighty nine patients (167 females (Carlsbad, California) dental implants, and 1.03% and 122 males) with a mean age of 63.53 years were treated with Biomet 3i (Palm Beach Gar- (range 31-87) were included in this retrospective dens, Florida) dental implants. Of the 17 dental observational study which had follow up times implant failures reported in this study, all occurred ranging from 12-39 months in function. A total with Nobel Biocare dental implants. Although of 1,704 dental implants were utilized to restore no failures were seen with MIS, Biomet 3i, and 222 maxillae and 182 mandibles with 327 arches Zimmer implants, the number of these implants being dentate and 77 edentulous. A total of 17 used in this study was very small compared to dental implants failed producing a cumulative den- the number of Nobel Biocare implants. Addi- tal implant survival rate of 99.00%. All implant tionally, Nobel Biocare dental implants were uti- failures occurred in the transitional prosthesis lized in much more challenging cases than the phase of treatment and none compromised the other implant systems. Overall dental implant final restoration resulting in a prostheses sur- survival rates were comparable between systems vival rate of 100%. The most common complica- with Nobel Biocare achieving a 98.95% survival tion encountered during treatment was fracture rate and all other brands achieving a 100% suc- of the transitional restoration which occurred in cess rate. If comparable numbers of implants 33 arches. The various dental implant systems were used for all brands mentioned in this study, utilized in this retrospective observational study it is likely that all would produce similar results. and their respective performances are listed in While all brands of dental implants used in this Table 1. Of the patients included in this study, study produced comparable statistical results, 93.08% were treated with Nobel Biocare (Yorba a number of intangible factors should be men- Linda, California) dental implants, 3.81% were tioned. First and foremost, each dental implant treated with MIS (Fair Lawn, New Jersey) den- system used in this study has uniquely different

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

Figure 3: Maxillary All-On-4 patient with final restoration. Figure 4: Multi-unit abutments with screwed long handle metal attachments.

properties. Concerning treating patients with multi-unit abutments, with some being much eas- the All-On-4 treatment concept, certain dental ier to use than others. The multi-unit abutments implant design characteristics proved to be very for one particular dental implant system came with important. Average torque values achieved in a long metallic handle that is screwed into place this study were 53.67 Ncm which is substantially (Fig. 4) while a different system utilized a shorter higher than that reported in many other dental metallic handle which was also screwed in place implant studies.24,25 To achieve such high torque (Fig. 5). Conversely, the multi-unit abutments for values, the authors routinely underprepared den- another system utilized plastic handles that were tal implant osteotomy sites. In such instances, the snapped onto the abutment (Fig. 6). In addition use of aggressive, self-tapping, end cutting den- to providing ease of handling, the multi-unit abut- tal implants was extremely beneficial. Particular ment handles are a valuable tool for determining dental implant systems proved to be more reli- path of insertion for screw access. The authors able and easier to use in this regard compared to found that the longer, screwed, metallic handles other implant systems. In fact, the lack of aggres- were much easier to use and more reliable than sive end cutting ability with some implant systems other types of multi-unit abutment handles. A resulted in some implants failing to achieve full third and final factor that differed between sys- placement depth. In such cases, the implant oste- tems was the multi-unit abutment temporary heal- otomy sites had to be widened with larger drills ing caps, with some systems using plastic caps causing a loss in placement torque. Such a loss (Fig. 7) while others utilized metallic caps (Fig. in torque had the potential to compromise the 8). When recontouring gingival tissue prior to ability to immediately load the transitional pros- final primary closure, the authors frequently used thesis, although this did not happen with any of biopsy punches to quickly and accurately trim the cases in this study. A second important factor around abutments. In cases where the metal found to differ between systems was the angled healing caps were utilized, the biopsy punches

16 • Vol. 7, No. 5 • May/June 2015 Holtzclaw et al

Figure 5: Multi-unit abutments with screwed short handle Figure 6: Multi-unit abutment with plastic snap on metal attachments. attachment.

Figure 7: White healing caps secured to multi-unit Figure 8: Metal healing caps secured to multi-unit abutments following suture closure. abutments following suture closure. would quickly dull due to friction between the is used. While all dental implant systems pro- metal components and often had to be replaced. duced comparable results, some systems and their respective components proved easier to CONCLUSION use than others for the clinicians in this study. ● This is the first known study to compare the results of different dental implant systems for the Correspondence and reprint requests All-On-4 treatment concept. Within the limita- Dan Holtzclaw, DDS, MS tions of this study, it can be concluded that the 4010 Sandy Brook Dr., Suite 204 All-On-4 treatment concept produces high suc- Round Rock, TX 78665 cess rates for both dental implants and pros- Tele: 512-375-0050 theses no matter what brand of dental implant e-mail: [email protected]

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

Disclosure: 9. Chu P. A case study: The all-on-4 treatment con- 18. Malo P, de Araújo Nobre M, Lopes A, et al. A lon- The authors claim to have no financial interests, either cept using Biohorizons tapered internal implants. gitudinal study of the survival of All-on-4 implants directly or indirectly, in the products or information Clin Pract Oral Implantol 2010;1:28-36. in the mandible with up to 10 years of follow-up. listed in this article. J Am Dent Assoc 2011;142:310-20. 10. Alves CC, Correia AR, Neves M. Immediate References implants and immediate loading in periodon- 19. Maló P, de Araújo Nobre M, Lopes A, et al. “All- 1. Maló P, Araújo Nobre MD, Lopes A, Rodrigues tally compromised patients-a 3-year prospective on-4” immediate-function concept for completely R. Double Full-Arch Versus Single Full-Arch, Four clinical study. Int J Periodontics Restorative Dent edentulous maxillae: a clinical report on the me- Implant-Supported Rehabilitations: A Retrospec- 2010;30:447-55. dium (3 years) and long-term (5 years) outcomes. tive, 5-Year Cohort Study. J Prosthodont 2014;1: Clin Implant Dent Relat Res 2012;14:139-50. (In Press). 11. Lazzara RJ, Testori T, Meltzer A, et al. Immediate Occlusal Loading (IOL) of dental implants: pre- 20. Maló P, de Araújo Nobre M. Partial rehabilitation 2. Maló P, Rangert B, Nobre M. “All-on-Four” imme- dictable results through DIEM guidelines. Pract of the posterior edentulous maxilla using axial diate-function concept with Brånemark System Proced Aesthet Dent 2004;16:3-15. and tilted implants in immediate function to avoid implants for completely edentulous mandibles: bone grafting. Compend Contin Educ Dent a retrospective clinical study. Clin Implant Dent 12. Capelli M, Zuffetti F, Del Fabbro M, Testori T. 2011;32:136-45. Relat Res 2003;5:2-9. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by 21. Maló P, Nobre MD, Lopes A. The rehabilitation of 3. Krekmanov L, Kahn M, Rangert B, Lindström H. either upright or tilted implants: a multicenter completely edentulous maxillae with different de- Tilting of posterior mandibular and maxillary im- clinical study. Int J Oral Maxillofac Implants grees of resorption with four or more immediately plants for improved prosthesis support. Int J Oral 2007;22:639-44. loaded implants: a 5-year retrospective study Maxillofac Implants 2000;15:405-14. and a new classification. Eur J Oral Implantol 13. Testori T, Del Fabbro M, Capelli M, et al. Imme- 2011;4:227-43. 4. Butura CC, Galindo DF, Jensen OT. Mandibular all- diate occlusal loading and tilted implants for the on-four therapy using angled implants: a three-year rehabilitation of the atrophic edentulous maxilla: 22. Malo P, Nobre Mde A, Lopes A. Immediate reha- clinical study of 857 implants in 219 jaws. Dent 1-year interim results of a multicenter prospective bilitation of completely edentulous arches with a Clin North Am 2011;55:795-811. study. Clin Oral Implants Res 2008;19:227-32. four-implant prosthesis concept in difficult conditions: an open cohort study with a mean follow- 5. Maló P, Rangert B, Nobre M. All-on-4 immediate- 14. Boyse B, Sullivan S. Implant placement and im- up of 2 years. Int J Oral Maxillofac Implants function concept with Brånemark System implants mediate provisional restoration of edentulous 2012;27:1177-90. for completely edentulous maxillae: a 1-year ret- arches: A case presentation. J Implant Recon- rospective clinical study. Clin Implant Dent Relat struc Dent 2011;2:1-5. 23. Agliardi E, Panigatti S, Clericò M, Villa C, Malò Res 2005;7:88-94. P. Immediate rehabilitation of the edentulous 15. Pomares C. A retrospective clinical study of jaws with full fixed prostheses supported by 6. Balshi TJ, Wolfinger GJ, Slauch RW, Balshi SF. A edentulous patients rehabilitated according to four implants: interim results of a single co- retrospective analysis of 800 Brånemark System the ‘all on four’ or the ‘all on six’ immediate func- hort prospective study. Clin Oral Implants Res implants following the All-on-Four™ protocol. J tion concept. Eur J Oral Implantol 2009;2:55-60. 2010;21:459-65. Prosthodont 2014;23:83-88. 16. Agliardi E, Clericò M, Ciancio P, Massironi D. 24. Salimov F, Tatli U, Kürkçü M, et al. Evaluation of 7. Jensen OT, Adams MW. All-on-4 treatment of highly Immediate loading of full-arch fixed prostheses relationship between preoperative bone density atrophic mandible with mandibular V-4: report of supported by axial and tilted implants for the values derived from cone beam computed tomog- 2 cases. J Oral Maxillofac Surg 2009;67:1503-9. treatment of edentulous atrophic mandibles. raphy and implant stability parameters: a clinical Quintessence Int 2010;41:285-93. study. Clin Oral Implants Res 2014;25:1016-21. 8. Acocella A, Ercoli C, Geminiani A, et al. Clinical evaluation of immediate loading of electro-eroded 17. Babbush CA, Kutsko GT, Brokloff J. The all-on- 25. Tadi DP, Pinisetti S, Gujjalapudi M, et al. Evalu- screw-retained titanium fixed prostheses support- four immediate function treatment concept with ation of initial stability and crestal bone loss in ed by tilted implant: a multicenter retrospective NobelActive implants: a retrospective study. J immediate implant placement: An in vivo study. J study. Clin Implant Dent Relat Res 2012;14:98- Oral Implantol 2011;37:431-45. Int Soc Prev Community Dent 2014;4:139-44. 108.

18 • Vol. 7, No. 5 • May/June 2015 Less pain for your patients.Holtzclaw1 et al Less chair side time for you.1

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Neoss Inc., 21860 Burbank Blvd. #190, Woodland Hills, CA 91367 Ph. 866-626-3677 www.neoss.com Garza et al Mandibular Reconstruction and Full Arch Rehabilitation with Dental Implants Following a Gunshot Injury: A Clinical Report

Luis Roberto Sanchez Garza, MCD1 Brayann Oscar Aleman, CD2 • Francisco José Carrillo Morales, CD3 Luis Roberto Sanchez Ramirez, DDS4 Abstract

Background: Management of gunshot inju- anterior mandible, with reconstruction of the ries to the face led in many ways to the resultant bony defect with Iliac Crest Bone development of modern maxillofacial sur- Graft and Implant-supported fixed prosthesis. gery, and it remains a cornerstone of the specialty of oral and maxillofacial surgery. Results: Reparative, reconstructive and reha- Bone grafts are frequently required in the man- bilitation procedures have achieved in a high agement of Gunshot wounds to the face, amount and quantity, the stability and sym- whether for replacement of true loss of bone or metry of facial soft tissues, phonetics, swal- in cases in which comminuted and misplaced lowing and chewing of the patient, therefore, fragments need to be replaced or reinforced. psychological health, allowing to the patient Insertion of osseointegrated dental implants get back to her social and occupational several months after mandibular reconstruc- activities with much more self-confidence. tion using bone grafts has proved to be a successful method to achieve mastication and Conclusion: Improvement in the management complete oral rehabilitation. The successful of gunshot wounds to the face has paralleled the restoration of patients with dental implants can advancement of oral and maxillofacial surgery. result in a change in dental function and health. Oral implantology is the treatment of choice not only for the restoration of missing teeth, other- Methods: This paper presents a 43-year-old wise the return of functional and aesthetic param- female who suffered gunshot wound to the eters allowing patients to their social reintegration.

KEY WORDS: Gun shot wound, dental implants, iliac crest, prosthodontics, oral surgery

1. Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery ISSSTE Monterrey, Nuevo León, México; Private Practice Monterrey, Nuevo León, Mexico 2. Private Practice Monterrey 3. Private Practice Monterrey 4. Private Practice Monterrey

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

INTRODUCTION The development of rigid fixation tech- The potential problems of a wound caused by a niques and their application to GSWs was an projectile can be better anticipated if one has important advance. By allowing the early sta- some knowledge of the weapon and projec- bilization of bone segments, percolation of tile type that caused the wound. Gugala and contaminated oral fluids was prevented, pri- Lindsey suggested a civilian gunshot injury clas- mary bone healing was made possible, and the sification scheme. It takes into account energy effects of scar contracture were minimized.1 (high or low), involvement of vital structures The surgeon facing a gunshot injury (neural and vascular), wound type (non- pen- should consider the concept introduced etrating, penetrating, perforating), fracture by Manson for evaluation of four compo- (intra-articular and extra-articular), and con- nents: soft tissue injury, bone injury, soft tis- tamination.1 Gunshot wounds involving the sues loss (true avulsion), and bone loss.3,1 face may be associated with an entrance or Teeth should be maintained if possible to exit wound in the neck, which is divided into aid in restoration of occlusion and proper jaw three zones originally described by Monson relations. Earlier repair leads to improved out- and colleagues from Cook County Hospital.1,2 comes with less scar contracture and resul- Zone I is most commonly defined as the tant deformity. Bone grafts at the time of area from the clavicles to the cricoid cartilage. It initial surgery may be indicated in the midface1 contains the inferior aspect of the trachea and Advocates of delayed repair point to a higher esophagus along with the major vessels of the incidence of infection and to benefits of closed thoracic inlet: the common carotid arteries, thy- treatment, whereas those advocating more rocervical trunk, internal jugular veins, brachio- aggressive management report improved func- cephalic trunk, subclavian arteries and veins, tional and aesthetic outcomes.4,5,1 The main thoracic duct, thyroid gland, and spinal cord. disadvantage of open reduction is infection, Zone II represents the area from the cricoid car- which primarily affects the mandible.6,1 Bone tilage to the angle of the mandible. It contains grafts are frequently required in the manage- the common carotid arteries, internal and exter- ment of GSWs to the face, whether for replace- nal carotid arteries, internal jugular veins, larynx, ment of true loss of bone (avulsive injuries) or hypopharynx, and cranial nerves X, XI, and XII. It in cases in which comminuted.These are frac- is the largest area and therefore the most com- tures that exhibit multiple fragmentation of the monly involved zone in penetrating neck trauma. bone at one fracture site. These are usually the Zone III spans the region from the skull base result of greater forces than would normally be to the angle of the mandible. It contains the encountered in simple fractures.and misplaced carotid arteries, the internal jugular veins, and the fragments need to be replaced or reinforced.1,9 pharynx along with multiple cranial nerves exit- Gruss and colleagues have published exten- ing the skull base. It should be appreciated that sively on their success with early bone graft- gunshot wounds that involve mandibular frac- ing to stabilize and support soft tissues, and tures are accompanied by injuries to Zone III. to decrease scar contracture and distortion.7, 1

22 • Vol. 7, No. 5 • May/June 2015 Garza et al

Most agree, however, that delayed grafting of The first step in reconstruction is to classify discontinuity defects of the mandible is still indi- the defect determined by its size, location, and cated because of the high risk of exposure and functional or cosmetic impairment.10,14,15 The use loss of bone grafts in this site, and that immedi- of osseointegrated dental implants is an impor- ate grafting in the mandible should be avoided.8,4,1 tant technique for the oral rehabilitation of these Maintenance of mandibular segments with rigid patients. Osseointegrated implants provide the reconstruction plates combined with delayed most rigid prosthetic stabilization available to grafting or free flap reconstruction offers a pre- withstand masticatory forces.16 Branemark & dictable result, and in most cases primary graft- Lindstrom used implants with free bone grafts. ing of the mandible is not indicated. Delayed Riediger was the first to place them in an iliac bone reconstructions frequently suffer from a crest flap.16 The incorporation of osseointe- scarred hypovascular environment that does not grated implantology in the oromandibular reha- support the graft. Vascularized bone grafts can bilitation of oncological head and neck patients support osseointegrated implants to complete has improved aesthetic and functional results the reconstruction.1 The goals of therapy9 are: spectacularly.16,17,18,19 When deciding if reha- 1) Obtain stable occlusion; 2) Restore interincisal bilitation should include a fixed prosthesis or opening and mandibular excursive movements; a removable prosthesis, a series of factors 3) Establish a full range of mandibular excursive should be analyzed: 1) Number and position of movements; 4) Minimize deviation of the man- implants; 2) Occlusal space; 3) Antagonist arch; dible; 5) Produce a pain-free articular appara- 4) TMJ function; 5) Labial or lingual hypoesthe- tus at rest and during function; 6) Avoid internal sia; 6) Patient’s attitude to prosthetic hygiene. derangement of the temporomandibular joint on the injured or the contralateral side; 7) Avoid the METHODS long-term complication of growth disturbance. A 43 year old female patient presented with a The goals of reconstruction under the afore- reference sheet to the Department of Oral and mentioned conditions are to provide morphology Maxillofacial Surgery, Hospital Clinic ISSSTE and position of the bone in relation to its opposing Monterrey, Nuevo Leon, for the assessment of the jaw, provide adequate height and width of bone, gunshot wound. The reference sheet indicated restore continuity of the mandible and maxilla, and that the patient was taken by the paramedics to provide facial contour and support for soft tissue the emergency department approximately 2 hours structures.10, 11,12 The body of the mandible is after the shooting, where ATLS protocol was probably the most complex area of the mandible to applied, the patient was admitted to the intensive reconstruct for several reasons. It has a complex care for 15 days and a maxillomandibular fixa- curved shape that makes reconstruction difficult, tion with Erich Arch Bars was made for the stabi- it is along the lever of the mandible and has the lization of the bone segments. When the patient highest loads placed on it, it contains a sensory was stabilized, she revealed that the gun was a nerve that is prone to injury, and it is the site of revolver which was shot at a distance of about attachment of a complex array of muscles.10,11,12,13 10cm with the projectile entry into the mouth

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

● Deferred mandibular bone reconstruction with corticocancellous graft anterior iliac crest ● Removal of dental organs with poor prognosis and placement of the endosseous biphasic dental implants. ● Discovery of the placement of dental implants and placement of healing abutments. ● Oral Rehabilitation with endosseous dental implants and implant-supported fixed prosthesis of precious-porcelain metal. Figure 1: Pre-op panoramic radiograph. Phase 1 - Bone Reduction and Fixation of symphysis region and exit on the left subman- Bone Fragments dibular region. In the clinical extraoral evaluation, Patient is placed under general anesthesia with the object of the observation is the scar gunshot balanced nasotracheal intubation, prior asep- wound in zone II associated with mandibular frac- tic surgical bed with 10% povidone-iodine ture as rated by Monson and colleagues, with the supine; anesthetic lidocaine 2% with epineph- presence of deformity of the lower lip, ecchymo- rine 1:100,000 in submental and submandibular sis, submental edema. Intraorally loss of multiple left region; an incision of about 8 cm in length is dental organs, trismus, generalized chronic peri- performed with a Nº 15 scalpel blade with sub- odontitis, tooth mobility grade II and III is being sequent dissection planes (figures 2-6). Once obseved, as well as pain and crepitus on palpa- addressed, nonviable fragments are removed tion in the left mandibular. AP cervical radiogra- from the fracture zone, and the bone is modeled phy and chest rule out the presence of foreign for better consolidation of the bone segments, bodies. Is important to point out that, once the viable fragments are reduced with 2 straight tita- missiles were introduced into the tissues, they nium mini-plates of 2mm system which are fixed rarely follow a straight path. In the panoramic with Monocortical titanium screws of 2.0 x 7mm. radiograph the comminuted fracture covering Once fragments are reduced, a 10 hole recon- symphysis region, parasymphyseal and left man- struction bar is preformed and molded, and dibular body is observed (figure 1). Surgical pro- attached to the bone fragments with titanium tocol studies were required, which are evaluated bicortical screws of the 2.7mm x 11 mm system. by determining internal medicine patient ASA I. Mouth floor muscles are sutured to the locking bar using simple nylon 1-0 points to prevent muscle TREATMENT PLAN breakdown with its subsequent closure plans. Open reduction and fixation of viable Intradermal closure is performed with 4-0 Vicryl bone fragments with titanium plates and maximizing the aesthetics of the wound closure. screws; placement of reconstruction plate; Semi-rigid inter-maxillary fixation is placed with removal of nonviable bone fragments. 4 screws of inter-maxillary fixation of 2.0 x 9mm

24 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 2: Pre-op submandibular view. Figure 3: Submandibular incision from midline to the posterior aspect of the gonial area, 2 cm below the inferior mandibular edge.

Figure 4: Blunt dissection minimizing risk of vascular Figure 5: Facial artery ligated. injury. system, two located in the buccal apical region to ments, and a correct relationship of temporo- the upper lateral incisors and two in the symphy- mandibular complex (figure 21). After 21 days sis apical area to the remaining teeth, anchored inter-maxillary fixation is removed and a stable with wire. It was decided to preserve the inter- presence of trismus occlusion is observed, so soft maxillary fixation with Erich Arch Bars to preserve diet, physical therapy, exercises of mouth open- existing occlusion parameters (figures 7-20). The ing and oral hygiene techniques are indicated. postoperative OPG shows a stable occlusion, 24 hours after the removal of the FIM, the patient’s appropriate reduction of mandibular bone frag- occlusion is evaluated, showing good stability.

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

Figure 6: Bone segments located and bony fragments Figure 7: Bone reduction with titanium straight 2.0mm removal. miniplates and 2.0 x 7mm monocortical screws.

Figure 8: Bone reduction with titanium straight 2.0mm Figure 9: Bone reduction with titanium straight 2.0mm miniplates and 2.0 x 7mm monocortical screws. miniplates and 2.0 x 7mm monocortical screws.

Phase 2 - Deferred Mandibular Bone that once established such graft would be fea- Reconstruction with Anterior Iliac Crest sible for the rehabilitation of the oral cavity to Corticocancellous Graft return functional and aesthetic parameters. Five months after the reduction of mandibu- Autologous grafts of anterior iliac crest, offer lar bone fragments, we proceed to the recon- a greater volume of bone progenitor cells, capa- struction of the bone defect by the anterior ble of creating a more favorable environment for corticocancellous graft anterior iliac crest, so the consolidation of the new bone. Mandibu-

26 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 10: Bone reduction with titanium straight 2.0mm Figure 11: Bone reduction with titanium straight 2.0mm miniplates and 2.0 x 7mm monocortical screws. miniplates and 2.0 x 7mm monocortical screws.

Figure 12: Bone reduction with titanium straight 2.0mm Figure 13: Presentation and fixation of locking miniplates and 2.0 x 7mm monocortical screws. reconstruction plate with bicortical screws.

lar reconstruction is performed simultaneously the reconstruction plate with bicortical screws by the trauma and maxillofacial surgery team, of 2.7 x 13mm system. Autologous fibrin clot wherein the first addresses the ilium obtaining and bovine bone Geistlich Bio-Oss® (Pharma the bone graft, and the second addresses the AG CH-6110 Wolhusen Suiza) of slow rese- mandibular region affected for its reconstruc- ption are placed to accelerate the bone heal- tion. After obtaining the graft, maxillofacial sur- ing (figures 22-50). Drenovac (Dimeja S.A. de gery team models, adapts, and sets the graft to C.V.®, Tepatitlán de Morelos, Jalisco) is a system

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

Figure 14: Presentation and fixation of locking Figure 15: Presentation and fixation of locking reconstruction plate with bicortical screws. reconstruction plate with bicortical screws.

Figure 16: Presentation and fixation of locking Figure 17: Presentation and fixation of locking reconstruction plate with bicortical screws. reconstruction plate with bicortical screws.

used for postoperative drainage, followed by the remaining teeth, anchored with wire. After suture closure plans and intradermal 4-0 Vicryl 10 days of control a satisfactory observa- suture (figures 51-52). Semi-rigid inter-maxil- tion is being observed, the wound is aes- lary fixation is placed with 4 screws of intermax- thetically acceptable, inter-maxillary fixation illary fixation of 2.0 x 9mm system, two located is removed and it was decided to wait in the buccal apical region to the upper lateral for the consolidation of the graft through incisors and two in the symphysis apical area to a course of six months (figures 53-58).

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Figure 18: Placement of four inter-maxillary fixation Figure 19: Placement of four inter-maxillary fixation screws screws (2.0 x 9mm system), two in the upper jaw and two in (2.0 x 9mm system), two in the upper jaw and two in the the lower jaw anchored with osteosynthesis wire. lower jaw anchored with osteosynthesis wire.

Figure 20: Placement of four inter-maxillary fixation Figure 21: Post-Op panoramic radiograph. screws (2.0 x 9mm system), two in the upper jaw and two in the lower jaw anchored with osteosynthesis wire.

Phase 3- Removal of Dental Organs with lowing essential aspects of implant place- Poor Prognosis and Placement of the ment: 1) Quantity of the bone; 2) Quality Endosseous Biphasic Dental Implants of the bone; 3) Number of implants; It is essential to do the CBCT study for the 4) Position of the implants in the arch; 5) Diam- implant position planning. With the radiographic eter of the implants; 6) Depth of the implants guide in the position and visualization software Once these data were done and analyzed, 3D of the images, we evaluated the fol- we found quality and suitable bone quantity so

The Journal of Implant & Advanced Clinical Dentistry • 29 Garza et al

Figure 22: Cortico-cancellous bone graft harvested from Figure 23: Ilium aspect after bone graft harvest. the ilium.

Figure 24: Submandibular incision in the same place done Figure 25: Sharp dissection of the skin layer and blunt before for the mandibular fracture reduction. dissection of the deepest layers. it was decided to perform the placement of six Under local anesthesia with 2% mepivacaine dental implants Certain (Biomet Inc. Warsaw, and epinephrine 1: 100,000, incision was made Indiana) biphasic endorsements to complete on alveolar ridge, rising mucoperiostic flap, pre- the rehabilitation of the lower arch in the areas fabricated surgical guide is positioned and oste- of dental bodies (FDI Tooth Numbering Sys- otomies are made to indicate the position of the tem) 46 of 4 x 10mm, O.D 44 x 13mm, 4, OD implants; deep osteotomies was made and par- 42 4 x 13mm, OD 32 4 x 13mm, OD 34 4 x allel pin and periapical radiographs are taken to 13mm and OD 36 4 x 11mm (figures 59-65). evaluate their position. Once the desired par-

30 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 26: Exposition of the bone defect taking care no Figure 27: Preparation of the mandibular bone edges, perforate the intraoral mucosa. drilling small holes encouraging bone bleeding.

Figure 28: Preparation of the mandibular bone edges, Figure 29: Preformation of bone graft with a low-speed drilling small holes encouraging bone bleeding. handpiece and constant irrigation. allelism was obtained, we continued with the come is satisfactory, so suture material is removed sequential osteotomies according to manufac- and the control appointment was made one week turer’s indications to the diameter of 4mm in the after showing complete closure of the wound. corresponding area, getting the implant place- Once the total wound healing was ment with an adequate insertion torque and settle- achieved, removable prosthesis is posi- ment to achieve primary stability. Wound closure tioned to return it to the possible, the peri- with single point interrupted 3-0 silk sutures. oral tissue support and as well as the phonetic Ten days after the surgery, the clinical out- and masticatory functionality (figure 66).

The Journal of Implant & Advanced Clinical Dentistry • 31 Garza et al

Figure 30: Appearance of the bone graft in the defect, Figure 31: Appearance of the bone graft in the defect, showing good fitting and continuity with smooth edges. showing good fitting and continuity with smooth edges.

Figure 32: Appearance of the bone graft in the defect, Figure 33: Appearance of the bone graft in the defect, showing good fitting and continuity with smooth edges. showing good fitting and continuity with smooth edges.

Phase 4 - Discovery of the dental Implants gical procedure under local anesthesia was and Placement of Healing Abutments performed. The position of the implants are Three months after placement, implants located located and incisions are made, rising full thick- in the area of 42 and 32 were observed, so ness flap, and healing abutments placed. it was not necessary to perform any surgi- Simple interrupted suture points were place cal maneuver in these areas, however, in with 3/0 silk retiring them 10 days after the event implants remaining total gingival epithelial with good performance and satisfactory insertion keratinized tissue coverage so infiltrative sur- of peri-implant keratinized tissue. (photo 67-70)

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Figure 34: Appearance of the bone graft in the defect, Figure 35: Appearance of the bone graft in the defect, showing good fitting and continuity with smooth edges. showing good fitting and continuity with smooth edges.

Figure 36: Appearance of the bone graft in the defect, Figure 37: Appearance of the bone graft in the defect, showing good fitting and continuity with smooth edges. showing good fitting and continuity with smooth edges.

The Journal of Implant & Advanced Clinical Dentistry • 33 Garza et al

Figure 38: Bone graft fixation to the reconstruction plate Figure 39: Bone graft fixation to the reconstruction plate with bicortical screws. with bicortical screws.

Figure 40: Bone graft fixation to the reconstruction plate Figure 41: Bone graft fixation to the reconstruction plate with bicortical screws. with bicortical screws.

Oral Rehabilitation with Implant-Supported periapical radiographs. Impression is taken Fixed Prosthesis with type A silicone of the brand Hydrox- Three weeks after the discovery of den- treme (Coltene® Feldwiesenstrasse Switzer- tal implants, we decided to start land) heavy and light body by drag technique, with the rehabilitation treatment. obtaining working model for the production Impression posts are placed with a base of a PFM fixed prosthesis implant-supported. of 4mm and 5mm on emergence profiles, Due to extensive restoration, was decided and total and passive seating is verified by to conduct two separate structures, which

34 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 42 : Bone graft fixation to the reconstruction plate Figure 43: Bone graft fixation to the reconstruction plate with bicortical screws. with bicortical screws.

Figure 44: Bone graft fixation to the reconstruction plate Figure 45: Bone graft fixation to the reconstruction plate with bicortical screws. with bicortical screws.

The Journal of Implant & Advanced Clinical Dentistry • 35 Garza et al

Figure 46: Placement of PRGF in the interphase of bone Figure 47: Placement of PRGF in the interphase of bone graft and mandibular bone. graft and mandibular bone.

Figure 48: Placement of PRGF in the interphase of bone Figure 49: Placement of PRGF in the interphase of bone graft and mandibular bone. graft and mandibular bone.

range from the situation of the organ 3.6 to 3.1 A design wax-up of the fixed prosthesis is and the other from the organ 4.1 to 4.6. Cus- created, which will give the base for the restora- tom temporary abutments are manufactured tion, these are tested before and after the metal from GingiHue® Abutment (Biomet Inc. War- is created and it is finalized over the abutments. saw, Indiana) designed with the emergence Once a tight seal and a liability settlement of profile dimensions that allow a more natural the structures are done, porcelain layering tech- appearance of the final restoration (photo 71-73). nique is applied to improve aesthetics of the final

36 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 50: Placement of PRGF in the interphase of bone Figure 51: Suture of the wound by layers with Vycril 4/0. graft and mandibular bone.

Figure 52: Final suture by intradermal technique, allowing Figure 53: Post-op panoramic radiograph were we a better scar appearance in the future and Drenovac evaluate the bone graft position. placement to reduce the post-op edema.

The Journal of Implant & Advanced Clinical Dentistry • 37 Garza et al

Figure 54: 10 days post-op extraoral photos, showing a Figure 55: 10 days post-op extraoral photos, showing a little edema, nice scar and healing evolution. little edema, nice scar and healing evolution.

Figure 56: 10 days post-op extraoral photos, showing a Figure 57: 10 days post-op extraoral photos, showing a little edema, nice scar and healing evolution. little edema, nice scar and healing evolution.

result (figures 74-75). When the manufacture or (figures 76-80). The control panoramic radio- the restauration are completed , we take them graph after oral rehabilitation shows bone stability to the mouth to verify the stability, occlusion and in the peri-implant area and fracture lines as well esthetic appearance, ones all of these is verified as continuity and sustainability of cortico-travecu- we cement the restorations with Glass Ionomer lar bone block graft of the iliac crest (figure 81).

38 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 58: 10 days post-op intraoral photo, that indicate Figure 59: Panoramic radiograph taken with the surgical nice occlusion, in this day we decide to remove inter- guide with barium sulphate teeth, showing the right maxillary fixation, allowing to the patient start with position where the implants should be placed. physiotherapy.

Figure 60: Meticulous evaluation of the CBCT, measuring Figure 61: Meticulous evaluation of the CBCT, measuring the quantity and quality of the bone, distance to the the quantity and quality of the bone, distance to the alveolar nerve, planning thus the position, profundity, alveolar nerve, planning thus the position, profundity, angulation and quantity of the dental implants to be angulation and quantity of the dental implants to be placed. placed.

The Journal of Implant & Advanced Clinical Dentistry • 39 Garza et al

Figure 62: Meticulous evaluation of the CBCT, measuring Figure 63: Meticulous evaluation of the CBCT, measuring the quantity and quality of the bone, distance to the the quantity and quality of the bone, distance to the alveolar nerve, planning thus the position, profundity, alveolar nerve, planning thus the position, profundity, angulation and quantity of the dental implants to be angulation and quantity of the dental implants to be placed. placed.

Figure 64: Meticulous evaluation of the CBCT, measuring Figure 65: Meticulous evaluation of the CBCT, measuring the quantity and quality of the bone, distance to the the quantity and quality of the bone, distance to the alveolar nerve, planning thus the position, profundity, alveolar nerve, planning thus the position, profundity, angulation and quantity of the dental implants to be angulation and quantity of the dental implants to be placed. placed.

40 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 66: Panoramic radiograph after the dental implants Figure 67: Appearance of second phase healing screws placement, showing a good disposition and parallelism. after three weeks of their uncover, exhibiting adequate keratinized tissue.

Figure 68: Appearance of second phase healing screws Figure 69: Appearance of second phase healing screws after three weeks of their uncover, exhibiting adequate after three weeks of their uncover, exhibiting adequate keratinized tissue. keratinized tissue.

RESULTS to the patient get back to her social and occupa- Reparative, reconstructive and rehabilitation pro- tional activities with much more self-confidence. cedures have achieved in a high amount and The patient is going annually to maintenance quantity, the stability and symmetry of de facial soft appointments where prophylaxis, periodontal tissues, phonetics, swallowing and chewing of the and dental assessment usually are performed. patient, therefore, psychological health, allowing Assessment of the durability of dental implants,

The Journal of Implant & Advanced Clinical Dentistry • 41 Garza et al

Figure 70: Appearance of second phase healing screws Figure 71: Aspect of the abutments with nice passive after three weeks of their uncover, exhibiting adequate settlement and parallelism. keratinized tissue.

Figure 72: Aspect of the abutments with nice passive Figure 73: Aspect of the abutments with nice passive settlement and parallelism. settlement and parallelism.

soft and hard periimplant tissue, as well as the tial loss of bone tissue are performed, mouth implant-supported restorations and the stabil- floor muscles tend to collapse obstructing the ity of the Iliac crest bone graft are performed, airways, making swallowing, breathing, pho- evidencing an uneventfully excellent evolution. netics, chewing, more difficult even impos- sible. The ilium is the most preferred donor DISCUSSION site for bone grafting. It contains the great- When procedures in which there is substan- est absolute cancellous bone volume and has

42 • Vol. 7, No. 5 • May/June 2015 Garza et al

Figure 74: Final prosthesis divided in two structures. Figure 75: Final prosthesis divided in two structures.

Figure 76: Cementation of the prosthesis with Glass Figure 77: Cementation of the prosthesis with Glass Ionomer and adjustment of the occlusion. Ionomer and adjustment of the occlusion.

The Journal of Implant & Advanced Clinical Dentistry • 43 Garza et al

Figure 78: Final appearance of the prosthesis. Figure 79: Final appearance of the prosthesis.

Figure 80: Blunt dissection minimizing risk of vascular Figure 81: Final panoramic radiograph after the injury. rehabilitation. the highest cancellous-to-cortical bone ratio. CONCLUSION The fixed prosthesis requires a larger num- Improvement in the management of GSWs to the ber of implants, occlusal adjustment is more face has paralleled the advancement of oral and complex and maintaining hygiene is more dif- maxillofacial surgery. Techniques and skills devel- ficult. Treatment is more costly, but it pro- oped by oral and maxillofacial surgeons in the vides greater satisfaction for the patient in management of these injuries translated directly to comparison with the removable prosthesis. other areas such as bone grafting, and promoted

44 • Vol. 7, No. 5 • May/June 2015 Garza et al

the growth and expanding scope of the specialty. Disclosure The successful restoration of the patient with den- The authors report no conflicts of interest with anything mentioned in this article. tal implants can result in a change in dental func- References 1. Principles of Oral and Maxillofacial Surgery, Gunshot Injuries, tion and health, with a happy patient. The basis Jon D. Holmes, DMD, MD, pg 509 - 525 for the use of dental implants is initiated by the 2. Monson DO, Saletta JD, Freeark RJ. Carotid vertebral trauma. J Trauma 1969;9:987–99. normal sequence of wound healing, the transla- 3. Thorne CH. Gunshot wounds to the face: current concepts. Advances in tion of surface engineering to implant design, and craniomaxillofacial fracture management. Clin Plast Surg 1992;19:233–44. 4. Deveci M, Sengenzer M, Selmanpakoglu M. Reconstruction of gunshot evidence-based trials that verify and confirm effi- wounds of the face. Gazi Med J 1998;9:47–56. cacy of treatment methods. Therefore, we would 5. Siberchicot F, Pinsolle J, Majoufre C, et al. Gun- shot injuries of the face. Analysis of 165 cases and reevaluation of the primary treat- like to stress the real possibility that we have of ment. Ann Chir Plast Esthet 1998;43:132–40. offering mandibulectomized patients that have 6. Neupert EA, Boyd SB. Retrospective analysis of low-velocity gunshot wounds of the mandible. Oral Surg Oral Med Oral Pathol 1991;72:383–97. been reconstructed with bony grafts and dental 7. Gruss JS, Mackinnon SE, Kassell EE, Copper PW. The role of primary bone grafting in complex craniomaxillofacial trauma. rehabilitation with an implant-supported pros- Plast Reconstr Surg 1985;15:17–24. thesis and/or implant-retained prosthesis that 8. Clark N, Birely B, Manson PN, Slezak S. High- energy ballistic and avulsive facial injuries: classification, patterns and an algorithm for pri- will improve facial harmony and quality of life. ● mary reconstruction. Plast Reconstr Surg 1996;98:583–601. 9. Principles of Oral and Maxillofacial Surgery, Principles of Management of Mandibular Fractures, Guillermo E. Chacon, DDS Peter E. Larsen, DDS, pg 401- 433 Correspondence: 10. Principles of Oral and Maxillofacial Surgery, Bony Reconstruction Dr. Luis Roberto Sanchez Garza of the Jaws, Randall M. Wilk, DDS, PhD, MD 11. Ahlmann E, Patzakis M, Roidis N, et al. Comparison of anterior and Gómez Morín 2003 L-9 posterior iliac crest bone harvest in terms of harvest site morbid- Col. Carrizalejo ity and functional outcomes. J Bone Joint Surg 2002;84:716–20. 12. Callan DP, Salkeld SL, Scarborough N. Histologic analysis San Pedro Garza García of implant sites after grafting with demineralized bone matrix putty and sheets. Implant Dent 2000;9:36–44. Zip Code: 66254 13. Lekholm U, Wannfors K, Isaksson S, Adielsson B. Oral implants in combi- Phone: 044-818-280-8992 nation with bone grafts. Int J Oral Maxillofac Surg. 1999;28:181–187. 14.Stoler A, Hill T. Part 1. Reconstruction after total mandibulectomy Office: 83032636 with free cranial and micro-vascular iliac crest grafts as prepa- email: [email protected]. ration for implants. J Oral Implantol. 1992;18:36–44. 15. Keller EF, Van Rockel NB, Desjardins RP, Tolman DE. Prosthetic-surgical reconstruction of the severely resorbed maxilla with iliac bone grafting and tissue-integrated prosthesis. Int J Maxillofac Implants. 1987;2:155–156. 16. Rehabilitacion implantosoportada en el colgajo libre de perone C. Navarro Cuellar1, S. Ochandiano Caicoya, F. Riba Garcia1, F.J. Lopez de Atalaya, J. Acero Sanz2, M. Cuesta Gil, C. Navarro Vila. 17. Cuesta Gil M, Ochandiano S, Barrios JM, Navarro Vila C. Rehabilitacion oral con implantes osteointegrados en pacientes oncologicos. Rev Esp Cirug Oral Maxilof 2001;23:171-82. 18. Marx R, Morales MJ. The use of implants in the reconstruction of oral cancer patients. Dent Clin North Am 1998;42:177-201. 19. Frodel JL, Funk GF, Capper DT, Fridrich KL, Blumer JR, Haller JR, Hoffman HT. Osseointegrated implants: a comparative study of bne thickness in four vascularized bone flaps. Plast Reconstr Surg 1993;92:449-55.

The Journal of Implant & Advanced Clinical Dentistry • 45 Brenes et al Brenes et al Current CAD/CAM Materials and Systems for All Ceramic Restorations: A Review of the Literature

Christian Brenes, DDS, MS1 • Ibrahim Duqum, DDS, MS2 Gustavo Mendoza, DDS, MS, PhD3 • Lyndon Cooper, DDS, PhD4

Abstract

Introduction: A literature review was done Results: The current literature shows that to review the evolution, properties, charac- multiple materials and systems are currently teristics, and marginal fit of current CAD/ available for clinical use and there is not a uni- CAM materials and fabrications systems for versal material or system for all clinical situations. all-ceramic restorations. Methods: A data search of peer-reviewed articles through Conclusion: Within the scope of this litera- PUBMED search, annual publications and ture review, there is a lack of evidence to sup- a hand search of textbooks and journals on port the universal application of a single system CAD/CAM all-ceramic materials was sought. or ceramic material for all clinical situations; The last search was conducted on July 2014. careful consideration of the material choice should be done as part of the treatment plan.

KEY WORDS: CAD/CAM, Glass Ceramics, Alumina Ceramics, Lithium Disilicate, Zirconia, All ceramic

1. Prosthodontist, Private Practice. Houston, Texas 2. Clinical Assistant Professor, Director of the Oral Health Innovation Center, Department of Prosthodontics at the University of North Carolina at Chapel Hill 3. Clinical Associate Professor, Department of Biologic and Materials Sciences, Division of Prosthodontics, University of Michigan School of Dentistry 4. Director of Prosthodontics Graduate Program, Distinguished Professor of Dentistry of the Department of Prosthodontics at the University of North Carolina at Chapel Hill

The Journal of Implant & Advanced Clinical Dentistry • 47 Brenes et al

tion that is saved in a computer and constitutes a extraordinary communication tool for evaluation. The incorporation of dental technology has not only brought a new range of manufacturing methods and material options but also some concerns about the processes involving restorations fit, quality, accuracy, short and long-term prognosis.1 The purpose of this document is to provide a review of the literature regarding the different materials and systems available until June 2014. In addition marginal fit of CAD/CAM restorations is included for clinical considerations.

CAD/CAM MATERIALS GLASS CERAMICS The first in office ceramic material was Vitablock Mark I (Vident), it was a feldspathic based ceramic Figure 1: Digital and Conventional Workflow for All- compressed into a block that was milled into a Ceramic Crown Fabrication. dental restoration. After the invention of the Mark I block the next generation of materials for CAD/ INTRODUCTION CAM milling fabrication of all-ceramic restora- Dental crowns have been used for decades to tions were Vita Mark II (Vident) and Celay, which restore compromised, heavily restored teeth, and replaced the original Mark I in 1987 for fine feld- for esthetic improvements. New CAD/CAM (Com- spathic porcelains primarily composed of silica puter Aided Design/Computer Aided Manufactur- oxide and aluminum oxide.2 3 Mark II blocks are ing) materials and systems have been developed fabricated from feldspathic porcelain particles and evolved in the last decade for fabrication of embedded in a glass matrix and used for single all-ceramic restorations. Dental CAD/CAM tech- unit restorations available in polychromatic blanks nology is gaining popularity because of its bene- nowadays. On the other hand, Celay ceramic fits in terms of time consuming, materials savings, inlays have been considered clinically acceptable standardization of the fabrication process, and by traditional criteria for marginal fit evaluation.4 predictability of the restorations. The number of Dicor-MGC was a glass ceramic material steps required for the fabrication of a restoration composed of 70% tetrasilicic fluormica crys- is less compared to traditional methods (Fig. 1). tals precipitated in a glass matrix; but this mate- Another benefit of CAD/CAM dentistry include rial is no longer available in the market.5 Studies the use of new materials and data acquisition; from Isenberg, et al. suggested that inlays which represents a non-destructive method of of this type of ceramics were judge as clini- saving impressions, restorations and informa- cally successful in a range from 3 to 5 years of

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clinical service.6-8 In 1997, Paradigma MZ100 of alumina based ceramic materials the In-Ceram blocks (3M ESPE) were introduced as a highly Spinell (VITA) blocks were developed as an alter- filled ultrafine silica ceramic particles embed- native for anterior esthetic restorations; it is a mix- ded in a resin matrix; the main advantage of ture of alumina and magnesia. Its flexural strength this material is that it can be use as a milled is less than In-Ceram Alumina, but veneering dense composite that was free of polymeriza- with feldspathic porcelain for a more esthetic tion shrinkage but can not be sintered or glazed.9 result could follow it after the milling process.14 15 In early 1998 IPS ProCAD (Ivoclar Vivadent) Nobel Biocare developed Procera mate- was introduced as a leucite reinforced ceramic rial; for its fabrication high purity aluminum oxide similar to IPS Empress but with a finer particle is compacted onto an enlarged die that is fabri- size; this material was designed to be use with cated from the scanned data.16 The enlarged the CEREC system (Sirona Dental, Germany) and fabricated core shrinks to the dimensions of the was available in different shades.2 More recently working die when sintered at 1550o C; this mate- the introduction of IPS Empress CAD (Ivoclar) rial offers a very high strength core for all-ceramic and Paradigm C that according to the manufac- restorations; the crown is finished with the appli- turer 3M ESPE it is a 30%-45% Leucite rein- cation of feldspathic porcelian.17 More recently forced glass ceramic with a fine particle size.10 In-Coris AL (Sirona Dental) has been intro- To overcome esthetic problems of most duced as a high strength aluminum oxide block CAD/CAM blocks having a monochromatic res- with similar mechanical properties as Procera.18 toration; a different version was developed as a multicolored ceramic block which was called LITHIUM DISILICATE Vita TriLuxe (Vident) and also IPS Empress Lithium disilicate is composed of quartz, lithium CAD Multiblock; the base of the block is a dark dioxide, phosphor oxide, alumina, potassium opaque layer, while the outer layer is more trans- oxide and other components. According to Saint- lucent; the CAD software allows the clinician Jean (2014) the crystallization of lithium disilicate to position or align the restoration into the block is heterogenous and can be achieved through a for the desire outcome of the restoration.11 12 two or three stage process depending if the glass In 2014 the Enamic (VITA) material was ceramic is intended to be used as a mill block released as a ceramic network infiltrated (e-max CAD) or as a press ingot (e-max press). with a reinforcing polymer network that has Lithium disilicate blocks (blue blocks) are the benefits of a ceramic and resin in one partially sintered and relatively soft; they are material but no clinical data is available.13 easier to mill and form to the desired restoration compared to fully sintered blocks; after ALUMINA BASED CERAMICS this process the material is usually heated to Alumina blocks (Vitablocs In-Ceram Alumina, 850°C for 20-30 minutes to precipitate the VITA) are available for milling with the CEREC final phase. This sintering step is usually associ- system (Sirona Dental) and now compatible with ated with a 0.2% shrinkage accounted for the other milling machines as well. Due to the opacity designing software.19 Nowadays, blocks of lith-

The Journal of Implant & Advanced Clinical Dentistry • 49 Brenes et al

Table 1: Recommended Dimensions for E-max CAD by Ivoclar Vivadent

Material Thickness Anterior Premolar Molar Veneers

Staining Technique 1.2 1.5 1.5 0.6

Cut-back Technique 1.2 1.5 1.5 0.6 Layering Technique 0.8 0.8 — —

ium disilicate are available for both in-office and fine grain size of approximately 1.5 μm and 70% in-laboratory fabrication of all-ceramic restora- crystal volume incorporated in a glass matrix.21 tions; monolithic blocks require layering or stain- In 2014 Vident company released Suprin- ing to achieve good esthetic results.8 Different in ity; the first glass ceramic reinforced with vitro studies that evaluate marginal accuracy of zirconia (10% weight); this material is a zirco- milled lithium disilicate reveal that these restora- nia reinforced lithium silicate ceramic (ZLS) tions could be as accurate as 56-63 microns.20 available in a precrystallized or fully crys- According to the manufacturer specifica- talized (Suprinity FC) state indicated for tions the designing principles for E-max lithium all kind of single all-ceramic restorations. disilicate are produced by default in the designing software, but in full all-ceramic crowns ZIRCONIA structures the minimum thickness must be Zirconia has been used in dentistry as a bioma- applied in the preparation design (Table 1). terial for crown and bridge fabrication since During the crystallization process the ceramic 2004; it has been useful in the most posterior is converted from a lithium metasilicate crys- areas of the mouth were high occlusal forces are tal phase to lithium disilicate. Some commercial applied and there is limited inter-occlusal space.22 types of ceramics are Empress CAD (Ivoclar) and Zirconia is a polymorphic material that can IPS E-max. The first one is a leucite based glass have three different forms depending on the tem- ceramic with a composition similar to Empress perature: monoclinic at room temperature, tetrag- ceramic. IPS E-max was introduced in 2006 onal above 1170 °C, and cubic beyond 2370° as a material with a flexural strength of 360 to Centigrade. According to Piconi (1999) “the 400MPa (two to three times stronger than glass phase transitions are reversible and free crys- ceramics); the blocks are blue in the partially crys- tals are associated with volume expansion”. Dif- tallized state but it achieves the final shade after ferent authors state that when zirconia is heated it is submitted to the firing process in a porcelain to a temperature between 1470°C and 2010°C oven for 20 to 25 minutes to complete the crystal- and cooled a volume shrinkage of 25 to 35% lization; the final result is a glass-ceramic with a can occur that could affect marginal fit or pas-

50 • Vol. 7, No. 5 • May/June 2015 Brenes et al

siveness of the restorations.22 This feature lim- the composition. Recently many companies have ited the use of pure zirconia until 1970 when integrated zirconia into their CAD/CAM work- Rieth and Gupta developed the yttria-tetragonal flow due to its mechanical properties, which are zirconia polycrystal (Y-TZP) containing 2-3% attractive for restorative dentistry; some of this mol-yttria in the intent to minimize this effect.10 properties are: high mechanical strength, frac- One of the most interesting properties of zir- ture toughness, radiopacity for marginal integ- conia is transformation toughening; Kelly (2008) rity evaluation, and relatively high esthetics.24 describes it as: “A phenomenon that happens Different systems in the market are using zir- when a fracture takes place by the extension of conia as one of their main matrials such as: Cera- al already existing defect in the material struc- mill Zolid (Amann Girbach), Prettau (Zirkonzahn), ture, with the tetragonal grain size and stabi- Cercon (Dentsply), BruxZir (Glidewell Labora- lizer, the stress concentration at the tip of the tories), IPS ZirCAD (Ivoclar Vivadent), Zenostar crack constitutes an energy source able to trig- (Ivoclar Vivadent), inCoris ZI (Sirona Dental), ger the transformation of tetragonal lattice into VITA In-Ceram YZ (Vident), among others. Com- the monoclinic phase.” This process dissipates panies have introduced materials that are in part of the elastic energy that promotes progres- combination with zirconia to improve its prop- sion of cracks in the restoration; there is a local- erties in different clinical situations. Lava Plus ized expansion of around 3.5% that increases for example is a combination of Zirconia and a the energy that opposes the crack propagation.23 nano-ceramic. Table 2 describes some of the Zirconia restorations can be fabricated from CAD/CAM materials used by dental clinicians fully sintered zirconium oxide or partially sintered and laboratories for all-ceramic restorations and zirconium oxide blanks (green-state). Proponent of its restorative indications by the manufacturers. milling fully sintered zirconia claim that fitness of restorations is better because it avoid volumetric CAD/CAM SYSTEMS changes during the fabrication process. On the A number of different manufacturers are providing other hand, the green state is easier and faster CAD/CAM systems which generally consist of a to mill and proponents of milling partially sintered scanner, design computer and a milling machines blanks claim that micro cracks can be induced to or 3D printers. Laboratories are able to receive the restoration during the milling process and it digital impression files from dentists or use a also requires more time and intensive milling pro- scanner to create digital models that are use for cesses; this micro defects or surface flaws can restorations designing or CAD. Dental scanners affect the final strength of the final restoration and vary in speed and accuracy. Milling machines could potentially chip the marginal areas; how- vary in size, speed, axes, and also in which restor- ever further research is needed about this topic.10 ative materials can be milled; in this category One of the first systems that used zirconia milling machines could be classified as wet or was In-Ceram Zirconia (Vident), which is a modi- dry depending if the materials require irrigation. fication of the In-Ceram Alumina but with the The development of dental CAD/CAM sys- addition of partially stabilized zirconia oxide to tems occurred around 1980 with the introduc-

The Journal of Implant & Advanced Clinical Dentistry • 51 Brenes et al

Table 2: Most Used CAD/CAM Materials for all Ceramic Restorations Available for 2014

Material Composition Company Indications

ArgenZ Zirconia Argen Crowns, abutments, onlays.

BruxZir Zirconia Glidwell Copings, multiunit, crowns, inlays/onlays

Ceramill Zolid Zirconia Amann Girbach Crowns, inlays, onlays, multiunit.

Cercon ht Zirconia Dentsply Copings, multiunit, crowns, veneers.

DC Zirkon Zirconia DCS Dental/Vita Crowns, copings.

Empress CAD Leucite reinforced Ivoclar Crowns, inlays, onlays.

Enamic Ceramic resin Ivoclar Vivadent Crowns, inlays/onlays.

InCoris AL Alumina oxide Sirona Copings, multiunit.

InCoris ZI Zirconia Sirona Multiunit, crowns, inlays/onlays.

IPS E-max Lithium Disilicate Ivoclar Crowns, inlays, onlays.

IPS Zircad Zirconia Ivoclar Copings, multiunits.

Lava Ultimate Ceramic resin 3M ESPE Crowns, inlays, onlays.

Paradigm C Leucite reinforced glass ceramic 3M ESPE Crowns, inlays, onlays.

Prettau Full contour zirconia Zirkonzahn Copings, multiunit, crowns, inlays/onlays

VITA Alumina Sintered Aluminum Oxide Vident Crowns, inlays, onlays, veneers.

Vita InCeram YZ Zirconia Vident Crowns, inlays, onlays, multiunit, veneers, abutments.

VITA Mark II Feldpathic porcelain Vident Crowns, inlays, onlays, veneers.

VITA Spinell Aluminum oxide glass infiltration Vident Anterior crowns, veneers.

Vita TriLux Felspathic ceramic Vident Crowns, veneers, onlays, inlays. Zenostar Zirconia Ivoclar Vivadent Copings, multiunit, crowns, veneers.

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tion of the Sopha system developed by Dr. reconstruction system (CICERO) introduced by Duret. Few years after that event Dr. Mormann Denison et al. in 1999 included a rapid custom and the electrical engineer Marco Brandestini fabrication of high strength alumina coping and developed the CEREC-1 system in 1983, the semi finished crowns to be delivered to dental first full digital dental system created to allow laboratories for porcelain layering and finishing.26 dentist to design and fabricate in office resto- Another system that was developed years rations. Since then the continuous evolution of ago was the Celay system, which fabricated feld- systems dedicated to this field has continue and pathic restorations through a copy-milling pro- has exponentially increased in the last decade.14 cess. The system duplicated an acrylic resin Cerec systems has evolved into CEREC pattern replica of a restoration. Zirkonzahn com- Bluecam scanner; accuracies as close as 17 pany developed a similar system called the Zirk- microns for a single tooth have been reported ograph in 2003 which was able to copy-mill by authors using this system. Recently CEREC zirconia prosthesis and restorations out a replica Omnicam was introduced offering true color of the restoration. Some years after Cercon sys- digital impressions without the need of a con- tem (Dentsply Ceramvo) was able to design and trast medium. In a recent study by Neves, et al mill zirconia restorations out of a wax pattern.24 (2013) about marginal fit of CAD/CAM resto- Almost at the same time that these compa- rations fabricated with CEREC Bluecam; they nies develop this first copy mill prototypes Lava compared lithium disilicate single unit restora- (3M ESPE) introduced in 2002 the fabrication of tions to heat-pressed restorations and 83.8% yttria-tetragonal zirconia polycrystal (Y-TZP) cores of the specimens had measurements of ver- and frameworks for all ceramic restorations. With tical gap with less or at least 75 microns.25 the Lava system the die is scanned by a optical The Cerec InLab CAD software (Sirona Den- process, the CAD software designs and enlarge tal) was designed for dental laboratories for a the restoration or framework that is milled from wide range of dental capabilities that can be a pre-sintered blank. Studies on marginal adap- combined with third party systems. With this soft- tation suggest that Lava restorations have a ware the dental technician is able to scan their marginal fit that can be as low as 21 microns.27 own models using Sirona inEos X5 (Sirona Den- Some other systems that were able to mill zirco- tal) scanner and design the restoration; once nia were DCS Zirkon(DCS Dental) and Denzir.28 this process is completed the file can be send In the last decade companies have decided to to a remote milling machine or a milling cen- differentiate their products by having a full CAD/ ter for fabrication in a wide range of materials. CAM platform or by focusing on specific areas of The Procera system introduced in 1994 was expertise like CAD software and intraoral scan- the first system to provide fabrication of a res- ners; this companies claim to be open platform toration using a network connection. Accord- because their systems allow to export universal ing to research data the average ranges of files such as STL. or OBJ. to be used with the marginal fit of this restorations are from 54 to majority of nesting softwares and milling machines 64 microns.20 A computer integrated crown in the market that are able to import them. Defend-

The Journal of Implant & Advanced Clinical Dentistry • 53 Brenes et al

Table 3: Most used Dental CAD Systems Available for 2014

CAD System Manufacturer File output 3Shape 3Shape Propietary/STL ARTI / Modelliere Zirkonzahn STL CeraMill Amann Girbach STL Cercon Eye/Art Dentsply Propietary Cerec Sirona Propietary Delcam Delcam STL Dental Wings Dental Wings STL E4D Planmeca Propietary/STL Exocad Exocad STL

InLab Sirona Propietary/STL Procera Nobel Biocare Propietary/STL ers of close platforms claim that the integration of for clinically acceptable marginal discrepancies.29 different CAD and CAM systems does not allow Poor marginal adaptation can result in disso- for a good integration between parts and probably lution of cement; increase plaque accumulation, lead to the incorporation of fabrication errors; at periodontal inflammation, and secondary caries.14 this point no research about systems integration Holmes, et al. (1989) did a research study is available. Table 3 shows some of the systems measuring the marginal fit of restorations and used for dental CAD with their file output; Table 4 defined absolute marginal discrepancy for the shows some of the most used CAM systems with first time. This concept states that marginal their material recommendations and capabilities. fit should be considered as the angular combination of the vertical and horizontal error.30 MARGINAL FIT Some of the main concerns from clinicians Marginal fit evaluation is considered an essential about all-ceramic CAD/CAM restorations accu- factor for clinical success. Christensen (1966) racy of fit are: scanning resolution, software reported that clinically detectable subgingival mar- designing limitations, and milling hardware limi- gins are in a range of 34-119 microns and 2-51 tations of accuracy. Clinicians’ and technicians’ microns for supragingival margins. McLean (1971) experience with the CAM/CAM system inte- suggested that 120 microns should be the limit gration is also a key factor for fabricating good

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Table 4: Most used Dental CAM Systems Available for 2014

CAM System Manufacturer Type Milling materials

BruxZir Mill Glidewell Dry Zirconia, wax, PMMA

CARES Straumann Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

CeraMill Motion 2 Amann Girbach Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Datron D5 Datron Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Denzir Ivoclar Dry Zirconia

E4D PlanMill 40 Planmeca Wet Lithium disilicate, ceramic resin

InLab MC XL Sirona Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

LAVA 3M ESPE Dry Zirconia, wax, glass ceramic

M1/M5 Zirkonzahn Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Procera Nobel Biocare Wet Aluminum oxide Zenotec Ivoclar Dry Zirconia, Wax, PMMA

The Journal of Implant & Advanced Clinical Dentistry • 55 Brenes et al

Table 5: Summary of Research Studies Including Marginal Adaptation of all Ceramic Restorations

Study Material and System Type of Study Mean Marginal Gap Att, et al. Zirconia/DCS In vitro 86 Baig, et al. Cercon/Zirconia In votro 66.4 Bindl, et al. In Ceram/CEREC In vitro 43 Procera 17 Boeining, et al. Procera In vivo 90-118 Colpani, et al. In ceram/CEREC In vitro 28.5 De Vico, et al. Zirconia/3shape In vitro 78.8 Denissen, et al. Mark II/ CEREC 2 In vivo 85 Procera 68 CICERO 74 Grenade, et al. Procera In vitro 51 Ceramill/zirconia 81 Hmaidouch et al. In Ceram YZ/ CEREC In vitro 81.6 In-sung, et al. In Ceram/Celay In vitro 83 Lee, et al. Alumina/Procera In vitro 89.5 Mark II/CEREC 94.4 Martinez, et al. In Ceram 12.3 Cercon 13.1 Procera 8.7 Matta, et al. Zirconia/Lava In vitro 51 Zirconia/Zenotec 82 May, et al. Procera In vitro 56-63 Neves, et al. Lithium disilicate/CEREC In vitro 39.2 Lithium disilicate/E4d 66.9 Pelekanos et al. In ceram Al/CEREC In vitro 55 Reich, et al. In Ceram/CEREC In vivo 77 Lava 80 Souza, et al. Leucite reinforced In vitro 28-99 ceramic/ CEREC

Syrek, et al. Lava In vitro 49 Tinschert, et al. DC Zirkon/Precident In vitro 60-71

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restoration; the computer software per se will that marginal fit of CAD/CAM restorations is not allow an inexperience operator to create compared to conventional restorations the fabri- an excellent dental restoration from scratch.31 cation of dental restorations still a complex task The clinical evaluation of the restorations is a that requires experience, knowledge and skills. process that is done routinely at delivery and is The incorporation of new systems and mate- usually evaluated by the use of instruments like rials bring a lot of concerns regarding system sharp dental explorers. In an article by Hickel implementation, capabilities and mechanical (2007) different recommendations regarding clini- properties of the different materials. One of cal evaluation of restorations were proposed. The the biggest problems that still remain in CAD/ use of explorers with blunt tips of 150 and 250 CAM dental systems is the accuracy of each microns are recommended as the development step in the CAD/CAM chain, from digital impres- of secondary caries has only been correlated to sion to the milling step. Using computer aided gaps >250 microns. It has been stated in differ- manufacturing is dependent on the calibration ent studies evaluating restorations made with of hardware with software in the workflow. Fur- conventional or digital impressions that marginal thermore, the virtual configuration of the die gaps that are not clinically detectable represent spacer between the tooth and the restorations is a harmonious continuation of the junction tooth/ essential for the accuracy of the marginal adap- restoration. According to Hickel (2007) “gaps tation and has to be calibrated for each one of that deviate from ideal but could be adjusted the systems. Weittstein et al. demonstrated that to ideal by polishing are between 50 and 150 the difference of fit between CAD/CAM resto- microns; gaps with leakage and discoloration lim- rations is directly related to the gap parameters ited to the borders of the restorations are easily from the computer design and also related to the perceptible with explorers and are not consid- intrinsic properties of the CAD/CAM system.32 ered to have a long-term negative impact if they On the other hand, analysis of the publica- are between 150 and 250; gaps larger than tions demonstrates that there is a wide diversity of 250 microns should be replaced to prevent sec- methodologies used to assess the level of adap- ondary caries or large fractures at the margins”. tation of restorations fabricated with CAD/CAM Although in clinical practice the previous meth- technology; standardization and reliability of methods in addition to radiographs are used to deter- ods should be use to guide investigations on this mine marginal fit; several authors using different field. Some of the methods that were used were: methods have investigated the fit of CAD/CAM 1) Marginal fit evaluation using microphotography restorations using different materials and systems. or light microscopy; 2) Microscope measurements with sectioned silicone replicas of the restorations DISCUSSION and abutments; 3) Measurements with electro- Several advantages can be drawn from including microscopy of cemented restorations after sec- CAD/CAM dental technology, 3D scanning and tioning; 4) Micro-CT technology with and without the use of mill materials for all-ceramic restora- cement; 5) Triple scan method and reconstruction tions. Even though clinical studies have shown using 3D scanners to visualize the internal space.

The Journal of Implant & Advanced Clinical Dentistry • 57 Brenes et al

CONCLUSION tion levels are expected. However, there is lim- This review of current and past literature regard- ited number of clinical studies and the diversity ing the evolution, characteristics, and marginal of the results between systems and protocols fit of milled CAD/CAM all-ceramic restorations does not allow giving a definitive conclusion. ● materials and systems show that it is possible to fabricate restorations with the same marginal fit expected from conventional methods and Correspondence: within the range of clinically accepted restora- Dr. Christian Brenes tions. When comparing both methods the advan- 4548 Bissonnet St. Bellaire, TX. 77401. tage of using CAD/CAM technology is not to Phone: (919) 627-3749 obtain the most precise level of fit, but rather to Fax: (713) 664-1140. obtain a high level of reliability in a large number E-mail: [email protected] of restorations; especially when high produc-

The Journal of Implant & Advanced Clinical Dentistry

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Disclosure 18. Esquivel-Upshaw JF, Chai J, Sansano S, 36. Da Costa JB, Pelogia F, Hagedorn B, Ferracane The authors report no conflicts of interest with any- Shonberg D. Resistance to staining, flexural JL. Evaluation of different methods of optical thing mentioned in this article. strength, and chemical solubility of core impression making on the marginal gap of onlays porcelains for all-ceramic crowns. Int J created with CEREC 3D. Oper Dent 2010; Prosthodont 2001. 35:324-9. References 19. Reich SM, Peltz I, Wichmann M, Estafan D. A 37. De Vico G, Ottria L, Bollero P, Bonino M, 1. Miyazaki T, Hotta Y, Kunii J, Kuriyama S, Tamaki Y. comparative study of two CEREC software Cialone M, Barlattani A Jr. et al. Aesthetic A review of dental CAD/CAM: current status and systems in evaluating manufacturing time and and functionality in fixed prosthodontic: future perspectives from 20 years of experience. accuracy of restorations. Gen Dent 2005 experimental and clinical analysis of the CAD- Dent Mat Journal 2009; 28: 44-56. 20. May, K. Russell, M. Razzoog, M. Lang, B. CAM systematic 3Shape. Oral Implantol. 2008; 2. Fasbinder DJ. Restorative material options for Precision of fit: The Procera AllCeram crown. J 1:104–115. CAD/CAM restorations. Compend Contin Educ Prosthet Dent. 1998: 394-404. 38. Gehrt, M. Wolfart, S. Rafai, N., Reich, S. Dent 2002. 21. Schwartz N, Whitsett L, Berry T, Steward J. Edelhoff, D. Clinical results of lithium-disilicate 3. Pallesen U, van Dijken JW. An 8-year evaluation Unserviceable crowns and fixed partial dentures: crowns after up to 9 years of service. Clinical of sintered ceramic and glass ceramic inlays Life span and causes for loss of serviceability. J Oral Investigations17(1), 275–84. processed by the Cerec CAD/CAM system. Eur J Am Dent Assoc 1970; 81:1395–1401. 39. Gupta TK, Bechtold JH, Kuznickie RC, Cadoff Oral Sci 2000. 22. Anusavice, K. Phillips’ Science of Dental LH, Rossing BR. Stabilization of tetragonal 4. Sorensen JA, McLaren E, Avera SP. Marginal Materials. 12edition. In: Saunders. Elsevier; phase in polycrystalline zirconia. J Mater Sci fidelity and microleakage of ceramic inlay 2014. 1978;13:1464. systems. J Dent Res 1994. 23. Kosmac T, Oblak C, Jevnikar P, Funduk N, 40. Hamza TA, Ezzat HA, El-Hossary MM, Katamish 5. Chang JC, Hart DA, Estey AW, Chan JT. Tensile Marion L. The effect of surface grinding and HA, Shokry TE, Rosenstiel SF Accuracy of bond strengths of five luting agents to two CAD- sandblasting on flexural strength and reliability of ceramic restorations made with two CAD/CAM CAM restorative materials and enamel. J Prosthet Y-TZP zirconia ceramic. Dent Mater 1999 systems. J Prosthet Dent 2013;109:83-7. Dent 2003. 24. Raigrodski AJ. Contemporary all-ceramic fixed 41. Hmaidouch R, Neumann P, Mueller W-D. 6. Isenberg, P. Essig, M. Leinfelder, K. Three year partial dentures: a review. Dent Clin North Am Influence of preparation form, luting space clinical evaluation of CAD/CAM restorations. J 2004. setting and cement type on the marginal and Esthetic Dent. 1992. internal fit of CAD/CAM crown copings. Int J 25. Neves F, Prado C, Prudente M, Carneiro T, Comput Dent. 2011;14:219–226. 7. Kelly JR, Denry IL. Stabilized zirconia as a Zancope K, Davi L, Mendonçe G, Cooper L, structural ceramic: an overview. Dent Mater 2008; Soares C. Marginal fit evaluation with micro 42. Keshvad A, Hooshmand T, Asefzadeh F, 24:289–98. CT of lithium disilicate crowns fabricated by Khalilinejad F, Alihemmati M, Van Noort R. 8. Kelly, R. Nishimura, I. Campbell, S. Ceramics chairside CAD/CAM systems and the heat- Marginal gap, internal fit, and fracture load of in dentistry: Historical roots and current pressing technique. J Prosthet Dent. 2014. leucite reinforced ceramic inlays fabricated by CEREC inLab and hot-pressed techniques. J perspectives. Journal of Prosthetic Dent. 1996. 26. Tinschert J, Natt G, Mautsch W, Spie- kermann Prosthodont 2011;20:535-40. 9. Tinschert J, Zwez D, Marx R, Anusavice KJ. H, Anusavice KJ. Marginal fit of alumina-and Structural reliability of alumina, feldspar, leucite zirconia based fixed partial dentures produced 43. Lee, K. Park, C. Kim, K. Kwon, T. Marginal and and zirconia based ceramics. J Dent 2000; by a CAD/CAM system. Oper Dent 2001 internal fit of all ceramic crowns fabricated with two different CAD/CAM systems. Dent Materials 28:529–535 27. Hertlein G. Kramer M, Sprengart T, et al. Milling J. 2008; 27(3): 422-426 10. Luthardt RG, Sandkuhl O, Reitz B. Zirconia- time vs marginal fit of CAD/CAM manufactured TZP and alumina advanced technologies for zirconia restorations. J. Dent Res 2003; 82:194. 44. Martinez, F. Suarez, M. Rivera, B. Pradies, G. Evaluation of the absolute marginal discrepancy the manufacturing of single crowns. Eur J 28. Guazzato M, Proos K, Quach L, Swain MV. of zirconia based ceramic copings. J of Prosth Prosthodont Restor Dent 1999. Strength reliability and mode of fracture of Dent. 2011 :108-114. 11. Kurbad A, Reichel K. Multicolored ceramic bilayered porcelain/zirconia (Y-TZP) dental blocks as an esthetic solution for anterior ceramics. Biomaterials 2004. 45. Matta RE, Schmitt J, Wichmann M, Holst S. Circumferential fit assessment of CAD/CAM restorations. Int J Comput Dent 2006. 29. McLean JW, von Fraunhofer JA. The estimation single crowns–a pilot investigation on a new of cement film thickness by an in vivo technique. 12. Fritzsche G. Treatment of a single-tooth gap with virtual analytical protocol. Quintessence Int. Br Dent J 1971:107–111. a Cerec 3D crown on an implant: A case report. 2012; 43:801–809. Int J Comput Dent 2004. 30.Holmes JR, Sulik WD, Holland GA, Bayne SC. 46. Pelekanos S, Koumanou M, Koutayas S, Marginal fit of castable ceramic restorations. J 13. Baig, M. Tan, K. Nicholls, J. Evaluation of Zinelis S, Eliades G. Micro-CT evaluation of Prosthet Dent 1992;67:594. marginal fit of zirconia ceramic computer aided the marginal fit of different In-Ceram alumina machined (CAM) crown system. J of Prosth 31. Martin N, Jedynakiewicz NM. Interface copings. Eur J Esthet Dent. 2009; 4:278–292. Dent. 2010 : 216-227. dimensions of CEREC-2 MOD inlays. Dent 47. Piconi C, Maccauro G. Zirconia as a ceramic Mater 2000. 14. Bindl A, Mormann WH. Marginal and internal biomaterial. Biomaterials 1999; 20:1–25. fit of all-ceramic CAD/CAM crown- copings 32. Syrek, A. Reich, G. Ranftl, D., Klein, C. Cerny, 48. Pjetursson, B. Sailer, I., Zwahlen, M. Hämmerle, on chamfer preparations. J Oral Rehabil B. Brodesser, J. Clinical evaluation of all- C. A systematic review of the survival and 2005;32:441-7. ceramic crowns fabricated from intraoral digital complication rates of all-ceramic and metal- impressions based on the principle of active 15. Bindl A, Mormann WH. Survival rate of ceramic reconstructions after an observation wavefront sampling. Journal of Dentistry 2010. mono-ceramic and ceramic-core CAD/ CAM- period of at least 3 years. Part I: Single crowns. generated anterior crowns over 2-5 years. Eur J 33. Att W, Komine F, Gerds T, Strub JR. Marginal Clinical Oral Implants Research, 18 Suppl 3, Oral Sci 2004. adaptation of three different zirconium dioxide 73–85. three-unit fixed dental prostheses. J Prosthet 16. Denissen H, Dozic A, van der Zel J, van 49. Schaefer, O. Schmidt, M. Goebel, R. Kuepper, Dent. 2009; 101:239–247. Waas M. Marginal fit and short-term clinical H. Qualitative and quantitative three-dimensional performance of porcelain-veneered CICERO, 34. Boening KW, Wolf BH, Schmidt AE, Kastner accuracy of a single tooth captured by CEREC, and Procera onlays. J Prosthet Dent K, Walter MH. Clinical fit of Procera AllCeram elastomeric impression materials: An in vitro 2000;84:506-13. crowns. J Prosthet Dent 2000;84:419-24. study. J Prosthet Dent. 2012: 108(3), 165-172. 17. Fradeani M, D’Amelio M, Redemagni M, Corrado 35. Colpani JT, Borba M, Della Bona A. Evaluation M. Five-year follow-up with Procera all-ceramic of marginal and internal fit of ceramic crown crowns. Quintessence Int 2005. copings. Dent Mater. 2013;29:174–180.

The Journal of Implant & Advanced Clinical Dentistry • 59 Cobb et al Cobb et al Biophysical Factors Affecting Bacterial Adhesion to Dental Implant Surfaces: A Focused Review

Charles M. Cobb, DDS, MS, PhD1 • Keerthana M. Satheesh, DDS, MS1 Mabel L. Salas, DDS, MS1 • Simon R. MacNeill, BDS, DDS1 Abstract

Background: Increased placement of dental bacterial adhesion, and biofilms. Both in vitro implants will lead to an increase in the prevalence and in vivo studies were considered in the review. of peri-implant disease. Peri-implant inflammatory lesions are initiated by the host response to the Results: Surface roughness, surface free presence of a microbial biofilms. How microbes energy, hydrophilicity, and adsorption of pro- attach themselves to implant surfaces involves tein-carbohydrate complexes derived from the interaction of several biophysical factors. This saliva and gingival crevicular fluid all interact limited review discusses the role of several inter- in a complex manner in the attraction and adhe- related biophysical factors that directly impact sion of supragingival and subgingival bacteria. microbial adhesion to dental implant surfaces. Conclusions: It has proven difficult to differen- Methods: An electronic search of MEDLINE tiate the effects of individual biophysical implant was conducted of studies published between surface attributes. Once bacteria begin to colo- 1995 through 2014. Subject specific articles nize a surface and are allowed to increase in that predated 1995 were also considered. mass without disturbance the biophysical char- The following terms were used in the search: acter of the surface becomes less important. dental implants, surface roughness, topog- From the clinicians view, this latter observation raphy, surface free energy, wettability, hydro- reinforces the need for exquisite oral hygiene philicity, hydrophobicity, microbial adhesion, to maintain a healthy peri-implant environment.

KEY WORDS: Dental implants, bacteria, bacteria adhesion, biofilm, review

1. Department of Periodontics, University of Missouri Kansas City School of Dentistry

The Journal of Implant & Advanced Clinical Dentistry • 61 Cobb et al

Figure 1: Profile view showing surface topography of a Figure 2: Profile view showing surface roughness of a Straumann SLA® dental implant. Original magnification of Steri-Oss HA® dental implant. Original magnification of 2,500x with bar = 10 μm. 2,500x with bar = 10 μm.

INTRODUCTION of literature and focus on the role of several The increased placement of dental implants will interrelated biophysical factors that influence lead to an increase in the prevalence of peri- microbial adhesion to dental implant surfaces. implant disease.1 Mombelli et al. 2 in a recent review reported that 10% of implants and MATERIALS AND METHODS 20% of patients exhibit clinical signs of peri- An electronic search of MEDLINE was con- implantitis. Other authors have reported prev- ducted of studies published between 1995 alence rates for peri-implantitis ranging from through 2014. Subject specific articles pub- 31% to 53% of patients and 22% to 38% of lished prior to 1995 were also considered. implants.3-5 Peri-implant mucositis and peri- The following terms were used in the search: implantitis represent inflammatory lesions initi- dental implants, surface roughness, topog- ated by the host response to the presence of a raphy, surface free energy, wettability, hydro- microbial biofilm.6 How microbes attach them- philicity, hydrophobicity, microbial adhesion, selves to an implant surface involves the inter- bacterial adhesion, and biofilms. The empha- action of several biophysical factors among sis was on in vivo studies but significant in which surface roughness has been viewed as vitro were also considered in the review. the dominant factor.6-8 However, the texture of a surface, i.e., surface roughness, brings RESULTS into play other biophysical factors that are sig- Surface Roughness nificant to the biology of cellular and bacte- Adhesion of bacteria to a solid substrate, such as rial adhesion to substrates. This attenuated a dental implant, is considered to be dependent review will summarize a relatively large body on several interrelated factors, such as surface

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Figure 3: Profile view showing surface roughness of a Figure 4: Bacterial colonization of smooth surfaced Nobel Replace Groovy® implant. Original magnification of implant collar and abutment. Original magnification of 20x 2,500x with bar = 10 μm with bar = 1 mm.

roughness, free energy, net charge, chemis- adhesion of bacteria and the maturation of bio- try, hydrophilicity, and the presence of salivary films on implant substrata.7, 8, 15, 16 However, this and gingival crevicular fluid (GCF) derived pel- may not always be the case as recent research lit- licles.9 It is notable that, with the exception of erature is conflicted regarding the role of implant the salivary and GCF derived pellicles, all the surface roughness and microbial adhesion.18-24 listed factors are controlled by implant sur- As early as 1996, Bollen et al.18 reported face chemistry and/or biomechanical design. little difference in the number of colony form- Implant surfaces with varying degrees of ing units, both supra- and subgingival aerobic roughness and with sophisticated biomechani- and anaerobic microbes, as surface roughness cal designs are intended to enhance the osseo- of implant abutments decreased to a rough- integration (Figs. 1-3). Indeed, some degree of ness average (Ra) of 0.2 μm. Indeed, at least surface roughness is considered essential to two papers have noted that polished surfaces osseointegration.10 There is considerable evi- do not reduce oral microbial colonization and dence correlating surface roughness to increased (Fig. 4), in fact, polishing a surface to mini- bone-to-implant contact, osteoblastic differentia- mize bacterial adhesion may be more miscon- tion and osseointegration.10-14 Likewise, it would ception than reality.19, 20 Recent studies have seem obvious that increasing surface roughness noted that although surface roughness does should equate to increased microbial adherence not appear to impact colonization of bacterial and, therefore, more aggressive colonization of the species,21-23 it may reduce treatment efficacy surface.15-18 Indeed, the early literature in this area when compared to smoother surfaces.24 This is repeatedly notes the interaction of surface rough- particularly true in the treatment of peri-implan- ness and surface free energy in the attraction and titis when it becomes necessary to decon-

The Journal of Implant & Advanced Clinical Dentistry • 63 Cobb et al

Figure 5: SteriOss HA® surface being colonized by various Figure 6: Surface of mature biofilm associated with peri- morphotypes of bacteria, e.g., cocci, rods, fusiforms and implantitis comprised predominantly of rods of various spirohetes. Original magnification of 5,000x with bar = 5 lengths and diameters, fusiforms and treponemes. Original μm. magnification of 5,000x with bar = 5 μm. taminate an implant surface that was designed and, therefore, greater hydrophobicity, have to facilitate osseointegration (Figs. 5 & 6). been shown to favor the adherence of biofilms.26, 27 In addition, research indicates that Surface Free Energy the amount of absorbed protein is greater on Surface free energy (SFE) has been defined hydrophobic surfaces and that the absorbed by as the difference between the energies of protein layer influences initial bacterial coloni- molecules located on the surface and within zation. The latter process is mediated through the mass of a material. Molecules embedded the protein-cell interface, with the absorbed within the mass of a material experience no protein functioning as a ‘bridge’ between the net forces whereas environmental factors may implant surface and the bacterium.27-29 This act on the outermost molecules. Because of phenomenon is confirmed by the adherence exposure to the environment the surface mol- of bacteria to saliva and GCF derived pellicles ecules are in a higher energy state than those that coat the implant substrata which, in turn, located internally. The net difference in energy are directly influenced by the material’s SFE. between internal and surface molecules is Numerous studies have recognized the bio- expressed as surface tension, i.e., SFE.25 SFE physical interactions of surface roughness, SFE, can also be thought of as a function of liquid and hydrophobicity. In consideration of these surface tension and the solid-liquid interfacial relationships, Quirynen and Bollen7 contend free energy, i.e., wettability of the surface.25 that the influence of surface roughness is domi- The SFE of an implant has been implicated nant over SFE in facilitating microbial adhesion in the promotion of plaque adherence; spe- to an implant surface. However, Subramani et cifically, those surfaces with higher energies al.30 have noted that the aforementioned domi-

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nance of surface roughness on accumulation surface composition and surface roughness.37, of biofilms is largely based on descriptive lit- 38 In addition, the degree of hydrophobicity of erature which is difficult to reliably quantify. an implant surface is influenced by surface Several studies, both in vitro and in free energy (SFE).37 Ultimately, the degree of vivo, have indirectly evaluated the impact hydrophobicity will, in part, dictate the interac- of SFE on bacterial adhesion with varying tion between an implant surface and the proxi- results.31-34 Collectively, these in vitro stud- mate biologic environment. Implant surfaces ies establish a tenuous hierarchy of implant exhibiting hydrophilicity are reported to have a surfaces that, in a given time period, attract “wicking” effect on tissue fluids, including blood the least numbers of bacteria to those that and likely other fluids, such as saliva and GCF. attract the most: gold-platinum alloy, tita- This, in turn, leads to absorption of proteins that nium nitride surfaces, zirconium, titanium may aid in binding of host cells (such as fibro- alloy, commercially pure titanium surfaces.31-34 nectin in blood) and bacteria to the implant A more recent study by Salihoğlu et al.23 surface.39 Further, surface hydrophilicity and reported no significant differences in DNA SFE have been shown, in vitro, to promote cell copy numbers for Porphyromonas gingiva- attachment, cell spreading, and osseointegra- lis (P.g.), Aggregatibacter actinomycemcomi- tion.12, 38-42 For these reasons most research tans (A.a.) and total bacteria both for titanium concerning implant surface hydrophilicity has and zirconium oxide abutments and biopsies been focused on the interactions of host cells taken from adjacent buccal gingiva. The differ- during the osseointegration of implants by ence between the SFEs of the abutments, zir- increasing SFE and wettability.37, 43 conium oxide being appreciably smoother, had There are relatively few studies address- no influence on the microbiologic findings. This ing the role of hydrophilicity in microbial adhe- conclusion, as regards SFE impact on bacte- sion to implant surfaces. Schmidlin et al.17 rial adhesion, is supported by Burgers, et al.35 reported that surface roughness had a moder- as they reported that initial adhesion of bacte- ate influence on in vitro biofilm formation while ria to differently textured titanium surfaces was hydrophilicity appeared to exhibit little effect. influenced by the roughness average value In apparent contradiction, Almaguer-Flores (Ra) and that SFE was of minor importance. et al.44 concluded that initial in vitro biofilm formation was significantly influenced by the micro- Hydrophilicity topography and hydrophilicity of the substrate Surface roughness can be viewed in terms of surface. Not surprisingly, regardless of surface hydrophilicity (a.k.a. wettability). Hydrophilic- topography, all implant specimens exhibited ity refers to a decrease in surface tension that higher numbers of attached bacteria when incu- allows a liquid to spread, thereby “wetting” bated in an enriched Mycoplasma broth-media the surface.36 In terms of implant surfaces it is compared to those cultured in human saliva. interesting to note that both hydrophobicity and Of greater interest, however, was the observa- hydrophilicity are determined, in major part, by tion that surface topography and the culture

The Journal of Implant & Advanced Clinical Dentistry • 65 Cobb et al

medium appeared to dictate the proportions of substrates, to include implant surfaces, have bacterial species in the early stage biofilm. For been identified and include Van der Waals example, the numbers of Actinomyces israelii forces, electrostatic interactions, and acid- and Porphyromonas gingivalis were depressed base bonding.48 Together these forces cre- when the biofilm was grown on an SLA or modi- ate a distance-dependent energy field that fied SLA surface in the presence of saliva. This can attract and bind proteins salivary and observation is likely related to the presence of GCF derived proteins and eventually bacteria. anti-bacterial components found in whole saliva. Once bacteria begin to attach to an implant surface the biophysical differences between Substrata, Protein Adsorption and various substrata become academic, particu- Bacterial Adhesion larly if bacterial accumulation remains undis- Saliva contains multiple components such as turbed and progress to a mature biofilm.49, 50 mucins, acidic proline-rich proteins, histatins, statherin, cystatins, agglutinins, amylase, secre- CONCLUSION tory IgA, lysozyme, and lactoferrin.45,46 When The research literature shows that microbial adhe- saliva is mixed with GCF, a transudate con- sion can occur on any implant surface, regard- sisting of serum glycoproteins, albumin and less of the degree of surface roughness. Initial heme, the result is a carbohydrate-protein biofilm formation and composition can be influ- complex the coats all exposed soft and hard enced by the interrelated biophysical character- tissue surfaces in the oral cavity.47 This com- istics of surface roughness, surface free energy, plex is referred to as the acquired pellicle. and degree of hydrophilicity. It has proven dif- The pellicle composition dictates the kinds ficult to differentiate between the effects of of bacteria that initially adhere to a specific the individual biophysical attributes. However, intraoral surface. The initial bacterial adhe- once bacteria begin to colonize a surface and sion involves recognition of oligosaccharide are allowed to increase in mass without distur- receptors by protein adhesions, in lectin-like bance, e.g., shear forces, the biophysical charac- reactions, protein-protein interactions, and ter of the surface becomes less important. From ionic or hydrophobic or hydrophilic associa- the clinicians view, this latter observation rein- tions between microbial surface components forces the necessity for exquisite oral hygiene to and the adhesion substrate. The compo- maintain a healthy peri-implant environment. ● nents of a microbial biofilm (i.e., microbial community) found at different sites within the Correspondence: oral cavity can exhibit considerable variabil- Dr. Charles M. Cobb ity. Basically, the bacteria that first adhere to 424 West 67th Terrace a site do so because of the biological prop- Kansas City, MO 64113 erties and number of available receptors. Phone: 816-444-3167 The forces that mediate adsorption of salivary E-mail: [email protected] and GCF derived proteins to dental materials

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Disclosure 17. Schmidlin PR, Muller P, Attin T, Wieland M, 35. Burgers R, Gerlach T, Hahnel S, Schwarz F, The authors report no conflicts of interest with Hofer D, Guggenheim B. Polyspecies biofilm Handel G, Gosau M. In vivo and in vitro biofilm anything mentioned in this article. formation on implant surfaces with different sur- formation on two different titanium implant face characteristics. J Applied Oral Sci 2013; surfaces. Clin Oral Implants Res 2010; 21(2): References 21(1): 48-55. 156-164. 1. Da Silva JD, Kazimiroff J, Papas A, et al. Out- 18. Bollen CM, Papaioanno W, Van Eldere J, 36. MIT Non-Newtonian Fluid Dynamics Research comes of implants and restorations placed in Schepers E, Quirynen M, van Steenberghe D. Group. Wettability, non-wettability and contact general dental practices: A retrospective study by The influence of abutment surface roughness on angle hysteresis. Available at: http://web.mit. the Practitioners Engaged in Applied Research plaque accumulation and peri-implant mucositis. edu/nnf/education/wettability/wetting.html. Ac- and Learning (PEARL) Network. J Am Dent Assoc Clin Oral Implants Res 1996; 7(3): 201-11. cessed January 6, 2015. 2014; 145(7): 704-13. 19. Riedewald F. Bacterial adhesion to surfaces: 37. Rupp F, Scheideler L, Eichler M, Geis-Gerstorfer 2. Mombelli A, Müller N, Cionca N. Epidemiology The influence of surface roughness. PDA J J. Wetting behavior of dental implants. Int J Oral of peri-implantitis. Clin Oral Implants Res 2012; Pharm Sci Technol 2006; 60(3): 164-71. Maxillofac Implants 2011; 26(6): 1256-66. 23(Suppl. 6): 67-76. 20. Barbour ME, O’Sullivan DJ, Jenkinson HF, Jag- 38. Noro A, Kaneko M, Murata I, Yoshinari M. Influ- 3. Marronne A, Lasserre J, Bercy P, Brecx MC. ger DC. 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