Site Preservation with Placental Membrane

Volume 3, No. 3 March/April 2011

The Journal of Implant & Advanced Clinical Dentistry

Extracellular Membrane Gingival Grafting Compatibility Innovation Value

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19 The Use of DynaMatrix® Extracellular Membrane for Gingival Augmentation and Root Coverage: A Case Series Stephen Andrew Saroff

35 BioXclude™ Placental Allograft Tissue Membrane Used in Combination with Bone Allograft for Site Preservation: A Case Series Dan Holtzclaw, Nicholas Toscano

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JIACD_April2011_Pinnochio.indd 1 3/8/2011 9:18:09 AM The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 3 • March/April 2011 Table of Contents 55 Decoronation for Ridge Preservation in Implant Dentistry: A Clinical Technique and Case Report Tareq Abu-Saleh

69 Neck Dissection for Oral Cancer Fayette C. Williams, Brent B. Ward, Sean P. Edwards

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1. Radiographic Analysis of Crestal Bone Levels on Laser-Lok Collar Dental Implants. CA Shapoff, B Lahey, PA Wasserlauf, DM Kim, IJPRD, Vol 30, No 2, 2010. 2. Implant strength & fatigue testing done in accordance with ISO standard 14801. 3. Initial clinical efficacy of 3-mm implants immediately placed into function in conditions of limited spacing. Reddy MS, O’Neal SJ, Haigh S, Aponte-Wesson R, Geurs NC. Int J Oral Maxillofac Implants. 2008 Mar-Apr;23(2):281-288. 4. Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim. International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP10109 REV D SEP 2010 The Journal of Implant & Advanced Clinical Dentistry Volume 3, No. 3 • March/April 2011

Publisher Copyright © 2011 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Disclaimer: Reading an article in JIACD does not qualify Stephanie Belcher the reader to incorporate new techniques or procedures 336-201-7475 discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their Copy Editor educational training, clinical experience, and professional JIACD staff expertise when attempting new procedures. JIACD, its staff, and parent company SpecOps Media, LLC (hereinafter Digital Conversion referred to as JIACD-SOM) assume no responsibility or NxtBook Media liability for the actions of its readers.

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ACE Surgical Supply Company, Inc. • 1034 Pearl Street, Brockton, MA 02301 The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory Board Tara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Michael Huber, DDS Terry Rees, DDS Michael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDS Daniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMD John Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDS Stepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMD David Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMD Charles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDS Sally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDS Tomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Alex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDS Nicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD 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 Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS

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Fads Come and Go . . . So Do Some Dental Products f you are like me, you probably have a big it was platform switching. Then it was thread stack of old dental journals sitting in the design. Then it was surface again. Wow! Implant Igarage. I hate to admit it, but I actually have design has certainly progressed over the past a giant bookcase full of over one thousand decade and many new innovations have become dental journals from the past decade. My wife commonplace. Other innovations, however, occasionally derides my huge collection of disappeared as fast as they showed up. “dental stuff.” Do you really need all of those The same thing held true with certain magazines? You haven’t looked at most of them growth factors. In the older journals, certain in years, you know. You know what…she is right. growth factors were all the rage. There Most of those journals were read once and were advertisements. There were tons of then put on the shelf. I have this knack for articles. Then, suddenly, everyone quit using keeping dental lit just in case I might want to that particular growth factor and moved on to look at it again one day in the future. Ninety something better…or they found that over the nine times out of one hundred, that day never long term, that growth factor didn’t really do as comes. The journals just sit on the shelf and much as we thought it did. collect dust. If there is a truly amazing article, Dental products are just like everything I now scan it and save it as a PDF in my else. Every company says they have the best computer for future reference. Other than that, thing since sliced bread. In some cases, they I am afraid that I have just been pack-ratting a are right…they do have a great new product. In bunch of old dental journals. other cases, they simply have a new flavor of the I was recently doing some spring cleaning in month, much like bell bottom pants, Members the garage and decided that my library of ancient Only jackets, and Snuggies. The new product dental scrolls needed to go. Before I parted with has some sizzle and generates some buzz, my beloved, yet dusty, old journals, I decided to but it simply doesn’t last. It could be because look through some of them just one more time. something better came along, it was hard to What I found was truly interesting. use, or that it simply did not work as well as the As I flipped through those old journals, many company claimed. of which had long since become defunct, merged When using something new, we should into other journals, or simply went out of business, stick to our basic science backgrounds. Test. I noticed that I was paying more attention to the Evaluate. Compare. Understand the science advertisements than to the actual articles. What behind the product and don’t simply rely on the caught my attention was how much things have word of the rep. ● changed over the past decade…how dental products tend to follow fads, much like everyday fashion. Take dental implant design, for example. In my older journals, implant companies were advertising “rough surfaces.” Then everyone was talking about how their new “tapered” design Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS was best. Then it was contoured platforms. Then Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 15 © MIS Corporation. All rights reserved.

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DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1

• The signaling proteins (growth factors, glycoproteins, glycosaminoglycans) Biopsy of Biopsy of communicate with the body to help DynaMatrix autogeneous stimulate the natural healing process2 treated site gingival graft

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1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543.

2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5.

3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract).

4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract).

Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Call: +1-781-328-3490 Burlington, MA 01803 USA Fax: +1-781-328-3400 Call: 1-866-902-9272 / Fax: 1-866-903-9272 [email protected] www.keystonedental.com Saroff The Use of DynaMatrix Extracellular Membrane for Gingival Augmentation and Root Coverage: A Case Series

Stephen Andrew Saroff, DDS, MSD1

Abstract

ver the years, mucogingival surgery spite of the many advances made in sur- has developed into an integral part of gical techniques and materials, the O periodontal therapy. Mucogingi- coverage of denuded root surface has val defects and deformities are conditions primarily focused on the soft tissue that deviate from the normal ana- and not on the underlying bone loss. tomic relationship between the gingival This article presents a series of cases margin and mucogingival junction. Some illustrating techniques that have of the most common conditions are yielded favorable surgical outcomes in gingival recession, an absence or insuf- challenging circumstances involv- ficient amount of keratinized tissue, ing the incorporation of allogeneic bone and the presence of probing depths putty and an extracellular matrix scaf- extending past the mucogingival junction. fold into the process of repair and A common factor is, often, the exis- reconstruction. tence of alveolar bone loss. However, in

KEY WORDS: Gingival augmentation, root coverage, periodontal plastic surgery, guided tissue regeneration

1. Former Professor of Periodontics and Oral Medicine and Director of Pre-doctoral Periodontics and Implantology at Fairleigh Dickinson University, Hackensack, New Jersey, USA.

The Journal of Implant & Advanced Clinical Dentistry • 19 Saroff

Int roduction augment the zone of attached keratinized gin- The goal of mucogingival surgery has been giva. Clinicians have utilized autogenous gin- to create, conserve, and preserve a function- gival or connective tissue grafts, freeze-dried ally adequate band of gingival tissue. Lang and skin allografts, and acellular dermal matrix. Each Loe previously established that a minimal zone method yielded a variety of results, and each of 2mm of keratinized tissue was essential to technique presented clinical compromises.14-18 maintain gingival health.1 From studies by Ken- While autogenous soft tissue grafts have nedy and Dorfman, this band may be much nar- demonstrated clinical efficacy, they require a rower than originally purported and is often donor site. Harvesting the tissue adds to patient predisposed to inflammation and recession.2 discomfort and can increase the likelihood of The surgical techniques developed and used complications. The use of an allogeneic soft tis- in the past have essentially been grounded in sue grafts like Alloderm® (Lifecell Corp, Branch- manipulation and use of only soft tissue. Tra- burg, NJ, USA) an acellular dermal graft, was an ditionally, a lateral positioned pedicle graft was attempt to offset many of the negative aspects first introduced by Grupe and Warren3 and sub- associated with harvesting donor tissue. How- sequently outlined by Wilderman and Wentz.4 ever, the acellular dermal matrix presented For years the primary means of augment- certain clinical limitations in handling charac- ing gingiva and covering roots was the free pal- teristics, surgical technique, and in enhanc- atal tissue autograft. Bjorn,5 Pennel and King,6,7 ing the quality and quantity of keratinized tissue. Cowan,8 and Nabers9,10 were all pioneers in It is generally accepted that attached kera- reporting the use of this procedure. Later in tinized tissue is an integral part of the periodon- 1968 Sullivan and Atkins11 refined the technique tium, and serves to function as an effective and outlined the wound healing associated with barrier by facilitating resistance to tissue dam- the procedure. Over the years many additional age from traumatic insults. This observation was investigators explored enhancements and altera- amplified in a recent study conducted at Har- tions to existing techniques in order to refine and vard University by Nevins et al.19 and published improve outcomes. In 1977 Maynard12 and Ber- in 2010. Their investigation was conducted nimoulin13 published on coronally positioning to assess the efficacy of an extracellular mem- of a previously placed autogenous gingival graft. brane (DynaMatrix®, Keystone Dental, Burlington, Tissue grafting procedures that increase the MA, USA) in augmenting keratinized tissue. The amount and quality of attached keratinized gin- results suggested that the “membrane may pres- gival tissue, and cover exposed and denuded ent a viable substitute for the autogenous gin- root surfaces accomplish a number of objec- gival graft” when the objective is to increase the tives: the prevention of additional root exposure, dimension of the keratinized attached gingival. decreased or eliminated sensitivity to thermal The study by Nevins et al.19 compared treat- and other stimuli, decreased susceptibility to root ment utilizing a free gingival graft versus an extra- caries, and improved esthetics. As a result, vari- cellular matrix (DynaMatrix®) and determined that ous surgical techniques were developed to both techniques produced a significant increase

20 • Vol. 3, No. 3 • March/April 2011 Saroff

in the amount of keratinized gingival tissue. In Ms ethod addition, the matrix-generated tissue was com- Seven patients were selected for the study. parable histologically to the tissue derived from Each patient had varying degrees of gin- the autograft. The study concluded that the gival recession and osseous destruction. DynaMatrix® extracellular matrix blended well Selection was based on a moderate to with surrounding tissue, and it produced supe- severe level of pathology with obvious clini- rior esthetic outcomes when compared to the cally relevant defects, and with an inter- autogenous graft. Finally, the report suggested est in regenerating, reconstructing, and that the extracellular matrix be considered in the repairing the damage to the periodontium. treatment for patients with gingival recession. In essence, this series of cases was This particular current investigation and case intended to evaluate the efficacy of the series builds on the study by Nevins and co- DynaMatrix® extracellular matrix membrane workers. Seven case studies were documented in a variety of treatment modalities. Many during 2009 and 2010 in Richmond, Virginia, of the articles written about this membrane and involved a variety of periodontal issues have outlined the fundamental qualities of the and defects. A critical difference from previous matrix.20 The membrane is obtained from the studies involved the treatment of gingival reces- small intestine submucosa of the pig and has sion and root denudation. This investigation been dubbed SIS technology by the producer was not a controlled study. However, based Cook Biotech Incorporated. The matrix is uti- on the clinical outcomes, perhaps a new para- lized as the structure to retain a construct of digm may be developing with respect to treat- collagen (types I, III, IV, and VI), proteogly- ing significant cases of gingival recession. The cans, glycosaminoglycans, glycoproteins, and author believes it is vital to explore the causal- additional growth factors such as fibronectin. ity associated with gingival recession. Certainly Investigation into the formulation and fab- a common denominator in all cases of gingival rication of the matrix-membrane warrants addi- recession and denudation is bone loss. How- tional explanation. Hodde and co-workers20 ever, when one reviews the literature on treat- investigated the effects of sterilization on the ment of gingival recession, seldom is there any matrix scaffold and determined that a “bio- mention of the role or treatment of lost alveolar logic scaffold can be prepared for human bone. use and still retain significant bioactivity.” Some of the techniques outlined in this DynaMatrix® has been successfully used article add another dimension. The motiva- in the treatment of a variety of damaged and tion was to determine if it were feasible to or diseased tissues in humans. The biologic treat some of the underlying bone loss, which scaffold stimulates the repair of compromised contributes to the recession along with obtain- tissues and organs with tissue similar in form ing root coverage. With that objective in and function to that which it replaced. It is not mind a surgical methodology was adopted within the purview of this case study series to for the majority of patients in this case study. explore in depth the biology and biochemistry of

The Journal of Implant & Advanced Clinical Dentistry • 21 Saroff

Figure 1: Localized gingival recession on tooth #25. Figure 2: Flap design to allow for access to denuded root and bone.

Figure 3: DynaBlast bone putty packed around exposed Figure 4: Extracellular membrane (DynaMatrix) placed and roots hydrated with blood.

Figure 5: Coverage of site with a laterally positioned flap Figure 6: 9 day post-op with tissue development. (pedicle); DynaMatrix is left exposed on donor site.

22 • Vol. 3, No. 3 • March/April 2011 Saroff

Figure 7: 6 week post-op with significant tissue Figure 8: 6 month post-op with developed keratinized development and normal healing. tissue and successfully covered exposed root.

the matrix. However, it is accepted that using a Rs e ults cell-free wound dressing derived from the extra- Case 1: cellular matrix of the small intestine of the pig can The patient presented with localized gingival facilitate the repair of damaged and diseased recession and severe bone loss on the facial of tissues. With these fundamental constructs tooth #25 (figure 1). The gingival margin around in place acting as a theoretical foundation, the exposed tooth was resected (No. 15 Bard- a series of cases was undertaken to assess Parker blade) to the depth of the pocket using the efficacy of the DynaMatrix® membrane. a v-shaped incision. A gingival flap was devel- A five step surgical process was adopted for oped which was somewhat larger than the recipi- the majority of the patients in this case study: ent site (figure 2). After the flap was elevated 1. Exposure of the defect with thorough and reflected, the root surface was thoroughly debridement scaled and planed. The bone putty (DynaBlast®) 2. Placement of bone putty (DynaBlast®) was then placed around the exposed root and 3. Placement of DynaMatrix® membrane over extended coronally to the cemento-enamel bone graft junction (figure 3). Complete coverage of the 4. Ligation of the matrix to surrounding tissue denuded root was obtained with the bone putty. 5. Soft tissue coverage of the surgical site The extracellular matrix membrane (DynaMa- Healing was evaluated and assessed sev- trix®) was placed on the bone graft and com- eral times over the following months. The ini- pletely covered the exposed roots (figure 4). The tial postoperative evaluation took place 9-10 matrix was then hydrated with the patient’s blood days following the surgical procedure. In addi- and secured with sutures (5-0 resorbable). In tion, follow-up visits were scheduled over the this particular case, a laterally positioned flap next six months. Clinical images were obtained (pedicle) was used to cover the surgical site and reproduced with the patients’ consent. (figure 5). The patient was seen for follow-up

The Journal of Implant & Advanced Clinical Dentistry • 23 Saroff

Figure 9: Tooth #24 demonstrates localized gingival recession and insufficient keratinized tissue along with aberrant frenum. Figure 10: Mucoperiosteal flap developed to expose roots.

Figure 11: DynaMatrix placed and hydrated with blood. Figure 12: Laterally positioned pedicle flap positioned over DynaMatrix and sutured.

care nine days post operatively and healing was progressing uneventfully (figure 6). Six weeks post-operatively there had been favorable tissue development along with normal healing (figure 7). Finally, the six-month follow-up demonstrates significant coverage of the denuded root with well-developed keratinized tissue (figure 8).

Case 2 Figure 13: 9 days post op, epithelial tissue development The patient presented with localized gin- over DynaMatrix. gival recession and insufficient keratinized tissue along with a concomitant aberrant fre-

24 • Vol. 3, No. 3 • March/April 2011 Saroff

Figure 14: Teeth #24 and #25 have localized recession and Figure 15: Mucoperiosteal flap developed to expose root inconsistent tissue heights due to severe bone loss. surface

Figure 17: Adjacent tissue was laterally positioned and Figure 16: DynaMatrix® placed and hydrated with blood. DynaMatrix sutured into place.

num associated with tooth #24 (Figure 9). A Case 3: mucoperiosteal flap was created to expose The patient presented with localized gingival the root and to permit a frenectomy (figure recession on teeth #25 and #25 (figure 14). Sig- 10). Debridement of the site was performed nificant crowding likely had an impact of the extant and subsequently DynaMatrix® was placed, facial bone loss. A mucoperiosteal flap was devel- hydrated with the patient’s blood and secured oped to expose the roots and revealed extensive (figure 11). In this particular case bone aug- denudation (figure 15). Following debridement mentation was not performed. A pedicle of the site along with scaling and root plan- flap was used to gain soft tissue coverage ing, DynaMatrix® was placed, hydrated with the of the site (figure 12). The nine-day postop- patient’s blood, and secured (figure 16). Adja- erative image (figure 13) reveals normal heal- cent tissue was laterally positioned to cover the ing and root coverage for this time period. site (figure 17). In this particular case an area of

The Journal of Implant & Advanced Clinical Dentistry • 25 Saroff

Figure 19: Shallow vestibule with little keratinized tissue.

ther dissection resulted in removal of attached muscle fibers from the bone. DynaMatrix® was adapted to the site and hydrated with blood Figure 18: 7 days post op, successful healing and (figure 21). The membrane was secured by epithelialization of DynaMatrix. sutures and then the site dressed. The healing was uneventful and at ten days healthy matrix was left exposed to evaluate claims that keratinized issue was developing (figure 22). no negative consequences are anticipated with exposure and bone grafting was not performed. Case 5: However, osseous augmentation would be per- The patient presented with severe gingival fectly justified based on expected outcomes. recession on teeth #24 and #25 (figure 23). After one week, uneventful healing was taking The likely source of the periodontal pathol- place and the area of exposed membrane was ogy may well relate to the ongoing orthodontic epithelializing without complications (figure 18). therapy. Both teeth demonstrated significant loss of facial bone as well as alterations in the Case 4: color, contour, texture, and consistency of the The patient presented, following a refer- gingiva. Two independent laterally positioned ral from an orthodontist, with a shallow man- flaps were used in the treatment of this prob- dibular anterior vestibule characterized by a lem and they were not performed on the same limited amount of attached keratinized gin- day. As in other instances a v shaped incision giva (figure 19). An incision was made at the was used to remove the affected gingival tis- mucogingival junction and reflected to expose sue (figure 24). Debridement of the site as the periosteum of the bone (figure 20). Fur- well as scaling and root planing of the teeth

26 • Vol. 3, No. 3 • March/April 2011 Saroff

Figure 20: Incision was made at the mucogingival Figure 21: DynaMatrix® was placed and hydrated with junction. blood.

Figure 22: 10 day post op, expanded vestibule and Figure 23: Teeth # 24 and #25 demonstrate severe healthy, keratinized tissue was developing. localized gingival recession and bone loss in association with orthodontic treatment.

Figure 25: DynaMatrix placed, hydrated with blood and Figure 24: V-shaped flap was created to expose the root. sutured into place with adjacent tissue.

The Journal of Implant & Advanced Clinical Dentistry • 27 Saroff

Figure 26: 6 months post op with tissue development over Figure 27: 6.5 month post op with developed keratinized exposed root. tissue. was performed. This was followed by place- was made at the mucogingival junction and ment of the matrix and ligation of the membrane after reflection, dissection of muscle fibers, (figure 25). Closure was obtained by creat- DynaMatrix® was placed, hydrated with blood ing a laterally positioned pedicle graft. Figures and secured with sutures to the adjacent tis- 26 and 27 demonstrate favorable healing and sue (figure 32). The site was dressed with improved root coverage after 24 and 26 weeks. periodontal pack and a six week follow-up image demonstrates a thicker and broader Case 6: band of healthy keratinized tissue (figure 33). The patient presented with an insufficient zone of attached gingiva in the mandibular Coio nclus n anterior region (figure 28). A shallow vesti- This case series demonstrates the effi- bule was present and was noted by the refer- cacy of DynaMatrix® extracellular mem- ring orthodontist. An incision was made at brane for the treatment of both localized the mucogingival junction and after reflec- gingival recession as well as for the devel- tion and dissection of muscle fibers, DynaMa- opment of attached keratinized tissue. Post- trix® was placed, hydrated with blood and operative evaluation revealed successful sutured into place (figure 29). A six week fol- tissue remodeling in the treated areas com- low up image revealed healthy tissue develop- bined with enhanced root coverage of areas ment with an esthetic outcome (figure 30). of localized recession. Substantial increases in the volume of keratinized tissue were noted. Case 7: In addition to the successful outcomes, The patient presented with a thin zone of DynaMatrix® extracellular membrane offers a attached gingiva (figure 31). The referring number of advantages over traditional methods doctor had requested augmentation of the of soft tissue grafting. This is especially noted attached and keratinized tissue. An incision as it relates to the procurement of donor tissue.

28 • Vol. 3, No. 3 • March/April 2011 Saroff

Figure 28: Insufficient zone of attached gingiva. Figure 29: Incision made at mucogingival junction, DynaMatrix placed, hydrated with blood and sutured to adjacent tissue.

Figure 30: 6 week post op with healthy tissue Figure 31: Thin zone of attached gingiva. development.

Figure 32: Incision was made at mucogingival junction. DynaMatrix was placed, hydrated with blood, sutured into Figure 33: 6 week post op with thicker tissue and healthy placed with adjacent tissue and left exposed. keratinized tissue development.

The Journal of Implant & Advanced Clinical Dentistry • 29 Saroff

The use of the matrix may reduce the need for Disclosure a surgical intervention in a secondary or donor The authors report no conflicts of interest with anything mentioned in this article. References site as required in autogenous mucosal grafts 1. Lang NP, Loe H. The relationship between the width of keratinized gingiva and including subepithelial connective tissue grafts. gingival health. J Periodontol. 1972 Oct;43(10):623-627. 2. K ennedy JE, Bird WC, Palcanis KG, Dorfman HS. A longitudinal evaluation of For patients, eliminating a donor site reduces varying widths of attached gingiva. J Clin Periodontol. 1985 Sep;12(8):667- the likelihood of post-operative pain, bleeding, 675. 3. Grupe HE. Modified technique for the sliding flap operation. J Periodontol. 1966 and infection. Furthermore, it reduces the treat- Nov-Dec;37(6):491-495. ment time and enhances the patient’s overall 4. W ilderman MN, Wentz FM. Repair of a Dentogingival Defect with a Pedicle Flap. J Periodontol. 1965 May-Jun;36:218-231. experience. The extracellular membrane does 5. Bjorn HaL, J. Influence of periodontal instruments on the tooth surface. A not require enclosure within the patient’s exist- methodological study. Odont Rev. 1963;13:355. 6. P ennel BM, Higgason JD, Towner JD, King KO, Fritz BD, Salder JF. Oblique ing tissue and the material may be left exposed Rotated Flap. J Periodontol. 1965 Jul-Aug;36:305-309. in the surgical site. Ultimately, it blends with 7. Pennel BM, King KO, Higgason JD, Towner JD, 3rd, Fritz BD, Sadler JF. Retention of Periosteum in Mucogingival Surgery. J Periodontol. 1965 Jan-Feb;36:39-43. native tissue and produces a fine esthetic result. 8. Cowan A. Sulcus Deepening Incorporating Mucosal Graft. J Periodontol. 1965 Thus, results outlined here support the use May-Jun;36:188-192. 9. Nabers JM. Free gingival grafts. Periodontics. 1966 Sep-Oct;4(5):243-245. of this extracellular matrix or scaffold. It pos- 10. Nabers JM. Extension of the vestibular fornix utilizing a gingival graft--case ses unique attributes for periodontal surgery history. Periodontics. 1966 Mar-Apr;4(2):77-79. 11. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of acting as an alternative to autogenous muco- successful grafting. Periodontics. 1968 Jun;6(3):121-129. sal grafts. Furthermore, it may well enhance 12. Maynard JG, Jr. Coronal positioning of a previously placed autogenous gingival the surgical outcomes of achieving root cov- graft. J Periodontol. 1977 Mar;48(3):151-155. 13. Bernimoulin JP, Luscher B, Muhlemann HR. Coronally repositioned periodontal erage in the advanced case as well as aug- flap. Clinical evaluation after one year. J Clin Periodontol. 1975 Feb;2(1):1-13. ● 14. Edel A. Clinical evaluation of free connective tissue grafts used to increase the menting the keratinized tissue present. width of keratinised gingiva. J Clin Periodontol. 1974;1(4):185-196. 15. Gher ME, Jr., Williams JE, Jr., Vernino AR, Strong DM, Pelleu GB, Jr. Evaluation of the immunogenicity of freeze-dried skin allografts in humans. J Periodontol. 1980 Oct;51(10):571-577. Correspondence: 16. Harris RJ. Gingival augmentation with an acellular dermal matrix: human Dr. Stephen Saroff histologic evaluation of a case--placement of the graft on bone. Int J Periodontics Restorative Dent. 2001 Feb;21(1):69-75. [email protected] 17. Y ukna RA, Tow HD, Caroll PB, Vernino AR, Bright RW. Comparative clinical evaluation of freeze-dried skin allografts and autogenous gingival grafts in humans. J Clin Periodontol. 1977 Aug;4(3):191-199. 18. Yukna RA, Tow HD, Carroll PB, Vernino AR, Bright RW. Evaluation of the use of freeze-dried skin allografts in the treatment of human mucogingival problems. J Periodontol. 1977 Apr;48(4):187-193. 19. Nevins M, Nevins ML, Camelo M, Camelo JM, Schupbach P, Kim DM. The clinical efficacy of DynaMatrix extracellular membrane in augmenting keratinized tissue. Int J Periodontics Restorative Dent. 2010 Apr;30(2):151-161. 20. Hodde J, Janis A, Hiles M. Effects of sterilization on an extracellular matrix scaffold: part II. Bioactivity and matrix interaction. J Mater Sci Mater Med. 2007 Apr;18(4):545-550.

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BioXclude™ Placental Allograft Tissue Holtzclaw et al Membrane Used in Combination with Bone Allograft for Site Preservation: A Case Series

Dan Holtzclaw, DDS, MS1 • Nicholas Toscano, DDS, MS Abstract

ite preservation entails conservation of riers such as non-cross linked collagen plugs, existing bone during tooth removal and cross linked collagen membranes, chitosan plugs, Saugmentation of the tooth socket. A expande poytetrafluoroethylene (PTFE) mem- variety of materials may be used to augment the branes, and connective tissue grafts are often socket including bone allograft, xenograft, cal- used. BioXclude™, a resorbable amnion chorion cium sulfate, beta-tricalcium phosphate, collagen membrane, has recently been introduced as a sponges, and growth factors such as platelet new barrier for site preservation. This case series rich fibrin. To contain these materials within the documents use of BioXclude™ amnion chorion socket and protect them from the oral cavity, bar- membrane for the purpose of site preservation.

KEY WORDS: Site preservation, tooth extraction, bone graft, guided bone regeneration, amnion

1. Private practice limited to periodontics and dental implants, Austin, Texas, USA 2. Private practice limited to periodontics and dental implants, New York, New York, USA

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

Boackgr und ure 1-2). The sectioned roots were removed Contemporary dental implant treatment rec- (figure 1-3) leaving an intact bony septum ommends at least 1mm of bone surround all (figure1- 4) which was adequate for immedi- aspects of the implant fixture.1 To achieve such ate implant placement. The patient declined a goal, the concept of site preservation is fre- this treatment due to finances and elected quently employed. Site preservation entails to have site preservation performed in con- conservation of existing bone during tooth sideration for future dental implant place- removal and augmentation of the tooth socket. ment. The site was grafted with mineralized A variety of materials may be used to augment freeze dried bone allograft (FDBA) (figure 1-5) the socket including bone allograft, xenograft, and covered with a BioXclude™ amnion cho- calcium sulfate, beta-tricalcium phosphate, col- rion membrane (figure 1-6). The flap was then lagen sponges, and growth factors such as replaced with resorbable sutures (figure 1-7). platelet rich fibrin. To contain these materials At 48 hours after surgery, rapid healing was within the socket and protect them from the seen with opacification of the BioXclude™ mem- oral cavity, barriers such as non-cross linked brane and granulation tissue evident over the collagen plugs, cross linked collagen mem- treatment site (figure 1-8). By 96 hours, healing branes, chitosan plugs, expande poytetrafluo- was advanced to a point where sutures could roethylene (PTFE) membranes, and connective be removed. At this time, complete closure of tissue grafts are often used. BioXclude™, a the treatment site was achieved, thus protecting resorbable amnion chorion membrane, has the underlying site preservation bone graft (fig- recently been introduced as a new barrier for ure 1-9). At 10 days after surgery, continued site preservation. This membrane differs from maturation of the tissue covering the treatment others in the fact that it has inherent growth site was evident (figure 1-10). By 21 days after factors within its structure. This case series surgery, there was complete keratinization of the documents use of BioXclude™ amnion chorion gingival tissue covering the area of site preser- membrane for the purpose of site preservation. vation surgery (figure 1-11) and at 45 days after surgery, further maturation of the keratinized tis- Case 1 sue covering the site was seen (figure 1-12). This case demonstrates the rapidity with which BioXclude™ seals an area treated with site preservation. A 56 year old Caucasian female presented for treatment of a hopeless maxillary right first molar (tooth #3) (figure 1-1). Local anesthesia was achieved with via infiltration using 4% articaine with 1:100,000 epinephrine. A sulcular full thickness mucoperiosteal flap was minimally elevated and the tooth was sectioned with a high speed hand piece (fig-

36 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Figure 1-1: Pre-surgical photo. Figure 1-2: Sectioned tooth.

Figure 1-3: Extracted roots. Figure 1-4: Intact bony septum.

Figure 1-5: Bone allograft placement. Figure 1-6: BioXclude placement.

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

Figure 1-7: Suture placement. Figure 1-8: 48 hours.

Figure 1-9: 96 hours. Figure 1-10: 10 days.

Figure 1-11: 21 days. Figure 1-12: 45 days.

38 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Case 2 with BioXclude™ chorion amnion membrane (fig- This case provides additional documentation of ure 2-5) and temporized with a temporary transi- the ability of BioXclude™ chorion amnion mem- tional partial denture (TTP) with an ovate pontic. brane to achieve rapid closure of sockets dur- At 48 hours after surgery, complete closure of the ing site preservation procedures. A 51 year old socket is evident (figure 2-6). Nearly complete Hispanic female presented for treatment of a keratinization of the tissue covering the extraction non-restorable maxillary left central incisor (tooth socket is evident by 1 week after surgery (figure #9) (figures 2-1, 2-2). Following administration 2-7). Further maturation of the gingival tissues is of local anesthesia, tooth #9 was atraumatically seen at 3 months after surgery (figure 2-8) and extracted (figure 2-3) and grafted with FDBA (fig- there is radiographic evidence of significant bony ure 2-4). The grafted socket was then covered fill of the pre-surgical bony defect (figure 2-9).

Figure 2-1: Pre-surgical photo.

Figure 2-3: Tooth extraction. Figure 2-2: Pre-surgical radiograph.

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

Figure 2-4: Bone allograft placement. Figure 2-5: BioXclude placement.

Figure 2-6 48 hours. Figure 2-7: 1 week.

Figure 2-9: 3 month radiograph.

Figure 2-8: 3 months.

40 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Case 3 gery. A minimal full thickness flap was reflected A 45 year old Caucasian female presented with at the location of the site preservation sur- an endodontically abscessed right maxillary lat- gery. The bone at the surgical site (figure eral incisor (tooth #7) (figures 3-1, 3-2). Follow- 3-12) was of type 2-3 quality and well vascu- ing administration of local anesthesia, the tooth larized. Histologic analysis of a trephine core was atraumatically extracted (figure 3-3) and sample taken from this site revealed 46.3% vital probing of the socket revealed a dehiscence of bone, 20.6% residual graft material, and 33.1% the facial bony plate. Due to this lack of bone, connective tissue (figures 3-12a, 3-12b). A immediate implantation of a dental implant was 3.75x13mm dental implant was placed (fig- not considered and site preservation was cho- ures 3-13, 3-14) and ISQ values of 75 were sen as the treatment of choice. The extraction achieved. Healing at 3 months revealed good site was grafted with FDBA (figure 3-4) and cov- bone contour and tissue quality (figure 3-15). ered with a BioXclude™ amnion chorion membrane (figure 3-5). A TTP with an ovate pontic was delivered for site temporization (figure 3-6). One week following surgery, the surgical site was completely covered with granulation tissue (figures 3-7, 3-8). At 10 weeks following surgery, complete keratinization of the tissue covering the surgical site was evident (figures 3-9, 3-10) and radiographic bone fill appeared adequate for placement of a dental implant (figure 3-11). The patient was seen for dental implant surgery 12 weeks after the site preservation sur-

Figure 3-1: Pre-surgical photo. Figure 3-2: Pre-surgical radiograph.

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

Figure 3-3: Tooth extraction. Figure 3-4: Bone allograft placement.

Figure 3-5: BioXclude placement. Figure 3-6: Ovate pontic TTP delivery.

Figure 3-7: 1 week. Figure 3-8: 1 week.

42 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Figure 3-9: 10 weeks. Figure 3-10: 10 weeks.

Figure 3-12: Bone at 10 weeks.

Figure 3-11: 10 week radiograph.

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

Figure 3-12a: 50x magnification. Figure 3-12b: 200x magnification.

Figure 3-13: Implant placement.

Figure 3-15: 3 months healing. Figure 3-14: Implant radiograph.

44 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Case 4 the initial site preservation surgery, keratinization of A 42 year old Caucasian female presented for treat- the tissue covering the area of site preservation ment of a maxillary right second premolar (tooth #4) was evident (figure 4-8). The only portion of the that was deemed non-restorable due to a vertical surgical site which was not completely keratinized root fracture (figures 4-1, 4-2). Following adminis- was an area where the apex of the ovate pontic of tration of local anesthesia, the tooth was atraumati- the TTP supported the gingival tissue (figure 4-9). cally extracted (figure 4-3). The extraction socket The patient was seen for dental implant sur- was grafted with FDBA (figure 4-4) and covered gery 12 weeks after the site preservation sur- with a BioXclude™ membrane (figure 4-5). A photo gery. A minimal full thickness flap was reflected was taken 5 minutes after placement to demon- at the location of the site preservation sur- strate how the amnion chorion membrane thickens gery. The bone at the surgical site (figure 4-10) and opacifies upon coming in contact with blood was of type 2-3 quality and well vascularized. A (figure 4-6). A TTP with an ovate pontic was deliv- 4.2x11.5mm dental implant was placed (fig- ered for site temporization. At the initial 7 day follow ures 4-11, 4-12) and ISQ values of 72 were up visit, complete tissue coverage of the extraction achieved. Healing at 3 months revealed good site was observed (figure 4-7). Ten weeks following bone contour and tissue quality figure 4-13)

Figure 4-1: Pre-surgical photo.

Figure 4-2: Pre-surgical radiograph.

Figure 4-3: Tooth extraction.

The Journal of Implant & Advanced Clinical Dentistry • 45 Holtzclaw et al

Figure 4-4: Bone allograft placement. Figure 4-5: BioXclude placement.

Figure 4-6: 5 minutes. Figure 4-7: 7 days.

Figure 4-8: 10 weeks. Figure 4-9: 12 weeks.

46 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Figure 4-10: Bone at 12 weeks. Figure 4-11: Implant placement.

Figure 4-13: 3 months healing.

Figure 4-12: Implant radiograph.

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

Case 5 such, the patient elected to have site preserva- A 34 year old Caucasian male presented for tion performed in consideration for future den- treatment of a non-restorable left mandibular tal implant placement. The extraction socket first molar (tooth #19) (figures 5-1, 5-2). Local was grafted with FDBA (figure 5-4) and cov- anesthesia was achieved with a standard infe- ered with a BioXclude™ amnion chorion mem- rior alveolar block injection using 4% articaine brane (figure 5-5). The flap was then replaced with 1:100,000 epinephrine. A sulcular full with resorbable sutures (figure 5-6). At the thickness mucoperiosteal flap was minimally initial 7 day follow up visit, the socket had fully elevated and the tooth was sectioned with a covered with tissue. By 2 weeks, maturation high speed hand piece. Upon removal of the of the tissue covering the socket was evident tooth, adequate bone was present for an imme- (figure 5-7). Forty five days after surgery, the diate molar implant (figure 5-3), but the patient site exhibited further maturation and complete declined this treatment due to finances. As keratinization of the gingival tissue (figure 5-8)

Figure 5-1: Pre-surgical photo. Figure 5-2: Pre-surgical radiograph.

Figure 5-3: Tooth extraction. Figure 5-4: Bone allograft placement.

48 • Vol. 3, No. 3 • March/April 2011 Holtzclaw et al

Figure 5-5: BioXclude placement. Figure 5-6: Suture placement.

Figure 5-7: 2 weeks. Figure 5-8: 45 days.

Dis scus ion tal ridge resorption may be reduced by 125% and Dimensional changes in ridge morphology fol- vertical resorption may be reduced by 244%.3 lowing extraction of teeth can drastically affect Use of barrier membranes such as BioXclude™ future treatment options. Studies have shown helps the process of site preservation through that alveolar ridge width may decrease by up to rapid closure of the surgical site. This seals the fifty percent within 12 months of tooth extraction underlying graft from harmful bacteria of the oral and that the majority of this loss occurs within the cavity, aiding bone and gingival tissue maturation. first 3 months.2,3 These negative changes can BioXclude™ is a processed, dehydrated, and be avoided through the process of site preserva- sterilized graft of human placenta amnion and tion. By simply grafting the tooth socket and any chorion tissue. Human placental tissue is immu- residual defects at the time of extraction, horizon- noprivileged and, as such, does not elicit a foreign

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

body inflammatory response.4 This membrane Disclosure: differs from other membranes currently available Dr. Holtzclaw is a member of the clinical advisory board for Snoasis Medical. in the fact that it has inherent anti-inflammatory References: 1. Shulman L. Surgical considerations in implant dentistry. Int J Oral Implantol and anti-bacterial properties.5 Additionally, this 1988; 5:37-41. membrane also contains high amounts of lam- 2. Sc hropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single tooth extraction: a clinical and radiographic inin-5 in the amnion layer of the graft. Laminin-5 12-month prospective study. Int J Peridontics Restorative Dent 2003; 23(4):313-323. is a protein with a high affinity for cellular adhe- 3. Iasella J, Greenwell H, Miller R, Hill M, Drisko C, Bohra A, Scheetz J. Ridge sion of gingival epithelial cells6, providing a bio- preservation with freeze dried bone allograft and a collagen membrane compared to extraction site alone for implant site development: a clinical active matrix for cellular migration. This allows and histologic study in humans. J Perioodontol 2003; 74(7):990-999. for rapid sealing of the underlying graft material 4. Chen E, Tofe A. A literature review of the safety and biocompatibil- ity of amnion tissue. J Implant Adv Clin Dent 2009; 2(3):67-75. used for site preservation. Furthermore, immu- 5. Park C, Kahanim S, Zhu L et al. Immunosuppressive property of dried nohistochemical stain analysis of BioXclude™ human amniotic membrane. Opthalmic Res 2009; 41:112-113. 6. Pakk ala, T Virtanen I, Oksanen J, et al. Function of laminins and laminin-binding has also shown the membrane to contain growth integrins in gingival epithelial cell adhesion. J Periodontol 2002; 73(7):709-719. factors such as platelet derived growth factors alpha and beta (PDGF-α, PDGF-β) as well as transforming growth factor beta (TGF-β). In addition to its unique composition advantages, BioXclude™ has other benefits as well. BioXclude™ is relatively thin (300µm) with self- adhering properties once it becomes moist. This eliminates the need for suturing of the membrane. Simply place the membrane into the extraction socket during site preservation procedures and BioXclude™ practically seals itself to the socket. This case report demonstrates proof of prin- ciple that BioXclude™ is an effective product for site preservation procedures. The unique properties of this membrane combined with its ease of use make it an ideal product for this procedure. ●

Correspondence: Dr. Dan Holtzclaw 711 W. 38th Street Suite G5 Austin, TX 78705, USA [email protected]

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Abu-Saleh Decoronation for Ridge Preservation in Implant Dentistry: A Clinical Technique and Case Report

Dr. Tareq Abu-Saleh1

Abstract

Background: Several methods have been Results: Clinical and radiographic findings were advocated to compensate for bone loss in ante- reported in one year follow-up visit and were sat- rior maxilla and achieve satisfactory esthetic isfactory in terms of preservation of bone dimen- results in implant treatment. Some of these sions horizontally and vertically. Another finding modalities are considered time consuming, tech- was the coronal growth of interseptal bone which nique sensitive, expensive, and unpredictable. allowed for reformation of interdental papillae.

Methods: In this report, decoronation of a max- Conclusions: Considering patient desires illary incisor tooth and submerging its root and her existing condition, decoronation was used to preserve alveolar bone level mini- was a valid treatment option from the per- mizing the need for bone augmentation in a spectives of function, esthetics, and main- severely resorbed maxilla. Dental implants tenance of dentition. Controlled studies are were placed adjacent to the retained tooth. recommended to validate these findings.

KEY WORDS: Esthetic dentistry, implant dentistry, restorative dentistry, periodontitis, decoronation.

1. Department of Oral Medicine and Periodontology, University of the Western Cape, Cape Town, South Africa

The Journal of Implant & Advanced Clinical Dentistry • 55 Abu-Saleh

Introduction existing bone and simplify the surgical phase.13 The loss of maxillary anterior teeth can lead to Another common esthetic challenge faced in esthetic, functional, and psychological problems the anterior maxillary area is the partial or com- necessitating prompt treatment.1,2 Extraction of plete loss of papillae causing what is called teeth is accompanied by loss of alveolar bone black triangles.14 The horizontal level of the both in vertical and horizontal directions.2-4 As tip of interdental papilla between teeth was the labial cortical plates surrounding roots of reported to be critically associated with the the anterior maxillary teeth are thin, extraction of vertical distance between the contact points these teeth often results in fracture of cortical and the interdental crest of bone between the plates which leads to considerable bone loss.5 two adjacent teeth. The reported optimum dis- The amount and rate of bone resorption tance is 5mm or less.15 As the distance exceeds vary between individuals and among differ- 5mm (for example, due to interdental bone loss) ent sites in the same person.6 Bone resorp- the position of the tip of the papilla shifts sig- tion can be further complicated by pre-existing nificantly towards the interdental crest.16,17 chronic periodontitis, trauma, periapical infec- As the contact point between two implant sup- tions, previous apicectomies and surgical extrac- ported crowns is attempted to correspond to that of tion which could lead to extensive resorption of natural teeth, loss of bone may be accompanied by the labial plates. Deficiency in alveolar ridge loss of papillae. This may result in “black triangles” may then compromise replacement of missing which necessitate the contact points be shifted teeth resulting in poor esthetics, or requires apically to close the deficiency. This is further com- ridge augmentation prior to implant placement.3 plicated by the fact that a distance of at least 3mm Atraumatic extraction of teeth has been sug- between two implants is necessary to maintain the gested for ridge preservation by reducing trauma interproximal height of bone after remodeling of the to the alveolar plates. Occasionally, examination of biologic width, while 1.5-2 mm is sufficient between the sockets after extractions reveals perforations an implant and natural tooth. This inter-implant dis- of the buccal plates.7 It has been suggested that tance might cause difficulties in achieving esthetic covering the sockets with hard and/or soft tissue emergence profile at time of restoration.4,18 grafts might compensate for the bone resorption Although several tissue management tech- and soft tissue loss during healing process.3,8 niques and site development procedures were Another suggested option for bone preserva- advocated to improve the esthetic outcome of tion in one-unit replacement is immediate implant implant prosthesis, the complete restoration of placement in a flapless technique after extraction the lost soft tissue contour particularly that of the of teeth.9,10 This maintains the soft tissue archi- interdental papilla for adjacent implants placed tecture of the original teeth by supporting the in the esthetic zone remains unpredictable.4 interdental tissues around the implants which One of the tested methods for maintain- helps maintain the interproximal bone and height ing alveolar bone is decoronation of teeth, and of papillae.11,12 The use of expansion osteotomes intentional submergence of roots on the prem- for the creation of implant beds can preserve ise that retaining the root will help preserve the

56 • Vol. 3, No. 3 • March/April 2011 Abu-Saleh

Figure 1: Initial presentation of patient. Figure 2: Note gingival recession.

Figure 3: Patient had soft friable gingiva with areas of Figure 4: Patient had soft friable gingiva with areas of amalgam tattoos (right view). amalgam tattoos (left view).

alveolar bone.6,19-27 The procedure involves gin- preservation but the method had some draw- gival mucoperiosteal flap elevation, sub-crestal backs, especially the accompanying inflamma- removal of the tooth crown leaving the root in the tion, cyst formation or even bone resorption.21,24 alveolus (whether or not it was endodontically In this report, tooth decoronation of a cen- treated).22,23,24 This method has been tested clini- tral incisor was utilized to preserve alveolar bone cally, radiographically, and histologically in animal and maintain papillae next to endosseos implants models as well as in humans. It has been pre- in a patient with severe maxillary alveolar bone sented to prevent bone resorption.6,19-21, 28 Gener- resorption. The clinical and radiological findings ally the results were satisfactory in terms of bone were noted one year following the treatment.

The Journal of Implant & Advanced Clinical Dentistry • 57 Abu-Saleh

Figure 5: Tooth #8 was extracted atraumatically and the Figure 6: The two FPD’s were splinted to support the socket was well debrided. socket.

Figure 7: Osteotomes were used for implant bed Figure 8: Bony defects were curetted and grafted. preparation.

CASE REPORT not contributory and she was non-smoker. The A 48 year old female patient was referred by her patient was well oriented about dental treatment dentist to the department of Oral Medicine and and her oral plaque control was satisfactory. Periodontics, University of the Western Cape, The patient presented with localized severe South Africa, for implant placement in the ante- chronic periodontitis around tooth #8 with rior region. Due to a gap between her ante- severe bone loss and grade III mobility (figure rior fixed partial dentures (FPD’s), the patient 2). The FPD in the upper right quadrant was very experienced embarrassment when talking in mobile. Tooth #9 was involved to a lesser extent front of people (figure 1). Medical history was and had grade I mobility. Diffuse patches of

58 • Vol. 3, No. 3 • March/April 2011 Abu-Saleh

Figure 9: Radiograph showing dental implants in position. Figure 10: Second stage surgery.

Figure 11: Tooth #9 being decoronated. Figure 12: Sealed decoronated root #9.

black discolorations were noted on the mucosa severe alveolar bone loss around tooth #8 and overlying the roots of teeth #7-10. The gingiva periapical lesions and calcified canals at teeth was soft, friable and of thin biotype (figures 3, #’s 22 and 27. Impressions were taken and 4). The patient experienced premature contacts study casts were prepared and mounted using in protrusive jaw movement, which aggravated occlusal records in maximum intercuspal posi- the periodontal disease around tooth #8. Earlier tion to study treatment options for the patient. orthodontic treatment resulted in that the patient Multiple treatment options were discussed had class 3 molar relationship. Periapical radio- with the patient, all of them included initial phase graphs and Orthopantomograph (OPG) showed of treating the periodontal disease and reduction

The Journal of Implant & Advanced Clinical Dentistry • 59 Abu-Saleh

of occlusal trauma. Treatment options with long using osteotomes rather than drills for osteotomy duration (such as ridge augmentation modalities), of the thin areas of bone, avoiding by this ridge or ones that involved fitting removable prostheses augmentation by block grafts (figure 7). Single were rejected by the patient. Cantilevers or splint- implants (Ankylos, Friadent, Germany) were placed ing of implants to natural teeth were discouraged in a submerged, two-stage surgical protocol (fig- prosthetically. Initially, treatment options included: ure 8). A minimal fenestration (1-2 mm) at the ● Extraction of both 8 and 9 followed by implant surface of #7 was grafted with autogenous placement of 6 or 8-units FPDs utilizing bony scraps and healing was uneventful (figure 9). teeth #5, 4, 11 and 12 as abutments. Three months later the second stage surgery was ● Extraction of 8 and 9 followed by placement performed and two sulcus formers were screwed of single implants in 7 and 10 regions, then in place. Modified Palacci flaps were used to bulk final restoration with a 4-unit implant supported the papillae (figure 10). Tooth #9 was then dec- FPD, and two PFM crowns at 6 and 11. oronated, removing the surrounding sulcular epi- Considering previous non-satisfactory experience thelium as well, until the root was level with crestal with tooth supported FPDs, the long span of miss- bone (figure 11). The root was conditioned and ing teeth, the need for provisional restorations, and restored with composite resin restoration and the the possibility of massive alveolar bone resorption peripheries were smoothened (figure 12). An inter- at extraction sites, it was finally agreed to extract positional piece of connective tissue was used to the tooth #8 and then place single implants at #7 cover the root and augment the soft tissue espe- and 10 areas, followed by decoronation of tooth cially in the papillae area (figure 13). Healing was #9. Restoration of the two implants would be uneventful. After a healing period of 4 weeks, the with 4-unit FPD’s, and for teeth #6 and 11 with tissue was bulky both vertically and horizontally (fig- PFM crowns. The patient consented to the treat- ures 14, 15). The sulcus formers were removed, ment plan as well as photographic documenta- and two abutments (3.0 mm - 15°) were screwed tion at multiple treatment and follow-up visits. and torqued to 35N for both implants and periapi- The first phase consisted of the treatment of peri- cal radiographs were taken to verify full engage- odontal disease starting with plaque control instruc- ment of both abutments to implant surfaces. Final tions and patient education followed by professional impression was taken with polyether impression scaling and root planning. Points of high occlusal material (Impregum® (Penta), 3M ESPE, USA) load were reduced. Tooth # 8 was extracted using an open tray technique. Two PFM crowns atraumatically, the socket was curetted thoroughly were delivered to restore teeth #6 and 11. An and a blood clot was formed (figure 5). The old implant supported prosthesis was used provi- FPDs were modified and splinted with orthodontic sionally to shape the soft tissue contours around wires and composite resin then fitted to support the the implants, then an implant supported four-unit socket walls (figure 6). The preservation of tooth FPD was fabricated to restore implants 7/10. #9 was beneficial as it helped to retain the FPDs. On three months and six months follow-up The surgical phase started two months later. visits, the tissues were healthy and maintained Implant beds were prepared in the 7 and 10 areas the bulk. Radiographs showed coronal growth

60 • Vol. 3, No. 3 • March/April 2011 Abu-Saleh

Figure 13: Connective tissue graft used to cover Figure 14: After soft tissue healing, the ridge gained decoronated root #9. sufficient bulk vertically and horizontally (facial view).

Figure 15: After soft tissue healing, the ridge gained Figure 16: At the one year follow-up visit, gingival tissues sufficient bulk vertically and horizontally (occlusal view). were healthy and aesthetically pleasing. of interseptal bone. One year later, papillae were challenging procedure due to the difficulty of restored and the esthetics were pleasing to the obtaining predictable esthetic results. In the patient (figures 16, 17). Periapical radiographs anterior maxilla, esthetic and functional treat- showed regeneration of bony defects, stable ment outcomes depend highly on the level of alveolar bone levels, and absence of signs of any alveolar ridge reconstruction or preservation. pathology around the retained root (figures 18-21). Insufficiency of alveolar bone may necessitate an augmentation procedure to achieve opti- Dscsioi us n mum results.1-4 It might be advisable to pre- Implant placement in the anterior maxilla is a serve rather than reconstruct the papillary tissue

The Journal of Implant & Advanced Clinical Dentistry • 61 Abu-Saleh

Figure 17: Patient smile at one year follow-up visit. Figure 18: Massive defect in site #8.

Figure 19: Bone regenerated in the socket of site #8. Figure 20: Coronal growth of interseptal bone was evident at 1-year follow-up visit (implant #7) since preservation can result in a more predict- alveolar bone and to maintain the dimensions of able outcome and avoid extensive surgeries.2 the alveolar ridge horizontally and vertically.21,22,25 Post-extraction resorption was reported to be This is especially important if proved to pre- prevented or compensated for by some methods serve interdental septa in the anterior region including, socket preservation procedures, vari- which supports the interdental papillae, losing of ous grafting techniques and immediate implant which is a commonly encountered esthetic prob- placement.5,7,9,10 Decoronation of teeth and sub- lem.14,15 When two or more contiguous teeth mergence of their roots has been suggested in are missing, esthetic outcome of implant treat- the literature in order to preserve the remaining ment becomes more complicated in this sense

62 • Vol. 3, No. 3 • March/April 2011 Abu-Saleh

the need for ridge augmentation before implant placement. Alveolar bone level around the implants was stable and helped support the papillae that later on reformed and filled the interdental spaces. The retained root had already been treated by apicectomy and the root canal treatment was redone as retaining roots without root canal treatment was reportedly not favourable.21 The coronal aspect was sealed in order to prevent leakage of sealer that was reported to induce inflammation or foreign body reaction and cyst formation.23,26 Also, in order to avoid cyst Figure 21: Coronal growth of interseptal bone was evident formation, the sulcular epithelium was removed.21 at 1-year follow-up visit (implant #10) No periapical pathologies or cysts were noted in the one-year follow-up visit of this patient. The and prevention of bone loss is encouraged. composite was cup-shaped and the peripheries Generally, restoration of the height of the were smoothened and contoured in order not alveolar ridge is less predictable than the to tear the soft tissue coverage and expose the width. Preservation of vertical bone level was root, which is a commonly encountered prob- not always reported following decoronation lem.21,24 The root was covered with a connec- and some reports indicated that bone loss tive tissue graft limiting communication with oral occurred and roots were exposed.21,24 However, cavity and subsequent periodontal disease.6 this report showed that bone preservation not Another advantage of retaining the root was only helped maintain existing bone dimension its potential to support a post-crown even though but also enabled vertical bone growth which the root did not support a future prosthesis.25 was observed coronally to the remaining root. That allowed for temporization using a fixed rather Debridement of the extraction socket resulted in than removable prosthesis and avoided early removal of granulomatous tissue and significant, or transmucosal loading of implants during the though incomplete, socket regeneration with- osseointegration period. The root was not loaded out any bone graft within two months. That was nor splinted to the implant-supported bridge. presumably aided by the support of the proxi- Therefore, should any complication arise in the mal wall of the extraction socket by the adjacent future, the root can be extracted without modify- remaining root. The papillae of the extraction ing the bridges and with minimum bone loss.24 socket were supported by the modified pontic.3 The retained root in the alveolar process Cioonclus ns served the objective of retaining bone dimen- The combined procedure of regenerating the sions and vertical bone apposition was observed socket and retaining the root presented an eco- coronal to the root one year later. It minimized nomic, safe, and time saving option for the severely

The Journal of Implant & Advanced Clinical Dentistry • 63 Abu-Saleh

resorbed maxilla and met the needs and expecta- tions of the patient. Bone height at interproximal Correspondence: surfaces adjacent to edentulous areas was pre- Dr. Tareq Abu-Saleh, served to support the formation of papillae. The Assistant professor in periodontics, method was satisfactory esthetically with regard Taibah University, Saudi Arabia to papillary form and the degree of filling between Cell: 00966597983090 implants, teeth and pontics. Controlled studies E-mail: [email protected] are recommended to validate these findings. ●

Disclosure 12. S alama H, Salama MA, Garber D et al. The 22. O’Neal RB, Gound T, Levin MP et al. The author reports no conflicts of interest with interproximal height of bone: a guidepost to Submergence of roots for alveolar bone anything mentioned in this article. predictable esthetic strategies and soft tissue preservation. I. Endodontically treated roots. contours in anterior tooth replacement. Pract Oral Surg Oral Med Oral Pathol 1978; 45(5): References: Periodontics Aesthet Dent 1998; 10(9): 1131- 803-810. 1. Atwood DA. Some clinical factors related to rate 1141. of resorption of residual ridges. J Prosthet Dent 23. Gound T, O’Neal RB, del Rio CE et al. 2001; 86(2): 119–125. 13. Rambla-F errer J, Peñarrocha-Diago M, Submergence of roots for alveolar bone Guarinos-Carbó J. Analysis of the use of preservation. II. Reimplanted endodontically 2. O’Brien TP, Hinrichs JE, Schaffer EM. The expansion osteotomy for the creation of implant treated roots. Oral Surg Oral Med Oral Pathol prevention of localized ridge deformities using beds. Technical contributions and review of the 1978; 46(1): 114-122. guided tissue regeneration. J Periodontol 1994; literature. Med Oral Patol Oral Cir Bucal 2006; 65(1): 17-24. 24. von Wowern N, Winther S. Submergence of 11(3): E267-71. roots for alveolar ridge preservation. A failure 3. Seibert JS. Treatment of moderate localized 14. T arnow DP, Cho SC, Wallace SS. The effect (4-year follow-up study). Int J Oral Surg 1981; alveolar ridge defects. Preventive and of inter-implant distance on the height of inter- 10(4): 247-250. reconstructive concepts in therapy. Dent Clin implant bone crest. J Periodontol 2000; 71(4): North Am 1993; 37(2): 265-280. 25. Rodd HD, Davidson LE, Livesey S et al. 546-549. Survival of intentionally retained permanent 4. Elian N, Jalbout ZN, Cho SC et al. Realities and 15. Tarnow DP, Magner AW, Fletcher P. The effect incisor roots following crown root fractures in limitations in the management of the interdental of the distance from the contact point to the children. Dent Traumatol 2002; 18(2): 92–97. papilla between implants: three case reports. crest of bone on the presence or absence of Pract Proced Aesthet Dent 2003; 15(10): 737- 26. Cohenca N, Stabholz A. Decoronation - a the interproximal dental papilla. J Periodontol 744. conservative method to treat ankylosed teeth 1992; 63(12): 995-996. for preservation of alveolar ridge prior to 5. Irinakis T. Rationale for socket preservation after 16. Choquet V, Hermans M, Adriaenssens P et permanent prosthetic reconstruction: literature extraction of a single-rooted tooth when planning al. Clinical and radiographic evaluation of the review and case presentation. Dent Traumatol for future implant placement. J Can Dent Assoc papilla level adjacent to single tooth dental 2007; 23(2): 87–94. 2006; 72(10): 917-22. implants. A retrospective study in the maxillary 27. Filippi A, Pohl Y, von Arx T. Decoronation 6. Simon JH, Kimura JT. Maintenance of alveolar anterior region. J Periodontol 2001; 72(10): of an ankylosed tooth for preservation of bone by the intentional replantation of roots. 1364-1371. alveolar bone prior to implant placement. Dent Oral Surg Oral Med Oral Pathol 1974; 37(6): 17. Grunder U. Stability of the mucosal topography Traumatol 2001; 17(2): 93–95. 936–945. around single tooth implants and adjacent 28. S alama M, Ishikawa T, Salama H et al. 7. Levitt D. Atraumatic extraction and root retrieval teeth: 1-year results. Int J periodontics Advantages of the root submergence technique using the periotome: a precursor to immediate restorative Dent 2000; 20(1): 11-17. for pontic site development in esthetic implant placement of dental implants. Dent Today 2001; 18. S alama H & Salama, M. The role of orthodontic therapy. Int J Periodontics Restorative Dent 20(11): 53-57. extrusive remodeling in the enhancement of 2007; 27(6): 521–527 8. Lambert PM, Skerl RF, Campana HA. Free soft and hard tissue profiles prior to implant autogenous graft coverage of vital retained placement: A systematic approach to the roots. J Prosthet Dent 1983; 50(5): 611-617. management of extraction site defects. Int J 9. Nowzari H. Esthetic Implant Dentistry. Compend Periodontics Restorative Dent 1993; 13(4): Contin Educ Dent 2001; 22(8): 643-50. 312–333. 10. Saadoun AP. Immediate Implant Placement and 19. Simon JH, Jensen JL, Kimura JT. Histologic Temporization in Extraction and Healing Sites. observations of endodontically treated Compend Contin Educ Dent 2002; 23(4): replanted roots. J Endod 1975; 1(5): 178–180. 309-312. 20. Johnson DL, Kelly JF, Flinton RJ et al. Histologic 11. Mankoo T. contemporary implant concepts in evaluation of vital root retention. J Oral Surg esthetic dentistry – Part 3: adjacent immediate 1974; 32(11): 829–833. implants in the esthetic zone. Pract Proced 21. Levin M, Getter L, Cutright D et al. Intentional Aesthet Dent 2004; 16(4): 327-334. submucosal submergence of nonvital roots. J Oral Surg 1974; 32(11): 834–839.

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Wiliams et al Neck Dissection for Oral Cancer

Fayette C. Williams, DDS, MD1 • Brent B. Ward, DDS, MD, FACS2 Sean P. Edwards, MD, DDS, FRCD(C)3

Abstract

Background: Cancer of the oral cavity and Results: Neck dissection remains the stan- oropharynx strikes over 35,000 patients each dard treatment for cervical metastases from year in the United States. At least one-third oral cancer. While the radical neck dissection of these patients will present with metas- described over 100 years ago resulted in sig- tases to the neck. The status of the cer- nificant morbidity, modern selective and modi- vical lymph nodes remains the strongest fied neck dissections maintain oncologic safety prognostic indicator for oral cancer. Appropri- while minimizing morbidity. Difficulty still exists in ate diagnosis and management of the neck is identifying which patients with clinically negative critical in the success of oral cancer treatment. necks require removal of cervical lymph nodes. Emerging technologies may eventually reduce Methods: The history and anatomy rel- the incidence of unnecessary neck dissections. evant to cervical lymphadenectomy are reviewed. The technique is described and Conclusions: Modern multi-disciplinary a surgical case is illustrated. The authors care strategies incorporate dentists as vital review the common complications of neck members of the cancer team. Dental pro- dissection and their management. Future fessionals are on the forefront of oral can- directions in the diagnosis and manage- cer detection and should be familiar with the ment of cervical metastases are discussed. rationale and implications of neck treatment.

KEY WORDS: Mouth neoplasms, neck dissection, lymph node excision, oral cancer

1. Clinical Faculty, John Peter Smith Hospital, Department of Oral and Maxillofacial Surgery, Fort Worth, Texas, USA. Formerly, Fellow in Oral and Maxillofacial Oncologic Surgery University of Michigan Medical Center, Ann Arbor, Michigan, USA 2. Assistant Professor and Program Director Oral and Maxillofacial Oncologic Surgery University of Michigan Medical Center, Ann Arbor, Michigan, USA. 3. Assistant Professor and Chief, Pediatric Oral and Maxillofacial Surgery C.S. Mott Children’s Hospital, University of Michigan Medical Center, Ann Arbor, Michigan, USA.

The Journal of Implant & Advanced Clinical Dentistry • 69 Williams et al

Figure 1: Incision marked. Figure 2: A) Platysma; B) Lymphatic tissue.

INTRODUCTION survival to half that of patients with no neck An estimated 35,000 new cases of oral and disease.9-11 Appropriate diagnosis and man- oropharyngeal cancer will be diagnosed in agement of the neck is therefore critical in the United States in 2009, and over 7,500 the overall success of oral cancer treatment. deaths will be attributed to this disease.1 Squamous cell carcinoma is the predominant Anatomy form of cancer in this region, encompass- Lymph node basins which drain the oral ing approximately 90% of malignant pathol- cavity are divided into 5 groups based ogy.2 The overall 5-year survival rate of oral on anatomically defined structures: cancer is approximately 61%, with early can- ● Level I – includes the submental nodes cers showing greater survival.3 Despite bounded by the anterior bellies of the digas- technological advances in detection and tric muscles and the hyoid bone as well as treatment, 5-year survival rates have shown the submandibular group bounded by the minimal improvement over recent decades. body of the mandible and the posterior bel- The most important prognostic indica- lies of the digastric muscles bilaterally. tor for oral cancer is the status of the cervical ● Level II – includes the upper jugular lymph lymph nodes.4,5 While only 3-10% of patients nodes extending from the base of the skull to will present with distant metastasis,6 at least the level of the carotid artery bifurcation. The 30% will have cervical lymph node metasta- anterior border is the lateral aspect of the ster- ses at the time of diagnosis.7,8 The presence nohyoid muscle while the posterior border is the of cervical node involvement decreases 5-year sternocleidomastoid (SCM). Level II is also sub-

70 • Vol. 3, No. 3 • March/April 2011 Wiliams et al

Figure 3: Lymphatic tissue removal from submental Figure 4: Lymphatic tissue reflected off submental triangle. triangle. A) Right anterior belly of digastric muscle; B) Mylohyoid muscle; C) Left anterior belly of digastric muscle; D) Platysma.

divided into levels IIA (inferior medial) and II B safety. The classic radical neck dissection, as (superior lateral) by the spinal accessory nerve. described by Crile, removes the cervical lym- ● Level III – includes nodes located adja- phatics of all five levels along with the internal cent to the middle 1/3 of the internal jug- jugular vein, the sternocleidomastoid muscle, ular vein from the carotid bifurcation to and the spinal accessory nerve. In the 1960s, the omohyoid muscle with the same ante- Suarez13 and later Bocca14 published a tech- rior and posterior boundaries as level II. nique preserving these three non-lymphatic ● Level IV – includes the lower jugular structures. This method achieved a similar group, inferior to the omohyoid muscle and degree of regional control while avoiding the superior the clavicle with the same anterior morbidity associated with the removal of the and posterior boundaries as levels II and III. three structures mentioned above. In 1972, ● Level V- includes nodes anterior to the Lindberg15 described the distribution of cervi- anterior border of the trapezius and poste- cal metastasis in relation to the primary tumor rior to the posterior border of the SCM. The site after reviewing 2004 patients with SCCA inferior border of this level is the clavicle. of the head and neck. This finding was later validated by Shah16 and Byers17 which led to H iSTORY the implementation of selective removal of only Since George Crile’s description12 of the radi- high-risk nodal basins for patients with clinical neck dissection in 1906, the surgical treat- cally negative necks. For carcinoma of the ment of the neck has evolved to include less oral cavity with a clinically negative neck, the morbid options while maintaining oncologic predominant lymph node basins removed in

The Journal of Implant & Advanced Clinical Dentistry • 71 Williams et al

Figure 5: Fascia removed from sternocleidomastoid Figure 6: Left neck after removal of lymphatic tissue. muscle. A) Sternocleidomastoid muscle; B) Fascia A) Inferior border of mandible; B) Masseter muscle; C) Anterior belly of digastric muscle; D) Posterior belly of digastric muscle; E) Mylohyoid muscle; F) Hypoglossal nerve; G) Carotid artery; H) Internal jugular vein a selective neck dissection are levels I, II and of the facial nerve is dissected free and elevated III. In contrast, the modified radical neck dis- above the inferior border of the mandible to pro- section removes all five levels and is indicated in tect it from injury. Fibrofatty lymph-bearing tis- the setting of positive cervical lymphadenopathy. sue is first removed from the submental area as the dissection proceeds posteriorly across Procedure level I. The posterior border of the mylohyoid The neck dissection begins with an incision muscle is retracted anteriorly as the subman- through skin and subcutaneous fat, utilizing an dibular gland is pulled inferiorly to expose the existing skin crease when possible. The inci- lingual nerve and submandibular duct. The sion extends from the tip of the mastoid bone to submandibular gland is included in the speci- just across the midline. The platysma muscle is men. The duct is transected along with the divided next so that skin-platysma flaps may be parasympathetic branches from the lingual elevated superiorly to the mandible and inferiorly nerve (chorda tympani) which course inferiorly to the clavicle. With full exposure of the neck, towards the submandibular gland. The lingual the sternocleidomastoid muscle (SCM) is read- nerve is preserved. The facial artery and vein ily apparent along with the external jugular vein are ligated and divided at the inferior border and great auricular nerve which course on top of the mandible with care to preserve the mar- of the SCM. The tail of the parotid gland is visi- ginal mandibular branch of the facial nerve. ble where it extends below the inferior border of The tail of the parotid gland is included in the the mandible. The marginal mandibular branch specimen which can now be retracted infe-

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The specimen now remains attached only to level V of the neck. Further posterior retraction of the SCM allows the specimen to be dissected off the scalene and levator scapulae muscles posteriorly towards the anterior border of the trapezius muscle, which serves as the posterior limit of dissection. Care is taken again to preserve the spinal accessory nerve which passes through level V. The specimen is passed off the field for pathologic evaluation . The entire surgical field is reviewed to assure that adequate hemostasis is achieved. A layered Figure 7: Final closure. closure is performed by re-approximating the platysma and skin over a closed-suction drain. The drain is usually removed in 3-5 days when the output is less than 30cc in a 24 hour period.

Complications riorly over the posterior belly of the digastric Surgical complications may be grouped into muscle to complete the level I dissection. The intraoperative and postoperative complica- facial artery is ligated again as it loops over tions. Intraoperative complications include the posterior belly of the digastric muscle. injury to uninvolved nerves, laceration of the Levels II, III, and IV are often dissected large neck vessels, or damage to the thoracic simultaneously in a broad front moving from duct. Postoperative complications include anterior to posterior. The omohyoid muscle is hematoma, chylous fistula, and infection. divided at the anterior extent of the dissection Although several nerves are at risk for and included in the specimen. The hypoglossal injury during neck dissection, careful technique nerve is preserved as the dissection proceeds usually allows for their preservation. Gross posteriorly below the posterior belly of the involvement of tumor is occasionally noted and digastric muscle. Retraction of the SCM poste- is an indication for sacrifice. A nerve stimula- riorly reveals the carotid sheath. The specimen tor serves as a useful aid for identifying motor is retracted laterally as the internal jugular vein is nerves which may be otherwise difficult to skeletonized from the skull base to the clavicle. locate in the previously operated or irradiated Multiple branches of the vein are ligated as they neck. Nerves at greatest risk during dissec- are encountered. The carotid artery and vagus tion include the marginal mandibular branch nerve are dissected free. The spinal acces- of the facial nerve, the lingual nerve, the hypo- sory nerve, deep to the SCM, is carefully pre- glossal nerve, and the spinal accessory nerve. served as the dissection of level II is completed. The thoracic duct is at risk for injury when

The Journal of Implant & Advanced Clinical Dentistry • 73 Williams et al

level IV is dissected immediately superior to the discolored, or tense. Hematomas which con- clavicle. Injury to the duct results in the leak- tinue to expand may cause airway deviation and age of chyle into the neck wound. This may vascular compromise of the skin or other cervi- be recognized intraoperatively by the presence cal structures due to pressure. The source of of oily or milky fluid in the wound. Suture liga- blood is commonly a small bleeding vessel or tion of the leaking tissue is necessary to pre- loose suture not detected at the time of clo- vent the formation of a postoperative chylous sure. Coughing, straining, or other increases in fistula. Prior to closing the neck incision, the intra-abdominal pressure in the early postopera- inferior neck should be observed for several tive period may also contribute to new bleeding. seconds while the anesthesiologist performs Other common etiologies include coagulopa- a Valsalva maneuver. Despite these mea- thy or postoperative hypertension. Small non- sures, a chylous fistula may develop postop- expanding hematomas may often be observed or eratively in 2% of patients.18 While thoracic treated conservatively with a pressure dressing. duct injury is more common on the left, a leak A return trip to the operating room is usually may develop on the right in as many as 25% necessitated by an expanding hematoma, air- of cases of chyle leaks.19 A postoperative chy- way concern, or to protect a reconstructive flap. lous fistula may be detected by milky fluid in the Postoperative infections may occur after neck drain. Conservative management, includ- neck dissection, especially when the neck ing pressure dressings, aspiration and dietary wound communicates with the upper aerodi- modification, is often successful in low-volume gestive tract. Prior radiotherapy, diabetes or chylous fistulas. Surgical exploration is indi- other systemic conditions affecting the immune cated in high-volume output or any chylous system may add further concern for infection fistula which fails conservative management. due to the poor healing qualities of irradiated Accidental injury to large vessels may tissue and systemic susceptibility to infec- increase morbidity simply due to increased tion from decreased immune response. An blood loss. While a unilateral internal jugu- oral-cutaneous fistula often results from neck lar vein may be resected with little conse- infections communicating with the oral cav- quence, bilateral ligation results in severe ity. Conservative wound care usually results facial and cerebral edema. Small lacera- in spontaneous closure of the fistula, although tions in the internal jugular vein may be surgical intervention may be required when repaired with sutures or ligaclips. Injury vital structures such as the carotid artery to the carotid artery requires immediate are exposed to the salivary contaminants. repair to avoid severe hemorrhage and the potential for cerebrovascular insufficiency. Future Directions Postoperative hematoma results from the The role of neck dissection for oral cancer accumulation of blood under the skin flaps. This over the past century has become more selec- often presents as a fluctuant neck swelling and tive as data and technological advancements may cause the overlying skin to appear bruised, have allowed for improved risk assessment to

74 • Vol. 3, No. 3 • March/April 2011 Wiliams et al

determine which patients require a neck dissec- While some centers recommend its routine use tion. Some difficulty still exists in identification for staging advanced (T3 or T4) tumors, the of occult neck disease undetectable by cur- high false-positive rate inherent to metabolic rent diagnostic modalities. The sentinel lymph imaging is problematic. Although studies26 node biopsy has become a standard staging have demonstrated the ability of PET to alter procedure for cutaneous melanoma and breast the staging of head and neck tumors, it is still cancer with well-documented accuracy and unclear if this benefit outweighs the disadvan- efficacy.20,21 This technique uses a radionu- tage of false-postives in routine staging. The clide and/or a blue dye to identify the regional most widely accepted role of PET in oral can- lymph nodes which receive drainage from the cer is in the detection of recurrences.27,28 Tis- primary tumor site. The purpose of sampling sue beds are often scarred, irradiated, and have the sentinel lymph node is to identify patients post-surgical alterations in anatomy which limit with positive nodes who will benefit from com- the utility of conventional imaging techniques pletion lymph node dissection. At the same and makes metabolic imaging more appeal- time, unnecessary lymph node dissections are ing. While PET has shown improved sensitiv- avoided in patients with a negative sentinel ity over conventional imaging techniques,29-31 lymph node. While still considered experimen- it is not accurate enough to preclude a neck tal, recent data suggests that this technique dissection in a patient with no detectable cer- may eventually be applicable to oral cavity vical disease.32-34 This limitation is due to the tumors.22,23 Further multi-institutional stud- inadequate spatial resolution of PET, resulting ies and long-term data are needed to validate in an inability to detect micrometastases below the accuracy and technical feasibility of senti- 5mm in diameter. As the technical resolution of nel lymph node biopsy for oral cavity cancer.24 PET increases with future refinements, unnec- Detection of cervical metastases by clini- essary neck dissections may be avoided. ● cal palpation and CT scan has shown a sensitivity of 91%.25 Increased detection rates have Correspondence: been demonstrated over recent years with Fayette C. Williams, DDS, MD the introduction of positron emission tomography (PET). This form of functional imaging John Peter Smith Hospital measures changes in metabolism. Regional Department of Oral and Maxillofacial Surgery glucose uptake is assessed by injecting a 1625 St. Louis Avenue radiotracer such as fluorodeoxyglucose (FDG) Fort Worth, TX 76107 prior to imaging the patient. Malignant cells [email protected] have high metabolic activity and demonstrate increased radiotracer uptake. PET has shown promise in the evaluation of metastatic disease, tumor recurrence, and in evaluation of treatment response after chemotherapy or radiation.

The Journal of Implant & Advanced Clinical Dentistry • 75 WilliamsWiliams et et al al

Disclosure 12. Crile, G., On the plan of excision in cancer 25. Merritt, R.M., et al., Detection of cervical The authors report no conflicts of interest with of the head and neck and an analysis of 132 metastasis. A meta-analysis comparing anything mentioned in this article. cases. Ohio State Medical Journal, 1906. 2: p. computed tomography with physical 1740189. References examination. Archives of otolaryngology--head & 13. Suarez, O., El problema de las metastasis 1. American Cancer Society. Cancer Facts & neck surgery, 1997. 123(2): p. 149-152. linfaticas y alejadas del cancer de laringe e Figures 2008. Atlanta: American Cancer Society; 26. Connell, C., et al., Clinical impact of, and hipofaringe. Otorrinolaringology, 1963. 23: p. , F-18 FDG PET/ 2008. prognostic stratification by 83-99. CT in head and neck mucosal squamous cell 2. Silverman, S., Epidemiology, in Oral Cancer. 14. Bocca, E. and O. Poignataro, A conservation 1998, B.C. Decker Inc: Hamilton, Ontario. carcinoma. Head & neck, 2007. 29(11): p. 986- technique in radical neck dissection. Ann Otol 3. Horner MJ, Ries LAG, Krapcho M, Neyman N, 995. Rhino Laryngol, 1967. 76: p. 975-87. Aminou R, Howlader N, Altekruse SF, Feuer EJ, 27. Kao, J., et al., The diagnostic and prognostic 15. Lindberg, R., Distribution of cervical lymph node utility of positron emission tomography/ Huang L, Mariotto A, Miller BA, Lewis DR, Eisner metastasis from squamous cell carcinoma of the computed tomography-based follow-up after MP, Stinchcomb DG, Edwards BK (eds). SEER upper respiratory and digestive tracts. Cancer, radiotherapy for head and neck cancer. Cancer, Cancer Statistics Review, 1975-2006, National 1972. 29: p. 1446-9. 2009. 115(19): p. 4586-4594. Cancer Institute. Bethesda, MD, http://seer. 16. Shah, J., Patterns of cervical lymph node 28. 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Strong, The modalities (CT, MRI, US) in lymph node staging and Neck, 1996. 18: p. 142. management of chyle fistula. The Laryngoscope, of head and neck cancer. European journal of 5. Klotch, D., C. Muro-Cacho, and T. Gal, Factors 1990. 100(7): p. 771-774. affecting survival for floor-of-mouth carcinoma. nuclear medicine, 1998. 25(9): p. 1255-1260. 19. Crumley, R.L. and J.D. Smith, Postoperative Koshy, M., et al., F-18 FDG PET-CT fusion in Otol Head Neck Surg, 2000. 122: p. 495-8. 30. chylous fistula prevention and management. The radiotherapy treatment planning for head and 6. Betka, J., Distant metastasis from lip and oral Laryngoscope, 1976. 86(6): p. 804-813. cavity cancer. ORL J Otorhinolaryngol Relat neck cancer. Head & neck, 2005. 27(6): p. 20. Landi, G., et al., Sentinel lymph node biopsy Spec, 2001. 63: p. 217-21. 494-502. in patients with primary cutaneous melanoma: Ha, P., et al., The role of positron emission 7. 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Myers, E. and J. Fagan, Treatment of the N+ 34. Biopsy in the Staging of Oral Cancer. Oral and neck in squamous cell carcinoma of the upper PET/CT for staging of oral squamous cell maxillofacial surgery clinics of North America, aerodigestive tract. Otolaryngology Clinics of carcinoma. Head & neck, 2008. 30(11): p. 2006. 18(4): p. 547-563. North America, 1998. 31: p. 671-86. 1488-1496. ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected]

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