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Clinical Advances in Periodontics

IN THIS ISSUE:

An Online Journal of the American Academy of Periodontology

www.clinicalperio.org

Stem Cell Allograft andTitanium Mesh Augmentation

Regenerative Treatment ofEndodonticPeriodonticLesion

Extracellular MatrixMembrane for Root Coverage

Periodontal Regenerationand Orthodontic Treatment inInfrabony Defects

Effect of a Root-Like Structureon Periodontitis

Pharmacovigilance inDentistry

Oral Granulomatosis WithPolyangiitis

Sonic Handpiece in ImplantDentistry

Volume 3 Number 1 February 2013

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VOLUME 3 | NUMBER 1 | FEBRUARY 2013

Clinical Advances in Periodontics

TABLE OF CONTENTS

CASE-BASED LEARNING

1 Alveolar Ridge Augmentation With Allograft Stem Cell Based Matrix andTitanium MeshBradley S. cAllister, . homas shraghi

ubstantial increase in horizontal an ertical bone imension w achieve ollowing treatment with stemcell base gra t, allowing or implant lacemen an restoration with mille bar supporte locking enture.

10 Use of Guided Tissue Regeneration in the Treatment of a SevereEndodontic Periodontic Lesion: A 15-Year Follow-Up Case ReportRonal o . Santana, Carolina . Mattos Santana n his case repor , a severe combine en o on ic erio on ic lesion was success ully rea e wi h gui e issue regeneration and cl inical improvements er preserved for several ear after rea men .

16 Use of an Extracellular Matrix Membrane for Root Coverage: Case Seriesand Review of the Literature

ons o a, Shayna Sanchez, Shilpa o at ar n extracellular matrix membrane was success ully use or root coverage an so t tissue augmentation in iller lass an efects in six patients.

24 Orthodontic Treatment After Induced Periodontal Regeneration in DeepInfrabony DefectsCarlo Ghezzi, Valeria . Vigan, Paola Francinetti, Gianfranco anotti, Silvia Masiero

regenerative proce ure that combine enamel matrix erivate an collagen bone bovine mineral as a perio ontal reortho ontic roce ure provi e excellen clinical results in this case series.

33 The Possible Effect of an Accessory Root-Like Structure on Periodontitis: A Clinical and Histologic Case Report

anx n u, aoy ng ang, n ang, Shiguo an, ang, s an ang n accessor root-like s ruc ure found on patient s left maxillary central incisor might have accelerate the rogression o periodontitis in this case repor .

continued n page iii)

ON THE COVER:Preoperative view of ingivalrecession on tooth #6 and 5months after treatment with

xtracellular matrix membrane.(Bhola t al.)

An Online Journal of the American Academy of Periodontology

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40 Medical Histories: A Case Report of Pharmacovigilance in SupportingDentists and Participation in a Drug-Safety ProgramEdward H. Karl, Frederick A. Curro his involves a verse event ollowing routine me ication an emonstrates the importance o me ical

histories taken by entists as a source o in ormation that can o ten be o value in assessing treatment regimens.

45 Rare Manifestation of Granulomatosis With PolyangiitisManoj Bhattarai, Weijia Yuan, Paul Fletcher,Adam Gersten, Anthony Chang,RobertSpiera, Anne Bass, Doruk Erkan, Dennis Tarnow n this case report, a 76-year-ol woman presentingwith ental implant ailure was iagnose with granulomatosiswith polyangiitis.

52 Applications of a Newly Developed Sonic Surgical Handpiece in ImplantDentistry Erich C. Schmidt, Dimitrios E. Papadimitriou, Jack G. Caton, Georgios E. Romanos n this series, recently develope sonic handpiece using oscillating echnology ha various clinical applications in implan entistry.

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

Clinical Advances in Periodontics, Vol. 3, No. 1, February 2013

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PORTANT SAFETY INFORMATIONM 21S Growth-factor Enhanced Matrix is intended for use by

has not been established in other non-

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VOLUME 3 | NUMBER 1 | FEBRUARY

Clinical Advances in Periodontics An Online Journal of the American Academy of Periodontology

Co-Editorsr. Kenneth S. Kornman

Interleukin GeneticsWaltham, MA

r. Michael S. Reddy University of Alabama at BirminghamBirmingham, AL

Associate EditorsDr. Anna Dongari-BagtzoglouUniversity of ConnecticutFarmington, CT

Dr. Steven P. EngebretsonNew York UniversityNew York, NY

Dr. David W. Paquettetony Brook Universitytony Brook, NY

Dr. Frank A. ScannapiecoUniversity at BuffaloBuffalo, NY

2012-2013 Of cers of the AAPPresident Dr. Nancy L. NewhouseIndependence, MO

President Elect Dr. Stuart J. Froum

New York, NY Vice President Dr. Joan Otomo-CorgelLos Angeles, CA

ecretary/Treasurer Dr. Wayne A. AldredgeHazlet, NJ

Past President Dr. Pamela K. McClain Aurora, CO

Founding Editorial BoardDr. Richard T. KaoPrivate practiceCupertino, CA

Dr. Paul S. RosenPrivate practice Yardley, PA

Dr. Hom-Lay WangUniversity of Michigan Ann Arbor, MI

Dr. Thomas G. Wilson Jr.Private practiceDallas, TX

Editorial Advisory BoardDr. Edward P. AllenDr. Steven B. BlanchardDr. Daniel Buser Dr. Joseph V. CalifanoDr. Jack G. CatonDr. David L. Cochran

Dr. Manuel De La Rosa Jr.Dr. Joseph P. FiorelliniDr. Paul A. FugazzottoDr. Nicolaas C. GeursDr. Henry GreenwellDr. Dan J. HoltzclawDr. T. Howard HowellDr. Vincent J. IaconoDr. Georgia K. JohnsonDr. Niklaus P. LangDr. Samuel B. LowDr. Angelo Mariotti

Dr. Pamela K. McClainDr. Michael K. McGuireDr. Brian L. Mealey Dr. Michael P. MillsDr. Dean MortonDr. Francisco H. Nociti

Dr. Terry D. ReesDr. Mark A. ReynoldsDr. Louis F. RoseDr. Mariano SanzDr. Robert G. SchallhornDr. Anton SculeanDr. Thomas C. WaldropDr. Hans-Peter Weber Dr. Jan L. WennstrmDr. Ray C. Williams

r. Hiromasa Yoshie

The American Academy of Periodontology xecutive Director, John M. Forbes

Publications Director, Katie GossManaging Editor, Julie DawProduction Manager, Bethanne Wilson737 N. Michigan Avenue, Suite 800Chicago, IL 60611-6660

o ce: 12.787.551

Fax: 312.573.3225

E-Mail: [email protected]

Website: www.perio.org

ournal: www.clinicalperio.org

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

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

orm at www.joponline.org/page/permissions/permission.jsp. Inquiries relating to reprints should be addressed to the Academy s reprint agent Beth Ann Rocheleau (e-mail: [email protected];telephone: 803/359-4578).

anuscripts must conform to the Instructions to Authors, which are available online at www.clinicalperio.org and http: mc.manuscriptcentral.com clinicalperio. ubscriptions are available only as bundlesubscriptions with the Journal o Periodontology . Annual rates or in ivi uals or linical Advances in Periodontics ournal o Periodontology : United States and Canada, $239; rest of world, $287. Pleasecontact [email protected] for institutional rates.

Copyright 2013 by the American Academy of Periodontology; all rights reserved.

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

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CASE REPORT

Alveolar Ridge Augmentation With Allograft Stem Cell BasedMatrix and Titanium Mesh

Bradley S. McAllister* and V. Thomas Eshraghi*

ntroduction: When bone surrounding a proposed implant site is deficient in both a vertical and horizontal dimension,bone augmentation procedures using titanium mesh can be used. Although there are multiple repor s of titanium mesh usewith a variety of graft materials, to ur knowledge, this presentation is the first to show use f a stem ell based titaniummesh augmentation.

Case Presentation: After the removal of a failing maxillary subperiosteal implant, significant atrophy of the maxillary al-veolus was vident. After bilateral sinus augmentation with an allograft-derived stem cell based matrix (cellular allograft), our posterior implants were placed. In preparation for future anterior maxillary ridge augmentation, an interim denture supported bythe posterior implants and O-ring attachments was fabricated. The anterior titanium mesh-supported cellular allograft wasplaced and allowed to heal for months, ollowed by placement f four additional implants. After months of integration,the patient was restored with a locking milled bar denture.

Conclusion: The use of a cellular allograft with titanium mesh for stabilization can result in significant horizontal and ver-tical augmentation for implant reconstruction. Clin Adv Periodontics 013;3:1-7.

Key Words Allograft; bone screws; dental implants; s em cells; surgical mesh; titanium.

BackgroundThe restoration of oral hard- and soft-tissue contours arevita to unction, est etics, an p onetics. We -esta is eresearch as been performed regarding one efect re-generation or uture imp ant p acement. 1 sseous -generation, a t oug possi e, remains c a enging in manyimplant reconstructive situations. Extraoral autogenous

one as ong een regar e as t e go stan ar o oneregeneration because o its inherent osteoconductive,

osteoinductive, and osteogenic potential.2

Although effica-c ous n use, autogenous one s not ithout significantshortcomings. Harvests of intraoral boneand bone marrowaspirates ave varying e u ar oncentrations an o tenhave limited numbers o mesenchyma stem cells MSCs)

and osteoprogenitor cells. 3 Such variation may be related toarvest ocation, age, sex, an genotype. 4 T ere are a so

great technicalchallenges related to the addition of a seconsurgica site, exten e operation time, imite supp y ointraoral one harvesting, onor-site morbidity, infection,an ee ing ris s. 5

Many rep acements or autogenous one ave een ex-amine , ranging rom processe a ogra ts an xenogra tsto synthetic and syntheticbiologic compos tes. 2 Varying

successhasbeen achieved witheach inalveolarridgedefects.Freeze- rie one, xenogra ts, an eminera ize ree- riebone allograftswork indifferentways. 2 eminera ize oneallografts offer vary ng osteoinductive potential, whereasminera ize one a ogra ts, xenogra ts, an a op asts pri-marily provide an osteoconductive scaffold. 2 Furt ermore,some alloplasts heal ecapsulated within a connective tissueinfiltrate with little to no bone formation. 2

W ensuc onerep acementmateria s are use , t ere isusually sufficient regenerative capacity in the surrounding

one e to a ow one ormation. MSCs an osteopro-gen tor ells m grate nto the graft, proliferate and

* epartment o erio ontology, regon ealth Sciences niversity,Portland, OR.

Private practice, Portland, OR.

Submitted ctober 18, 2011; accepted for publication March 16, 012

o : 10.1902/cap.2012.110094

Clinical Advances in Periodontics, ol. , No. 1, ebruary 013 1

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differentiate into osteoblasts, and form bone. However,w en t e size o a e ect encroac es a t res o in w iccell proliferation from the lateral wound borders is re-duced, a significant reduction in ossification and turnovero gra ting materia s occurs. W en appropriate ce popu-lations do not exist in the bone graft or the adjacent boney

or ers, imite one ormation wi occur an t e centraregion of the graft will be the slowest to heal. 6 hus, itwould be prudent to consider grafting with a material thathas the appropriate cellular constituents. 3,7

MSCs are uniquece s t at, w enactivate , can un ergoasymmetric division leading to an identical daughter cell(self-renewal) and a cell that can go on to additional pro-i eration an i erentiation to ecome t e nee e spe-

cialized cell. 8 Embryonic stem cells are undifferentiatedp uripotent ce s erive rom t e innerce masso t e em-bryo during the blastocyst stage. 9 The embryonic stem cellcan differentiate into cells for ectodermal , mesodermal,an en o erma tissue eve opment. Feta stem ce s arefound in great concentration during early developing tis-sues, suc as t e p acenta, amniotic ui , t e eve opingeta organs, an marrow. 10 Embryonic and fetal stem cellsave enjoye researc success; owever, et ica concerns

ea ing to po itica consi erations ave s owe t eir eve -opment and pushed science to evaluate adult stem cells. 10A u t stemce s are mu tipotent, meaning t att ey ave anability to differentiate into one of a variety of similar celllineages (i.e., hematopoietic stem cells, MSCs) but cannot

eve opinto everyce type. Ce -type i erentiationcan eprovoked by multiple routes, including signals from solu-

e growt an i erentiation actors,extrace u ar matrixcontact, mechanical stimuli, and cell-to-cell interactions. 11

Of particular interest to theperiodontist, MSCs have the

capacity to develop into bone, muscle, ligament, cartilage,tendon, andadipose cells, which indicates the potential ap-p ication or perio onta an imp ant surgery. 12 H stor -cally, the majority of efforts for bone grafting witMSCs ave ocuse on t e concept o arvesting ce s, o -owed by in vitro culture expansion for later implanta-

tion. 13-15 MSCs ave a so een s own y investigators tobe hypoimmunogenic, opening the potential for allogenicMSCs for bone grafting applications. 9

T e ce u ar a ogra t one matrix use is commercia yprepared from cadavers recovered by a licensed tissue pro-curement agency. Ca avers are processe wit in 24 ourspostmortem. In parallel rigorous safety testing, donor

screening and evaluation for bacterial, fungal, and sporecontamination egins. Screening measures consist o p ys-ical examination andevaluation of both medical andsocial

istory, inc u ing a next o in interview. Compre ensivesero ogic an micro ia testing is a so per orme .

Cortical bone from thecadaver is separatedfrom thecel-u ar cance ous one an processe into eminera ize

bone particles, which are added back to thecellular cancel-lous graft component after all processing is complete. Thece u ar component processing inc u es a se ective immu-nodepletion that involves several wash steps to removece s , suc as re oo ce s an ymp ocytes, t a t can

provoke an immune response. This cellular cancellousone component containing t e native MSCs an osteopro-enitor cells then undergoes a broad-spectrum antimicrobiareatment designed to eliminate potentialcontamination but

preserve t e via i ity o t e ce s. T ese remaining via e

MSCs and osteoprogenitor cells remain attached to the can-ellous bone matrix as demonstrated previously in scanningelectron microscopic images. 16 A cryopreservation solutionis a e an t e pro uct is store at 0 5C, permittinga 5-year shelf life.

The depletion approach that leaves the native MSCsand osteoprogenitor cells found within allogenic bonemarrow and substantially reduces unwanted cells, liket ose o ematopoietic ineage, as een stu ie pre-vious y 6,7 and is demonstrated in the case presentation

e ow.

Clinical Presentation and CaseManagementA 71-year-old female presented to the private clinic of theauthors in Portland, Oregon on March 4, 2009 with a fail-ing subperiosteal implant extending bilaterally from theright and left tuberosity areas (Fig. 1). Previously, the sub-periostea imp ant a een partia y remove . Fu -t ic -ness flap elevation was completed, and the subperiosteaimplant was removed. Simultaneously, a classic lateral wallsinus e evation proce ure was per orme i atera y. T ecellular allograft x was p ace i atera y, an no mem-

ranes were p ace over t e access win ows an onerafts. A 4-month healing period was used based on pub-

is e isto ogy at t e time.6

A ter 4 mont s o ea ing,four implants were placed in the sinus lift areas (Fig. 2). Af-ter a 4-mont integration perio , a comp ete maxi arydenture was fabricated using O-ring attachments on theposterior implants for retention. The ridge deficit in thean-terior maxi a containe a signi icant vertica an orizon-tal component. Residual bone in the anterior maxilla wasseen to be only 2 to 3 mm in thickness (Figs. 3 and 4). Aftera palatal displaced incision a full-thickness flap was

FIGURE 1 Preoperative CBCT scan with panoramic view of failingsubperiosteal implant.

AlloSource, Centennial, CO.steocel, A E urgical upply, Brockton, MA.

C A S E R E P O R T

2 linical Advances in Periodontics, Vol. 3, No. 1, February 201 tem ell Allograft and Titanium Mesh Augmentation

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e evate an cortica penetrations were comp ete in aneffort to improve vascularity to the cellular allograft(Fig. 4). Titanium mes was a apte to t e ri ge (Fig. 5),o owe y p acement o t e ce u ar a ogra t. ina

fixation of the titanium mesh was achieved by using screws {(Fig. 6). Tension- ree primary c osure o so t tissues wasachieved using periosteal releasing incisions, horizontalmattress, an simp e interrupte 4-0 sutures # (Fig. 7). T e

FIGURE 2 ross-sectional CBCT scan of the cellular allograft sinusaugmentat on.

FIGURE 3 Preoperative CBCT scan. A sagittal slice of the premaxillashowing only a 2- to 3-mm vertical bone height from the floor of the nose tothe alveolar crest. Anterior is to the left.

FIGURE 4 Mucoperiosteal elevation with cortical penetrations before bonegrafting.

FIGURE 5 Initial fixation of titanium mesh and placement of the cellular allograft.

FIGURE 6 Final fixation of titanium mesh and cellular allograft.

FIGURE 7 Primary closure of surgical site using polyglactin sutures.

Osteocel, ACE Surgical Supply. ACE Bone Screw, ACE Surgical Supply.

# VI RYL utures, Ethicon, Johnson & Johnson, an Angelo, TX.

C A S E R E P O R T

cAllister, Eshraghi linical Advances in Periodontics, Vol. 3, No. 1, February 2013 3

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maxi ary prost esis was cut ac in t e anterior (Fig. 8),an t e patient was instructe to wear t e prost esis or so-cial occasions only and to ensure that no food pressure wasapp ie . T is essentia y necessitate a iqui iet or t e 4-month healing period. Primary closure of tissues was main-tained throughout the healing process.

Clinical Outcomes

After 4 months of healing, the titanium mesh (Fig. 9) wasremove an one i was note in a orizonta an

ertical dimension, filling the space maintained by themes . Four one eve imp ants**o 4.1 mm iameter weresuccessfully placed into thegraft site, which appeared to beype III bone quality (Fig. 10). Soft-tissue healing was un-

event u , wit a equate an s o eratinize tissue presentaround all healing abutments (Fig. 11). Placement of fourbone level andfour 4.1mm diameter tissue level implants wit goo anteroposterior sprea is emonstrate onthe axial slice shown in Figure 12 from the final cone-

eam computerize tomograp y (CBCT) scan. A ter t e

FIGURE 8 Complete denture with four O-ring attachments and anterior relief to eliminate tissue contact.

FIGURE 9 Four-month reentry of graft site and titanium mesh removal.

FIGURE 10 Placement of four implants.

FIGURE 11 Soft-tissue healing around transmucosal abutments.

FIGURE 12 Post-restoration CBCT scan. Axial slice view and panoramicview of implants and grafted bone.

SLA Surface RC and RN Implants, Straumann, Andover, MA.LA urface R and RN Implants, traumann.

C A S E R E P O R T

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4-month integration period, the finalmilled bar restorationwit oc ing enture was a ricate (Figs. 13 t roug 15).Excellent stability and retention of final prosthesis wasnote .

Discussion

It is apparent from the presented case and multiple publica-tions 6,7 that cellular allografts containing MSCs and osteo-progenitor cells can be used to treat challenging implant

reconstructions. It is also important to note that titaniummesh is very technique sensitive, with exposure rates re-ported from 20% to 40%. 2 Because of the porosity of tita-nium mes , t e rate o revascu arization is i e y more rapicompared to more conventional techniques, such as tita-nium-reinforced polytetrafluoroethylene or collagen mem-branes. In addition, mesh exposure complications can oftenbe managed without a significant impact on the results. Forexamp e, a sma exposure o t e mes can usua y e man-age wit p aque remova at t e expose portion o t e mesand local application of 0.12% chlorohexidine. As long as noo vious in ection ispresent,t e mes remova can e e ayeuntil the originally planned time.

Additionally, the literature has demonstrated successfuluse of autogenous-derived stem cells for implant recon-struct on. 15 T e uture o s promise or improve pre ict-ability in thearea of large implant reconstruction as studiesareperformed toevaluatethe long-termsuccessofcell-basedtreatment mo a ities. n

FIGURE 13 Milled bar ixed in place.

FIGURE 14 Occlusal view of the locking denture in place.

FIGURE 15 Facial view of the denture in place.

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Summary

Why is this case new information? j To the best of our knowledge, this is the first case report using a stemcellbased allograft matrix and titanium mesh for horizontal andvertical bone augmentation.

What are the keys to successful

management of this case?

j Tension-free primary soft-tissue closurej

Appropriate temporizationj Vascular supply for maintaining viability of implanted allogenic MSCsand osteoprogenitor cells

j Space maintenance and immobility of the bone graft matrixj Case selection and management of patient expectations during the

healing process

What are the primary limitations tosuccess in this case?

j Limited prospective clinical trials of short- and long-term efficacy of stem cell based cellular allograft matrix grafting supported bytitanium mesh

j Titanium mesh can be very difficult to manage clinically

AcknowledgmentsDr. McAllister has received financial support for researchand lecture fees from ACE Surgical Supply, Brockton,Massac usetts. T e exce ent prost esis a ricationplaced by Dr. Alberto Ambard (private practice, Portland,Oregon). r. Eshraghi reports no onflicts of interest re-ate to t is case report.

ORRESPONDENCE:Dr. Brad McAllister, Periodontal Associates, 11525 .W. Durham Rd.,

D-6, Tigard, OR 97224. E-mail: [email protected].

C A S E R E P O R T

6 linical vances in erio ontics, ol. , o. 1, ebruary 1 tem ell llogra t n itanium esh ugmentation

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References1. Fiorellini JP, Nevins ML. Localized ridge augmentation/preservation. A

systematic review. Ann Periodontol 2003;8:321-327.2. McAllister BS, Haghighat K. Bone augmentation techniques. J Peri-

odontol 2007;78:377-396.3. Gonshor A, McAllister BS, Wallace SS, Prasad H. Histologic and

histomorphometric evaluation of an allograft stem cell-based matrix sinusaugmentation procedure. Int J Oral Maxillofac Implants 2011;26:123-131.

4. Muschler GF, Nitto H, Boehm CA, Easley KA. Age- and gender-related

changes in the cellularity of human bone marrow and the prevalence of osteoblastic progenitors. Orthop Res 2001;19:117-125.5. Nkenke E,Weisbach V, Winckler E, et al. Morbidity of harvesting of bone

grafts from the iliac crest for preprosthetic augmentation procedures: Aprospective study. Int J Oral Maxillofac Surg 2004;33:157-163.

6. McAllister BS, Margolin MD, Cogan AG, Buck D, Hollinger JO, LynchSE. Eighteen-month radiographic and histologic evaluation of sinusgrafting with anorganic bovine bone in the chimpanzee. Int J Oral Maxillofac Implants 1999;14:361-368.

7. McAllister BS, Haghighat K. Clinical applications of a stem cell basedtherapy for oral bone reconstruction. In: Elisseeff J, Li S, LHeureux N,eds. Stem Cells and Tissue Engineering . Hackensack, NJ: WorldScientific Publishing; 2011:14.

8. Muschler GF, Nakamoto C, Griffith LG. Engineering principles of clinicalcell-based tissue engineering. J Bone Joint Surg Am 2004;86-A:1541-1558.

9. Ryan JM, Barry FP, Murphy JM, Mahon BP. Mesenchymal stem cellsavoid allogeneic rejection. J Inflamm (Lond) 2005;2:8.

10. Barry FP, Murphy JM. Mesenchymal stem cells: Clinical applicationsand biological characterization. Int J Biochem Cell Biol 2004;36:568-

4.. Brafman DA, Willert K, Chien S. High-throughput systems for stem cell

engineering. In: Elisseeff J, Li S, LHeureux N, eds. Stem Cells and Tissue Engineering . Hackensack, NJ: World Scientific Publishing;2011:17.

2. Chamberlain G, Fox J, Ashton B, Middleton J. Concise review:

Mesenchymal stem cells: Their phenotype, differentiation capacity,immunological features, and potential for homing. Stem Cells 2007;25:2739-2749.

13. Kadiyala S, Young RG, Thiede MA, Bruder SP. Culture expandedcanine mesenchymal stem cells possess osteochondrogenic potentialin vivo and in vitro. Cell Transplant 1997;6:125-134.

14. Malekzadeh R, Hollinger JO, Buck D, Adams DF, McAllister BS.Isolation of human osteoblast-like cells and in vitro amplification fortissue engineering. J Periodontol 1998;69:1256-1262.

15. Kaigler D, Pagni G, Park CH, Tarle SA, Bartel RL, Giannobile WV.Angiogenic and osteogenic potential of bone repair cells for craniofacialregeneration. Tissue Eng Part A 2010;16:2809-2820.

16. McAllister BS, Haghighat K, Gonshor A. Histologic evaluation of a stem cell-based sinus-augmentation procedure. J Periodontol ;80:679-686.

indicates key references.

C A S E R E P O R T


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CASE REPORT

Use of Guided Tissue Regeneration in the Treatmentof a Severe Endodontic Periodontic Lesion:

-Year Follow-Up Case eportRonaldo B. antana* nd Carolina M. Mattos antana*

Introduction: Treatment f combined endodontic periodontic lesions remains a considerable challenge in clinicalpractice. The degree f success in the management of hese lesions is related to the efficacy f both periodontal and end-

dontic treatments and is influenced by specific anatomic haracteristics of the lesion. This report presents the long-termlinical outcomes f a severe endodontic periodontic lesion treated by guided tissue regeneration (GTR) and documentedver a 15-year period.

Case Presentation: A non-smoking, 42-year-old female presented with a combined endodontic periodontic lesiononsisting f a large through-and-through apical lesion ommunicating with the marginal periodontium as a result of theomplete loss of the facial bone plate. Treatment consisted of GTR andgrafting with absorbable hydroxyapatite. The clinical

variables evaluated were plaque, bleeding on probing (BOP), gingival recession, probing depth (PD), and clinical attachmentlevel (CAL).Reevaluationwas performed 1 year and 15 years after the surgical procedure. Healing was uneventful. Measure-ments revealed that PD was reduced by 17 mm, a 16-mm CAL gain was recorded, and no BOP was etected a any toothaspect. CALgains were maintained up to the15-year recall. Radiographic evaluation demonstrated a complete resolution of the bony lesion at both 1 year and 15 years after surgery.

Conclusion: Severe combined endodontic periodontic lesions an be successfully treated via regenerative tech-niques, and the resultant bone and CAL gains are preserved for several years after the active treatment. Clin Adv Periodon-tics 2013;3:10-13.

Key Words : Guided tissue regeneration, periodontal; root canal bturation.

BackgroundW en periapica an perio onta iseases simu taneous yaffect the same tooth an are merge n a single lesioncommunicating he apical and marginal issues, a om-

ine en o onticperio ontic esion is esta is e . 1 T epresence of apical pathology or inadequately illed root

ana systems as been associate with increase probing

dept PD , increase oss o clinical attachment level(CAL), and reduced response to conventional and surgicalperio onta t erapy. 2-4 Advances n surgica managemento periradicular pathosis, ith particular emphasis

uided tissue regeneration (GTR) techniques, may improveu rates 5 an use or t e treatment o om ine

en o onticperio ontic esions. 5-10 T e r one e-struct on c aracteristic o t e com ine en o onticperio ontic esions s ma or t erapeutic c a enge. T isreport presents the long-term clinical outcomes of a vendodonticperiodontic lesion treated y GT and docu-mented over a 15-year period.

* Department of Periodontology, Fluminense Federal University, ental School, Niteroi, Rio de Janeiro, Brazil.

Submitted November , 011; accepted for publication February 12,2012

doi: 10.1902/cap.2012.110098

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Clinical PresentationClinical parameters (bleedingon probing [BOP],PD,reces-sion [REC], an CAL), were assesse as escri e previ-ous y11 at baseline and repeated 12 months and 15 yearsafter the initial surgery. BOP was recorded dichotomouslyas t e percentage o tota sur aces (six sites per toot ).

A non-smoking, 42-year-old female was treated from

Marc 1994 to May 2009 at t e Perio onto ogy C inic oF uminense Fe era University (Rio e Janeiro, Brazi ). T epatient reported diffuse, spontaneous pain in the region rel-ative to t e maxi ary rig t centra an atera incisors (teet#7and#8)andmentionedthat these teethhadbeenendodon-tically treated several years before her first appointment.

Teet #7 an #8 presente oca ize re ness in t e oramucosa and pain after vertical percussion and palpationon t e ucca a veo ar mucosa a jacent to t e apexes o

ot teet . Perio onta pro ing revea e PD an CAL 15mm ( z 21 mm) in the buccal aspect of tooth #8, followed

y rainage o oo y puru ent exu ate. No REC wasnoted. Millers Class III mobility was noted in tooth #8,

and Class II mobility was noted for tooth #7. The baselinera iograp ic image (Fig. 1a) revea e an extensive ra io u-centimage inthe periapical areaofteeth #7and #8 thatwascontinuous wit t e ra io ucency in t e interproximacresta one wa s o toot #8. Ra iopaque eposits, sug-gestive of dental calculus, were observed on the root sur-aces o toot #8. T e root cana s o ot teet were

filledwith a radiopaque material, which was overextendeand overfilled to the canal spaces of teeth #7 and #8.In toot #7, t e amina ura seeme to e intact exceptfor discontinuity in the apical portion. A diagnosis of si-mu taneous com ine en o onticperio ontic esion an

t roug -an -t roug periapica esion was ormu ate .Written informed consent was obtained from the patientafter comprehensive explanation of available treatmentoptions .

Case ManagementLoca anest esia was o taine , an a acia trapezoi a

mucoperiosteal flap and a palatal envelope flap were ele-vate . Bone e ect e ri ement an root p aning werethoroughly performed. Tooth #8 exhibited an extensiveapica osseous e ect associate wit t e comp ete osso t e ucca a veo ar one wa . An extensive t roug -and-through lesion involving the buccal and palatal apicalosseous wa s o toot #7 was a so o serve (Fig. 1 ).

T e rootapexes o teet #7 an #8 wereresecte , an t eneo apexes were rounded, retro-prepared, and retro-filledwit ama gam. A ou e- ayere co agen mem rane wasadjusted in the palatal aspect of the osseous crypt. The os-seous esion an t e atera an acia aspects o toot #8were completely filled with a resorbable microparticulate

hydroxyapatite,

and then a polytetrafluoroethylene mem-rane x was positioned buccally over the borders of the le-sion (Fig. 1e). T e ap was sp it at its apica extent ancorona y a vance . Primary c osure was o taine witsling and interrupted single sutures. Postoperative recom-mendations and maintenance schedule were performed as

escribed previously 11 in the first year and then repeatedonce annua y or 14 years.

FIGURE 1 Clinical and radiographic findings. 1aRadiographic view at baseline. 1b Radiographicview 1 year after treatment. 1c Radiographicview 15 years after treatment. 1d Trans-surgicalview after mucoperiosteal flap reflection anddefect debridement. 1e Trans-surgical view of membrane placement. 1f Trans-surgical viewafter flap reflection and membrane removal.

ollaTape, Zimmer Dental, Carlsbad, CA.Biohapatita, Dentoflex, So Paulo, Brazil.

ento lex.

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Clinical OutcomesHea ing unevent u an , 1 mont s a ter urgery, -open ng surgery as per orme o remove t e arriermembrane. Visual and clinical inspection revealed a com-p ete y repaire apica one e ect an acia a veo ar oneplate (Fig. 1f). A 0.5-mm-thick superficial soft-tissue layer

a so oun covering e acia one p ate. T e aps

were orona y positione to comp ete y cover t e new yformed tissues. Sixmonthsafter membrane removal, prob-ing measurements were repeate . Mi acia measurementsat toot #8 revea e t at PD re uce to 4 mm. REC mea-surements were equal to mm, and a total 6-mm CALgain was recor e . t t e 5-year reca , was mm,REC was 3 mm, an 6-mm CAL gain as ocumented.Measurements at ot er aspects o teet #7 an #8 emon-strate PD < 3 mm, an no RECorBOP was etecte a ter 1and 15 ears. Radiographic follow-up revealed increasedra iograp ic ensity in e periapica r o teetan # continuous wit restore mesia an ista crestabone walls of tooth #8 1 year after treatment (Fig. 1b).Sim-

i ar y, improve ra iograp ic resu ts were seen earsafter treatment (Fig. 1c), bot classified as Class 1D ac-cor ing o Mo ven et a .s 12 radiographic lassificationo ea ing a ter en o ontic surgery.

DiscussionTreatment o teeth ith advance ombined endodonticperio ontic esions s comp ex c inica c a enge t at

requires t e e imination o t e apica an margina compo-nents o t e pat o ogic process. 1-4,8 Endodontic factors, in-cluding the diameter of the apical lesion 6,13-15 and absenceof facial or lingual/palatal bone plate in conjunction witha periapical lesion, 13,14 directly influence periodontal heal-ing. In per orating t roug -an -t roug esions, ea ing is

5 .7 T us,t epresenceo a arget roug -an -t rougapica esion communicating it t e margina perio on-tium as a resu t o t e comp ete a sence o t e acia onep ate, o serve in e presente , is c inica a -enge ecause o t e presence o signi icant negative prog-

nost c actors. 7,13-15 Positive c inica responses ave eenocumente ort e treatment o uman urcation e ects 11

wit e regenerative approac use in t e present case.C inica an ra iograp ic o ow-up o t e present case re-vea e sustaine one an CAL gains or 15 years a ter ac-tivetreatment.To t e est o our now e ge, t isis t e irstong-term report o success u treatment an maintenance

of regenerativetherapy of advancedendodonticperiodonticlesions followed for > 2 years. Considering the important

technical developments in surgical endodontic retreat-ment that occurred in the past decade (use of microscope,microinstruments, absorbable membranes, and biocom-patible filling materials, such as super ethoxybenzoicacid or mineral trioxide aggregate), 8-10 we speculate thatproce ures per orme wit state-o -t e-art materia s antec niques ma resu t n signi icant y improve an re-

icta e outcomes. n

Summary

Why is this case new information? j This case demonstrates that short-term clinical benefits of combinedsurgical endodontic periodontic therapy can be longitudinally stablefor a long time in severe lesions treated by a regenerative approach.

What are the keys to successfulmanagement of this case?

j Adequate case selection, use of regenerative materials, elimination of both the apical and marginal components of the pathologic process,and careful longitudinal supportive periodontal therapy are mandatoryfor successful outcomes.


j The degree of success in the management of these lesions isinfluenced by specific anatomic characteristics of the lesion.

AcknowledgmentThe authors report onflicts o nterest related o hiscase report.

ORRESPONDENCE:Dr. Ronaldo B. Santana, Department f Periodontology, Dental chool,Fluminense Federal University, Rua ao Paulo 28, Niteroi, Rio deJaneiro 24040 115, Brazil. E-mail: [email protected].

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References. Zehnder M, Gold SI, Hasselgren G. Pathologic interactions in pulpal

and periodontal tissues. J Clin Periodontol 2002;29:663-671.2. Jansson L, Ehnevid H, Blomlof L, Weintraub A, Lindskog S. Endodon-

tic pathogens in periodontal disease augmentation. J Clin Periodontol 1995;22:598-602.

3. Ehnevid H, Jansson LE, Lindskog SF, Blomlo LB. Periodontal healingin relation to radiographic attachment and endodontic infection. J Periodontol 1993;64:1199-1204.

4. Ehnevid H, Jansson LE, Lindskog SF, Blomlof LB. Periodontal healingin teeth with periapical lesions. A clinical retrospective study. ClinPeriodontol 1993;20:254-258.

5. Rankow HJ, Krasner PR. Endodontic applications of guided tissueregeneration in endodontic surgery. J Endod 1996;22:34-43.

6. Pecora G, Kim S, Celletti R, Davarpanah M. The guided tissueregeneration principle in endodontic surgery: One-year postoperativeresults of large periapical lesions. Int Endod J 1995;28:41-46.

7. Brugnami F, Mellonig JT. Treatment of a large periapical lesion withloss of labial cortical plate using GTR: A case report. Int J PeriodonticsRestorative Dent 1999;19:243-249.

8. Karabucak B, Setzer FC. Conventional and surgical retreatment of complex periradicular lesions with periodontal involvement. Endod 2009;35:1310-1315.

9. Kim E, Song JS, Jung IY, Lee SJ, Kim S. Prospective clinical studyvaluating endodontic microsurgery outcomes for cases with lesions

of endodontic origin compared with cases with lesions of combinedperiodontal-endodontic origin. J Endod ; :5 -55 .

10. Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature Part 1:Comparison of traditional root-end surgery and endodontic microsur-gery. J Endod ; : 757- 7 5.

11. Santana RB, de Mattos CM, Van Dyke TE. Efficacy of combinedregenerative treatments in human mandibular Class II furcation defects. J Periodontol 2009;80:1756-1764.

12. Molven O, Halse A, Grung B. Observer strategy and the radiographicclassification of healing after endodontic surgery. Int J Oral MaxillofacSurg 1987;16:432-439.

13. Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors affecting thelong-term results of endodontic treatment. J Endod 1990;16:498-504.

14. Skoglund A, Persson G. A follow-up study of apicoectomized teeth withtotal loss of the buccal bone plate. Oral Surg Oral Med Oral Pathol 1985;59:78-81.

15. Danin J, Stromberg T, Forsgren H, Linder LE, Ramskold LO. Clinicalmanagement of nonhealing periradicular pathosis. Surgery versusendodontic retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:213-217.


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CASE SERIES

Use of an Extracellular Matrix Membrane or Root Coverage: Case Seriesand Review of the Literature

Monish Bhola,* hayna Sanchez,* and Shilpa Kolhatkar*

Introduction: The treatment of gingival recession (GR) is a growing need in patients as a result of functional, esthetic,and preprosthetic demands. Techniques that primarily use autogenous grafts, although well established, often require a re-mote secondsurgicalsite.Clinicians have attemptedto achieve comparable results without a donor site by using substitutesor autogenous grafts, such as allografts. Recently, the efficacy andpredictabilityof an extracellular matrix(ECM) membraneor root coverage procedures has received lose attention. This ase series investigates whether the use of an ECM mem-

brane for root coverage procedures achieves bjectives, such as complete root coverage (CRC), stable results, and oodsthetics in the form of uniform gingival color and contour. The results of six such cases in a variety of clinical situations are

presented.Case Series: Six cases f Miller Class II and III GR defects were treated using an ECM membrane. The flap oper-

ation was conducted with a trapezoidal or sulcular flap, followed by placement of the ECM over the GR defect. A follow-up range f 15 months showed complete (two cases) to partial (four cases) root coverage and an increase in tissuehickness.

Conclusion: These results suggest that the use of an ECM membrane is a viable alternative to the use of autogenousrafts when treating GR defects or for soft-tissue thickness augmentation. lin Adv Periodontics 2013;3:16-21.

Key Words: Extracellular matrix; gingival recession.

BackgroundGingival recession (GR) is a common finding in the adultpopu ation in t e Unite States. 1 Treatmento GR is nee ein an increasing number o individuals, primarily forunctiona an est etic nee s. A t oug many ora p astic

treatment mo a ities 2 have een available o treat GR, theneed for a secondary surgical site frequently adds discom-ort an onger air time an increases t e i e i oo o

issue morbidity and intraoperative and/or postoperativeomp ications. 3 n a e concern s e imite t ic ness

o autogenous gra ts in e presence o in pa ata tissue.

Additionally, in patients with shallowpalates, the sizeof theautogenous gra t at an e arveste at a sing e time islimited. All of his makes the treatment of multiple GR

efects difficult an contribute to reduce pat entacceptance. Ace u ar erma matrix gra ts ave eenoffered as a substitute for autogenous rafts, but theresu ting root coverage was not sta e over time.

Recently, an extracellular matrix (ECM) membrane hasreceive c ose attention or use in root coverage proce uresas a resu t o avora e c inica outcomes. A sp it-moutstudy was performed to evaluate he safety, feasibility,an e icacy o an E M or gingiva augmentation. 5 T at

* Department of Periodontology and Dental Hygiene, University of Detroit Mercy, School of Dentistry, Detroit, MI.

Submitted October 9, 011; ccepted for publication December 12,2011

doi: 10.1902/cap.2012.110096


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study compared the clinical and histologic results of ECMversus an autogenous gingiva gra t in augmenting erati-nized ssue. The authors concluded that EC w effec-tive n increasing he zone o keratinize issue anseeme to ave a more est etica y p easing outcome.

The newly forme t ssue resembled the origina gingivaco or an texture more c ose y compare to t e autoge-nous graft. The advantages of using ECM included theelimination of a secondary surgical s te, unlimited graftsupp y, an a natura est etic appearance.

The current case series investigates whether the use of anE M for root coverage procedures achieves objectivessuch as complete root coverage (CRC), stable results,andgood esthetics, such as uniform gingival color andcon-tour. T e resu ts o six suc cases in a range o c inica sit-uations are presented.

Clinical PresentationSix non-smo ing patients (one ma e an ive ema es, age 39to 63 years) presented to private practice (Detroit, Michigan)rom January 2009 to Ju y 2011, or eva uation o GR t at re-

quire root coverage an /or so t-tissue augmentation or io-type modification (Table ). The cases treated had GR

ept s ranging rom s ig t (2 mm) to severe (9 mm) an werepresent on ot anterior an posterior teet (Figs. 1a, 2a, 3a,and 4a). A presurgical evaluation was completed on each pa-tient,inc u inga etai e ora examan necessary ra iograp s.Medicalhistoryof all patients was non-contributory. Oralpro-p y axis or sca ing an root p aning were comp ete an cari-ous esions, i any, were treate e oreso t-tissue augmentation.

Case ManagementT e recommen e treatment t oroug y exp aine toeac pat ent, an wr tten in orme onsent was o taine .Thematerialused in thiscase series is anECM derivedfromt e sma intestina su mucosa (SIS) o pigs rom qua i ieanimal production facilities. SIS is obtained from the intes-tine using a process that retains the natural composition of matrix mo ecu es, suc as co agen (types I, III, VI), g ycos-aminoglycans(hyaluronicacid, chondroitin sulfateA andB,

eparin, an eparan su ate), proteog ycans, growt actors

( i ro ast growt actor-2, trans orming growt actor-b), an i ronectin. 6,7

A procedures w performe under profound locaanest esia. ite preparation was accomp is e using eo owing tec niques: iverging trapezoi a incisions (Figs.

1b and 2b) and sulcular incisions followed by reflection oa mucoperiostea ap. oot sur ace e ri ement was ac-complished using hand instruments and flame-shaped ro-tary instruments x an c emica y treate or minutes.T e mem rane { was then appropriately trimmed and su-ture using resor a le sling suture # Fig. 4b) an placeover e root sur ace. A s ing suture was use to coro-nally advance the facial flap by using periosteal releasingincisions (Fig. 1c). T e vertica incisions were secure witinterrupte sutures (Figs. 1d, 2b, and 3b). Detailed writ-ten and verbal postoperative instructions were given. Eachpatient was p ace on250mg amoxici inevery 8 ours or

days, 800 mg ibuprofen every 6 hours as needed, and

.12 or exi ine g uconate mout rinse twice ai yor seconds.

Clinical OutcomesFor a patients, ea ing o t e surgica site was unevent u ,an intraoperative postoperative complications -curre . A GR e ects were sta e a ter a o ow-up perioof 15 months (Figs. 1e, 2c, 3c, and 4c). Table 1 illustratespreoperat ve R an tota root v in millimetersan percentage) o taine . Two o e six e ects treate(cases 1 and 3) obtained 100% root coverage. A severeGR defect (case 2) gained67%root coverage, andmultiplea jacentGR e ects (case 4) gaine 50% root coverageansuccessful biotype convers on rom thin to thick gingiva

iotype as assesse t roug visua examination. T e co orof the gingiva closely matched he adjacent teeth and

TABLE 1 Case Descriptions

Case Age, Sex Tooth #Initial GR

Depth (mm)Miller

Classification 9 Medical HistoryRoot CoverageObtained (mm)

Root CoverageObtained (%) Figure

1 55, Female 4 II Non-contributory 4 100 1

2 60, Male 14 9 III Reynaud syndrome 6 67 2

50, Female III Non-contributory 100 3

4 63, Female 23 through 26 2 to III Mitral valve prolapse 1 to 2 50 4

5 41, Female 24 3 III Non-contributory 1.5 50 N/A

6 39, Female 24 5 II Non-contributory 4 80 N/A

yna atrix lus, eystone ental , url ington, .Septodont, Lancaster, PA.

406, rasseler U A, avannah, A. PrefGel, traumann, n over, .

DynaMatrix Plus, Keystone Dental.# thicon, ohnson ohnson, omerville, .

thicon, ohnson ohnson.Ethicon, Johnson & Johnson.3 PE, t. aul, .

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root coverage. These results maintaine stability for ao ow-up uration o 15 mont s.

This ser es presents results of root v us ngECM or root coverage in varying an comp ex c inica cir-cumstances. The results are favorable and have maintained

stability up to a 15-month observation period. In this case se-ries, we present six cases t at were treate using ECM as analternativeto harvestinganautogenousgraft, fortreatment oGR. In a cases, we werea e to o tain an increase wi t okeratinized tissue and partial-to-complete root coverage. n

Summary

Why are these cases newinformation?

j ECM eliminates the need for an autogenous graft.j The root coverage obtained is comparable to that seen in connective

tissue graft with good color match.

What are the keys to successfulmanagement of these cases?

j It is important to ensure thorough debridement and preparation of theroot surface, tension-free closure, and immaculate oral hygiene.

j Complete coverage of the ECM with the flap is also necessary.

What are the primary limitations tosuccess in these cases?

j The maximum time of observation is 15 months, and a clinical trial of longer duration with a larger sample size is needed to assesslong-term results.

AcknowledgmentsDr. B o a is a consu tant or Keystone Denta (Bur ington,Massachusetts) and has iven ectures sponsore or co-sponsore y e company. rs. Sanc ez an Ko at arreport no on icts o nterest re ate to t is case ser es.

CORRESPONDENCE:Dr. Shayna Sanchez, 2700 Martin Luther King Jr. Blvd., Detroit, MI 48208-2576. E-mail: [email protected].

FIGURE 2 Case . 2a Preoperative view of tooth #14. 2b ECM was placed and pedicle was flap secured over membrane and R efect. 2c Follow-up t 3months.

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FIGURE 3 ase 3. 3a Preoperative view of tooth #6. 3b After the ECM wasplaced, the flap was coronally advanced and sutured. 3c Follow-up at 1year.

FIGURE 4 ase 4. 4a Preoperative view of teeth #23 through #26. 4b ECMwas sutured into place. 4c Follow-up at 3 months.

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References1. Albandar JM, Kingman A. Gingival recession, gingival bleeding, and

dental calculus in adults 30 years of age and older in the United States,1988-1994. J Periodontol 1999;70:30-43.

2. Chambrone L, Pannuti CM, Tu YK, Chambrone LA. Evidence-basedperiodontal plastic surgery. II. An individual data meta-analysis forevaluating factors in achieving complete root coverage. J Periodontol 2012;83:477-490.

3. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative

complications following gingival augmentation procedures. J Periodontol 2006;77:2070-2079.4. Harris RJ. A short-term and long-term comparison of root coverage

with an acellular dermal matrix and a subepithelial graft. J Periodontol 2004;75:734-743.

. Nevins M, Nevins ML, Camelo M, Camelo JM, Schupbach P, Kim DM.The clinical efficacy of DynaMatrix extracellular membrane in aug-

enting keratinized tissue. Int J Periodontics Restorative Dent 2010;30:151-161.

6. Hodde J, Janis A, Ernst D, Zopf D, Sherman D, Johnson C. Effects of sterilization on an extracellular matrix scaffold: Part I. Compositionand matrix architecture. J Mater Sci Mater Med 2007;18:537-543.

7. Hodde JP, BadylakSF, BrightmanAO,Voytik-HarbinSL.Glycosaminoglycancontent of small intestinal submucosa: A bioscaffold for tissue replacement.Tissue Eng 996;2:209-217.

8. Saroff S. The use of DynaMatrix extracellular membrane for gingivalugmentation and root coverage: A case series. J Implant Adv ClinDent 2011;3:19-30.

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


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by a Student t est, andthe level of significancewasassessedat 5% 0.05 .

Clinical Outcomes

In Table 2, the intrasurgicalmeasurements of infrabonyde-fects are reported (mean SD, 5.5 1.1 mm). Tables 2 and3 s ow in ivi ua c inica ata o a sing e toot , inc u ing

mean va ues an stan ar eviations at ot T.0 an T.END. The mean baseline PD was 7.7 1.2, with an initialmeanCALof 10 1.05. Mean PDre uction was 3.7 1.mm, wit an average resi ua PD o 4 1. 5 mm; meanCAL gain was 4.4 1.71 mm, with a residual CAL of

. 1.72 mm. Bot i erences are statistica y signi icant(P < 0.001) (Ta e 3). T ere was a re uction in GR, ut itwas not statistically significant (gain of 0.8 mm).

FIGURE 6 The defect filled with EMD after the bone graft was added.

FIGURE 7 The combination of mattress and single suture was done tocomplete the primary closure.

FIGURE 8 linical view at the start of the orthodontic treatment (1 month).

FIGURE 3 Modified papilla preservation technique.

FIGURE 4 Intrasurgical view exhibiting an infraosseus component of mm.

FIGURE 5 The defect filled with EMD before the bone graft was added.

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Summary

Why are these cases newinformation?

j Follows a multidisciplinary treatment to define a new clinical approachin periodontal patients

j Shows that early orthodontic movement after regenerative surgery isa great possibility in periodontal patients

j Lack of information in literature about the relationship betweenperiodontics and orthodontics

What are the keys to successfulmanagement of these cases?

j Patient compliancej Financial resourcesj High-level experience in periodontal surgeryj Communication between different specialties

What are the primary limitations tosuccess in these cases?

j Patient compliance and motivationj The multidisciplinary treatment approachj Lack of follow-up

AcknowledgmentsT e aut ors t an Pro . Giampietro Farronato o t e Uni-versity o Mi an (Mi an, Ita y) or is contri utions to t iscase series. he authors report no conflicts of interestre ate to t is series.

ORRESPONDENCE:Dr. Valeria Maria Vigan, Via . Pellico, 26/2, I-20019 Milan, Italy. E-mail:valeria.vi [email protected].

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859-866.2. Lindhe J, Svanberg G. Influence of trauma from occlusion on pro-

gression of experimental periodontitis in the beagle dog. J ClinPeriodontol 1974;1:3-14.

3. Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infectedand non-infected dentitions in dogs. Clin Periodontol 1977;4:278-293.

4. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment inperiodontally compromised patients: 12-year report. Int J PeriodonticsRestorative Dent 2000;20:31-39.

5. Wennstro JL, Stokland BL, Nyman S, Thilander B. Periodontal tissueresponse to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop ; : - .

6. Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontalresponse after tooth movement into intrabony defects. J Periodontol 1984;55:197-202.

7. Diedrich P, Fritz U, Kinzinger G, Angelakis J. Movement of peri-odontally affected teeth after guided tissue regeneration (GTR) Anexperimental pilot study in animals. J Orofac Orthop ; : -227.

8. Geraci TF, Nevins M, Crossetti HW, Drizen K, Ruben MP. Reattach-ment of the periodontium after tooth movement into an osseous defectin a monkey. 1. Int J Periodontics Restorative Dent 990;10:184-197.

. Melsen B, Agerbaek N, Eriksen J, Terp S. New attachment throughperiodontal treatment and orthodontic intrusion. Am J Orthod Dentofacial Orthop 1988;94:104-116.

10. Ross SE, Cohen DW. The fate of a free osseous tissue autograft. Alinical and histologic case report. Periodontics 1968;6:145-151.

11. Camelo M, Nevins ML, Lynch SE, Schenk RK, Simion M, Nevins M.Periodontal regeneration with an autogenous bone-Bio-Oss composite

raft and a Bio-Gide membrane. Int J Periodontics Restorative Dent 2001;21:109-119.

12. Sculean A, Windisch P, Chiantella GC. Human histologic evaluation of n intrabony defect treated with enamel matrix derivative, xenograft,nd GTR. Int J Periodontics Restorative Dent 2004;24:326-333.

13. Camelo M, Nevins ML, Schenk RK, et al. Clinical, radiographic, andistologic evaluation of human periodontal defects treated with Bio-Oss

and Bio-Gide. Int J Periodontics Restorative Dent 998;18:321-331.14. Murphy KG, Gunsolley JC. Guided tissue regeneration for the

treatment of periodontal intrabony and furcation defects. A systematic

review. Ann Periodontol 2003;8:266-302.15. Needleman I, Tucker R, Giedrys-Leeper E, Worthington H. A system-

tic review of guided tissue regeneration for periodontal infrabonyefects. J Periodontal Res 2002;37:380-388.

16. Trombelli L, Heitz-Mayfield LJ, Needleman I, Moles D, Scabbia A. Aystematic review of graft materials and biological agents for peri-dontal intraosseous defects. J Clin Periodontol 2002;29(Suppl. 3):

7- 5.17. Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley

JC. The efficacy of bone replacement grafts in the treatment of peri-odontal osseous defects. A systematic review. Ann Periodontol 2003;8:227-265.

18. Esposito M, Coulthard P, Thomsen P, Worthington HV. Enamel matrixerivative for periodontal tissue regeneration in treatment of intrabony

defects: A Cochrane systematic review. J Dent Educ 2004;68:834-844.19. Esposito M, Grusovin MG, Papanikolaou N, Coulthard P, Worthington

HV. Enamel matrix derivative (Emdogain(R)) for periodontal tissue

regeneration in intrabony defects. Cochrane Database Syst Rev 2009;7:CD003875.

20. Corrente G, Abundo R, Re S, Cardaropoli D, Cardaropoli G.Orthodontic movement into infrabony defects in patients with ad-vanced periodontal disease: A clinical and radiological study.Periodontol 2003;74:1104-1109.

21. Cirelli JA, Cirelli CC, Holzhausen M, Martins LP, Brandao CH.Combined periodontal, orthodontic, and restorative treatment of pathologic migration of anterior teeth. A case report. Int J Periodontics

estorat ve Dent ; :5 -5 .

22. Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of themaxillary midline papilla following a combined orthodonticperiodon-tic treatment in adult periodontal patients. J Clin Periodontol 2004;31:

- .2 . Ghezzi C, Masiero S, Silvestri M, Zanotti G, Rasperini G. Orthodontic

treatment of periodontally involved teeth after tissue regeneration. Int J Periodontics Restorative Dent 2008;28:559-567.

24. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Bio-Osscollagen and orthodontic movement for the treatment of infrabonydefects in the esthetic zone. Int J Periodontics Restorative Dent 2006;26:553-559.

25. Diedrich PR. Guided tissue regeneration associated with orthodontictherapy. emin Orthod 1996;2:39-45.

. Schneider B, Wehrbein H, Meyer R, Diedrich P. Intrusion of peri-odontally affected teeth using a polyglactin-910-membrane (Vicryl) (inGerman). Dtsch Zahnarztl Z 1990;45:171-175.

27. Cardaropoli D, Re S, Corrente G. The Papilla Presence Index (PPI): A

new system to assess interproximal papillary levels. Int J Periodonticsestorat ve ent 004;24:488-492.28. Reichert C, Deschner J, Kasaj A, Jager A. Guided tissue regeneration

and orthodontics. A review of the literature. Orofac Orthop 2009;70:6-19.

29. Gkantidis N, Christou P, Topouzelis N. The orthodontic-periodonticinterrelationship in integrated treatment challenges: A systematicreview. J Oral Rehabil 2010;37:377-390.

30. OLeary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.

31. Cortellini P, Prato GP, Tonetti MS. The modified papilla preservationtechnique. A new surgical approach for interproximal regenerativeprocedures. J Periodontol 1995;66:261-266.

32. Cortellini P, Prato GP, Tonetti MS. The simplified papilla preservationflap. A novel surgical approach for the management of soft tissues inregenerative procedures. Int J Periodontics Restorative Dent 999;19:589-599.

33. Tu YK, Woolston A, Faggion CM Jr. Do bone grafts or barriermembranes provide additional treatment effects for infrabony lesionstreated with enamel matrix derivatives? A network meta-analysis of randomized-controlled trials. J Clin Periodontol ; 7:5 -7 .

34. Roberts WE, Goodwin WC Jr, Heiner SR. Cellular response toorthodontic force. Dent Clin North Am 1981;25:3-17.

35. Nemcovsky CE, Sasson M, Beny L, Weinreb M, Vardimon AD.Periodontal healing following orthodontic movement of rat molarswith intact versus damaged periodontia towards a bony defect. urOrthod 2007;29:338-344.

36. Nemcovsky CE, Beny L, Shanberger S, Feldman-Herman S, VardimonA. Bone apposition in surgical bony defects following orthodonticmovement: A comparative histomorphometric study between root- andperiodontal ligament-damaged and periodontally intact rat molars. J Periodontol 2004;75:1013-1019.

37. Zachrisson BU. Oral hygiene for orthodontic patients: Current con-cepts and practical advice. Am J Orthod 1974;66:487-497.


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CASE REPORT

The Possible Effect of an Accessory Root-Like Structure on Periodontitis: A Clinical and Histologic Case Report

Jianxin Du,* Xiaoying Wang,* Jin Zhang,* Shiguo Yan,* Li Wang,* and Pishan Yang*

ntroduction: ooth-related factors, such as cemento-enamel projections and furcations, are contributing factors operiodontal disease. Tooth morphologic variations in the anterior teeth are less frequently reported.

Case Presentation: A 25-year-old female patient was referred to our linic with eneralized severe aggressive peri-odontitis. An accessory root-like structure on the mesio-labial surface of he root of tooth 9 was identified. This root-likestructure was z 7 mm long and had a sharp tip. Clinical xamination revealed tooth 9 had Miller Class III mobility, a7-mm-deep periodontal pocket n the mesio-labial aspect of the tooth, and a clinical attachment loss of 12 mm. Althoughperiodontal destruction could also be observed at ther tooth sites, he estruction on tooth #9 was more prominent. After initial periodontal reatment, tooth #9 was deemed hopeless, extracted, and then replaced with a provisional removablepartial enture.

Conclusions: Although evelopmental dental anomalies are important contributing factors for the evelopment andprogression of periodontitis, they are frequently undiagnosed. Therefore, early recognition f the abnormal ental morphol-

ogy is f reat clinical significance in effectively reating periodontitis. Clin Adv Periodontics 013;3:33-38.Key ords : Developmental biology; histology; periodontitis; risk factors.

BackgroundSome anatomic abnormalities are considered as contributingfactors or periodonta iseases ecause o their associationwit t e retention o enta p aque. 1,2

The anatomic structure of he maxillary entral incisormost i e y presents wit a sing e root an rootcana . 3 ow-ever, developmenta root anomalies ave been reported.Most cases reported two roots and/or two root canals. ,5n 1 , a cervica ename pro ect on on t e acia aspect

of a maxillary entral incisor was reporte as being associ-ate it gingiva enestration. 6 n e current report,we report an unusual accessory root-like structure on the

mesio- a ia aspect o t e root o t e e t maxi ary centranc sor toot (tooth #9). ow this morphologic var at on

might have contri ute to the evelopment an progres-sion o perio ontitis is a so iscusse .

Clinical PresentationT isstu y was approve y t e Institutiona Review Boar

of Shandong University, Jinan,Shandong,China, andwrit-ten in orme consent was o taine rom t e patient. OnFe -ruary 11, 2011, a 25-year-old female patient was referred forperiodonta treatment with the omplaint of mobility otoot #9 or 1 year. Duringc inica examination, an acces-sory root-like structure on the mesio-labial aspect of theroot of tooth #9 (Fig. 1a) was identified. The probing depthat t is site was7 mm, an t e c inica attac ment osswas 12mm (Fig. 1b). The mobility of tooth #9 was assessed as Class

using Mi ers mo i ity in ex. 7 eriodonta destructioncould also be observed at other teeth with a lesser degreeo estruction, s own in t e panoramic ra iograp .

* Shandong Provincial Key aboratory of Oral Biomedicine, School and Hospital of Stomatology, Shandong University, Jinan, Shandong, China.

Submitted November 4, 2011; accepted for publication February 16,2012

doi: 10.1902/cap.2012.110105

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The location of the vertical bone resorption on tooth #9 cor-respon e to w ere t e accessory root- i e structure wasfound, whereas the other teeth sites only showed horizontal

alveolar bone resorption to the middle third of the roots(Fig. 1c). No morphologic variations were found on thecon-tralateral tooth. No similar a normalities were foun on theteet o er ami y mem ers. T e patient i not ta e anymedications andno systemic diseases or trauma history werereported.

Case ManagementInitia perio onta treatment was per orme , inc u ingora ygiene instructions an sca ing an root p aning.At the following appointment, a general improvement wasnote at most toot sites. However, toot #9 ai e to s ow

an obvious positive response and still represented severemo i ity. T ere ore, extraction was recommen e .

Clinical OutcomesA ter t e extraction o toot #9, t e patient receive a pro-visional removable partial denture (Fig. 2).The patient wasp ace on a 3-mont perio onta maintenance program,and dental implantation was scheduled.

The accessory root-like structure was z 7 mm long witha s arp tip, an originate rom t e cemento-ename junc-ion. Pointing apically, the accessory root-like structure

was separate rom t e mi e t ir o t e main root at anang e o 45 (Fig. 3).

Histologic AnalysesThe ground section of the extracted tooth was preparedfor investigation of its microstructure. The tooth was sec-tione ongitu ina y t roug t e centra part o t e root-

like structure and fixed in 4% paraformaldehyde for 48oursat 4C. A ter eingt oroug y rinse in p osp ate-

buffered saline, thespecimenwasthen slicedvertically alongthe longitudinal axis using a high-precision diamond disk toexpose t e enta pu p tissue, w ic was su sequent y re-moved. The specimen was ground to z 100- mm thick with

rin ing ap an 75- m t ic wit roste g ass, t en po -ished, demineralized in 1% hydrochloride alcohol, and de-

y rate t roug a gra e a co o series. Un er a ig tmicroscope, we o serve t at t e accessory root- i e struc-ture was composed of dentin covered with a thin layer of ementum. No o vious root cana ormation was o serve

FIGURE 1a An accessory root-like structurewas identified on the mesio-labial aspect of ther oot of tooth #9. 1b A deep probing depth wasobserved at the corresponding site. 1c Thealveolar bone loss of tooth #9 extended to theapex (black arrow).

FIGURE 2 The patient received a provisional removable partial denture.

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FIGURE 4 Ground sec tion resu l t s o f theaccessory root-like structure. 4a The acces-sory root-like structure was composed of dentincovered with a thin layer of cementum. Noobvious root canal formation was observed. 4bthrough 4d In the coronal two thirds of theaccessory root, the dentinal tubules werearranged to form an organized, radial structure(white arrow) and covered with a thin layer of cementum (black arrow). 4e nd 4f The dentinaltubules in the apical third of the accessory rootshowed a disordered orientation and a vortex-like structure. C ellular cementum; D dentin;E enamel; T translucent zone; AC acellular cementum. 4a, 4c, 4e, scale bars 200 mm; 4b,4d, 4f, scale bars 100 mm. 4b, 4d, and 4f arelarger magnifications of the white frames in 4a, 4c,an e , respectively.

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Summary

Why is this case new information? j The accessory root-like structure reported in this case report servesas an important coetiologic factor for the breakdown of the supportingtooth structures.

j This morphologic anomaly is rarely seen and frequently missed byperiodontists.

What are the keys to successfulmanagement of this case?

j Our study suggests that a thorough examination of the rootmorphology is an essential prerequisite for the success of periodontaltherapy, especially for those with advanced localized periodontaldisease.

j Careful periodontal probing and radiographic examination may be of great help in the early recognition of the abnormal root structures.


j The accessory root-like structure may be difficult to identify and isfrequently missed during clinical diagnosis and periodontal treatment.

AcknowledgmentsDrs. Jianxin Du an Xiaoying Wang contri ute equa y tot is case report. T e aut ors report nocon icts o interestrelated o this case report.

CORRESPONDENCE:Dr.PishanYan g,Schoolof Stomatology,ShandongUniversity. 44-1WenhuaxiRd. , Jinan, Shandong 50012, China. E-mail: [email protected].

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References. Gher ME, Vernino AR. Root morphology Clinical significance in

pathogenesis and treatment of periodontal disease. J Am Dent Assoc1980;101:627-633.

2. Olsson M, Lindhe J. Periodontal characteristics in individuals with varyingform of the upper central incisors. J Clin Periodontol 1991;18:78-82.

3. Kerekes K, Tronstad L. Morphometric observations on root canals of uman anterior teeth. J Endod 1977;3:24-29.

4. Benenati FW. Endodontic treatment of a maxillary central incisor with

two separate roots: Case report. Gen Dent 2006;54:265-266.5. Ghoddusi J, Zarei M, Vatanpour M. Endodontic treatment of maxillary

central incisor with tworoots. A case report. Y State DentJ 2007;73:46-47.6. Askenas BG, Fry HR, Davis JW. Cervical enamel projection with

gingival fenestration in a maxillary central incisor: Report of a case.Quintessence Int 1992;23:103-107.

7. Miller SC. Textbook of Periodontia . Philadelphia: BlakistonCompany;1938;.

8. Kogon S. Unusual malformed root. Oral Surg Oral Med Oral Pathol 1984;57:580.

9. Kocsis GS, Marcsik A. Accessory root formation on a lower medialnc sor. Oral Surg Oral Med Oral Pathol ; : - 5.

10. Goldstein AR. Enamel pearls as contributing factor in periodontalbreakdown. Am Dent Assoc 7 ; : - .

11. Chan HL, Oh TJ, Bashutski J, Fu JH, Wang HL. Cervical enamelprojections in unusual locations: A case report and mini-review. J Periodontol 2010;81:789-795.

12. Blanchard SB, Derderian GM, Averitt TR, John V, Newell DH. Cervicalenamel projections and associated pouch-like opening in mandibularfurcations. Periodontol 2012;83:198-203.

13. Lin HJ, Chan CP, Yang CY, et al. Cemental tear: Clinical character-istics and its predisposing factors. J Endod 2011;37:611-618.

14. Ishikawa I, Oda S, Hayashi J, Arakawa S. Cervical cemental tears inolder patients with adult periodontitis. Case reports. J Periodontol 1996;67:15-20.

15. Wei PC, Geivelis M, Chan CP, Ju YR. Successful treatment of pulpal-periodontal combined lesion in a birooted maxillary lateral incisor withconcomitant palato-radicular groove. A case report. J Periodontol 1999;70:1540-1546.


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CASE REPORT

Medical Histories: A Case Report of Pharmacovigilance in SupportingDentists and Participation n a Drug-Safety Program

Edward H. Karl* nd Frederick A. Curro

Introduction: Antibiotics are a class of medications widely used by dentists. The class f agen s has a number f listed side effects. This ase report details an unusual adverse ffect f tetracycline-induced psychosis recognized dueto the diligence of a practitioner. To ur knowledge, this is the irst reported case by a dentist.

Case Presentation: A 44-year-old patient was started on tetracycline therapy for prophylaxis before a periodontalprocedure. The patient began having paranoid and psychotic experiences. The patient sought psychiatric medical care and

as iagnosed with tetracycline-induced psychosis. He was treated with an antipsychotic drug, hich resolved hissymptoms.

Conclusion: Dental medical histories are a resource that is underused and can often be f value in the continualassessment f drug safety and pharmacovigilance. Clin Adv Periodontics 013;3:40-43.

Key Words : Drug toxicity; pharmacovigilance; psychotic isorders; safety; etracycline.

BackgroundThe Food and Drug Administration (FDA) constantly triesto balance he promotion of greater drug safety itha quicker drug-review process. The director of the enterfor Drug Evaluation and Research, which now includest e Center or Bio ogics Eva uation an Researc , overseesthe alance of drug safety versus nnovat on hrougscience. Dentists have traditionally not been included inthis process. Drug utilization by dentists has not een

etermine by the pharmaceutical industry. However, therecent FD opioi rug-sa ety nitiative program 1 hass own at entists ontri ute o t e overprescri ing oopioids, which led to stricter prescription patterns alreadyn place n states. The ma or ty of entists not

aware, nor o ey participate in t e FDAs Me Watcprogram 2 directed at drug safety. As more targeted drugsaime at re ucing rug-a verse e ects are eve ope , t eUS drug safety net woul require the participation o allprescribers, especially for the ompleteness o all elec-tronic me ica recor s. ne examp e o entists partici-pating in this process was the reporting of osteonecrosis of t e aw. 3 T e me ica istories entists ta e re, or t emost part, isolated and remain in their offices. Electronic

enta recor s par o t e patients e ectronic ea trecor or e ectronic me ica recor un er e roa er

anner o t e e ectronic me ica ome wi orever c angehow dentists record medical histories. An electronic dentalrecord wil be integrate nto the pat ents recor and

ere orerequire oversig t or some eve o qua ityassurance,muc ike ospita record. This report describesa entists (EHK) nitiative to su stantiate a me icalfinding before and during periodontal treatment.

Pharmacotherapy s playing ncreas ng role n thereatment an therapy for the management of oral on i-

ions, nota y perio onta isease. A t oug t e entapharmaceutical armamentar um s ncreas ng, there s aoncomitant wi er use o conventiona rugs, suc as tet-

racyc ine. T e tetracyc ine ami y o rugsconsists o a num-er o altere chemica modifications o increase efficacy,

distribution, and substantivity. As newer chemically-modi-fie rugs ecome more specific or targeted therapy, thea verse effects ecome more su tle an more ifficult orecognize un ess urt er training n p armaco ogy s -quired. 3 T e current case report ocuments a case o tetra-cycline-inducedpsychosis observed by a periodontist duringtreatment ofa patient andas followedusing drug-safetypro-e ures o p armacovigi ance. T e patient was receiving

routine treatment for chronic periodontal disease.t s wel ocumente that severa lasses o anti iotics

ave psyc iatrica verse e ectst atrange rom minor con-fusion o psychosis. 4 These classes inclu e antibacterials,antimyco acteria s, an anti unga s. T e term Hoigne syn-drome 5 is used to describe an acute non-allergic reaction toprocaine penici in, wit pre ominant acute psyc iatricsymptomatology. The onset of symptoms in this syndromecan be abrupt. Typical disturbances of perception are audi-tory, visua , o actory, ustatory, an /or somatosensorypseudohallucinations recognized by the patient as eingunreal perceptions. 6 T e experience o anxiety para e s

* rivate practice, West Hartford and lastonbury, T.

PEARL Practitioners Engaged in Applied Research and Learning)Practice-Based Research Network, New York University, College of

entistry, New York, NY.

Submitted January 5, 2011; accepted for publication February 1, 2012

o : 10.1902/cap.2012.110007


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theonsetof perceptual disturbancesor maybe conceivedasa reaction to t eir extraor inary an rea u nature. 6 Per-ceptual disturbances and anxiety are accompanied bytachycardia, increase in blood pressure, feeling of breath-essness, num ness in t e extremities, an psyc omotor

agitation. 6 Occasionally, these symptoms may progressinto a u - own psyc osis or e irium, wit isorienta-tion, true hallucinations (mostly visual), and, in rare cases,delusions. 6

Tetracyclines havetheability to distributewidely through-out t e o y an into tissues an secretions. 5 In ammationof the meninges is not required for the passage of tetracy-clines into the cerebrospinal fluid. Tetracyclines have also

een reporte to cause neuropsyc iatric toxicity. T e in-tent of this case report is to describe an actual delusion orpsychotic event of a patient who was diagnosed withtetracycline-induced psychosis by a hospital known forits professional expertise in mental illness.

Clinical Presentation

A 44-year-old male patient presented to a private practice(EK), inGlastonbury, Connecticut,and wasstartedona tet-racyc ine ant

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