The Maltese Dental Journal - University of Malta · 2019. 11. 3. · an Invisalign course in Athens in conjunction with Page Technology. Between 21–23 October there is a hands-on

The Maltese Dental Journal

71ISSUE

SEP19

EditorialBy Dr David Muscat

DENTAL ASSOCIATION OF MALTAThe Professional Centre,Sliema Road, GziraTel: 21 312888Fax: 21 343002Email: [email protected]

ISSN 2076-6181

Dear colleagues,

The DAM Mediterranean Dental Conference was held on 27/28 September at the Hilton and was a resounding success. We also had gala reception on the 28 September at The Quarterdeck bar.

The lecturers included:• DrSubirBanerjifromKingsLondon• DrApolloniusAllenFacialand

reconstructive surgeon Ark AcademyUK

• Dr,MatthiasMahringDentalmaterials specialist Oldenberg University Germany;

• DrDavidAndrewMaxillofacialradiologistSheffieldUniversity

• DrSimonAtkinsspecialistoralsurgeonSheffieldUniversity

• DrJonasLorenzMaxilllofacialsurgeonGoetheUniversityFrankfurt

• DrMinasLeventisOralsurgeonAthens University .

• DrRebeccaKomischeadentalpractitioner from Germany gave a presentation on Orthodontic aligners.

Sponsors included: Platinum • BartEnterprisesLtd• MarlettaEnterprises• PageTechnology

• MOI(MastersinOralImplantology,Frankfurt)

Silver • Chemimart• Cherubino• MetropolisLtd(Perioaid)• CollisWilliams(SunstarGum)• AandMMangion(Keral)• GSK• ProHealth(Kin)• Suratek• BryantDentalBronze • OralB• Perfecta

This event took a lot of time and effortonthepartofthecommittee.Dr Noel Manche and Dr Nik Dougall spearheaded the event.

We recently had a very good lecture inStJulian'sonDentalLasersorganisedbyBartEnterprisesandthisiswrittenupinthisissue.

AnITIstudygroupentitled‘Findingsuccess and Avoiding Complications’ byProfessorDeanMortonwasheldatPalazzoCastellettiinconjunctionwithBartEnterprisesLtd.

Recentlyanotherwasheldatthesame venue with the same sponsor

and this was a lecture entitled ‘BoneAugmentationinconjunctionwith implant treatment’ by Dr PeterNilsson.Theseeventsareco-ordinatedbyDrEdwardSammut.

Between17–19OctoberthereisanInvisaligncourseinAthensinconjunctionwithPageTechnology.Between21–23Octoberthereisahands-onIvoclairVivadentcourseorganisedinLichenstieninconjunctionwithBartEnterprisesLtd.

A Straumann course was also held in PortugalinearlyOctoberandseveralMaltesedentistsattended.

On30Octoberthereistheannual‘SmileForHealth’conferenceorganisedby the Department of Health.

We hope to see most of you at the DAM Christmaspartyon21Decembersoplease keep that date free.

The cover photo is entitled “Apple’s Eye”byDrJosefAwad.

Bestregards,

DavidDrDavidMuscatB.D.S.(LON)Editor/Secretary,P.R.O.D.A.M.

Advertisers are responsible for the claims they make in their ads and the opinion of the advertisers and editors of articles in the issue are not necessarily the opinion of the DAM.

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September 2019 – Issue 71

3

Alaserislightamplificationbystimulated emission. There are three modes: continuous, chopped and peak pulse.

Laserinteractionswithtissueinvolvetransmsission, dispersion, absorption andreflection.

Lasersmaybeusedfor• Disruption(destructionofcellsduetoplasmaleakage)

• Ablation(removal,smoothing)• Vaporisation(evaporation)• Coagulation(hemostasis)• Photodynamics(photochemical)• Biostimulation(accelerationofmetabolicprocesses)

Lasersaredifferentiatedbytheiractive medium. Dental soft lasers are used for biostimulation.

Continues on page 6.

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Sales Synergy and Product Management Leader, Dentsply Sirona in conjunction with bart Enterprises Ltd. At Le Meridien, St Julian’s on 24th July 2019.Summarised by Dr David Muscat.

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* Compared to a regular toothpaste and professional clean and 24 weeks’ twice-daily brushing. Reference: 1. Data on file, GSK, RH02434, January 2015.

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Continues from page 6.

Dental hard lasers are used on dental hard substances, soft tissue, and bacterial reduction in endo and perio.

Other applications are cysts,incisions,abscesses,gingivectomy,operculectomy,epulisandgingivaltroughing.)

Lasersusedindentistryhaveawavelengthrangebetween200nM(UVrange)and10,600nM(IRrange).

TheLaserendolightwhenusedresultsinabetterprognosisifrootgangrene is removed with it.

With laser applications one is more precise. There is less damage to the adjacenttissuewhencomparedtoelectrosurgery.Lasersareuseforhemostasis.WiththeSirolaserBlueone may cut without contact.

One may achieve uncomplicated wound healing and scar free healing –nosutures.Itisraretohavepostoppain and swelling.

Lasersarealsousedaspaintherapyfor herpes and aphthous ulcers.No anaesthetic is needed.

One achieves immediate pain relief and there is improved wound healing.

Photobiomodulation(PBM)-theprincipleistousea660nMwavelength. This causes an absorption peak in cytochrome c oxidase(CCO)whichismainlyresponsible for the reactions of the cell to the laser penetration.

TheindicationsofPBMarecontrollinginflammation,managingoedema, enhancing tissue repair, reducing pain and enhancing tissue and muscle performance.

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APICAL SURGERYA MoDERN SuRGICAL APPRoACh

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» What drives me? Best results. And Primescan is my answer. «Dr. Carlos Repullo, BDS, DipImpDent RCS (UK)

NAME:

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Please cut out this section and send with a cheque for 50 euro payable to Dental Association of Malta for your 2020 DAM membership – the best 50 euro investment ever!

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The Treasurer, Dr Noel Manche,The Dental Association of Malta, Federation of Professional Associations,Sliema Road, Gzira.

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The Mediterranean Dental Conference at Hilton, Malta 27–28 September, 2019

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APPLYING DIGITAL DENTISTRY TO THE PATIENT’S jOURNEY (PART 2)Mr Matt Perkins bDS MSc MClinDent MFD RCSI FDS RCSEdSpecialist in Periodontics, ITI Fellow


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MANAGEMENT oF A FAILED IMPLANT wITh A SELF-hARDENING bIoACTIvE SYNThETIC boNE GRAFT Minas Leventis1,2 DDS, MSc, PhD and Peter Fairbairn1,3 bDS1 Private Practice, London, uK2 Researcher, Laboratory of Experimental Surgery and Surgical Research “N. S. Christeas”, Medical School, university of Athens, Greece3 visiting Professor, Department of Periodontology and Implant Dentistry, School of Dentistry, university of Detroit Mercy, Detroit, uSA

aBStractThis case report highlights the use of a bioactive in situ hardening synthetic resorbable bone substitute, composed ofbetatri-calciumphosphate(β-TCP)andcalciumsulfate(CS),fortheminimally invasive treatment of a demanding case of a failed implant in theaestheticzone.

Astandardizedstagedapproachand a digital implant planning with fully guided placement enabled the correct replacement of the implant and the simultaneous regeneration ofvitalboneandnewly-formedthick keratinised soft tissues, thus minimizingthepatientmorbidity,complication risk, cost, length andcomplexityoftheprocedures;resulting to a successful outcome, regarding aesthetics and function.

caSe rePortAfemalepatient,38yearsofage,presented with a wish to restore the soft tissuedefectbuccallytoherimplant11.According to the patient, due to trauma 10yearsago,shelostbothheruppercentral incisors, which were replaced atthattimewith2XiveSPlusimplants(Dentsply,Mannheim,Germany)–both5.5mmindiameterand9.5mminlength–andseparateimplantcrowns.

Clinicalexaminationrevealedasofttissuedehiscencewithexposureofthe labial mesial and apical threads oftheimplant11(Fig.1).Therewasno clinical mobility of the implant nor othersignsorsymptoms.Regardingtheadjacentimplant21therewereno clinical problems associated. The initialCBCTscanshowedsignificantbone loss, with complete bone loss

atthebuccalaspectoftheimplant11(Fig.2).Thesameradiologicalfindingswerealsoobservedforimplant21.

Thediagnosiswasthattheimplant11wasnotsalvageable,andimplant21hadapoorprognosis.Itwasdecidedtotreatfirstlyonlythefailedimplant11,asremovalofbothimplants11and21at the same time would result in severe collapse of the area, that would be verydifficulttorestore.Thetreatmentplan consisted of removal of implant 11,placementofanewimplant6weekspost-opwithsimultaneousboneaugmentationaccordingtotheFairbairnandLeventis(2015)publishedprotocol[1],andloadingoftheimplant12weekspost-opwiththefinalrestoration.

Underlocalanesthesia,thenon-salvageableimplant11was“atraumatically”removedwithoutraisingaflap.

Firstly,thescrew-retainedcrownwasremoved(Fig.3)andtheimplantwaseasily mobilised and removed using the implant driver and the ratchet in ananti-clockwisedirection(Fig.4).Then,thesitewasthoroughlycurettedand debrided of any soft tissues with theuseofLucashandbonecurettesanddegranulationburs(EthossEKStraussDegranulationBurKit,EthossRegenerationLtd,Silsden,UK),followed by rinsing with sterile saline.

After completion of the procedure, a severe buccal hard and soft tissue defectwasevident(Fig.5).Thepatientused an acrylic partial denture as a provisional prosthesis during the whole healing period, without applying any pressure on the surgical site.

The site was left to heal spontaneously under secondary intention. After 6weeks,theareawasfreeofanyinflammationanduneventfullycoveredbynewly-formedsofttissues(Fig.6).AnewCBCTscananddigitalimpressions were taken and a digital workflowwascarriedoutbyPaltopDigitalSolutionsusingtheImplantStudiosoftware(3Shape,Copenhagen,Denmark)inordertoidentifytheidealsizeofimplantanditsprecise3Dpositioning(Fig.7).

According to the digital plan a surgical guidewas3Dprinted.Underlocalanesthesia,asite-specific,papilla-sparing,full-thicknessflapwasdesigned, as described by Greenstein andTarnowin2014[2]andcarefullyraised,revealingalarge3-wallbonydefect with completely missing buccal plate(Fig.8).

The site was then debrided from all soft tissues; the surgical guide was fittedandallthedrillingstepswerecarriedoutinafully-guidedmanner(Fig.9).A3.75x11.5taperedimplant(PaltopAdvancedPlus,PaltopDentalSolutionsLtd,Israel)wasplacedintheplanned3Dposition(Fig.10).

After placing the cover screw, the sitewasgrafted(Fig.11)utilizingaself-hardeningresorbablesyntheticbonegraftingmaterial(EthOss,EthossRegenerationLtd,Silsden,UK),consistingofβ-TCP(65%)andCS(35%),asdescribedbytheauthorsinpreviouspublications[1,3,4].Nobarrier membranes were used.


Fig. 1: Initial situation of the failing implant 11. Note the buccal soft and hard tissue defect, leading to the exposure of the implant threads.

Fig. 2: Initial CbCT. The wide diameter (5.5mm) and the wrong positioning of the implant in the upper central incisor area contributed to the loss of the buccal hard and soft tissues.

Top – Fig. 3: Clinical view after removing the screw-retained implant crown.

Right – Fig. 4: “Atraumatic” removal of the failed implant using the implant driver in an anti-clockwise direction.

Far right – Fig. 5: The site immediately after removal of the implant, presenting a severe lack of soft and hard tissues buccally.

Top – Fig. 6: Secondary intention healing for 6 weeks to allow the body create new soft tissues.

Right – Fig. 7: Digital planning of the case. A 3.75x11.5 implant was selected, and the optimal positioning was digitally planned.

Far right – Fig. 8: Site specific, papillae sparing flap raised, revealing the bone defect.

Fig. 9: The surgical guided fitted on the adjacent teeth and a fully-guided osteotomy was carried out using the dedicated NSK handpiece (Nakanishi Inc., Tokyo, Japan).

Fig. 10: Fully-guided accurate 3D placement of the implant.

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MANAGEMENT oF A FAILED IMPLANT wITh A SELF-hARDENING bIoACTIvE SYNThETIC boNE GRAFT


Theflapwasrepositionedandsuturedwithouttensionwith5-0monofilamentsutures(Fig.12)andaperiapicalx-raywastaken(Fig.13).Antibiotictherapyconsistingof500mgamoxicillinevery8hoursfor5daysandmouthrinsingwithoxygen-releasingmouthwash(blue®m, Zwolle, Netherlands)every8hoursfor10dayswere prescribed. The sutures were removedoneweekpost-op(Fig.14).

After12weeks,thehealingwasuneventful(Fig.15).Aperiapicalx-rayshowedexcellentosseointegration of the implant and consolidation of the grafting material (Fig.16).Alinearcrestalincisionwas made to access and remove the cover screw, and the secondary stability of the implant was measured by resonance frequency analysis (PenguinRFA,IntegrationDiagnosticsSwedenAB,Göteborg,Sweden).

AnISQ-value(ImplantStabilityQuotient)of75wasrecorded,demonstrating high stability. A healing abutment was placed, and after allowing the soft tissues to maturefor2weeks(Fig.17),anopen-tray impression was taken and the finalscrew-retainedcrownwasfittedresulting to a successful outcome, regarding aesthetics and function (Figs.18and19).

Atfollow-up1yearpost-operative,thearchitecture and the volume of the site had been successfully restored and the ridge buccally was covered by thick regeneratedkeratinizedsofttissues(Fig.20).ACBCTatthispointshowedthat the buccal bone was successfully regenerated(Fig.21).

DiScuSSionInthepresentedcase,asimplifiedstaged approach was designed and followed in order to replace the failed implant and to reconstruct the missing hard and soft tissues in a minimally invasive, safe and successful way. The firststepconsistedjustinsimplenon-surgical removal of the failed implant without performing any kind of soft and/or hard tissue augmentation, in order to allow the area to heal spontaneouslyforthenext6weeks.

This initial healing period was of great clinical importance as it enabled the host to regenerate new soft tissues that covered the buccal dehiscence as well as the crestal area of the site, while allowing at the same period of time the immune system to remove any remnants of local infection.

Inthisway,therewereenoughvolumeof soft tissues during the second step of the treatment to cover the placed new implant and the graft, without theneedtoadvancetheflaporuseadditional soft tissue grafting, which would increase the morbidity, length, complexityandcostoftheprocedure.

The hard tissue reconstruction was achievedutilizingasyntheticfullyresorbablegraftingmaterial(EthOss)whichconsistsofβ-TCP(65%)andCS(35%).Asshowninpreclinicaland clinical studies conducted and publishedbytheauthors[1,3-8],aswellas documented in thousands of similar cases of failing teeth that are treated according to the published protocol [1],suchbiomaterialscanaccelerateand enhance the regeneration of high quality vital bone around placed implantsinsuchlocalizedosseousdefects, without the need of using additional barrier membranes.

Thebioactiveβ-TCPelement,apartfrom being osteoconductive, shows an osteoinductive potential which might further improve the bone healing process[9-11],whiletheCSelementisbacteriostatic and produces an in situ self-hardeningscaffoldthatdoesn’tneedadditionalstabilizationwiththeuse of collagen membranes or other meshes.Inthisway,theCSactsasan“integratedbarriermembrane”,haltingthe ingrowth of soft tissue during the early phases of bone regeneration.

BothCSandβ-TCParefullyresorbable biomaterials, having an appropriate resorption time in relation toboneformation[5,6],leadingtothe fast regeneration of vital host bonewithoutthelong-termpresenceof residual graft particles. The CS elementwillresorbovera3-6-weekperiod, thus increasing the porosity intheβ-TCPscaffoldforimprovedvascular ingrowth and angiogenesis, whiletheβ-TCPelementresorbsbyhydrolysisandenzymaticandphagocytic processes, usually over a periodof9-16months[12-16].

Inthepresentedcase,virtualdentalimplant planning allowed not only for a prosthetically driven approach, but also for the selection of the appropriate implant diameter and its precise positioning into the bony envelope, which are fundamental parameters for the successful reconstruction of themissingbonebuccally[17,18].Inthis case, the wrong positioning of the failed implant, and its wide diameter seem to be the most important factors that resulted in the severe biological and aesthetic complications of the initialtreatment10yearsago.


Far left – Fig. 11: The area was grafted with 0.5cc β-TCP/CS (Ethoss). No membranes were used.

Left – Fig. 12: Periapical x-ray immediately post-op.

Top – Fig. 13: Repositioning of the mucoperiosteal flap and suturing with 5-0 monofilament sutures.

Top – Fig. 14: uneventful healing of the site one week post-op.

Above – Fig. 15: Clinical view 12 weeks post-op. The architecture of the area has been successfully restored. Note the zone of thick keratinised soft tissues that have been regenerated by the host to cover the reconstructed high quality bone around the implant.

Fig. 16: Periapical x-ray 12 weeks post-op. Top – Fig. 17: Two weeks after uncovering the implant.

Above – Fig. 18: Final result.

Left – Fig. 19: Periapical x-ray after fitting the screw-retained implant crown. The grafting material is turning over, being replaced by the regenerated bone.

Top – Fig. 20: Clinical view 1 year post-op revealing a stable outcome and further maturation and adaptation of the soft tissues.

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MANAGEMENT oF A FAILED IMPLANT wITh A SELF-hARDENING bIoACTIvE SYNThETIC boNE GRAFT


Inconclusion,thiscasehighlightsthebenefitsofearlyimplantplacementwithsimultaneous bone augmentation for themanagementnotonlyofextractionsites, but also for the treatment of more demanding cases of failing implants withsoftandhardtissuedeficiencies.

Thespecificselectionofmaterialsand methodology, which is routine practice for the authors, enabled the minimallyinvasive,safe,cost-effectiveand successful regeneration of the soft and hard tissues in the presented case, withouttheneedofutilizingsofttissuegrafting and barrier membranes.

Althougharesorbablebiphasicβ-TCP/CS graft was used for bone regeneration, the architecture and dimensions of the ridge were preserved one year after loading of the new implant. The loading oftheimplant12weeksafterplacement,which enhanced the metabolic activity and triggered the remodeling of the surrounding regenerated vital bone.

This biological activation of the reconstructed high quality vital bone seemstobeakeyfactorforlong-termsitevolume stability, which in turn provides thestablehealthybonyscaffoldoverwhich the new soft tissues will further mature and thicken, as documented, published and observed in these treatment scenarios by the authors.

referenceS1. Fairbairn P, Leventis M. Protocol for

bone augmentation with simultaneous early implant placement: A retrospective multicenter clinical study. Int J Dent. 2015;2015:589135.

2. Greenstein G, Tarnow D. Using papillae-sparing incisions in the esthetic zone to restore form and function. Compend

Contin Educ Dent. 2014;35:315-322.3. Leventis M, Fairbairn P. Simplified

protocol, successful results. EDI Journal. 2017;13(2):78-82.

4. Leventis M, Fairbairn P, Vasiliadis O. Bone grafting with simultaneous early implant placement: A new approach with an in-situ self-hardening grafting material. EDI Journal. 2018;14(1):74-78.

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2016;20:2259-2265.10. Yuan. H, Fernandes H, Habibovic P, et

al. Osteoinductive ceramics as a synthetic alternative to autologous bone grafting. Proc Nat Acad Sci USA. 2010;107:13614-13619.

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15. Artzi, Z.; Weinreb, M.; Givol, N.; Rohrer, M.D.; Nemcovsky, C.E.; Prasad, H.S.; Tal, H. Biomaterial Resorption Rate and Healing Site Morphology of Inorganic Bovine Bone and β-Tricalcium Phosphate in the Canine: A 24-month Longitudinal Histologic Study and Morphometric Analysis. Int. J. Oral Maxillofac. Implants 2004;19:357-368.

16. Palti, A.; Hoch, T. A concept for the treatment of various dental bone defects. Implant Dent. 2002;11:73-78.

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Fig. 21: CbCT 1 year post-op showing the regeneration of the buccal bone.Th

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The Maltese Dental Journal - University of Malta · 2019. 11. 3. · an Invisalign course in Athens in conjunction with Page Technology. Between 21–23 October there is a hands-on