Professional Documents
Culture Documents
A Peer-Reviewed CE Activity by
Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment
and accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.
CONTINUING EDUCATION
B
one preservation is a central tenet of any reconstructive such as recombinant human bone morphogenetic protein-2
protocol. Observational1-4 as well as volumetric1,2,5 stud- (rhBMP-2) have demonstrated success in a variety of dental and
ies of bone remodeling subsequent to tooth extraction craniofacial indications,13,31-35 including socket preserva-
have clearly demonstrated the inevitable reduction in alveolar tion31,32,36,37 and alveolar ridge augmentation.33,38-42
bone volume that occurs in the absence of clinical interventions The use of DBM allografts in fresh extraction sockets with the
to prevent it. The clinical consequences of this process often se- objective of preserving bone volume has been studied in parallel
verely compromise restorative outcomes and/or reconstructive with the evolution of the predictability of dental implants.36,43-46
treatment planning. However, more clinical evidence is needed to support their use in
In the case of extraction sockets, immediate implant place- this specific scenario. Bioresorbable membranes have been used
ment has yielded success in preserving bone (in the aesthetic in conjunction with DBM products for socket preservation proce-
zone6,7) but has still been shown to perform suboptimally.8,9 dures with demonstrated clinical success.47
While bone grafting of fresh extraction sockets and other ridge Graft excipients are natural or synthetic substances formu-
1
CONTINUING EDUCATION
2
CONTINUING EDUCATION
3
CONTINUING EDUCATION
4
CONTINUING EDUCATION
Case Selection
Healthy patients who therapeu-
tically required extraction of at
least one natural tooth (with
the exception of third molars
Figure 11. Core biopsies (4 months, Figure 12. Implant placement in
and mandibular incisors), and Figure 10. Assessment of alveolar immediately prior to implant place- position No. 31 immediately after
for whom a socket preservation ridge width at re-entry, 4 months ment), position No. 31, mesial and core biopsies; displayed resonance
post-graft, position No. 31.
procedure was desired and fea- distal borders of graft site. frequency implant stability quotient
(ISQ) of 68.76 (mean ISQ = 72).
sible prior to implant place-
ment, voluntarily chose to
undergo these procedures after
receiving detailed explana-
tions of what they entailed, the
potential risks, and the poten-
tial for variability in individual
clinical outcome. All patients
gave written, signed informed
consent to undergo the proce- Figure 13. Postoperative periapical Figure 14. Final periapical Figure 15. Final photo of full-cast
dures with this understanding. radiograph immediately after radiograph of restored implant, 30 gold implant crown, 30 months after
All individuals who re- implant placement and abutment months after placement, position placement, position No. 31.
ceived grafts were patients of connection, position No. 31. No. 31.
5
CONTINUING EDUCATION
tion, as well as at one-month post-extraction, to evaluate mor- dehydrated in 95% and 100% ethanols. Samples were embed-
phological changes from cross-sectional and axial perspectives. ded for 4 to 5 hours in an aqueous encapsulating gel, placed into
A final surgical followup was done for all patients 12 to 16 a mega cassette, and embedded in celloidin-paraffin. A micro-
weeks after implant placement. tome was used to obtain the 5-m sections, which were stained
with hematoxylin and eosin (HE).
Bone Biopsies Whole-slide photomicrographs were captured using a
At 4 months post-extraction (time of implant placement), a 2-mm whole-slide scanning microscope (Olympus VS120 [Olympus
trephine bur (Salvin Dental) (Figure 2) was used to obtain core Corporation]). Histomorphometry was performed in each spec-
biopsies in all patients, to evaluate the histology of the hard tis- imen under original, 4x, and 2x magnifications. The analysis
sue at the grafted site. Although incorporation of some native was based on the entire specimen using Image-Pro Plus quanti-
bone into the specimen was a possibility, every effort was made tative analysis software (Media Cybernetics).
to procure only grafted tissue. Each bone core biopsy sample Five slides were selected from each specimen for histomor-
was left in the trephine and placed in formalin in a tissue con- phometry. The mean of these 5 slides for each specimen was re-
6
CONTINUING EDUCATION
Figure 20. CBCT full-mandible panoramic view (non-focused field) at 24 Figure 22. Figure 24.
hours post-extraction, showing newly grafted socket, position No. 31. Focused-field Focused-field
CBCT image CBCT image
Figure 21. Full- showing cross- Figure 23. Full- showing cross-
arch field sectional slice arch field sectional slice
(mandible) CBCT through mesial- (mandible) CBCT through distal-
cross-sectional root portion of image showing root portion of
slice through position No. 31, cross-sectional position No. 31,
mesial-root at 4 months slice through dis- at 4 months
portion of post-graft (imme- tal-root portion of post-graft (imme-
socket, position diately prior to socket, position diately prior to
No. 31, at 24 implant place- No. 31, at 24 implant place-
hours post-graft. ment), showing hours post-graft. ment), showing
bridging of new bridging of new
bone at crest bone at crest
(creeping (creeping
substitution). substitution).
stone Dental]) were placed (Figure 6) following atraumatic The surgical postoperative course was uneventful in both
extraction and thorough degranulation, and primary closure extraction/grafting and re-entry/biopsy/implant placement in
achieved, as described above (Figure 7). Other medications ad- all cases. Other than expected slight to moderate discomfort and
ministered intravenously included 30 mg Toradol for analgesia, swelling at the operative sites postoperatively, no adverse events
and 8 mg dexamethasone to combat swelling and nausea. were reported by any patient at either surgical phase.
After 4 months of healing (Figures 8 and 9), re-entry was per- However, it should be noted that some sites healed with second-
formed, the width of the newly grafted ridge assessed (Figure 10), and ary intention while others, such as the case reported here, healed
2 core biopsies obtained, one each from the mesial and distal sockets with primary intention wound healing. In an effort to obtain the
previously grafted (Figure 11). Opposite-border biopsies were per- most favorable earlier wound healing, primary wound closure was
formed to avoid procuring any native bone (eg, from the furcation attempted. However, based on current literature, the absence of pri-
area or mesial/distal socket wall borders) that might influence the mary flap closure in extraction socket preservation healing does
percentage of vital bone formation assessed by histomorphometry. not appear to affect the percentage of vital bone formation.30,81
After the biopsies were obtained, osteotomy site prepara-
tion was performed (bone harvested during osteotomy was Histologic Interpretation
placed into the biopsy sites) and a Keystone Genesis 5-mm im- Figures 16 to 19 show core biopsy histology from the mesial and
plant (Keystone Dental) was placed, with an initial mean distal biopsy samples of position No. 31 (pre-osteotomy). Figures
resonance frequency implant stability quotient (ISQ) of 72. 16 and 18 show histologic sections at 4x (mesial biopsy, Figure
Figures 12 and 13 show implant placement and postoperative 16) and 2x magnifications (distal biopsy, Figure 18). Figures 17
radiograph, respectively. Figure 14 shows the final post-restora- and 19 identify detailed parameters of regenerative activity at
tion periapical radiograph (30 months post-implant placement), 40x magnification, from mesial and distal biopsies, respectively.
demonstrating osseointegration and uniform bone growth The majority of the specimens showed new bone growth as
within the graft site, and Figure 15 shows the final photo of the woven bone. Figure 16 shows the whole-slide photomicrograph
full-cast gold implant crown (30 months post-implant place- of the mesial core biopsy of the grafted position No. 31, captured
ment). Of note, both images also show effective restoration of using a whole-slide scanning microscope (Olympus VS120) at
tooth No. 30 with a PFM crown. 4x magnification. The woven new bone was stained red in HE.
7
CONTINUING EDUCATION
8
CONTINUING EDUCATION
9
CONTINUING EDUCATION
10
CONTINUING EDUCATION
11
CONTINUING EDUCATION
12
CONTINUING EDUCATION
POST EXAMINATION QUESTIONS 4. The DBM material used in the case series presented in
this article differs from other currently available DBMs. It
contains growth factors, transforming growth factor-beta,
1. The ideal bone graft is one that is: and several types of bone morphogenetic proteins.
a. Osteoinductive. a. The first statement is true, the second is false.
b. Osteoconductive. b. The first statement is false, the second is true.
c. Stable in volume. c. Both statements are true.
d. All of the above. d. Both statements are false.
13
CONTINUING EDUCATION
9. It is hypothesized that demineralized grafting products 14. In the case series presented, the variation in the
possess greater osteoinductivity than do mineralized percentages of new bone that was observed was 25.5%
allografts. It is further hypothesized that subsequent to 75.5%.
addition of BMPs and growth factors in a controlled a. True.
fashion further enhances osteoinductive function. b. False.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true. 15. Poloxamer 407 is:
c. Both statements are true. a. A form of autologous bone.
d. Both statements are false. b. DBM.
c. A graft excipient.
10. In the case series presented, histomorphometry d. None of the above.
demonstrated vital bone formation greater
than _______ in 6 of the 11 cases evaluated. 16. The highest percentages of new vital bone content
a. 40%. observed in the case report presented were:
b. 50%. a. Up to 50.7%.
c. 70%. b. Up to 65.5%.
d. 75%. c. Up to 75.5%.
d. Up to 86.5%.
11. In the case series presented, there was considerable new
bone growth from the periphery of the socket inward.
However, there was no favorable creeping substitution at
the alveolar crest.
a. The first statement is true, the second is false.
b. The first statement is false, the second is true.
c. Both statements are true.
d. Both statements are false.
14
CONTINUING EDUCATION
Please provide the following (please print clearly): PROGRAM EVAUATION FORM
Please complete the following activity evaluation questions.
Rating Scale: Excellent = 5 and Poor = 0
Exact Name on Credit Card Course objectives were achieved.
/
Content was useful and benefited your clinical practice.
Review questions were clear and relevant to the editorial.
Credit Card # Expiration Date
Illustrations and photographs were clear and relevant.
Written presentation was informative and concise.
Signature How much time did you spend reading the activity and
completing the test?
Approved PACE Program Provider
FAGD/MAGD Credit Approval does
Dentistry Today, Inc, is an ADA CERP Recognized
What aspect of this course was most helpful and why?
not imply acceptance by a state or
provincial board of dentistry or AGD Provider. ADA CERP is a service of the American Dental
endorsement. June 1, 2012 to Association to assist dental professionals in indentifying
May 31, 2015 AGDPACE approval quality providers of continuing dental education. ADA
number: 309062 CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit
hours by boards of dentistry. Concerns or complaints
What topics interest you for future Dentistry Today CE courses?
about a CE provider may be directed to the provider or
to ADA CERP at ada.org/goto/cerp.
15