Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these...

50
The Journal of Implant & Advanced Clinical Dentistry VOLUME 9, NO. 8 OCTOBER 2017 Hybrid Dental Implants Inverted Gingival Pouch Grafting Technique

Transcript of Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these...

Page 1: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry

Volume 9, No. 8 october 2017

Hybrid Dental Implants

Inverted Gingival Pouch Grafting Technique

Page 2: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

ATTENTION PROSPECTIVE

AUTHORSJIACD wants to publish

your article!

The Journal of Implant & Advanced Clinical Dentistry

For complete details regarding publication in JIACD,

please refer to our author guidelines at the following link:

jiacd.com/author-guidelines or email us at:

[email protected]

Page 3: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Best Things in Life Are FREE!

Subscribe now to enjoy articles free of charge that will benefit you, the actively practicing dental provider. With each JIACD issue, readers are afforded the opportunity to

assess clinical techniques, cases, literature reviews, and expert commentary that can immediately impact their daily dental practice.

Email notification when new issues are available online.

Start your FREE subscription today at www.jiacd.com

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 8 December 2016

Full Mouth Rehabilitation of Periodontitis Patient

Implant-Supported Milled Bar

Overdenture

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 1 march 2016

Treatment of the Atrophic Maxilla with Autogenous Blocks

Modified Mandibular Implant Bar Overdenture

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 3 may/JuNe 2016

Treatment of Mandibular Central Giant Cell Granuloma

Titanium Mesh Ridge Augmentation for Dental

Implant Placement

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 4 July/August 2016

Mandibular Overdentures with Mini-Implants

Augmentation of Severe Ridge Defect with rhBMP-2

and Titanium Mesh

Page 4: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 8 • october 2017

Table of Contents

6 Hybrid Dental Implants as an Alternative to Conventional Dental Implants, Eliminating the Need for Associated Ridge Augmentation Procedures Dr. Amit Bali, Dr. Jatinder Pal Singh Chawla, Dr. Aayush Malhotra, Dr. Pavneet Kaur Pandher

12 Gingival Revitalization by Inverted Gingival Pouch (IGP) Technique Leon Chen, DMD, MS, Xiaoxin Zhang, Wen-Sheng Cheng, Syue-Fu Chen, Jennifer Cha

2 • Vol. 9, No. 6 • August 2017

Page 5: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 8 • october 2017

Table of Contents

26 The Comparison of ImplantStability Between Two Dental Implant Surfaces using Resonance Frequency Analysis: A Pilot Study Sasikran Thongborisoot, Pravej Serichetaphongse, Michel Marcel Dard, Atiphan Pimkhaokham, Pornchai Jansisyanont

38 Decontamination of TitaniumSurfaces with Air Polishing and Glycine Powder Joseph Datar, Kerri Font, Charles Powell, Michael Schurr

Page 6: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 8 • october 2017

PublisherLC Publications

DesignJimmydog Design Group www.jimmydog.com

Production ManagerStephanie Belcher 336-201-7475 • [email protected]

Copy EditorJIACD staff

Digital ConversionJIACD staff

Internet ManagementInfoSwell Media

Subscription Information: Annual rates as follows: Non-qualified individual: $99(USD) Institutional: $99(USD). For more information regarding subscriptions, contact [email protected] or 1-888-923-0002.

Advertising Policy: All advertisements appearing in the Journal of Implant and Advanced Clinical Dentistry (JIACD) must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. The publication of an advertisement in JIACD does not constitute an endorsement by the publisher. Additionally, the publisher does not guarantee or warrant any claims made by JIACD advertisers.

For advertising information, please contact:[email protected] or 1-888-923-0002

Manuscript Submission: JIACD publishing guidelines can be found at http://www.jiacd.com/author-guidelines or by calling 1-888-923-0002.

Copyright © 2017 by LC Publications. All rights reserved under United States and International Copyright Conventions. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying or any other information retrieval system, without prior written permission from the publisher.

Disclaimer: Reading an article in JIACD does not qualify the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD readers should exercise judgment according to their educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its staff, and parent company LC Publications (hereinafter referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.

Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-SOM. JIACD-SOM disclaims any responsibility or liability for such material and does not guarantee, warrant, nor endorse any product, procedure, or technique discussed in JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims made by manufact-urers of products advertised in JIACD, its affiliated websites, or affiliated communications.

Conflicts of Interest: Authors submitting articles to JIACD must declare, in writing, any potential conflicts of interest, monetary or otherwise, that may exist with the article. Failure to submit a conflict of interest declaration will result in suspension of manuscript peer review.

Erratum: Please notify JIACD of article discrepancies or errors by contacting [email protected]

JIACD (ISSN 1947-5284) is published on a monthly basis by LC Publications, Las Vegas, Nevada, USA.

4 • Vol. 9, No. 8 • October 2017

Page 7: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 5

Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefLeon Chen, DMD, MS, DICOI, DADIA

The Journal of Implant & Advanced Clinical Dentistry

Page 8: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Bali et al

Background: Bone augmentation procedures are demanding concerning surgical skills and biostability of materials. As such, the revolu-tion of advancements and search for alternative procedures for the replacement of missing teeth has evolved to avoid obvious problems and com-plications of bone augmentation procedures.

Materials & Method: In the current article, two cases of horizontal bone discrepancies in the anterior edentulous maxilla are presented. The cases were restored with hybrid dental implants followed by immediate prosthesis placement. Thus, avoiding horizontal bone augmentation

which would be typically required for the place-ment of traditional endosseous dental implants. No postoperative complications were noted immedi-ately after surgical procedure and upon follow up. Conclusion: These cases present the suc-cessful restoration of the missing maxil-lary central incisor in a ridge with horizontal defect or dehiscence, performed with hybrid dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional dental implants when bone aug-mentation would be normally required.

Hybrid Dental Implants as an Alternative to Conventional Dental Implants, Eliminating the Need

for Associated Ridge Augmentation Procedures

Dr. Amit Bali1 • Dr. Jatinder Pal Singh Chawla2 • Dr. Aayush Malhotra3

Dr. Pavneet Kaur Pandher4

1. Professor, Department of oral & maxillofacial surgery, M.M. College Dental Sciences & Research, MMU, Mullana, Ambala, Haryana, India-133207

2. MDS student, Department of oral & maxillofacial surgery, M.M. College Dental Sciences & Research, MMU, Mullana, Ambala, Haryana, India-133207

3. Reader, Department of oral & maxillofacial surgery, M.M. College Dental Sciences & Research, MMU, Mullana, Ambala, Haryana, India-133207

4. MDS student, Department of oral & maxillofacial surgery, M.M. College Dental Sciences & Research, MMU, Mullana, Ambala, Haryana, India-133207

Abstract

KEY WORDS: Dental implants, hybrid dental implants, bone augmentation, bone defect

6 • Vol. 9, No. 8 • October 2017

Page 9: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Bali et al

The Journal of Implant & Advanced Clinical Dentistry • 7

Bali et al

INTRODUCTIONThe present situation of dental implantology has been initiated in 1952 by Branemark who gave the demonstration in which he anchored com-mercially pure titanium implants into jaw bones which were used successfully for tooth replace-ment in edentulous arches.[1] The use of endos-seous implants for partial or complete dental restoration has gained popularity in the past few decades, with reliable long-term stability.[2] Endos-seous implants require great vertical and horizon-tal dimensions for implant placement predicting its failure or success. But ridge deficiency creates an unfortunate obstruction in implant dentistry. The quality of residual alveolar ridge and its character-istics is one of the most important decisive factors in the success and survival of dental implant.[3]

Bone augmentation procedures in dental implantology are demanding concerning surgical skills and mechanical stability of the biomaterial. Available techniques are the use of autologous bone block grafts, alloplastic grafts/ membranes, and allogeneic cancellous block graft materials, among others. A significant difference in material properties and technical needs, as well as com-plication and failure rates between horizontal & vertical defects, have been noted with ridge pres-ervation, lateral/ horizontal augmentation, and similar indications. Similarly, for many decades, subperiosteal implants were used successfully in edentulous ridges where significant ridge resorp-tion was present. These devices, however, are no longer commonly used.[4] The ultimate goal in prosthodontics is to provide artificial teeth which are mounted firmly in the oral cavity & remain in place under routine activities with a pleasant natu-ral appearance. For the placement of contempo-rary dental implants, adequate volumes of bone

are typically required. In the absence of such bone, the placement of traditional endosseous dental implants is often contraindicated. Hybrid dental implants have been used in cases where inadequate bone volume is present and augmen-tation cannot be performed. The present article shows two cases in which hybrid dental implants were used as an alternative to conventional den-tal implants, thus eliminating the need for hori-zontal anterior maxillary ridge augmentation.

CASE REPORTSA 24 year old male reported to department of oral & maxillofacial surgery with a chief com-plaint of a missing upper anterior tooth. Tooth 11 (FDI Tooth Numbering System) was lost as a result of sports injury 8 months prior. Another male patient aged 38 years came with chief complaint of missing upper anterior tooth but with history of traumatic extraction 1 year back. Both patients were healthy systemically and had good oral and periodontal health. Mucosa was of normal thickness and firm/resilient upon clini-cal examination. Using transgingival probing, the thickness of oral mucosa was assessed at dif-ferent points over and around the recipient site.

Radiographic examination revealed excellent periodontal condition of the remaining dentition with adequate bone height and mesiodistal width for implant placement. The remaining bone was of good quality and sufficient density. Labially, how-ever, the alveolar ridge deficient to the extent that a traditional endosseous dental implant could not be placed without bone augmentation pro-cedures. With this significant limitation in mind, the alternative of hybrid dental implants was con-sidered. As per preoperative planning and mock surgery on models, hybrid dental implants were

Page 10: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

8 • Vol. 9, No. 8 • October 2017

adapted labially and palatally to reduce intraop-erative time. After complete evaluation clinically, radiographically and on mock surgery, implants of specific size (Abutment: 3mm diameter, plate 0.5mm thick & 35 mm length) were consid-ered ideal for the site taking into consideration the fact that the tooth-implant distance should be greater than or equal to 3mm at the site.

After anesthetizing the surgical site, a muco-periosteal flap was elevated with hand instru-

ments. The implant was moulded in such a way that the abutment was projecting into the oral cavity in the direction of the tooth to be replaced. The implant was fixed to the alveolar bone with 2 screws on the labial side and 1 screw pala-tally. The mucoperiosteal flap was sutured to its normal position covering the complete plate and screw portion of the implant, only exposing the abutment portion in the oral cavity maintaining the required direction. Pain, mobility, and peri-implant bone loss was evaluated at regular inter-vals postoperatively (Figures 1a-1c, Figures 2a-c).

DISCUSSION & CONCLUSIONAfter the Branemark’s evolution of implants in dentistry, implant designs and placement tech-niques have been revolutionised in many ways for the favourable outcomes of patients and clini-cians.[5] Apart from the great survival and success rates, implants often have certain limitations and unfavourable results due to many anatomical and physiological discrepancies, which sometimes require additional surgical procedures, usage of biocompatible materials and armamentarium

Figure 1a: Pre-operative of missing tooth edentulous site. Figure 1b: Implant adaptation and placement.

Figure 1c: Post-operative radiograph view of implant fixation.

Bali et al

Page 11: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 9

which is to be used more precisely and skilfully. In population of all origins, many patients

have clinical presentations of tissue deficien-cies (soft and/ or hard tissue including vertical or horizontal deficits) in the anterior maxilla, either because of endodontic or periodontal reasons or traumatic tooth loss. These deficits or their com-binations may lead to structural, functional or esthetic compromises in the final prosthesis.[6]

As presented in the two cases of this article, the pre-existing bone discrepancies would require bone augmentation for the placement of tradi-tional endosseous dental implants. Issues with this traditional technique include: 1) bone width in bucco-lingual direction is crucial as there must be presence of 1mm bone around endosse-ous implant; 2) adequate bone-implant interface should be achieved by placement of grafts in com-pensation of bone discrepancies; 3) primary bone grafting procedures require more than 6 months to take up the graft which requires patience from patient and bone formation is also unpredictable; 4) Control of implant angulation is very crucial at final stages of prosthesis which becomes diffi-

cult in these situations; 5) Usage of more costly armamentarium leads to increased total treatment costs; 6) Highly technique sensitive procedures lead to specialised training and skills development.

Having these problems or aforesaid reasons in mind, we used hybrid dental implants[5] for the rehabilitation of missing maxillary central incisors which didn’t require any additional reconstruc-tive procedures for horizontal ridge augmen-tation. Excellent tissue adaptation against the

Figure 2a: Pre- operative of missing tooth edentulous site. Figure 2b: Implant adaptation and placement.

Figure 2c: Post-operative radiograph view of implant fixation.

Bali et al

Page 12: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

10 • Vol. 9, No. 8 • October 2017

Figure 3a: Successful restoration of missing right maxillary central incisor. Case 1.

Figure 3b: Successful restoration of missing right maxillary central incisor. Case 2.

subperiosteal portion of implant was seen on postoperative follow-up. There was uneventful tissue healing with little/ no signs of inflamma-tion. Satisfactory results (Figures 3a, 3b) can be seen on clinical and radiological analysis. The hybrid dental implants utilized in these cases pro-vide proof of principle that this is a viable alter-native to traditional dental implants when bone augmentation would be normally required. l

Correspondence:Dr. Jatinder Pal Singh Chawla Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything in this article.

References1. Branemark PI, Adell R, Breine U et al (1969) Intra-osseous anchorage of dental

prostheses. I. Experimental studies. Scand J Plast Reconstr Surg 3(2):81–100.

2. Zakhary IE, El-Mekkawi HA, Elsasanty ME. Alveolar ridge augmentation for implant fixation: status review. Oral Surg Oral Med Oral Pathol Oral Radiol 2012; 114 (suppl 5):S179-S189.

3. Roshna T. Implant with Simultaneous Bone Grafting for Replacement of Maxillary Anterior Tooth - A Case Report. People’s Journal of Scientific Research 2010; 3(2): 41-44.

4. el Askary AS, Meffert RM, Griffin T. Why do dental implants fail? Part I. Implant Dent 1999; 8:173-85.

5. Mani V, Sivaprasad KK, George A, Vinod VS, Mathew M, Paul S. Hybrid Implant: A Novel Implant System. J. Maxillofac. Oral Surg. (July–Sept 2015) 14(3):720–727.

6. Kuchler U, von Arx T. Horizontal Ridge Augmentation in Conjunction with or Prior to Implant Placement in the Anterior Maxilla: A Systematic Review. The International Journal of Oral & Maxillofacial Implants 2014; 29:14-25.

Bali et al

Page 13: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • XX

Bali et al Get Social with

@JIACD on twitter

“JIACD dental journal” on LinkedIn

JIACD on FB

Page 14: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Chen et al

Introduction: The reconstruction of bone and soft tissue in implant therapy for periodontally compromised patients is challenging. Based on our previous findings of periodontal sur-gery, a 10-year follow-up multicenter case series study was carried out in the United States, China and Taiwan. In the current arti-cle, we introduce a novel periodontal surgi-cal procedure for Gingival Revitalization using the Inverted Gingival Pouch (IGP) Technique.

Material and Methods: In this case series, 3 patients treated with the surgical protocols of IGP technique are described and evaluated.Discussion: Primary stability of the dental implant and soft tissue primary closure were crucial to achieve the IGP technique. We believe that this report is the first dental literature in which nor-

mally discarded diseased epithelialized granu-lomatous tissue is utilized for the purpose of primary closure. The application of epithelialized granulomatous tissue was acceptable based on the biological process of wound healing. To bet-ter illustrate the indications of IGP technique, we established a classification of tooth vertical mobility, Class II and III were potential candi-dates for IGP technique. The necessity of barrier membrane in Guided Bone Regeneration in IGP technique remained is to be further explored.

Conclusion: The Inverted Gingival Pouch Tech-nique might be potentially useful in achieving the goals of periodontal infection control, soft tissue regeneration, including increased width and thick-ness of keratinized tissue, bone augmentation, improved aesthetics, clinical safety, and efficiency.

Gingival Revitalization by Inverted Gingival Pouch (IGP) Technique

Leon Chen, DMD, MS1 • Xiaoxin Zhang, DDS, PhD2 • Ting-Fang Huang, DDS3

Wen-Sheng Cheng, DDS4 • Syue-Fu Chen, DDS5 • Jennifer Cha, DMD, MS6

1. Chairman, Dental Implant Institute, Las Vegas, NV USA

2. Doctor, Hospital of Stomatology, Wuhan University, Wuhan China

3. Head of Dental Department, FengYuan Hospital, FengYuan, Taiwan

4. Doctor, Private practice, Kaohsiung, Taiwan

5. Doctor, Private practice, Taichung, Taiwan

6. President, Dental Implant Institute, Las Vegas, NV USA

Abstract

KEY WORDS: Gingival Revitalization, vertical tooth mobility, Leonchen classification for vertical tooth mobility, Vertical Mobility Index (VMI)

12 • Vol. 9, No. 8 • October 2017

Page 15: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Chen et al

INTRODUCTIONIn 1988, Miller described Periodontal Plastic Surgery to correct or eliminate anatomic, devel-opmental or traumatic deformities in morphol-ogy, position and/or amount of gingiva.1 In the 1960s to 1980s, a good amount of keratinized tissue was considered to be crucial for periodon-tal health. At that time, the most widely used mucogingival surgery technique was the free gin-gival graft.2 This technique consisted of a split-thickness approach to withdraw the tissue from an edentulous ridge or from the palatal mucosa. It is carried out latter that despite the width of keratinized tissue, plaque control is prior in main-taining the attachment level. The therapy of free gingival graft was fail to treat gingival recession, the displacement of the gingival margin apical to the cementoenamel junction, as the technique to cover denuded roots turned out to be unsatisfac-tory and very unpredictable.3 Another technique known as the pedicle flaps is an alternative tech-nique that has gained popularity. It essentially was a variation of a laterally positioned flap, introduced by Grupe & Warren,4 and coronally advanced flap, described by Norberg in 1950’s.5 Modifi-cations were made by Bernimoulin and Miller in 1980’s.6 Plenty of new surgical techniques have been proposed over the past 20 years; however, they have often been modifications of these two pedicle flap procedures.7,8 The achievement of ideal clinical outcomes requires high standards of clinical protocols, including flap design and incision techniques, flap elevation, root condition-ing, flap mobility and flap stability and suturing.5,9

Gingival recession in many periodontally com-promised patients often coincides with a history of Endodontic treatment, tooth mobility, alveo-lar bone loss and local soft tissue infection. It

is very challenging to achieve implant survival and final aesthetics in the absence of both hard tissue and soft tissue in cases of implant ther-apy.10 For these patients, laterally positioned and coronally advanced flap techniques may not be attractive since the need for multiple sur-geries of tooth extraction, bone augmentation, soft tissue regeneration and implant placement may be time consuming and costly. Addition-ally, the clinical outcomes remain controversial.11

Thus, it is of great significance to explore new techniques to deal with bone loss and gin-gival recession for patients with compromised periodontal conditions and severe local infec-tions, especially in implant therapy. Previously, according to the treatment results of both single and multiple teeth, our group successfully proved that the application of Enamel Matrix Derivatives (EMD) would significantly promote the clinical efficiency of root coverage.12-14 L ater, with the use of EMD, we established an original tech-nique of “three-point-translation” for root cov-erage.15 In a follow-up of 4 years, the clinical outcomes were promising in achieving the goals of periodontal tissue regeneration, root cover-age, increase of width and thickness of keratin-ized tissue, clinical efficiency, and aesthetics.15 In light of this well-established technique, we came up with a new surgical to solve the prob-lem and carried out a 10-year follow up multi-center case study in the US, China and Taiwan.

The intention of this study is to introduce a novel periodontal surgical technique, Inverted Gingival Pouch Technique, to implant ther-apy for patients with gingival recession, tooth mobility, alveolar bone loss and local soft tis-sue infection. The treatment plan includes: tooth

extraction and debridement, immediate implant

The Journal of Implant & Advanced Clinical Dentistry • 13

Chen et al

Page 16: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Figure 1: Step by step illustration of Inverted Gingival Pouch technique (IGP).

Figure 1a: Normal tooth structure, soft tissue and supporting bone.

Figure 1b: Partial attachment loss and initial bone resorption.

Figure 1c: Complete attachment loss and bone resorption.

Figure 1d: Contour of soft and hard tissue after tooth extraction, the granulomatous tissue on the bottom of socket was intact.

Figure 1e: Incision on the highest bony wall of the alveolar ridge.

Figure 1f: Release a full thickness flap from one side of the crest; carefully elevate the granulomatous. tissue as the flap across the bottom of socket to the other side of the crest.

Figure 1h: Immediate implant with primary closure.

Figure 1i: Restoration after healing period.

Figure 1g: To ensure complete removal of granulomatous tissue, it is necessary to sound the bone after the curettage then bone grafting materials of your choice can be filled.

14 • Vol. 9, No. 8 • October 2017

Page 17: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Chen et al

Figure 2: Probing depth of implant #18 was more than 10mm, suggesting a complete attachment loss.

Figure 3: Clinical assessment of implant #18: vertically mobility more than 2mm; abscess present but no bleeding upon probing; no temperature sensitivity; suggest the failed implant is VMI class III vertical mobility.

Figure 4: Inverted Gingival Pouch technique: extraction of implant #18 scalpel blade 15c incision over the buccal bony wall of the extracted socket.

placement, Guided Bone Regeneration and Inverted Gingival Pouch technique for soft tis-sue management. Apply the soft tissue from the infected socket both as a barrier membrane of GBR and soft tissue graft for soft tissue man-agement, all these procedures can be well per-formed simultaneously in only one surgery.

Figure 5: Inverted Gingival Pouch technique: full thickness flap, leaving the granulomatous tissue and its epithelial layer intact with the lingual flap.

MATERIALS AND METHODSA typical surgical protocol of the Inverted Gin-gival Pouch technique involves the following steps: extraction of the hopeless tooth due to severe bone resorption and attachment loss; thorough debridement in the socket; an inci-sion on the crest of alveolar ridge (preferably

The Journal of Implant & Advanced Clinical Dentistry • 15

Chen et al

Page 18: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

substitutes under the principles of Guided Bone Regeneration; apply the elevated flap as a barrier membrane and suturing (Fig. 1).

Figure 6: Inverted Gingival Pouch technique: using periosteal elevator, carefully elevate the granulomatous tissue as the full thickness flap; curettage the socket and sound the exposed bone surface.

Figure 7: Inverted Gingival Pouch technique: fill the exposed socket with bone graft particulates.

Figure 8: Inverted Gingival Pouch technique: using the intact granulomatous tissue as a cap to achieve the complete primary closure, no additional flap release is needed.

on the highest bone wall); release a full thick-ness flap f rom t he i ncision o n o ne s ide o f t he crest, across the bottom of the socket, to the other side of the crest; drilling and preparing for implant placement; fill the socket with bone

16 • Vol. 9, No. 8 • October 2017

Figure 9: Occlusal view of the tissue primary closure immediately after the surgery. There is no need to do any more buccal flap to release and gain more passive closure.

Chen et al

Page 19: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Figure 10: Radiographic view of complete failure of implant #18 with lucency all around before surgery.

Figure 11: Radiographic view of immediate implant #18 after Inverted Gingival Pouch technique.

Figure 12: Pretreatment radiographic view of surgery site on tooth #’s 28 and 29 with severe periodontal lesion and bone resorption, no bone contacting to the teeth, teeth were floating over the granulomatous tissue.

Case 1A 47-year-old, Caucasian female, treated at Dental Implant Institute, Las Vegas, NV USA, presented with a failed #18 implant that had-severe chronic inflammation, no symptoms,

Figure 13: Tooth #’s 28, 29: vertically mobility more than 2 mm; abscess but no bleeding upon probing; no temperature sensitivity; teeth were non-vital, suggest the implant is VMI Class II vertical mobility. The clinical assessment indicate that the case is appropriate to Inverted Gingival Pouch technique: extraction of tooth #’s 28 and 29, leaving granulomatous tissue intact.

but with vertical mobility index (VMI) class III (see Table 1). According to the patient, this implant was placed in 1997 and eight years after the restoration the patient noticed the crown was loose. Since the implant and loose

The Journal of Implant & Advanced Clinical Dentistry • 17

Chen et al

Page 20: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

18 • Vol. 9, No. 8 • October 2017

Clinical Application Classification Vertical Mobility X-ray Lucency Symptoms of IGP)

I < 1mm Circumferential Has horizontal Limited root lucency mobility class III

extended all the vertically push the way down tooth less than except the 1mm. Abscess

apical root tip mixed with area. bleeding when

probe. Sensitive to temperature.

Tooth is mostly vital.

II ≥ 1mm Less than 3mm Vertically push Limited to lucency all the tooth 1-2mm. Yes around the Abscess mixed entire root. with bleeding

when probe. No Sensitivity to temperature.

Tooth is mostly Non-vital.

III ≥ 2mm More than 3mm Vertically push Yes lucency all the tooth more around the than 2mm. entire root. Abscess but

no bleeding when probe

No temperature sensitivity. Tooth

is non-vital.

Table 1: The Leonchen Classification of Vertical Mobility for Inverted Gingival Pouch Technique

Chen et al

Page 21: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 19

Figure 14: Inverted Gingival Pouch technique: scalpel blade 15#c incision over lingual socket bony wall at the site of tooth No.28 and 29; using periosteal elevator carefully elevate the granulomatous tissue as the flap; curettage and sound the exposed bone surface; implant placement. Bone graft material augmentation immediate after implant placement.

Figure 15: Inverted Gingival Pouch technique: primary closure using the intact buccal flap with granulated tissue as a cap to close up the socket, no further releasing flap needed.

Figure 16: Five weeks after immediate implant surgery, showing excellent revitalized keratinized gingiva with no inflammation tissue.

Figure 17: (right) Buccal view of tooth #22 before surgery, showing severe local inflammation, bone loss, no keratinized gingiva and more than 8mm root exposure. Vertically mobility more than 1 mm less than 2 mm; abscess but no bleeding upon probing; no temperature sensitivity; tooth was non-vital, suggest the tooth is VMI Class II vertical mobility.

Chen et al

Page 22: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

20 • Vol. 9, No. 8 • October 2017

Figure 18: Buccal view of tooth #22 two weeks after the Inverted Gingival Pouch surgery, showing the recovery of vertical height of soft tissue, and some characteristics of keratinized gingiva.

Figure 19: Buccal view of tooth #22 three months later, showing gingival revitalization, fully recovered keratinized tissue.

crown were asymptomatic, the patient was in no particular rush for a dental evaluation until now.

Case 2A 56-year-old, Asian male, treated at the Shanghai private practice, presented with severe chronic periodontal condition on tooth #28 and #29. Tooth #30 was missing. Peri-odontal evaluation revealed great attach-

ment loss, probing revealed chronic abscess mixed with bleeding. Radiographic examination showed an extensive area of periodontal lesion and bone loss. There was no bone tissue sur-rounding the entire apical area. Teeth #28 and 29 were floating over granulomatous tissue on the socket, mobility of these teeth were vertical mobility index Grade II (See Table I). Treatment procedures are presented in Figures 12-16.

Case 3A 74-year-old, Asian male, heavy smoker, treated at the private practice in Taiwan, pre-sented with generalized chronic periodon-titis with localized advanced periodontal lesion on tooth #22, severe circumferential bone loss, and severe buccal recession with root exposure 8mm. Tooth #22 had an active abscess, but was asymptomatic.

Chen et al

Page 23: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 21

Figure 20: Leonchen classification for vertical tooth mobility (VMI).

Figure 21: Clinical examination according to Leonchen classification for vertical tooth mobility, it is obvious that the mobility is 1-2mm, abscess mixed with bleeding when probe, no sensitivity to temperature, tooth is mostly non-vital (see red arrow), thus the vertical mobility was Class II.

Figure 22: Clinical examination according to Leonchen classification for vertical tooth mobility, it is obvious that the mobility is 1-2mm, abscess mixed with bleeding when probe, no sensitivity to temperature, tooth is mostly non-vital (see red arrow), thus the vertical mobility was Class II.

Chen et al

Page 24: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Figure 23: X-ray examination, a radiolucency area of approximately 3mm, all around entire root, vertical mobility was Class II.

RESULTS Case 1 presented as an implant failure patient with severe chronic inflammation. F igures 2 -11 documented the surgical phase of therapy including implant extraction and debridement, incision design, releasing of the flap, i mplant placement, application of bone substitutes and securing the flap. A fter t he surgery, t he r esults are shown in Figures 8, 9 and 11. We obtained excellent primary closure and primary stability of implant #18 after surgery. No clinical complica-tions, post op swelling or delayed healing were evident. In the period of follow-up, recurrence of periodontal problem, loss of bone or any other local infections were not observed. Addition-ally, bone height of the patient remained stable and the peri-implant tissue was in good health.

22 • Vol. 9, No. 8 • October 2017

In case 2, teeth with severe chronic peri-odontal inflammation were floating over granu-lomatous tissue. Figures 12-16 document the surgical phase of therapy including implant extraction and debridement, incision design, releasing of the flap, implant placement, appli-cation of bone substitutes and securing the flap. After the implant surgery, the result of 5 weeks’ recovery is demonstrated in Figure 16. We obtained a diseased granulomatous gingiva revitalized it into an excellent keratinized gin-giva. We also achieved sufficient implant stabil-ity with regenerated bone on implants #28 and 29 at 5 weeks after implant surgery. No recur-rence of the periodontal problem, loss of bone or any other local infections were observed in the period of follow-up. The aesthetics and function of the prosthesis was satisfactory to both clinicians and the patient. The implant stability and bone osseointegration were well achieved at the time of final prosthesis delivery.

The patient in Case 3 (Figure 17) pre-sented with severe bone loss and buccal reces-sion with root exposure. This heavy smoking patient was treated with the IGP (Figure 18). Three months after Inverted Gingival Pouch technique surgery, vertical height and well-being of soft tissue were achieved (Figure 19).

DISCUSSIONIn Cases 1, 2 and 3, the periodontally compro-mised patients were in poor conditions in terms of well-being of periodontal tissue and insuf-ficient bone volume for implant placement. The application of Inverted Gingival Pouch Technique achieved infection control, flap design, implant placement and bone augmentation simultaneously in one surgery. In all cases, the clinical outcomes

Chen et al

Page 25: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

were appealing and the long-term effectiveness were achieved. These results suggested that the Inverted Gingival Pouch Technique was an effec-tive and safe alternative technique in the implant therapy for patients suffering from periodontal diseases. Primary implant stability and primary closure are prerequisites for successful osseointe-gration, wound healing and tissue regeneration.16 The clinical understanding of primary implant stability is often based on the resistance of the implant during its insertion. An ideal stability may be accentuated if there is a feeling of abrupt stop at the seating of the implant.17 Thus, we strongly recommended that the torque should be at least 20 Ncm, Primary closure is recognized as an important factor for success. The flap has to be fully raised and completely closed for bone regen-eration. It ensures undisturbed and uninterrupted wound healing.18 However, for periodontally com-promised patients, soft tissue is frequently insuf-ficient to achieve complete primary closure as the result of recession of periodontal tissue and thin soft tissue biotype. Particularly in patients with severe local infection on the extraction site, it is well accepted that granulomatous tissue formed in the process of infection on the socket is not only useless to raise a flap for primary clo-sure, but also needs to be thoroughly removed after tooth extraction for debridement. Instead of discarding the granulomatous tissue, the Inverted Gingival Pouch techniques make full use of epithelialized granulation for primary closure.

Different techniques have been applied for primary closure, including soft tissue punch, con-nective tissue graft, barrier membrane, soft tissue replacement matrix.19 Normally we tried to rebuild the lost tissue with these methods after the removal of all the tissue underneath the extracted

socket. This time-consuming treatment required multiple surgeries after extraction. As for Inverted Gingival Pouch Technique, it can eliminate all the extra regeneration surgeries at the time of tooth extraction. We have to put special empha-sis here: this is the first time in the dental world that normally discarded diseased epithelialized granulomatous tissue is utilized for the purpose of primary closure. The treatment concept of Inverted Gingival Pouch Technique brings light on implant therapy for periodontally compromised patients.

This Inverted Gingival Pouch Technique may only be used in special situations. The indica-tions have to be fully discussed and appreciated. It is not rare to see many patients who were likely to neglect their periodontal disease so long to the point that the affected teeth came out to be hopeless to maintain and there was no longer any bone contacting the teeth roots. These hope-less teeth are potential candidates for Inverted Gingival Pouch Technique. To better describe the indication, we establish a novel classification of tooth mobility on vertical dimension (Figure 20). Given this novel classification, the most cru-cial criteria of the indication of Inverted Gingival Pouch Technique is the integrity of the granulo-matous tissue in the socket. In Class 1 patients, no granulomatous tissue completely covered the socket after tooth extraction and bone sound-ing, the insufficiency of soft tissue fail to raise complete flap for primary closure. Thus, Inverted Gingival Pouch Technique is limited. Meanwhile, in class 2 and 3 patients, the priority thing to do after tooth extraction is to exam and sound the tissue. Our interest lay in the patients with granu-lomatous tissue and keratinizes epithelium. The bottom of the affected socket was covered by a

layer of granulomatous tissue in these patients. In

The Journal of Implant & Advanced Clinical Dentistry • 23

Chen et al

Page 26: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

the progress of periodontitis or other local infec-tions, this granulomatous tissue would develop to an epithelial lining surrounding the granulo-matous tissue around the root tip. If the thick-ness of these tissues is all more than 2 mm intact, we suggest performing Inverted Gingi-val Pouch technique. Additionally, another fac-tor that should be taken into consideration is bleeding after. If the tooth extraction causes no bleeding, which means the epithelium has grown over and completely cover the bottom of the socket, Inverted Gingival Pouch technique is preferred. Only in these situations can you utilized the Inverted Gingival Pouch Technique applying invagination pouching: instead of dis-carding the epithelialized granulomatous tis-sue, it is better to release a full thickness flap by peeling the tissue away from the bony layer.

Wound healing in periodontal tissue was a complex process involving inflammation, g ranu-lomatous tissue formation, neo- vascularization, re-epithelization and matrix remodeling.20 In a typical process, a clot in the wounded tissues would initially was formed. Then the invasion of inflammatory c ells, fi broblasts an d en dothelial cells to the clot would generate a granuloma-tous tissue, while the migration of the epithelial cells result in a cover of the denuded surfaces. Finally, in contraction or scarring, the healing tissue matrix became mature.21 Granulomatous tissue, as a complex reservoir of cytokines and growth factors, consisted of new capillaries, macrophages, fibroblasts and some loose con-nective tissue.21,22 The formation and matura-tion of granulomatous tissue is the result of a series of cellular and molecular mechanisms. The ingrowth of macrophages, fibroblasts a nd

new blood vessels to the wound space in a

24 • Vol. 9, No. 8 • October 2017

coordinated manner resulted in the formation of granulomatous tissue.23 The chemo-attractive, mitogenic and other regulatory activities of the cytokines and growth factors contributed to the epithelialization of granulomatous tissue. From this biological point, the application of epithelialized granulomatous tissue in Inverted Gingival Pouch Technique is reasonable.

On one hand, making use of the epithelial-ized granulomatous tissue could be effective in Inverted Gingival Pouch technique. On the other hand, the epithelialized granulomatous tissue is emerged in the process of resisting local infection and wound healing. The sites selected to conduct this technique are usually affected with chronic infections, which would no doubt jeopardize bone regeneration. As a result, the Inverted Gingival Pouch technique Grafting area should be thoroughly cleaned up.

In patients with implant therapy, insuffi-cient bone volume for implant placement was another problem as well as the well-being of the soft tissue. Inverted Gingival Pouch Tech-nique, however, presented a novel solution to this problem. After peeing epithelialized granu-lomatous tissue, the released full thickness flap was able to pouch bone grafts as a barrier membrane in Guided Bone Regeneration to gain vertical bone height in area that is severely resolved. Using colleges membrane along with the flap or not needs further research, but for now it is surgeon’s preferences.

CONCLUSIONWe conclude that, within the limits of this pre-liminary case study, this Gingival Revitaliza-tion by Inverted Gingival Pouch Technique might be potentially useful in achieving the

Chen et al

Page 27: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 25

Correspondence:Dr. Leon Chen6170 W. Desert Inn RdLas Vegas, NV 89146 Tel: 1(702)220-5000Email: [email protected]

Disclosure All the authors have no financial interest, either directly or indirectly, in the products or information listed in the paper.

AcknowledgementsSpecial thanks to Dr. Nina-Monique Chen for all the figures, illustration and tables.

References1. Miller PD, Allen EP. The Development Of

Periodontal Plastic Surgery. Periodontology2000 1996;11:7-17.

2. Miller Jr PD. Root Coverage With TheFree Gingival Graft: Factors AssociatedWith Incomplete Coverage. Journal OfPeriodontology 1987;58:674-81.

3. Matter J. Creeping Attachment Of Free GingivalGrafts: A Five-Year Follow-Up Study. Journal OfPeriodontology 1980;51:681-5.

4. Bernimoulin JP, Lüscher B, Mühlemann H.Coronally Repositioned Periodontal Flap.Journal Of Clinical Periodontology 1975;2:1-13.

5. Kassab MM, Badawi H, Dentino AR. TreatmentOf Gingival Recession. Dental Clinics Of NorthAmerica 2010;54:129-40.

6. Roccuzzo M, Bunino M, Needleman I, Sanz M.Periodontal Plastic Surgery For Treatment OfLocalized Gingival Recessions: A SystematicReview. Journal Of Clinical Periodontology2002;29:178-94.

7. Hägewald S, Spahr A, Rompola E, Et Al.Comparative Study Of Emdogain® AndCoronally Advanced Flap Technique In TheTreatment Of Human Gingival Recessions.Journal Of Clinical Periodont ology2002;29:35-41.

8. Allen EP, Miller Jr PD. Coronal PositioningOf Existing Gingiva: Short Term Results InThe Treatment Of Shallow Marginal TissueRecession. Journal Of Periodontology1989;60:316-9.

9. Cairo F, Pagliaro U, Nieri M. Treatment OfGingival Recession With Coronally AdvancedFlap Procedures: A Systematic Review. JournalOf Clinical Periodontology 2008;35:136-62.

10. Mengel R, Flores-De-Jacoby L. Implants InPatients Treated For Generalized AggressiveAnd Chronic Periodontitis: A 3-YearProspective Longitudinal Study. Journal OfPeriodontology 2005;76:534-43.

11. Baelum V, Ellegaard B. Implant Survival InPeriodontally Compromised Patients. JournalOf Periodontology 2004;75:1404-12.

12. Chen L, Allen P, Bruno J. Different Modalitiesfor Root Coverage. The 89th Annual meetingof the American Academy of Periodontology.September 23, 2003.

13. Chen L, Root Coverage with an EnamelMatrix Protein Derivate (Emdogain): A reportof 38 cases. The 86th Annual meeting ofthe American Academy of Periodontology.September 18, 2000.

14. Chen L, Cha J, Guiha R, Bouwsma OJ. RootCoverage With Enamel Matrix Derivatives.Compendium Of Continuing EducationIn Dentistry (Jamesburg, NJ: 1995)2002;23:797-800.

15. Chen L, Cha J, Ho C. A Three-Point-Translation Technique For Root CoverageWith 4-Year Follow-Up. Dentistry Today2002;21,10: 112

16. Lioubavina Hack N, Lang NP, KarringT. Significance Of Primary Stability ForOsseointegration Of Dental Implants. ClinicalOral Implants Research 2006;17:244-50.

17. Sennerby L, Meredith N. Implant StabilityMeasurements Using Resonance FrequencyAnalysis: Biological And BiomechanicalAspects And Clinical Implications.Periodontology 2000 2008;47:51-66.

18. Wang H-L, Boyapati L. “PASS” PrinciplesFor Predictable Bone Regeneration. ImplantDentistry 2006;15:8-17.

19. Hämmerle CH, Araújo MG, Simion M.Evidence‐Based Knowledge On The BiologyAnd Treatment Of Extraction Sockets. ClinicalOral Implants Research 2012;23:80-2.

20. Murakami S, Takayama S, Ikezawa K, Et Al.Regeneration Of Periodontal Tissues ByBasic Fibroblast Growth Factor. Journal OfPeriodontal Research 1999;34:425-30.

21. Aukhil I. Biology Of Wound Healing.Periodontology 2000 2000;22:44-50.

22. Martin P. Wound Healing--Aiming For PerfectSkin Regeneration. Science 1997;276:75-81.

23. Sporn M, Roberts AB. Peptide GrowthFactors And Inflammation, Tissue Repair,And Cancer. Journal Of Clinical Investigation1986;78.2:329

goals of periodontal infection control, soft tis-sue regeneration, including increased width and thickness of keratinized tissue, bone aug-mentation, improved aesthetics, clinical safety, and efficiency. Clearly, further clinical and his-tological studies are required before this tech-nique can be recommended for routine use. l

Chen et al

Page 28: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Thongborisoot et al

Background: Although the chemically modi-fied implant topography proves its positive rapid bone formation effect, the comparative studies on implant stability changes between the standard and modified surfaces are limited. Methods: Thirty patients were selected ran-domly into two groups: Straumann SLA and Straumann SLActive (Straumann Institute AG, Waldenburg, Switzerland). CBCT was used to determine the quantity and quality of bone. RFA measurement was performed on day 0 and 2; week 1, 2, 3, 4 and 8. The rela-tionship between ISQ values, implant surface or bone quality were analyzed statistically.

Results: Both implant surfaces showed a dra-matic decrease of ISQ values on day 2 and stayed on a plateau until week 3. The SLAc-tive surface showed a significant increase in ISQ values (P < 0.05) on the 4th week; while the SLA implant surface exhibited a significant increase in ISQ value on the 8th week. How-ever, in the type IV bone, SLActive implants showed a statistically higher ISQ values on the 4th and 8th week compared to SLAs.

Conclusion: The implant surface played an important role in stably implanting particularly in type IV bone. Therefore, it may be considered to utilize the SLActive surface for early loading protocols, especially with the poor type of bone.

Comparison of Implant Stability Between Two Dental Implant Surfaces using

Resonance Frequency Analysis: A Pilot Study

Sasikran Thongborisoot DDS, MSc1 • Pravej Serichetaphongse DDS, MSc2

Michel Marcel Dard DDS, MSc, PhD3 • Atiphan Pimkhaokham DDS, PhD4

Pornchai Jansisyanont DDS, MSc5

1. Esthetic Restorative and Implant Dentistry, Faculty of Dentistry, Chulalongkorn University, Henri-Dunant Rd,Patumwan, Bangkok, 10330, Thailand

2. Assistant Professor Department of Prosthodontic, Faculty of Dentistry, Chulalongkorn University, Henri-Dunant Rd,Patumwan, Bangkok, 10330, Thailand

3. Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, New York,United States of America

4. Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Henri-Dunant Rd,Patumwan, Bangkok, 10330, Thailand

5. Assistant Professor Department of Oral and Maxillofacial surgery, Faculty of Dentistry, Chulalongkorn University,Henri-Dunant Rd, Patumwan, Bangkok, 10330, Thailand

Abstract

KEY WORDS: Dental implants, dental implant surface, resonance frequency analysis, bone, healing

26 • Vol. 9, No. 8 • October 2017

Page 29: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Thongborisoot et al

The Journal of Implant & Advanced Clinical Dentistry • 27

Thongborisoot et al

INTRODUCTIONInitially, implant stability is provided by the mechanical retention between the implant sur-face and the recipient bone. Later the dynamic process of bone healing occurs and creates the direct structural and functional connection between living bone tissue and the surface of a load-bearing area of an implant, known as “osseo-integration”. The implant stability is prerequisites for the successful long-term function of implants.1,2

Resonance frequency analysis (RFA) is a method used to determine stability of dental implants. The stability is presented as an implant stability quotient (ISQ) value, which is depen-dent on the stiffness of the implant/tissue inter-face and the distance from the transducer to the first bone contact.3 It can also detect the overall stiffness of the implant/bone complex (the summation between mechanical stability and biological stability occurred at that particu-lar observing time). RFA measurement has been widely accepted as the standard implant sta-bility detector that can be used to assess the stability of the implant immediately after place-ment, as well as to monitor the development of the implant stability during the healing phrase.

For many years, the Sandblasted, Large grit, Acid-etched (SLA) implant surface has proven itself to be a superior choice of implant-to-bone interface.4,5,6 As the roughness of SLAs induces higher local cytokines and growth factor, increases fibronectin adsorp-tion, enhanced bone apposition and higher removal torque values. Thus, restoration over the SLA surface implant could be done as early as 6-8 weeks of healing with 99% predictabil-ity of success in 2-5 years observation period.7,8

With the same topography as SLAs, SLActives

are produced under N2 atmosphere and then sub-merged in an isotonic NaCl solution. These proce-dures give the properties of super-hydrophilicity, 0-degree water contact angles, high chemical activity and high surface free energy.9 These prop-erties render SLActives a promising solution for rapid bone anchorage.10,11 This, in turn, shortens the healing phase and allows patient the benefit of earlier-loading implant restorations. This study aimed to compare the longitudinally changes in the stability of implants between two different surface chemistries by using RFA over the first 8 weeks and to determine the functional load-ing protocol for the SLA and SLActive implants.

MATERIALS AND METHODSStudy participants were patients seeking den-tal implant treatment at the Special Clinic, Fac-ulty of Dentistry, Chulalongkorn University during June 2011 to January 2012. All patients under-stood the objectives of the study, protocols, their obligations to the study as well as the ben-efits and risks of participation. All informed con-sents were obtained. Exclusion criteria were systemic diseases that could alter bone and soft-tissue healing, pregnancy, and participants < 18 years of age.12 The study was approved by the standing ethics committee for human research, Chulalongkorn University (Thailand) with an IRB authorized number of HREC-DCU 2011-080. The study was conducted as a pro-spective clinical trial in accordance with the Hel-sinki Declaration (Version 2008) guidelines.

Cone Beam Computer Tomography; CBCT (CB Mercuray, Hitachi, Japan) was used for pre-operative evaluation. A pre-fabricated acrylic resin surgical template, which incorporated a 4-mm diameter gutta percha at the center of

Page 30: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

28 • Vol. 9, No. 8 • October 2017

proper designated implant area, was placed into the patient’s mouth prior to CBCT scan-ning. InVivo5 software (Anatomage, USA) was used to measure the mean bone den-sity of the implant area and to convert the CBCT Greyscale unit to Houndsfield units (HU).13 The measurements were performed at seven different cross-sectional images which were at the center of gutta percha, 1, 2, 3 mm mesial and distal to the center of the gutta percha. For each image, three measure-ments were performed by defining a 5 x 5 mm square-shaped area at the crest of the edentu-lous ridges (Graph 1). Then, the mean HU val-ues were used to classify bone quality of each implant area according to Misch’s criteria.14

Clinical ProtocolThe implants used in this study were the Straumann® ITI dental implant system (Strau-mann Institute AG, Waldenburg, Switzerland) and the standard plus SLA-surface topography or the modified SLA-surface (SLActive). All 51 implants were placed randomly (block random-ized technique). Implants number 1 - 5 were assigned for SLAs meanwhile implant number 6 - 10 were assigned for SLActives. The type of implant alternated between SLAs and SLAc-tives for every 5 implants. The implant num-ber was kept anonymous from the surgeons.

All implants were placed randomly by two oral surgeons, using a non-submerged tech-nique, according to a strict surgical protocol

Graph 1: The InVivo5 software indicated the HU value of the defined 5 x 5 mm2 area.

Thongborisoot et al

Page 31: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 29

following the manufacturer’s instructions. The choice of the implant size and length were left to the decision of the surgeons and depend-ing on available bone volume and quality.

Immediately after the implant was placed, the RFA values were determined using an Osstell® ISQ (Osstell AB, Gamlestadvä-gen 3B, Göteborg, Sweden). The ISQ read-ings were obtained three times by buccal, lingual and mesial. The measurements were further taken at 2nd day, 1st, 2nd, 3rd, 4th and 8th week post-operatively. One individual inves-tigator did all measurements. In case any implant presented any clinical mobility, a post-surgical infection or abnormal pain, the implant would be excluded from the study.

Statistical AnalysisAll statistical analyses were conducted using the SPSS software version 22.0.0.0 (SPSS Inc., Chicago, IL). The Kolmogorov-Smirnov test was used to test the distribution normality. The Fried-man test was used to compare the ISQ variables of the SLA and SLActive groups in longitudi-nally model. Each pair of within-implant differ-ences across the time periods were assessed using Wilcoxon Signed-Rank. The Mann-Whit-ney U test was used to determine statistical sig-nificance between mean ISQ values of SLA and SLActive at each single point of observations.

Differences between the ISQ values of vari-ous bone structures at each point of obser-vations were compared using Kruskal-Wallis

Graph 2: Mean ISQ values for overall assessment at the various observation points. (n=51) (*Statistically significant different (P<0.05).

Thongborisoot et al

Page 32: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

30 • Vol. 9, No. 8 • October 2017

test. The Friedman test was used to indicate statistical significance of implant surfaces and bone quality in longitudinal pattern. Mul-tiple Wilcoxon Signed-Rank tests were used to analyze the differences of ISQ values across each pair of observations. The level of signifi-cance for all statistical tests was set at α=0.05.

RESULTSThe study included thirty patients (mean age of 55.1 ± 10 years) with 51 implants placed in the mandible (14 in premolar area, 37 in molar area). Twenty-five standard plus SLA implants and twenty-six SLActive implants were placed in control and test groups consecutively. Forty implants were 10 mm in length while 9 and 2

implants were 8 and 12 mm in length respec-tively. Seventeen implants were 4.1mm in diam-eter with regular neck platform while 34 implants were 4.8 mm in diameter with wide neck platform. The bone density varied from 188.66 to 968.29 HU, with the mean of 609.06 HU. Fifteen, 24, and 12 implants were placed in Type II , III, and IV bone respectively. Adequate primary stabil-ity was achieved and healing was uneventful in all cases. No implant exhibited clinical mobility at any time point. All participants collaborated very well and strictly came for their appointments.

Overall Implant StabilityGraph 2 shows the minimum ISQ val-ues occurred on the first two days of heal-

Graph 3: The comparison of Mean ISQ values between the SLActives (n=26) and the SLAs (n=25).

Thongborisoot et al

Page 33: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 31

Graph 4: The comparison of Mean ISQ values between the SLActives (n=26) and the SLAs (n=25).

Table 1: Distribution of the implants based on implant length & preparation sites according to Misch’s bone classification.

Implant Type II Bone Type III Bone Type IV Bone

The standard plus SLA-surface implant 7 13 5

The modified SLA-surface (SLActive) implant 8 11 7

Total number of implants (%) 15 (29.4%) 24 (47.1%) 12 (23.5%)

ing. Thereafter, continuously rose back and became statistically significant (P = 0.05) on the 4th week of healing. The implants regained their initial stability on the 8th week. ISQ val-ues of all implants varied between 48 and 87.

Implant Stability According to Implant SurfaceThe influence of the implant surface on ISQ val-ues was depicted in Graph 3. The mean ISQ val-ues of both groups were decreased and reached its lowest value at 2nd day. No significant differ-

Thongborisoot et al

Page 34: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

32 • Vol. 9, No. 8 • October 2017

Graph 5: Mean ISQ values of the SLAs(n=7) and the SLActives(n=8), placed in bone Type II.

ence of the mean stability values across time was observed. A significant change (P = 0.015) in the pattern of stability from decreasing to increas-ing for the SLActives and SLAs was found at the 4th week and 8th week time point respectively.

Implant Stability According to Bone TypeThe distribution of the implants according to the bone structure is presented in Table 1.14

The implant stability patterns in each type of bone regardless of the implant surface were shown in Graph 4. It revealed that the stabil-ity values in Types II bone were relatively sta-ble throughout the observations. Contrastingly, Type III bone showed markedly ISQ decrease during the first two days, followed by a period

of increasing ISQ value, until it returned to the initial value at 8th week. Type IV bone, dif-ferently, showed the fluctuation stability pat-tern. The mean ISQ value decreased at day 2 and increased slightly at week 1. Later at week 2, ISQ value decreased and demonstrated the lowest stability value on the 3rd week. After 4th

week, the mean ISQ value rose up and returned to its initial value at 8th week. By 8 weeks, no bone groups showed any difference in implant stability, except on the 3rd week that Type IV bone showed significant difference of ISQ values, compared with the other bone types.

Thongborisoot et al

Page 35: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 33

Graph 6: Mean ISQ values of the SLAs(n=13) and the SLActives(n=11), placed in bone Type III.

Implant Stability on Different Surfaces in Each Type of BoneIn Type II bone, little change in stability values was observed in SLAs, while the change of ISQ values of the SLActives decreased mark-edly during the first week. Then, it rose back on 2nd week and remained stable throughout the end of observation. No significant difference of ISQ values between SLAs and SLActives.

In bone Type III, there was no significant difference of initial stability at the installation visit. Both of implant types showed a significant decreasing stability on day 2. The mean ISQ values constantly climbed up to reach initial val-ues on the 3rd week. No significant difference of ISQ values between SLAs and SLActives.

In bone Type IV, the results showed a dras-tic decrease for SLActives on 2nd day while ISQ values of SLAs remained constant for the first two weeks before experiencing a signifi-cant decrease from 2nd week to 3rd week. After reaching their minima on the 3rd week of heal-ing, SLAs rose drastically throughout the end of the study. Both implant surfaces showed a significant improvement in stability from week 3 to week 8. The SLActives returned to the initial stability level on the 4th week, however it took 8 weeks to achieve the same result for the SLAs. Interestingly, SLActives displayed significantly higher in RF values as compared to SLAs on 4th

week and 8th week in Type IV bone (Graph 7).

Thongborisoot et al

Page 36: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

34 • Vol. 9, No. 8 • October 2017

Graph 7: Mean ISQ values of the SLAs(n=5) and the SLActives(n=7), placed in bone Type IV.

DISCUSSIONThe objective of this investigation was to com-pare longitudinal implant stability patterns of two different surfaces implants over the first 8 weeks following implant installation. Bornstein et al. showed a dip of stability of implants placed in mandible between 2nd week and 6th week.15 This confirmed an initial decrease in the ISQ values within the first three weeks of healing.16,17,18 The cumulative stability of the SLActives changed from decreasing to increasing on 2nd week mean-while it was found on week 4 in the SLAs.15,19 Therefore, the implant loading protocol estab-lished the concept of early loading on the 3rd week after placement while the concept of immediate loading and delayed loading were set on the 2nd

day and 8th week respectively.20 In order to moni-tor the implant stability by using RFA and to deter-mine the time point when the implant has the lowest stability, this study measured ISQ values weekly in the first month and the final ISQ mea-surement were set on the 8th week after surgery.

Influence of Implant Surface The SLActives and SLAs displayed the same point of stability change from decreasing cumu-lative stability to increasing cumulative stability at 2nd day and gained the maximum cumulative stability by 8th week. This was the result from reducing in purely the initial stability, mechani-cal and followed by the increasing in the sec-ondary stability which is the biological stability.

Thongborisoot et al

Page 37: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 35

Within implant surface analyses, no sig-nificant in-between two implant surfaces at any point in time could be found. Correspon-dently, Valderrama et al. studied ISQ values of 17 SLAs and 17 SLActive s over 12 weeks in human model. The type of implant surface did not reveal any significant differences in ISQ values either in early healing or over time.18

It may be speculated that either no differ-ences existed in the extent of implant stabil-ity between the two implant surfaces in the early phase of healing or that the RFA may not be sensitive enough to detect minute dif-ferences. Moreover, the possibility of under-powered sample size has to be realized.

The study reported the favorable properties of the chemically modified SLA surface implants in fasten the healing process as the SLAc-tives presented a significant increase of ISQ values at 4th week, compared to at 8th week for the SLAs. Oates et al., likewise, demonstrated a transition point from a decreasing of RF val-ues to an increasing RF values at 2nd week for SLActives compared to at 4th week for SLAs.19 In addition to faster healing times, many clini-cal studies with long-term follow-up also dem-onstrated favorable success rates for SLActive surface implants.21,22 These findings sup-ported the hypothesis of an enhanced healing process and reliable success rate associated with the early loading protocol in the modi-fied implant surface. Still, the clinical signifi-cance of the difference in stability between the 2 implant surfaces has yet to be determined.

Influence of Bone Types Many articles have proven a positive correlation between bone density and dental implant stabil-

ity. Nonetheless this study showed no signifi-cant difference in initial stability among bones types, the trend clearly revealed three different patterns over the 8 week of recovery, measured by Resonance Frequency Analysis as following.

Pattern 1 was mainly found in Type II bones, regardless of implant surface (Graph 5). The trend of ISQ values over the eight-week period was non-fluctuating. There was also no sig-nificant change in stability between two types implant over the same observation period. This concurred with Sim and Lang/Barewal who found no statistically significant change implant stability at all times of observations in dense bone.16,23 As the denser type of bone possess larger cortical bone around the neck of implant, better resistance to the lateral bending forces are seen with the RFA. Pattern 2 began with a strong decrease in ISQ values as early as the 2nd day of healing. After that the ISQ values increased with the significant change occurred between 2nd day and 8th week (Graph 6). This pattern was mainly found in Type III bone. It demonstrated the stability pattern change with decreasing values in the early phase of heal-ing, before consistently increased. This pat-tern was named as “the dipping effect”.24

Pattern 3 was observed in bone type IV (Graph 7). It displayed the greatest change in stability from the 2nd day to the 3rd week. Stabil-ity level reached minima on the 3rd week of heal-ing. The result was in agreement with Barewal et al.16 One histological study in a rabbit model explained the significant changes of bone den-sity during the early period by the callus bridg-ing formation from week 0 to 6th week (when extrapolated to humans) and later lamellar com-paction within the loose stroma of woven bone

Thongborisoot et al

Page 38: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

36 • Vol. 9, No. 8 • October 2017

from 6th week to 18th week.25 Consequently, the 3rd week after surgery was considered the most critical healing time point for a dental implant.

In conclusion, the finding from this analy-sis suggested that differences in bone quality affected the implant stability during the early healing phase. High initial stability and insig-nificant change of stability during the early heal-ing phrase in which mostly found in denser type of bone would be considered as a good can-didate for an early loading protocol. Several articles from the literature suggested an early loading protocol to implants placed in Type I and Type II bone.26,31 Moreover, the early load-ing of Straumann implants with the SLA surface in Type I to III sites, either edentulous mandible or maxilla, after a healing time of 6 weeks pro-vided successful osseointegration with high success rates after 5 years. While in Type IV bone, a conventional loading protocol of 12 weeks healing time was recommended.27-30

Apparently, implant surface modification played a significant role in improving implant stability especially within poorer type of bone (D4).19,31 The stability patterns of SLA and SLActive implants were statistically significant different in Type IV bone at the 4th week and 8th week, as depicted in Graph 7. The outcome implied that SLActive implants provided a bet-ter and faster RF values when compared to the SLA implants in poor bone quality.31 Further, the most critical period for the SLA-surface implant exclusively when placed in the poor bone quality was at 3rd week post-operative. Subsequent to the critical 3rd week, SLA implants experienced a consistent increasing ISQ values and returned to its initial stability at 8th week. This was in line with the result from Barewal et al. who found the

dramatic 27% increase in stability (P <0.0001) for Type IV bone from 3rd to 10th week.16

One limitation of the present study was a small sample size per group. The pos-sibility of under-powered study has to be realized. The clinical significance of the difference in stability between the 2 implant surfaces in different types of bone, therefore, has yet to be determined.

CONCLUSIONSUnder the limitations of this study, the follow-ing conclusions can be drawn. Bone den-sity apparently influences the development of implant stability during the early phase of heal-ing. In dense bone type, the cumulative stabil-ity as displayed in ISQ values was found to be steady during early healing phase. Meanwhile, ISQ values changed more distinctly for the poor bone type. Regardless of bone type, there was no significant difference in RF values between types of implant surface. However, the chemical modification of the SLA surface potentially pro-moted faster healing and demonstrated signifi-cant increases in cumulative stability at the 4th

week, meanwhile the cumulative stability of SLA implant increased significantly at 8th week. l

Correspondence:Dr. Atiphan Pimkhaokham Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Chulalongkorn University, Henri-Dunant Rd, Patumwan, Bangkok, 10330, ThailandFax : +(66)2-218-8581 e-mail : [email protected]

Thongborisoot et al

Page 39: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 37

DisclosureThis article was partially supported by THE 90th ANNIVERSARY OF CHULALONGKORN UNIVERSITY FUND (Ratchadaphiseksomphot Endowment Fund).

References 1. Zarb GA, Albrektsson T. Osseointegration : A

Requiem for the Periodontal Ligament? Int. J. Periodontics Restor. Dent 1991; 11: 88-91.

2 Meredith N. Assessment of implant stability as a prognostic determinant. Int. J. Prosthodont, 1998; 11: 491–501.

3. Meredith N, Alleyne D, Cawley P. Quantitative determination of the stability of the implant-tissue interface using resonance frequency analysis. Clin Oral Implants Res. 1996 Sep; 7(3): 261-7.

4. Buser D, Schenk RK, Steinemann S, Fiorellini JP, Fox CH, Stich H. Influence of surface characteristics on bone integration of titanium implants. A histomorphometric study in miniature pigs. J Biomed Mater Res. 1991 Jul; 25(7): 889-902.

5. Cochran DL, Schenk RK, Lussi A, Higginbottom FL, Buser D. Bone response to unloaded and loaded titanium implants with a sandblasted and acid-etched surface: a histometric study in the canine mandible. J Biomed Mater Res. 1998 Apr; 40(1): 1-11.

6. Buser D, Nydegger T, Oxland T, Cochran DL, Schenk RK, Hirt HP, Snétivy D, Nolte LP. Interface shear strength of titanium implants with a sandblasted and acid-etched surface: a biomechanical study in the maxilla of miniature pigs. J Biomed Mater Res. 1999 May; 45(2): 75-83.

7. Cochran DL, Buser D, ten Bruggenkate CM, Weingart D, Taylor TM, Bernard JP, Peters F, Simpson JP. The use of reduced healing times on ITI implants with a sandblasted and acid-etched (SLA) surface: early results from clinical trials on ITI SLA implants. Clin Oral Implants Res. 2002 Apr; 13(2): 144-53.

8. Bornstein MM, Lussi A, Schmid B, Belser UC, Buser D. Early loading of nonsubmerged titanium implants with a sandblasted and acid-etched (SLA) surface: 3-year results of a prospective study in partially edentulous patients. Int J Oral Maxillofac Implants. 2003 Sep-Oct; 18(5): 659-66.

9 . Rupp F, Scheideler L, Olshanska N, de Wild M, Wieland M, Geis-Gerstorfer J. Enhancing surface free energy and hydrophilicity through chemical modification of microstructured titanium implant surfaces. J Biomed Mater Res A. 2006 Feb; 76(2): 323-34.

10. Buser D, Broggini N, Wieland M, Schenk RK, Denzer AJ, Cochran DL, Hoffmann B, Lussi A, Steinemann SG. Enhanced bone apposition to a chemically modified SLA titanium surface. J Dent Res. 2004 Jul; 83(7): 529-33.

11. Schwarz F, Herten M, Sager M, Wieland M, Dard M, Becker J. Histological and immunohistochemical analysis of initial and early osseous integration at chemically modified and conventional SLA titanium implants: preliminary results of a pilot study in dogs. Clin Oral Implants Res. 2007 Aug; 18(4): 481-8. Epub 2007 Apr 30.

12. Buser D, von Arx T, Ten Bruggenkate C. Basic surgical principles with ITI implants. Clin Oral Impl Res, 2000; 11:59-68.

13. Cassetta M, Stefanelli LV, Pacifici A, Pacifici L, Barbato E. How accurate is CBCT in measuring bone density? A comparative CBCT-CT in vitro study. Clin Implant Dent Relat Res. 2014 Aug; 16(4): 471-8.

14. Misch CE. Contemporary Implant Dentistry, 3rd

ed. Missouri: Mosby/Elsevier; 2008.15. Bornstein MM, Hart CN, Halbritter SA, Morton

D, Buser D. Early loading of nonsubmerged titanium implants with a chemically modified sand-blasted and acid-etched surface: 6-month results of a prospective case series study in the posterior mandible focusing on peri-implant crestal bone changes and implant stability quotient (ISQ) values. Clin Implant Dent Relat Res. 2009 Dec; 11(4): 338-47.

16. Barewal RM, Oates TW, Meredith N, Cochran DL. Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface. Int J Oral Maxillofac Implants. 2003 Sep-Oct; 18(5): 641-51.

17. Crismani AG, Bernhart T, Schwarz K, Celar AG, Bantleon HP, Watzek G. Ninety percent success in palatal implants loaded 1 week after placement: a clinical evaluation by resonance frequency analysis. Clin Oral Implants Res. 2006 Aug; 17(4): 445-50.

18. Valderrama P, Oates TW, Jones AA, Simpson J, Schoolfield JD, Cochran DL. Evaluation of two different resonance frequency devices to detect implant stability: a clinical trial. J Periodontol. 2007 Feb; 78(2): 262-72.

19. Oates TW, Valderrama P, Bischof M, Nedir R, Jones A, Simpson J, Toutenburg H, Cochran DL. Enhanced implant stability with a chemically modified SLA surface: a randomized pilot study. Int J Oral Maxillofac Implants. 2007 Sep-Oct; 22(5): 755-60.

20. Cochran DL, Schou S, Heitz-Mayfield LJ, Bornstein MM, Salvi GE, Martin WC. Consensus statements and recommended clinical procedures regarding risk factors in implant therapy. Int J Oral Maxillofac Implants. 2009; 24 Suppl: 86-9.

21. Bornstein MM, Wittneben JG, Brägger U, Buser D. Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year results of a prospective study in the posterior mandible. J Periodontol. 2010 Jun; 81(6): 809-18.

22. Morton D, Bornstein MM, Wittneben JG, Martin WC, Ruskin JD, Hart CN, Buser D. Early loading after 21 days of healing of nonsubmerged titanium implants with a chemically modified sandblasted and acid-etched surface: two-year results of a prospective two-center study. Clin Implant Dent Relat Res. 2010 Mar; 12(1): 9-17

23. Sim CP, Lang NP. Factors influencing resonance frequency analysis assessed by Osstell mentor during implant tissue integration: I. Instrument positioning, bone structure, implant length. Clin Oral Implants Res. 2010 Jun; 21(6): 598-604.

24. Boronat López A, Balaguer Martínez J, Lamas Pelayo J, Carrillo García C, Peñarrocha Diago M. Resonance frequency analysis of dental implant stability during the healing period. Med Oral Patol Oral Cir Bucal. 2008 Apr 1; 13(4): E244-7.

25. Roberts WE. Bone tissue interface. J Dent Educ. 1988 Dec; 52(12): 804-9.

26. Szmukler-Moncler S1, Piattelli A, Favero GA, Dubruille JH. Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Implants Res. 2000 Feb; 11(1): 12-25.

27. Roccuzzo M, Wilson T. A prospective study evaluating a protocol for 6 weeks’ loading of SLA implants in the posterior maxilla: one year results. Clin Oral Implants Res. 2002 Oct; 13(5): 502-7.

28. Roccuzzo M, Aglietta M, Bunino M, Bonino L. Early loading of sandblasted and acid-etched implants: a randomized-controlled double-blind split-mouth study. Five-year results. Clin Oral Implants Res. 2008 Feb; 19(2): 148-52.

29. Cochran DL, Jackson JM, Bernard JP, ten Bruggenkate CM, Buser D, Taylor TD, Weingart D, Schoolfield JD, Jones AA, Oates TW Jr. A 5-year prospective multicenter study of early loaded titanium implants with a sandblasted and acid-etched surface. Int J Oral Maxillofac Implants. 2011 Nov-Dec; 26(6): 1324-32.

30. Lethaus B, Kälber J, Petrin G, Brandstätter A, Weingart D. Early loading of sandblasted and acid-etched titanium implants in the edentulous mandible: a prospective 5-year study. Int J Oral Maxillofac Implants. 2011 Jul-Aug; 26(4): 887-92.

31. Chambrone L, Shibli JA, Mercúrio CE, Cardoso B, Preshaw PM. Efficacy of standard (SLA) and modified sandblasted and acid-etched (SLActive) dental implants in promoting immediate and/or early occlusal loading protocols: a systematic review of prospective studies. Clin Oral Implants Res. 2015 Apr; 26(4): 359-70.

Thongborisoot et al

Page 40: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Datar et al

Background: The efficacy of remov-ing bacteria from smooth-surface tita-nium using an air-polishing device with glycine powder abrasive was evaluated.

Methods: Smooth-surface titanium discs were inoculated individually with Aggregatibacter actinomycetemcomitans, Streptococcus ora-lis, Streptococcus mutans, and Tannerella for-sythia. Discs were treated with an air-polishing device with glycine powder and water, glycine powder alone, water alone, or tetracycline and water. Bacteria remaining on the surface of the titanium disks were removed and quantified.

Results: Compared with untreated con-trol discs, all treatment types saw a statisti-

cally significant reduction in bacteria (p <0.01) regardless of bacterial species. There were no statistically significant differences in bac-terial reduction between treatment types. Although not statistically significant, air pol-ishing with glycine powder alone tended to be least effective in reducing total residual bacteria, while Tannerella forsythia showed the least amount of bacterial reduction.

Conclusions: For smooth surface titanium, air polishing with glycine powder and water, glycine powder alone, water alone, or tet-racycline and water significantly reduced the amount of Streptococcus oralis, Strep-tococcus mutans, Aggregatibacter actino-mycetemcomitans, and Tannerella forsythia.

Decontamination of Titanium Surfaces with Air Polishing and Glycine Powder

Joseph Datar, DDS, MSD1 • Kerri Font, DDS, MS2 • Charles Powell, DDS, MS3 • Michael Schurr, PhD4

1. Private Practice, Greenwood Village, Colorado, USA

2. Assistant Director, Graduate Periodontics, University of Colorado School of Dental Medicine, Aurora, Colorado, USA

3. Chair, Department of Surgical Dentistry, Chair, Division of Periodontics, Director, Graduate Periodontics, University ofColorado School of Dental Medicine, Aurora, Colorado, USA

4. Associate Professor, University of Colorado Department of Immunology & Microbiology, Aurora, Colorado, USA

Abstract

KEY WORDS: Dental implants, dental implant surface, decontamination, air polish, Glycine

38 • Vol. 9, No. 8 • October 2017

Page 41: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

Datar et al

INTRODUCTIONDental implant therapy has become a predict-able treatment modality for the replacement of missing natural teeth. As the placement of dental implants becomes common practice, the preva-lence of peri-implant diseases also rises. In a recent systematic review and meta-analysis, the prevalence of peri-implant mucositis was 30.7% of implants and 63.4% of patients. Addition-ally, the prevalence of peri-implantitis was 9.6% of implants and 18.8% of patients.[1] Because of the recently recognized increase in the preva-lence and impact of peri-implant diseases, no treatment protocol has been universally accepted.

The primary etiology of peri-implant diseases has been determined to be bacterial plaque.[2]

Thus, successful treatment of peri-implant dis-eases includes the removal of bacterial plaque from the implant surface. Air polishing devices (APDs), which utilize pressurized air to deliver a slurry of abrasive powder and water, can be uti-lized for the removal of supra- and subgingival bacterial plaque. Traditionally, sodium bicarbon-ate has been used as the abrasive for biofilm removal, but its harmful nature to the surfaces of teeth and implants has become controver-sial.[3] Alternatively, the use of glycine powder as the abrasive for air polishing has been explored, demonstrating reduced residual roughness on the surface of titanium discs after treatment when compared with sodium bicarbonate.[4]

Glycine, the simplest amino acid, is used as a metabolic product in some bacteria but can function as an antimicrobial with other bacte-ria. Antimicrobial peptides found in nature typi-cally contain more glycine than other types of amino acids. These glycine-rich polypeptides have shown effectiveness against Gram-negative

bacteria. One such example is a family of anti-microbial peptides, called Gloverins. These mol-ecules act by inhibiting synthesis of vital outer membrane proteins in Gram-negative bacteria resulting in increased permeability of these mem-branes.[5] It is also speculated that glycine has a cationic effect, which increases permeability of the bacterial cytoplasmic membrane. Excess glycine also inhibits growth of bacteria and can be used as an antiseptic agent due to its low-level toxicity.[6] It is these properties of glycine that make it an interesting material for bacterial removal in the treatment of peri-implant diseases.

In an animal study evaluating biofilm removal from titanium abutments, APDs were found to be the least effective as compared to metal, plastic, and ultrasonic instruments, daily brush-ing with a conventional toothbrush, and weekly rubber cup polishing.[7] However, its effective-ness in bacterial decontamination from implant surfaces is unknown. Thus, the purpose of this study is to evaluate the efficacy of remov-ing bacteria from smooth-surface titanium using an air-polishing device with glycine powder.

MATERIALS AND METHODSFour bacterial species were included in this experiment. The first bacterium was Aggregati-bacter actinomycetemcomitans (ATCC 33384), a Gram-negative, facultative, ß-hemolytic, non-motile rod. Aggregatibacter actinomycetemcomitans is categorized as a green complex bacteria[8]. It is highly implicated in the initiation and progres-sion of periodontal diseases, particularly aggres-sive periodontitis. The second bacterium was S. oralis (ATCC 9811), a Gram-positive, facultative, α-hemolytic, non-motile cocci. It is categorized as a yellow complex bacteria under the classi-

The Journal of Implant & Advanced Clinical Dentistry • 39

Datar et al

Page 42: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

fication system by Socransky et al. (1998) and is a component of the normal human oral micro-biota. Although considered to be a component of normal, healthy oral microflora, i t is capable of opportunistic pathogenicity in immunocom-promised individuals. The third bacterium was Streptococcus mutans (ATCC 25175), a Gram-positive, facultative, α-hemolytic, non-motile cocci. It is also categorized as a yellow complex bacte-ria under the classification system by Socransky et al. and is the leading cause of dental caries, or tooth decay. The fourth bacterium was Tanner-ella forsythia (ATCC 43037), a Gram-negative, anaerobic, motile rod. It is categorized as a red complex bacteria under the classification sys-tem by Socransky et al. and is highly implicated in the pathogenesis of periodontal disease. Bac-terial growth times, for A. actinomycetemcomi-tans, S. oralis, and S. mutans were determined from previous growth curve data collected in a previous experiment, showing maximum CFU/mL for these three bacterial species at approxi-mately 12 hours. Maximum bacterial growth for T. forsythia was demonstrated to be at approxi-mately 48 hours in a previous experiment.[9]

Fifty-four titanium discs were purchased from All Metal Sales, Inc (Westlake, Ohio). All discs were fabricated to the same specifications, mea-suring 5mm in circumference and 2mm in height. The discs were machine sectioned, with a smooth surface and no surface modifications (i.e. acid etching, sand blasting, titanium-plasma spray).

The air polisher used was a Prophy BriteTM Air Polisher (Bosworth, Gibbstown, New Jer-sey) using AIR-FLOW® PERIO powder (Elec-tro Medical Systems, Nyon, Switzerland). The Prophy BriteTM Air Polisher is capable of deliv-ering 40-60mL per minute of fine powder and

40 • Vol. 9, No. 8 • October 2017

water slurry at 47-53 psi for the removal of bac-terial plaque and dental staining. AIR-FLOW® PERIO powder is a glycine-based, extra-fine particulate with a size of approximately 25µm and a low specific density used specifically for subgingival removal of bacterial biofilm.

After inoculation of the discs with the bac-teria for 18 hours at 340 C and 5% CO2, each titanium disc was treated individually using the Prophy BriteTM Air Polisher for five seconds per surface, per manufacture’s recommendations at a distance of 5mm. The treatment discs were sub-jected to one of four treatment modalities: 1) air polishing with AIR-FLOW® PERIO glycine pow-der and water (manufacture’s protocol), 2) air pol-ishing with glycine powder alone, 3) air polishing with water alone (negative control), 4) air polish-ing with tetracycline powder and water (positive control) and placed into 1.5 mL microcentrifuge tubes containing 1mL phosphate-buffered saline (PBS). The contents of each 1.5mL microcen-trifuge tube was sonicated for 15 seconds (Sonic Dismembrator 100, Fisher Scientific, Hampton, NH, USA) to remove any residual bacteria from the titanium disc and suspend the bacteria into the PBS. Serial dilutions were created, plated onto blood agar plates, and incubated at 340 C and 5% CO2 for 18 hours. For each bacteria and treatment modality, the experimental protocol was repeated an additional two times so that three bio-logic replicates were treated with each treatment modality in addition to a corresponding number of untreated discs. Following an 18-hour incubation period, each blood agar plate was inspected and the colony-forming units (CFUs) were counted.

For T. forsythia, the above protocol was com-pleted with the following modifications in order to accommodate the anaerobic nature of the organism:

Datar et al

Page 43: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

1. All agar (blood agar) and liquid/broth (BHI)media used for A. actinomycetemcomitans, S.oralis, and S. mutans were substituted withagar and liquid forms of N-acetylmuramic acid(NAM) growth media for growth of T. forsythia.

2. The following steps were completed in ananaerobic chamber containing80%N2, 10% CO2, and 10%H2:A. Incubation of pure T. forsythia on NAM

agar plateB. Transfer of pure colonies of T. forsythia

from NAM agar plate to NAM brothC. Incubation of T. forsythia on titanium discsD. Transfer of 20µL PBS and T. forsythia to

96-well microplateE. Creation of 103 to 107 dilutions in 96-well

microtiter plateF. Transfer of dilutions from 96-well microtiter

plate to NAM agar plateG. Incubation of NAM agar plates containing

serial dilutionsIncubation periods of 12 hours and 18 hours

for the three aerobic organisms were extended to 48 hours and 60 hours, respectively to accommo-date the slower, anaerobic growth of T. forsythia.

Each titanium disc resulted in four data points, represented in CFUs. In total, 1152 CFU data points were collected represent-ing 36 treated titanium discs and 36 untreated titanium discs (four data points per titanium disc). The breakdown of the titanium discs is as follows for each bacterial species: 3 bio-logic replicates x 3 discs each x 4 treatments x 4 data points per disc x 2 for untreated discs = 288 data points per bacterial species.

Statistical AnalysisData manipulation was carried out in Rx64 version

3.1.1. Statistical analysis was carried out using SAS software, Version 9.4. Using a mixed models random intercept approach, colony counts from each plate were analyzed accounting for the cor-relation between the four dilutions from each plate.

Dilutions of the initial 1mL PBS were accounted for outright in the analysis. The lowest limit of detection was 103 CFUs and an unstructured covariance estimate pat-tern was used for analysis. Mixed mod-els for all bacteria together and individually converged to the tolerance of the SAS platform.

A random intercept model was assessed to compare each treatment tested against the untreated controls, as well as to compare each treatment with the other treatments tested. Comparisons were made for each bacteria spe-cies individually as well as across all bacterial species to determine the differences in CFUs after treatment. A type I error level of 0.05 was used to assess significance for all tests.

RESULTSAnalysis of Treatment Types for All Bacteria When pooling the data for all four bacterial spe-cies, discs treated with glycine and water were significantly different than untreated discs, with an average of 2,569,470 less CFUs per tita-nium disc (p <0.0001; 95% CI: 1.6 x 106 to 3.5 x 106. Discs treated with glycine alone were significantly different than untreated discs, with an average of 2,497,100 less CFUs per tita-nium disc (p <0.0001; 95% CI: 1.5 x 106 to 3.4 x 106). Discs treated with water alone were sig-nificantly different than untreated discs, with an average of 2,566,350 less CFUs per titanium disc (p <0.0001; 95% CI: 1.6 x 106 to 3.5 x 106). Discs treated with tetracycline and water were

The Journal of Implant & Advanced Clinical Dentistry • 41

Datar et al

Page 44: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

significantly different than untreated discs, with an average of 2,571,040 less CFUs per titanium disc (p <0.0001; 95% CI: 1.6 x 106 to 3.5 x 106).

Analysis of Treatment Types with AGGREGATIBACTER ACTINOMYCETEMCOMITANSFor A. actinomycetemcomitans, discs treated with glycine and water were significantly d if-ferent from untreated discs, with an aver-age of 3,720,050 less CFUs per titanium disc (p <0.0001; 95% CI: 1.4 x 106 to 5.9 x 106). Discs treated with glycine alone were sig-nificantly d ifferent f rom u ntreated d iscs, w ith an average of 3,577,140 less CFUs per tita-nium disc (p <0.0001; 95% CI: 1.3 x 106

42 • Vol. 9, No. 8 • October 2017

to 5.8 x 106). Discs treated with water alone were significantly different than untreated discs, with an average of 3,706,690 less CFUs per titanium disc (p <0.0001; 95% CI: 1.4 x 106 to 5.9 x 106). Discs treated with tetracycline and water were significantly dif-ferent than untreated discs, with an aver-age of 3,720,130 less CFUs per titanium disc (p <0.0001; 95% CI: 1.4 x 106 to 5.9 x 106).

Analysis of Treatment Types with STREPTOCOCCUS ORALISFor S. oralis, discs treated with glycine and water were significantly different than untreated discs, with an average of 5,929,470 less CFUs per titanium disc (p <0.0001; 95% CI:

Table 1: Comparison of mean CFUs (log10) on treated (red) versus untreated (blue) discs

after air polishing with glycine and water.

Table 2: Comparison of mean CFUs (log10) on treated (red) versus untreated (blue) discs

after air polishing with glycine alone.

Datar et al

Page 45: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

4.1 x 106 to 7.7 x 106). Discs treated with gly-cine alone were significantly different than untreated discs, with an average of 5,779,570 less CFUs per titanium disc (p <0.0001; 95% CI: 3.9 x 106 to 7.5 x 106). Discs treated with water alone were significantly different than untreated discs, with an average of 5,928,210 less CFUs per titanium disc (p <0.0001; 95% CI: 4.1 x 106 to 7.7 x 106). Discs treated with tetracycline and water were significantly dif-ferent than untreated discs, with an average of 5,934,590 less CFUs per titanium disc (p <0.0001; 95% CI: 4.1 x 106 to 7.7 x 106).

Analysis of Treatment Types with STREPTOCOCCUS MUTANSFor S. mutans, discs treated with glycine and water were significantly different than untreated discs, with an average of 723,560 less CFUs per titanium disc (p <0.0001; 95% CI: 3.7 x 105 to 1.0 x 106). Discs treated with glycine alone were significantly different than untreated discs, with an average of 721,940 less CFUs per tita-nium disc (p <0.0001; 95% CI: 3.7 x 105 to 1.0 x 106). Discs treated with water alone were sig-nificantly different than untreated discs, with an average of 724,490 less CFUs per titanium disc (p <0.0001; 95% CI: 3.7 x 105 to 1.0 x 106). Discs treated with tetracycline and water were significantly different than untreated discs, with

The Journal of Implant & Advanced Clinical Dentistry • 43

Table 3: Comparison of mean CFUs (log10) on treated (red) versus untreated (blue) discs

after air polishing with water alone.

Table 4: Comparison of mean CFUs (log10) on treated (red) versus untreated (blue) discs

after air polishing with tetracycline and water.

Datar et al

Page 46: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

an average of 724,620 less CFUs per titanium disc (p <0.0001; 95% CI: 3.7 x 105 to 1.0 x 106).

Analysis of Treatment Types with TANNERELLA FORSYTHIAFor T. forsythia, discs treated with glycine and water were significantly d ifferent t han untreated discs, with an average of 137,930 less CFUs per titanium disc (p <0.0001; 95% CI: 1.1 x 105 to 1.5 x 105). Discs treated with glycine alone were significantly d ifferent t han untreated discs, with an average of 136,150 less CFUs per titanium disc (p <0.0001; 95% CI: 1.1 x 105 to 1.5 x 105). Discs treated with water alone were significantly d ifferent t han untreated discs, with an average of 137,340 less CFUs per titanium disc (p <0.0001; 95% CI: 1.1x 105 to 1.5x 105). Discs treated with tetracycline and water were significantly d if-ferent than untreated discs, with an aver-age of 137,340 less CFUs per titanium disc (p <0.0001; 95% CI: 1.1 x 105 to 1.5 x 105).

Comparison of Treatment TypesRegardless of a pooled sample including all bacteria or subsets of each individual bacte-ria, the untreated control was the only group that significantly d iffered f rom a ny t reatment type. In other words, the treatment of tita-nium discs with glycine with water, glycine alone, water alone, and tetracycline with water did not differ significantly i n b acterial c ounts after treatment. In terms of reducing bacte-rial counts, these four treatment groups were most effective with S. oralis and least effec-tive with T. forsythia, although these dif-ferences were not statistically significant.

44 • Vol. 9, No. 8 • October 2017

DISCUSSIONIn the present study, all treatment types were found to significantly reduce the amount of bac-teria from smooth surface titanium compared to untreated controls. However, no treatment type was found to be superior overall or for any bacteria individually. There are several possible explanations for the lack of differences between treatment groups. First, the use of water as an irrigant in the air polishing process may reduce the amount and duration with which the abrasives, glycine powder and tetracycline, interact with the bacteria. As described previously, glycine is speculated to have several antibacterial proper-ties.[4] Tetracycline is a broad-spectrum antibiotic effective against Gram-positive and Gram-nega-tive bacteria. The antimicrobial properties of tetra-cycline, require time to interact with and influence microbial metabolism and structural integrity. The copious water irrigation may reduce the time these particles interact with the bacteria and, thus, their impact on the treatment. The effectiveness of the water irrigation with air polishing, regardless of abrasive particle type, was evident in the present study. Air polishing with water only was not found to be significantly less effective than the other treatments, including the positive control with tet-racycline. A human study demonstrated that APD with glycine powder provided minimal additional PD and BOP reduction with added to ultrasonic instrumentation with carbon curettes.[10] Addi-tional studies demonstrated no additional benefits of CO2 laser or pumice on rotating cups versus cotton pellets with saline.[11] Together, these stud-ies demonstrate the efficacy of water alone in the removal of bacterial plaque from titanium surfaces. It is entirely possible that the osmotic changes induced by water alone may induce bacterial cell

Datar et al

Page 47: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • 45

lysis. An investigation into this mechanism may be a possible subsequent investigation. Conversely, there was a strong tendency for glycine without water irrigation to have the highest CFUs after treatment, amongst all treatment types, though this did not reach statistical significance. This trend held true for the pooled data and for each bacterial species individually. Together, these two trends indicate that the water irrigation more heavily influences the efficacy of air polishing on smooth titanium surfaces than the particle type.

The development of a biofilm on the surfaces of natural teeth or dental implants involves an ordered colonization of many species of bacte-ria. It is believed that over 500 bacterial species form this complex dental biofilm. Streptococci spe-cies appear to be the early colonizers that adhere to the dental pedicle and are thought to compro-mise up to 80% of early dental plaque. They are thought to contain receptors for initial adhesion onto implant and tooth surfaces and facilitate the attach-ment of secondary and tertiary colonizers later in plaque development. S. mutans is implicated as the major bacterial species in the pathogenesis of dental caries. S. oralis contains surface lectins that also bind salivary glycoproteins, facilitating bind-ing to saliva-coated surfaces.[12] Early binding of S. oralis is thought to facilitate adhesion of P. gingiva-lis, a red-complex bacteria thought to be strongly influential in the pathogenesis of periodontal and peri-implant diseases.[13] Aside from increasing its complexity and pathogenicity, bacterial co-adhesion is thought to stabilize dental plaque. It does so by creating favorable nutritional and metabolic relationships between bacteria. Thus, a biofilm containing multiple, cooperative bacte-ria, is more stable than a single bacterial species alone and perhaps more likely to resist debride-

ment during treatment with APD. In the present study, titanium discs were inoculated with the bacterial species individually. Their adherence to a smooth titanium disc may not have been as stable as in-vivo biofilm formation, increasing the effectiveness of air polishing in this experiment.

It should also be noted that no treatment type, including the positive control of air pol-ishing with tetracycline and a water spray, was 100% effective in eliminating bacteria from the titanium discs. Thus, some degree of residual bacteria remained after all treat-ment types. A subsequent investigation could investigate the effects of increasing the treat-ment time per surface from five seconds which may reduce or eliminate the residual bacteria.

Comparisons of the efficacy of air polish-ing with glycine powder versus other types of treatment have been explored. In an in-vitro study, dental implants were stained with indel-ible ink and mounted in resin models with vari-ous simulated bone defects. In this study, implants were debrided with either: 1) steel Gracey curettes; 2) an ultrasonic device with a steel tip; or 3) APD with glycine powder. It was found that residual ink was significantly less for implants debrided with APD and glycine pow-der. The efficacy of APD with glycine powder also increased as access was improved with wider simulated bone defects. SEM evalua-tion also revealed only minor changes in surface alterations on implants treated with APD and gly-cine powder, compared to other treatments.[14] l

Correspondence:Kerri Font, DDS, MSEmail: [email protected]

Datar et al

Page 48: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

46 • Vol. 9, No. 8 • October 2017

AcknowledgementsSupported by NIH/NCATS Colorado CTSI Grant Number UL1 TR001082. Contents are the authors’ sole responsibility and do not necessarily represent official NIH views. Statistical analysis provided by UCAMC Department of Biostatistics and Informatics, courtesy of Andrew Hammes, MS Candidate and Dave Weitzenkamp, PhD.

Conflicts of InterestThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References[1] Atieh MA, Alsabeeha NH, Faggion Jr CM,

Duncan WJ. The frequency of peri-implant diseases: a systematic review and meta-analysis. J Periodontol 2013;84:1586-1598.

[2] Mombelli A. Microbiology and antimicrobial therapy of peri-implantitis. Periodontol 2000 2002; 28:177-189.

[3] Petersilka GJ, Tunkel J, Barakos K, Heinecke A, Häberlein I, Flemmig TF. Subgingival plaque removal at interdental sites using a low-abrasive air polishing powder. J Periodontol 2003;74:307-311.

[4] Cochis A, Fini M, Carrassi A, Migliario M, Visai L, Rimondini L. Effect of air polishing with glycine powder on titanium abutment surfaces. Clin Oral Implants Res 2013; 24:904-909.

[5] Bulet P, Hetru C, Dimarcq JL, Hoffmann D. Antimicrobial peptides in insects; structure and function. Dev Comp Immunol 1999;23:329-344.

[6] Holo H, Nes IF. High-frequency transformation, by electroporation, of Lactococcus lactis subsp. cremoris grown with glycine in osmotically stabilized media. Appl Environ Microbiol 1989;55:3119-3123.

[7] Speelman JA, Collaert B, Klinge B. Evaluation of different methods to clean titanium abutments. A scanning electron microscopic study. Clin Oral Implants Res 1992;3:120-127.

[8] Socransky SS, Haffajee AD, Cugini MA, Smith C, Kent RL. Microbial complexes in subgingival plaque. J Clin Periodontol 1998;25:134-144.

[9] Honma K, Mishima E, Sharma A. Role of Tannerella forsythia NanH sialidase in epithelial cell attachment. Infect Immun 2011;79:393-401.

[10] Ji YJ, Tang ZH, Wang R, Cao J, Cao CF, Jin LJ. Effect of glycine powder air-polishing as an adjunct in the treatment of peri-implant mucositis: a pilot clinical trial. Clin Oral Implants Res 2014;25:683-689.

[11] Persson LG, Mouhyi J, Berglundh T, Sennerby L, Lindhe J. Carbon dioxide laser and hydrogen peroxide conditioning in the treatment of periimplantitis: an experimental study in the dog. Clin Implant Dent Relat Res 2004;6:230-238.

[12] Rosan B, Lamont RJ. (2000). Dental plaque formation. Microbes Infect 2000;2:1599-1607.

[13] Maeda K, Nagata H, Kuboniwa M, Ojima M, Osaki T, Minamino N, Amano A. Identification and characterization of Porphyromonas gingivalis client proteins that bind to Streptococcus oralis glyceraldehyde-3-phosphate dehydrogenase. Infect Immun 2013;81:753-763.

[14] Sahrmann P, Ronay V, Hofer D, Attin T, Jung RE, Schmidlin PR. In vitro cleaning potential of three different implant debridement methods. Clin Oral Implants Res 2015;26:314-319.

ATTENTION PROSPECTIVE AUTHORSJIACD wants to publish your article!

The Journal of Implant & Advanced Clinical Dentistry

For complete details regarding publication in JIACD, please refer to our author guidelines at the following link:

jiacd.com/author-guidelines or email us at: [email protected]

Datar et al

Page 49: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

The Journal of Implant & Advanced Clinical Dentistry • XX

Datar et alThe Best Things in Life Are FREE!

Subscribe now to enjoy articles free of charge that will benefit you, the actively practicing dental provider. With each JIACD issue, readers are afforded the opportunity to

assess clinical techniques, cases, literature reviews, and expert commentary that can immediately impact their daily dental practice.

Email notification when new issues are available online.

Start your FREE subscription today at www.jiacd.com

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 8 December 2016

Full Mouth Rehabilitation of Periodontitis Patient

Implant-Supported Milled Bar

Overdenture

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 1 march 2016

Treatment of the Atrophic Maxilla with Autogenous Blocks

Modified Mandibular Implant Bar Overdenture

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 3 may/JuNe 2016

Treatment of Mandibular Central Giant Cell Granuloma

Titanium Mesh Ridge Augmentation for Dental

Implant Placement

The Journal of Implant & Advanced Clinical Dentistry

Volume 8, No. 4 July/August 2016

Mandibular Overdentures with Mini-Implants

Augmentation of Severe Ridge Defect with rhBMP-2

and Titanium Mesh

Page 50: Hybrid Dental Implants - JIACD · dental implants. The hybrid dental implants utilized in these cases provide proof of prin-ciple that this is a viable alternative to traditional

ATTENTION PROSPECTIVE

AUTHORSJIACD wants to publish

your article!

The Journal of Implant & Advanced Clinical Dentistry

For complete details regarding publication in JIACD,

please refer to our author guidelines at the following link:

jiacd.com/author-guidelines or email us at:

[email protected]