A 70 year old male patient presented for extraction of unrestorable, fractured maxillary cuspid (#6) and central incisor (#8). (FIGURES 1 & 2) The extractions would then be followed by immediate placement of Nobel Biocare™ dental implants in the maxillary right cuspid, lateral and central incisor sites (#6, #7, & #8).

The extractions proceeded without complication or damage to the labial plate. However, it was then obvious that the conical shape of the cuspid root was larger than the Nobel Biocare 4.3mm x 13mm Replace® Select dental implant. Prior to placement of the dental implants, DynaBlast^™ Paste (Keystone Dental, Inc., Burlington, MA) was injected into the implant sites (FIGURE 3). DynaBlast^™ is a premixed combination of osteoinductive DFDBA and osteoconductive cancellous chips in a reverse phase medium, which allows for easy handling and accurate placement. The dental implants were then threaded directly into the filled sockets (FIGURE 4). Once in place, the viscosity of DynaBlast^™ reduced the risk of dislodgement of the graft during final implant placement, irrigation and site closure.

The area was allowed to heal for four and a half months. A removable transitional appliance was used to temporarily restore the edentulous area. The post-operative panoramic radiograph (FIGURE 5) and periapical radiograph (FIGURE 6) illustrate the excellent fill of the socket site including the crestal portion.

A 49 year old male patient presented for a single Straumann® RN 4.8mm x 10mm dental implant in the edentulous mandibular area of #19 (FIGURE 1). The implant was placed and healing progressed without complications. Approximately 6 months after final seating of the implant retained crown, the patient returned with a fractured mandibular second molar (#18). This root canal treated tooth had fractured vertically and was replaced with a Straumann 4.1mm x 10mm dental implant. At the time the patient presented for this fractured tooth, it was noted that the neck of the 4.8mm implant had also fractured and the abutment had loosened. The broken implant was trephined out (FIGURE 2) and a Straumann WN 4.8mm implant was placed, but the implant did not integrate and was shortly removed. Approximately four months passed before an implant procedure would be attempted again.

After anesthesia, a flap was made in preparation for placement of a Nobel Biocare 5.0mm x 13mm Replace® Speedy dental implant. A large granulation was removed from the socket area and DynaBlast^™ (Keystone Dental, Inc., Burlington, MA) bone graft substitute was placed in the area after site preparation and prior to implant placement. While DynaBlast^™ is composed of both demineralized and mineralized bone in RPM, (reverse phase medium – a bioresorbable carrier with increased viscosity at higher temperatures) the graft site will appear relatively radiolucent immediately post-surgery (FIGURE 3). However, the graft site will increase in radiodensity as healing continues, providing a radiographic indicator of bone growth.

The area was allowed to heal for three months before restoration of the implants began. A radiograph taken at the time of impression illustrates the outstanding integration around the Nobel Biocare Speedy implant where the DynaBlast^™ was placed (FIGURE 4). The implants were restored with splinted cement retained crowns.

A 62 year old male patient was seen for a failing fixed bridge at sites #3 to #6, due to the fracture of abutment tooth #6. Post and core build-up on the abutment at tooth #6 led to the horizontal fracture at the gingival level (FIGURE 1).

The bridge covering teeth #3 to #6 was sectioned mesial to tooth #3, retaining the crown, but removing the segment encompassing teeth #4, #5 and #6. Tooth #6 was extracted with the Easy X-Trac® (A. Titan, Hamburg, NY) system maintaining gingival and osseous architecture (FIGURE 2). Following the extraction, a Straumann® implant was placed at site #6 with simultaneous bone grafting using DynaBlast^™ (Keystone Dental, Inc., Burlington, MA) to fill the peri- implant defect. At site #4, an osteotome internal sinus lift procedure with DynaBlast^™ bone graft material and simultaneous placement of a second Straumann implant was performed (FIGURE 3). Small internal healing caps were placed on the implants to allow for submerged implant healing (FIGURE 4). The sites were covered with DynaBlast^™ and sutured for submerged closure at site #4 and semi-submerged closure at site #6, including the placement of a resorbable collagen barrier membrane.

At the two week post-operative appointment, excellent healing and slow disintegration of the membrane at site #6 were observed. At the 3 month post-operative visit, the patient had excellent tissue health at the surgical site. Final restoration was performed at 5 months with ease and no complications due to the excellent soft and hard tissue integration of both implants assisted by DynaBlast^™, resulting in successful bone remodeling (FIGURES 5 & 6).

The implants were revealed after 3 months of healing with a punch-type uncovering of implants. Larger healing caps were placed on the implants for 1 month. Final impressions and placement of abutments for a cementable final restoration were performed after 4 months of healing, and the final restoration was placed at 5 months post-surgery (FIGURE 7).

DynaBlast^™, comprised of demineralized bone and RPM (reverse phase medium – a bioresorbable carrier that demonstrates increased viscosity with increased temperature), allowed for easy handling and precise application into the peri-implant extraction defect at site #6 and allowed for a non-invasive osteotome internal sinus lift procedure at site #4. The increase in radiographic density of the DynaBlast^™ bone graft material in the sinus further underscored the successful outcome of the procedure.

A 45 year old female patient was referred by her primary dental provider to evaluate missing and decayed dentition in the posterior maxillary right quadrant.  Clinical and radiographic examination demonstrated decay and fracture of tooth #2 with failed endodontic therapy; region #3 was edentulous; and tooth #4 had a fractured crown with a retained endodonticly treated root.  The patient had a history of first premolar extractions x 4 with orthodontic treatment as a child.   Prior medical history was unremarkable and the patient is a non-smoker.

Under IV sedation and profound local anesthesia, tooth #2 and #4 were extracted carefully without difficulty (fig. 1).  Following extraction, access was created through the lateral maxillary sinus wall preserving the integrity of the sinus membrane.  The membrane was carefully lifted off the sinus floor.   Straumann Standard Plus implants were placed into sites #2 and #4 successfully with nice angulation and orientation and good primary stability (fig. 2).  DynaBlast^™ bone graft substitute was placed around the coronal aspect of the implant in position #2 to fill the void between the socket wall and the implant.  DynaBlast^™ was also placed around the implants in positions #2 and #4 where they extended through the maxillary sinus floor (fig. 3).  Primary closure was achieved without complication.

Immediately after implant and DynaBlast^™ placement, a radiograph was taken. With the DynaBlast^™ comprised of demineralized bone and RPM (reverse phase medium- a bioresorbable carrier that demonstrates increased viscosity with increased temperature), the radiograph initially demonstrated a radiolucency where the bone graft material was placed (fig. 4).  The patient returned after one week without complaints and demonstrating excellent soft tissue healing.   After 8 weeks, a follow-up visit also demonstrated excellent soft tissue healing.  Radiographs showed radiodensity around the implants both coronally and apically, which is consistent with bone regeneration due to the graft material at both implants sites #2 and #4 (fig. 5).  Based on the progression of increased opacity of the bone grafted regions representative of bone regeneration over the healing interval, stage two of implant placement was completed with 4 mm solid abutments torqued to 35 Ncm.

A 58 year old male patient presented requesting implants as a treatment modality for several missing posterior teeth in the upper quadrant after the loss of tooth #13. His natural teeth (#14, #15, #16) had been lost due to periodontal disease many years earlier resulting in a resorbed alveolar ridge (Fig. 1).

Under local anesthesia, a crestal incision is made extending the length of the edentulous area and a full thickness mucoperiosteal flap is elevated and reflected (Fig. 2). After the position of the sinus is determined with radiographs, an osteotomy of the buccal bone is performed with a #6 round diamond bur. With the sinus membrane preserved, the bony fenestration is gently pressed inward carrying the underlying membrane along with it. The sinus window access is expanded with a Kerrison side cutting rongeur (Fig. 3). Buccal bone fragments are preserved for additional autogenous graft material. Dissection and elevation of the antral floor is performed with a Freer elevator (Fig. 4).

Three implant osteotomies were prepared with the assistance of an acrylic surgical template after performing an alveoloplasty with a #6 round diamond bur (Fig. 5). A synthetic, dense hydroxylapatite bone graft material was deposited along the perimeter of the elevated sinus membrane (Fig. 6). The HA material adds a mineralized, slowly-resorbing component to the composite bone graft materials and aids in the radiographic visualization of the total sinus augmentation fill. DynaGraft·D^™ DBM Putty (Keystone Dental, Inc., Burlington, MA) was used to augment the sinus void. DynaGraft·D^™ is an osteoinductive DFDBA offering the benefits of a bio-assayed human allograft combined with a reverse phase polymer carrier that assists in binding the bone particles and exogenous graft materials together in a cohesive mass (Fig. 7). Additional graft materials were added, including a bovine HA, harvested, particulated autogenous bone and Ampicillin as a prophylactic antibiotic.

Two BioHorizon® Maestro D4 - 4x12mm and one BioHorizon® Maestro D4 - 6x12mm wide platform implants (BioHorizons Implant Systems, Birmingham, AL) were placed into the prepared osteotomy sites (Fig. 8). Ideal three-dimensional angulations and interproximal spacing was confirmed visually. Cover screws were inserted with a coating of Polysporin® antibiotic ointment. Once the implants are positioned, the graft material is checked to verify that the cavity fill is devoid of air pockets and extended to the lateral aspect of the maxillary bone.

An Inion® (Citagenix Inc., Montreal, Quebec) 30x40mm rigid resorbable synthetic membrane was trimmed and prepared for placement prior to surgery (Fig. 9). The Inion® membrane is a synthetic dental membrane that is soft and pliable for trimming, after being prepared in a plasticizer bath, and then becomes rigid in-situ from the absorption of moisture in the oral environment. The membrane provides a rigid, space-maintaining cavity for bone regeneration for approximately 8-12 weeks. It then begins to resorb naturally through the Krebs cycle into natural hydroxyl acids and is eliminated as CO2 and water. The softened Inion® membrane is positioned over the lateral wall window and fixated into place with the Inion® resorbable press-fit membrane tacks and tack applicator kit (Fig. 10). Tension free primary flap closure was achieved with Vicryl® resorbable sutures (Fig. 11).

A two stage submerged protocol was indicated. The patient did not wish a transitional appliance. Healing continues uneventfully. Ultimately, the prosthetic reconstruction will be completed within 7-9 months after implant placement.

A 63 year old female patient presented requesting implants as a treatment modality to replace several missing posterior teeth in the lower left quadrant.  Her natural teeth had been extracted 20 years earlier without replacement, resulting in a significant horizontal ridge deficiency.  It was explained to the patient that although implants represented an ideal treatment option, it would be necessary to simultaneously augment the bone to allow for optimum bone integration and stability of the implants.  The patient agreed to the proposed surgical and prosthetic treatment plan.

Two threaded, cylindrical, external hex Osseotite® implants (3i, Implant Innovations Inc., Palm Beach Gardens, FL) were placed into the areas of #20 and #18.  With optimum implant positioning, and given the horizontal resorption of the host hone in the area, approximately 5-6 threads were exposed on the buccal surface of the implant in site #20 and 3-4 threads on the buccal surface of #18 (Fig. 1).

1.0 cc of DynaGraft·D^™ Putty (Keystone Dental, Inc., Burlington, MA) was used to augment the deficient ridge and cover the exposed threads of the implants.  DynaGraft·D^™ is a bio-assayed DFDBA offering the inductive capability required to achieve regeneration of vital bone.  DynaGraft·D^™ comes supplied pre-mixed in a reverse phase medium allowing for ease of handling and accurate placement of the material.  With simple finger manipulation, the material can be molded into the ideal three dimensional shape to augment the deficient area (Fig. 2).  Once in position, the viscosity of DynaGraft·D^™ reduces the risk of dislodgement during final placement, irrigation and flap closure.

A 30x40mm Neomem (Citagenix Inc., Montreal, Quebec) GBR resorbable membrane was placed over the graft to assist in bone graft containment and to eliminate connective tissue and epithelial invagination into the surgical site (Fig. 3).  Re-approximation of the flaps was achieved and tension free primary closure established utilizing 5-0chromic gut sutures.  A two stage submerged protocol was undertaken given the simultaneous GBR procedure.

Healing was uneventful and the implants were uncovered at 9 months.  Clinical evaluation confirmed the apparent regeneration of bone on the buccal aspect of the mandible with coverage of the exposed implants threads (Fig. 4).  At this time, the implants were stable and integrated and 3i’s emergence profile transitional healing abutments were placed.  A soft tissue healing period followed for the next 6 weeks.  Prefabricated, preparable GingiHue™ Post (3i) prosthetic abutments were inserted and the patient restored with a ceramo-metal cemented fixed bridge  (Fig. 5).

Without the assistance of augmentation materials, endosseous implants would be limited to only those patients that presented with alveolar ridges with adequate bone volume.  The predictability of guided bone regeneration techniques has increased the number of implant candidates and has facilitated prosthetically driven restorations.

A 32 old female was referred to my Oral and Maxillofacial Surgery Clinic six weeks after a motor vehicle accident. As a result of this accident, she suffered a dento-alveolar fracture involving her four maxillary incisors and the supporting alveolar bone. Unfortunately, no treatment was initially rendered at the time of the accident and the segments were all loose and unsalvageable. The initial treatment plan was to remove the fractured roots, debride the area and perform a secondary autogenous bone grafting procedure once the soft tissue had healed.

Intravenous sedation was utilized when opening and debriding the affected area. The four incisor teeth and their fractured root segments were removed. A considerable amount of granulation tissue and fibrous tissue was also debrided from the wound. This left only the palatal component of the alveolus remaining. Much of the buccal component of the alveolus, although encased in fibrous tissue, was found to be vital. This bone was removed from the fibrous tissue and mixed with DynaGraft·D^™ Putty in approximately a 1: 4 ratio. The graft was subsequently covered with a non-resorbable membrane, after which primary closure was achieved.

The patient tolerated the procedure well and experienced no postoperative complications. She had been forewarned about the possibility of additional bone grafting, however healing progressed very well and no additional grafting was deemed necessary. Six months following the bone grafting procedure, four endosseous implants were placed in the anterior maxilla. The anterior ridge form was more than adequate for the placement of the implants and the bone proved clinically to be very solid.

Radiographic assessment of the post-op results showed satisfactory bone healing, around the implants. The procedure of choice in this case avoided the need for any secondary autogenous bone harvesting and its inherent morbidity.

A 32 year old male patient was referred for retreatment of tooth #24. This tooth has a history of trauma at age 12 and was endodontically treated 2 years ago (Fig. 1). Patient now has a periapical radiolucency, labial sinus tract and labial periodontal pocket probing to apex of tooth. Endodontic treatment appears to have been performed at or above the accepted standard of care. The treatment plan involved exploratory periapical surgery. The patient was made aware of a high likelihood of a root fracture finding.

The patient was injected with 3.6cc Ultracaine with 1:100,000 epinephrine. A full thickness flap was elevated and reflected. Apical curettage was performed and the root was examined under a surgical operating microscope. The entire labial surface of the #24 root was totally denuded of bony attachment. The root showed no evidence of fracture. The apical lesion was extensive enough to clearly see the lateral aspects of the roots of #23 and #25.

The root apex was retro-filled using IRM (a zinc oxide-eugenol intermediate restorative material, Dentsply Caulk). DynaGraft·D^™ (Keystone Dental, Inc., Burlington, MA) was used to augment the periapical surgical site. DynaGraft·D^™ is a bio-assayed DFDBA in a gel that stiffens in-situ. With simple instrument or finger manipulation, the material can be molded to augment the deficient periapical area. Once in position, the viscosity of DynaGraft·D reduces the risk of migration during final placement, irrigation and flap closure, Because DynaGraft·D^™ is a demineralized bone graft material, immediate post-operative radiographs will show the augmented site as radiolucent (Fig. 2). The radiographs will appear more radiopaque as the bone augmentation material turns over into new, vital, mineralized bone in the short term (2-4 months). A 30x40mm Neomem (Citagenix Inc., Montreal, Quebec) GTR resorbable collagen membrane was trimmed and placed along the labial surface of the bone. The membrane will assist in bone graft containment and will aid in eliminating connective tissue and epithelial invagination of the surgical site. Reapproximation of the flap was achieved with tension-free primary closure.

The patient was prescribed post-op medications: Clindamycin 150mg qid for 10 days, Peridex mouth rinse bid for 30 days and Tylenol 3 q4h as needed for pain. Healing was uneventful and the three month post-op clinical evaluation showed significant periapical bone fill with no evidence of a sinus tract and labial periodontal probing depth of 2mm (Fig. 3).

Guided Tissue Regeneration and Guided Bone Regeneration can prove invaluable in endodontic/periodontal cases that may otherwise have a poor prognosis which may ultimately lead to tooth loss. Augmentation materials can assist in the regeneration of new attachment cells and bony support for previously compromised cases.