Volume 11, Number 6

EDITOR Arun K. Garg, DMD Associate Professor of Surgery Director, Center for Dental Implants Division of Oral/Maxillofacial Surgery University of Miami School of Medicine EDITORIAL ADVISORS Editor Emeritus: Morton L. Perel, DDS, MScD Charles A. Babbush, DDS, MScD Head, Section of Dental Implant Reconstructive Surgery Mt. Sinai Medical Center Cleveland

June 2001

Platelet-Rich Plasma for Dental Implants and Soft-Tissue Grafting

Platelet-rich plasma (PRP) contains a variety of growth factors that are specific for bone and tissue healing and maturation. PRP is obtained from whole blood after a procurement and centrifugation process, explains Paul Petrungaro, DDS, MS, who practices aesthetic/cosmetic periodontology and implantology in Stillwater, MN. Petrungaro tells Dental Implantology Update how PRP is formed, as well as how a PRP/ graft complex is created.

The processing disposable then is loaded into the centrifuge rotor cup of the SmartPrePTM System. A

Anita Daniels, RDH Clinical Instructor Center for Dental Implants University of Miami School of Medicine Miami Charles E. English, DDS Staff Prosthodontist Veterans Affairs Medical Center Augusta, GA Jack A. Hahn, DDS Private Practice Cincinnati

counterbalance is placed in the opposing rotor cup, unless a second processing disposable is required. During the processing, the blood initially is centrifuged at 3,650 rpm to separate the red blood cells from the plasma. The centrifuge slows to

Kenneth W.M. Judy, DDS Clinical Professor Department of Prosthodontics University of Pittsburgh School of Dental Medicine Jack T. Krauser, DMD Private Practice, Periodontics and Implantology Boca Raton, FL Department of Periodontics Nova Southeastern College of Dental Medicine Davie, FL Richard J. Lazzarra, DMD, MScD Associate Clinical Professor Periodontal and Implant Regenerative Center University of Maryland Private Practice West Palm Beach, FL Robert E. Marx, DDS Professor and Chief Division of Oral/Maxillofacial Sur gery University of Miami School of Medicine

Formation of PRP
At the beginning of this process, a 60 mL syringe is filled with 5 mL of a citrate-based anticoagulant. Approximately 45-55 mL of the patient's blood then is drawn from a venous puncture in the upper arm into the 60 mL syringe. The anticoagulated blood is dispensed into a blood processing disposable with a specially designed blood chamber. The blood must be drawn before the start of surgery, because the surgery itself leads to platelet activation of the coagulation system within the body, Petrungaro explains.

about 60 rpm, which allows the plasma to automatically decant into the plasma chamber. The centrifuge then accelerates to 3,000 rpm to form a pellet of pure platelet concentrate in the bottom of the plasma chamber, Petrungaro explains. The entire process to separate the whole blood into red blood cells, platelet-poor plasma (PPP), and PRP is automated and is completed in approximately 12 minutes. The blood chamber of the process disposable contains the red

Carl E. Misch, DDS, MDS Co-Director, Oral Implantology University of Pittsburgh School of Dental Medicine E. Robert Stultz, DMD, MS Associate Professor of Periodontics University of California, San Francisco Private Practice San Rafael, CA

Inside This Issue

Clinically Significant Abstracts ...46

Daniel Y. Sullivan, DDS Private Practice, Implant Prosthodontics McLean, VA; Washington, DC

42
blood cells. The second chamber contains the platelet concentrate (a button-like precipitate) and PPP (supernatant). Approximately t wo thirds of the PPP is removed and saved for hemostatic applications, Petrungaro elaborates. The platelet concentrate then is resuspended in the remaining PPP, which creates a very concentrated PRP solution. Petrungaro tells Dental Implantology Update that the activator for the PRP and PPP is a mixture of 5,000 units of topical bovine thrombin and 5 mL of 10% calcium chloride. The activator is drawn into two 1 mL syringes. Then, 10 mL of PRP is added to a 10 mL syringe, while 10 mL of PPP is added to another 10 mL syringe. Two syringes are attached to each setup of a dual-cannula applicator tip (activator/PRP in one; activator/ PPP in the other), where the contents are mixed and applied to the bone graft, wound, or incisions. following this application technique will result in the formation of a cohesive PRP gel in which the graft is incorporated," continues Petrungaro. This result routinely is observed after only three to four seconds, at which time the PRP graft complex can be molded into the desired shape for delivery to the surgical area. The benefit of applying PRP to the wound surface and delivering growth factors to the surgical site is invaluable for healing and maturation of the soft tissue, Petrungaro states. When PRP is used in cosmetic periodontal surgery (e.g., connective-tissue grafting), a more rapid soft-tissue maturation rate is observed clinically. In addition, the recipient tissue appears to revascularize more rapidly, and therefore, less sloughing is noticed with larger grafts. During implant or bone grafting procedures, soft-tissue closure often is compromised. PRP enhances the i nitial soft-tissue migration and reepithelialization, and a higher incidence of wound closure has been noted clinically at days 3, 7, and 14.

Ridge preservation techniques Acceleration of hard-tissue matu Regeneration of peri-implant Coating the implant surfaces
defects

Bone grafting to reconstruct an

atrophic ridge

ration and block graft procedures

Formation of the PRP/Graft Complex

The chosen graft material is placed on the top surface of a specimen cup in its granular form. After a repeated crisscross technique, the PRP is incorporated into the bone graft material, Petrungaro explains. "Rotating the receptacle while
Dental Implantology Update''"' (ISSN 10620346) is published monthly by American Health Consultant 3525 Piedmont Road NE, Building Six, Suite 400, Atlanta, GA 30305. Telephone: (404) 262-7436. Periodical postage paid at Atlanta, GA 30374. POSTMASTER: Send address changes to Dental Implantology Update''", P.O. Box 740059, Atlanta, GA 30374. American Health Consultants'', in affiliation with Boston University Goldman School of Graduate Dentistry, offers continuing dental education to subscribers. Each issue of Dental I mplantology Update''"' qualifies for 1.5 continui ng education units. Customer Service: (800) 688-2421. Fax: (800) 284-3291. Hours of operation: 8:30 a.m. 6:00 p.m. Monday - Thursday; 8:30 a.m. - 4:30 p.m. Friday EST. E-mail: customcrservice ahcpub.com . World Wide Web: www.ahcpub.com . Subscription rates: U.S., $547 per year. Students, $300 per year. To receive student/

Use of PRP With Dental Implants

Petrungaro outlines for Dental Implantology Update the possible

uses of PRP in dental implantology:

resident rate, order must be accompanied by name of affiliated institution, date of term, and the signature of program/residency coordinator on institution letterhead. Orders will be billed at the regular rate until proof of student status is received. Outside U.S., add $30 per year, total prepaid in U.S. funds. Two to nine additional copies, $328 per year; 10 to 20 additional copies, $219. For more than 20 copies, contact Customer Service for special handling. Missing issues will be fulfilled by customer service free of charge when contacted within 1 month of the missing issue date. Back i ssues, when available, are $91 each. For 18 continuing education units, add $96 per year. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. Clinical, l egal, tax and other comments are offered for general guidance only; professional counsel should be sought for specific situations. Copyright 2001 by American Health Consultants". Dental huplantology Update'"' is a

before placement to aid in the initial stabilization and bonding of the implant to the alveolar bone Sinus lift procedures I mmediate-extraction and implant placement procedures I mmediate-extraction, implant placement, and restoration procedures Treatment of failing implants Petrungaro primarily uses PRP to deliver growth factors to the surgical site at different times during an implant placement surgical procedure. "For example, in an i mmediate-extraction/implant placement procedure, I will apply PRP to the surface of the implant before seating the fixture. I will use PRP to reconstitute the graft substrate (demineralized freeze-dried bone allograft or hydroxyapatite). I will apply PRP over the graft receptor site before placement of the graft because the PRP acts as a growth factor-impregnated barrier. And after closure, I will apply PRP first and then PPP over the surgical site to act as a growth factorimpregnated surgical dressing."

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Do,,tal Ilnplnntoltgij Update"'

hum

2001

Soft-Tissue Grafts With and Without PRP

Soft-tissue grafting has been performed successfully in periodontal

43
surgery for more than 40 years. Potential complications of soft-tissue grafting (e.g., free gingival grafting/connective-tissue grafting) include:

Excessive bleeding at the donor

site

Infection at the graft receptor site Sloughing of the graft tissue at

the receptor site

Figure 1: Preoperative clinical view of a molar with failing endodontic treatment.

Figure 2: Implant placement in the immediate-extraction socket.

Figure 3: The PRP/graft complex has been placed into the osseous defect around the implant fixture; PRP and PPP have been applied over the implant/graft site.

Figure 4: Three-month postoperative view of the onestage immediate-extraction/implant procedure.

Figure 5: Sculpted gingival contour three months after the one-stage procedure.

Figure 6: Final implant-supported restoration seated four months after the immediate-extraction/implant procedure.

June 2001

Dental Implantology Update"'

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Excessive bleeding at the receptor
site Micromovement of the tissue graft over the root surface in connective-tissue grafting Sloughing of the donor site Pain and/or discomfort at the the root surface and on completion of suturing techniques. Petrungaro also has observed a decrease in the i ncidence of failure to cover deep/wide gingival recession over root surfaces. "Clinically, it appears that soft-tissue grafts treated with "When patients are informed that we will draw their own blood and secure their own growth factors

donor or receptor site "The advantage of soft-tissue grafting that I have experienced clinically is a dramatic decrease in

the incidence of postoperative pain and bleeding at both the donor site and the receptor site," Petrungaro comments. The inherent hemostatic nature of PRP is one of its main properties. In addition, the cohesive properties of PRP help to stabilize the graft over

PRP produce thicker graft receptor sites once re-epithelialization occurs, and oftentimes this newly regenerated tissue requires tissueplasty to reduce its buccal thickness," Petrungaro says.

Patient Acceptance
Petrungaro has observed high patient acceptance with regard to the material and the procedure.

after a separation process, and that we will reintroduce these growth factors to the surgical site to enhance soft- and hard-tissue healing and maturation, they seem more willing to accept larger treatment plans," Petrungaro continues. "In addition, the patients' perceptions of the postoperative healing course are more enjoyable because the incidence of pain, swelling, and bleeding is greatly reduced when using PRP." According to Petrungaro, the only drawback of using this material/procedure is that some doctors

Figure 7: Preoperative clinical view of a molar with a vertical fracture in the mesial root.

Figure 8: Implant placement within the housing of the extraction socket.

Figure 9: PRP/graft complex (demineralized freeze-dried bone allograft in this case) before placement into the defects surrounding the implant.

Figure 10: The PRP/graft complex has been seated into the extraction socket and in the peri-implant area; PRP and PPP have been applied, respectively, over the exposed bone-grafted site.

Dental Imi7ln'Ifolotiry Update"

I mic 2001

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may be uncomfortable with phlebotomy. A venous puncture technique in the anticubital fossa is used to draw 55 mL of whole blood. The preparation procedures are simple, and clinical application is practically foolproof, Petrungaro comments. with form and function similar to those of the definitive prosthesis Facilitated fabrication of the transfer impression for use by the dental laboratory Petrungaro emphasizes that his patients are more willing to undergo extensive dental surgical procedures if they will never be without teeth and will have stable dentition throughout more extensive dental surgical rehabilitation. This has been made possible by using transitional i mplants. months. He uses implants that either have an HA-coated or resorbable blast media surface. From the time Petrungaro started incorporating PRP into his bone grafting and surgical armamentarium, he has been placing the final load on the implants at three to four months in both the mandible and the maxilla. In addition, for sinus grafts without immediate implant placement, he is placing implants into the sinus grafts at four months after grafting, and then placing the load on these implants at four months after placement. "Before the use of PRP, 1 would wait eight months after a sinus grafting procedure to place the implants and

The Use of Mini-Transitional Implants

Petrungaro feels that the use of transitional implants is an invaluable tool to bridge the healing phase for partially or completely edentulous patients who are undergoing bone grafting and/or implant reconstruction. The use of transitional i mplants can allow edentulous patients wearing a full or partial denture to undergo implant surgery and immediately experience the benefits of implantology. The benefits of using transitional implants to bridge the healing phase include: Support for a full or partial temporary prosthesis Uninterrupted healing of the bone-grafted or implantreconstructed ridge Maintenance or establishment of a vertical dimension throughout the healing phase Prevention of premature loading of the definitive implant fixtures Use of a provisional restoration

PRP and Geriatric Patients

According to Petrungaro, treatment planning and clinical delivery do not change for the geriatric patient. However, the use of PRP becomes even more important because as individuals age, they have less mesencyml stem cells in circulation. Therefore, they have an added need for growth factors to enhance the hard- and soft-tissue healing and maturation rate, in addition to healing and uptake of the grafted tissues.

PRP and Surface-Enhanced Implants

Petrungaro has been coating i mplants with PRP for several

another eight months after implant placement to load," Petrungaro elaborates. Immediate-extraction/implant placement with PRP-enhanced bone grafts and PRP-enhanced implant surfaces allows Petrungaro to place the definitive load at three months after implantation. Prior to the PRPenhanced procedure, Petrungaro waited six months before placing the final load (see Figures). When placing shorter implants, Petrungaro has not changed his practice of using the available bone that is present. "I believe that it is more important to select an implant

Figure 11: Soft-tissue appearance three months postoperatively.

Figure 12: Clinical view of the PRP/graft complex site three months postoperatively. PPP was the only regenerative barrier used. Compare the original defect in Figure 9 and the amount of regeneration at three months.

June' 2001

Dental huplnutOI(c. i/ Llhdate"'

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that is appropriate in diameter and length for the type of bone you are dealing with," Petrungaro states. "In my practice, PRP is used to enhance the healing phase of bone and soft PRP benefits and applications, and bone grafting techniques, Petrungaro states. A history of the procedure and future applications also are discussed. Petrungaro also recommends participating in a workshop or symposium on PRP sponsored by Harvest Technologies. This company produces the SmartPreP TM unit that prepares the platelets from the whole blood. By participating in a workshop, clinicians can obtain a working knowledge of the history of PRP, an overview of bone biology and biochemistry, and PRP applications in various surgical procedures. In addition, the hands-on portion allows participants to prepare PRP and experience its use and application with various bone grafting materials. V Bone volume, using two techniques, was measured by displacement volumetry. The average volumes obtained from the two volumetry techniques were 4.84 mL and 4.71 ml, (range, 3.25-6.50 mL). The average block size was 20.9 x 9.9 x 6.9 mm; the smallest block was 21.0 x 6.5 x 6.0 mm; and the largest was 25.0 x 13.0 x 9.0 mm. V Kudo M, Matsui Y, Ohno K, et al. A histomorphometric study of the tissue reaction around hydroxyapatite implants irradiated after placement. J Oral Maxillofac Surg 2001; 59:293-300. The reaction of tissue surrounding hydroxyapatite (HA) implants was analyzed histologically and histomorphometrically to determine the relationship between irradiation and tissue reaction shortly after i mplant placement. Cylindrical high-density HA i mplants were placed in the mandibles of 48 Japanese white rabbits. The mandibles were irradiated with a single 15 Gy dose on days 5, 14, or 28 after implantation. The rabbits were sacrificed on days 7, 14, 28, or 90 after irradiation. Non-irradiated rabbits with implants were used as controls. Nondecalcified specimens stained with toluidine blue were used for histologic and histomorphometric analysis. In the rabbits irradiated five days after implantation, the Hz bone contact occurred later than in the controls. The bone-implant contact surface ratio was lower in the radiation group than in the controls at each time of sacrifice because of radiation-induced necrosis of the newly formed bone. The HA-bone contact in rabbits irradiated on days 14 and 28 after i mplantation was similar to that of the controls. Bone remodeling was suppressed in the rabbits in each group sacrificed 90 days after irradiation.

tissue, as well as to accelerate the bone maturation between the i mplant and the bone."

Petrungaro has observed a decreased number of nonintegrated i mplants at the conventional Stage II procedure, as well as at the time of i mplant loading. Additionally, he has observed a decrease in the sloughing of bone grafts and postoperative infections, and has virtually eliminated the use of tissue barriers and the potential complications observed with their use. PRP has taken over the function of tissue barriers in Petrungaro's practice. When bone augmentation/regeneration is accomplished around implant fixtures, Petrungaro routinely augments the buccal contours of the alveolar bone with the remaining PRP/graft complex before flap closure. After the PRP/graft complex has been placed, the PRP is applied over the PRP/graft complex, followed by PPP application and closure. At days 7 and 14 postoperatively, Petrungaro has found that the buccal ridge contour remains augmented. "I have found this to be an important step in replacing osseous and gingival contours in the aesthetic zone and around an implant fixture/restoration where the previously extracted tooth underwent a traumatic extraction, or no grafting was accomplished at the time of extraction," he concludes.

ABSTRACTS

Clinically Significant

Montazem A, Valauri DV, StHilaire H, et al. The mandibular symphysis as a donor site in maxillofacial bone grafting: A quantitative anatomic study. J Oral Maxillofac Surg 2000; 58:1368-1371. The goal of this study was threefold: to quantify the amount of bone graft material present in the mandibular symphysis; to determine the maximal size of the corticocancellous bone block that can be harvested without mental nerve and tooth injury; and to preserve the preoperative facial contour. Sixteen fixed dentate cadaver mandibles were studied. Osteotomies were performed in a monocortical fashion, 5 mm anterior to the mental foramen, cephalad to the inferior border of the mandible, caudal to the expected position of the apices of the anterior teeth, and at the midline. Then the size of the corticocancellous block was measured.

Incorporating the Use of PRP Into Practice

For those who are serious about incorporating the use of PRP into their practice, Petrungaro recommends purchasing the textbook Tissue Engineering by Lynch, Genco, and Marx (Quintessence Publishing Company, 1999). This textbook is an excellent source of information on

Dental Implantology Update"

June 2001

47
Therapeutic irradiation shortly after implantation inhibits direct contact between the HA implant and the surrounding bone. Bone contact occurring before irradiation was minimally affected. Regardless of the interval between implantation and irradiation, postimplantation irradiation inevitably delays bone remodeling. V sectional imaging of the whole maxilla and mandible CT of the maxilla with and without methods for dose reduction (number of axial slices and mA settings reduced) CT of the mandible without methods for dose reduction Dose measurements were carried out with two different types of phantoms. Here, an effective dose results from the sum of all mean organ doses to radiosensitive organs or tissues. A grouping was made for simulations of intraoral radiography using E-Speed film with round and rectangular collimation, followed by survey examinations and crosssectional imaging with conventional and computed tomography. The kV settings were highest for CT (120 kV); all other radiographic exposures studied were exposed at kV settings ranging from 60 kV to 80 kV. During all extraoral imaging, patients were exposed to distinctly higher mA settings. Cross-sectional imaging of a single-tooth gap with conventional tomography required settings between 196 mA and 523 mA. The effective dose ranged from 0.001 mSv for a periapical radiograph to 0.564 mSv for a standard examination with CT of the maxilla. Intraoral radiography was connected with the lowest effective dose as long as single images were taken. Generally, examinations of the maxilla resulted in a higher effective dose. The estimated mortality risk varied according to the differences in the effective dose. Panoramic radiography imparts a 30% lower risk to the patient than a full-mouth survey taken with rectangular collimation and a 53% lower risk than a full-mouth survey taken with round collimation. The risk related to cross-sectional imagi ng is different for CT and conventional tomography. When the whole maxilla or mandible is imaged with conventional tomography or CT using standard procedures, the risk is lower for conventional tomogra-

Spiral film tomography for cross-

phy, especially in the mandible. If methods for dose reduction in CT are applied, the risk for CT examinations can be decreased by 57%. However, if conventional tomography is used to study a single-tooth gap, the risk is only 30% of the risk imposed by CT with dose reduction.

Imaging Techniques in Implant Dentistry

Periapical radiography. Although absence of the screen requires a dose higher than otherwise necessary, the effective dose and biologic risk for the patient from an E-Speed periapical radiograph of the molar region is five times lower than that of a panoramic radiograph. Panoramic radiography. If determination of the bone width is possible by clinical findings, panoramic radiography techniques may be the only radiographs necessary for treatment planning. Conventional and computed tomography. The available bone volume
cannot be judged only from panoramic radiography. With conventional tomography, it is possible to obtain cross-sectional images that can be used to determine bone width. Contemporary machines for panoramic radiography generally include the possibility of curved linear tomography, parallel linear tomography, or spiral tomography. Differences may be seen in the depiction of images, the power of object delineation, and the dose to the patient. A decisive difference between conventional and computed tomography is that conventional tomography generally applies a lower dose of radiation to the patient. If the complete maxilla or mandible is examined with crosssectional images, the dose involved in conventional tomography is about 80% of that associated with CT. If methods for dose reduction are applied to CT, the dose to the patient can be reduced to 50% of that associated with conventional tomography when the complete

Dula K, Mini R, van der Stelt PF, et al. The radiographic assessment of implant patients: Decisionmaking criteria. Int J Oral Maxillofac

Implants 2001; 16:80-89.

This report described the criteria and process used to evaluate implant patients as performed in one institution. An acceptable clinical examination and an appropriate radiographic examination are mandatory prior to every implant surgery. If the clinical examination and radiographic findings with plain films do not provide sufficient information about alveolar process morphology, there are two possibilities for crosssectional imaging of both the maxilla and mandible, namely, conventional or computed tomography (CT). With CT, axial slices from the maxilla and mandible can be recorded. In a series of studies, dose measurements were conducted with i maging techniques commonly used in oral radiology. The imaging techniques comprised simulations of: Panoramic radiography with conventional technique (film)

Panoramic radiography with digital technique (charge-coupled device [CCD]) Curved-linear tomography for cross-sectional imaging of three definite locations of the mandible with digital technique (CCD) Spiral film tomography for crosssectional imaging of a singletooth gap in the maxilla and mandible with two different x-ray units

June 2001

Dental Implnntology Update'"

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maxilla or mandible is examined. However, if an edentulous region of one to three teeth is examined, the dose from conventional tomography is smaller than that from CT with dose reduction. The hypothetic mortality risk from dentomaxillofacial radiology may be put in its proper place by comparing it with the hypothetical mortality risk of general radiologic imaging techniques. The risk from dental radiology may be the lowest in medical radiology; however, the risk from maxillofacial radiology is comparable to the risk from conventional exposures in general radiology. For this reason, a classification is proposed that outlines when to perform cross-sectional imaging: Class 1: Anterior segments in the maxilla (from canine to canine) Class 2: Posterior segments distal to the canines in the maxilla Class 3: Anterior segments in the mandible (from canine to canine) Class 4: Posterior segments distal to the canines in the mandible Prior to implant placement, it seems appropriate to consider panoramic radiography as a standard radiographic examination for referred patients because it provides a low biologic risk and gives an excellent survey and an accurate means of determining implant length in both the maxilla and mandible. Periapical radiographs may be used to complete the findings in regions not sharply depicted in the panoramic radiograph. In situations that require more than five periapical images, panoramic radiography may be used instead.

Axiom No. I
General considerations. A distinction should be made between treatment planning and follow-up. Prior to implant placement, it seems appropriate to consider panoramic radiography as a standard radiographic examination for referred

Brazilian College of Oral Implantology-June 29-30, 2001, Sao Paulo, Brazil. For more information, contact: BCOI, (55) 11983-3171.

Calendar
Philadelphia. For more information, contact: AAP, (312) 787-5518, or fax: (312) 573-3225.

patients because it provides a low biologic risk while giving an excellent survey and an accurate means of determining implant length in both the maxilla and mandible.

Hands-On Bone Grafting and Implant Placement Surgical Workshop with Cadavers-July 6-7,2001, Miami. For more information, contact: MECC, (305) 6631628, or fax: (305) 663-1644. American Association of Oral/Maxillofacial Surgery Annual Meeting-September 12-16, 2001, Orlando. For more information, contact: AAOMS, (800) 822-6637, or fax: (847) 6786286. FDI Annual World Dental Congress-September 27-October 1, 2001, Kaula Lumpur, Malaysia. For more information, contact: FDI World Dental Federation, (44) 171-935-7852, or fax: (44) 171-4860183.
Periodontology Annual Meeting-October 6-10, 2001,

Australasian Osseo-integration Society October 10-14, 2001, Perth, Australia. For more information, contact: Petrie International, (61) 8-9257-2088, or fax: (61) 8-9257-2099.

American Dental Association Annual Meeting-October 13-17,2001, Kansas City, MO. For more information, contact ADA, (312) 440-250; or fax: (312) 4402800. American Academy of Implant Dentistry Annual Meeting-November 14-18,2001, New Orleans. For more information, contact: AAID, (312) 3351550, or fax: (312) 335-9090.
and Implant Placement Surgical Workshop with CadaversNovember 23-24,2001, Miami. For more information, contact: MECC, (305) 663-1628, or fax: (305) 663-1644. V

Periapical radiographs may be used to complete the findings in regions not sharply depicted in the panoramic radiograph. Considering the dose involved, intraoral radiography may be considered the standard radiographic examination during follow-up, particularly for implants in the anterior region of the maxilla or for scientific studies. In situations that require more than five periapical images, panoramic radiography may be used instead.

Axiom No. 2
Applications for cross-sectional imaging. In the mandible, cross-

sectional imaging should be used when planning a fixed prosthesis in the completely edentulous mandible.

Hands-On Bone Grafting

Axiom No. 3
Optional applications for crosssectional imaging. In both the maxilla

American Academy of

and mandible, conventional or computed tomography can be used when it is impossible to assess bone volume by means of clinical examination because of unfavorable softtissue conditions. V

Dental Implantology Update"

June 2001