Cover test.qxp_Mise en page 1 12/09/2018 11:14 Page1 CaSepstodeont Studies September 2018 ion SPECIAL ECDolIleTct ION R.T.R. Full resorption... strong new bone formation Case Studies Collection_RTR_Synthesis.qxp_Mise en page 1 31/08/2018 10:56 Page2 Case Studies Collection_RTR_Synthesis.qxp_Mise en page 1 31/08/2018 10:56 Page3

Content

Bone Augmentation Biomaterials for bone regeneration in oral surgery: A multicenter study to evaluate the clinical application of “R.T.R.” ...... 04 P. Brunamonti Binello, G. Galvagna, M. Galli, M. Labanca

Use of ß-tricalcium phosphate for bone regeneration in oral surgery ...... 12 G. Galvagna, P. Brunamonti Binello, M. Galli, M. Labanca ß-tricalcium phosphate used with onlay graft for horizontal bone augmentation yielded preferable result: a case report ...... 22 Yaqian Chen, Qingqing Wu, Yi Man

Post-extraction sockets Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction sockets ...... 27 O. H. Arribasplata Loconi

Use of R.T.R. and PRF as filling material in post extraction sockets ...... 36 P. González, O. González, C. Zenteno, J. Urrizola

Alveolar Ridge Preservation Alveolar Ridge Preservation With Alloplastic Material ...... 40 Ana I. Coello Gómez, Selene P. Navarro Suárez, Daniel Torres Lagares, Jose Luis Gutiérrez Perez Clinical case of alveolar ridge preservation with alloplastic material: Results at 6 months ...... 46 Dr. S. P. Navarro Suárez, Dr. D. Torres Lagares, Dr. J. L. Gutiérrez Pérez

Alveolar preservation with R.T.R ...... 50 Dr Gabriela Vilar Pineda Periodontal defects R.T.R. and aggressive periodontitis ...... 59 D. Bouziane, K. L. Makrelouf, M. Bouziane

Alloplastic Grafts - Beta-tricalcium phosphate ...... 67 Mario Ernesto García-Briseño Periodontal intraoseous defects and post-extraction compromised socket. Treatment with Beta Tricalcium Phosphate ...... 74 Dr. Mario Ernesto García Briseño

Sinus Lift Sinus Floor Augmentation with ß-Tricalcium Phosphate (R.T.R. Septodont) ...... 79 Mario Ernesto García-Briseño

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Biomaterials f or bone regeneration in oral surgery: A multicenter study to evaluate the clinical application of “R.T.R.” (ß-Tricalcium Phosphate)

Paolo Brunamonti Binello : Consultant Professor, University of Genoa Giuseppe Galvagna : Private practice, Catania, Italy Massimo Galli : Private practice, Pistoia, Italy Mauro Labanca : Consultant Professor in Oral Surgery and Anatomy, Milan, Italy

In Literature there isn’t any conflicting data about the clinical results obtained in Oral Surgery for bone regeneration using Biomaterials of either animal or synthetic origin. (1) What is the most important, however, is the creation of a microenvironment suitable for the proliferation and differentiation of hard tissues, such as to successfully promote the regeneration of new bone at the implant-prosthetic purposes. (1-2) For this reason, therefore, the Authors always prefer the use of synthetic materials with reduced risk of inflammation and complete absence of potential cross infections. (1) The Goal of this study is, therefore, to illustrate - through a case series - short term results of a multicenter research on bone regeneration in Oral Surgery by using an heterologous filling material that consists of ß-Tricalcium Phosphate, called R.T.R.

Introduction

International Literature about bone regeneration the surgical technique), turned out to be predic - in implant dentistry describes many different table if done correctly. (3) available surgical techniques and the following The Literature data, then, show how - osteogenic are the principal: distractions aside - the use of a biomaterial • Guided Bone Regeneration (G.B.R.) (regardless of its origin, whether animal or • Bone Grafting synthetic) is helpful if not indispensable to the • Osteogenic Distractions attainment of an adequate clinical outcome. (4) Each of the above mentioned methods, while Finally, the use of semi-permeable barriers - presenting different and precise application whether or not absorbable membranes - rather limits (mostly related to the type of defect and than metal grids, in order to maintain a suitable

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space, has proved indispensable in G.B.R., while genesis, understood as a budding center of it is still extremely discussed in other regenerative deputies to the new bone genesis: techniques. (5) - Osteoinduction: stimulation of the differentiation In fact, when we speak about Biomaterials in of mesenchymal cells in preosteoblasts. Regenerative Oral Surgery it is appropriate to - Osteoconduction: biological scaffold as a support make a distinction between the following to new cells in the differentiation process. elements: - Semi-permeable membranes : they allow the It is deduced that the new bone tissue formation stabilization of cloth and the selection of cell occurs if the following organic conditions exist: lines that will colonize the bone defect (space - Availability of mesenchymal cells capable of maintainer = maintenance of biological space). differentiating following the osteoinductive input - Filling material : Support the membrane and - Presence of osteoinductive input ("Osteoin - act as a "scaffold" for the migration, growth ductive Boost"), which initiates the differentiation and differentiation of pre-osteoblasts into of mesenchymal preosteoblasts in osteoblasts osteoblasts. - Existence of an osteoconductive environment To contribute to the regeneration process, here that promotes the colonization and proliferation are the following basic mechanisms of Osteo - of graft.

R.T.R. (ß-tricalcium phosphate)

Except for autologous bone, on the fundamental into the site of regeneration: this creates an concepts of Osteogenesis, remains today still ideal ionic concentration with an alkaline pH, open the debate as to which type of currently which stimulates the activation of alkaline phos - available bone grafting material is the best. (6) phatase enzyme, which is essential to the ossification process. (6-8) Given that, the Authors have carried out a multi - center research about clinical application of a Then, all resources of this study and the attention synthetic filler (already known for years on the of the authors are focused on the use of ß-Trical - market) based on ß-Tricalcium Phosphate for cium Phosphate called “R.T.R.” basically because bone regenerative purposes, called “R.T.R.” this synthetic biom aterial would possess - as a (Resorbable Tissue Replacement). (6) prerequisite - all the features that a generic

The Ca 3(PO 4)2 powder (treated with naphthalene filling material should have -with the exception and subsequently compacted by sintering) form of Osteinduction. (6-7-8) the ß-tricalcium phosphate, with macropores of These characteristics may be summarized as a diameter between 100 and 300 microns ideal, follows: that is, for the Osteoconduction. (6) - High biocompatibility and minimum autoimmune This heterologous biomaterial, once placed, is response completely absorbed in 6 or 9 months, and - Bio-inert (absence of local inflammatory reac - replaced by new bone. (6-7) tion) Recent studies on large crestal defects show a - Ideal time of resorption for the type of bone significant increase in the regeneration with defect ß-Tricalcium Phosphate already after 2 weeks - Total reabsorption compared to the other control sites, thereby - Excellent osteoconductivity proving the effectiveness of this filling material. (7) - Good packaging During resorption, in addition, ß-Tricalcium Phos - - High handling during surgery phate provides with Ca ions and phosphate - Absolutely no risk of cross-infection transmission

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In particular, since “R.T.R.” is completely resor - implant-prosthetic rehabilitation, in contrast with bable over a period of time, reasonably useful many other filling materials that do not resorb for important bone defects resolution, the authors completely - and allow only a repair instead of a think “R.T.R.” is particularly appropriate for all healing of the bone defect. (8-9) regenerations conducted for the purpose of

Materials and methods

This multicenter Study provides for the regene - Regarding the type of defect, it is deliberately ration of bone tissue with ß-tricalcium phosphate excluded to standardize the same, in terms of ”R.T.R.” in patients with a residual bone defect morphology and etiopathogenesis, in order to of the maxillary and with implant-prosthetic verify the regenerative effectiveness of “R.T.R.” rehabilitation purposes. in different conditions of bone atrophy (and, The selection of patients is randomized. However, therefore, of different “regenerative thrusts”). in order to standardize the number of cases, It is, therefore, decided to treat the following this random selection requires that patients clinical situations: have the following basic requirements: - Post-extractive sites - Aged between 20 and 60 years - Bone regeneration around implants placed - Either male or female in areas with deficiencies in bone or post- - Non-smokers extraction - In good general health - Overall G.B.R. (sinus lift or major bone defects) - Having at least a residual crestal bone defect

Case series

The Authors, from 4 different cities and from In all cases, the patients were subjected to anti - different working situations (private practice, biotic therapy with 200 mg / day of Doxycycline hospital and private clinic) have treated (in 2 doses daily beginning the day before 12 patients with the following bone defects: surgery up to 8 days after the intervention), to - N 3 peri-implant defects daily repeated rinses with chlorhexidine and - N 2 sinus floor lifts therapy with FANS as needed (Ibuprofen 800 mg - N 4 post extractive sockets / day in single-dose). - N 3 bone defects of various types

Case Report no.1

The first is a case report of a 54-year-old male permeable membranes. (Fig. 4-5-6-7-8) patient, in good health general conditions, with About 6 months after the first surgery, the next a mandibular residual cyst in area 46. (Fig. 1-2-3) step will involve the placement of one implant. In accordance with the patient, we opted for an The local objective examination and routine intervention of Partsh II, filling the remaining radiographic examination showed a good healing cavity with R.T.R. granules without using semi- short-term. (Fig. 9-10-11)

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Fig. 1-2-3 : Mandibular residual cyst in area 46.

Fig. 4-5-6-7-8 : Intervention of Partsh II and filling of the remaining cavity with R.T.R. without using semi-permeable membranes.

Fig. 9-10-11 : The local objective examination and routine radiographic examination showed a good healing short-term.

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Case Report no.2

The second case report is a 45-year-old female For this case the syringe form of R.T.R. has patient, in good general health conditions with been chosen. edentulous in area 25-26 and progressive The fixtures had a good primary stability, equal atrophy of the corresponding alveolar process. to about 60 newtons. (Fig. 14-15) (Fig. 12-13) The subsequent exposition of the implants and In accordance with the patient, by full-thickness the beginning of the prosthetic phase will be mucosal flap in the area 25-26, we opted for a managed about 6 months after sinus lift proce - transcrestal sinus floor lift with a R.T.R. graft dure. and simultaneous placement of two fixtures. The good health of the superficial soft tissues In this case R.T.R. has been used also as a and surveys Rx screening show the excellent filling material around implants contextually. health of deep tissues in short term. (Fig. 16-17)

Fig. 12-13: Edentulism in area 25, 26 with partial atrophy of the alveolar process residue.

Fig. 14-15: Full-thickness mucosal flap in the area 25-26 and transcrestal sinus floor lift with a R.T.R. graft to a simultaneous placement of two fixtures. R.T.R. has been used also as a filler around implants.

Fig. 16-17: The good health of the superficial soft tissues and surveys Rx screening show the excellent health of deep tissues in short term.

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Case Report no.3

The third case report involves a 52-year-old executed a graft of R.T.R., presented in a cone female patient, in good general health conditions, with collagen. (Fig. 21-22-23-24-25) who has been subject to avulsion of the elements About 6 months following R.T.R. graft will be 16 and 17, because they were irreparably positioned an implant. compromised and extremely symptomatic. Also in this clinical case as in the others the (Fig. 18-19-20) local objective examination and the Rx screening In area 16, for regenerative purposes, has been showed an excellent recovery in the short term.

Fig. 18-19-20 : Avulsion of the elements 16 and 17 due to a severe periodontal defect.

Fig. 21-22-23 : In area 16, for regenerative purposes, has been executed a graft of R.T.R.

Fig. 24-25 : Immediate post op clinical and radiological situation.

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The on-going research, currently in the initial Discussion phase, involves a series of stages, in which will also be performed (if and where possible) the The post-surgical follow-up in the short term implant-prosthetic rehabilitation of bone defects (which provides an objective local examination treated and, if possible, a histological evaluation and Rx control after 8 days and also in following suitable to document the degree of absorption weeks after the first surgical step) showed that and regeneration. (10-11) in all cases treated were found the following items: • Good immediate healing of superficial soft tissues Conclusion • Excellent radiographic condition of deep tissues • Absence of autoimmune reactions The interesting initial and partial results obtained • Absence of local reactive inflammation to date are encouraging for the authors to • Absence of excessive bleeding continue the study in progress. The goal remains to propose a predictable thera - The authors also confirm that R.T.R. material, peutic solution, though alternative and not a besides having a packaging extremely functional, replacement of the other existing and fully has expressed high qualities of practicality and described in the Litterature. (12-13-14-15-16) manageability during the surgical procedure, in its mode of use, application and compaction (in all the forms of packaging).

Authors (left to right) Mauro Labanca : From 2001 to 2005: Creator and Director of the very first Italian course “Anatomical surgery with Cadaver lab”. From 2006 up to date: Director of the course of “Anatomical surgery with Cadaver lab” at the Institute of Anatomy at the University of Wien, Austria. 2006: Creator and Director of the first Master of Marketing and Communications in Medicine and Private Dentistry at IULM University (Libera Università di Lingue e Comunicazione) in Milan, Italy. From 2007 up to date: International Consultant in Dentistry for MEDACorp, Leerink Swann LLC Boston, MA, USA. From 2007 up to date: Consultant Professor of Oral Surgery in the department of Dentistry at “Vita e Salute University” - S. Raffaele Hospital - Milan, Italy. From 2008 up to date: Consultant Professor of Anatomy in the Department of Medicine at the University of Brescia, Italy. 2009: Co-Founder and vice President of the Italian Society for the study of Oro- Facial Pain (SISDO). 2011: Founder and President of the “Labanca Open Academy” (LOA) devoted to the improvement of all aspects of Dentistry. Created to have an open network among all participants of his courses. From 2012: Visiting professor at the Periodontology Department of the “Universitat Internacional de Catalunya”, Barcellona, Spain. Paolo Brunamonti Binello : Consultant Professor, University of Genoa. Executive Doctor “Galliera Hospital”, Genoa, Italy Giuseppe Galvagna : Private practitioner, Catania, Italy Massimo Galli : Oral surgeon and private practitioner, Pistoia, Italy

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References

01. Labanca M, Leonida A, Rodella FL Natural or synthetic biomaterials in Dentistry: Science and ethic as criteria for their use. Implantologia 2008; 1:9-23 02. Nociti FH Jr, Machado MA, Stefani CM, Sallum EA, Sallum AW. Absorbable versus nonabsorbable membranes and bone grafts in the treatment of ligature-induced per-implants defects in dogs. Part I. A clinical investigation. Clinical Oral Implants Research 2001;2:115-120. 03. Hardwick R, Scantlebury T, Sanchez R, Whitley N, Ambruster J. Membrane design criteria for guided bone regeneration of the alveolar ridge. In: Buser D, Dahlin C. Schenk RK, eds. Guided bone regeneration in implant dentistry. Chicago, IL: Quintessence. Ist edition, 1994;101- 136. 04. Dahlin C, Linde A, Gottlow J, Nyman S. Healing of bone defects by guided tissue regeneration. Plastic and Reconstructive Surgery 1988;81:672-676. 05. Hockers T, Abensur D, Valentini P, Legrand R, Hammerle CH. The combined use of bioreasobable membranes and xenografts or autografts in the treatment of bone defects around implants. A study in beagle dogs. Clinical Oral Implants Research 1999;6:487-498. 06. Coetzee AS. Regeneration of bone in the presence of calcium sulfate. Arch Otolaryngol 1980;106.405-409. 07. Irrigary J. A study of atomic elements diffusion in coral after implantation in vivo. Publication de Biomat Bordeau, France 1987:241-248. 08. Guillemin G. The use of coral as bone graft substitute. Journal of Biomedical Materials Research 1987;21:557-567. 09. Gielkens PF, Bos RR, Raghoebar GM, Stegenga B. Is there evidence that barrier membranes prevent bone resorption in autologous bone graft during the healing period? A systematic review. Int J Oral Maxillofac Implants 2007;22(3):390-398. 10. Raymond AY, Sotirios V. Comparative evaluation of decalcified and non-decalcified freeze-dried bone allograft in Rhesus monkeys. I. Histologic findings. Journal of Periodontology 2005 Jan;76(1):57-65. 11. Sommerland S, Mackenzie D, Johansson C, Atwell R. Guided bone augmentation around a titanium bone- anchored hearing aid implant in canine calvarium: an initial comparison of two barrier membranes. Clin Implant Dent Relat Res 2007;9(1):22-33. 12. Maeda H, Kasuga T. Control of silicon species released from poly(lactic acid)-plysiloxane hybrid membranes. J Biomed Mater Res A 2007; [Epub ahead of print]. 13. Mattout P, Mattout C. Conditions for success in guided bone regeneration: retrospective study on 376 implant sites. Journal of Periodontology 2000;12:1904-1909. 14. Chou AM, Sae-Lim V, Hutmacher DW, Lim TM.: Tissue engineering of a periodontal ligament-alveolar bone graft construct. Int J Oral Maxillofac Implants 2006;21(4):526-534. 15. Kohal RJ, Hurzeler MB. Bioresorbable barrier membranes for guided bon regeneration around dental implants. Schweiz Monatsschr Zahnmed. 2002;12:1222-1229. 16. Hartman GA, Arnold R.M, Mills MP, Cochran DL, Melloing JT. Clinical and histologic evaluation of inorganic bovine bone collagen with or without a collagen barrier. International Journal Periodontics Restorative Dentistry 2004;2:127-135.

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Use of ß -tricalcium phosphate for bone regeneration in oral surgery A multicenter study to evaluate the clinical applications of R.T.R. (Resorbable Tissue Replacement)

Giuseppe Galvagna : Private practice, Catania, Italy Paolo Brunamonti Binello : Consultant Professor, University of Genoa Massimo Galli : Private practice, Pistoia, Italy Mauro Labanca : Consultant Professor in Oral Surgery and Anatomy, Milan, Italy

In prosthetic implant rehabilitation, loss of bone volume in atrophic maxillae is one of the major problems faced by surgeons in their clinical practice. In the presence of horizontal and vertical bone defects, atrophic ridges need to be restored to make them suitable for implant placement and for restoration of masticatory and aesthetical functions. For this reason, in recent years the term “GBR” has been closely associated with the concept of prosthetically guided implantology. The purpose of this study is to demonstrate the osteoconductive properties of synthetic biomaterials, particularly ß -tricalcium phosphate or R.T.R., and its benefit for a suitable GBR.

Introduction

In order to obtain effective bone regeneration through adequately prepared surrounding bone using natural or synthetic fillers, a series of (cortical perforation) favourable conditions must occur that allow the - stabilization and maintenance of volume under - body to perform the bone growth (15) as follows: neath the membrane - presence of a blood clot with a high concen - - protection of blood clot with a membrane, tration of mesenchymal stem cells (MSC) with the function of the stabilization of the capable of evolving in the osteoblast line and clot, protecting growing vascular structures of endothelial cells forming a rich vascular and blocking the migration of epithelial cells, network which proliferate faster than bone cells. - presence of vital bone tissue, from which In 1980 Nyman and Karring first introduced the osteogenic and angiogenic cells originate concept of guided tissue regeneration (GTR) of

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periodontal tissues, showing that the cells of Graft biomaterials soft tissue can grow faster than bone tissue (10). Thus, based on the results obtained, the migration The alloplastic biomaterials available on the of soft tissue cells above the implanted material market represent an excellent alternative to must be stopped, thereby blocking migration autologous bone graft and are classified into within the porosity of the same material, thus two large groups: bioinert and bioactive, accor - promoting osseointegration rather than fibroin - ding to their interaction when they come into tegration. The main characteristic of a membrane contact with the receiving site. should be semi-permeability, i.e. the presence of The main requirement of a synthetic biomaterial porosity approximately 22 microns in diameter. is to have a surface porosity that must promote Initially, a thin vascular network and a primary colonization and development within its structure. fibrous osteoid tissue -also called primary spon - These porosities must measure between 200/400 giosa- will begin to form within the clot. The microns in diameter (Lynch et al., 2000; Bauer latter is later mineralized thanks to osteoblasts and Muschler, 2000). Synthetic biomaterials that cover its surface, forming a new poorly have been the subject of many studies, though calcified cortical bone. their long term results have not always been The process stops when intertrabecular spaces considered. (1-2-3) narrow due to the formation of new bone tissue, Today, osteoblastic cells or bone morphogenetic until they reach the characteristic dimensions proteins (BMP obtained with in vitro cultures) of Havers channel which, along with concentric can be added to a graft material (4-5) to enhance lamellae, originate primary osteomas. All this its osteoinductive and osteoconductive abilities occurs during the first 3-4 months, though and therefore reduce the time required for cells actual bone remodelling requires more time, as colonization. (6-7-8) it creates secondary spongiosa. Among alloplastic biomaterials, ß -tricalcium Research conducted by Hämmerle in 1996 (11) phosphate is the one that mostly displays a on human subjects confirmed what had stable bond with bone neoformation; indeed, previously been observed in animals, i.e. in the its characteristics have made it suitable for presence of large bone defects, regeneration use in orthopedics since the early 1900s. In can be limited to the more peripheral areas of the presence of H2O it becomes instable, the defect, while less activity is observed in the turning into hydroxyapatite, and this characte - central area, where granules of biomaterial ristic makes it suitable as an osteoconductive remain over time, though less frequently when material (Coetree, 1980, De Leonardis and tricalcium phosphate is used. The process of Pecora, 1999; 2000). ossification always starts from the walls of the ß-TCP is characterized by a lower Ca/P ratio, defect toward the center of the clot, along the which makes it more soluble than natural apatite. newly formed vessels. The Beta form is commonly obtained by mixing A number of studies clearly describe the rege - calcitis (CC) and dibasic calcium phosphate nerative ability of autologous bone compared anhydrous (DCPA). The product obtained is with synthetic biomaterials, but unfortunately rapidly cooled, and Alfa-TCP is obtained. Conver - not without negative aspects. Indeed, collection sely, extended repeat baking at 800/950°C from the donor site is very often painful for the results in the beta form (9-12-13). patient; additionally, this results in longer surgical Multiple studies conducted on the TC and bone procedures and postoperative pain ; finally, the interaction have shown that histological exami - implanted material has a high degree of resorption nation at four months shows an initial bone (not a negligible factor). neoformation in the intergranular spaces and in The materials used for bone regeneration are the surface porosity that helps guided bone grouped into: Autogenous bone, allogenic bone, formation. Indeed, the granules are reabsorbed xenogenic bone, alloplastic bone. by phagocytosis, releasing Ca/Mg and phos -

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phates in the surrounding bone tissue, thereby Unlike hydroxyapatite, R.T.R. is progressively activating alkaline phosphatase, a key ossification and totally reabsorbed, thereby releasing calcium process. Between 6 and 18 months, fibroblasts and phosphate ions that participate actively in begin invading the biomaterial, activating the the formation of new bone tissue. Over a period extracellular dissolution process which ends of time between 6 and 9 months, which may with the calcification phase. If this should occur vary according to the patient’s physiological sooner, graft integration, rather than biodegra - response, while stimulating bone regeneration, dation, would happen. (5-6-7-8). R.T.R. is progressively reabsorbed, leaving space for bone neoformation.

R.T.R. Indications: • Post-extraction sites Synthetic, biocompatible and totally resorbable • Filling post-extraction sites to maintain the 99% pure tricalcium phosphate bone replace - dimensions of alveolar bone ment, available in granules and in a cone shape, • Implant defects for regeneration in periodontal defects, implant, • Sinus lift procedure post-extraction bone defects and bone lesions • Reconstruction of peri-implant defects following endodontic surgery. • Filling periodontal pockets with two or more walls The micro and macro-porous R.T.R. structure, • Residual cavities after oral surgery (like cyst) with macropores measuring between 100 and • Filling defects after apicectomy 400 µm and micropores measuring less than • Alveolar filling following extraction of impacted 10 µm. teeth. These morphological characteristics allow excel - lent osteogenic cell in-depth colonization and easy compacting.

Materials and methods

We conducted a multicenter study to evaluate The cases treated were identified in the following the clinical application of R.T.R. (ß -tricalcium clinical situations: phosphate). - Post-extraction sites - Bone regeneration around implants placed in This study examines the regeneration of bone areas with bone loss or post-extraction. defects with R.T.R. (ß -tricalcium phosphate) in - GBR (sinus lift or major bone defects). patients eligible for prosthetic implant rehabili - In all cases, patients received antibiotic therapy tation. Patients were randomly selected, with 1 gr every 8 h of Amoxicilline plus Clavulanic according to the following key criteria: Acid (starting 24 hours before surgery up to day - aged between 20 and 60 years 5 post-surgery), repeated daily rinses with chlo - - either male or female rhexidine and therapy with FANS (ibuprofen - non-smokers 800 mg/day in single dose), as necessary. - in good general health - having at least one crestal bone defect (no morphology and etiopathogenesis restrictions).

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Case Report no.1

Patient : Female Age : 30 History : odontogenic cyst in maxillary bone at 2.1. Cyst was removed in October 2013. Vertical guided regeneration with resorbable membrane and R.T.R. was performed. Implant placement: bone peak follow-up intraoral X-ray in consecutive months. 2 nd surgery ISQ value: 61.

Fig. 1-4: Different projections of radiographic C.T images show the large bone defect in site 2.1. Fig. 5: Temporary prosthesis to cover the cosmetic defect.

Fig. 6: X-ray image before Fig. 7: X-ray image after 5 months. Fig. 8: X-ray after insertion Fig. 9: The local objective grafting. of the implant. examination and routine radiographic examination showed a good short-term healing.

Fig. 10: The ISQ test confirms a good stability of the implant. Fig. 11: To obtain a good aesthetics of the final prosthesis is important to condition the soft tissue with the healing screws that favors the emergence profile.

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Case Report no.2

Patient : female Age : 60 History : large cyst in upper maxillary bone extending from 2.2 to 1.1. The cyst was removed and the cavity was filled with R.T.R. enhanced with PRGF (platelet-enriched plasma) and simultaneous placement of five implants was also performed.

Fig. 12-13: Presence of large cysts of 2.1. The oral cavity examination shows a poor oral hygiene.

Fig. 14-15: Removal of the cyst; it is very Fig. 16-17-18: Filling the bone cavity with granular R.T.R. important to remove all residual epithelial.

Fig. 19-20: During the same surgery were included five implants. Fig. 21: X-ray control after five months.

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Case Report no.3

Patient : female Age : 50 History : severe atrophy of the alveolar ridge, upper right jaw, affecting the area of 1.3, 1.4, 1.5, 1.6. These teeth were extracted and the alveolar ridge was reconstructed with R.T.R., covering biomaterial with Tabotamp (oxidized cellulose).

Fig. 22-23: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

Fig. 24-25-26: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

Fig. 27-28: Use of Tabotamp to cover the Fig. 29-30: The local examination after Fig. 31-32: The radiographic image after graft. 10 days. 4 months showed an increase in the vertical dimensions.

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Case Report no.4

Patient : female Age : 30 History : root fracture of 1.6, previously treated with root canal treatment and large crown composite reconstruction. The roots were carefully extracted, and an implant was placed, using the interadicular septum bone and by performing an elevation of the maxillary sinus with osteotomes. The alveoli were filled with R.T.R. and covered with a collagen membrane.

Fig. 33-34: Fracture of the first molar with the insertion of implant with post-extraction procedure.

Fig. 35-36-37: Extraction was performed with piezosurgery technique to preserve the alveolar bone.

Fig. 38-39-40: The gap was filled using R.T.R.-size cone.

Fig. 41-42: The intraoral examination and radiographic examination after 4 months showed good integration of the implant.

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Case Report no.5

Patient : female Age : 64 History : loss of 2.2 and 2.3 due to trauma. CT revealed a significant resorption of buccal vestibular alveolar process. Two implants were placed (measuring 3.3 mm in diameter and 13 mm long) and the gap was filled with R.T.R. Re-opening was done after 5 months and evaluation of osteointegration with Osstel. 2.2 showed a value of 22-ISQ, and 2.3 –ISQ 64.

Fig. 43-44-45: Severe post-traumatic atrophy of the alveolar process in place 2.2- 2.3.

Fig. 46-47: Insertion of two implants with “split-crest” surgical Fig. 48-49: The gap between the two margin bone was filled with technique. phosphate-tricalcium R.T.R.

Fig. 50: X-ray control after 4 months Fig. 51-52: The intraoral examination does Fig. 53-54: The ISQ value confirms a good showed a good bone density. appreciate a good recovery and an increase osseointegration. in bone volume.

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Case Report no.6

Patient : female Age : 55 History : residual cyst at 3.6. To proceed to prosthetic molar rehabilitation with an implant, the cyst was extracted and the cavity was filled with R.T.R.; after a 4-month period for bone regeneration, the implant was placed.

Fig. 59: Wound at 30 days.

Fig. 55-56: The C.T. examination before Fig. 57-58: After having removed the cyst, Fig. 60: X-ray at 3 months. surgery showed a residual cyst. to speed up the healing time, the cavity has been filled with R.T.R. granules.

Conclusion

Based on the results obtained in the short term, occurred in any of the cases examined. The the authors confirm the excellent properties of most encouraging data came from the obser - R.T.R., both in the first weeks of healing and in vation of the compactness and density of the the following months, and they consider it an bone neo-formation, which easily allowed the excellent alternative to autologous bone grafts. placement of implants with high ISQ values No inflammatory reactions or loss of bone both during and after the placement of R.T.R. volume evaluated clinically and radiographically graft.

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Authors (left to right) Giuseppe Galvagna : Dental practitioner, Catania, Italy Paolo Brunamonti Binello : Consultant Professor, University of Genoa. Galliera Hospital, Genoa, Italy Massimo Galli : Oral surgeon, dental practitioner, Pistoia, Italy Mauro Labanca : Professor of Oral Surgery and Anatomy, Milan, Italy

References

01. Labanca M., Leonida A., Rodella FL: Natural synthetic biomaterial in Dentistry: Science and ethics as criteria for their use. Implantologia 2008; 1:9-23 02. Ohgushi H, Caplan AI: Stem Cell Technology and Bioceramics: From Cell to Gene Engineering. J Biomed Mater Res 48(6): 913-927, 1999 03. Anselme K: Osteoblast adhesion on biomaterals. Biomaterials 2000 Apr; 21(7):667-81. 04. Toquet J, Roahanizadeh R, Guicheux J, Couillaud S, Passuti N, Daculsi G, Heymann D: Osteogenic. Potential in vitro of human bone marrow cells cultured on macroporous biphasic 05. Maddox E, Zhan M, Mundy GR, Drohan WN, Burgess WH: Optimizing human demineralized bone matrix for clinical application. Tissue Eng 6(4): 441-448, 2000 calcium phosphate ceramic. J Biomed Mater Res. 1999 Jan; 44(1):98-108. 06. Gauthier O, Bouler JM, Aguado E, Pilet P, Daculsi G: Macroporous biphasic calcium phosphate ceramics: influence of macropore diameter and macroporosity percentage on bone ingrowth. Biomaterials 1998 Jan Feb;19(1-3):133-9. 07. Martinetti R, Belpassi A, Nataloni A, Biasini V, Martignani G: Idrossiapatite porosa sintetica per sostituzioni ossee: Caratterizzazione Chimico-Fisica. Biomateriali: Atti del Congresso; 51 55, Roma Enea, 1999 08. Martinetti R, Belpassi A et al.: Key Engineering Materials Vols. 192-195 (2001), 507-510 – Proceeding of the 13th Int. Symp. On Ceramics in Medicine, Bologna, Italy, 22-26 Nov. 09. Caplan AI: Mesenchymal stem cells. J Orthop Res 9: 641-650, 199 10. Nyman S, Lindhe J, Karring T et Rylander H: New attachment following surgical treatment of human periodontal disease. Journal of Clinical Periodontology 9: 290-296, 1982; 39 11. Hämmerle CH, Brägger U, Bürgin W, Lang NP: The effect of subcrestal placement of the polished surface of ITI implants on marginal soft and hard tissues. Clin Oral Implants Res. 1996 Jun;7(2):111-9 12. Chin M: Distraction Osteogenesis in Maxillofacial Surgery. In Lynch SE, Genco RJ, Marx RE (eds). Tissue Engineering – Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co, Inc, 1999; 147 13. Arun K. Garg: Grafting Materials in Repair and Restoration. In Lynch SE, Genco RJ, Marx RE, (eds). Tissue Engineering - Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co, Inc, 1999; 83 14. Scipioni A, Bruschi GB, Calesini G: The edentulous ridge expansion technique: A five-year study. Int J Periodont Rest Dent 14: 451-459, 1994 Trans Tech Publications, Switzerland 15. Schenk RK and Buser D: Osseointegration: a reality. Periodontology 2000, Vol 17. 1998, 22.35 16. Bauer TW and Muschler GF: Bone graft materials. An overview of the basic science. Clin Orthop Relar Res, 2000 Feb;(371):10-27.

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ß-tricalcium phosphate used with onlay graft for horizontal bone augmentation yielded preferable result: a case report Yaqian Chen, Qingqing Wu, Yi Man State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, China

Introduction

Rehabilitation of teeth lost due to disease, been described in different oral surgeries. (6.7.8.9) trauma, surgery or congenital problems with Recently, the synthetic bone graft based on implant-supported prosthesis has become a ß-tricalcium phosphate which can be completely common practice worldwide. (1) However, various absorbed in 6 to 9 months has been reported bone defects often exist in implant area. In to be used in different oral surgeries such as some severe atrophic cases, alveolar bone must alveolar preservation and periodontal defects be restored before or in combination with implant with satisfactory clinical and histologic results. placement. Bone augmentation using onlay (10.11.12) Tricalcium phosphate grafts has struc - bone grafts which are harvested from either tural characteristics which is similar to bone intraoral or extraoral sites is currently one of the tissue, moreover, during reabsorption it can most reliable techniques with potential success provide ion calcium and magnesium for surroun - rate. (2,3) However, the use of autografts only ding tissue, thus creating a correct ionic as onlay grafts has some drawbacks such as environment, which could activate more alkaline the high morbidity at the donor site, limited phosphatase for further bone synthesis. (13) bone graft supply and the need for multiple The purpose of this case report is to present surgical sites. (4,5) Therefore, synthetic bone clinical and radiographic results for a patient graft materials have become a popular choice treated with ß -TCP bone substitute with auto - for bone augmentation during last decade and genous bone block harvested in situ as onlay the application of different bone substitutes has grafts for horizontal bone augmentation.

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Case Report

A 36 year-old healthy male with good oral site and dressed on the autogenous block. hygiene required implant supported prosthesis (Fig.4-9) Then the incision was closed after a for his two maxillary central incisors and right titanium mesh and a barrier membrane was lateral incisor (tooth 11,12,21). (Fig1,2) Pre- covered. (Fig.10) Routine anti-inflammatory surgery radiographic examination showed therapy and prophylactic antibiotics were pres - insufficient bone volume for placement of cribed. implants 3.3 mm in diameter. (Fig.3) Six months later, a reentry surgery was performed. After administration of local anesthesia, crestal The bone graft material has been replaced by and vertical incisions were made to expose the new formed bone which is an inspiring result as labial surface of the absorbed alveolar ridge compared with six months ago. Two implants and two autogenous bone block was harvested were inserted at tooth 12 and 21with good apical to the recipient site from the basal base primary stability. (Fig.11-13) CBCT examinations and ß -TCP bone graft (RTR Syringe package, presented favorable outcome of the horizontal Septodont, France) was placed in the donor bone augmentation. (Fig.14-15)

Fig. 1: Pre-surgery oral examination showed acceptable vertical Fig. 2: Pre-surgery oral examination from occlusal view indicated height of the frontal bony shelf in anterior maxillary. horizontal bone defect.

Fig. 4: Vertical and crestal incision was made to expose the labial surface of anterior alveolar bone.

Fig. 5: Two bone blocks outlined by ultrasonic instruments from basal base apical Fig. 3: Presurgery CBCT examination showed width and height of to the recipient site. alveolar ridge before bone augmentation.

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Fig. 6: Use the filter of the syringe package sucking blood in Fig. 7: Fix two blocks on the alveolar ridge with titanium screws. surgical area.

Fig. 8: Inject R.T.R. graft into the donor site. Fig. 9: Finish dressing R.T.R. graft on the blocks.

Fig. 10: Flap closed with a releasing Fig. 11: Occlusal view six months later. Fig. 12: Horizontal alveolar ridge was incision. augmented by new formed bone.

Fig. 14: CBCT of tooth 12 immediately after bone augmentation , six month later and immediately after implantation.

Fig. 13: Two implants were placed in the anterior maxillary.

Fig. 15: CBCT of tooth 21 immediately after bone augmentation , six month later and immediately after implantation.

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Discussion

This case report showed the potential advantage The bone graft used in this case consists of of ß -tricalcium used with onlay graft for bone pure ß -tricalcium with an appropriate macro- augmentation. The clinical and radiographic and micro-scale which turn to be good osteo - results show that this synthetic graft has been conductivity and make this graft a potential replaced by new formed bone six months later. scaffold for osteoblasts. Moreover, pure ß -TCP Among all the graft materials, tricalcium phos - can be totally absorbed in 6 months thus phate is of special interest because it is a leaving no residuals in the implant area which resorbable and osteoconductive biomaterial. (15) may influence the remodeling of bone regene - The in vivo osteoconductivity of synthetic bone ration. (15) graft is dependent on several properties including ß-TCP used with autogenous bone block as surface morphology, chemical composition and onlay graft for anterior bone augmentation in geometry at both the macro- and micro-scale. this case gained inspiring result which is a moti - The pore size and interconnectivity of biomaterials vation for more oral surgeons to conduct similar can significantly influence the exchange of fluids cases. Despite the favorable result of the primary through grafts and the delivery of ions, nutrients surgery, long term observation is still needed within and through the bone substitute. (16,17,18) for a series of clinical cases.

Authors: Yi Man From 2007 up to date: Clinical Lecturer of Implant Center, West China College of Stomatology, Sichuan University, China. From 2010.09 – 2012.07: Clinical instructor, Clinical Lecturer of Tufts University School of Dental Medicine, Boston, USA. From 2011.6-2012.7: Research Scholar of Massachusetts General Hospital of Harvard University, Massachusetts, USA. From 2012.6 up to date: Standing Committee Member of Special Committee of Implant, Medical Society of Sichuan province, China. From 2012.7 up to date: Associate professor of Oral Implantology Department, West China School of Stomatology, Sichuan University, China. From 2012.9 up to date: Standing Committee Member of Committee of Implantology, Medical Society of China. From 2013.2 up to date: Chair of Oral Implantology Department, Chair of Educational and research section of Oral Implantology, West China School of Stomatology, Sichuan University, China. From 2014.11 up to date: International team for Implantology fellow.

Yaqian Chen Resident of Department of Implantology, West China Hospital of Stomatology, Sichuan University, China.

Qingqing Wu Resident of Department of Implantology, West China Hospital of Stomatology, Sichuan University, China.

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References

01 Levin L. Dealing with dental implant failures. J Appl Oral Sci 2008;16:171-175. 02 Hill NM, Horne JG, Devane PA. Donor site morbidity in the iliac crest bone graft. Aust N Z J Surg 1999;69:726-728. 03 Isaksson S, Alberius P. Maxillary alveolar ridge augmentation with onlay bonegrafts and immediate endosseous implants. J Cranio maxillofac Surg 1992;20:2-7. 04 Chiapasco M, Zaniboni M, Rimondini L. Autogenous onlay bone grafts vs. alveolar distraction osteogenesis for the correction of vertically deficient edentulous ridges: a 2-4-year prospective study on humans. Clin Oral Implants Res 2007;18:432-440. 05 Felice P, Marchetti C, Iezzi G, Piattelli A, Worthington H, Pellegrino G, et al. Vertical ridge augmentation of the atrophic posterior mandible with interpositional bloc grafts: bone from the iliac crest vs. bovine an organic bone. Clinical and histological results up to one year after loading from a randomized-controlled clinical trial. Clin Oral Implants Res 2009;20: 1386-1393. 06 Wang M. Developing bioactive composite materials for tissue replacement. Biomaterials 2003; 24:2133-2151. 07 Schmitt CM, Doering H, Schmidt T, Lutz R, Neukam FW, Schlegel KA. Histological results after maxillary sinus augmentation with Straumann ® BoneCeramic, Bio-Oss ®, Puros ®, and autologous bone. A randomized controlled clinical trial. Clinical Oral Implants Research 2013; 24:576-585. 08 Klijn, R.J., Meijer, G.J., Bronkhorst, E.M. & Jansen, J.A. A meta-analysis of histomorphometric results and graft healing time of various biomaterials compared to autologous bone used as sinus floor augmentation material in humans. Tissue Engineering Part B: Reviews 2010; 16: 493–507. 09 Tamimi F, Torres J, Al-Abedalla K, Lopez-Cabarcos E, Alkhraisat MH., Bassett DC., Gbureck U, Barralet JE.. Osseointegration of dental implants in 3D-printed synthetic onlay grafts customized according to bone metabolic activity in recipient site. Biomaterials 2014; 35:5436-5445. 11 Brkovic BM, Prasad HS, Rohrer MD, Konandreas G, Agrogiannis G, Antunovic D, Sándor GK. Beta- tricalcium phosphate/type I collagen cones with or without a barrier membrane in human extraction socket healing: clinical, histologic, histomorphometric and immunohistochemical evaluation. Clin Oral Investig 2012; 16: 581-590. 12 Stavropoulos A, Windisch P, Gera I, Capsius B, Sculean A, Wikesjö UM. A phase IIa randomized controlled clinical and histological pilot study evaluating rhGDF-5/ß -TCP for periodontal regeneration. Journal of Clinical Periodontology. 2011; 11:1044-1054. 13 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with beta- tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin Oral Implants Res. 2006; 17:102-108. 14 Hirota M, Matsui Y, Mizuki N, Kishi T. Combination with allogenic bone reduces early absorption of beta- tricalcium phosphate (beta-TCP) and enhances the role as a bone regeneration scaffold. Experimental animal study in rat mandibular bone defects. Dent. Mater. J. 2009; 28: 153. 15 Rodella LF, Favero G, Labanca M. Biomaterials in Maxillofacial Surgery: Membranes and Grafts. International journal of Biomedical science 2011; 7: 81-88. 16 Gendler E. Perforated demineralized bone matrix: a new form of osteoinductive biomaterial. J Biomed Mater Res 1986;20:687-697. 17 Habibovic P, Yuan H, van der Valk CM, Meijer G, van Blitterswijk CA, de Groot K. 3D microenvironment as essential element for osteoinduction by biomaterials. Biomaterials 2005;26:3565-3575. 18 Walsh WR, Vizesi F, Michael D, Auld J, Langdown A, Oliver R, et al. ß -TCP bone graft substitutes in a bilateral rabbit tibial defect model. Biomaterials 2008;29:266-271.

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Bone regeneration with ß-tricalcium phosphate (R.T.R.) in post-extraction sockets Prof. Oscar Hernán Arribasplata Loconi Department of Odontology, Norbert Wiener University, Lima, Peru

Two clinical cases are presented in which ß-tricalcium phosphate "R.T.R." (Septodont) was used for post-extraction bone regeneration to preserve the alveolar ridge in height and width for future dental implants placement. Resorption of the filling material is demonstrated by a histological study as well as good clinical and tomographic results.

Introduction

The dimensions of the alveolar ridge may be alveolar ridge augmentation. 7, 8 seriously affected following dental extraction as The main advantages in using bone grafting a result of normal alveolar bone remodelling. 1, 2 substitutes are their unlimited availability and Although the bone loss occurs in both the hori - the reduction in the morbidity associated with zontal and vertical aspects, greater bone loss is the harvest of autologous bone at a second observed in the horizontal dimension. 3 intraoral or extraoral surgical site. 9 Schropp et al. 1 found that the greatest loss of The development of synthetic or combined alveolar height occurred during the first 3 months biological-synthetic alloplastic materials for bone and less than 50% of the width of the ridge was regeneration has become more widespread lost after 1 year. Other studies observed losses during recent years. This type of material may amounting to 40% of height and 60% of width integrate or resorb completely, forming lamellar after only 6 months. 3,4 bone at the site. Inorganic ceramics based on calcium phosphate ( α-tricalcium phosphate, During the 80's and in the early 90's, bone ß-tricalcium phosphate and hydroxyapatite) grafting procedures were commonly performed contrast with bone regeneration materials of using autogenous bone or fresh frozen allografts, biological origin in the sense that the synthetic but the advent of efficient and safe processing materials have their physical and crystallographic and the sterilisation techniques led to an increa - characteristics clearly defined in addition to the sing use of bone graft substitutes for the chemical properties (chemical composition and procedures of periodontal regeneration and purity). 11

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ß-tricalcium phosphate has been used in various The results obtained in this study confirm the studies in animals and in humans in order to main observations of other clinical and experi - demonstrate its efficiency as a bone regeneration mental studies performed any other groups of biomaterial. professionals.

Aims Case Report no.1

Histological, tomographic and clinical evaluation A 29-year-old woman came with a fistula at of alveolar ridge preservation in width and height the level of tooth 2.5; grade II tooth mobility. following the insertion of ß-tricalcium phosphate On X-ray examination, a radiopaque image “R.T.R”. (Septodont) in post-extraction sockets was observed in the canal showing a post and for future dental implants placement. core restoration; periapically, a radiolucent lesion was observed, potentially revealing an infectious process. Materials & Methods

In order to be able to observe whether the alloplastic filling material, ß-tricalcium phosphate “R.T.R.” (Septodont) resorbs completely, a histological study was performed 12 months after grafting the material in the alveolar socket, the biopsy being done at the time of implant placement. Fig. 1: Presence of the fistula at tooth 2.5. This material was used in cone presentation when the post-extraction socket was well preserved by atraumatic extractions. However the material was used in syringe presentation combined with resorbable membranes in bone defects in which the vestibular bone plates were lost. Absorbable polyglycolic acid sutures of 4/0 zeroes with a sharp needle 3/8 circle were used. The grafted sockets were observed radiogra - phically after 6 and 12 months.

Fig. 2: Fistulography (cone no. 25). Results

The material’s ability to resorb and form new bone yielded excellent results, demonstrated by a histo - logical study done 12 months after placement, as well as by a case of bone regeneration using a membrane (imminent vestibular destruction), for which a control tomography was performed after 18 months showing excellent results. Fig. 3: Panoramic X-ray.

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Fig. 4: Atraumatic extraction. Fig. 5: Extracted tooth. Fig. 6: ß-tricalcium phosphate (R.T.R.).

A B C

Fig. 7: a) Partial thickness flap, b) Placement of the ß-tricalcium phosphate (R.T.R.) in the alveolar socket, c) Suturing of the flap with Vicryl 5/0 zeroes figure-of-eight sutures.

The tooth was extracted and the ß-tricalcium phosphate filling material "R.T.R" (Septodont) was placed, without a membrane; a partial thick - ness flap was raised in order to cover the graft and the wound was sutured using 4/0 polyglycolic acid sutures with a sharp needle 3/8 circle. She was prescribed: Amoxicillin 500 ml/clavulanic acid 125 mg once every 8 hours x 5 days. Ibuprofen 400 mg once every 8 hours for 3 days. Soft diet x 48 hours. Fig. 8: Clinical examination (12 months). The sutures were removed after 2 weeks. She was advised to get X-ray controls after 3, 6 and 12 months. After 12 months, the patient returned for consultation; she had been unable to do so before for reasons beyond her control. A clinical examination was performed (Fig. 8 ) in addition to a periapical X-ray with a metal mesh (grip). On the periapical X-ray done after 12 months a circumscribed radiopaque image, round in shape, was observed in the area of the graft as if it were apparently an encapsulation of the material (Fig. 9) . Fig. 9: Periapical X-ray (12 months).

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After 12 months, it could be clinically observed how the alveolar ridge had been maintained both in width and height and in order to verify whether the ß-tricalcium phosphate (R.T.R.) had resorbed completely, we took a sample from the area to be implanted and performed a histo - logical study (Fig. 10) . A B The treatment plan was thoroughly implemented for a correct insertion and placement of the dental implant. We knew that computerised axial tomography would provide a more precise diagnosis with respect to bone width and height. However since a single dental implant was involved and moreover a fairly well preserved ridge was clinically observed, we used the clinical mapping method. Doing our measurements, we had a palatine vestibular width of 8 mm and a width of 7 mm mesiodistally. The calculation of the height using C the periapical X-ray done with metallic mesh Fig. 10: a) Tissue sample, removed using a 2mm trephine drill, in the area in which the dental implant is to be inserted. b,c) Histological (grip) and a parallel method gave us an approxi - results after 12 months. Haematoxylin eosin tincture under light mation of the actual height, which was 10 mm. microscopy. New bone formation at the level of the ß-tricalcium phosphate absorption site. After obtaining all the measurements of 8x7x10mm, it was decided to perform maxillary of the preparation was taken, inserting a paral - sinus lift using Summer's technique. leling pin in the alveolar socket (Fig. 12b) , which showed us correct parallelism with the prepa - Dental implant placement ration; it was observed how the paralleling pin Using a trephine drill 2 mm in diameter, we remained exactly 2 mm away from the sinus removed bone tissue from the alveolar ridge for floor (Fig. 12c) , since it was taken with a grip; its histological study in which we wanted to then Summer's technique was performed find out whether the ß-tricalcium phosphate approach to the Schneider membrane using (R.T.R.) had resorbed completely. The sample osteotomes, from crestal bone leaving 1-2 mm was placed in 10% formocresol. of residual bone before the floor of the maxillary Then we positioned our surgical guide in order sinus 13 . to perform the sequential drilling for implant This dimension of bone was increased by means placement, using helical drills; a control X-ray of pressure, pushing the membrane upwards

A B C

Fig. 11: Clinical mapping. a) Placement of the saddle-shaped acrylic on the area for taking of measurements, tooth 2.5. b) Taking of measurements (file no. 25). c) Transfer of measurements to the trimmed model.

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A B C

Fig. 12: Preparation for implant placement. a) Paracrestal incision and raising of the flap. b) Insertion of the paralleling pin. c) X-ray showing 2 mm before reaching the maxillary sinus.

without perforating the latter and creating the sutured with circumferential sutures. Vicryl 5/0 space required to place biomaterials or the zeroes was used for synthesis (Fig. 14 a) . The implant. postoperative X-ray was performed confirming Once the sinus floor elevation was achieved, the elevation of the sinus floor by approx. which could allow a gain between 3 and 4 mm 3.5 mm. (Fig. 14b) in height 13-15, the implant, Conexão of She was prescribed: Amoxicillin 500 ml/clavu - 11.5 x4mm cylindrical internal hexagon, was lanic acid 125 mg once every 8 hours x 5 days. inserted; in this case we succeeded in elevating Ibuprofen 400 mg once every 8 hours for 3 days. the sinus floor by 3.5 mm. (Fig.13) Soft diet x 48 hours. Finally, a partial thickness flap was performed The sutures were removed after 2 weeks. The with 2 liberating incisions in order to be able to patient was advised to wait for 6 months for confront the soft tissues in the palatine direction; osseointegration. The results of the histological figure-of-eight sutures and X (cross) sutures study showed bone neoformation with absence were inserted in order to protect the tissue and of ß-tricalcium phosphate (R.T.R.) filling material. avoid collapse; the liberating incisions were

Fig. 13: Maxillary sinus lift with osteotomes (Summer's technique) and placement of the 11.5 x 4 cylindrical, internal connection Conexão implant.

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Fig. 14: Full thickness flap and suture with Vicryl 5/0 zeroes. g) Postoperative X-ray showing the 3.5 mm maxillary sinus lift achieved using Summer's technique.

Implant activation

Fig. 15: Open-tray impression taking, application of transfer and analog on the impression.

Fig. 16: Prepared abutment and application of the porcelain crown.

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Case Report no.2

A 54-year-old woman came with grade III tooth was done, in addition to the use of a resorbable mobility at tooth 1.1. On X-ray examination, a membrane. A partial thickness flap was radiopaque image was observed in the canal performed in order to cover the graft and the showing a post and core restoration. The patient membrane, the wound was sutured using 4/0 presented with an obvious root fracture on polyglycolic acid sutures with a sharp needle clinical examination. 3/8 circle. The sutures were removed after Atraumatic extraction of the tooth was performed, 2 weeks. She was recommended to get X-ray then the guided bone regeneration procedure controls after 3, 6 and 12 months. with ß-tricalcium phosphate (R.T.R. - Septodont)

Fig. 1: Initial photo. Tooth 1.1 with extrusion and grade III mobility. Fig. 2: Initial X-ray. a) Tooth 1.1, presence of an excessively wide post and core, the probable cause of root fracture. b) X-ray with grip.

Fig. 3: The major root fracture can be Fig. 4: Extraction of tooth 1.1, loss of the Fig. 5: R.T.R. in cone presentation. confirmed when raising the full thickness vestibular bone plate due to the fracture flap. which remained for a long period in the mouth.

Fig. 6: Major vestibular bone loss. Fig. 7: Placement of the R.T.R. cone. Fig. 8: Modelling of the R.T.R. cone.

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Fig. 9: Insertion of a collagen membrane Fig. 10: Interrupted figure-of-eight sutures. Fig. 11: Interrupted figure-of-eight sutures. due to an important vestibular bone loss. A partial thickness flap was performed to Palatine view. cover the membrane.

Fig. 12: Ridge preservation in width and height. The appearance of recessions at the level of Fig. 13: Final X-ray. teeth 1.2 - 2.2 had been explained to the patient before surgery.

Fig. 14: Tomography 18 months after surgery in order to check bone regeneration before Fig. 15: Bone regeneration in the area inserting a dental implant. corresponding to tooth 1.1 was visible.

Conclusion

• ß-tricalcium phosphate (R.T.R.) has proven to using a membrane, since vestibular destruction be a good osteoconductive material for bone was imminent, where a control tomography regeneration following the filling of a post- was performed after 18 months showing extraction socket, allowing the preservation excellent results. of the alveolar ridge in order to place a dental • It is easy to use and handle. implant. • The results obtained in this project confirm • It s ability to resorb and form new bone yielded the main observations of other clinical and excellent results, demonstrated by a histolo - experimental studies performed any other gical study done 12 months after placement, groups of professionals. as well as by a case of bone regeneration

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References

01. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313-323. 02. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 2006;26:19-29. 03. Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodonto.l 1998; 69: 1044-1049. 04. Iasella JM, Greenwell H, Miller RL, et al. Ridge preservation with freeze-dried bone allograft and a collage membrane compared to extraction alone for implant site development: A clinical and histologic study in humans. J Periodontol 2003;74:990-999. 05. Schallhorn RG, Hiatt WH, Boyce W. Iliac transplants in periodontal therapy. J Periodontol 1970;41:566-580. 06. Tonetti MS, Hammerle CH. Advances in bone augmentation to enable dental implant placement: Consensus Report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008;35:168-172. 07. Cortellini P, Bowers GM. Periodontal regeneration of intrabony defects: an evidence-based treatment approach. Int J Periodontics Restorative Dent 1995;15:128-145. 08. Mellonig JT, Bowers GM, Bright RW, Lawrence JJ. Clinical evaluation of freeze-dried bone allografts in periodontal osseous defects. J Periodontol 1976;47:125-131. 09. Rawashdeh MA, Telfah H. Secondary alveolar bone grafting: the dilemma of donor site selection and morbidity. Br J Oral Maxillofac Surg 2008;46:665-670. 10. Gustavo Avila-Ortiz; Satheesh Elangovan; Nadeem Karimbux. Bone Graft Substitutes for Periodontal Use Available in the United States. Clinical Advances in Periodontics; Copyright 2012. DOI: 10.1902/ cap.2012.120043. 11. Horch HH, Sader R, Pautke C, Neff A, Deppe H, Kolk A. Synthetic, pure-phase ß-tricalcium phosphate ceramic granules (Cerasorb) for bone regeneration in the reconstructive surgery of the jaws. Int J Oral Maxillofac Surg. 2006;35(8):708-13.

Author: Prof. Oscar Hernán Arribasplata Loconi Studied Dentistry at the University Inca Garcilaso de la Vega. (Peru-2001). Second Specialization in Periodontics and Implants at the University National of San Marcos (Peru-2010). Master of Dentistry at the University Inca Garcilaso de la Vega (Peru-2011). Certified in Orthodontics at the Dental Association of Peru ( Lima-2005). Certified in Teaching Strategies and competency assessment at the University Norbert Wiener (Peru-2012). Post-Graduate Course in Forensic Dentistry at the University National of San Marcos ( Peru -2011). Post-Graduate Course in Auditing and Forensic Dentistry at the University Peruana Cayetano Heredia (Peru-2012). Professor of Periodontology II, Theory and Practice at the University Norbert Wiener (Lima; 2010-2013). Professor invited to the second specialty in Oral Rehabilitation at the University National of San Marcos (2012). Ex-Professor of Periodontal Surgery at the University National of San Marcos (2010). Publication of articles in the specialty of Periodontics. Member of the Peruvian Association of Periodontology and Osseointegration. Lecturer at National and International Conferences.

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Use of R.T.R. and PRF as filling material in post extraction sockets Dr. Patricio González, Dr. Omar González, Dr. Claudia Zenteno, Dr. Joaquín Urrizola San Sebastian University, Concepción, Chile

Introduction

Currently, the great majority of the extractions this, the use of platelet rich fibrin (PRF), a second are followed by the immediate use of an implant. generation platelet concentrate, that acts as a In some cases the bone volume is not enough bioscaffold and has multiple growth factors, can to get the desired primary stability, in that case accelerate the process of regeneration 3. the clinician will need a first surgery where he The characteristics of R.T.R. are its porosity, would win the bone volume required for that that helps in the formation of stronger clots, no implant, and then a second surgery for the final systemic toxicity and its resorbability that placement of the implant 1. promotes new bone formation in 3 - 6 months. To obtain the best results possible, the use of a In synergy with this, PRF thanks to its growth material that guides the bone regeneration is factors promotes the new bone formation and, necessary and ß -tricalcium phosphate has proven as an optimized clot, helps to get a faster rege - a great efficacy in helping and maintaining the neration of the extraction socket and to have a space for the bone regeneration 2. In addition to more predictable outcome 4, 5 .

Case report

A 59 year-old woman, systemically healthy and was explained to the patient with the risks and under periodontal treatment, requires the extraction benefits and an informed consent was signed. of the left central incisor (2.1) and left lateral Local anesthesia was administered to the patient. incisor (2.2) to be rehabilitated with osseointegrated The teeth were extracted with a forceps taking implants in a second surgery after the alveolar care to preserve the alveolar walls. After the preservation surgery. The lateral incisor presents extraction, a full mucoperiostal flap was elevated a radiolucent lesion around the root and no which allowed to confirm the great loss of presence of vestibular wall in 2.1. The surgery alveolar bone.

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Fig. 1: Extraction of 2.1 Fig. 2: Extraction of 2.2 Fig. 3: The two alveolar sockets

Fig. 4: The extracted dental pieces Fig. 5: Mucoperiosteal flap elevation

Two blood tubes of 9 ml without anticoagulant used as a membrane 6, 7 . were obtained from the patient’s ante cubital R.T.R. was fragmented to get a better adaptation vein for the production of the PRF. The PRF to the defects, and once mixed with the PRF was produced following Choukroun protocol membrane, it was placed in the defects. When (3000 rpm by 10 min) 6, 7 and then compressed the graft was ready the exudate was then into two membranes 8, 9 . The exudate of the applied to it. When suturing, the membrane compression was collected with a syringe to was applied with a pocket technique to ensure be applied over the bone graft. One of them its intimate contact with the bone graft 10 . The was cut and mixed with R.T.R. fragments to be flap was closed with simple stitches and in used as the bone graft and the other one was first intention.

Fig. 6: R.T.R. cone Fig. 7: PRF clot Fig. 8: PRF clot before mixing with the graft

Fig. 9: PRF membrane mixed with the graft Fig. 10: Application of the graft Fig. 11: Graft placed

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Fig. 12: Application of the exudate Fig. 13: Suture Fig. 14: PRF membrane

Fig. 15: Immediate post-operative situation Fig. 16: X-ray pre-operative Fig. 17: X-ray 1 week post- operative

Discussion

The use of platelet concentrates has become Beta-Tricalcium Phosphate has a proven biocom - popular during the last 10 years, but among patibility, osteoconductivity and resorbability. them, one of the simplest and cheapest form As it resorbs, R.T.R. releases calcium and phos - has raised as one of the best options, the PRF. phate ions which help in the neo formation of As a cheap and free access platelet concentrate, the bone 11 . its homogenous bibliography supports its good The combination of two materials with not results as an adjuvant in multiple surgeries like known local or systemic toxicity and that syner - sinus lifts, intrabony defect fillings and of course gize in the formation of bone should reduce the bone grafting 6, 7 . Although PRF acts as a bios - time needed to place the implants. The bone caffold, it lacks a good resistance and resorbs graft that best suits the PRF characteristics still in around 28 days, thus the use of a material needs further and deep study, but R.T.R. seems that sustains bone regeneration is necessary, to perfectly fit all the characteristics to maximize and that material is R.T.R. the bone regeneration.

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Authors Dr. Patricio González Catalán : Oral Surgeon, University of Concepción, Chile. Specialist of Periodontics and Implantology, University of Chile. Specialist of Oral Pathology, University of Concepción, Chile. Resident in department of Maxillofacial Surgery, St Sebastian University, Chile. Ex-docent of Periodontics Chair, University for Development, Concepción, Chile. National and international speaker. Dr. Omar González : Oral Surgeon, University of Concepción, Chile. Docent, Chair of Anatomy, St Sebastian University, Concepción, Chile. Resident in department of Oral Rehabilitation, St Sebastian University, Concepción, Chile. Dr. Claudia Zenteno : Specialist of Oral Rehabilitation. Master in Education in Catholic University of the Most Holy Conception, Chile. Docent coordinator of adult clinic and pre-clinic in San Sebastián University, Concepción, Chile. Secretary and active member of the Society for Oral Rehabilitation, University of Conception, Chile. Dr. Joaquín Urrizola : Degree in Dentistry, St Sebastian University, Concepción, Chile. Pending certification.

References

1. Ten Heggeler, J. M. a G., Slot, D. E. & Van der Weijden, G. a. Effect of socket preservation therapies following tooth extraction in non-molar regions in humans: a systematic review. Clin. Oral Implants Res. 22, 779–88 (2011). 2. Geurs, N. et al. Using growth factors in human extraction sockets: a histologic and histomorphometric evaluation of short-term healing. Int. J. Oral Maxillofac. Implants 29, 485–96 (2014). 3. Kang, Y.-H. et al. Platelet-rich fibrin is a Bioscaffold and reservoir of growth factors for tissue regeneration. Tissue Eng. Part A 17, 349–59 (2011). 4. Dohan Ehrenfest, D. M., Del Corso, M., Diss, A., Mouhyi, J. & Charrier, J.-B. Three-dimensional architecture and cell composition of a Choukroun’s platelet-rich fibrin clot and membrane. J. Periodontol. 81, 546–55 (2010). 5. Choukroun, J. et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 101, e56–60 (2006). 6. Del Corso, M. et al. Current Knowledge and Perspectives for the Use of Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF) in Oral and Maxillofacial Surgery Part 1: Periodontal and Dentoalveolar Surgery. Curr. Pharm. Biotechnol. 13, 1207–1230 (2012). 7. Simonpieri, A. et al. Current Knowledge and Perspectives for the Use of Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF) in Oral and Maxillofacial Surgery Part 2 : Bone Graft , Implant and Reconstructive Surgery. 1231–1256 (2012). 8. Dohan Ehrenfest, D. M. How to optimize the preparation of leukocyte- and platelet-rich fibrin (L-PRF, Choukroun’s technique) clots and membranes: introducing the PRF Box. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 110, 275–8; author reply 278–80 (2010). 9. Kobayashi, M. et al. A proposed protocol for the standardized preparation of PRF membranes for clinical use. Biologicals 40, 323–9 (2012). 10. Dohan Ehrenfest, D. M., Doglioli, P., de Peppo, G. M., Del Corso, M. & Charrier, J.-B. Choukroun’s platelet- rich fibrin (PRF) stimulates in vitro proliferation and differentiation of human oral bone mesenchymal stem cell in a dose-dependent way. Arch. Oral Biol. 55, 185–94 (2010). 11. Observations, H., Brkovic, B. M. B. & Prasad, H. S. Pratique Simple Preservation of a Maxillary Extraction Socket Using Beta-tricalcium Phosphate with Type I Collagen : Preliminary Clinical and. 74, 523–528 (2008).

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Alveolar Ridge Preservation With Alloplastic Material Ana I. Coello Gómez Dentist, Master Oral Surgery, University of Seville, Spain Selene P. Navarro Suárez Dentist, Master Oral Surgery, University of Seville, Spain Daniel Torres Lagares Co-director of the Master in Oral Surgery, University of Seville, Spain Jose Luis Gutiérrez Perez Co-director of the Master in Oral Surgery, University of Seville, Spain

Introduction and objective

Alveolar ridge preservation is done when it is differentiation of local connective tissue cells expected that following a tooth extraction this in bone-forming cells, under the influence of part will be rehabilitated by an implant to minimize one or more inductors. the bone resorption that occurs during the biolo - - Osteoconduction: formation of new bone by gical healing of the socket. Current studies the network generated by a non-vital graft allow us to expect that, with the alveolar ridge material, which allows the penetration of preservation technique, we will decrease the precursor osteoblasts present in the defect. volume loss by around 1 mm in height and The various types of grafts can be classified 3 mm in width.1 according to their origin in: autografts, allografts, xenografts, and alloplastic materials. Different techniques and materials have been - Autografts: bone grafts that come from a used in recent years, all based on three biological donor area of the same individual. They are mechanisms that promote alveolar healing: 2-4 osteogenic, but have high resorption. - Osteogenesis: formation of new bone from - Allografts: bone grafts from a member of the viable and precursor osteoblasts, transplanted same species. They can be mineralized. In with graft material. principle, they are associated with osteoin - - Osteoinduction: formation of new bone by ductive and osteoconductive properties.

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- Xenografts: bone grafts from other species with osteoconductive properties. - Alloplastic materials: bone grafts of synthetic origin (hydroxyapatite, bioactive glass, tricalcium phosphate, etc). They have osteoconductive properties.

Among the various available techniques described, the objective of this article is to present a case report of preservation with an alloplastic material without the need for membrane. Fig. 1: Preoperative intraoral view of the 1st and 4th quadrants.

Case Report

A female patient, 53 years of age, with no Fig. 2: Preoperative occlusal Fig. 3: Panoramic X-ray view of the lower arch. showing tooth 47, posterior special medical history, presented for alveolar three-unit porcelain-metal ridge preservation of tooth 47 for subsequent dental bridge, fractured, endodontically treated tooth, rehabilitation with implant. The patient had an and apical radiolucent image. endodontically-treated, infected and fractured tooth (Fig. 1-3) . The chosen treatment was its Fig. 4: Preoperative extraction and, given the risk of placing an periapical X-ray. implant in such conditions, we decided to post - pone it, preserving the alveolar ridge.

After the careful extraction of the tooth and without raising a flap (Fig. 4) , we proceeded to a thorough curettage, irrigating the socket using 0.2% chlo - rhexidine. Once the socket was disinfected, we checked that the walls were intact and proceeded to fill it with the selected biomaterial.

In this case, we used a sterile resorbable beta- tricalcium phosphate material from Septodont (R.T.R.), presented in the form of 0.3 cm³ cones, Fig. 5: Image of the socket Fig. 6: Image of the placement made of beta tricalcium phosphate granules after extraction, where we of the selected biomaterial, observe the integrity of its walls. easy handling using clamps. coated with a matrix of highly purified collagen fibers of bovine origin which, in the case of cavities that cannot be closed, prevents the granules from leaking out.

The cone was placed in the socket using clamps (Fig. 5, 6) , waiting for it to be carefully impregnated with the patient's own blood and compacting it Fig. 7: Image that shows the Fig. 8: Image where it is seen filling of the socket with the how the cone is impregnated (Fig. 7, 8) . Finally, three crossed sutures were biomaterial. with the blood from the socket. done on top, leaving the material slightly exposed

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and checking the final status by X-ray (Fig. 9, 10) . After one week (Fig. 11) , we removed the sutures As post-op instructions, the patient was and observed the start of healing of the soft instructed to rinse with 0.2% chlorhexidine tissues, also anticipating some maintenance of mouthwash, three times a day, from the second the alveolar ridge architecture, with less resorption day, and as medical treatment, amoxicillin 1 g than would occur spontaneously after simple 1 tab/8hr/7days and ibuprofen 600 mg removal of the molar. 1 tab/8 hr/7 days were prescribed.

Fig. 9: Image finishing compacting the biomaterial. Fig. 10: Immediate postoperative image where the socket suturing is visible.

Fig. 11: Immediate postoperative periapical X-ray. Fig. 12: One-week periapical X-ray.

Discussion

The case presented in this article correlates with by using biomaterials or bone substitutes. Tradi - previous studies in which, by using ß-tricalcium tionally, the ideal material, considered as "gold phosphate and collagen bone grafts, it was standard" for bone regeneration has been the possible to largely maintain the dimensions of autologous bone, taken from the patient. However, the alveolar ridge. in recent decades, new human, animal or synthetic materials have been introduced, such as beta- In oral implantology, the goal of bone regeneration tricalcium phosphate (R.T.R.), which has been techniques is to increase or maintain bone very successful in implantological surgical tech - volume for implant placement. Bone regeneration niques in experimental studies. 5-14 can be modified, by systemic factors, and also Cardaropoli et al.15 and other studies16-18

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showed that sites where preservation had phase is more recommended because it is less previously been done presented less resorption soluble than the alpha phase. at six months compared with areas without The dissolution rate of the material is related to preservation. However, even having performed its porosity, meaning that a greater porosity an alveolar ridge preservation, the crestal resorp - favors its resorption. In addition, the porosity is tion in width was 17% to 25%. essential for perfusion, since the blood vessels and neoformed bone tissue need pores of at On the other hand, it has also been studied that least 60 microns to grow. The size of the particles there is a little loss of crest height and width is also important since it has been shown that a after preservation19, but even so, Lasella et smaller size causes less inflammatory reaction al.20 concluded that the dimensions were to a foreign body, which allows a stable mecha - improved, achieving conditions favorable for nical interconnection and prevents phagocytic subsequent implant placement. disintegration 21.

The alloplastic material used in this case is From a clinical viewpoint, the various studies presented in the form of granules of beta trical - that use ß-tricalcium phosphate in oral implan - cium phosphate forming an osteoconductive tology show that about six months can be micro- and macro-porous structure that encou - considered as a bone healing period. 22-31 rages a dense growth of new bone. The case reports in the literature show some successful results and provide clinical evidence The degree of bone regeneration from tricalcium to consider for future randomized and controlled phosphate varies depending on its formulation, clinical trials that more broadly study the benefits porosity, and the size of the particles. The beta of this technique.

Conclusion

Alveolar ridge preservation is a technique that maintaining an adequate alveolar ridge for subse - has shown to significantly reduce the bone quent placement of a dental implant. resorption observed in the alveolar crest after tooth extraction, helping in the formation of When ß-tricalcium phosphate is gradually resorbed, hard tissue that is necessary for correct subse - it is replaced by bone similar to the original quent implant placement. bone, obtaining a regenerated vital bone tissue. The cone presentation, in addition to adapting ß-tricalcium phosphate (R.T.R.) has shown to to the shape of the socket, does not need to be be a good osteoconductive material for bone covered with a membrane, thus facilitating its regeneration after filling a post-extraction socket, placement and handling.

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Authors: Ana Coello Gómez (Main author) Dentist, University of Seville. Master Oral Surgery, University of Seville. Assistant Professor of the Master of Oral Surgery, University of Seville. Member of the Spanish Society of Oral Surgery (SECIB) Private practice limited to oral surgery.

Selene P. Navarro Suárez Dentist, University of Seville. Master Oral Surgery, University of Seville. Assistant Professor of the Master of Oral Surgery, University of Seville. Member of the Spanish Society of Oral Surgery (SECIB) Private practice limited to oral surgery.

Daniel Torres Lagares Dentist, University of Seville. Master Oral Surgery, University of Seville. Full Professor of the Master of Oral Surgery, University of Seville. Member of the Spanish Society of Oral Surgery (SECIB).

José Luis Gutiérrez Pérez Dentist and Oral and Maxillofacial Surgeon, University of Seville. Master Oral Surgery, University of Seville. Full Professor of the Master of Oral Surgery, University of Seville. Member of the Spanish Society of Oral Surgery (SECIB).

References 01 Orgeas et al. Surgical Techniques for Alveolar Socket Preservation: A systematic Review. Int. J. Oral Maxillofac. Implants. 2013; 28: 1049-1061. 02 Barone A, Nicoli N, Fini M, Giardino R, Calvo JL, Covani U. Xenograft versus extraction alone for ridge preservation after tooth removal: a clinical and histomorphometric study. J Periodontol 2008; 79: 1370- 1377. 03 Mardas N, Chadha V, Donos N. Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial. Clin. Oral Impl. Res. 21, 2010; 688–698. 04 Araujo M, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss collagen on healing of an extraction socket: an experimental study in the dog. Int J Periodontics Restorative Dent. 2008; 28: 123-135. 05 Sixto García lInares, Óscar Hernán Arribaspiata Loconi. Caso clínico: Utilización del fosfato tricálcico beta (R.T.R) para relleno alveolar post-exodoncia, para la posterior colocación de un implante dental. 06 Barone A, Nicoli N, Fini M, Giardino R, Calvo JL, Covani U. “Xenograft versus extraction alone for ridge preservation after tooth removal: a clinical and histomorphometric study.” J Periodontol 2008; 79: 1370- 1377. 07 Jensen SS, Aaboe M, Pinholt EM, Hjorting-Hansen E, Melsen F, Ruyter IE. Tissue reaction and material characteristics of four bone substitutes. Int J Oral Maxillofac Implants 1996; 11: 55-66. 08 Norton MR, Wilson J. Dental implants placed in extraction sites implanted with bioactive glass: human histology and clinical outcome. Int J Oral Maxillofac Implants 2002; 17: 249-57. 09 Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental implants in deficient alveolar bone sites augmented with beta-tricalcium phosphate. Implant Dent 2006; 15: 395-403.

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References

10 Ogose A, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. Comparison of hydroxyapatite and beta tricalcium phosphates as bone substitutes after excision of bone tumors. J Biomed Mater Res 2005; 72B: 94-101. 11 Linovitz RJ, Peppers TA. Use of an advanced formulation of beta-tricalcium phosphate as a bone extender in interbody lumbar fusion. Orthopedics 2002; 25 (suppl): 585-589. 12 Franch J, Diaz-Bertrana C, Lafuente P, Fontecha P, Durall I. Beta-tricalcium phosphate as a syntehetic cancellous bone graft in veterinary orthopaedics. Vet Comp Orthop Traumatol 2006; 4: 1-9. 13 Jensen SS, Broggini N, Horting-hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Impl Res 2006; 17: 237-43. 14 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with betatricalcium phosphate in humans: desnity and microarchitecture of the newly formed bone. Clin Oral Impl Res 2006; 17: 102-108. 15 Cardaropoli D, Cardaropoli G. Preservation of the postextraction alveolar ridge: a clinical and histologic study. Int J Periodontics Restestorative Dent 2008; 28: 469-477. 16 Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997; 68: 563–570. 17 Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol 1998; 69: 1044-1049. 18 Ellingsen JE, Thomsen P, Lyngstadaas P. Advances in dental implant materials and tissue regeneration. Periodontology 2000 2006; 41: 136-56. 19 Vance G, Greenwell H, Miller R, Hill M, Johnston H, Scheetz J. Comparison of an allograft in an experimental putty carrier and a bovine-derived xenograft used in ridge preservation: a clinical and histologic study in humans. Int J Oral Maxillofac Impl 2004; 19: 491–497. 20 Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, Scheetz JP. Ridge preservation with freeze- dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in humans. J Periodontol 2003; 74: 990-999. 21 Jensen OT, Garlini G, Bilk D, Peters F. Use of alloplasts for sinus floor grafting. En: Jensen OT. The sinus bone graft (2ª ed). Quintessence: Chicago 2006. pag: 201-9. 22 Zijderveld SA, Zerbo IR, van der Bergh JPA, Schulten EAJM, ten Bruggenkate CM. Maxillary sinus floor augmentation using a beta-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts. Int J Oral Maxillofac Implants 2005; 20: 432-40. 23 Mardas N, Chadha V, Donos N. Alveolar ridge preservation with guided bone regeneration and a synthetic bone substitute or a bovine-derived xenograft: a randomized, controlled clinical trial.Clin. Oral Impl. Res. 21, 2010; 688–698. 24 Ormianer Z, Palti A, Shifman A. Survival of immediately loaded dental implants in deficient alveolar bone sites augmented with beta-tricalcium phosphate. Implant Dent 2006; 15: 395-403. 25 Ogose A, Hotta T, Kawashima H, Kondo N, Gu W, Kamura T, Endo N. Comparison of hydroxyapatite and beta tricalcium phosphates as bone substitutes after excision of bone tumors. J Biomed Mater Res 2005; 72B: 94-101. 26 Linovitz RJ, Peppers TA. Use of an advanced formulation of beta-tricalcium phosphate as a bone extender in interbody lumbar fusion. Orthopedics 2002; 25 (suppl): 585-589. 27 Boix D, Weiss P, Gauthier O, Guicheux J, Bouler JM, Pilet P, Daculsi G, Grimandi G. Injectable bone substitute to preserve alveolar ridge resorption after tooth extraction: a study in dog. J Mater Sci Mater Med 2006; 17: 1145-52. 28 Sela MN. Steinberg D. Klinger A, Krausz AA. Kohavi D. Adherence of periodontopathic bacteria to bioabsorbable and non-absorbable barrier membranes in vitro. Clin Oral Impl Res 1999: 10: 445-52. 29 Szabo G, Huys L, Coulthard P, Maiorana C, Garagiola U, Barabas J, Néemth Z, et al. A prospective multicenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone for bilateral sinus elevation: histologic and histomorphometric evaluation. Int J Oral Maxillofac Implants 2005; 20: 371-81. 30 Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with betatricalcium phosphate in humans: desnity and microarchitecture of the newly formed bone. Clin Oral Impl Res 2006; 17: 102-108. 31 Trisi P, Rao W, Rebaudi A, Fiore P. Histologic effect of pure-phase beta-tricalcium phosphate on bone regeneration in human artificial jaw bone defects. Int J Perio Rest Dent 2003; 23: 69-77.

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Clinical case of alveolar ridge preservation with alloplastic material: Results at 6 months Selene P. Navarro Suárez. Odontologist. Master in dental surgery, Seville. Daniel Torres Lagares. Co-director, Master in dental surgery course, Seville. Jose Luis Gutiérrez Pérez. Co-director, Master in dental surgery course, Seville.

Introduction

The aim of this study is to demonstrate the results Current studies indicate that, using the socket of treatment with dental implants placed after preservation technique, it is possible to reduce using bone filling biomaterial: beta-tricalcium phos - this loss of volume by around 1 mm vertically phate (RTR bone grafting material - Septodont). and around 3 mm horizontally. 3 In the case As is known, when the absence of a tooth is to shown here, the patient presented an infected be restored through a dental implant after extrac - alveolus due to failed endodontic treatment and tion, even though the implant is not placed irreparable fracture. Given the risk involved in immediately for a reason, e.g. infection in the placing an implant in these conditions, it was dental alveolus, the alveolus is preserved to decided to carry out the procedure in a second minimize bone resorption as far as possible. session. In these cases, the preservation of the The postextraction resorption or bone loss alveolus is highly recommended to avoid bone mainly occurs in the vestibular wall. The measu - resorption as far as possible. From among the rements were made at 1.24 mm (vertical) and techniques available, we opted for filling with 3.79 mm (horizontal). 1 Some authors estimate biomaterial of choice. The different steps taken that 50% of the resportion volume occurs in are documented in a previous article. Once the the 12 months following the extraction and that regeneration period was over, we took a 3D two-thirds of this volume are lost in the first image of the dental arch to plan the placement three months. 2 The need to maintain hard and of the implant, which we describe below. soft tissue means that it is crucial to avoid or minimize the bone resorption caused by the loss of a tooth.

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Clinical Case

The implants were placed six to nine months after the rege - nerative surgery following a surgical protocol similar to the Fig. 1: Control Preoperative radiography of Fig. 2: 3D study cut. one previously indicated for alveolar preservation. the extraction. The 53-year- old female patient was anaesthetized in the area, a crestal incision made (Fig. 1-4) with mucoperiosteal flap [total thickness] procedure without any vertical incisions. We visualised the appearance of the regenerated bone (Fig. 5) Fig. 3: 3D reconstruction where the height Fig. 4: Preoperative intraoral view of the of the preserved ridge is seen. quadrant to be intervened. in line with the 3D image (Fig. 1-3) previously made and studied. We placed the two implants (Figs. 6-8) in accor - dance with the manufacturer's milling protocol (Straumann ®). Finally, the flap was adapted by suturing and a post-opera -

tive image was taken Fig. 5: Image showing the height and width Fig. 6: Image of implant placement (Fig .9-10) . The patient was of the preserved alveolar ridge. process I. advised to rinse with 0.5 chlo - rhexidine three times a day for 10 days, starting from the second day. As medical treat - ment, 1 g of amoxicilin every 8 hours for 7 days and 600 mg of Ibuprofen every 8 hours for days. The stitches were Fig. 7: Image of implant placement Fig. 8: Placement of the two implants in an removed after 10 days. The process II. ideal position. patient was checked over three months, and the re-entry and placement of the healing abut - ments carried out to create the soft tissue and begin the prosthetic procedure.

Fig. 9: Immediate postoperative image Fig. 10: Immediate postoperative where the suture is observed. ortopantomography radiography.

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Discussion

The dimensional changes in the alveolar ridge tricalcium phosphate is an option to be consi - following a tooth extraction considerably compro - dered, both from the clinical point of view and mise the functional and aesthetic results of from the patient's perspective. restorations made in partially edentulous areas. Following a healing period of between 6-9 months The restoration of isolated alveoloar defects it was possible to place the implants without the using implants, as is the case here, shows that need for any other regeneration procedure. 4-7 bone regeneration through the use of beta-

Conclusion

The case presented indicates that beta-trical - graft, both in the intraoral and the extraoral cium phosphate (RTR bone grafting material - areas. 8-11 Septodont) can be used successfully for bone regeneration in dental implant treatment. The patient's opinion on the treatment was very positive, both on the process itself and on the One of the main advantages of this technique appearance achieved, and on the functioning is the elimination of the inevitable morbidity observed after 12 months of monitoring. and problems associated with autologous bone

Authors: Selene P. Navarro Suárez Dentist, University of Seville. Master Oral Surgery,University of Seville. Assistant Professor of the Master of Oral Surgery, University of Seville. Member of the Spanish Society of Oral Surgery (SECIB) Private practice limited to oral surgery.

Daniel Torres Lagares Co-director, Master in dental surgery course, Seville.

Jose Luis Gutiérrez Pérez Co-director, Master in dental surgery course, Seville.

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References

01. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes in humans. Clin Oral Implants Res. 2012 Feb;23 Suppl 5:1-21 02. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003 Aug;23(4):313-23. 03. Orgeas et al. Surgical Techniques for Alveolar Socket Preservation: A systematic Review. Int. J. Oral Maxillofac. Implants. 2013; 28: 1049-1061. 04. Nkenke E, Schulze-Mosgau S,Radespiel M. Morbidity of harvesting of chin grafts: A prospective study. 2001. Clin Oral Implant Res 12:495-502. 05. Silva FM, Cortez AL, Moreira RW, Mazzonetto R. Complications of intraoral donor site for bone grafting prior to implant placement. Implant Dentistry 2006. 15, 420-426 06. Nkenke E, Wcisbach V, Winckler E, Kessler P. Morbidity of harvesting of bone grafts for the iliac crest for preprosthetic procedures: A prospective study. Int J Oral Maxillofac Surg. 2004. 33:157-163. 07. Bagain ZH, Anabtawi M, Karaky AA, Malkawi Z. Morbidity from anterior iliac crest bone harvesting for secondary alveolar ridge augmentation: an outcome assessment study. Journal of Oral & Maxillofacial Surgery. 2009. 67, 570- 575. 08. Antoun H, Sitbon JM, Martinez H, Missika P. A prospective randomized study comparing two techniques of bone augmentation: inlay graft alone or associated with membrane. Clinical Oral Implants Research. 2001. 12, 632-639. 09. FriedmannA, Strietzel FP, Maretzki B, Pitaru S, Bernimoulin JP. Histological assessment of augmented jaw bone utilizing a new collagen membrane compared to standard barrier membrane to protect a granular bone substitute material. Clinical Oral Implants Research 2002. 13, 587-594. 10. Valentini P, Abensur DJ. Maxillary sinus grafting with an organic bovine bone: a clinical report of long- term results. Int J Oral Maxillofac Implants. 2003;18:556-60. 11. Wallace SS, Froum SJ, Cho SC, Elian N, Monteiro D, Kim BS, Tarnow DP. Sinus augmentation utilizing anorganic bovine bone (Bio-oss) with absorbable and nonabsorbable membranes placed over the lateral window: histomorphometric and clinical analysis. International Journal of Periodontics and Restorative Dentistry.2005. 25, 844-852.

49 Use of ß-tricalcium phosphate for alveolar preservation; a report on a series of cases. Authors: Medina Ramírez Jorge Michel*, Gabriela Vilar Pineda**, René García Contreras***. Corresponding author: Gabriela Vilar Pineda.

Summary

ß-tricalcium phosphate is a high purity material the quadrant with the R.T.R, favorable bone that helps to safely generate bone neoformation neoformation process was observed in a after tissue extraction or loss. Preservation shorter time compared to the left quadrant, treatment was performed using a ß-tricalcium and a progressive and total reabsorption of phosphate cone (R.T.R Cone, Septodont, the R.T.R was observed after 3 months. The France) in the lower right quadrant, at the use of ß-tricalcium phosphate is a useful alter- lower third molar area (tooth 48), for research native for post-extraction alveolar preservation, purposes; it was kept under observation for improving the speed of bone regeneration. periods of 1 week, 1 month and 3 months. In

*Student of Dentistry at the National School of Higher Studies of the National Autonomous University of Mexico, León Unit (ENES UNAM León Unit). **Specialist in Oral and Maxillofacial Surgery at the ENES of the UNAM, León Unit. ***Doctor of Health Sciences at ENES/UNAM, León Unit. 50

Case Studies Collection_RTR_Synthesis2.indd 50 31/08/2018 11:01 Introduction

Bone regeneration with alveolar preservation biological process, the material is reabsorbed following tooth extraction has been a topic of and replaced by the recipient’s own bone. major significance recently due to the use of The interconnection between pores facilitates dental implants as a method of esthetic and osteoconduction. When the graft is placed functional rehabilitation;(1) the improvement at the receptor site, some serum proteins of regeneration time is therefore a significant are absorbed and retained on the surface of issue, and for such purpose alveolar preser- the particles, contributing to the subsequent vation techniques using various materials have cellular migration that will stimulate a neovas- been proposed (hard and soft tissue grafts) in cularization process in the porous structure.(3) view of maximizing tissue preservation and The R.T.R. (Resorbable Tissue Replacement), minimizing defects.(2) is composed of ß-tricalcium phosphate, a ß-tricalcium phosphate (ß-TCP) is a synthetic material used for alveolar preservation after ceramic bone graft material that has been in a tooth removal when posterior prosthetic use in medicine and dentistry for more than rehabilitation is planned. The objective of 30 years, in the fields of orthopedics, perio- the following series of clinical cases was to dontology and maxillofacial surgery. Pore size evaluate the alveolar preservation achieved varies from 5 to 500 μm, and the porosity with the use of R.T.R cones and without the ranges from 20 to 90% depending on particle use of R.T.R. by radiographic evaluations at size. For dental use, particle size is gene- three-month follow-up. Case reporting was rally less than 100 μm.(3) Used as a graft conducted in compliance with Case Report material, ß-TCP stands in for the mechanism Guidelines (CARE). of osteoconduction; when it is used in the

Report on a series of cases

Four patients were selected to conduct alveolar Patients meeting the admission criteria for preservation with the use of ß-tricalcium the clinics and oral surgery department of the phosphate (R.T.R) cones; these patients were “Escuela Nacional de Estudios Superiores”, of required to meet certain criteria. The inclusion the UNAM, León Unit, were evaluated. criteria used for this report were: patients of both sexes, retained third molars Pell & Gregory Auxiliary diagnostic studies were performed class I and II subdivision A and B, bilateral, (Panoramic radiographs, Periapical views), age range between 18 and 22 years, no perio- and no disorders being found in any patient, a dontal or periapical disease in the lower molar diagnosis was made in the full series of cases; region, and willingness to perform the alveolar retained third molars Pell & Gregory class I preservation procedure for research purposes. and II, subdivision A and B, bilateral. The exclusion criteria used for this report were: patients with uncontrolled systemic diseases, The patients signed informed consent forms in acute infectious processes, pregnant or which they are made aware of the diagnosis, lactating patients, patients with bone diseases, treatment plan and possible complications use of bisphosphonates, and poor oral hygiene. during treatment.

51

Case Studies Collection_RTR_Synthesis2.indd 51 31/08/2018 11:01 PATIENT 1

Fig. 1: Extraoral photographs Fig. 2: Intraoral photographs (A: frontal B: lateral) (A: right side B: top C: left side D: bottom)

PATIENT 2

Fig. 3: Extraoral photographs Fig. 4: Intraoral photographs (A: frontal B: lateral) (A: right side B: top C: left side D: bottom)

PATIENT 3

Fig. 5: Extraoral photographs Fig. 6: Intraoral photographs (A: frontal B: lateral) (A: right side B: top C: left side D: bottom)

52

Case Studies Collection_RTR_Synthesis2.indd 52 31/08/2018 11:01 PATIENT 4

Fig. 7: Extraoral photographs Fig. 8: Intraoral photographs (A: frontal B: lateral) (A: right side B: top C: left side D: bottom)

Fig. 9: Initial panoramic radiograph, patient 1. Fig. 10: Initial panoramic radiograph, patient 2.

Fig. 11: Initial panoramic radiograph, patient 3. Fig. 12: Initial panoramic radiograph, patient 4.

Surgical odontectomies of teeth 38 and 48 were opposite side the lower left quadrant in the area performed under local anesthesia by infiltration of tooth 38 was left with nothing placed inside with lidocaine and epinephrin 2%, 1:100,000; a the alveolus, and both sides were sutured using Newman’s incision was performed, the muco- polyglactin 910 4/0; postoperative management periosteal flap lifted, osteotomy and odon- with Amoxicillin 500 mg, 1 every 8 hours for tectomy conducted, the cavity washed, and a 5 days, and Ibuprofen 400 mg, 1 every 8 hours cone of ß-tricalcium phosphate (R.T.R) placed for 3 days; instructions for general postope- in the residual alveolus of tooth 48; on the rative measures were likewise provided.

53

Case Studies Collection_RTR_Synthesis2.indd 53 31/08/2018 11:01 A B C

D E F

G H I

J K L

Fig. 13: Surgical procedure (A) Anesthesia, (B) Incision, (C) Preparation of the flap, (D) Ostectomy, (E) Luxation, (F) Extraction, (G) Extraction sample, (H) Residual Alveolus, (I) Septodont ß-tricalcium phosphate, (J) ß-tricalcium phosphate Cone, (K) ß-tricalcium phosphate Cone transport, (L) Application of ß-tricalcium phosphate Cone, (M) Syneresis.

M

Patients were evaluated 7 days after surgery; a radiolucent image was observed in tooth 38, good evolution was observed, with an adequate corresponding to the residual alveolus; after a healing process underway; radiographically, a month of evolution, we were able to observe mixed image was observed (black and white improved healing. The area treated with R.T.R radiographic image), interpreted as the ß-tri- showed larger areas of radiopacity, interpreted calcium phosphate cone (R.T.R) in tooth 48, and as improved bone neoformation compared to the

54

Case Studies Collection_RTR_Synthesis2.indd 54 31/08/2018 11:01 residual alveolar process area at tooth 38, where a radiopaque image of the residual alveolus at slower bone formation was observed, consi- tooth 48, in addition to total reabsorption of the dering the greater areas of radiolucency. The material, as indicated by the manufacturer, and third month of observation allowed us to verify reduced bone trabeculation compared to the the presence of improved bone regeneration, residual alveolar process area at tooth 38.

Od 48 Od 38 Od 48 Od 38

1 week 1 week

1 month 1 month

3 months 3 months

6 months 6 months

Fig. 14: Control periapical radiograph patient 1 Fig. 15: Control periapical radiograph patient 2

Od 48 Od 38 Od 48 Od 38

1 week 1 week

1 month 1 month

3 months 3 months

6 months 6 months

Fig. 16: Control periapical radiograph patient 3 Fig. 17: Control periapical radiograph patient 4

55

Case Studies Collection_RTR_Synthesis2.indd 55 31/08/2018 11:01 Fig. 18: Panoramic radiograph, 3 months, patient 1. Fig. 19: Panoramic radiograph, 3 months, patient 2.

Fig. 20: Panoramic radiograph, 3 months, patient 3. Fig. 21: Panoramic radiograph, 3 months, patient 4.

Discussion

Classically, the ideal material considered for When the ß-tricalcium phosphate is reabsorbed, bone regeneration has been autologous bone. it is replaced by bone that is anatomically and However, in recent decades new materials of functionally similar to the original bone, thus human, animal or synthetic origin have been producing regenerated vital bone tissue, which incorporated into the arsenal, which have revo- means that this bone remodeling and matu- lutionized alveolar preservation techniques.(4) ration process, necessary for the functional The action of ß-tricalcium phosphate (R.T.R) loading of implants, is not disturbed by the on alveolar preservation, in comparison to material.(7) Residual elements may occasionally the natural bone healing process, has been remain, which can be demonstrated clinically proven.(5) As for its regeneration mechanism, and radiologically after 6 months.(8) ß-tricalcium phosphate (R.T.R) is a biocompa- tible material that would seem to have scaffold The overall results of the study showed that action permitting osteoblasts to grow on its at clinical follow-up, 1 year after the functional surface and invade its structure.(3) loading of implants (6 months after surgery), no It has proved to be an excellent biomaterial with failures were observed in either the implants or high success in bringing about the bone rege- the various different implant-supported pros- neration necessary to maintain adequate space thodontic options.(9) for implant insertion.(6)

Conclusion

In light of the case reports discussed above as compared to the residual alveolar process it was thus observed that after 3 months of where no alloplastic material had been placed; observation the time of bone neoformation was R.T.R is thus a choice material for the effective significantly improved where R.T.R was used, post-odontectomy preservation of alveolar bone.

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Case Studies Collection_RTR_Synthesis2.indd 56 31/08/2018 11:01 Author:

Dra. Gabriela Vilar Pineda Dental Surgeon specialized in Oral and Maxillofacial Surgery by the Faculty of Dentistry of the National Autonomous University of Mexico (UNAM) and recertified by the Mexican Council of Oral and Maxillofacial Surgery. Master of Education with focus on Innovation in Teaching Practice. She currently works as a Career Researcher and Holder of the Degree in Dentistry of the National School of Advanced Studies (ENES) at the UNAM Campus León. She actively participates as an academic in several Continuing Education Programs, recently recognized for her performance in the field of Oral and Maxillofacial Surgery with the distinction of participation in the Scientific Commission of the Mexican Association of Oral and Maxillofacial Surgery. She held the position of Associate Professor of the subject of Pharmacology in the Division of Postgraduate Studies and Research by the UNAM from August 2010 to July 2011. Coordinator of the University Diploma “Professional Update in Oral Surgery for the Dentist of General Practice” in the period of August 2008 to July 201. Coordinator of the Diploma “Training and Update for Dental Assistants” in the period of February 2010 to July 2011, both taught through the Continuing Education Coordination of the Faculty of Dentistry of the UNAM. At the bachelor's level teaches the theoretical-practical subjects of Anatomy-Physiology of the Segment, Head and Neck, Problem-Based Learning, Introduction to Surgical Procedures, Exodontia and Human Anatomy Physiology. In addition, teaches the subject of Cardiopulmonary Resuscitation; within other subjects that have been taught are Exodontia, Oral Surgery, Dental Medical Emergencies and Anesthesia in the period of July 2005 to July 2011 at the Faculty of Dentistry of the UNAM. She was Professor of Pharmacology, Toxicology and Clinical Analysis at the Faculty of Biological Sciences of the Westhill University in the period of August 2008 to December 2009. She also was Professor of Exodontia and Surgery Oral at the Faculty of Dentistry of the Autonomous University of the State of Mexico (UAEM) in the period of September 2005 to March 2006. Among the activities that he has carried out throughout his academic practice are the following: Synodal of professional exams at bachelor´s degree, Tutor and Adviser of thesis to undergraduate students of the Faculty of Dentistry at the UNAM. Tutor of undergraduate students in the programs “BECALOS”, “PARA” and “PRONABES”, all of these by the Faculty of Dentistry of the UNAM and of the National School of Advanced Studies of the UNAM Campus León. In her professional experience she has worked as a Physician assigned to the Oral and Maxillofacial Surgery Service at the Social Security Institute of the State of Mexico and Municipalities (ISSEMYM) from July 2005 to July 2011, simultaneously as a Physician attached to the Oral and Maxillofacial Surgery Service of the Teachers' Union at the service of the State of Mexico in the period of January 2009 to July 2011. She has also worked in a private practice in the “Hospital Angeles Mexico” in the period of October 2004 to April 2012 and currently a private practice in the “Hospital Angeles León”. She has publications in national and international journals with topics with Craniomandibular Dysfunction and Regenerative Medicine, including some studies on Health, Education and Happiness. She has participated as a national and international lecturer in conferences, courses and congresses in the area of Maxillofacial Surgery, with topics such as Orthognathic Surgery, Dentoalveolar Surgery, Implantology, Craniomandibular Dysfunction, Tissue Regeneration and Regenerative Medicine among others. Currently, she is responsible for projects PAPIME (Project Support Program for Innovation and Improvement of Teaching), Multi-centric and International Research Projects and joint projects with the area of Biomedical Engineering of the Autonomous University of Aguascalientes and develops research projects in the area of Craniomandibular Dysfunction and Regenerative Medicine.

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Case Studies Collection_RTR_Synthesis2.indd 57 31/08/2018 11:01 References 1. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol. 2005;32:212-8. 2. De, P., Ernesto, M., & Briseño, G. (2015). Materiales de injerto substitutos óseos. Fosfato tricálcico ß. Presentación de casos clínicos. [Bone substitute graft materials. ß-tricalcium phosphate. Presentation of clinical cases.] 3. Labanca M, Leonida A, Rodella, Natural synthetic biomaterial in Dentistry: Science and ethics as criteria for their use. Implantologia. 2008; 1: 9-23 4. Jensen SS, Broggini N, Horting-hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Impl Res 2006; 17: 237-43. 5. Salgado Castellanos, J., Zea del Rio, D. M., Gonzalez Miranda, J. M., & Velosa Porras, J. (2014). Effectiveness of Alveolar Preservation Techniques over Post-Extraction Socket Compared with and without Socket Preservation. Systematic Review of Literature. Universitas Odontologica, 33(70). https://doi.org/10.11144/Javeriana.UO33-70.etpa. 6. Jensen OT, Garlini G, Bilk D, Peters F. Use of alloplasts for sinus floor grafting. In: Jensen OT. The sinus bone graft (2nd ed.). Quintessence: Chicago 2006. pg.: 201-9. 7. Trisi P, Rao W, Rebaudi A, Fiore P. Histologic effect of pure-phase beta-tricalcium phosphate on bone regeneration in human artificial jaw bone defects. Int J Perio Rest Dent 2003; 23: 69-77. 8. Suba Z, Takács D, Matusovits D, Barabás J, Fazekas A, Szabó G. Maxillary sinus floor grafting with ß-tricalcium phosphate in humans: density and microarchitecture of the newly formed bone. Clin Oral Impl Res 2006; 17: 102-108. 9. Zijderveld SA, Zerbo IR, van der Bergh JPA, Schulten EAJM, ten Bruggenkate CM. Maxillary sinus floor augmentation using a ß-tricalcium phosphate (Cerasorb) alone compared to autogenous bone grafts. Int J Oral Maxillofac Implants 2008; 20: 432-40.

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ß-TCP (R.T.R.) and aggressive periodontitis Djamila BOUZIANE - Professor, University of Oran, Algeria Khadidja L. MAKRELOUF - Professor, University of Oran, Algeria Mohamed BOUZIANE - Professor, University of Oran, Algeria

We have not found in the international literature any study regarding the use of ß-TCP in the treatment of infrabony pockets in young patients with aggressive periodontitis, which are a clinical entity that very rapidly results in the destruction of alveolar bone with tooth morbidity as a consequence. For this reason the objective of this study is to evaluate and analyse the action of ß-TCP (R.T.R.) on infrabony lesions in young patients suffering from aggressive periodontitis.

Introduction

Aggressive periodontitis, a clinical case frequent These diseases are characterised by a anaerobic in the Maghreb, represents the most destructive Gram negative flora. form of periodontal diseases which results in There are two classes: bone lysis, dental mobility and then loss of teeth. • The form localised in the incisors and the first Their appearance starts early in life causing molars, as shown clinically in Figure 1 and with aesthetic and functional damage. X-ray in Figure 2.

Fig. 1: Clinical aspect Fig. 2: Notice the terminal lysis at the level of 21

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• The form generalised to the entire dentition (Fig. 3 & 4 ). The size of the bone lesions requires a well targeted therapeutic strategy. The objective of our work is to choose sites at the level of the upper or lower incisors and first molars of patients suffering from aggressive perio - dontitis with pockets deeper than 5 mm, infrabony defects that allow the insertion of ß-TCP (R.T.R.). We will test the influence and impact of this subs - Fig. 3: Inflammatory aspect titute material on bone behaviour.

Materials & methods

We perform on each patient a clinical, radiological and bacteriological examination followed by a surgical treatment consisting in flap surgery combined with R.T.R. grafting material (syringe). The clinical evaluation consisted in measuring

the depth of the pockets. Fig. 4: Terminal lysis at 21 and 11 The X-ray examination allowed the evaluation of the bone level of our patients thanks to the retroal - veolar - panoramic and radiovisiography images. The bacteriological evaluation consisted in sub- Case series gingival specimens and fresh bacterial profile study, Gram staining, culture and PCR. 4 patients were chosen for whom five sites The therapeutic schedule consisted in: were treated: • Initial therapy (scaling and root planing) • 2 upper sites (16-21) • A systemic anti-infectious therapy with amoxicillin • 3 lower sites (36-46-46) 1 g/d and metronidazole 600 to 800 mg/d over 10 days. - The first patient presented a generalised • A surgical therapy combining flap surgery aggressive periodontitis with a severe intrabony and insertion of R.T.R. defect at 21 associated with an extrusion • The surgical sequence is the following: and at the level of 16 a terminal bone lysis - Anaesthesia with a pocket depth of 9 mm. - Incisions - The second patient suffered from generalised - Careful debridement aggressive periodontitis with class 3 bifurcation - Elimination of granulation tissue involvement at the level of 46 as well as - Scaling and root planing mesial and distal pocket depth of 7 to 5 mm. - In situ placement of R.T.R. using the syringe - The third patient, 17 years old, with localised presentation aggressive periodontitis and mesial infrabony - Sutures lesions with a pocket depth of 8 mm. - Placement of surgical pack - The fourth patient, 16 years old, with a loca - - A maintenance phase with clinical and radio - lised aggressive periodontitis, presented 5 mm graphy re-assessments over four years pockets distally at the level of 46.

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Case Report no.1

A 19-year-old woman presented with severe generalised aggressive periodontitis. On a clinical level, this patient presented an inflammatory condition of the maxillary and mandibular gum with migration of 21 ( Fig. 5 ). Fig. 5: Clinical inflammatory aspect On a radiographic level, the panoramic X-ray of the maxillary showed infrabony lesions ( Fig. 6 ) with deep lysis at the level of 21 and terminal lysis at the level of 16 ( Fig. 7 ).

It was decided to treat 21 and 16 given the situation of these severe lesions.

The therapeutic schedule adopted is the following Fig. 6: X-ray :Generalised lysis at the level of the maxillary at the level of 21. T0 • Etiological therapy + amoxicillin + metronidazole antibiotic therapy • Surgical phase: flap + bone substitute: R.T.R. (Fig. 8 & 9 )

T 1 year • Clinical and X-ray reassessment. On the X- Fig. 7: Severe infrabony defect Fig. 8: Incisions - raising of a ray, filling of infrabony lesion with 25% bone at the level of 21 flap gain. ( Fig. 10 ) • At this stage the migration treatment was performed. • Orthodontic treatment phase due to migration of 21 ( Fig. 11 ) A stabilisation of the bone gain after initiation of orthodontic treatment was observed ( Fig. 12 ) The reassessment of the infrabony lesion at 4 years by radiovisiography showed a bone gain of 50% ( Fig. 13 ). A definitive fixation was Fig. 9: Insertion of bone substitute performed.

Fig. 10: Result at Fig. 11: DFO treatment of migration at Fig. 12: Stabilisation of bone Fig. 13: RVG 50% bone gain at 1 year 1 year gain 4 years

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The study of the posterior site (16) in the same patient showed: • On a clinical level, the probing detected pocket depths of 9 to 11 mm ( Fig. 14 ). • On the X-ray, a terminal bone lysis ( Fig. 15 ).

The therapeutic schedule of the infrabony lesion of 16 is the following: • Etiological therapy Fig. 14: Clinical aspect Fig. 15: Terminal lysis • Surgical phase: mucoperiosteal flap associated with in situ placement of R.T.R. The surgical treatment sequence: - Incision and raising of the flap ( Fig. 16 ) - Debridement of lesion - Elimination of granulation tissue - Polishing and planing of root - Insertion of R.T.R. using the syringe: the granules are mixed with a few drops of blood (Fig. 17 ) - Sutures - Surgical pack ( Fig. 18 ) Fig. 16: Incision and raising of flap - Placement of surgical pack

The reassessment at 1 year shows the filling of the infrabony lesion ( Fig. 19 ). At 4 years it shows a 50% bone gain ( Fig. 20 ).

Fig. 17: In situ placement of R.T.R.

Fig. 18: Surgical pack Fig. 19: At 1 year Fig. 20: At 4 years

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Case Report no.2

A 18-year-old patient presented with severe

generalised aggressive periodontitis ( Fig. 21 ). Fig. 21: Clinical aspect Fig. 22: Class 3 bifurcation The panoramic x-ray showed at the level of 46: Inf rabony lesion + bifurcation involvement and depth of pockets of 7 mm ( Fig. 22 ).

Clinical aspect before surgery ( Fig. 23 ). Placement of R.T.R. ( Fig. 24 ). Fig. 23: Clinical aspect The radiography X-ray shows an infrabony lesion associated with a class 3 bifurcation involvement Fig. 24: Placement of R.T.R. (Fig. 25 ). At 15 days the filling material is in place ( Fig. 26 ).

At 4 years the reduction in the pocket depth is of 4 mm, we noticed the absence of bifurcation Fig. 25: Before treatment involvement ( Fig. 27 ).

Fig. 26: 15 days after the filling

Fig. 27: Result at 4 years

Case Report no.3

A 17-year-old patient presented with localised aggressive periodontitis ( Fig. 28 ) with an average pocket depth of 8 mm and mesial infrabony lesion of 36 ( Fig. 29 ). Fig. 28: Clinical aspect Fig. 29: Deep lysis The therapeutic schedule is the following: • Etiological therapy associated with medical treatment which consisted in a combination of amoxicillin and metronidazole during 10 days • Surgical treatment: incision ( Fig. 30 ), raising of the flap, placement of the bone substitute (Fig. 31 ). Fig. 30: Placement of R.T.R. Fig. 31: Sutures

The results at 1 year ( Fig. 32 ) and at 4 years ( Fig. 33 ) are very satisfactory.

Fig. 32: At 1 year Fig. 33: At 4 years

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Case Report no.4

The 16-year-old patient presented with inflam - At 4 years we see the filling of the infrabony matory gum condition ( Fig. 34 ). In the X-ray, we lesion with an absence of periodontal pocket observed prior to treatment an infrabony defect and a normal aspect of the desmodontal space of 46 with a pocket depth of 5 mm and 25% (Fig. 36 ). bone loss ( Fig. 35 ).

For this patient, it was decided to follow the same therapeutical protocol as previously described.

Fig. 34: Clinical aspect Fig. 35: Infrabony defect before treatment Fig. 36: Bone repair

Discussion

The use of R.T.R. ( ß-TCP ) allowed: toxic potential and the modification of their • A reduction in the depth of pockets and an tissue environment. attachment gain. We thus observed in our patients a decrease • A decrease in the dental mobility index. in bacteria such as Tannerela forsythus, Prevo - • The panoramic and the visiography X-rays tella intermedia, Porphyromona gingivalis showed a bone gain with filling of infrabony Aggregatibacterium actinomycetemcomitans, lesions. Treponema denticola at 1 year and 4 years. • Modifications of the bacterial biofilm in nume - The flap combined with the filling would be in rous studies (Haffajee and al.) show that favour of the restoration of the epithelial barrier certain species of the red complex (Tannerela at the bottom of the pocket with an almost forsythus, Treponema denticola) and of the absence of the available nutrients essential orange complex (Prevotella intermedia, Campy - for the red and orange complex bacteria. lobacter rectus) can evolve differently. • The bone gain obtained would be related to Depending on the surgical debridement, these the use of phosphocalcium derivative bioactive species can recolonise the sites in a very materials which increase bone formation. delayed manner due to the decrease in their

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Conclusion

Our work demonstrates that an advanced aggres - The success of our therapy would not have sive periodontitis with the presence of terminal been possible without fighting against the bacte - lysis could be currently treated whereas about rial biofilm, or without the full cooperation and fifteen years ago tooth extraction was the only consent of our patients. alternative. These diseases constitute a public health problem A significant improvement of the depth of the due to the speed and severity of their evolution pockets, attachment level, decrease in dental with functional consequences and psychosocial mobility, modification of subgingival bacterial repercussions related to the early loss of teeth. biofilm and bone gain are the results obtained This technique has given excellent results in at 4 years. young subjects.

Authors Prof. Djamila Bouziane: University Hospital Professor (University of Oran/Oran University Hospital) - Head of Department of Periodontology - Head of Department of Dental Surgery - President of the scientific council of the health research topic agency - President of the national dental medicine teaching committee - President of the regional speciality teaching committee (Parodontology) - President of the national speciality teaching committee (Periodontology) - Director of the oral biology laboratory - Member of the scientific council of the Oran university academy - ANDRS expert (National Agency for the development of health research) in charge of building a national health research program - Founder and President of the Société Algérienne de Médecine Dentaire (SAMD, Algerian Dental Medicine society) - Member of the Société Algérienne d’Odontologie Pédiatrique (SAOP, Algerian Paediatric Odontology Society) - Member of the National Dental Committee - Vice-President of the International Conference of French language Deans - Member of the Académie Française de Chirurgie Dentaire (ANCD, French Academy of Dental Surgery) - Leader of numerous research projects.

Mohamed Bouziane: University Hospital Professor (University of Oran/Oran University Hospital) - Head of Department of Prosthetics.

Leila Khadidja Makrelouf: University Hospital Professor (Periodontology) (University of Oran/Oran University Hospital).

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References

01. ANAGNOSTOU F., OUHAYOUN J.P. Valeur biologique et nouvelle orientation dans l’utilisation des matériaux de substitution osseuse. J parodontologie et implantologie orale 19.317-243 2000 02. BAEHNI P.C., GUGGENHEIM B. (1999). Potential of diagnostic microbiology for treatment and prognosis of dental caries and periodontal diseases. Crit Rev Oral Biol Med. 7(3):259-277(1996). 03. BARSOTTI O., BONNAURE-MALLET M., CHARIN H., CUISINIER F., MORRIER J.J., ROGER LEROY V. Tests biologiques en odontologie. Dossiers ADF edit SAGIM-CANALE 6-60-2007. 04. BOUZIANE D. Conférence épidémiologie analytique et prise en charge des parodontites juvéniles. Symposium sur les parodontites agressives de l’enfant et du jeune adulte. Société Française de parodontologie et Académie internationale de parodontologie - Marrakech 01 Juin 2001 05. CHARDIN H., BARSOTTI O., BONNAURE-MALLET M. Microbiologie en Odonto Stomatologie Edit Maloine 2006. 06. CHARON J.A., SANDEL é P., JOACHIM F. Conséquences pratiques des nouveaux moyens de diagnostic en parodontie Inf. Dent. M. 5 (12) 873-883-1993. 07. GIBERT P., TRAMINI P., BOUSQUAT P. H., MARSAL P. Produits antibactériens d’usage local en parodontie AOS n° 212 : 455-465-décembre 2000. 08. HAFFAJEE A.D., TELES R.P., SOCRANSKY S.S. The effect of periodontal therapy on the composition of the subgingivalmicrobiota. J. Periodontol 2000, 42: 219-258-2006. 09. M. LABANCA and Coll. Biomaterials for bone regeneration in oral surgery: A multicenter study to evaluate the clinical application of “R.T.R.” Case studies Collection n°7: 4-11 Mars 2014 10. O.H. ARRIBASPLATA LOCONI . Bone regeneration with ß -tricalcium phosphate (R.T.R.) in post-extraction sockets. Case studies Collection n°7: 12-20 Mars 2014 11. MATTOUT P., MATTOUT C. Les thérapeutiques parodontales et implantaires Quintessence Inter 2003. 12. MICHEAU C., KERNER S., JAKMAKJIAN S. Intérêt du phosphate tricalcique ß en parodontologie et implantologie. Le Chirurgien Dentiste de France: 1308 : 31-38-2007 13. PRINC G., BERT M., SZABO C. Utilisation de substitut osseux ß-phosphate tricalcique. Etude préliminaire. CDF, 2001 ; 1055 : 29-34 14. PRINC G., BERT M., IFI J.C. Utilisation du substitut osseux ß-phosphat tricalcique (ß-TCP résultats a 3 ans) Le Chirurgien dentiste de France 1250/1251/23-30 Mars 2006 15. SIXOU M., DUFFAUT D., LODTER JP. Distribution and prevalence of Haemophilus actinomycetemcomitans in the oral cavity. J. BiolBuccal 19: 221-228-1991. 16. SOCRANSKY S.S., HAFFAJEE A.D. The bacterial etiology of destructive periodontal diseases: current concepts. J. Periodontol 63: 322-331-1992. 17. TENNE BAUME H. Les matériaux de substitutions osseuses. Dossier ADF - Edit SAGIM CANALE: 5-49- 2005. 18. VAN WINKELHOFF A.J. et WINKEL E.G. Microbiological diagnostics in periodontics: biological significance and clinical validity Periodontology 2000, Vol. 39: 40-52-2005.

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Alloplastic Grafts - Beta-tricalcium phosphate Presentation of clinical cases

Mario Ernesto García-Briseño DDS and Professor in Periodontics - Autonomous University of Guadalajara (UAG), Mexico

This case report presents a brief review of bone loss due to periodontal infection and tooth extraction, and evaluates the biological characteristics, description and indications of an alloplastic graft material, beta-tricalcium phosphate, as an alternative treatment in two clinical cases.

Introduction

The effects of periodontal infection and its alloplastic graft material, beta-tricalcium phos - consequences, attachment and bone losses, phate, before presenting Clinical Cases using a result in the formation of periodontal bone commercial presentation of beta-tricalcium phos - defects (1,2). Tooth extraction involves two phate. The objective of this presentation is to processes, the healing of the alveolus (3) and demonstrate the clinical applications of beta- any change that may appear during post-extrac - tricalcium phosphate alloplastic graft in tion healing (4). The clinical consequences of periodontal bone defects and extraction sites. tooth extraction are the resorption of the alveolar ridge (5) and the pneumatization of the maxillary sinus (6). If the effects of periodontal disease Modifications in the Alveolar and tooth extraction are combined, the conse - Process quences will be even more severe and will complicate tooth restoration (7). The use of The most common modifications involving the bone grafting materials prevents and/or repairs bone tissue of the oral cavity are: Horizontal the insufficient bone conditions due to the bone loss due to periodontal infection, bone previously mentioned situations (8). We will first defects caused by periodontal disease, tooth evaluate the biological characteristics (9) of the extraction resulting in vertical and horizontal

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resorption, pneumatization of the maxillary alveolus has a very high and predictable chance sinus and a combination of these. The clinical of healing in a natural and healthy way without consequence of these conditions are inappro - any intervention. The biological principle of priate bone dimensions for prosthetics on the alveolus repair is based on the formation natural abutment teeth and the placement of of a blood clot that covers it completely. Post- its substitutes, dental implants (10). extraction healing process has been accurately described. The stages of this natural process may be summarised in the following manner: Periodontal bone defects At 30 minutes: clot; at 24 hours: formation of blood clot and haemolysis; at 2-3 days: forma - As a result of inflammatory and immune reac - tion of granulation tissue. At 4 days: increase tions to the presence of bacterial plaque and in fibroblast density and epithelial proliferation the way in which it progresses apically over over the edge of the wound and presence of the cement surface in one of the periodontal osteoclasts indicating the alveolus remodelling. attachment components, the alveolar bone, At 1 week: defined vascular network and matu - specific patterns of destruction can be observed. ring connective tissue; osteoid formation in These patterns depend mainly on the type of the bottom of the alveolus. At 3 weeks: dense subgingival bacterial plaque and the anatomical connective tissue; full epithelial cover. At characteristics of the alveolar process (11). 2 months: full bone formation is complete but Basically there are two bone loss patterns, without reaching the original height (15,16). horizontal or vertical forms. The vertical form of bone loss has been described as intrabony loss and the resulting defects have been histo - Graft Material Characteristics rically classified according to the number of bone walls lost: one, two or three-wall intrabony Autogenous bone is the only graft material defects. Other bone loss patterns have been that meets the requirement of being osteogenic described as osseous craters and circumferential activating new bone formation via viable osteo - defects. The special anatomy of molars and genic cells (Periostium osteoblasts, endostium, premolars involves furcations as a special bone marrow cells, perivascular cells and undif - condition in periodontal defect (12). ferentiated and/or stem cells) which are transplanted with the material and is considered as the "Gold Standard" as it also has osteoin - Tooth extraction ductive and osteoconductive properties (17,18). The term “Osteoinduction” implies the biological The consequences of tooth extraction represent effect of inducing differentiation of pluripotent specific conditions and a special challenge in undifferentiated cells and/or potentially inducible conventional restorative dentistry and oral reha - cells to express the osteoblast phenotype bilitation, especially with the use of dental leading to new bone growth both within bone implants (13). Whether in case of single or tissue and in ectopic sites. i.e. sites in which multiple implants - as abutments for fixed there is no natural bone formation. Even though bridges and/or removable prosthesis – or in there are several molecules able of inducing complete oral rehabilitation, the bone loss that "de novo" bone tissue formation, the Bone follows tooth extraction in alveolar area or in Morphogenetic Protein (BMP) is the main protein edentulous arch represents a clinical challenge involved (19). The term “Osteoconduction” (14). The consequences of this biological refers to the characteristic of the graft material process are both functional -which complicates to act as a scaffold or mesh on which existing the prosthesis design - and aesthetic, especially bone cells can proliferate and form new bone. in the anterior zone. After tooth extraction, the In the absence of this supporting structure

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provided by the material, the defect or bone osteoconduction with the subsequent resorption surface would be filled or covered by fibrous and replacement by host bone. (25) Osteo - soft tissue. The porosity, pore size, shape, conduction is facilitated by the interconnection particle size and physical/chemical characte - between pores. In the biological process the ristics influence the biological effects of cell material is resorbed and replaced by bone adhesion, migration, differentiation and vascu - from the receptor individual. When the graft is larisation at the receptor site (20,21). placed in the receptor site, serum proteins are adsorbed on the surface of the particles, which later favours cell migration to initiate neo- Classification of graft materials vascularisation in the porous structure. Over by origin time, the particles inferior to 1 micron start to dissolve and are then resorbed in a process Autogenous materials or Autografts are tissues mediated by phagocytic cells, thus allowing from the same individual transplanted from bone deposit over the material. The level of one site to another. Viable cortical or porosity and the particle size will define the spongy/medullar bone is commonly used in resorption rate and the bone replacement periodontology and maxillofacial surgery. Allo - process which occurs in 9 to 12 months in genic materials or Allografts are tissue from average (26). one individual of the same species; usually via a freeze-drying process; bone and skin are the most common ones. Xenografts are tissue from different species; mainly mineral bone component or collagen. Alloplastic graft mate - Case Report no.1 rials are synthetic materials, i.e. they are manufactured by industrial processes and the 48-years-old male patient in general good health most representative in medical dental use are conditions with two localized areas presenting Hydroxyapatite, ß -Tricalcium Phosphate and some discomfort since a couple of months Bioactive glasses or polymers (22). mainly in tooth 15 where the patient refers recurrent swelling but without need to take analgesics. A full periodontal examination reveals Beta-tricalcium phosphate a localized distal periodontal probing of 10 mm. with bleeding and suppuration and a mild Beta-tricalcium phosphate (ß -TCP) is a synthetic redness ( Fig. 1 ). ceramic bone graft material which has been used in orthopaedic and dentistry -periodon - tology and maxillo-facial surgery - for more than 30 years (23). ß -TCP can be treated during the manufacturing process so that it has a structure similar to the bone mineral component, either in a block or in particles similar to spongy or trabecular bone (24). This structure has randomly interconnected pores. Porosity may range from 20% to 90%. The variation in pore size ranges from 5µm to 500µm depending on the particle size. The particle size in dental use is generally inferior to 1000µm. The mechanism of action of ß -TCP as a graft material is via Fig. 1: Bleeding and suppuration in 10 mm pocket in tooth 15

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On X-ray examination a wide distal intrabony- A flap debridement procedure is indicated and two walls defect is present( Fig. 2 ). The previous it is confirmed the bone defect and irregular root canal treatment seems without complica - bone loss in the vestibular cortical plate. ( Fig. 3). tions in the periapical area. The localized periodontal attachment loss and the overall With the pulpar involvement as main etiology periodontal health could support the etiology an effort is done to find clinical evidence i.e. of pulpar complication i.e. a lateral canal since localized area of resorption and/or lateral foramen the patient report at least 8 years of root canal without confirmation. It is decided to use treatment after a painfull episode in the tooth. ß-tricalcium phosphate “R.T.R.” (Septodont) as a graft material. ( Fig. 4 ).

Fig. 2: Initial X-ray showing the intrabony- Fig. 3: After debridement, scaling and root Fig. 4: ß-tricalcium phosphate “R.T.R.” two walls defect. planning a complicated bone loss is (Septodont) as a graft material. present.

Fig. 5: X-ray taken immediately after the surgical procedure showing Fig. 6: X-ray six months post-surgery where the particules of the particles of ß-tricalcium phosphate “R.T.R.” (Septodont) in the ß-tricalcium phosphate “R.T.R.” (Septodont) has been replaced with defect. recently formed trabecular bone and the bone defect appears with some lateral reduction.

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is indicated. In order to avoid the collapse of Case Report no.2 the residual alveolar bone and the socket, parti - cles of ß-tricalcium phosphate “R.T.R.” A second problem is identified at the periodontal (Septodont) is used as graft material. ( Fig. 8,9 ). examination in tooth 46 and confirmed with the X-ray. An extensive root resorption on the distal root is present ( Fig. 7 ) with any symptom reported by the patient except some discomfort and “bad taste” occasionally. The root canal treatment Conclusion was done at the same time than tooth 15 (eight years before). The clinical condition makes In concepts of Osteogenesis, remains today difficult to try endodontic retreatment or other still open the debate as to which type of currently treatment options like hemisection, the extraction available bone grafting material is the best.

Fig. 9: Composite blood clot and ß-tricalcium phosphate “R.T.R.” (Septodont) Fig. 7: X-ray showing extensive root Fig. 8: Clinical view showing the extensive used as graft material prior the suture. In the resorption on the distal root of tooth 46. bone loss in the residual ridge after the area of resorption a cone shaped tooth extraction. Notice the minimal width ß-tricalcium phosphate “R.T.R.” (Septodont) at the crestal area in the buccal and lingual is used and in the mesial root alveolus plates and the attachment loss at the particles of ß-tricalcium phosphate “R.T.R.” mesial root of tooth 47. (Septodont) are used.

Fig. 10: X-ray taken immediately after the Fig. 11: 6 months of clinical healing. Fig. 12: X-ray 6 months post-surgery where surgical procedure showing ß-tricalcium the particles of ß-tricalcium phosphate phosphate “R.T.R.” (Septodont) in the bone “R.T.R.” (Septodont) have been replaced by defect and mesial root alveoli recently formed trabecular bone in the bone defect and mesial root alveolar.

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Author: Dr Mario Ernesto García-Briseño DDS at Universidad Autónoma de Guadalajara, México, 1976. Certificate program in Periodontology at Universidad Nacional Autónoma de México 1985-87. Director and Professor of the certificate program in Periodontology since 1992 to date at Universidad Autónoma de Guadalajara School of Dentistry. Professor of Periodontology at certificate programs in Endodontics, Orthodontics, and Oral Rehabilitation since 1992 at Universidad Autónoma de Guadalajara School of Dentistry. Founder and President of the Mexican Association of Periodontology 1996-98. Founding member and Secretary of the Mexican Board of Periodontology 1996/2001. Academy affairs coordinator College of Dental Surgeons of Jalisco 2000/2004. Founder and academic coordinator of the College of Periodontics GDL. National and international lecturer. Private practice in Periodontics and Implant Dentistry.

References

01. Listgarten MA. Pathogenesis of periodontitis. J Clin Periodontol. 1986; 13: 418-425. 02. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth of subgingival plaque. J Clin Periodontol 1979: 6: 61-82. 03. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966; 21:805-813. 04. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent 1967;17:21-27. 05. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and wound healing. Compend Contin Educ Dent 1983;4:437-453. 06. Smiler DG, Johnson PW, Lozada JL, et al. Sinus lift grafts and endosseous implants. Treatment of the atrophic posterior maxilla. Dent Clin North Am 1992;36:151-186. 07. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997;68:563-570. 08. Mellonig, JT. Autogenous and Allogeneic Bone Grafts in Periodontal Therapy. Crit Rev Oral Biol 19923(4):333-352 09. Jarcho M. Biomaterials aspects of calcium phosphates. Properties and applications. Dent Clin North Am 1986;30:25–47. 10. Dhingra K. Oral Rehabilitation Considerations for Partially Edentulous Periodontal Patients J Prosthodontics 21 (2012) 494–513 11. Listgarten MA. Pathogenesis of periodontitis. J Clin Periodontol. 1986; 13: 418-425. 12. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth of subgingival plaque. J Clin Periodontol 1979: 6: 61-82. 13. Zitzmann NU, Krastl G, Walter C, et al: Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth. J Prosthet Dent 2010;104:80-91 14. Craddock HL, YoungsonCC, Manogue M, Blance A. Occlusal Changes Following Posterior Tooth Loss in Adults. Part 2. Clinical Parameters Associated with Movement of Teeth Adjacent to the Site of Posterior Tooth Loss J Prosthodont 2007;16:485-494. 15. Amler MH. The time sequence of tissue regeneration in human extraction wounds. Oral Surg . 1969 27; 309-318 16. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966; 21:805-813.

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References

17. American Academy of Periodontology. Glossary of Periodontol Terms, 4th ed. Chicago: American Academy of Periodontolgy; 2001;44. 18. Reynold MA, Aichelmann-Reidy ME, Branch-Mays GL. Regeneration of periodontal tissue: Bone replacement grafts. Dent Clin North Am 2010;54:55-71 19. Urist MR. Bone: Formation by autoinduction. Science 1965;150:893-899. 20. Jarcho M. Biomaterials aspects of calcium phosphates. Properties and applications. Dent Clin North Am 1986;30:25-47 21. Hollinger JO, Brekke J, Gruskin E, Lee D. Role of bone substitutes. Clin Orthop 1996;Mar(324):55-65 22. Gross JS. Bone grafting materials for dental applications: a practical guide. Compend Contin Educ Dent. 1997;18:1013-1036 23. Labanca M, Leonida A, Rodella FL Natural or synthetic biomaterials in Dentistry: Science and ethic as criteria for their use. Implantologia 2008; 1:9-23 24. Metsger D.S. et al. (1982). Tricalcium phosphate ceramic--a resorbable bone implant: review and current status. J Am Dent Assoc.105: 1035-1038. 25. Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res 2006; 17:237–243. 26. Artzi Z, Weinreb M, Givol N, et al. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: A 24-month longitudinal histologic study and morphometric analysis. Int J Oral Maxillofac Implants 2004;19:357–368.

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Periodontal intraoseous defects and post-extraction compromised socket. Treatment with Beta Tricalcium phosphate C.D.E.P. Mario Ernesto García Briseño

The use of safety graft materials, with predictability and availability, is indicated in intraoseous defect treatment and in tooth extractions where the healing of the alveolar ridge is compromised. A clinical case is presented with both conditions and the osseous graft substitute, R.T.R., is used in their treatment.

Introduction

The inflammatory response as a result of perio - to the replacement of the lost tooth with dontal infection leads to the loss of tooth support fixed/removable prosthetics and/or dental tissues 1. The alveolar bone and its three compo - implants 6,7,8 . Restoration of adequate conditions nents, cortical plates, trabecular bone and in the periodontium destroyed by periodontal bundle bone (alveolar bone proper), are lost infection to preserve the dentition in health and through periodontal infection 2. Other conditions function 9,10 , and/or maximizing the healing condi - can worsen the periodontal condition, mainly tions in the alveolar ridge post extraction for endodontic, prosthetic and traumatic compli - prosthetic restoration 11,12 , is indicated with the cations 3,4,5 . When the tooth extraction is indicated, use of graft materials. It provides predictable the anatomic characteristics of the alveolus, results, safe use and no availability restrictions. the associated lesion and phenotype of the These characteristics are present in the synthetic periodontal tissues can lead to a healing of the bone graft substitute R.T.R. (beta tricalcicum alveolar ridge with an inadequate morphology phosphate) 13,14,15,16 .

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Clinical Cases

62-year-old patient with recurrent periodontal disease without infection control after a previous treatment in February 2007. The main concern is “I do not want to lose my teeth”. The clinical aspect shows high plaque score, signs of inflam - mation, bleeding on probing, periodontal attachment lost and, radiographically, bone lost, pathologic migration and inadequate occlusal relations (figs. 1,2) . At the beginning of the Fig. 1 retreatment the patient was instructed about the problem with emphasis on infection control by meticulous daily plaque control and oral home care. Once the change in attitude and compromise were noted, the treatment plan was initiated.

Diagnosis Chronic generalized periodontal disease with advanced periodontal attachment lost.

Treatment plan Flap debridement and scaling and root planing in superior arch and scaling and root planing alone in lower arch. Prognosis in the anterosu - Fig. 2 perior segment is reserved.

Procedure description Anterosuperior segment. Flap debridement and scaling and root planning filling the osseous defects with bone graft substitute, R.T.R, and collagen membrane (Figs. 3,4) .

Fig. 3 Fig. 4

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Healing filled with bone graft substitute, R.T.R. cones. The initial radiographs show bone loss and, in The blood clot covers the intact alveolus of the radiographs 10 months later, the bone-fill in the mesial root (Fig. 7) . defects is evident (Fig. 5) . Initial clinical view and healing (Fig. 6) . Figure 9 shows the complete osseous filling of the osseous defect and the compromised socket In the lower right quadrant, extraction of tooth post extraction at the time of the implant surgery 46 is depicted. The distal alveolus and bone with bone regeneration at 9 months, and radio - defect with loss of the vestibular plate was graphic evidence.

Fig. 5 Fig. 6 Fig. 7

Fig. 8: View of the radiographic initial lesion. Fig. 9

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Conclusion

Loss of periodontal attachment and the conse - cations, periapical lesions and/or traumatic quent alveolar bone destruction resulting from events. Prevention and improvement of the the periodontal infection require procedures to healing post extraction is a common procedure provide periodontal regeneration. This goal with restorative, prosthetic and implant dentistry. requires an accurate diagnosis of the condition The use of a bone substitute graft material like and high practitioner skills. Predictability is beta tricalcium phosphate (R.T.R., Septodont) restricted to certain situations. The loss of the ensures biologically secure procedures, predic - bone morphology in the residual ridge post tability in results and total availability. The clinical extraction is worse if combined with periodontal results are adequate and scientific evidence- attachment loss, extraction procedure compli - based.

Authors: Mario Ernesto García Briseño Graduated from the Universidad Autónoma of Guadalajara as a Dental Surgeon (1971-1976). Specialty in Periodontics at the Universidad Nacional Autónoma of México (1985-1987). Coordinator of the specialty program in Periodontology at the Universidad Autónoma of Guadalajara from 1993 to 2015 (22 years). Professor of the Pathogenesis of Periodontal Disease I and II, Etiology of Periodontal Disease, Occlusion, IV Periodontics, Clinical Cases I and II Seminar and Interdisciplinary Seminar in the Periodontics Specialty of the Autonomous University of Guadalajara from 1993 to date. Instructor in the Periodontics specialty clinic from 1993 to date (24 years). Professor of the Periodontics Course in the Specialties of Endodontics, Oral Rehabilitation and Orthodontics from 1993 to 2015. Founding Member of the Mexican Association of Periodontology and President Biennium 1996- 1998). Founding Member and Secretary in the first board of directors of the Mexican Council of Periodontics 1996. Certificate no. 005 of the Mexican Board of Periodontics from 1996 to date. Founder and Academic Coordinator of Periodontology GDL, A.C. College of Periodontist from 2005 to date. Prize Jalisco Dentistry 2002. Opinion leader at Crest Oral B. Leader of opinion in Septodont Mexico. International lecturer and author of 3 publications of the company Septodont, France. Member of the Academy of Osseointegration since 2015. Member of the American Academy of Periodontology 1989 to 2010. Author of 10 publications in national and foreign journals and 3 international presentations (Webinar) (Coa, Septodont and CMD). Director and private practice in Professional Periodontology from 1987 to date.

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References

01. Listgarten M A: Patogenesis of periodontitis. J Clin Periodontol 1986;13:418-425. 02. Waerhaug J. The angular bone defect and its relationship to trauma from occlusion and down growth of subgingival plaque. J Clin Periodontol. 1979;6:61-82. 03. Iqbal MK, Kim S. A review of factors influencing treatment planning decisions of single-tooth implants versus preserving natural teeth with nonsurgical endodontic therapy. J Endod. 2008;34: 519-529. 04. Zitzmann NU, Krastl G, Walter C et al. Strategic considerations in treatment planning: deciding when to treat, extract, or replace a questionable tooth. J Prosthet Dent. 2010;104:80-91. 05. Hiatt WH. Pulpal periodontal disease. J Periodontol. 1977;48:598-609. 06. Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol. 1966;21:805-813. 07. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent. 1967;17:21-27. 08. Lekovic V, Kenney EB, Weinlaender M et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol. 1997; 68: 563-570. 09. Bowers GM, Granet M, Stevens M, Emerson J, Coria R, Mellonig J et al. Histologic evaluation of new attachment in humans. J Periodontol. 1986; 75: 280-293. 10. Hammerle CH. Membranes and bone substitutes in guided bone regeneration. In: Lang NP, Karring T, Lindhe J, eds. Proceedings of the 3rd European workshop on periodontology. Implant dentistry. Berlin: Quintessenz Verlag; 1999. pp.468-499. 11. Avila-Ortiz G, Elangovan S, Kramer KWO, D. Blanchette, Dawson DV. Effect of Alveolar Ridge Preservation after Tooth Extraction: A Systematic Review and Meta-analysis. J Dent Res. 2014 93:950- 958. 12. Orgeas GV, Clementini M, De Risi V, de Sanctis M. Surgical Techniques for Alveolar Socket Preservation: A Systematic Review Int J Oral Maxillofac. 2013;28:1049–1061. 13. Labanca M, Leonida A, Rodella FL. Natural or synthetic biomaterials in dentistry: science and ethic as criteria fortheir use. Implantologia. 2008; 1: 9-23. 14. Metsger DS et al. Tricalcium phosphate ceramic. a resorbable bone implant: review and current status. J Am Dent Assoc. 1982; 105: 1035-1038. 15. Jensen SS, Broggini N, Hjorting-Hansen E, Schenk R, Buser D. Bone healing and graft resorption of autograft, anorganic bovine bone and beta-tricalcium phosphate. A histologic and histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res. 2006; 17: 237-243. 16. Artzi Z, Weinreb M, Givol N et al. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. Int J Oral Maxillofac Implants. 2004; 19: 357-368.

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Sinus Floor Augmentation with ß -Tricalcium Phosphate (R.T.R. Septodont) Mario Ernesto García-Briseño DDS and Professor in Periodontics - Autonomous University of Guadalajara (UAG), Mexico

Resorption of the alveolar process and pneumatization of sinus in the edentulous posterior maxilla are a clinical challenge in the restorative/prosthetic treatment with dental implants. Diverse surgical procedures, bone grafts and substitutes have been used to repair that clinical situations. Reports have shown radiographic, histomorphometric and clinical significant results with ß-Tricalcium Phosphate. Two clinical cases of sinus floor augmentation with ß-Tricalcium Phosphate (R.T.R. Septodont) or the subsequent insertion of dental implant are presented in this report.

History (BSM) have been described in terms of osteoin - ductivity, osteoconductivity and osteogenicity. Resorption of the alveolar process and the Osteoconductivity can be described in terms of pneumatization of the sinus in the posterior a biocompatible scaffold, resorbable at different edentulous maxilla often represents a clinical speeds and time, in which the material reacts challenge in restorative/prosthetic treatment without consequences with the tissues at the with dental implants (1). receptor site. The three-dimensional structure Al-Nawas and Schiegnitz (2014), continuing the of the material mostly facilitates vascular proli - work of Klein (3), have proposed a classification feration and, soon after, colonization and growth of augmentation procedures in which graft mate - of osteoprogenitor and osteogenic cells. The rials are used for bone formation in therapy physical and chemical properties influence bone with dental implants: formation to a lesser degree (4). 1) Maxillary sinus floor augmentation, including the lateral window technique and transalveolar Tricalcium Phosphate approach and, 2) vertical and/or lateral alveolar ridge augmentation, including dehiscence-type With a composition and crystallinity similar to and/or fenestration-type defect around the the mineral phase of bone, Tricalcium Phosphate implant (2). (Ca3(PO4)2) is a biocompatible and bioresorbable The biological and physiological properties of material. Biodegradation of the material occurs the bone grafts and bone substitute materials in two ways: dissolution and osteoclastic resorp -

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tion (5). Animal models have shown the resorption the maxillary sinus floor with the use of graft of beta-TCP, its replacement by bone and forma - and/or bone substitute materials placed between tion of bone marrow (6). Particle size, microporosity detached epithelial membrane and the denuded and speed of resorption confer its osteoconductive bone (17, 18, 24). The use of bone substitute properties and promote the bone formation materials has been report ed in maxillary sinus process (7, 8). Placed directly in cancellous bone, floor augmentation procedures (19), including it retains its osteoconductive properties, and no beta-tricalcium phosphate (20-22), with histo - tissue or systemic reactions were reported (9). morphometric analysis (23) and simplified Osteoconductive properties have been reported techniques (24). Trombelli et al. (2014) report the at ectopic sites (10). For decades, it has been results of transcrestal maxillary sinus floor elevation used in Orthopaedics and multiple dental appli - done with a minimally invasive procedure and cations (11-14). combined with the additional use of deproteinized bovine bone mineral or beta-tricalcium phos - Procedure for maxillary sinus floor phate. (24) The survival of dental implants in elevation maxillary sinus floor augmentation procedures with ß -tricalcium phosphate has been reported. (1) Two authors developed the surgical technique to The authors report an increase in bone quantity augment bone height from the base of the maxillary associated with a decrease in grafted material floor (15, 16). Various modifications have been and the presence of osteoclasts around the reported in the literature, but retaining the initial remaining particles of material. No complications proposal: increasing the vertical dimension from or loss of implants were reported at 12 months.

Case Report no.1 Female patient, 56 years of age

Fig. 1: Edentulous area, first quadrant. Absence of premolars and Fig. 2: Occlusal view, quadrant 1. molars lost 12 years ago. Replaced with removable partial denture.

Fig. 3: Maxillary sinus floor augmentation procedure with lateral Fig. 4: Pre-op X-ray (day 0). approach and ß -Tricalcium Phosphate "R.T.R." Septodont with bone graft substitute material (day 0).

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Fig. 5: X-ray immediately post-op showing the location of the Fig. 6: X-ray six months after the maxillary sinus floor augmentation ß-Tricalcium Phosphate on the maxillary sinus floor -radiolucent procedure with lateral approach and ß-Tricalcium Phosphate "R.T.R." area- (day 0). Septodont as bone graft substitute material. The decrease in the radiolucent area shown in Fig. 6 is obvious, indicating the replacement of the material with new bone.

Fig. 7: During the surgical procedure (at 7 months) of implant Fig. 8: ß-Tricalcium Phosphate "R.T.R." Septodont as bone graft placement, at the site of 14, the presence of the vestibular cortical substitute material in the vestibular plate of 14. Distal implant in the plate of inadequate thickness is noted. first molar area placed in the area of the maxillary sinus floor augmented 7 months earlier.

Fig. 9: X-ray immediately after placement of the prosthetic pillars on Fig. 10: Prosthetic restoration 10 months after the maxillary sinus the implants. Stability of the implant in the area of 16 was clinically floor augmentation procedure with lateral approach and ß-Tricalcium proven. Phosphate "R.T.R." Septodont and 3 months after placement of the implants.

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Case Report no.2

Female patient, 55 years of age

Fig. 1: Left atrophic posterior maxilla. Absence of molars lost Fig. 2: Occlusal view of the area. approx. 10 years ago. Replaced with removable partial denture.

Fig. 3: Pre-op X-ray. Fig. 4: X-ray immediately post-op showing the placement of the ß-Tricalcium Phosphate on the maxillary sinus floor -radiolucent area- (day 0).

Fig. 5: Pre-op clinical image 6 months after ß-Tricalcium Phosphate Fig. 6: In the window of the sinus lift procedure done 6 months graft "R.T.R." Septodont. earlier, granules of ß-Tricalcium Phosphate "R.T.R." Septodont are observed, which indicates partial replacement with new bone.

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Fig. 7: X-ray image to confirm the cutting depth (2.5 mmØ) of the Fig. 8: With osteotomes (Summers technique, 1994) the maxillary implant receptor site at 10 mm (arrow). Partial replacement of the sinus floor is lifted 2 mm to achieve insertion of a 12-mm long bone substitute material with receptor bone is obvious. implant.

Fig. 9: Implant 12 mm long by 5 mm diameter placed at bone crest Fig. 10: X-ray image showing the placement of the implant. level.

Conclusions

Resorption of the alveolar process and pneu - comparable with survival rates of implants placed matization of the sinus in the edentulous posterior in pristine bone. For maxillary sinus floor elevation, maxilla often represents a clinical challenge in all investigated bone substitute materials restorative/prosthetic treatment with dental performed equally well compared with bone, implants (1). Various surgical procedures and with high dental implant survival rates and graft materials have been used to correct such adequate histomorphometric data” (3). The two changes (20-22), including ß-Tricalcium Phos - cases presented show satisfactory results in phate (23). Miyamoto et al. report “… particles the use of the bone graft material, ß-Tricalcium of tricalcium phosphate attract osteoprogenitor phosphate “R.T.R.” Septodont based on the cells that migrate into the interconnected micro - evidence reported. This, along with the availability pores of the bone substitute material by six of the material and its safety in use, make it a months” (25). The stability of the implants placed therapeutic choice with multiple benefits. at the sites has been evaluated (24). A recent systematic review concludes: "There is a high level of evidence that survival rates of dental implants placed into augmented areas are

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Author: Dr Mario Ernesto García-Briseño DDS at Universidad Autónoma de Guadalajara, México, 1976. Certificate program in Periodontology at Universidad Nacional Autónoma de México 1985-87. Director and Professor of the certificate program in Periodontology since 1992 to date at Universidad Autónoma de Guadalajara School of Dentistry. Professor of Periodontology at certificate programs in Endodontics, Orthodontics, and Oral Rehabilitation since 1992 at Universidad Autónoma de Guadalajara School of Dentistry. Founder and President of the Mexican Association of Periodontology 1996-98. Founding member and Secretary of the Mexican Board of Periodontology 1996/2001. Academy affairs coordinator College of Dental Surgeons of Jalisco 2000/2004. Founder and academic coordinator of the College of Periodontics GDL. National and international lecturer. Private practice in Periodontics and Implant Dentistry.

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