Socket Augmentation: Rationale and Technique

Hom-Lay Wang, DDS, MSD,* Koichi Kiyonobu, DDS, PhD,† and Rodrigo F. Neiva, DDS‡

ooth extraction results in alveo- The consequences of exodontia should not be acutely infected and be lar bone loss as a result of re- include alveolar bone resorption and completely free of any soft tissue frag- sorption of the edentulous T ultimately atrophy to basal bone of the ments before any grafting or augmen- ridge.1–4 An average of 40% to 60% of original height and width is expected edentulous site/ridges. Ridge resorp- tation is attempted. Socket bleeding to be lost after tooth extraction, with tion proceeds quickly after tooth ex- that mixes with the grafting material the greatest loss happening within the traction and significantly reduces the seems essential for success of this pro- first 2 years.5–9 This can negatively possibility of placing implants without cedure. Various types of influence bone volume that is needed grafting procedures. The aims of this materials have been suggested for this for future placement. article are to describe the rationale purpose, and some have shown prom- Research has demonstrated that the al- behind alveolar ridge augmentation ising results. Coverage of the grafted veolar ridge at the maxillary anterior procedures aimed at preserving or extraction site with wound dressing area can be reduced by 23% in the first minimizing the edentulous ridge vol- materials, coronal flap advancement, 6 months after exodontia, and an ad- ume loss. Because the goal of these or even barrier membranes may en- ditional 11% in the following 5 approaches is to preserve bone, ex- hance wound stability and an undis- years.10 In the posterior mandible, re- sorption happens primarily in the buc- odontia should be performed to pre- turbed healing process. Future con- cal/labial direction, resulting in a lin- serve as much of the trolled clinical trials are necessary to gual displacement of alveolar crest.10 as possible. After severance of the determine the ideal regimen for socket The rate of reduction of residual alve- supra- and subcrestal fibrous attach- augmentation. (Implant Dent 2004; olar ridges has shown to be greater in ment using scalpels and periotomes, 13:286–296) mandibular (0.4 mm/year) than in elevation of the tooth frequently al- Key Words: alveolar ridge augmenta- maxillary arches (0.1 mm/year).11 As a lows extraction with minimal socket tion, socket preservation, exodontia, consequence, alveolar ridge atrophy wall damage. Extraction sockets dental implants may prohibit optimal implant place- ment, compromising the final esthetic and functional outcomes.12 traction sockets.16–18 Generally, these sorbable barrier membranes and ex- Augmentation of the residual al- procedures are primarily aimed at pre- tractions alone. At 6 months, signifi- veolar socket at the time of tooth ex- serving the current bone level and cantly less crestal bone loss (Ϫ0.38 traction (ie, socket augmentation, hopefully regenerating new bone. mm vs. Ϫ1.50 mm), more internal socket preservation, ridge preserva- This article presents the rationale socket fill (Ϫ5.81 mm vs. Ϫ3.94 mm), tion) has been evaluated in many stud- behind socket augmentation for future 13–15 and less horizontal ridge resorption ies. Multiple bone graft regimens implant placement and describes a (Ϫ1.31 mm vs. Ϫ4.56 mm) were and techniques have been suggested to technique that has shown to not only found in the membrane group than in minimize alveolar ridge atrophy and to facilitate tooth extraction with mini- the control group.19 As this study sug- evaluate new bone growth within ex- mal damage to the surrounding ana- gested, successful early alveolar ridge tomic structures, but also to improve augmentation (preservation) proce- alveolar bone quality and quantity. *Professor and Director of Graduate Periodontics, Department dures may reduce, or eliminate, the of Periodontics/Prevention/Geriatrics, School of , University of Michigan, Ann Arbor, MI. need for future ridge augmentation. †Private practice, Tokyo, Japan; and formal Visiting Research Fellow, Department of Periodontics/Prevention/Geriatrics, RATIONALE Bone healing and subsequent new School of Dentistry, University of Michigan, Ann Arbor, MI. ‡Clinical Assistant Professor, Department of The rationale for alveolar ridge bone formation after grafting take Periodontics/Prevention/Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, MI. preservation relies on the knowledge place through osteogenesis, osteoin- that alveolar ridge resorption is an un- duction, and/or osteoconduction.20–22 ISSN 1056-6163/04/01304-286 1 Implant Dentistry avoidable sequela of tooth loss. Lek- Osteogenic graft materials supply via- Volume 13 • Number 4 Copyright © 2004 by Lippincott Williams & Wilkins ovic et al. compared the outcome of ble osteoblasts that form new bone, DOI: 10.1097/01.id.0000148559.57890.86 alveolar ridge preservation using ab- whereas osteoinductive grafts stimu-

286 SOCKET AUGMENTATION late pluripotential mesenchymal cells ridge atrophy have been made.43–46 lial and connective tissue attachments to differentiate into osteoblasts that These grafting materials have shown to the tooth surface. Utilization of can form new bone. Osteoconductive to not only aid in osteoconduction of sharp instruments for this purpose graft materials, however, merely act as osteogenic cells by preserving the minimizes trauma and loss of the gin- a lattice for cell growth, permitting space and excluding unwanted cells gival tissues. osteoblasts from the wound margins to from the wound, but also to promote Periotomes are then applied to infiltrate the defect and migrate across formation new bone.47–50 Iasella et al. sever the subcrestal attachment appa- the graft.23 Autologous grafts are con- conducted a randomized, controlled, ratus. Straight periotomes are indi- sidered to be the ideal material for masked clinical trial in 24 patients. cated for use on single-rooted teeth, bone grafting procedures because it Subjects received either extraction whereas angled periotomes allow ac- possesses osteogenic, osteoinductive, alone or socket augmentation using cess to posterior multirooted teeth. and osteoconductive properties.24 tetracycline hydrated freeze-dried These instruments are used in a similar Transplantation of living cells in- bone allograft (FDBA) and a collagen manner for extraction of intact teeth or creases the possibility of retained cell membrane. Histologic analysis dem- removal of retained root fragments. viability and graft revasculariza- onstrated greater bone formation in The instrument is used first to com- tion.25–28 In addition, autologous grafts augmented sites after a 6-month heal- plete rupture of the at do not present a risk of disease trans- ing period. The most predictable the cervical area of the tooth (Fig. 1a). mission because donor and recipient maintenance of ridge width, height, During this procedure, the long axis of are the same individual.29 However, and position was achieved when a the blade should be angled converging they do increase the risk of additional socket augmentation procedure was at approximately 20° from the tooth pain, , and donor site morbid- used.50 However, some reports have long axis. This maneuver ensures that ity because an additional surgical pro- shown negative results when a alveo- the tip of the periotome blade is lo- cedure is necessary for harvesting.23 lar ridge preservation was attempted, cated within the crest of the alveolar Hence, bone substitutes have gained possibly as a result of use of inade- bone only, thus preventing the blade increasing acceptance as alternatives quate techniques and/or materials.51–54 from sliding out of the ridge and lac- to autologous bone for patients requir- For example, Zubillaga et al. evalu- erating the gingiva. The blade is thrust ing bone augmentation in an effort to ated a combination of demineralized to the depth of the and decrease the morbidity associated with freeze-dried bone allograft (Re- the gingival attachment is severed cir- autologous graft harvesting.30 Allo- genafill; Regeneration Technologies, cumferentially. It is necessary to re- grafts, xenografts, and alloplasts come Inc., Alachua, FL) and a bioabsorb- peat this procedure to ensure that all in many forms, and data support their able membrane (Resolut XT; W.L. gingival fibers are severed. The instru- safety, clinical applicability, and low Gore & Associates, Inc., Flagstaff, ment is then inserted into the peri- antigenicity.31 Bone graft materials AZ) for socket augmentation. The odontal ligament space and moved re- have been used to augment bony de- negative results observed were attrib- peatedly in a mesiodistal direction, on fects adjacent to dental implants and to uted to the slow resorption of the gel- the whole circumference of the root, repair chronic extraction socket de- atin carrier of the graft material.54 severing the periodontal ligament im- fects, with and without the use of bar- mediately below the alveolar crest. rier membranes.32–34 When combined The periotome is then pushed further with barrier membranes, bone graft TECHNIQUE down into the periodontal ligament to- materials have also shown to prevent After a complete medical history ward the root apex. It is possible to collapse of the .35–38 has been reviewed, and no contraindi- reach up to two thirds of the root Xenografts and alloplasts have also cations for a surgical procedure have length by repeatedly using this maneu- been applied for correction of bony been found, local anesthetic can be ver. With the completion of this pro- defects adjacent to dental implants and administered. Excessive infiltration of cedure, the tooth remains attached to alveolar ridge preservation before im- anesthetic agents containing high con- the alveolus only by the most apical plant placement, showing promising centrations of vasoconstrictor (ie, part of the periodontal ligament. Ad- results.39 Despite lack of osteoinduc- 1:50,000 epinephrine) into the extrac- ditional elevation may be required if tivity, these materials have shown re- tion site is discouraged. Bone graft significant is not sults comparable with the results materials work best when thoroughly achieved. A dental forceps should not achieved with allografts.15 Because wetted by blood. Thus, bleeding from be applied until significant tooth mo- these materials are mineralized, their the site should be encouraged and not bility is achieved. It is then possible to osteoconductive property is enhanced avoided. extract the tooth without having to in- as a result of formation of a more rigid Radiographic analysis of the sur- trude the dental forceps into the peri- scaffold for new bone formation.40–42 gical site should consider root mor- odontal ligament space, thus avoiding Because alveolar ridge atrophy is phology and surrounding anatomic distortion or other damage to the alve- a common consequence of tooth loss, structures. After local anesthesia is olar bone.55–57 and various bone grafting materials achieved, sulcular incisions performed After tooth removal, the socket is have shown positive results in many with a 15-C scalpel will initiate rup- thoroughly curetted of all soft tissue clinical scenarios, attempts to graft ex- ture of the supracrestal attachment ap- debris. Bleeding, if absent, should be traction sockets to reduce alveolar paratus, which is composed of epithe- stimulated from the osseous base. The

IMPLANT DENTISTRY /VOLUME 13, NUMBER 4 2004 287 rinsing twice daily with warm salt wa- ter for the first 2 weeks. Prescription of antibiotics should be limited to cases presenting signs of active infec- tion. Systemic antibiotic prophylaxis is generally not recommended as a result of the odontogenic nature of the majority of chronic . Hence, the source of infection is removed dur- ing exodontia, eliminating the need of additional antibiotic coverage. At 14 days, profuse granulation of soft tissue from the margins of the wound is a common finding, partially or com- pletely covering the grafted area. The Fig. 1. (a) Atraumatic tooth extraction. (b) Bleeding is stimulated with curettes or rotary healing process should be monitored instruments. (c) Bone graft fills two thirds of the socket depth. (d) Wound dressing material fills radiographically and implant place- the remaining one third of the socket. (e) A crossmattress suture is applied. (f) Ovate pontics are used for soft tissue development. ment can usually be performed 90 to 120 days after alveolar ridge preserva- tion procedures. If a radiographic im- age shows immature bone formation at key for maximum bone fill is adequate 1c). If this rule is followed, the most this time, implant placement should be bleeding from the bone, because blood coronal aspect of the graft stays at or postponed until normal radiodensity is contains fundamental proteins and slightly below the osseous crest, and observed. Radiolucencies persisting growth factors for bone healing.47,58,59 the remaining coronal one third of the for more than 180 days are indicative Profuse bleeding can be easily socket is mainly composed of gingival of inadequate graft incorporation, fre- achieved by scraping the walls of the tissue. An absorbable collagen dress- quently requiring an additional proce- socket with either curettes or rotary ing material (CollaPlug; Zimmer Den- dure for of the graft par- instruments (Fig. 1b). This procedure tal, Inc., Carlsbad, CA) is then placed ticles and possibly a new grafting also triggers the regional acceleratory to seal the coronal portion of the procedure. phenomena (RAP), which is known to socket (Fig. 1d). This material pro- stimulate new bone formation and vides stabilization for the treatment graft incorporation.60–62 site. Collagen dressing materials are DISCUSSION The selection of grafting material preferable because of their physiolog- Traditional tooth extraction is should be based on the following cri- ical absorption process and high bio- known to result in alveolar bone loss teria: 1) have unlimited supply, 2) be compatibility with oral tissues. In ad- as a result of atrophy of the edentulous biologically inert (no immunologic re- dition, collagen is a hemostatic agent ridge.1–4 Before implant therapy was action), 3) facilitated revasculariza- and possesses the ability to stimulate introduced, the concern was often re- tion, 4) osteoconduction, and 5) be platelet aggregation and to enhance fi- lated to stability of removable prosthe- completely replaced by new bone. Af- brin linkage, which may lead to initial ses. However, atrophic ridges can neg- ter selection, the bone graft material clot formation, stability, and matura- atively influence or even prohibit should be inserted into the extraction tion.67 Furthermore, collagen has been implant placement and often result in socket to provide a stable osteoinduc- demonstrated to be chemotactic for fi- poor esthetic outcomes. Ridge resorp- tive/osteoconductive environment broblasts in vitro.68 This property tion caused by tooth extraction should during the healing process. The mate- could enhance cell migration and pro- be reduced or eliminated.5–9 rial should be tamped down lightly mote primary wound coverage that is Recently, a socket preservation and overfill should be avoided. Ade- fundamental for bone growth. A cross- technique named “Bio-Col” was intro- quate space between the graft particles mattress suture is then used to secure duced.66 This technique involves: 1) is critical to allow for revasculariza- the collagen dressing material in the atraumatic tooth extraction followed tion to spread throughout the graft, socket for the initial 14 days of the by socket curettage and cortical socket bringing the proteins and growth fac- healing process (Fig. 1e). Ovate fixed perforation, 2) socket grafting with tors that are necessary for new bone or removable pontics may be used to bovine hydroxyapatite (HA) (Bio-Oss; growth.63–65 Overfilling the socket will provide support to both interdental pa- Osteohealth Co, Shirley, NY), 3) only result in sequestration of the pillae and facilitate development of a placement of an absorbable collagen coronal graft particles, possibly lead- more esthetically pleasing soft tissue dressing (CollaPlug), and 4) socket ing to development of an infectious profile (Fig. 1f). A step-by-step illus- sealing with an impervious tissue glue source that may negatively influence tration of using this technique to aug- (Isodent; Ellman International, osseous formation.66 Only the apical ment sockets is shown in Figures 2 Hewlett, NY). An interim ovate pontic two thirds of the socket should be and 3. form of provisional restoration is then filled with bone grafting material (Fig. Postoperative care should include fabricated to replicate the contours of

288 SOCKET AUGMENTATION with greater predictability. However, no controlled studies have been con- ducted to confirm these findings. The technique presented in this article has been extensively used in our institu- tion. Positive outcomes have been constantly achieved with minimal morphologic changes noticeable up to 6 months after exodontia. Augmented sockets have shown not only adequate morphology, but also density; both of which are noticeable during implant osteotomy preparation. As a conse- quence, soft tissue profile has been constantly preserved, maximizing the esthetic outcome. Future investiga- tions should provide scientific evi- dence of our experiences. Many bone grafting materials Fig. 2. (a) Preoperative view. (b) Periotomes facilitate rupture of the supracrestal attachment have been suggested for socket aug- apparatus. (c) Tooth extraction occurs with minimal trauma to the surrounding tissues. (d) The mentation.69–73 These include autoge- socket is free of infection and presents profuse bleeding. nous bone, demineralized freeze-dried bone allograft (DFDBA),74 mineral- ized freeze-dried bone allograft (FDBA),75 bovine hydroxyapatite (HA)10; and alloplasts.14 Becker et al. evaluated the bone-forming capacity of DFDBA in extraction sockets.74 The sites were reentered for the pur- poses of obtaining biopsies of the grafted areas. The biopsies showed that DFDBA-grafted sites had no evi- dence of new bone formation and that there was no evidence of osteoclastic resorption of the graft particles, whereas the autograft-treated sites re- vealed vascular channels with woven and lamellar bone. The evidence sug- gests that DFDBA may not be a good material for socket augmentation.74 A potential delay in osteogenic cell in- growth has also been observed when a demineralized bone matrix (Grafton DBM Plugs; Osteotech, Inc., Eaton- town, NJ) was used for socket aug- mentation.76 However, Brugnami et al. combined DFDBA with barrier mem- branes and found positive results, sug- gesting that barrier membranes may overcome possible deficiencies of this grafting material.32 Recently, a human Fig. 2e. (e) The bone graft material is inserted into the extraction socket (Puros; Zimmer bone mineralized graft (Puros; Zim- Dental, Carlsbad, CA). (f) A wound dressing material (CollaPlug; Zimmer Dental) covers the augmented extraction socket. (g) A crossmattress suture is placed to stabilize the wound. (h) mer Dental, Carlsbad, CA) was intro- An ovate pontic is used for soft tissue development. (i) Postoperative view 14 days after socket duced. It constitutes a mineralized augmentation. (j) Reentry 120 days later showing complete bone fill. bone allograft material processed through unique solvent-preserved pro- cesses for tissue preservation and viral the extracted tooth and to facilitate both hard and soft tissues, 2) reduces inactivation, which differ from the soft tissue profile. The authors claim the number of surgical interventions, standard cryopreserved process. Data that this technique 1) prevents loss of and 3) provides optimum esthetics have demonstrated that after standard

IMPLANT DENTISTRY /VOLUME 13, NUMBER 4 2004 289 This facilitates future implant place- ment.79 Future studies in this area are needed. The use of barrier membranes in socket augmentation procedures has also been evaluated. Lekovic et al. ob- served the clinical effectiveness of barrier membranes in preserving alve- olar ridges after tooth extraction. Re- sults showed that membrane-covered sites presented with significantly less ridge atrophy than control sites. The authors suggested that treatment of ex- traction sockets with membranes is valuable in preserving alveolar bone in extraction sockets and preventing al- veolar ridge defects.86 Difficulties as- sociated with barrier membrane use during socket augmentation include: Fig. 3. (a) Periotomes are progressively inserted around the whole circumference of the tooth. (b) Atraumatic tooth extraction. (c) The socket is free of infection and presents profuse bleed- 1) the potential reduction of keratin- ing. (d) The bone graft material is inserted into the extraction socket (Puros; Zimmer Dental, ized gingiva, 2) alterations of gingival Carlsbad, CA). contours, and 3) migration of the mu- cogingival junction, as a result of coronal displacement of the flap to achieve soft tissue closure over the membrane.87–90 Even with these draw- backs, some studies have demon- strated success in the use of a variety of membranes for socket augmenta- tion, including nonabsorbable, absorb- able, and acellular dermal allo- grafts.53,91–93 Fowler et al. used acellular dermal matrix (AlloDerm; Lifecore Biomedical, Oral Restorative Division, Chaska, MN) as a barrier membrane with a demineralized freeze-dried bone allograft for ridge preservation. A series of cases demon- strated an acceptable esthetic result with no apparent loss of ridge height or width. The 2 graft materials were well accepted by the body and healing was rapid and without significant dis- Fig. 3. (e) A wound dressing material (CollaPlug; Zimmer Dental) covers the augmented 18 extraction socket. (f) An ovate pontic is used for soft tissue development. (g) Adequate ridge comfort. Reports in the literature width 90 days after exodontia. (h) Soft tissue profile shows fully preserved 90 days after tooth have also suggested use of other ma- extraction. terials such as xenografts and allo- plasts with varying results.93–95 How- ever, these reports were primarily case tissue bank processing and limited group uses either FDBA or human study series. gamma radiation, the bone appears to mineralized bone as the primary bone remain intact, providing excellent graft for this type of procedure. These CONCLUSION bone matrix and load-bearing capabil- materials have optimal osteoconduc- Future controlled clinical trials are ities.77,78 Research has demonstrated tive properties and may also be os- encouraged to validate the findings of lamellar bone formation as quickly as teoinductive by releasing bone mor- the technique presented in this article 15 days after implantation of this ma- phogenic proteins (BMPs), which to provide needed scientific evidence. terial in the tibia of rabbits and almost could induce osteogenesis from sur- complete disappearance in 60 days.79 rounding bone.80–84 In addition, these These findings suggest that this mate- materials have shown to be completely DISCLOSURE rial may be a good alternative for resorbed and consequently replaced The authors do not have any fi- socket augmentation procedures. Our with host bone within 2 to 4 months.85 nancial interests, either directly or in-

290 SOCKET AUGMENTATION directly, in the products listed in this absorbable collagen sponge device for lo- 26. Maatz R, Lentz W, Graf R. Bone study. cal alveolar ridge preservation or augmen- tissue formation by preserved particles; tation. Int J Periodontics Restorative Dent. bone banks. Zentralbl Chir. 1952;77: 1997;17:124–139. 1376–1382. ACKNOWLEDGMENTS 13. Ashman A, Lopinto J. Placement of 27. Maatz R. Biological principles of implants into ridges grafted with Bioplant healing of bone wounds. Dtsch Med J. This study was partially supported by HTR synthetic bone: histological long-term 1953;4:255–260. the University of Michigan, Periodon- case history reports. J Oral Implantol. 28. Maatz R, Lentz W, Graf R. Spon- tal Graduate Student Research Fund. 2000;26:276–290. giosa test of bone grafts for transplanta- 14. Froum S, Orlowski W. Ridge pres- tion. J Bone Joint Surg [Am]. 1954;36: ervation utilizing an alloplast prior to im- 721–731. REFERENCES plant placement—clinical and histological 29. Goldberg VM, Stevenson S. Natu- 1. Bays R. The pathophysiology and case reports. Pract Periodontics Aesthet ral history of autografts and allografts. Clin anatomy of edentulous bone loss. Recon- Dent. 2000;12:393–402; quiz 404. Orthop. 1987;225:7–15. structive Preprosthetic Oral and Maxillofa- 15. Froum S, Cho SC, Rosenberg E, et 30. Russell JL. Grafton demineralized cial Surgery. 1986;1:1–17. al. Histological comparison of healing ex- bone matrix: performance consistency, 2. Mecall RA, Rosenfeld AL. Influence traction sockets implanted with bioactive utility, and value. Tissue Engineering. of residual ridge resorption patterns on fix- glass or demineralized freeze-dried bone 2000;6:435–440. ture placement and tooth position, Part III: allograft: a pilot study. J Periodontol. 2002; 31. Buck BE, Malinin TI. Human bone presurgical assessment of ridge augmen- 73:94–102. and tissue allografts. Preparation and tation requirements. Int J Periodontics Re- 16. Bartee BK. Extraction site recon- safety. Clin Orthop. 1994:8–17. storative Dent. 1996;16:322–337. struction for alveolar ridge preservation. 32. Brugnami F, Then PR, Moroi H, et 3. Mecall RA, Rosenfeld AL. The influ- Part 1: rationale and materials selection. al. GBR in human extraction sockets and ence of residual ridge resorption patterns J Oral Implantol. 2001;27:187–193. ridge defects prior to implant placement: on implant fixture placement and tooth po- 17. Becker W, Hujoel P, Becker BE. Ef- clinical results and histologic evidence of sition. 2. Presurgical determination of fect of barrier membranes and autologous osteoblastic and osteoclastic activities in prosthesis type and design. Int J Periodon- bone grafts on ridge width preservation DFDBA. Int J Periodontics Restorative tics Restorative Dent. 1992;12:32–51. around implants. Clin Implant Dent Relat Dent. 1999;19:259–267. 4. Mecall RA, Rosenfeld AL. Influence Res. 2002;4:143–149. 33. Kassolis JD, Rosen PS, Reynolds of residual ridge resorption patterns on im- 18. Fowler EB, Breault LG, Rebitski G. MA. Alveolar ridge and sinus augmentation plant fixture placement and tooth position. Ridge preservation utilizing an acellular utilizing platelet-rich plasma in combina- 1. Int J Periodontics Restorative Dent. dermal allograft and demineralized freeze- tion with freeze-dried bone allograft: case 1991;11:8–23. dried bone allograft: Part I. A report of 2 series. J Periodontol. 2000;71:1654– 5. Sevor JJ, Meffert R. Placement of cases. J Periodontol. 2000;71:1353– 1661. implants into fresh extraction sites using a 1359. 34. Simion M, Trisi P, Piattelli A. GBR resorbable collagen membrane: case re- 19. Lekovic V, Kenney EB, Weinlae- with an e-PTFE membrane associated with ports. Pract Periodontics Aesthet Dent. nder M, et al. A bone regenerative ap- DFDBA: histologic and histochemical anal- 1992;4:35–41. proach to alveolar ridge maintenance fol- ysis in a human implant retrieved after 4 6. Polizzi G, Grunder U, Goene R, et lowing tooth extraction. Report of 10 years of loading. Int J Periodontics Restor- al. Immediate and delayed implant place- cases. J Periodontol. 1997;68:563–570. ative Dent. 1996;16:338–347. ment into extraction sockets: a 5-year re- 20. Marx RE, Snyder RM, Kline SN. 35. Nevins M, Mellonig JT. Enhance- port. Clin Implant Dent Relat Res. 2000;2: Cellular survival of human marrow during ment of the damaged edentulous ridge to 93–99. placement of marrow-cancellous bone receive dental implants: a combination of 7. Grunder U, Polizzi G, Goene R, et grafts. J Oral Surg. 1979;37:712–717. allograft and the GORE-TEX membrane. al. A 3-year prospective multicenter 21. Urist MR, Granstein R, Nogami H, Int J Periodontics Restorative Dent. 1992; follow-up report on the immediate and et al. Transmembrane bone morphogene- 12:96–111. delayed-immediate placement of implants. sis across multiple-walled diffusion cham- 36. Nevins M, Mellonig JT. The advan- Int J Oral Maxillofac Implants. 1999;14: bers. New evidence for a diffusible bone tages of localized ridge augmentation prior 210–216. morphogenetic property. Arch Surg. 1977; to implant placement: a staged event. Int J 8. Werbitt MJ, Goldberg PV. The im- 112:612. Periodontics Restorative Dent. 1994;14: mediate implant: bone preservation and 22. Burwell RG. Osteogenesis in can- 96–111. bone regeneration. Int J Periodontics Re- cellous bone grafts: considered in terms of 37. Mellonig JT, Nevins M. Guided storative Dent. 1992;12:206–217. cellular changes, basic mechanisms and bone regeneration of bone defects associ- 9. Werbitt MJ, Goldberg PV. Immedi- the perspective of growth-control and its ated with implants: an evidence-based ate implantation. Preservation of bone vol- possible aberrations. Clin Orthop. 1965; outcome assessment. Int J Periodontics ume and osseous regeneration. J Peri- 40:35. Restorative Dent. 1995;15:168–185. odontol. 1991;10:157–166. 23. Feinberg SE, Fonseca RJ. Biologic 38. Mellonig JT, Nevins M, Sanchez R. 10. Artzi Z, Tal H, Dayan D. Porous bo- aspects of transplantation of grafts. In: Evaluation of a bioabsorbable physical vine bone mineral in healing of human ex- Davis WH, ed. Reconstructive Prepros- barrier for guided bone regeneration. Part traction sockets. Part 1: histomorphomet- thetic Oral and Maxillofacial Surgery, 1st I. Material alone. Int J Periodontics Restor- ric evaluations at 9 months. J Periodontol. ed. Philadelphia: WB Saunders; 1986. ative Dent. 1998;18:139–149. 2000;71:1015–1023. 24. Schallhorn RG. The use of autoge- 39. Smiler DG. Comparison of anor- 11. Nemcovsky CE, Serfaty V. Alveolar nous hip marrow biopsy implants for bony ganic bovine mineral with and without syn- ridge preservation following extraction of crater defects. J Periodontol. 1968;39: thetic peptide in a sinus elevation: a case maxillary anterior teeth. Report on 23 con- 145–147. study. Implant Dent. 2001;10:139–142. secutive cases. J Periodontol. 1996;67: 25. Maatz R, Lentz W, Graf R. Experi- 40. Camargo PM, Lekovic V, Weinlae- 390–395. mental principles in transplantation of pre- nder M, et al. Influence of bioactive glass 12. Howell TH, Fiorellini J, Jones A, et served bones. Langenbecks Arch Klin Chir on changes in alveolar process dimensions al. A feasibility study evaluating rhBMP-2/ Ver Dtsch Z Chir. 1952;273:850–855. after exodontia. Oral Surg Oral Med Oral

IMPLANT DENTISTRY /VOLUME 13, NUMBER 4 2004 291 Pathol Oral Radiol Endod. 2000;90:581– BI, et al. Changes in alveolar bone height collagen-derived peptides. Proc Natl Acad 586. and width following post-extraction ridge SciUSA. 1978;75:871–875. 41. Aichelmann-Reidy ME, Yukna RA. augmentation using a fixed bioabsorbable 69. Gross J. Ridge preservation using Bone replacement grafts. The bone substi- membrane and demineralized freeze-dried HTR synthetic bone following tooth extrac- tutes. Dent Clin North Am. 1998;42:491– bone osteoinductive graft. J Periodontol. tion. Gen Dent. 1995;43:364–367. 503. 2003;74:965–975. 70. Serino G, Biancu S, Iezzi G, et al. 42. Yukna RA, Evans GH, Aichelmann- 55. Quinn JH, Kent JN. Alveolar ridge Ridge preservation following tooth extrac- Reidy MB, et al. Clinical comparison of bio- maintenance with solid nonporous hy- tion using a polylactide and polyglycolide active glass bone replacement graft mate- droxylapatite root implants. Oral Surg Oral sponge as space filler: a clinical and histo- rial and expanded polytetrafluoroethylene Med Oral Pathol. 1984;58:511–521. logical study in humans. Clin Oral Implants barrier membrane in treating human man- 56. Quinn JH, Kent JN, Hunter RG, et Res. 2003;14:651–658. dibular molar class II furcations. J Peri- al. Preservation of the alveolar ridge with 71. Sy IP. Alveolar ridge preservation odontol. 2001;72:125–133. hydroxylapatite tooth root substitutes. using a bioactive glass particulate graft in 43. Hirai S. Evaluation of hydroxyapa- J Am Dent Assoc. 1985;110:189–193. extraction site defects. Gen Dent. 2002; tite ceramics implants in the fresh extrac- 57. Kentros GA, Filler SJ, Rothstein 50:66–68. tion sockets for the alveolar ridge preser- SS. Six month evaluation of particulate Du- 72. Yukna RA, Castellon P, Saenz- vation. Nippon Hotetsu Shika Gakkai rapatite in extraction sockets for the pres- Nasr AM, et al. Evaluation of hard tissue Zasshi. 1988;32:920–935. ervation of the alveolar ridge. Implantolo- replacement composite graft material as a 44. Cranin AN, Simons A, Klein M, et gist. 1985;3:53–62. ridge preservation/augmentation material al. The use of a particulate, microporous, 58. Jensen OT, Greer RO Jr, Johnson in conjunction with immediate calcified copolymer as a ridge mainte- L, et al. Vertical guided bone-graft aug- hydroxyapatite-coated dental implants. J nance device in dogs. J Vet Dent. 1995;12: mentation in a new canine mandibular Periodontol. 2003;74:679–686. 53–58. model. Int J Oral Maxillofac Implants. 73. Vasilic N, Henderson R, Jorgenson 45. Ashman A. Ridge preservation: the 1995;10:335–344. T, et al. The use of bovine porous bone new buzzword in dentistry. Implant Soc. 59. Kay SA, Wisner-Lynch L, Marxer mineral in combination with collagen mem- 1995;6:1–7. M, et al. Guided bone regeneration: inte- brane or autologous fibrinogen/fibronectin 46. Bartee BK. A simplified technique gration of a resorbable membrane and a system for ridge preservation following for ridge preservation after tooth extrac- bone graft material. Pract Periodontics tooth extraction. J Okla Dent Assoc. 2003; tion. Dent Today. 1995;14:62–77. Aesthet Dent. 1997;9:185–194; quiz 196. 93:33–38. 47. Becker W, Urist M, Becker BE, et 60. Trevisan C, Ortolani S, Monteleone 74. Becker W, Becker BE, Caffesse R. al. Clinical and histologic observations of M, et al. Regional migratory osteoporosis: A comparison of demineralized freeze- sites implanted with intraoral autologous a pathogenetic hypothesis based on three dried bone and autologous bone to induce bone grafts or allografts. 15 human case cases and a review of the literature. Clin bone formation in human extraction sock- reports. J Periodontol. 1996;67:1025– Rheumatol. 2002;21:418–425. ets. J Periodontol. 1994;65:1128–1133. 1033. 61. Melsen B. Tissue reaction to orth- 75. Feuille F, Knapp CI, Brunsvold MA, 48. Pinholt EM, Haanaes HR, Roervik odontic tooth movement—a new para- et al. Clinical and histologic evaluation of M, et al. Alveolar ridge augmentation by digm. Eur J Orthod. 2001;23:671–681. bone-replacement grafts in the treatment osteoinductive materials in goats. Scand J Dent Res. 1992;100:361–365. 62. Melsen B. Biological reaction of al- of localized alveolar ridge defects. Part 1: 49. Pinholt EM, Bang G, Haanaes HR. veolar bone to orthodontic tooth move- mineralized freeze-dried bone allograft. Int Alveolar ridge augmentation by osteoin- ment. Angle Orthod. 1999;69:151–158. J Periodontics Restorative Dent. 2003;23: duction in rats. Scand J Dent Res. 1990; 63. Becker W, Lynch SE, Lekholm U, 29–35. 98:434–441. et al. A comparison of ePTFE membranes 76. Korsnes J. Effects of a demineral- 50. Iasella JM, Greenwell H, Miller RL, alone or in combination with platelet- ized bone matrix on alveolar ridge preser- et al. Ridge preservation with freeze-dried derived growth factors and insulin-like vation. Orban Competition, American bone allograft and a collagen membrane growth factor-I or demineralized freeze- Academy of , Annual compared to extraction alone for implant dried bone in promoting bone formation Meeting; September 2003. site development: a clinical and histologic around immediate extraction socket im- 77. Scharf H. Humane Tibialis- study in humans. J Periodontol. 2003;74: plants. J Periodontol. 1992;63:929–940. anterior-Sehnen als lo¨ sungsmittelkonser- 990–999. 64. Valentin-Opran A, Wozney J, ciertes Transplantat fu¨ r den Kreuzbander- 51. Cohen ES. Ridge enhancement Csimma C, et al. Clinical evaluation of re- satz. Universita¨ t Ulm. 1990:23–28. and socket preservation utilizing the sub- combinant human bone morphogenetic 78. Gu¨ nther KP, Scharf H-P, Pesch epithelial connective tissue graft: a case re- protein-2. Clin Orthop. 2002:110–120. H-J, et al. Osteointegration of solvent- port. Pract Periodontics Aesthet Dent. 65. Mellonig JT. Bone allografts in peri- preserved bone transplants in an animal 1995;7:53–58; quiz 60. odontal therapy. Clin Orthop. 1996:116– model. Osteologie. 1996;5:4–12. 52. Tal H. Autogenous masticatory 125. 79. Dalkyz M, Ozcan A, Yapar M, et al. mucosal grafts in extraction socket seal 66. Sclar AG. Preserving alveolar ridge Evaluation of the effects of different bioma- procedures: a comparison between sock- anatomy following tooth removal in con- terials on bone defects. Implant Dent. ets grafted with demineralized freeze-dried junction with immediate implant place- 2000;9:226–235. bone and deproteinized bovine bone min- ment. The Bio-Col technique. Atlas Oral 80. Urist MR. Bone: formation by auto- eral. Clin Oral Implants Res. 1999;10:289– Maxillofac Surg Clin North Am. 1999;7:39– induction. Science. 1965;150:893–899. 296. 59. 81. Urist MR, Silverman BF, Buring K, 53. Zitzmann NU, Scharer P, Marinello 67. Sableman E. Biology, Biotechnol- et al. The bone induction principle. Clin Or- CP. Factors influencing the success of ogy, and Biocompatibility of Collagen. Bio- thop. 1967;53:243–283. GBR. Smoking, timing of implant place- compatibility of Tissue Analogs, 1st ed. 82. Urist MR, Dowell TA, Hay PH, et al. ment, implant location, bone quality and Boca Raton, FL: CRC Press; 1985:27. Inductive substrates for bone formation. provisional restoration. J Clin Periodontol. 68. Postlethwaite AE, Seyer JM, Kang Clin Orthop. 1968;59:59–96. 1999;26:673–682. AH. Chemotactic attraction of human fi- 83. Urist MR, Iwata H. Preservation 54. Zubillaga G, Von Hagen S, Simon broblasts to type I, II, and III collagens and and biodegradation of the morphogenetic

292 SOCKET AUGMENTATION property of bone matrix. J Theor Biol. based root coverage procedure: a pilot 94. Oikarinen KS, Sandor GK, Kainu- 1973;38:155–167. case study. Int J Periodontics Restorative lainen VT, et al. Augmentation of the nar- 84. Urist MR, Iwata H, Ceccotti PL, et Dent. 2002;22:119–127. row traumatized anterior alveolar ridge to al. Bone morphogenesis in implants of in- 89. Wang HL, Bunyaratavej P, Labadie facilitate dental implant placement. Dent soluble bone gelatin. Proc Natl Acad Sci U M, et al. Comparison of 2 clinical tech- Traumatol. 2003;19:19–29. SA. 1973;70:3511–3515. niques for treatment of . 95. Wiesen M, Kitzis R. Preservation of 85. Wang HL, Misch C, Neiva RF. J Periodontol. 2001;72:1301–1311. the alveolar ridge at implant sites. Peri- ’Sandwich’ bone augmentation technique: 90. Wang HL, Carroll MJ. Guided bone odontal Clin Investig. 1998;20:17–20. rationale and report of pilot cases. Int J regeneration using bone grafts and colla- Periodontics Restorative Dent. 2004;24: gen membranes. Quintessence Int. 2001; 232–245. 32:504–515. 86. Lekovic V, Camargo PM, 91. Bartee BK. Extraction site recon- Reprint requests and correspondence to: Klokkevold PR, et al. Preservation of alve- struction for alveolar ridge preservation. Hom-Lay Wang, DDS, MSD olar bone in extraction sockets using bio- Part 2: membrane-assisted surgical Professor and Director of Graduate absorbable membranes. J Periodontol. technique. J Oral Implantol. 2001;27: Periodontics 1998;69:1044–1049. 194–197. Department of 87. Wang HL, Al-Shammari KF. 92. Yang J, Lee HM, Vernino A. Ridge Periodontics/Prevention/Geriatrics Guided tissue regeneration-based root preservation of dentition with severe peri- University of Michigan School of Dentistry coverage utilizing collagen membranes: odontitis. Compend Contin Educ Dent. 1011 North University Avenue technique and case reports. Quintessence 2000;21:579–583; quiz 584. Ann Arbor, MI 48109-1078 Int. 2002;33:715–721. 93. Ashman A. Postextraction ridge Phone: (734) 763-3383 88. Wang HL, Kimble K, Eber R. Use of preservation using a synthetic alloplast. Fax: (734) 936-0374 bone grafts for the enhancement of a GTR- Implant Dent. 2000;9:168–176. E-mail: [email protected]

IMPLANT DENTISTRY /VOLUME 13, NUMBER 4 2004 293 Abstract Translations [German, Spanish, Portugese, Japanese]

AUTOR(EN): Hom-Lay Wang, D.D.S., Versta¨rkung der Zahnho¨hle: Grundprinzipien und Methodik M.S.D.*, Koichi Kiyonobu, D.D.S., Ph.D.**, und Rodrigo F. Neiva, D.D.S.***. *Professor ZUSAMMENFASSUNG: Zu den Folgen der Zahnextraktion geho¨ren die Resorption des und Leiter des Graduiertenkollegs Orthodon- Alveolarknochens und letztendlich eine Atrophie des Basalknochens im zahnlosen Kief- tie, Abteilung fu¨r Orthodontie/Pra¨vention/ erbereich bzw. Zahnkamm. Die Resorption des Kamms geht erfahrungsgema¨␤ nach Geriatrie, zahnmedizinische Fakulta¨t, Univer- erfolgter Zahnextraktion schnell vonstatten und verringert damit die Chancen fu¨r eine sita¨t von Michigan, Anna Arbor, MI. **Privat erfolgreiche Implantierung ohne vorherige Transplantierungsnotwendigkeit. Die vorlieg- praktizierender Arzt, Tokio, Japan. Mitglied ende Arbeit konzentriert sich auf eine Beschreibung der den Behandlungsschritten zur des Forschungsteams mit Gaststatus, Abtei- Anreicherung des Zahnkamms zu Grunde liegenden Grundprinzipien. Die Behandlung an lung fu¨r Orthodontie/Pra¨vention/Geriatrie, sich zielt auf eine Erhaltung des zahnlosen Kammvolumens oder zumindest doch auf eine zahnmedizinische Fakulta¨t, Universita¨t von Verringerung des entstehenden Volumenverlustes ab. Da jeder Behandlungsansatz letz- Michigan, Anna Arbor, MI. *** Klinischer tendlich die Erhaltung des vorhandenen Knochengewebes vorsieht, sollte bei der Zah- Assistenzprofessor, Abteilung fu¨r Orthodontie/ nextraktion versucht werden, das maximale Ma␤ des Alveolarprozesses zu erhalten. Nach Pra¨vention/Geriatrie, zahnmedizinische Trennung des u¨ber und unter dem Kamm gelegenen fibro¨sen Gewebes mittels Skalpell Fakulta¨t, Universita¨t von Michigan, Anna Ar- und Periotom kann eine Anhebung des Zahnes die Extraktion mit nur minimalen Scha¨- bor, MI. Schriftverkehr: Hom-Lay Wang, digungen an der Wand der Zahnpfanne begu¨nstigen. Die Extraktionsho¨hlen sollten ge- DDS, MSD, Professor und Leiter des Gradui- nerell immer infektionsfrei und ohne Ru¨ckstande von Weichgewebsteilen gehalten wer- ertenkollegs Orthodontie (Professor and Di- den, bevor der Versuch einer Transplantierung oder Gewebsanreicherung unternommen rector of Graduate Periodontics), Abteilung wird. Entstehen Blutungen in der Zahnho¨hle, ko¨nnen sich diese mit dem zur Transplan- fu¨r Orthodontie/Pra¨vention/Geriatrie (Dept. tation vorgesehenen Material vermischen und so den Gesamterfolg der Behandlung of Periodontics/Prevention/Geriatrics), Uni- gefa¨hrden. Hier empfiehlt es sich, die mit Transplantat versehene Extraktionsstelle mit versita¨t von Michigan, zahnmedizinische Wundverbandmaterialien zu bedecken, den Zahnkronenlappen bedeckend vorzuziehen Fakulta¨t (University of Michigan School of oder sogar Barriermembrane vorzusehen, um somit die Wundstabilita¨t zu erho¨hen und Dentistry), 1011 North University Avenue, einen ungehinderten Heilungsprozess zu ermo¨glichen. Fu¨r die Bestimmung der idealen Ann Arbor, Michigan 48109 - 1078, USA. Ma␤nahmen zur Zahnho¨hlenanreicherung mu¨ssten kontrollierte klinische Versuchsreihen Telefon: (734) 763 - 3383 Fax: (734) 936 durchgefu¨hrt werden. –0374. eMail: [email protected] SCHLU¨ SSELWO¨ RTER: Versta¨rkung des Alveolarkammes. Erhaltung der Zahnho¨hle, Zahnextraktion, Zahnimplantate

AUTOR(ES): Hom-Lay Wang, D.D.S., M.S.D.*, Expansio´n de la cavidad: Razones y te´cnica Koichi Kiyonobu, D.D.S., Ph.D.** y Rodrigo F. Neiva, D.D.S.***. *Profesor y Director de Period- ABSTRACTO: Las consecuencias de la exodoncia incluye la reabsorcio´n alveolar del oncia para Graduados, Departamento de Peri- hueso y finalmente la atrofia del hueso basal de las crestas/lugares edentulosos. La odo´ntica/Prevencio´n/Geria´trica, Facultad de Od- reabsorcio´n de la cresta ocurre ra´pidamente luego de la extraccio´n del diente y reduce ontologı´a, Universidad de Michigan, Ann Arbor, significativamente la posibilidad de colocar implantes sin procedimientos de injertos. El MI. **Pra´ctica Privada, Tokio, Japo´n. Ex- objetivo de este trabajo es describir las razones de los procedimientos de expansio´n de la Investigador Visitante, Departamento de Periodo´n- cresta alveolar para preservar o reducir la pe´rdida del volumen de la cresta edentulosa. tica/Prevencio´n/Geria´trica, Facultad de Odontolo- Debido a que la meta de estos me´todos es preservar hueso, la exodoncia debera´ realizarse gı´a, Universidad de Michigan, Ann Arbor, MI. para preservar la mayor cantidad posible del proceso alveolar. Luego de cortar las fibras ***Profesor Clı´nico Asistente, Departamento de supra y subcretales usando escalpelos y periotomos, la elevacio´n del diente frecuent- Periodo´ntica/Prevencio´n/Geria´trica, Facultad de emente permite la extraccio´n con un mı´nimo de dan˜o a la pared de la cavidad. Las Odontologı´a, Universidad de Michigan, Ann Ar- cavidades de extraccio´n no deben estar agudamente infectadas y deben estar completa- bor, MI. Correspondencia a: Hom-Lay Wang, mente libres de fragmentos de tejidos suaves antes de intentar cualquier injerto o DDS, MSD, Profesor y Director of Graduate Pe- expansio´n. El sangrado de la cavidad que se mezcla con el material de injerto parece riodontics, Department of Periodontics/Prevention/ esencial para el e´xito de este procedimiento. Varios tipos de materiales para el injerto de Geriatrics, University of Michigan School of Den- hueso se han sugerido con este propo´sito, y algunos han demostrado resultados promet- tistry, 1011 North University Avenue, Ann Arbor, edores. Cubrir el lugar de extraccio´n injertado con materiales para vendar heridas, avance Michigan 48109-1078, U.S.A. Tele´fono: (734) 763- de aletas coronales e incluso membranas para barreras, podrı´a mejorar la estabilidad de la 3383, Fax: (734) 936-0374. Correo electro´nico: herida y un proceso de curacio´n sin problemas. Pruebas clı´nicas futuras controladas son [email protected] necesarias para determinar el re´gimen ideal para la expansio´n de la cavidad. PALABRAS CLAVES: expansio´n de la cresta alveolar, preservacio´n de la cavidad, exodoncia, implantes dentales.

294 ABSTRACT TRANSLATIONS AUTOR(ES): Hom-Lay Wang, Cirurgia˜o- Aumento do Alve´olo: Fundamento & Te´cnica Dentista, Mestre em Odontologia*, Koichi Kiyonobu, Cirurgia˜o-Dentista, PhD.** e Ro- RESUMO: As consequ¨eˆncias da exodontia incluem reabsorc¸a˜o o´ssea alveolar e posteri- drigo F. Neiva, Cirurgia˜o-Dentista**** Pro- ormente atrofia ate´ o osso basal do(s) local/rebordos desdentados. A reabsorc¸a˜o dos fessor e Diretor de Periodontia Graduada, rebordos prossegue rapidamente apo´s a extrac¸a˜o do dente e reduz significativamente a Depto. de Periodontia/Prevenc¸a˜o/Geriatria, possibilidade de colocar implantes sem procedimentos de enxerto. Os objetivos deste Escola de Odontologia, Universidade de paper sa˜o descrever o fundamento por tra´s dos procedimentos de aumento do rebordo Michigan, Ann Arbor, MI. ** Clı´nica particu- alveolar com vistas a preservar ou minimizar a perda de volume do rebordo desdentado. lar, To´quio, Japa˜o. Bolsista de Pesquisa For- Ja´ que o objetivo destas abordagens e´ preservar o osso, a exodontia deve ser realizada para mal Visitante, Depto. de Periodontia/Preven- preservar o ma´ximo de processo alveolar possı´vel. Apo´s o rompimento do encaixe fibroso c¸a˜o/Geriatria, Escola de Odontologia, supra e subcrista usando-se bisturis e periotomos, a elevac¸a˜o do dente frequ¨entemente Universidade de Michigan, Ann Arbor, MI. permite a extrac¸a˜o com dano mı´nimo a` parede do alve´olo. Os alve´olos de extrac¸a˜o na˜o *** Professor Assistente Clı´nico. Depto. de devem estar agudamente infectados e estar completamente isentos de quaisquer fragmen- Periodontia/Prevenc¸a˜o/Geriatria, Escola de tos de tecido mole antes que qualquer enxerto ou aumento seja tentado. O sangramento do Odontologia, Universidade de Michigan, Ann alve´olo que se mistura com o material de enxerto parece essencial para o sucesso deste Arbor, MI. Correspondeˆncia para: Hom-Lay procedimento. Va´rios tipos de materiais de enxerto o´sseo foram sugeridos para este Wang, DDS, MSD, Professor and Director of propo´sito, e alguns mostraram resultados promissores. A cobertura do local de extrac¸a˜o Graduate Periodontics, Dept. of Periodontics/ enxertado com materiais de bandagem de feridas, avanc¸o do retalho coronal ou mesmo Prevention/Geriatrics, University of Michigan membranas protetoras, podem aumentar a estabilidade da ferida e um processo de cura School of Dentistry, 1011 North University tranqu¨ilo. Futuros testes clı´nicos controlados sa˜o necessa´rios para determinar o regime Avenue, Ann Arbor, Michigan 48109-1078, ideal para o aumento do alve´olo. USA. Telefone: (734) 763-3383, Fax: (734) 936-0374, E-mail: [email protected] PALAVRAS-CHAVE: aumento de rebordo alveolar, preservac¸a˜o do alve´olo, exodontia, implantes denta´rios.

IMPLANT DENTISTRY /VOLUME 13, NUMBER 3 2004 295 296 ABSTRACT TRANSLATIONS