International Poster Journal of Dentistry and Oral Medicine, Supplement Osteology/2013

Objectives: This study characterized the usage of dietary supplements by patients who attend a periodontal clinic according to gender, age and smoking status. Understanding this usage facilitates the design of evidence-based intervention studies that result in improved patient care after periodontal procedures. Methods: A sample of 376 consecutive surveys regarding supplement use was collected from a periodontal implant clinic in Southern Ontario. The survey includes a checklist of 33 supplements and allows patients to include other supplements used. Patients were referred to the clinic by their general dentist for 1 of 3 reasons: general periodontal assessment (n=90), implant exam (n=126) or surgical consult (n=160). A supplement was considered used if the patient indicated any use of the supplement. Male (40%) and female (60%) patients over age 30 were studied and were divided into 3 age categories: 31-50 years (30%), 51-70 years (58%) and over age 70 years (12%). 16% were current smokers. Pregnant or lactating women were not included. Frequency of supplement use by age, gender or smoking status were assessed using a Chi-square test (p Keywords: dietary supplements, periodontal disease, supplement use, wound healing

Objectives: To evaluate the labial bone thickness with or without simultaneous guided bone regeneration around single tooth implants after at least one year in function using cone beam computed tomography (CBCT). Furthermore, the influence of timing of implant placement on the labial bone thickness was evaluated. Methods: 46 single tooth implant restorations in the maxillary aesthetic zone (inter-canine) with at least 12 months post-loading follow-up period were evaluated using CBCT scans. Rough hydrophilic (Straumann SLActive) implants placed without guided bone regeneration (non-GBR) were compared to the ones placed with simultaneous guided bone regeneration (sGBR) using deprotinized bovine bone and porcine collagen membrane. Two experienced radiologists measured the labial bone thickness (LBT) on CBCT scans at three different points along the implant length (i) L0 - identified as the shoulder in a bone level (BL) and the SLA junction in a tissue level (TL) implant; (ii) L25 - 25% and; (iii) L50 - 50% of the implant length. The groups were further subdivided based on Type 1, Type 2 and Type 4 placement protocol for comparison of LBT. Results: Mean age of patients was 33y. Mean time from surgery to CBCT was 3.7y (max. 5.6y). The inter-examiner reliability was confirmed (r>0.8). Mean LBT (SD) in Type 1 placement protocol at L0, L25 and L50 for nonGBR were 0, 0.8(0.4), and 1.3(0.8)mm respectively in comparison to 1.1(0.8), 1.8(1), and 2.1(0.9)mm for the sGBR group. The differences for L0 and L25 were statistically significant (p Keywords: labial bone thickness, dental implants, immediate implants, early delayed implants

Objectives: The aim of this clinical case is to show that is possible to do vertical ridge augmentation of the posterior mandible with just 2 mm of bone height using an inlay technique without the use of miniscrews or miniplates. Methods: Female patient, 46 years old, healthy, non-smoker came to the dental practice for fixed rehabilitation in the right molar area. The patient was diagnosed with just 2 mm of bone height. It was decided to increase the alveolar ridge vertically using an inlay technique with a block of xenograft without screws or plates as described by Scarano, A. in 2011. After a paracrestal incision in the buccal vestibule and a subperiosteal tissue dissection limited to the buccal side, a horizontal osteotomy was performed just above the mandibular canal, and two oblique cuts were made using piezosurgery. The osteotomized segment was then raised in the coronal direction, sparing the lingual periosteum. One block of equine bone was inserted between the cranial osteotomized segment and the mandibular basal bone. The residual space was filled by particles of cortical-cancellous porcine bone. A resorbable collagen membrane was applied above the buccal surface of the surgical site and the flap was sutured. Results: The increase of bone height, during the surgery, was 9 mm, measured with the periodontal probe in the buccal aspect. 6 months after the graft procedure, it was done a Cone Beam Computed Tomography for evaluation of available bone to place implants. It was observed an increase of height of 6 mm, measured in the buccal aspect of the mandible. With the limitation of these measures it can be said that occurred a bone resorption of 3 mm. Two submerged implants were placed in the areas of teeth 4.6 and 4.7. 3 months after implant placement it was done an implant-supported fixed rehabilitation, a metal-ceramic framework with two teeth. The scientific evidence to help us in making decisions regarding vertical bone regeneration is still insufficient. For the protocol used in this case there is still no long term evidence. So, there is a greater responsibility to the dentist and the patient who, together, make a decision. Conclusions: This technique seems to allow the placement of implants in patients with high bone resorption in the posterior mandible. However, the bibliography tells little about this procedure. There is only a published article and belongs to the lowest level of evidence. As in most surgical interventions, the success of this approach depends largely on the surgical skill and experience of the surgeon. Keywords: vetical augmentation, inlay technique, atrophic posterior mandible

Objectives: This is a clinical case of a severely resorbed, in vertical dimension, mandible, treated with implants, using cone beam computed tomography (CBCT) and a dental implant planning software (SimPlant). Methods: 72 years old, male patient non smoker, with no medical relevant history, was planned to be treated with dental implants. Severely reduced alveolar height at the posterior mandible was clear from clinical examination, and panoramic radiograph. CT scan with radiographic template was taken. Data analysis was carried out using SimPlant planning software and a surgical guide stabilized on natural teeth, and implant - specific drilling instrumentation, for the first drills, were produced. Three Implants (XiVE, FRIADENT, DENTSPLY 3.4 X 9.5 mm, 3.4 X 9.5 mm and 3.0 X 11mm) were scheduled to be placed at positions 46, 34 and 36 respectively. Inadequate height at position 36 (7mm) and adequate crestal width at IAN's canal plane, resulted in planning implant insertion bypassing lingually the IAN. All implants were inserted under local anesthesia in full thickness flap approach. 3 months later, the patient came in, and prosthetic rehabilitation took place. Results: Three implants (XiVE) were placed. All planned implants were placed successfully using the surgical template. A second after implant placement CBCT revealed close proximity with IAN without any paresthesia or other postoperative complications. The patient was restored according to the prosthodontic plan, with one screw - retained porcelain fused to metal (PFM) crown at position 46 and one cemented PFM bridge at 34 to 36 position. Conclusions: Guided surgery, with the use of computer aided implant placement (CT scan and SimPlant software for data analysis), allowed to treat a patient with edentulous posterior mandible and reduced height of alveolar ridge, with implants and fixed prosthodontic restorations. One implant was inserted "by passing" the IAN in lingual orientation. Keywords: inferior alveolar nerve, lingually, CBCT, SimPlant

Objectives: This clinical study aimed to compare the free gingival graft from the palate (FGG) with a new porcine collagen matrix (CM, Mucograft) in terms of augmenting the keratinized peri-implant mucosa, based on clinical and histological assessments. Methods: The study included 14 patients that underwent a vestibuloplasty, either with a FGG from the palate (n=7) or with the CM (n=7). An implant-fixed vestibular retention splint was inserted for 30 days. Follow-up examinations were performed at 4, 10, 30, and 90 days post-surgery. Width of keratinized mucosa was measured in the region of each implant (10th, 30th and 90th day). After 90 days, a biopsy was harvested for histological and immunohistological analyses. To characterize newly formed soft tissue, we stained for tissue and differentiation-specific markers, cytokeratin (CK) 5/6, 13, and 14, to detect presence or absence of keratinization. Results: The groups showed similar healing, with increased peri-implant keratinized mucosa. The CM group had overall significantly shorter operation times than the FGG group. Both groups showed similar overall shrinkage (CM 32.98% vs. FGG 28.35%) after 90 days. All biopsies showed a multilayered, keratinized, squamous epithelium. Cytokeratins 5/6 and 14 were detected in the basal and suprabasal layers, and spots of cytokeratin 13 were detected in the suprabasal layers. CK expressions were similar to cytokeratin expression patters of keratinized gingiva. Conclusions: During the whole observation period, both groups showed comparable clinical and histologic outcomes. Within the limitations of the present study, CM seems to be a promising alternative for the regeneration of keratinized mucosa without tissue harvesting. Comparative long-term studies are needed to investigate changes over time. Keywords: dental implants, collagen, transplants, clinical trial, dental materials, keratins

Objectives: Mechanical complications caused by malpositioned implant are mostly associated with unfavorable cantilever load distribution and increase the risk of structural failures. The aim of this study is to identify the relation between the implant malposition and complications. Methods: 191 cases were investigated for 34 months from January 2010 to October 2012 in the department of dentistry, the general hospital. Radiographic evaluations were performed to determine the cases showing non-axial occlusal loading. Patients' charts and clinical photos were reviewed for detailed information. Results: Among 191 cases, 30 cases showed fractures of fixtures, abutments, screws or implants. Out of a total 30 cases, 17 cases were evaluated to be complication caused by the malpositioned implant: 4 cases had ceramic fracture, 5 cases had occlusal screw loosening, 7 cases had abutment screw loosening, and the other 1 case had abutment screw fracture. One case of which had abutment screw loosening 3 times, another had ceramic fracture 2 times, and another had occlusal screw loosening 2 times. Malpositioned implant was clearly confirmed in 56.7% of the cases where the complication had occurred. In addition, Patient who had implant installation in other dental clinic, showed ceramic fracture twice for 2 years due to malpositioned placement. The implant was removed after 3rd ceramic restoration because of the loss of osseointegration. Conclusions: Malpositioned implant seems to cause several implant complications: ceramic fracture, occlusal screw loosening or fracture, abutment or abutment screw loosening or fracture, and implant fracture. In order to prevent the failure and complication caused by the malpositioned implant, proper diagnosis and treatment plan are required. On the basis, implant placement should be performed carefully in a position that receives optimum axial loading. Keywords: malpositioned implant, occlusal complication

Objectives: The purpose of the present study was to assess long-term crestal bone level changes in avascular fibula bone grafts of the severely atrophied maxilla and mandible. It was also considered whether this treatment results in adequate reconstruction and successful long-term functional rehabilitation of edentulous patients with severely atrophied jaws. Methods: This retrospective study included 6 patients with a mean observation period of 8,7 years (5-12 years). All patients presented a Class VI atrophy according to the Cawood classification. Grafting and implantation were performed simultaneously or in a second procedure. A total of 26 implants were placed (8 Camlog implants and 18 Sterioss). Postoperative evaluation included clinical and radiographic examinations which were conducted by two different evaluators to standardize the judgment. Clinical criteria included implant success and crestal bone resorption. The radiographic evaluation aimed to quantify the resorptive changes and the measurements were performed using panoramic radiographs. Histologic specimens (Azur II and Pararosanilin staining) were obtained from a patient after 10 years with a trephine bur for the auxiliary placement of an implant. Results: 6 patients received subperiosteal onlay augmentation with avascular corticocancellous fibula bone grafts. The grafting procedure was successfully performed in all patients and no regrafting was necessary. All implants were integrated, but one implant was lost 2 years after the abutment connection. All other implants fulfilled the Buser criteria, thus rendering to a success rate of 97%. The maximum bone resorption of 8 % (±2,7%) after 12 years with values ranging from 1,4 to 2,4 mm was independent of the region (maxilla or mandible) and independent of the implant system. Histologic evaluation of the augmented fibula bone revealed a completely vascularized cortical bone with 95% of bone. Conclusions: In this clinical and radiographic evaluation, it was found that nonvascular fibula graft shows a long-term stable crestal peri-implant bone level. Keywords: fibula bone grafts, implants, atrophy, alveolar bone

Objectives: To evaluate benefits of combined therapy in gingival recession coverage using collagen matrix together with platelet-rich plasma. Methods: Restoration of natural gum margin is one of the main goals in gingival recession coverage. Traumatic brushing, insufficient amount and width of keratinized gingiva and protrusion of teeth are among the most frequent causes of gingival recession. Microsurgery procedures such as autologous free mesenchymal grafts are used for coverage of gingival recession. However, some patients experience pain and discomfort of the donor site after the surgery. New methods are developed to avoid such complications. Results: Collagen Matrix (CM, Mucograft, Geistlich, Switzerland) was designed for gingival recession coverage and for augmentation of keratinized tissue around teeth and implants. CM can be trimmed using scissors and is packed in a sterile box. CM is ready for immediate use without any activation or preparation and is taken as a predictable alternative to free mesenchymal graft. In dry state the handling is almost similar to autologous tissue. CM might be sutured to allow tight adaptation to the root surface and to ensure complete immobility during healing. Platelet-Rich Plasma (PRP) is autologous peripheral blood derivate that contains high concentration of growth factors. Combined therapy using PRP with CM can lead to better clinical outcomes and diminish postoperative complications of the patient. Conclusions: Successful gingival recession coverage using combination of CM and PRP is presented. Within the limitation of small number of operated patients we can conclude that PRP improves the postoperative comfort and diminishes swelling of the wound in the early stage of healing. Randomized controlled trials are needed to prove the potential benefits of combined CM and PRP therapy. Keywords: gingival recession, collagen matrix, platelet-rich plasma

Objectives: Application of a stereolithographic (SLA) technique for the non-invasive treatment of a severely resorbed maxilla that conventionally requires a major bone grafting & sinus lifting surgery was presented in this case report. Methods: A 56 year old female patient with a severely resorbed maxilla was referred to the Department Oral Implantology, Faculty of Dentistry, Istanbul University. Iliac and sinus grafting was indicated in previous consultations due to the lack of sufficient bone height. The panoramic radiograph revealed a bone height of 6-8 mm in the anterior maxilla. The residual bone height under the sinuses was also below 1mm. Initially, the patient underwent cone-beam CT imaging by using the existing prosthesis, which was used as a scanning appliance. A total of six implants (8mm length and 3.75mm diameter) were planned and a corresponding SLA template was produced. The implants were inserted in a flapless fashion and left for osseointegration for 4 months. Results: All procedures were uneventful and all implants were clinically osseointegrated. The patient was restored with a metal-ceramic fixed restoration. The follow-up examination after six month revealed normal peri-implant conditions and optimal function. The patient was satisfied because of having avoided a major surgery. Conclusions: In selected cases, SLA techniques may help bypassing major surgical procedures required in the classic treatment approach. Keywords: stereolithography, flapless surgery, dental implants

Aim: The objective of this retrospective cohort study was to evaluate whether evidence from randomized clinical trials on the successful treatment of intrabony defects by regenerative therapy can be transferred to patients in a private periodontal practice. Material and Methods: In 191 patients a total of 1099 teeth with intrabony defects were treated using bovine bone mineral with or without collagen membrane. Defects were classified as 1- and 2-wall and as shallow (11 mm). A total of 1008 defects in 176 patients were monitored clinically and radiographically for collection of 1-year short-term, mid-term (2-4yrs) and long-term (5-10yrs) data. Baseline measurements were taken clinically and radiographically for standardisation of defect size. IMAGE J Software allows measurement accuracy of 0.01 mm. During supportive periodontal therapy, measurements were recorded from 1y post-operative x-rays (N=1008) and at following investigation stages, up to 10 years (mean 5.2 years). Change in radiographic bone levels was used as primary outcome parameter. Due to lack of compliance or supportive care alio loco, 15 patients (91 teeth) were excluded from analysis. Results: Overall a mean radiographic bone fill of >50% was observed. Deep and moderate defects showed a higher degree of radiographic bone fill than shallow defects (54,5% vs. 50% vs. 43,3%). Radiographic bone gain obtained at 1year remained stable during mid-term and long-term follow-up. Tooth loss amounted to 2.6% and was dependent on initial defect size (1.2% for shallow, 1.4% for moderate, 5.7% for deep defects) and occurred mainly due to endodontic failures. Conclusion: Under conditions of daily periodontal practice, regenerative treatment using bovine bone mineral with or without collagen membrane can lead to a mean defect resolution of greater than 50%, based on radiographic (2D) measurement. A 3D defect reconstruction of approximately 75% can be assumed from this finding. The radiographic bone gain achieved at 1y post-operatively could be maintained up to 10 years after surgical intervention in patients with compliance to periodontal supportive care. Keywords: periodontal regenerative surgery, long-term attachment level gain, DBBM

With the increasing development of implant dentistry, dental implants has become a common treatment alternative for oral rehabilitation also for the periodontitis patient who has experienced loss of parts of the dentition. Implant treatment in periodontitis-susceptible individuals is frequently debated. A question is whether this subgroup of patient susceptible to periodontitis may also show an elevated risk for peri-impalnt tissue destruction. Purpose: To determine whether there is a relationship between susceptibility to periodontitis and dental implant survival rates, the occurrence of peri-implantitis and its influence on marginal bone loss and to present the results of a meta-analysis carried out to find out whether this relationship is statistically significant. Materials and methods: PubMed search was performed in the period between 2002 -2012. Studies of >=5 years of follow-up and reporting on the outcomes of peri-implantitis and/or implant survival and/or peri-implant bone loss in patients with a history of periodontitis compared with non-periodontitis patients were searched. We carried out a meta-analysis using the random-effects model. Results: All of the 13 studies showed better implant survival rates for non-periodontitis patients' subgroup. Six studies out of 7 reported statistically significantly higher marginal bone loss and prevalence of peri-implantitis among periodontally compromised patients. Our meta-analysis did not find dental implant survival rates to be significantly lower among periodontally compromised patients (p=0.99), but revealed a history of periodontitis to be significantly related to the higher prevalence of peri-implantitis (p Keywords: dental implants, periodontitis, prognosis

Aim of our study was to identify sources of stem cells in human adult oral cavity, which can be of interest in the dental practice. In this study we focused on periosteal cells isolated from periosteum of human maxilla or mandibula. Periosteum (5 mm x 5 mm square) from human maxilla or mandibula was taken during normal surgery procedures in the oral cavity (e.g. implant placement, periodontal/bone regeneration), for a total of 30 specimens and patients (aged 32 to 68) and an average weight of 0.96 grams. The tissue was gently minced, then digested enzymatically in a Collagenase type II 0.25% solution for 90 mins at 37°C, then plated. Periosteal stem cells (PSCs) were cultivated in Coon's F12 with 10% FBS added with 2 mM Gln, penicillin 100 U/ml and streptomycin 0.1 mg/ml. Medium was changed every 4 days. We made some in vitro studies to characterize this cell population (Alkaline Phosphatase and Collagen I, and RT-PCR) and also took advantage of the immunodeficient mouse model to preliminary test PSCs' osteogenicity in vivo: they were loaded onto a 4 mm cubic porous ceramic (hydroxiapatite) scaffold and implanted subcutaneously; animals were sacrificed at 2 and 4 months after surgery. After 10 to 15 days the PSCs were clearly visible in the culture dishes. Phenotypic characterization by immunohistochemical analysis showed that PSCs were positive for Collagen type I and ALP activity. By RT-PCR investigation we observed that PSCs expressed Runx2 (cbfa-1), BSP and Osteocalcin. This means that this cell population expresses both early and late bone markers. The histological analysis of the scaffolds implanted in the immunodeficient mice showed the formation of a good quantity of lamellar bone inside, both at 2 and 4 months after the implant. Therefore PSCs - isolated during ordinary surgery procedure in the everyday dental practice in our office - should be considered with great attention in the future clinical procedures, as a valid adult stem cells source. Our in vitro studies showed a strong osteogenic commitment of this population, and the immunodeficient mouse model showed PSCs' capacity to form bone in vivo. Further investigations are needed, of course, but this seems to be quite a good pathway. Keywords: tissue engineering, periosteal stem cells, bone regeneration

"Immediate Loading" is currently the golden standard in order to maintain appropriate anatomic and topographic proportions between dental archers, to maintain the contact with the marginal periodontium and finally for the "occlusal/contact memory". The concepts of "primary stability", torque wrench, osseointegration and adequate/suitable denture, are the main factors for immediate and long-distance clinical outcome. We placed 233 implants - 110 in the mandibula and 123 in the maxilla. 115 implants have been prosthesized with cemented technique after 60-90 days; 118 implants have been prosthesized with screwed technique after 72 hours. We used autologous fibrin glue to increase peri-implant connective tissue formation, to manage inflammation and healing, and to accelerate vascularization thanks to growth factors (i.e. VEGF, PDGF) contained in the buffy coat. All clinical cases have been monitored radiographically with the same machine after 12 and 24 months from loading. The same doctor monitored all the clinical cases making periodontal probe after 6, 12, 18 and 24 months. Basing on our controls, we report a 2 mm conical peri-implant reabsorption on 6 implants loaded after 72 hours after 18 months; in our opinion this may be caused by prosthetic parafunctions in full-arch rehabilitations of only one arch and natural teeth as antagonist. We did not notice any reabsorption in full-arch rehabilitations regarding both arches on the same patients. 2 implants in the maxilla (first left molar and first right molar in the same patient), both loaded after 72 hours, got lost. We succeeded in confirming an augmentation of the short-term aesthetic in the Immediate Loading technique within 24 months, with a physiological maintenance of the interimplant papilla and a good trophism of the periodontium. Both the techniques used reached a good mid- and long-term predictability and repeatability; with both methods we could assure mid-grade aesthetic and function. Finally, in our opinion, the Immediate Loading technique (with full-arch rehabilitation using the screwed technique) represents nowadays the gold standard in implantoprosthetic rehabilitation, because it reduces intraoperatory time and increases wound healing, both in bone and in soft tissues, with an excellent compliance from patients. Keywords: immediate loading, early loading, implantoprosthetic rehabilitation

Introduction: The main task of the practical surgeon during implantation is to restore the lost structure of the jaw alveolar bone. In our opinion, researcher has a somewhat different task: to find alternative methods of diagnostics and treatment that would prevent the manifestation of inflammatory and degenerative processes in the tissues as a result of surgery. Literature data shows that in many cases surgical trauma on the first and second stages of implantation leads to loss of bone tissue. We consider that the use of the interactive methods is the best ways to prevent it. Therefore, the goal of our study is the assessment of the efficiency of medical navigation method in preclinical research for maximum preservation of patient bone tissue. Materials and methods: We have carried out the experimental surgery dental implantation (during 6 month observation) with the registration of physical factor influence on the periosteum in the implant region. We have used the phantom implants (similar to real: D = 3.5mm; L = 10.0 mm). We have supposed that the surgical operation is a destroying pathogenic factor and leads to uncontrolled pressure (traumatic stimulus) on the periosteum. To control the implant moving and positioning, we used our own method on the base of device "Navigator YК" (Ukraine Patent № 68641). The device receiver is fixed rigidly on the bone segment. Position appliance was integrated with the tip, transition was fixed on conventional implant point. The calibration carried out with the help of micrometer GTC-A-650 (Miutoyo, Japan), the measurement accuracy was 0.001 mm. A standard operational protocol was developed. Dynamic pressure on the periosteum also determined according to a technique using a silicon tensoresistor, which was fixed on a conical titanium plate, placed on the dorsum of the implant (Patent of Ukraine № 75649 and 73268). Deformation of bone tissue was determined using inductive displacement meter, developed by the Geotechnical Mechanics Institute of the Ukraine Academy of Sciences. In the absence of medical navigation device, as the signal to stop rooting dental implant operation during his latest revs, considered compression to a thickness of 0.5 mm of homogenous bone layer placed on the back of the platform implant. Results: Precision of the implant angular positioning with deviation of less than 25 and more than 5 angular minutes is about 10% and increases to 20% with smallest deviation, less than 5 angular minutes. It was determined that the implant pressure on the bone tissue grew disproportionally with the same rotatory force and became destructive at some value. Since our aim was to completely eliminate pathogenic factors, we have not determined the minimal pathogenic values in different areas. In 20% of cases we observed a continuing bone layer deformation for 3-5 minutes after mechanical load removing. It caused the nonuniform bone structures deformation. The bone layer about 1 mm thickness diminished to 0.5 mm at last implant turns and tightens gap between the periosteum and the implant platform. Further movement of the implant was destructive. Conclusion: The proposed approach optimizes the process of surgery and recommended for clinical usage in order to preserve alveolar ridge and the most favorable conditions for the realization of their own osteogenic potential. Keywords: implant, implantоgingival pockets, bone augmentation, prosthetic rehabilitation, medical navigation

Objectives: The aim of this study was to evaluate the effectiveness in the bone volume preservation in the area of the periosteum during oral implantation with improved medical navigation method. Methods: We studied condition of bone segments preparations in the area of the periosteum at 30 cases after the previous implantations. The study was conducted in the Cologne University, Germany (course of prof. J. Zoeller). For medical navigation "Navigator YK" (Pat. 68641) device was used. In experimental clinical studies the selection of 20 patients after surgery in the our private dental clinic was examined. The experimental group (10 patients) included those who had operation (root implant) with constant control of the process. The control subgroup (10 patients) consisted of persons for whom we have applied the standard technique of dental implantation. To prevent uncontrolled pressure damaging load on the periosteum and bone segment loss a homogeneous layer of autogenous bone material was placed circularly on the back side of the implant platform. The rooting dental implant operation was shut down was when the compression arise and the residual layer thickness was about 0,5 mm. Results: When studying of bone segments in 22 cases (73%) in the area of the periosteum adjoining to the implant the presence of bone defect was observed. When analyzing RVG shots in 58% we observed the presence of wedge defects, which were formed gradually during three to four months. Further the process of remodeling bone structures was stabilized. The results of bone tissue densitometry in the periosteum zone close to the implant show the bone density increase on 20-30%. Clinical analysis within 3 months showed that the patients of experimental subgroup had no complaints. The gum changes and the problems with subsequent prosthetics were determined with significantly lower frequency. Upon further observation over 12 months the patients of the experimental subgroup had no complaints. After evaluating of vertical bone resorption for 2 patients of the experimental subgroup the additional bone augmentation for cosmetic reasons was done. Conclusions: Thus our study allowed us to optimize the process of surgery, to predict the influence of pathogenic factors in the process of an implantation and to offer a method of its elimination. Also the clinical symptoms were eliminated, including the later periods. Keywords: implant, implantоgingival pockets, bone augmentation, prosthetic rehabilitation, medical navigation

OBJECTIVES: The aim is to show that a moderate to severe Seibert III defect could be augmented by stages. First horizontally using Autogenous Block Grafts, second vertically with Osteogenesis Distraction, third Guided Bone Regeneration at the implant placement time; finally, a Connective Tissue Platform Graft. METHODS: We made three stage bone augmentation procedures in a 48 year-old male patient from site 1.2 to 2.2. First, in a 2.5 mm. width ridge two Autogenous Block Grafts (ABG) were performed with the right measurements according to the defects in order to augment horizontally. When five months have passed, there was the necessity of 4 mm. vertical augmentation; consequently, an Osteogenesis Distraction (OD) was made at a rate of 1mm. per day. Each three days during the activation period the device went back 1 mm. for not having the classic sandglass shape defect postdistraction. Four small diameter implants were able to be placed at each site with Guided Bone Regeneration (GBR) after the consolidation period. Once hard tissue was augmented, soft tissue management was required as well; thus, Connective Tissue Platform Grafts (CTPG) were done to improve aesthetic contours. Finally, temporary restorations will be necessary to reshape margins and papillas before the final restoration. RESULTS: The ABG provided 4 mm. horizontal augmentation after the healing period. We augmented 7 mm. vertically by OD since it is always necessary to overcorrect expecting bone remodeling. At the end, a 4 mm. vertical augmentation was achieved with a light to moderate horizontal decrease. It was well managed by GBR at the moment of implants placement allowing correcting ridge contour. Furthermore, implants were well osseointegrated in the grafted and new formed bone. The soft tissue vertical improvement obtained with CTPG was about 3.5 mm. It was adequate and sufficient for shaping the scalloped gingival anatomy. There was not any flap dehiscence during the process. DISCUSSION: It is known that 4 mm. vertical augmentation is not easily obtained with grafts without complications. On the other hand, we need to create a thicker ridge, as a first stage, to provide cells to regenerate vertically and for fixing the distractor device. Consequently, before implants a vertical augmentation was performed after horizontal augmentation. The sandglass shape defect was not totally avoided, but was light. The CTPG is an effective technique to manage vertical gingival defects. REFERENCES 1. ZAKHARY IE, EL-MEKKAWI HA, ELSALANTY ME. Alveolar ridge augmentation for implant fixation: status review.Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 Nov;114(5 Suppl):S179-89. doi: 10.1016/j.oooo.2011.09.031. Epub 2012 May 12. 2. ZUCCHELLI G, MAZZOTTI C, BENTIVOGLI V, MOUNSSIF I, MARZADORI M, MONACO C. The connective tissue platform technique for soft tissue augmentation. Int J Periodontics Restorative Dent. 2012 Dec;32(6):665-75. Keywords: osteogenesis distraction, dental implants, connective tissue platform graft, block bone grafts, vertical augmentation, horizontal augmentation

Objectives: The aim of this clinical case was to show a new type of DENTSPLY (Mannheim, Germany) tilted abutment and to test its use in an immediate full mouth rehabilitation. Methods: A 45 years old male patient presented to observation with pain and instability of many teeth. After clinical and radiographical exams, the extraction of all of the teeth was decided. On the upper jaw, the insertion of 6 dental implants, 4 of which with an external connection (Xive TG®, DENTSPLY implants) and 2 with an internal connection (Xive S®, DENTSPLY implants) was planned; then 2 tilted abutments were screwed into the implants inserted with an inclination of 30° (SmartFix™, DENTSPLY implants). All the implants had an immediate-loading screwed restoration. In the lower jaw 6 dental implants (Xive TG®, DENTSPLY implants) with an immediate-loading bridge restoration were placed. Radiographs were taken after surgery and 12 months later. Results: At 1-year follow-up no radiographical or clinical difference between the implants positioned in a standard way and the tilted ones was found. The masticatory function was restored with a good aesthetic outcome. The patient was satisfied with the final result. Conclusions: The use of 30° tilted implants and Smartfix™ abutments (DENTSPLY implants) allowed to obtain an immediate screwed restoration avoiding sinus lift surgery, and facilitates taking impressions and the prosthetical procedures. Further clinical cases and a longer follow-up are necessary to validate our results. Keywords: tilted abutment, immediate loading, screwed restoration

Objectives: Acknowledging the meaning of alveolar preservation in the esthetic zone and show the importance of filling the gap at immediate implants in terms of soft and hard tissue preservation. Methods: Female pacient, 40-years-old, with the upper incisors protruded and periodontally compromised. Atraumatic extraction of 4 upper incisors was performed without raising flaps to preserve the vascularization of the bony walls through the periosteum. The buccal and palatal bone plate integrity was evaluated using a probe to exclude the presence of fenestration or dehiscence. Immediate implants were placed in the sockets of 11 and 21, with preservation of the gap. The lateral incisors postextraction socket were preserved using a particulated xenograft of deproteinized bovine bone and connective tissue graft that was harvested from the palate to keep the anatomy of esthetic zone. The implants had primary stability so were made an acrylic provisional screwed prosthesis to limit buccal mucosal recession. Results: After 4 months, was notorious the alveolar bone crest preservation in both height and width and the gengival contours are well defined. Impressions were taken and a screwed fixed prosthesis with ovoid pontics was done, achieving the aesthetic outcome of implant prosthodontic rehabilitation. After 1-year of follow-up, the gingival margin remains stable and the periapical Rx confirms the hard tissue stability without signs of bone loss around the implants. Conclusions: Tooth extractions in the aesthetic zone lead to typical bone remodeling of the alveolar crest in both width and height. Many authors have proposed as a solution the socket preservation technique, using bone grafts with or without barrier membranes. Current literature also alerts us increasingly to the dangers of immediate implants with immediate loading in the aesthetic zone. These should only be made in well selected cases, with a thick periodontum and when the alveolar buccal wall is intact, always with preservation of the gap between the walls and the implant. Keywords: implants, esthetic zone, ridge preservation

Objectives: The main objective is to optimize a short drilling technique that will not produce changes at the periimplant level. In this study a reduced number of drills, with a final one of special design will be evaluated in order to obtain similar or better results compared to the standard drilling protocol. Methods: In this study 32 C1 implants with diameter of 4.2 mm were inserted in pairs in mandibular free end situations, in consolidated bone. All patients were non-smokers. The mesial implant was inserted with the standard drilling protocol. The distal implant was inserted with the short protocol drilling sequence: round bur, pilot drill with integrated stopper and final single use drill. Insertion torque did not exceed 55Ncm. After insertion, all implants received healing screws. Impressions were taken 3 month after the surgical phase. The analyze for bone reshaping was radiographically accomplished for each patient. Bone measurements were taken on the retro-alveolar radiographies at insertion, at 3 months, 6 months and one year after insertion. The results were analyzed using software Image J 1.46r. Each radiographic image was calibrated at a 1:1 scale, knowing the length in mm for the implants, from the platform level until its apex. Bone loss was measured in mm distally for each implant. Results: The study was conducted over o period of one year and there were no implants lost. The primary stability was accomplished in all cases. There were no significant differences between women and men regarding bone loss. All the implants were osteointegrated and all the patients completed the follow up examination.The mean values of crestal bone loss at time of the insertion of the final restoration were 1.30 mm for the standard protocol and 1.27 mm with short drill protocol. Following our research it was determined that the drilling time was reduced up to 50%, without significant differences between the bone reshaping for the two protocols. The final precalibrated single use drill, found together with the implant, is fine cutting and doesn?t create pressures or heat at the bone level. Due to the guiding marks of the final drill the drilling depth is correspondent for each implant. Conclusions: Short drill protocol seems to limit crestal bone remodeling same as standard techniques. This may be especially beneficial when is need to insert more implants and the operator time is reduced more than 50%, reducing also the healing process. By using the single use sharp final drill with the short drilling technique the overheating is limited therefore the bone loss is minimum. Keywords: short drilling protocol, bone remodeling, conical conection, periimplant level

Objectives: The study aimed to evaluate the biocompatibility of nano-hydroxyapatite or biphasic nano-hydroxyapatite/ß-tricalcium phosphate with two different ratios(HA60:TCP40, HA70:TCP30) in vitro. Methods: The nanoHA (HA100) and biphasic calcium phosphate (nanoHA/ß -TCP) with two different ratios of nanoHA/ß-TCP (HA70/TCP30, HA60/TCP40) were prepared and cultured in osteoblast cell line MC3T3-E1 (ATCC). Cell loading and proliferation were assessed using a WST-1 colorimetric assay. Cellular morphology and adhesion to the scaffolds and cell viability were assessed optically using SEM. The alkaline phosphatase assay and osteocalcin assay were used to detect the early and late stage of osteoblastic cell differentiation. Results: Results showed that osteoblasts were attached to the surfaces of all nano HA and HA/TCP well as seen by SEM observation. Cell proliferation from WST-1 was increased higher on Day 3 than Day 1 in all groups except HA60 which was slightly stable but HA 60 showed higher cell numbers than the other two groups on the first day but no significance. ALP activity also showed the same profile as WST-1 that HA60 enhanced better activity than the other groups on both Day 1 and 3 but activity on both days were comparable whereas the other two groups had increased activity on Day 3. The osteocalcin production on Day 21 was opposite to ALP activity that HA70 presented the highest value which was comparable to HA100, while HA60 showed the lowest level of osteocalcin production. Conclusions: It can be concluded that higher TCP ratio enhanced better cell proliferation in the early phase of cell differentiation while higher ratio of HA yielded better osteocalcin production in the late state of osteoblast differentiation. Keywords: biphasic cacium phosphate, biocompatibility, nanohydroxyapatite, osteoblast, tricalcium phosphate

Objectives: The excision of maxillary tumors causes face mutilation, which leads to a functional and esthetic deficit. Maxillary reconstruction has four objectives: closure of the defect, function retrieval, repair of the shape and symmetry of the face, and of the eye socket if necessary. Methods: The following case illustrates the prosthetic treatment of a palatal defect after the excision of an epidermoid carcinoma. Surgical reconstruction of the defect was not possible in this case. Surgical reconstruction and prosthetic reconstruction were compared in a literature review. Results: The clinical case underlines some of the difficulties encountered during a maxillofacial prosthetic treatment. Rehabilitation after maxillectomy can be surgical or prosthetic. It is also possible to combine both treatments. The tissue loss must be treated as soon as possible, in a functional and esthetic manner, so that the patient can return to a "normal" life. Very few studies compare prosthetic and reconstructive techniques. The choice of the best technique still remains quite subjective, as evidenced by multiple and sometimes contradictory publications. There is no consensus on an "ideal" treatment indication for each anatomic situation. The decision to reconstruct the maxillary defect surgically or to conceive a prosthetic obturator depends on factors such as: the age and medical history of the patient, the size of the maxillary defect, and the experience of the surgeon. Surgical reconstruction and prosthetic rehabilitation both provide advantages and disadvantages. Conclusion: In all cases, teamwork between doctors, and the psychological and social aspects are essential. The treatment must include surveillance of the defect, and an adaptive global rehabilitation. The future reconstructions of maxillary defects seem to evolve towards an alliance of techniques: microvascular surgery, osseous distraction, implantology, and prosthetic rehabilitation by Computer-Aided Design and Computer-Aided Manufacturing (CAD-CAM). Keywords: cancer, maxilla, surgery, maxillofacial prosthesis

Objectives: We present a novel method of 3D evaluation of peri-implant hard tissue microstructure. Synchrotron µCT consists of a parallel beam and a high photon flux density which makes it possible to evaluate the peri-implant bone volume down to the micrometer scale and reproduce it as a 3D tomography. Methods: A dental implant 8 mm in length and 3.5 mm in diameter was installed in a critical size defect in a goat mandible, with the micro threads above bone level surrounded by bone graft. After 20 weeks of healing the bone sample was harvested. The bone samples were evaluated at ID19 beam line, at the European Synchrotron Radiation Facility in Grenoble, France. The beam line specializes in microtomography due to high flux and coherence, and a small beam size which creates high resolution tomography. A high energy, monochromatic beam was used due to the necessity of scanning through the titanium implant. The pixel size was 5 µm. The region of interest was defined as the part of the sample which representing de novo bone and micro threads. The bone volume surrounding the entire implant surface was evaluated, in conjunction with the level of mineralization, bone to implant contact, and the absorption coefficient of the entire 3D sample and compared to 2D histomorphometry. Results: The high flux x-rays of synchrotron µCT (SR µCT) were able to penetrate the titanium dental implant. Based on the 3D data, it was possible to evaluate the difference in bone volume fraction, density and porosity of the peri-implant hard tissues. The 3D SRµCT analysis was compared with 2D analysis (e.g. histological sections), showing that 3D tomogram evaluation is significantly more certain as evaluations by 2D methods. The results from the 3D SRµCT scans showed a low percentage of bone in proximity to the implant when using the 5 µm resolution. The bone volume within the first 70 µm where approximately 50 %. This was in accordance to the results from the histomorphometry. When comparing SRµCT with histomorphometry a significant deviation in bone to implant contact was found. Conclusion: Using synchrotron µCT for evaluating peri-implant bone has been successful in depicting the bone and cavities in three dimensions thereby enabling us to give a much more precise answer to the area of the bone to implant contact compared to previous methods. The next step will be to further develop our method into an even more accurate picture of the bone fraction in the very near proximity (0-100 µm) of the dental implant. Keywords: Synchrotron uCT, High resolution scan, SRuCT

Purpose: Regenerative therapy with cultured bone marrow MSCs is associated with uncertainties with regard to the extent of bone regeneration. This technique is expensive and complex. In this study, we examined the bone-inducing ability of uncultured cells of bone marrow aspirate concentrate (BMAC). Material and Method: ß-tricalcium phosphate (ß-TCP) block, 5×5×5mm, with BMAC (BMAC group) or ß-TCP block with nonconcentrated bone marrow aspirate (BMA group) was implanted into the back muscle of beagle dogs. ß-TCP alone was implanted as a control (TCP group). Bone marrow is extracted from the iliac and femur bone. We compared the ability to induce bone formation between the three groups at 3 and 6 weeks after surgery. Histological evaluation was performed in decalcified specimens (HE stain) at two levels of sections per sample. In addition, we compared the number of bone marrow cells that could be cultured for 1 week and collected between the BMAC group and BMA group. We measured the platelet counts, fibrinogen and TGF-ß concentrations of BMAC. We used SEM for morphometric analysis of the implant materials. Next experiment, we evaluated the bone-inducing ability in bone defects (8×7×4mm) of canine mandible. Histological evaluation was performed at 6 and 12 weeks after surgery. Results: The number of bone marrow cells collected from the BMAC group was 4.9-fold those collected from the BMA group. In SEM analysis, the fibrin network of BMAC group was dense than that of BMA group. In ectopic bone formation, average new bone area was 0.79 mm2 and 1.96 mm2 in the BMAC group, 0.06 mm2 and 1.52 mm2 in the BMA group, and 0 mm2 and 0.61 mm2 in the TCP group at 3 and 6 weeks, respectively. Ability of bone formation was significantly higher in the BMAC group than in the TCP group at both 3 and 6 weeks. In the BMA group, ability of bone formation was higher than the TCP groups. In bone defects of mandible, the contour of the alveolar bone crest was well retained in the BMA group and a significant difference was observed between the TCP group and BMA groups at 6 and 12 weeks. Conclusion: In this study, increase of cells from BMA and the importance of fibrin network as scaffold were indicated. These findings indicate that BMAC, which comprises concentrated bone marrow stem cells and a fibrin scaffold that has the ability to induce ectopic bone formation; furthermore, this technique is safe, simple, and useful for bone regeneration in the clinical setting. In our future plan, the optimal type of cells, ECM and growth factors for bone formation in BMA should be investigated. Keywords: bone regeneration, bone marrow aspirate, MSCs

Objectives: The effects and differences of PRP and PRF in bone regeneration have been not indicated clearly. Our experimental studies have shown the favorable effects of platelet-poor plasma (PPP) in bone regeneration. This study evaluated the effect of autogenous plasma and platelet-released growth factors to bone formation. Methods: In vitro study: Blood from healthy subjects was collected, after centrifugation PRP and PPP were taken. The concentrations of platelet-released growth factors in PRP, PPP and whole blood were measured. The proliferation and the differentiation assay were examined using human bone marrow stromal cells. In vivo study: At first, PPP, PRP and PRF were implanted to each extraction socket with dehiscence in canine mandible (n = 12). The extraction sockets of the control group were left unfilled. The morphology in each material of PPP, PRP and PRF was analyzed using SEM. The defects were evaluated at 4 and 8 weeks after surgery and quantification of bone formation was performed. Results: In vitro study: The average concentrations of platelets, TGF-ß1 and PDGF-AB in blood products were all increased in PRP and decreased in PPP. When different concentrations of platelet-released growth factors were added to the human MSC cultures, PRP showed a stimulative effect on proliferation. Contrary to the effect of PRP on proliferation, PRP exhibited an inhibitory effect on osteoblastic differentiation of MSCs in a dose-dependant manner. In vivo study: In SEM analysis, the fibrin network of PRF was most dense. The fibrinogen concentration of PPP was higher than that of PRP. PPP and PRF could sufficiently maintain the bone width and height for the preservation of the socket. However PRP could not maintain the bone width. When bone particles were used as the implant materials, PPP group performed the largest amount of bone. However, bone maturation in the PRF and the PRP groups was more progressed than that in the PPP and control groups. Conclusion: PRP and PRF did not promote bone formation in bone defect site that differentiated osteoblastic cells are few. This study showed that PPP is an effective material for the preservation of sockets with buccal dehiscence and PPP plays a significant role in the presence of fewer osteogenic cells. The fibrin network of PPP has played a role as space making for bone regeneration and would be stimulatory to bone formation. Keywords: bone regeneration, plasma, platelet-released growth factors

Objectives: The aim of this study was to carry out clinical and radiographic outcomes of bone healing using a new medical device, a sterile gel formulation of sodium hyaluronate and amino acids Gly-Leu-Pro-Lys (AMINOGAM®) in treatment of third stage bisphosphonates-related osteonecrosis of the jaws (BRONJ). Materials and methods: We selected 32 third stage BRONJ patients divided in two groups according to systemic pathology: - Neoplatic diseases group that includes 21 patients; - Non-neoplastic diseases group of 11 patients. According to AAOMS guidelines, all patients suspended biphosphonate therapy three-six months before the surgery and were subjected to antibiotic therapy: three courses of 1g ceftriaxone intramuscular injection/die and 250mg metronidazolo oral tablet two times/die for 8 days with 10 days rest between each course. Surgical treatment provides local anesthesia without vasoconstrictor, segmental resection, Piezosurgery osteoplasty, intracavitary intraoperative use of gel to fill up residual bone defect and a first application upon the stitches (sandwich technique). Our procedure includes using of gel 4 times/die till to complete mucosal healing. Finally a clinical and radiographic follow-up by orthopantomograph and CT examinations at 3, 6, 12 and 24 months was carried out. Results: Clinical outcomes showed complete hard and soft tissue healing in all post-surgical sites, with a difference between two groups: neoplastic deseases group needed a longer soft wound healing time of 5 days compared to non-neoplastic diseases group. Radiographic outcomes show radiolucent areas decreasing due to gel direct osteoinductive effect with a faster osteoregeneration time in non-neoplastic deseases group: 15% difference between ossification level at 3 and 6 months. Gel preparation of sodium hyaluronate and amino acids enhances angiogenesis, fibroblast and osteoblast proliferation, collagen biosynthesis and production of growth factors as evidenced by MTT test and alkaline phosphatase histochemical staining. In vivo and in vitro studies have suggested that hyaluronic acid plays important roles in bone wound healing by enhancement of osteoblast differentiation through the down-regulation of BMP-2 antagonists. Lysine and proline regulate collagen matrix synthesis during osteogenesis. Conclusions: Sodium hyaluronate and amino acids gel formulation decreases postoperative pain, swelling and infective complications after surgery by surgical wound mechanical protectection. This new medical device is biocompatible, extremely cheap, safe and useful in all surgical procedure in order to obtain a faster healing of oral hard and soft tissues, specially in BRONJ that are often prone to difficult, slow and complicate recovery. Keywords: BRONJ, soft and hard tissue regeneration

Objective: This study was designed to evaluate whether a sterile gel formulation of sodium hyaluronate and amino acids Gly-Pro-Leu-Lys (AMINOGAM®) is effective in accelerating post-surgical bone defects regeneration, implant rehabilitation and complication management. Materials and Methods: We selected 56 patients aged between 16 and 64 years and we evaluated different healing in 80 bone defects divided in 2 groups: - Test group: 40 defects treated with intracavitary intraoperative filling of gel and application 4 times/die upon the stitches till the complete mucosal healing (sandwich technique). - Control group: 40 untreated defects. Each group was divided in two subgroups: minor (1cm2). Outcomes were evaluated by clinical and radiographic follow-up with OPT rx and CT scan through densitometric analysis. Defects treatment after bone healing in both groups was completed with histological pre-implantar examination and insertion of 52 implants in test group and 49 implants in control group. Clinical and radiographic examinations of implants were performed at 12 months after functional loading. Gel preparation enhances angiogenesis, fibroblast and osteoblast proliferation, collagen biosynthesis, production of growth factors as evidenced by MTT test and alkaline phosphatase histochemical staining. In vivo and in vitro studies suggested that hyaluronic acid plays important roles in bone wound healing by enhancement of osteoblast differentiation through the down-regulation of BMP-2 antagonists. Lysine and proline are important metabolic factors regulating collagen matrix synthesis during osteogenesis. Results: Soft tissues outcomes in test group show similar results in both subgroups with immediate haemostatic effect, pain and swelling decrease and infective complication dejection (0%) compared to control group (6%). Gel preparation reduces the removing stitches and wound complete healing time at 6 days in minors defects and 14 days in major ones of test group compared to 14 and 23 days of control group. Hard tissues outcomes show faster healing time: 20% difference between ossification level in test and control group at 2 months. The difference decrease in following months until 3% at 12 months. Pre-implantar bone specimen get with 2,5mm trephine drill shows a more dense and mature lamellar bone with twisted fiber and different calcification level also evaluated through densitometic analysis, allowing implant insertion at 30-45 days in minor defects and at 60 days in major ones of test group compared to 60 and 90 days of control group. Osseointegration rate in regenerated defects is 100%. Conclusions: Sterile gel based on sodium hyaluronate and amino acids is a new cheap and useful medical device able in resetting post-surgical morbidity to zero. It allows a quickly bone defects healing time with an earlier implant insertion and a faster osseointegration thanks to more quality bone evaluated by histological analysis and grey scale densitometry. Keywords: bone regeneration

Objectives: The aim of this study was to investigate if cells isolated from DP differentiate toward osteoblastic phenotype and express osteoblastic markers. Methods: Bone remodeling is the process maintaining bone mass and occurs during the whole life; it is regulated by osteoblast differentiation and activity and is influenced by many pathological events that could determine bone loss. Osteoblast differentiation has been studied starting from mesenchymal stem cells of the bone marrow or periosteum. Stem cells are defined as clonogenic cells capable of self-renewal and multi-lineage differentiation. A population of these cells has been identified in human Dental Pulp (DP). Dental Pulp Stem Cells (DPSCs) were found in young adult wisdom teeth and have been shown to differentiate, under particular conditions, into various cell types of the mesenchymal tissues. We studied the immunophenotype of DPSCs by flow cytometric analysis, the osteoblastic markers of differentiated DPSCs were assayed by histochemical methods and real-time PCR. Results: We demonstrated that DPSCs are easily obtained from wisdom teeth, a source of easier access than bone marrow and periosteum, and successfully differentiated into osteoblast-like cells, producing mineralized matrix nodules and expressing the typical osteoblastic markers, Alkaline Phosphatase (ALP) and Collagen I (Coll I). Conclusion: This study suggests that DPSCs differentiate into osteoblasts representing a perfect source of cells for bone regeneration. Keywords: stem cells, osteogenic markers, bone tissue engineering, human postnatal dental tissue

Objectives: Reconstruction of bony defects can be done by free flaps. Donor site morbidity and misfit of the shape are limiting factors. The concept of using the patient as bioreactor solved many problems. The aim of the study was to evaluate if the great omentum is a capable anatomical site for prefabrication. Methods: In each of 30 adult male New Zealand white rabbits (4.0kg) 2 blocks of biomaterial were implanted in the great omentum with a central vascular pedicle in a cavity of the scaffold. The following five groups were created according to the biomaterial: (1) Bio-Oss® Block, (2) Bio-Oss® Block + rhBMP-2, (3) Bio-Oss® Block + rhBMP-2 + VEGF-165 (4) Bio-Oss® Block + autologous bone, (5) Bio-Oss® Block + autologous bone + rhBMP-2. CT examinations were performed after the implantation and 2, 4, 6 and 10 weeks later to define the bone density. The animals were sacrificed at 10 weeks postsurgery after intraperitoneal injection of fluorochromes and the specimens were collected for histological, immunohistochemical and histomorphometric analysis. Results: First analyses could show that the great omentum has advantage among other sites previously described with a long vascular pedicle, less postoperative functional impairment and more flexibility. The central blood vessel in the center of the scaffold resembles the natural anatomy of the mandible and other bones with a marrow cavity and enhances the ossification. The bone density increases particularly with the use of BMP-2 and VEGF-165 and has the highest values with additional use of autologous bone (HU: average between 483 (BioOss-Block alone) and 1054 (+ autologous bone with BMP-2). The floureszenz staining shows ossification also with BMP alone. Also the toluidine blue and HE staining shows ossifcation and development of new vessels in the scafold. There are indications that the efficacy of the dosage could be enhanced by addition of VEGF-165. Conclusions: We could demonstrate for the first time that the great omentum is a capable new anatomical site for prefabrication. It can be used as a bioreactor in vivo for prefabrication tissue-engineered bone. Prefabrication in the great omentum may go from bench to bedside and will show effectiveness in mandibular reconstruction. Keywords: prefabrication, omentum majus, reconstruction, bmp, vegf

Objectives: The aim of this study was to investigate the ability of an osteinductive calcium phosphate ceramic alone or in combination with rhBMP-2 to bridge a critical sized calvarial defect in rats. The hypothesis was that the use of intrinsically osteoinductive ceramic could minimize the dosage of rhBMP-2. Methods: 120 male Wistar Han rats were used upon approval by institutional animal ethics committee (IMI,Zg,HR). 14mm critical sized circular defects were created on calvaria of animals by using a dental drill. Animals received a PTFE ring Ø14mm h 4mm, that was filled with either only a biphasic calcium phosphate ceramic BCP, particles 150-500 µm, consisting of ß tricalcium phosphate and hidroxyapatite in 20:80 ratio, or BCP loaded with 5µg of rhBMP-2, or 2.5µg of rhBMP-2 or left empty (sham). Animals were sacrificed at 3, 6 and 12 weeks post-implantation. Bone formation was quantitatively evaluated using µCT (SkyScan 1076, BE).3D reconstruction was performed by CTAn software, different tresholding values were used to distinguish ceramic particles from the newly formed bone and to determine BV% in total volume of interest BV/TV. ANOVA with Duncan's post hoc test was used to compare different conditions, in addition qualitative histological analysis on Goldner trichrome stained tissue sect. Results: Macroscopically, implants appeared firmly attached to the calvaria. In sham groups only limited new bone formation was observed 9.5 ±1.1%, 7.2±1.7%, 9.6±2.8%, 3,6,12 weeks respectively. The newly formed bone extended from host bone bed to the center of the defect, between particles of implanted ceramics (Xpand ) in all test groups with or without growth factor. Newly formed bone tissue was observed in all cases as early as 3 weeks with %BV/TV of 24.33±0.9% in BCP, 27.9 ±1.2% in BCP/rhBMP-2 2.5µg and 24.5±1.7% in BCP/rhBMP-2 5.0µg. At 6 weeks, a slight increase in the amount of bone was observed in all conditions with a % BV/TV of 36.4 ±3.8%, 31.0±3.8% and 35.0±5.0% in BCP, BCP/rhBMP-2 2.5 µg and BCP/rhBMP-2 5.0µg respectively, while a decrease between 6 and 12 weeks, with %BV/TV values of 24.7±3.9%, 32.54±1.2% and 31.3±2.8% for BCP, BCP/rhBMP-2 2.5-µg and BCP/rhBMP-2 5.0µg, respectively. No statistical differences among the groups were observed at any time point. Conclusions: Study results showed no statistically significant differences in bone formation between the BCP alone and loaded with 2.5 or 5 µg rhBMP-2 in a critical sized calvarial deffect in rats.While it is generally thought that CaP biomaterials are not osteoinductive, BCP used here was previously shown to possess intrinsic osteoinductivity which may explain comparable performance in this study in terms of dynamic bone formation and the total ammount of bone formed in presence and in absence of rhBMP-2. Keywords: bone regeneration, BCP, growth factor

Objectives: Critical-size defect models have been developed to assess the biologic potential, efficacy and safety of new regenerative approaches prior to their use in humans. The objective of this report is to describe the animal model used to study the regenerative potential of periodontal mesenchymal cells. Methods: 9 male beagle dogs aging 12-14 months were used for this investigation.After 3 weeks of quarantine, animals undergo defect creation surgery: mucoperiosteal flaps were raised and P1, P2 and M1 were extracted. Bilateral circumferential horizontal defects were surgically created around P3 and P4. Defects were standardized to have 6mm from the bone to the furcation fornix and the mesial and distal CEJ. Ligatures and a soft diet were used for 2 months to allow plague accumulation and defects chronification. 7 days prior to regenerative therapy oral hygiene was performed and systemic antibiotics were administered. After flap elevation, defect de-granulation and root notches creation for histological analysis, regeneration was performed with a xenogeneic bone substitute (Bioss-Collagen®) with or without canine periodontal mesenchymal cells. Post surgical regimen included broad-spectrum antibiotic and analgesics. Sutures were removed at 2 weeks and plaque control was maintained twice weekly. Results: At time of defect creation, the distance between cemento-enamel junction and bone crest (CEJ-AB) was 5.19±0.38 mm and the distance between furcation fornix and bone crest (F-AB) was 3.65±0.47 mm. Two months after ligature chronification, prior to performing the regenerative surgery the CEJ-AB was 4.64±0.46 and F-AB was 3.99±0,67, showing that periodontal defects remained with evident loss of attachment and furcation exposure. Four weeks after treatment healing occurred uneventfully. The histological analysis performed at 3 months showed that most of the furcation defects healed partially. Periodontal regeneration was mainly located at the most apical areas. Bioss-Collagen® underwent a considerable degree of resorption, residual graft particles were located mostly in the proximity of the basal bone. The formation of new acellular cementum was evident in all specimens at varying degrees. Conclusions: The chronified supra-alveolar periodontal defect in the beagle dog closely resembles challenging defects in humans and proved to be a valid model for the study of periodontal regeneration with cell therapy. Keywords: periodontal regeneration, regeneration materials, cell therapy

Horizontally augmentation of a deficient lower posterior ridge (knife edge) using a combination of anorganic bovine bone matrix (DBBM) with autogenous bone and native collagen membrane. 60 years old male missing teeth 35,36 and 37 for more than 20 years. CBCT scan showed good height but only 3 mms width contraindicating implant placement. Procedure included full thickness flap, isolation of mental foramen, cortical perforation for angiogenesis, autogenous bone scraped from external oblique ridge combined with DBBM (Bio-Oss®) 1:1 ratio. Stabilization of bone graft was performed using a porcine natural collagen membrane (Bio-Gide®) with bone tacks and flaps released and closed with Cytoplast® suture. Nine months after bone regeneration, a new CBCT scan showed a horizontal bone gain of 6 mms for a total of 9 mms width. The treatment of horizontally deficient alveolar ridges with the GBR technique using autogenous bone mixed with ABBM and a natural collagen resorbable barrier membrane can be regarded as succesful. Keywords: sausage technique, bone regeneration, collagen membrane, xenograft

Tooth extraction today need to be handle carefully in order to preserve the remaining tissues left (bone/gingiva) . Confused criteria of the management of extraction sockets should be better reviewed understanding the bone physiology and considering the changes after tooth extraction. An anorganic bovine bone matrix material appear to meet the expectations for implant placement with very low morbidity and long-term stability. Keywords: ridge preservation, extraction sockets

After the classification of the timeing of implant placement - the meaning of the early implant approach Type 2 became relevant for obtaining pleasent clinical outcomes. The present report intend to analyze clinically the results of the modality. Keywords: early implant placement, gingival control recession

Sinus lift procedures increase the morbidity of the surgery in atrophic sites in the near of the sinus ridge areas before implant placement. The present case will show the rationale use of a biomaterial in order to place implants avoiding sinus elevation therapy. Keywords: ridge preservation, sinus elevation, atrophic sites

Atrophic lower anterior ridges after tooth extraction appear to be a contraindication for implant therapy.The present case report will follow the use of Anorganic Bovine Bone Marix (ABBM) in order to augment the knife - edge sites before implant placement. Keywords: atrophic sites, bone augmentation, implants

Objectives: The aim of this study was to evaluate the effect of the use of deproteinized bovine bone as a filler material of bony defects derived from surgical excision of maxillary and mandibular cysts having a diameter >= 20 mm. Methods: The study was approved by the local ethics committee. 19 patients requiring the removal of maxillary cyst >= 20mm diameter were considered. Patients were randomly divided into 2 groups: the bone defect was filled with granules of deproteinized bovine bone (group 1); no filling material (group 2). Clinical and radiological follow up was performed for every patient. Clinical follow up was scheduled as follows: 7 days, 1, 6 and 12 months after surgery. A computerized method was adopted to compare the pre-op and the 1-year post-op CT scans. Using an in-house software, cysts and residual radiolucent areas, corresponding to pre operatory CT and to post-operatory CT respectively, were manually outlined on single axial layers. The volume of each cyst was computed as the sum of the voxel included in the segmentation. Results: Results are preliminary, since not all the 19 patients enrolled for this study completed the 1-year follow up. 8 patients were considered. The comparison between the pre-operatory and the post-operatory CT revealed that the average volume of residual radiolucency in group 1 was reduced with respect to group 2 (2.26% vs 27,87%). Conclusions: The use of deproteinized bovine bone seems to influence positively the healing of alveolar bone critical size defects in humans. Keywords: bioss, alveolar bone defect, maxillary cyst, deproteinized bovine bone

Objectives: Simultaneous implant placement in conjunction with lateral or transcrestal maxillary sinus floor augmentation gives the benefit of reduction in healing times and surgical interventions. Primary implant stability, however, may be significantly reduced in resorbed residual ridges. Aim of the present study was to investigate the impact of residual bone height, bone density and implant diameter on primary stability of implants in the atrophic sinus floor. Material and Methods: A total of 66 NobelActive™ implants were inserted in the sinus floor of fresh human cadaver maxillae: 22 narrow (3.5 mm), 22 regular (4.3 mm) and 22 wide (5.0 mm) diameter implants in residual ridges of 2 to 6 mm height. Presurgical computed tomographic scans were acquired to assess bone height and density. Primary implant stability was evaluated by insertion torque values (ITV), Periotest values (PTV) and Osstell implant stability quotients (ISQ). Results: Correlations within outcomes (ITV, PTV, ISQ) were highly significant (p

Objectives: To retrospectively evaluate a novel narrow diameter implant, (NobelActive, Nobel Biocare, Göteborg, Sweden) with a 3.0 mm diameter that has been developed for safe and reliable implant placement in areas with limited space. The 3.0 mm implant is intended for replacement of single unit maxillary lateral incisors as well as single unit lateral and central mandibular incisors. Methods: Six centers participated in the retrospective study. Twenty-four patients (11 females and 13 males) with a mean age of 31.9 years (range: 18 to 75 years) receiving a total of 29 implants between November 2010 and October 2011 were included in this analysis with a minimum follow-up of 1 year. Implants were placed in healed sites, extraction sites or in sites exhibiting congenitally missing teeth. Implants were inserted either with an open fl ap or a fl apless surgical protocol. All types of loading protocols were applied (i.e. immediate, early or conventional loading). When necessary, bone grafting was performed. Implants were restored according to the manufacturer's guidelines. At routine follow-up, the implants were inspected clinically according to each clinic's standard practice. For some centers this included Jemt's papilla index and bleeding on probing (BOP). Hygiene level was assessed as: excellent, good, acceptable or poor. Results: One implant was lost due to trauma after 2 months the remaining 28 implants were followed for 12 to 24 months (mean 15.1). One additional complication, a broken abutment screw, was noted. 21 implants were placed in the maxilla for replacement of the maxillary lateral incisors and 8 implants were inserted in the mandibular incisor region. 6 implants were placed in extraction sites, 6 in healed sites and 17 replaced congenitally missing teeth. 9 implants were loaded immediately (within 48 h), 8 were loaded after 48 h but prior to 3 months, and 9 were loaded after a minimum waiting period of 3 months. 8 implants were placed using flapless surgery and 21 using a flap. For 15 implants a 1-stage surgical protocol was chosen and for 11 implants a 2-stage protocol was used. At follow-up, papilla index was assessed in 21 implants. One implant showed an index of 1, 7 implants of 2, 12 an index of 3 and 1 implant an index of 4. BOP was assessed in 14 implants, all showing no signs of bleeding. Conclusion: Within the limitations of this retrospective study, the results on implant survival and soft tissue analyses with this novel 3.0 mm diameter tapered variable-thread design implant (NobelActive) seem to indicate that this implant is a viable and safe treatment option for subjects in need of an implant in anterior areas with limited space or for the treatment of congenitally missing teeth areas. Additionally, soft tissue evaluation indicates that the implant supports stable tissue. Keywords: anterior region, incisors, congenitally missing, single unit, single crown, survival, soft tissue

Objectives: The aim of this study was to evaluate the outcomes of regenerative treatment of intrabony defects in conjunction with orthodontic tooth movements in patients with severe periodontitis. Methods: A total of 526 periodontally severely compromised teeth in 48 patients (age 29-66 years) were treated using bovine derived bone mineral with/without collagen membrane and/or enamel matrix derivative. Orthodontic tooth movements were initiated three months after surgery. Bone levels were measured at time of surgery (T0). Periodontal probing depths and digitized and calibrated periapical radiographs were assessed at T0, at 12 months (T1) and up to 36 months (T2). Changes in radiographic bone levels were the primary outcome. Results: From baseline to 12 months the mean PPD reduction was 2.75 mm (from 5.87 mm to 3.12 mm). Radiographic analysis showed a mean mineralized tissue gain of 4.64 mm at 12 months (from 8.4 mm to 3.76 mm) and further clinical improvements up to 3 years. Only one tooth was lost during the observation period. No differences in treatment modalities of regenerative therapy were shown. Conclusions: The results of this retrospective clinical cohort study in patients in need of orthodontic therapy as a consequence of advanced periodontal destruction indicate favorable clinical and radiographic outcomes after periodontal regenerative therapy followed by orthodontic tooth movements. Regenerative periodontal treatment of intrabony defects in conjunction with orthodontic tooth movement resulted in substantial radiographic bone gain up to 3 years. Keywords: regenerative periodontasl treatment, orthodontic treatment, long-term stability, demineralized bone mineral, attachment level gain

Tooth loss due to trauma or periodontal disease is often associated with atrophy of the alveolar ridges. Due to atrophy the final volume of bone tissue and height of bone ridges are insufficient for dental implants placement. The preservation of alveolar ridge dimensions and bone characteristics could be more effective than any augmentation methods. Augmentative bone treatment may result in extensive surgical interventions and increased treatment costs. Attempts to reduce alveolar bone resorption include the placement of natural roots, root analogues and immediate implantations into the extraction socket, sometimes in combination with membrane or graft techniques and other restore techniques. The aim of this study was to evaluate the effectiveness of reverse tooth retention methods in alveolar bone volume preservation. Materials and methods: The study included 65 consecutive patients presenting beaked teeth or their roots after trauma or periodontal disease with atrophy beginning. The own method of reverse teeth retention (Ukraine patent for invention U200612) was performed in all cases. According to this method the treated roots or remains of processing dental crown were covered with gum flap sometimes in combination with membrane. The place was treat with red rays laser. The height of the alveolar bone ridges, the height required for insertion of the appropriate implants were calculated in each patient after X-ray or CT evaluation. Results: Stable marginal bone conditions can be preserved after 1-8 years following reverse tooth retention. Laser illuminations during several days after operation prevent some acute complications. Follow up observation of patients show a mean marginal bone loss of 1.2 mm (SD 0.8 mm) during the period. The vertical resorption in frontal area was 1,4±0,5 mm in molar area the horizontal resorption was absent during 3 years, during 5 years it was 1,7±0,7 mm and during 8 years 1,6±0,9 mm. The absence of any alveolar ridge atrophy in retromolar area was registered in 8 patients during 5 years of observation. The degree of atrophy measured by teeth height correlates with intensive smoking habits (r=-0,54, p Keywords: reverse retention, atrophy of alveolar ridge, bone augmentation, implant

Objectives: Scar formation and defective regeneration may hamper the functional recovery of the muscles after cleft palate repair. The aim of this study is to investigate the anatomy and histology of the soft palate in rats, and to establish an in vivo model for muscle regeneration after surgical injury. Methods: Approval for the research protocol was obtained from the local Board for Animal Experiments in accordance with Dutch laws and regulations (RU-DEC 2011-125). 14 male adult Sprague Dawley rats were used. The animals were divided into three groups: Group 1 (n = 4) and 2 (n = 2) to investigate the anatomy and histology of the soft palate respectively, and group 3 (n = 8) for surgical wounding of the soft palate. In the last group, the wound area was evaluated after 7 and 56 days using (immuno)histochemistry for muscle markers. Results: All animals survived surgery and showed no weight loss. After seven days, all wounds showed complete clinical healing. AZAN staining demonstrated an accumulation of collagen in the wound area, and extensive granulation tissue. Initial regeneration of muscle fibers and salivary glands was observed. Myofibroblasts were not present in the muscle tissue of the controls but only in blood vessels and salivary glands. In contrast, in the wound area in the experimental group showed large numbers of myofibroblasts was observed. Conclusions: We show that this model is suitable to study muscle regeneration in the rat soft palate, and allows the development of novel adjuvant strategies to promote muscle regeneration after surgery. Keywords: cleft palate, muscle regeneration, branchiomeric muscles, head mucles, satellite cells, tissue engineering

Objectives: Thermal cameras have a wide range of use like millitary, industry or medical diagnosis. The aim of this study was to evaluate heat generation with thermal camera during gingivectomy with Er:YAG, Nd:YAG lasers and electrocautery. Materials and Methods: A 18 year old male patient referred our clinic with the complaint of gingival enlargement in upper and lower anterior areas of the jaws. The gingival surgery was performed with Er:YAG, Nd:YAG lasers, electrocautery. Heat generation, heat radiation areas and temperature differences from the proximal tissues in the operation sites were evaluated and photographed with a thermal camera and a computer program. Results: Nd:YAG laser attained the highest temperature level at 274,9˚C and the heat resolution time was 16-20 seconds after several applications. Er:YAG laser with water and air cooling reached maximum temperature of 53,11˚C and the heat resolved in 1-2 seconds. Electrocautery reached maximum temperature of 92,7˚C and resolution of heat was about 7 seconds after 5 seconds continuing applications. Conclusion: In this clinical case, thermal camera provided instant thermal display of working area. Additionally heat resolution time after application and heat radiation areas were evaluated. Non-contact heat measuring was one of the advantages that eleminated sterilization procedures while working in surgical areas, however, measuring only the superficial heat was the limitation of these cameras. Keywords: gingivectomy, heat generation

Objectives: There exist only few human histomorphological studies on the long- term behavior of bone substitute materials after sinus lift. This study shows a systematic histomorphometric analysis of two human bone biopsies 1 and 5 years after grafting with a xenogenic bovine bone substitute material (BSM). Methods: 2 healthy patients received grafting of the maxillary sinus with a xenogenic BSM (Bio-Oss). Due to personal circumstances, implant placements could not performed before 10.5 months or even 4 years 7.5 months after the augmentation procedures. During preparation of the implant site, trephine bur bone biopsies were harvested. After fixation and dehydration through an ethanol gradient and defatting in xylene, the obtained trephine biopsies were embedded without decalcification in methacrylate. The untreated blocks underwent microcomputed tomography (µ-CT). 3-D reconstructions provided visualization of the complex bone-biomaterial interactions. The volume ratios of the following compartments were determined: non-mineralized soft tissue, newly formed (mineralized) bone and (persistent) bone substitute material. Afterwards, sec- tions of a thickness of approximately 80µm were made and conventionally HE-stained. A descriptive analysis of the bony healing was performed. Results: For both investigated specimen, µ-CT revealed formation of bone tissue with good and tight bony incorporation of the BSM. For the specimen obtained after 10.5 months, 30% of new-formed bone with 26.6% of remaining BSM was calculated. After 4 years and 7.5 months, 32.8% of new bone with 15.8% residual BSM was seen. In the histological examination, between the Bio-Oss particles, a directed, well vascularized bony tissue with close contact to the individual BSM particles was seen. For both time points, only superficial resorptions could be detected. An osteoconduction into small porous structures with establishment of osteons was observed. However, the bony tissue surrounding the BSM particles showed considerable differences for the two investigated time points. While after 10.5 months an active bone regeneration with all signs of desmal ossification could be observed, after 55.5 months a de facto completed ossification with uniformly directed lamellar bone was detected. Conclusions: In these two rare cases of human long-term biopsies of a xenogenic BSM a completed bony integration without extensive resorption of the BSM particles could be detected with differences between the two time points (immature vs. mature bone). Altogether, a good integration in the surrounding bone with good osteoconduction and a high biocompatibility was seen. Keywords: sinuslift, xenogenic bone substitute, histomorphometry

The objectives of the "early build-up" technique are to simplify the hard tissue augmentation procedure and to reduce discomfort for the patient.The biological approach is to augment simoultaneously bone and keratinized gingiva in the early phase of the post-extractive healing process. Keywords: early, augmentation technique, bone, gingiva, exposed biomaterials

The objectives of the "early build-up technique" are to simplify the hard tissue augmentation procedure and to reduce discomfort for the patient.The biological approach is to augment simultaneously bone and keratinized gingiva in the early phase of the post-extractive healing process. Keywords: exposed biomaterials, papilla preserved, papilla cut, 1 week healing

Introduction: Combination of bone substitute materials with growth factors may enhance prognosis of vertical bone augmentations (VBA). The aim of the study was an evaluation of the effect of a collagen membrane (Bio-Gide, Geistlich, Wolhusen, Switzerland) and a signal protein (rhPDGF, Sigma, St. Louis, USA) on VBA together with an implant-fixed bovine bone block (DBB; Bio-Oss, Geistlich, Wolhusen, Switzerland) in a rabbit animal model. Materials and Methods: In 16 rabbits, a DBB-block was implant fixed on the tibia in a split-leg design (figure 1). The groups were: 1. DBB only (control; n=8), 2. DBB+collagen membrane (test; n=8), 3. DBB+rhPDGF (test; n=8) and 4. DBB+collagen membrane+rhPDGF (test; n=8). Prior operation as well as 1h, 24h, 72h, 7d, 2 weeks and 3 weeks after operation, blood samples were taken and evaluated for alcalic and acid phosphatase (ALP, AP). Histomorphometric evaluation for new bone area (NBA; %)) and new vertical bone height (VBH; mm) was conducted after 3 (n=16) and 6 weeks (n=16). Results: ALP and AP were significant higher in the membrane-groups after 1h and 72h (all p Keywords: Vertical Bone Augmentation, Xenogenic Bone Substitute, Collagen Membrane, rhPDGF

Background & Aim: Due to the continuously increasing number of implants placed in everyday clinical practice, it is reasonable to anticipate an increasing prevalence of peri-implantitis, which underlines the necessity for a predictable therapy. Peri-implantitis-associated bone loss is characterized by a non-linear progression, with the rate of loss increasing over time. After bone loss the implant surface becomes exposed to microbial colonization in the form of microbial plaque biofilms. The anti-infective surgical treatment of peri-implantitis in cases with a considerable pocket formation larger than 5mm is based on the open flap debridement followed by implant surface decontamination. To achieve a sufficient implant debridement concrements and tissue remnants have to be removed. Well designed rotating brushes with stiff titanium made bristles allow an efficient debridement in a short time of treatment. Additional disinfection is necessary in order to avoid recontamination after mechanical cleaning. Previous in-vitro tests about the effects of titanium made debridement brushes compared to the treatment with curettes demonstrated an effective surface cleaning of the exposed implants with only minor impact on the implant structure. The aim of the study is to give treatment recommendations for the use of the rotating brush (Tigran™ PeriBrush™) regarding the load/force used in the mechanical debridement. Methods and material: The correct horizontal load/force for the rotating PeriBrush and therefore onto the surface of implants was measured using SEM images of the surface and the brush before and after treatment. A spring based construction (spring steel wire) with defined distances of impression under load was used. Patients with similar peri-implantitis (pocket depth higher than 6 mm) were treated by open flap debridement followed by implant surface decontamination. The mechanical debridement was performed with rotating titanium made brushes using a horizontal load/force of 20-30 g / 0.2-0.3N and additional rinsing with saline solution. The time used for the procedure was measured. Results: Rotating titanium debridement brushes allow a surface cleaning with only minor impact on different tested implant structures. The analyzed brush (Tigran™ PeriBrush™) is more effective compared to the vertical movements of curettes in the treatment of peri-implantitis and can shorten the treatment time. The optimal horizontal load/force onto the angle-piece for a sufficient debridement and minor effects on the implant surface and the bristles should be 20-30 g / 0.2-0.3 N for 60 sec. Keywords: peri-implantitis, open flap debridement, titanium brush, mechanical debridement

Objectives: Immediate functional loading considered an advantage reducing time , cost and second surgery time. Implant design plays a great role to enhance osseointegration ; providing an additive. Aim of this study is evaluating the results of an immediate functional loading in single mandibular posterior region. Methods: - Sixteen patients with very restrict inclusion criteria including bone quality , bone quantity and bone angle - All patients evaluated by CBCT to identify the selection criteria - Eighteen implants ( Kontact ®Implants, BIOTECH international)were received according to surgical protocol - All implants inserted with insertion torque more than 35 N. - All patients received straight nano post abutments and definitive restoration within 48 hours post implant insertion - Radiographic evaluations were performed at the base line and after year to evaluate crestal bone level - Three measures were obtained for each implant ; implant length at midaxis and mesial and distal crestal perpendicular bone lengths to the apical end of the implants ( used as reference point ) - Mesial and distal crestal perpendicular bone results were standardized with the known midaxis implant length - Mesial and distal bone lengths were then averaged and the mean bone level change was computed. Results: - Seventeen implants were clinically successful , one implant failed due to infection , yielding a success rate of 95 % - The radiographic crestal bone levels were expressed in millimeters from the top of implant platform to the first bone to implant contact - The radiographic analysis reveals the mean crestal bone level change for one year was - 0.45 mm ± 0.10 mm. Conclusion: With the limitations of this study concerning the sample size ; this prospective study indicates that immediate functional loading protocol can achieve a clinically predictable outcome with respect to restricted inclusion criteria of the patients. Keywords: immediate functional loading, immediate loading, loading protocol

Objectives: Change in keratinized mucosa due to fistula associated with periapical granuloma may alter the outcome of apicectomy procedure Aim of this study is to evaluate the possibility of use of collagen matrix (Derma® Osteobiol) to change biotype over apicectomy. Methods: - 32 years female patient with periapical lesion related to upper left lateral incisor exhibiting fistula in the buccal surface - Quality of keratinized mucosa assist photography and clinical using endodontic file - Surgical removal of periapical lesion was performed according to the surgical protocol after endodontic treatment for the affected tooth - Bony defects were augmented using bone substitute - Fistula was surgically removed - Collagen matrix is fashioned to cover the defect size and surrounding area - Flap suturing and antibiotic regime for 10 days - Clinical , photographic and radiographic evaluation follow up extended for one year. Results: Complete closure of fistula and thickened keratinized mucosa were observed demonstrating a change of biotype from thin biotype to a thick one maintained through one year follow up. Radiographic evaluation reveals successful apicectomy procedure. Conclusion: This clinical report reveals possible change of biotype by using collagen matrix over apicectomy site. This provides secured media for successful apicectomy procedure. Keywords: gingival biotype, collagen matrix, apicectomy, keratinized mucosa

Objectives: To assess the clinical and radiographic (change in crestal bone level from implant placement to 12 months) outcome of Straumann 3.3 mm Roxolid® Bone Level implants in the treatment of partially edentulous ridges of adequate bone height but limited bucco-lingual and/or mesio-distal distance. Methods: Thirty-one implants were inserted into 21 consecutive patients en-rolled in a non-interventional study and restored with single crowns or two-unit fixed partial dentures. As a part of a non-interventional study, no specific patient inclusion or exclusion criteria were applied to select patients. If their general medical condition was sufficient to allow an oral surgical procedure, if there were no contraindications for dental implant placement and if dental implants were indicated for tooth restoration they were included in the study. Clinical and radiographic examina-tions were carried out immediately after implantation (baseline) and 12 months postoperatively (primary endpoint), periapical standardized digital radiographs were taken to evaluate changes in crestal bone level. Implant success rate (SC), survival rate (SR), peri-implant conditions and pros-thetic complications were assessed as secondary variables. Results: All implants were stable and functional at the 1-year visit and present-ed no prosthetic complications, with a survival rate of 100%, despite 3 cases of peri-implantitis. The mean change in functional bone level after 1 year was -0.53 ± 0.81 mm (-0.50 ± 0.81 mm and -0.56 ± 0.82 mm mesial and distal, re¬spectively). Excluding data related to the peri-implantitis cases, the corrected mean change in functional bone level was -0.33 ± 0.51 mm (-0.29 ± 0.54 mm and 0.36 ± 0.48 mm mesial and distal, respectively). Conclusions: Within the limits of this case series study, the performance of Roxolid® Bone Level implants was safe and reliable in daily practice conditions. This implant seems to be useful for the rehabilitation of narrow ridges, fre-quently avoiding the need for bone regeneration procedures. Keywords: narrow implants, crestal bone level, narrow ridges, titanium-zirconium

Background: The augmentation of large and complex alveolar bone defects remains a major challenge for clinical implant therapy. Although there have been developments in the field of bone substitute materials for dental implant reconstruction, there are still challenges to be met for large bone defects, compromised patients and severe alveolar ridge resorption. One of the major current limitations is the inability to provide a sufficient blood supply in the initial phase following implantation. Insufficient vascularisation can result in nutrient limitations or deprivation which leads to suboptimal integration and cell death in the graft materials. Growth, function, and survival post-implantation are entirely dependent on ingrowth of blood vessels from the host. Therefore, additional strategies that serve to enhance vascularisation are essential for the survival of large bone augmentation. Aim/Hypothesis: In vitro pre-vascularisation involves vascularising a construct using a cell-based strategy to induce in vitro vascularisation prior to implantation. The concept has stemmed from previous success in optimising the conditions for endothelial cells to achieve formation of prevascular structures in vitro. Given a more natural 3D environment, endothelial cells will organise spontaneously to form capillary-like structure that upon implantation, these capillary-like structures can successfully connect to the host vasculature and become functional perfused vessels. Subsequently they are able to accelerate functional anastomosis with host tissue upon implantation and eventually aid the survival of the implanted tissue. Materials and Methods: Synthetic porous block graft of ß metacalcium phosphate were produced by sintering monocalcium phosphate powder pressed with poly(vinyl alcohol) PVA as the porogen. Pore size and interconnectivity of scaffold was reconstructed and analysed using µ-CT. Primary human alveolar osteoblast cells (aHOB) were employed to investigate biocompaibility and biofunctionality of the novel graft material. A co-culture model with osteoprogenitor cells and endothelial cells (EC) was optimized and applied to exploit the potential of forming, an in vitro, 3D prevascular network inside the synthetic block graft in order to facilitate vascularization and enhance bone regeneration. Results: The novel block graft was observed to have macro and micro porosity, and interconnectivity was confirmed. The pore size range was 0-400µm with highest frequency pores between 80-100µm. Physico-chemical properties of the graft were investigated and also the biological responsiveness, specifically, biocompatibility and biofunctionality was evaluated. The result demonstratedthat in vitro prevascularised could be achieved; this vasculogenic process was influenced by type of cells that were cultured with endothelial cells and the additional of exogenous VEGF. When HUVECs were co-cultured with aHOB or HUVEC monoculture with addition of VEGF, they demonstrated the ability to form networks with the subsequent formation of tube like structures. The response seen in the absence of exogenous VEGF, is thought to be due to the integral relationship between ECs and osteoblasts offering support and cross talk (direct and indirect), thus enhancing the process. This effect was not observed with coculture with messenchymal stem cells (hBMSC). It is concluded that by providing the optimised coculture condition of endothelial cells and osteoblast into 3D porous construct could be a promising strategy to prevascularised block graft for cranio-maxillofacial reconstruction. Further investigation by translates this model to in vivo study will facilitate a greater understanding the benefit of prevascularised tissue engineered bone graft for reconstruction of critical bone defect prior to implant placement.

Objectives: The aim of this case series of 9 cases, presenting a total of 13 implants was to evaluate the effectiveness of a modified, minimally invasive vestibuloplasty technique to reestablish stable soft tissue conditions around ailing dental implans exhibiting compromised soft tissue conditions. Methods: All treated patients exhibited moderate periimplant bone loss, increased probing depths, bleeding on probing and lack of buccal attached periimplant mucosa. Mechanical debridement and chemical disinfection of periimplant pockets were performed as conservative treatment prior to surgery. After 1 month healing time, a modified, minimally invasive vestibuloplasty procedure was used to deepen the vestibular fold, and to reestablish previously lost attached mucosa around ailing dental implants. Following local anesthesia, a paramarginal, inverse bevelled incision was placed 2-3 mm from the mucosal margin. A split thickness flap was elevated, and fixed with continous resorbable sutures (Coated Vicryl 6/0, Etichon, East Brunswick NJ, USA) to the underlying periosteal layer, 3-6 mm apically from the incision line. The uncovered periosteum was left to heal by secondary epithelialisation. Periodontal dressing was applied for 7 days; sutures were removed after 14 days. Results: 3-5 mm gain of non-inflammatory attached mucosa was observed at the buccal aspect of treated dental implants. Bleeding on probing and probing depths were reduced at each implant. Reestablished mucogingival conditions were more consecutive for oral hygiene, and helped to prevent from bacterial irritation resulting from masticatory movements. Conclusions: The presented minimally invasive, secondary epithelialisation based vestibuloplasty technique may improve soft tissue conditions around ailing dental implants. Reestablished attached mucosa, and vestibular fold may result in improved periimplant tissue health. The presented surgical approach may also serve for creating more appropriate soft tissue conditions for further periimplant hard tissue reconstructions. Keywords: periimplantitis, periimplant mucositis, vestibuloplasty, soft tissue reconstruction

Objectives: The aim of this case presentation was to evaluate the effectiveness of a surgical technique combining vestibuloplasty, and free gingival graft (FGG) transplantation at the same time as uncovering dental implants. Methods: The patient exhibited inadequate soft tissue condition at the buccal aspect of submerged dental implants (45, 46), 3 months after implant insertion: shallow vestibular fold and less than 1 mm, unstable keratinized mucosa (KM) were present. Following local anesthesia a crestal incision was made above submerged implants, continued in a paramarginal incision at the neighboring dentition. Split thickness flap was elevated, and fixed with resorbable sutures to the underlying periosteum 5-7 mm apically from the incision line. After uncovering the implants, temporary abutments were mounted. A FGG was harvested from the palate, adjusted to cover the exposed periosteal layer, and fixed with resorbable sutures to the underlying periosteum, and to the surrounding KM. Periodontal dressing was applied for 7 days at implant site, palatal donor site was covered with an absorbable collagen fleece fixed with mattress sutures. Sutures were removed 14 days postoperatively. Results: 2-3 mm keratinized mucosa was observed at the buccal aspect of 45, 46 dental implants, with no signs of inflammation. 3 months postoperatively, final restauration was cemented. Reestablished soft tissue conditions helped to prevent bacterial irritation resulted from masticatory movements, and helped the patient in oral hygiene maintenance. Conclusions: The presented combination of vestibuloplasty and FGG resulted in a stable, soft tissue environment around dental implants in the presented case. Further investigation needed to compare surgical modalities aiming to create KM around submerged dental implants. Keywords: uncovering implants, FGG, vestibuloplasty, soft tissue reconstruction, periimplantitis

Introduction and objectives: In cleft palate (CP) patients, traditional palatoplasty seems to impair mid-facial growth due to the extensive mucoperiosteal flaps. In this study we aimed to develop a novel flapless procedure for CP repair by injecting a BMP-2 containing hydrogel: the injection/adhesion technique [Martínez-Álvarez C, González-Meli B, Berenguer-Froehner B, Paradas-Lara I, López-Gordillo Y, Rodríguez-Bobada C, González P, Chamorro M, Arias P, Hilborn J, Casado-Gómez I, Martínez-Sanz E: Injection and adhesion palatoplasty: a preliminary study in a canine model. Journal of Surgical Research 2013, in press, doi:10.1016/j.jss.2013.03.009]. Material and methods: We used the Old Spanish Pointer dog breed, which develops CP in 15-20% of the offspring. Twenty pups were included in 4 groups. A: normal palate controls (n=5), B: CP controls (untreated) (n=4), C: CP individuals repaired with 2-flap palatoplasty (n=6) and D: CP individuals repaired with the injection/adhesion technique (n=5) as the novel experimental approach which consisted in the injection of a hyaluronan based hydrogel (Termira, Sweden), containing BMP-2 and nanohydroxyapatite, in the CP edges of pups aged 6 weeks, followed by the removal of the overlying mucosa and suture at week 10. Both techniques were compared in terms of results of repaired tissues, difficulty, duration, and complications. Results: Compared to palatoplasty, the injection/adhesion technique was easier, and the post-surgical recovery was faster and better, although it required two sessions. Lateral scar and denuded bone were avoided with the experimental approach. The palatal bones did not show overlapping or bone defects in the experimental or untreated controls, as observed in the palatoplasty group. No adverse effects were observed although small fistulas were observed in the first experimental pups. Conclusion: The injection/adhesion technique may represent an attractive clinical alternative to traditional palatoplasty for CP patients. Keywords: cleft palate, BMP-2, hyaluronic acid, hydrogels, dog, palatoplasty

Objectives: Surgical procedures in implantology are in general elective. Therefore the oral regeneration should be patient friendly. To avoid donor site morbidity a living tissue consisting of juvenile fibroblast cells where used to regenerate soft tissue defects in oral mouth. Methods: Juvenil fibroblast cells where seeded on a bio resorbable vicryl mesh and incubated in a closed bioreactor system. Under these conditions the cells form a dermal like tissue wich is called Dermagraft. After tissue formation the layers are frozen at -80 grad celcius and thawed if needed. The tissue was characterized and found to produce an array of growth factors like vascular endothelial growth factor (VEGF), keratinocyte growth factor (KG) as well transforming growth factor alpha, beta1, beta2 among others. 12 patients with variable intra oral soft tissue defects resulting from tumor surgery, praeprosthetic procedures and periodontal diseas were included in this study. To avoid soft tissue harvesting procedures the defects were covered with the fibroblast layer. The fibroblast layer was fixed with sutures over the defect in order to get intense contact between the fibroblast cells and the underlying patient tissue. Results: In all patients the soft tissue defects regenerated in a time period up to 10 days. Histiological biopsy of the regenerated tissue did not show any signs of scar tissue. The formed tissue was clinical functional. The secreted growth of the fibroblast layer over a prologed time period seems to promote soft tissue formation. The effect of the fibroblast layer on bone formation seems to be promising. Conclusion: With means of tissue engeneering it is today possible to produce tissues of living fibroblast cells. Growth factor produced of these cells are able to promote soft tissue formation. Keywords: soft tissue regeneration

Problem statement: The focus of this paper is to evaluate the influence of implant mechanical characteristics on primary stability in different bone types, based on resonance frequency analysis (RFA). Methods of study: A number of 60 Nobel Biocare Replace Select Ti-Unit Tapered implants of two different lengths (10 mm and 13 mm) and three different widths as 3.4 mm (narrow platform (NP)), 4.3 mm (regular platform (RP)) and 5 mm (wide platform (WP)) were placed into two different groups of bone blocks. Bone blocks were different in bone quality but similar to the bone types D1 and D3. Immediately after the implant placement, implant stability quotient (ISQ) was measured using the Osstell mentor device. Results: ISQ values for implant placements in D1 bone were found to be significantly higher than those for implants placed in D3 bone. In D1 bone, implant length did not make any significant difference in primary stability; however, in D3 bone implant primary stability increased when longer implants were utilized. NP implants presented significantly lower ISQ values compared to two wider implants. Conclusions: In cases of low bone quality, optimum increase in implant length and diameter should be taken into account to achieve higher primary stability. Keywords: primary stability, implant length, implant diameter, bone type

The immediate implant placement even in the esthetic zone is an often performed procedure. The position of the implant is closed to the palatal part of the socket. There are different concepts for the management of the remaining gap between the implant and the buccal bone plate. The aim is to keep the contour of the alveolar process. In this study, the gap was filled up with titanium granules. 28 implants were placed in the region of the upper incisors and canines. After the placement, a healing abutment in the same diameter as the implant was connected. The granules were mixed with blood and pushed with gentle pressure into the gap. The "small" healing abutment was removed and replaced by an abutment in a diameter corresponding to the replaced tooth. A temporary crown was fixed to the abutment and adhered to the adjacent teeth. After a healing time of 3 months, the abutments and temporary crowns were replaced by definite reconstruction. To evaluate the stability of the alveolar process, clinical pictures were taken before extraction and after the delivery of the final crown. In addition measuring was made using the planning model and the master cast. The healing period was uneventful in all cases. The restorations showed a healthy gingival margin and no discoloration of the soft tissue. All patients were satisfied with the clinical results so the minimal collapse of the alveolar process as the result of the measuring of the models seems not to result in a compromised clinical situation. These early results justify further use for this indication. Keywords: immediate placement, bone substitutes, red-white esthetic