Journal of Oral Science & Rehabilitation No. 1, 2015

Journal of Oral Science & Rehabilitation No. 1, 2015

Cover / Editorial / Contents / About / Immediate replacement of failed dental implants owing to periimplantitis / Comparison of new bone formation between biphasic β -TCP bovine vs. β -TCP bovine doped with silicon biomaterials in small and large defects: Experimental study in dogs / Complications of postoperative swelling of the maxillary sinus membrane after sinus floor augmentation / The prevalence and quantitative analysis of the Epstein–Barr virus in healthy implants and implants affected by periimplantitis: A preliminary report / Immunohistochemical osteopontin expression in bone xenograft in clinical series of maxillary sinus lift / Evaluation of the effect of supervised plaque control after the surgical removal of partially erupted mandibular third molars on the periodontal condition distal to second molars affected by localized periodontal disease: A randomized blind clinical study / A volumetric 3-D digital analysis of dimensional changes to the alveolar process at implants placed immediately into extraction sockets / Influence of smoking and oral hygiene on success of implants placed after direct sinus lift / Guidelines for authors / Imprint

Open PDF View E-paper Edit Epaper Edit Epaper ads save

Table of contents

) ) [pdf_filetime] => 1729640844 [s3_key] => 66679-0604fbed [pdf] => JORS0115.pdf [pdf_location_url] => https://e.dental-tribune.com/tmp/dental-tribune-com/66679/JORS0115.pdf [pdf_location_local] => /var/www/vhosts/e.dental-tribune.com/httpdocs/tmp/dental-tribune-com/66679/JORS0115.pdf [should_regen_pages] => 1 [pdf_url] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/66679-0604fbed/epaper.pdf [pages_text] => Array ( [1] =>

Journal of

Oral Science
&
Rehabilitation

Volume 1 — Issue 1/2015

ISSN 2365-6891

Volume 1 — Issue 1/2015

Journal of Oral Science & Rehabilitation

Journal for periodontology, implant dentistry,
dental prosthodontics and maxillofacial surgery

[2] =>

Co-sponsored by:

ICOI is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association
to assist dental professionals in identifying quality providers of continuing dental education. ADA
CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints
about CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp.
ICOI is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider
are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry
or AGD endorsement. The current term of approval extends from April 1, 2014 to March 31, 2018. Provider ID# 217378.
Photos courtesy of Berlin Tourismus & Kongress GmbH

[3] =>

Editorial

Journal of

Oral Science
&
Rehabilitation
Dear reader,

Launching a new journal is never easy, especially in times in which
a multitude of them are being published. The Journal of Oral Science
& Rehabilitation originated from the efforts of a large group of researchers involved in the development of implant dentistry. Since
the mid-1980s, the concept of osseointegration has had a profound influence on treatment planning in dentistry, markedly
changing it. It is my view that implant dentistry has been developed
to the point that it should be considered an independent dental
specialty.

Prof. Ugo Covani
Editor-in-Chief
Professor of Implant Dentistry,
University of Pisa, Italy
Chairman of the Istituto
Stomatologico Toscano,
Versilia general hospital,
Camaiore, Italy

Even though implant dentistry is characterized by surgical aspects
that fundamentally involve basic oral science, it should be considered the cornerstone of oral rehabilitation. In fact, while in the past
oral rehabilitation aimed to replace missing crowns, implant dentistry has evolved to the restoration of the entire crown–root complex. This, in turn, means that this discipline not only addresses
prosthetic issues, but also takes into consideration the biology of
the soft and hard tissue.
The title of the journal, which refers to basic scientific knowledge
and oral rehabilitation, conveys our attempts to illustrate the complexity of implant dentistry and our wish to develop a platform for
researchers and clinicians so that implant dentistry may be considered an all-inclusive discipline that addresses all biological, clinical
and aesthetic issues related to patients. The journal will encourage
clinicians to play an active role as coordinators of oral rehabilitation, replacing their traditional view of themselves as primarily
surgeons. Consequently, this will require a deeper understanding
of oral surgery, oral biology, oral rehabilitation and stomatology,
and we hope with this journal to contribute to the improvement of
knowledge in these fields.
Prof. Ugo Covani
Editor-in-Chief
Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[4] =>

Contents

3
Editorial
Ugo Covani
6
About the Journal of Oral Science & Rehabilitation
8
Eduardo Anitua et al.
Immediate replacement of failed dental implants owing to periimplantitis
16
José Luis Calvo Guirado et al.
Comparison of new bone formation between biphasic β-TCP bovine
vs. β-TCP bovine doped with silicon biomaterials in small and large defects:
Experimental study in dogs
26
Yasuhiro Nosaka et al.
Complications of postoperative swelling of the maxillary sinus membrane
after sinus ﬂoor augmentation
34
Luigi Canullo et al.
The prevalence and quantitative analysis of the Epstein–Barr virus
in healthy implants and implants affected by periimplantitis:
A preliminary report
42
Pablo Galindo-Moreno et al.
Immunohistochemical osteopontin expression in bone xenograft in clinical
series of maxillary sinus lift
52
Anne-Sofie Pipkorn et al.
Evaluation of the effect of supervised plaque control after surgical removal
of partially erupted mandibular third molars on the periodontal condition
distal to second molars affected by localized periodontal disease:
A randomized blind clinical study
62
Isacco Szathvary et al.
A volumetric 3-D digital analysis of dimensional changes to the alveolar
process at implants placed immediately into extraction sockets
70
Luis Martorell Calatayud et al.
Inﬂuence of smoking and oral hygiene on success of implants placed
after direct sinus lift
76
Guidelines for authors
78
Imprint — about the publisher

04 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[5] =>

[6] =>

About

About
the Journal of Oral Science & Rehabilitation
The aim of the Journal of Oral Science & Rehabilitation is to promote rapid
communication of scientiﬁc information between academia, industry
and dental practitioners, thereby inﬂuencing the decision-making in
clinical practice on an international level.
The Journal of Oral Science & Rehabilitation publishes original and highquality research and clinical papers in the ﬁelds of periodontology, implant dentistry, prosthodontics and maxillofacial surgery. Priority is
given to papers focusing on clinical techniques and with a direct impact
on clinical decision-making and outcomes in the above-mentioned
ﬁelds. Furthermore, book reviews, summaries and abstracts of scientiﬁc
meetings are published in the journal.
Papers submitted to the Journal of Oral Science & Rehabilitation are subject to rigorous double-blind peer review. Papers are initially screened for
relevance to the scope of the journal, as well as for scientiﬁc content and
quality. Once accepted, the manuscript is sent to the relevant associate
editors and reviewers of the journal for peer review. It is then returned to
the author for revision and thereafter submitted for copy editing. The
decision of the editor-in-chief is made after the review process and is
considered ﬁnal.

About
Dental Tribune Science
Dental Tribune Science (DT Science) is an online open-access publishing
platform (www.dtscience.com) on which the Journal of Oral Science &
Rehabilitation is hosted and published.
DT Science is a project of the Dental Tribune International Publishing
Group (DTI). DTI is composed of the leading dental trade publishers
around the world. For more, visit:

www.dental-tribune.com

06 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[7] =>

About

Benefits
of publishing in the journal for authors
There are numerous advantages of publishing in the Journal of Oral
Science & Rehabilitation:
– Accepted papers are published in print and as e-papers on
www.dtscience.com.
– Authors’ work is granted exposure to a wide readership, ensuring
increased impact of their research through open-access publishing on
www.dtscience.com.
– Authors have the opportunity to present and promote their
research by way of interviews and articles published on both
www.dtscience.com and www.dental-tribune.com.
– Authors can also post videos relating to their research, present
a webinar and blog on the DT Science website.

Subscription price
€50.00 per issue, including VAT and shipping costs

Information for subscribers
The journal is published quarterly. Each issue is published as both a print
version and an e-paper on www.dtscience.com.

Terms of delivery
The subscription price includes delivery of print journals to the recipient’s
address. The terms of delivery are delivered at place (DAP); the recipient
is responsible for any import duty or taxes.

Copyright © 2015 Dental Tribune International GmbH. Published by
Dental Tribune International GmbH. All rights reserved. No part of this
publication may be reproduced, stored or transmitted in any form or by
any means without prior permission in writing from the copyright holder.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

07

[8] =>

Periimplantitis: Immediate implant replacement

Immediate replacement
of failed dental implants owing
to periimplantitis

Abstract

Introduction

Objective

The high predictability of dental implants makes
them the ﬁrst choice for replacing missing
teeth.1–3 This, in addition to the long-term success of implant-supported ﬁxed prostheses,4 results in the wide acceptance of implant therapy
among the general population.
New improvements in clinical protocols can
increase the predictability of implant therapy further and reduce rehabilitation time and cost. One
such improvement is the graftless rehabilitation
of missing teeth. Lazzara et al. have introduced
the concept of immediate implant placement after tooth extraction.5 This procedure results in a
reduction in the number of surgical procedures
and in the time required to complete oral rehabilitation.5, 6 Also, immediate implant placement is
one of the surgical procedures by which to
achieve alveolar ridge preservation.4
Published data document the high success
rate of immediate implant placement and support the predictability of the technique in the absence of periapical lesions.4, 7–10 Even in the presence of periapical infection, recent research has
shown that immediate placement of dental implants is possible provided there is adequate
socket cleaning and decontamination.10–12 In a
recent randomized clinical trial, MontoyaSalazar et al. studied the inﬂuence of periapical
infection on the success rate of immediately
placed dental implants after tooth extraction.10
The infected sockets were curetted and decontaminated before implant placement.10 In the
group of infected sockets, all implants placed
were successfully osseointegrated and loaded.
The three-year survival rate was 94.44 % with
no signiﬁcant differences when compared with
the noninfected socket group.10
Periimplant mucositis and periimplantitis are
inﬂammatory diseases of bacterial origin, but
bone loss only occurs in the case of peri-

This work aimed at determining whether immediate implant
placement to replace infected implants can be a treatment
method for periimplantitis.
Materials and methods

Immediate replacement of failed dental implants requires a conservative implant extraction technique capable of preserving as
much viable soft and hard tissue as possible. An implant extraction kit was employed to extract safely dental implants failed
owing to periimplantitis. The explantation socket was curetted
and decontaminated before the immediate placement of new
implants. The implants were then followed clinically and radiographically to assess their survival rate.
Results

Seven patients were treated to remove nine implants. The failed
dental implants were extracted at a torque of 162 ± 41 N cm. The
presence of dental plaque and metallic contamination due to
surface cleaning was detected under a scanning electron microscope. The implants were followed for 50 ± 2 months after placement and 43 ± 3 months after loading. No implant failure was registered during this period. The mesial bone loss was 1.0 ± 0.8 mm
and the distal bone loss was 1.0 ± 0.8 mm.
Conclusion

The survival of all implants and the minimal marginal bone loss
would support this procedure for the immediate replacement
of dental implants in sockets affected by periimplantitis.
Keywords

Periimplantitis, implant removal, immediate implant placement, implant survival.

08 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[9] =>

Periimplantitis: Immediate implant replacement

Fig. 1

d
Fig. 1
(a) A nonmobile implant with
advanced bone loss due to
periimplantitis. (b) An
extraction ratchet placed into
the implant connection. (c)
Implant removal by application
of counterclockwise torque.
(d) The dental implant placed
after careful curettage of the
socket.

implantitis.13 The prevalence of periimplantitis
varies between different studies and a prevalence (implant based) of 6.6–36.6% has been
reported.14–18 Dental implant extraction may be
indicated in cases of advanced bone loss around
the implant. In these cases, could immediate implant replacement be considered?
No study has reported on immediate implant
placement after the extraction of infected dental
implants. This dearth could be related to the need
for a predictable technique that permits conservative implant extraction that preserves most of
the viable soft and hard tissue. At the same time,
the technique should not damage the bony walls
of the socket and thereby compromise the osseointegration of the new dental implant. A kit
for implant extraction has been developed to fulﬁll the above-mentioned requirements and to
enhance the possibility of achieving adequate
implant stability.1, 19
A clinical protocol that aims to decrease the
bacterial load by curetting and decontamination
of the socket, maintain the regenerative capacity
of the surrounding alveolar walls, and achieve
primary stability would result in favorable outcomes for immediate replacement of failed dental implants. In this article, we analyze the outcomes of this clinical protocol. To that end, failed,
nonmobile, infected dental implants were extracted using an implant extraction kit and new

implants were immediately placed in replacement of these. Plasma rich in growth factors was
placed in the explantation socket before implant
placement. The extracted dental implants were
analyzed under a scanning electron microscope
and the patients were followed for four years.

Materials & methods
Outcome criteria

In order to achieve the objectives of the study, demographic and anamnesis data were obtained
from the patients’ records. Implant failure was
deﬁned as any implant lost owing to failure to
achieve osseointegration or to loss of acquired
osseointegration. The patient was the statistical
unit for the description of demographic data. The
implant was the statistical unit for the statistical
description of implant location and removal
torque. For the new implants, data on insertion
torque, failure and marginal bone loss were collected. Implant length was used as a reference to
calibrate the linear measurements on the digital
panoramic radiograph. Implant survival rate was
analyzed using the Kaplan–Meier method. All
the statistical analyses were performed using
the SPSS for Windows statistical software package (Version 15.0; SPSS, Chicago, Ill., U.S.).

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[10] =>

Periimplantitis: Immediate implant replacement

Surgical protocol
Fig. 2
Scanning electron
micrographs of ﬁve implants
removed owing to
periimplantitis. All of the
implants showed clear signs of
bacterial contamination and
plaque formation,
accompanied by vertical bone
loss. Full implant images have
been reconstructed using
three to ﬁve scanning electron
micrographs. The areas where
bone resorption around the
implants occurred are
highlighted (white line). A
scale bar is indicated for every
implant image.

In all of the patients, the same surgical protocol
was followed. All of the patients received prophylactic antibiotic medication before and after surgery. Infiltrative anesthesia was administered and incisions were made to elevate a
full-thickness flap (Fig. 1). Implant explantation was carried out using an implant extraction kit (BTI Biotechnology Institute, Vitoria,
Spain). A ratchet was first engaged into the implant connection and the removal torque was
exerted by a wrench in a counterclockwise direction, maintaining a perpendicular position
of the assembly in relation to the implant platform (Fig. 1).1, 19
After implant removal, the explantation
socket was carefully curetted to remove any
granulation tissue and immediate placement of a
new implant was performed only in those sockets in which the four bony walls were preserved
(Fig. 1). Bone drilling for placement of the new
implant was performed to remove only 0.2–
0.5 mm of bone. An implant with a wider diameter than that of the failed implant was then
placed using a surgical motor set at an insertion
torque of 25N cm and the implant placement
was then continued manually to ﬁnish (Fig. 1).
Activated fraction 2 of plasma rich in growth fac10 Volume 1 | Issue 1/2015

tors (PRGF-Endoret; BTI Biotechnology Institute, Vitoria, Spain) was placed in the socket before implant placement. The surgical site was
then covered with a ﬁbrin membrane before ﬂap
closure.
In order to obtain plasma rich in growth factors,20 peripheral blood was extracted by
venipuncture into two 9 ml extraction tubes containing 3.8 % sodium citrate (BTI Biotechnology
Institute, Vitoria, Spain) and processed according to the manufacturer’s instructions. To activate platelets and ﬁbrin formation, 50 μl of calcium chloride solution (PRGF Activator, BTI
Biotechnology Institute, Vitoria, Spain) per milliliter of plasma was employed. Activated fraction
1 (platelet count comparable to the peripheral
blood) was employed to prepare a ﬁbrin membrane that was compressed (Fibrin compactor,
BTI Biotechnology Institute, Vitoria, Spain) to
provide a thin and consistent membrane to cover
the surgical site before ﬂap repositioning and suturing with a 5-0 monoﬁlament nylon suture.
Activated fraction 2 (platelet count two to three
times higher than peripheral blood) was injected
into the implant bed and was used to humidify
the dental implants before placement. Followup visits were scheduled to remove sutures,
detect any surgical complications and fabricate
the implant-supported prosthesis.

Journal of
Oral Science & Rehabilitation

Fig. 2

[11] =>

Periimplantitis: Immediate implant replacement

Scanning electron microscopy

The extracted implants were studied under a
scanning electron microscope (SEM, Quanta
200FEG, FEI, Eindhoven, Netherlands). Owing to
the presence of organic components on the surface after explantation, the samples were ﬁxed
with a 2.5 % glutaraldehyde solution (SigmaAldrich, St. Louis, Mo., U.S.) in phosphatebuffered saline (PBS, Sigma-Aldrich, St. Louis,
Mo., U.S.) for 8 h. The samples were then dehydrated by sequential immersion in serial diluted
solutions of 0, 10, 30, 50, 70, 90 and 100% v/v of
ethanol in water. Dehydrated samples were then
air-dried, carbon-coated in a sample preparation
chamber with a sputtering system (Gatan Alto
1000E, Gatan, Abingdon, UK) and examined by
SEM. Images were taken at 20 kV acceleration
voltage. The SEM-attached energy-dispersive
X-ray unit served to analyze the elemental composition of the surface remnants.

Results
Seven patients with nine dental implants failed
owing to periimplantitis were treated according to the previously described protocol. Six patients were females and the mean age was
61 ± 4 years. All patients were nonsmokers.
Six of the failed dental implants were in the
maxillae. Four of the maxillary implants were in
the anterior region and all of the mandibular
implants were in the posterior region. The aver-

Fig. 3

age extraction torque of the failed dental implants was 162 ± 41 N cm.
All of the explanted implants were analyzed
by scanning electron microscopy. Figures 2
and 3 show representative sets of SEM images
of the explanted implants. All of the implants
were scanned completely at several magnifications. The lower magnification was used to obtain a general image of each of the implants extracted (Fig. 2). In these general images, traces
of dental plaque can clearly be observed at
the coronal parts of the implants. The area
depicted over the implants (white line) corresponds to vertical bone defects detected before implant extraction. By increasing the magnification, details such as bacterial arrangements could be detected (Fig. 3). These were
mainly cocci (Fig. 3: g & h) and bacilli (Fig. 3:
b–f), although more sensitive techniques are
needed to correctly identify the particular bacterial taxonomy. Biofilms disrupted by dehydration during the preparation of the samples
could also be clearly identified (Fig. 3: d). In a
in Figure 3, energy-dispersive X-ray spectroscopy (EDX) showed the presence of residue
of inorganic materials on the implant surface,
mainly iron and chrome. These particles could
come from stainless-steel surgical tools used
to attempt to eliminate the plaque adhering to
the surface. From the image, we can clearly see
that not only did the biofilm remain on the surface, but these procedures also left contaminants on the implant surface. In b in Figure 3, it
can be seen how the plaque preferentially

Fig. 3
Scanning electron
micrographs showing details
of the surfaces of the removed
implants shown in Figure 2. In
some cases, EDX was
performed to determine the
composition of particles found
on the titanium (Ti) surfaces.
Several explants showed
abundant microbial
colonization and bioﬁlm
formation (b–h). In some
cases, attempts at
decontamination could be
traced back to the surface of
the implants: In a, we
performed EDX spot analysis
of the particles found on the
surface and found that they
corresponded to surgical tools
(stainless steel: Fe, Cr).
Bacterial accumulation was
preferential in the rough parts
of the implant surfaces
(arrows in b and g).

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[12] =>

Periimplantitis: Immediate implant replacement

Fig. 4
(a) Preoperative panoramic
radiograph showing the
presence of bone resorption
around the dental implants in
position #34.
(b) The immediate placement
of a new dental implant.
(c) The provisional prosthesis.
(d) The provisional prosthesis
one year after seating.
(e) The seating of the deﬁnitive
prosthesis.
(f) The clinical situation four
years after implant placement.

formed on the rougher parts of the surface.
Overall, the evaluation of both the post-extraction sockets and the SEM images of the implant
surfaces found that most of the dental plaque
remained adhered to the removed implant surfaces.
New dental implants were immediately
placed at a torque of 36 ± 16 N cm. Only two implants were placed at a torque of < 25 N cm.
Two short implants of 5.5 mm × 5.5 mm and
5.5 mm × 7.5 mm were placed. Three implants
were 8.5 mm in length and had a diameter of
4.0, 4.5 and 5.5 mm, respectively. The rest of
the implants were 10.0–13.0 mm in length and
3.75–5.0 mm in diameter, respectively.
The nine implants gave support to a single
crown, four partial fixed prostheses and four
12 Volume 1 | Issue 1/2015

complete fixed prostheses. All of the partial
and complete fixed prostheses were screw retained. The implant loading was immediate for
the single crown and delayed for the partial and
complete fixed prostheses.
The implants were followed for 50 ± 2
months after placement (range: 48–52
months) and 43 ± 3 months after loading
(range: 40–48 months). No implant failure was
registered during this period. The mesial bone
loss was 1.0 ± 0.8 mm and the distal bone loss
was 1.0 ± 0.8 mm. The marginal bone loss was
measured on radiographs taken after 40 ± 6
months of implant loading. Figure 4 shows a
case that was treated according to the described protocol and followed for four years
after implant placement.

Journal of
Oral Science & Rehabilitation

Fig. 4

[13] =>

Periimplantitis: Immediate implant replacement

Discussion
The results of this study support the immediate
replacement of failed dental implants after extraction. The clinical protocol followed for the
management of failed dental implants would
enhance the possibility of osseointegration of
dental implants placed in infected sites.
The positive outcomes of this protocol
could be related to the decrease in the bacterial
load through the removal of the infected implant. The SEM analyses showed that bacterial
plaque still adhered to the implant surface
upon removal, and this represents a first step in
the cleaning of the extraction socket. Adequate
socket curettage to remove any granulation
tissue and the drilling of the socket would additionally contribute to the mechanical decontamination of the socket. Furthermore, placement of PRGF-Endoret in the socket could have
had an antimicrobial effect. It has been reported that PRGF-Endoret has antimicrobial
effects against Candida albicans, Enterococcus
faecalis, Streptococcus agalactiae, Streptococcus oralis, Staphylococcus aureus and Staphylococcus epidermidis.21, 22 All of these measures
would reduce the risk of infection and early implant failure.
Implant primary stability is crucial for implant osseointegration and is the result of mechanical anchoring (direct contact) of the implant to the host bone.23 Implant primary stability serves to prevent excessive implant
micromovements and thus permit implant
osseointegration.24 The insertion torque of the
dental implants placed in this study was
36 ± 16 N cm. Engelke et al. have concluded
that an insertion torque of > 30 N cm is advisable to obtain adequate primary stability and a
torque of ≤ 11 N cm is considered a risk factor
that increases the likelihood of implant failure.25
Different methods to remove osseointegrated dental implants have been described.
Some of them include trephining a bone block
in which the dental implant is present and the
use of a thin bur at low speed with irrigation to
separate the implant from the surrounding
bone.1, 19 These methods have the limitation of
being traumatic and of jeopardizing the explantation socket for future implant placement.
In this study, the use of an implant extraction kit was efficient and minimally invasive in
removing dental implants while preserving the

alveolar bone. This made it feasible to replace
the failed implant immediately. This immediate
replacement of failed implants reduced the
number of surgical procedures required to treat
the patient.
In a recent study,81 patients were treated
with the same implant extraction kit to remove
158 nonmobile implants from the maxillae and
the mandible.1 With the kit, the conservation of
hard and soft tissue is possible and implant failure can be resolved within a shorter period and
at reduced cost by avoiding advanced tissue
regeneration techniques.

Conclusion
Atraumatic implant explantation permitted the
preservation of viable tissue and the immediate
placement of a new implant. The implant survival
and marginal bone loss outcomes would support
the immediate placement of dental implants in a
socket affected by periimplantitis.

Competing interests
EA is the Scientific Director of BTI Biotechnology Institute (Vitoria, Spain) and head of the
Eduardo Anitua Foundation (Vitoria, Spain).
MHA and RT are scientists at BTI Biotechnology Institute (Vitoria, Spain).

Journal of
Oral Science & Rehabilitation

Eduardo Anitua,*†
Mohammad Hamdan Alkhraisat†
& Ricardo Tejero†
*

Private practice in oral implantology, Vitoria, Spain
Eduardo Anitua Foundation, Vitoria, Spain

†

Corresponding author:
Dr. Eduardo Anitua
Calle José María Cagigal, 19
01007 Vitoria
Spain
T +34 945 16 0653
F +34 945 16 0657
eduardoanitua@eduardoanitua.com

Volume 1 | Issue 1/2015

[14] =>

Periimplantitis: Immediate implant replacement

References
1.
Anitua E, Murias-Freijo A, Alkhraisat
MH. Conservative implant removal
for the analysis of the cause, removal
torque and surface treatments of
failed nonmobile dental implants.
→ J Oral Implantol.
Epub 2014 Dec 1.
2.
Esposito M, Grusovin MG, Coulthard
P, Thomsen P, Worthington HV. A 5year follow-up comparative analysis
of the efﬁcacy of various
osseointegrated dental implant
systems: a systematic review of
randomized controlled clinical trials.
→ Int J Oral Maxillofac Implants.
2005 Jul-Aug; 20(4):557–68.
3.
Wennerberg A, Albrektsson T.
Current challenges in successful
rehabilitation with oral implants.
→ J Oral Rehabil.
2011 Apr; 38(4):286–94.
4.
Wang RE, Lang NP. Ridge
preservation after tooth extraction.
→ Clin Oral Implants Res.
2012 Oct; 23 Suppl 6:147–56.
5.
Lazzara RJ. Immediate implant
placement into extraction sites:
surgical and restorative advantages.
→ Int J Periodontics Restorative
Dent. 1989; 9(5):332–43.
6.
Parel SM, Triplett RG. Immediate
ﬁxture placement: a treatment
planning alternative.
→ Int J Oral Maxillofac Implants.
1990 Winter;5(4):337–45.
7.
Chen ST, Wilson TG Jr, Hämmerle
CH. Immediate or early placement of
implants following tooth extraction:
review of biologic basis, clinical
procedures, and outcomes.
→ Int J Oral Maxillofac Implants.
2004; 19 (7 Suppl):12–25.
8.
Covani U, Marconcini S, Galassini G,
Cornelini R, Santini S, Barone A.
Connective tissue graft used as a
biologic barrier to cover an
immediate implant.
→ J Periodontol.
2007 Aug;78(8):1644–9.

23.
Sennerby L, Meredith N. Resonance
frequency analysis: measuring
implant stability and
osseointegration.
→ Compend Contin Educ Dent.
1998 May;19(5):493–8, 500, 502;
quiz 504.

9.
Marconcini S, Barone A, Gelpi F,
Briguglio F, Covani U. Immediate
implant placement in infected sites: a
case series.
→ J Periodontol.
2013 Feb;84(2):196–202.

16.
Marrone A, Lasserre J, Bercy P, Brecx
MC. Prevalence and risk factors for
peri-implant disease in Belgian
adults.
→ Clin Oral Implants Res.
2013 Aug;24(8):934–40.

10.
Montoya-Salazar V, Castillo-Oyagüe
R, Torres-Sánchez C, Lynch CD,
Gutiérrez-Pérez JL, Torres-Lagares D.
Outcome of single immediate
implants placed in post-extraction
infected and non-infected sites,
restored with cemented crowns:
a 3-year prospective study.
→ J Dent.
2014 Jun;42(6):645–52.

17.
Mir-Mari J, Mir-Orﬁla P, Figueiredo
R, Valmaseda-Castellón E, GayEscoda C. Prevalence of peri-implant
diseases. A cross-sectional study
based on a private practice
environment.
→ J Clin Periodontol.
2012 May;39(5):490–4.

24.
Anitua E, Alkhraisat MH, Piñas L,
Orive G. Efﬁcacy of biologically
guided implant site preparation to
obtain adequate primary implant
stability.
→ Ann Anat.
2015 May;199:9–15.

18.
Roos-Jansåker AM, Lindahl C,
Renvert H, Renvert S. Nine- to
fourteen-year follow-up of implant
treatment. Part II: presence of periimplant lesions.
→ J Clin Periodontol.
2006 Apr;33(4):290–5.

25.
Engelke W, Müller A, Decco OA, Rau
MJ, Cura AC, Ruscio ML, Knösel M.
Displacement of dental implants in
trabecular bone under a static lateral
load in fresh bovine bone.
→ Clin Implant Dent Relat Res.
2013 Apr;15(2):160–5.

11.
Blus C, Szmukler-Moncler S, Khoury
P, Orrù G. Immediate implants placed
in infected and noninfected sites
after atraumatic tooth extraction and
placement with ultrasonic bone
surgery.
→ Clin Implant Dent Relat Res.
2015 Jan;17 Suppl S1:e287–97.
Epub 2013 Jul 30.
12.
Siegenthaler DW, Jung RE,
Holderegger C, Roos M, Hämmerle
CH. Replacement of teeth exhibiting
periapical pathology by immediate
implants. A prospective, controlled
clinical trial.
→ Clin Oral Implants Res.
2007 Dec;18(6):727–37.
13.
Sanz M, Chapple IL. Clinical research
on peri-implant diseases: consensus
report of Working Group 4.
→ J Clin Periodontol.
2012 Feb;39 Suppl 12:202–6.
14.
Fransson C, Lekholm U, Jemt T,
Berglundh T. Prevalence of subjects
with progressive bone loss at
implants.
→ Clin Oral Implants Res.
2005 Aug;16(4):440–6.
15.
Koldsland OC, Scheie AA, Aass AM.
Prevalence of peri-implantitis related
to severity of the disease with
different degrees of bone loss.
→ J Periodontol.
2010 Feb;81(2):231–38.

14 Volume 1 | Issue 1/2015

19.
Anitua E, Orive G. A new approach for
atraumatic implant explantation and
immediate implant installation.
→ Oral Surg Oral Med
Oral Pathol Oral Radiol.
2012 Mar;113(3):e19–25.
20.
Anitua E. Plasma rich in growth
factors: preliminary results of use in
the preparation of future sites for
implants.
→ Int J Oral Maxillofac Implants.
1999 Jul-Aug;14(4):529–35.
21.
Anitua E, Alonso R, Girbau C, Aguirre
JJ, Muruzabal F, Orive G.
Antibacterial effect of plasma rich in
growth factors (PRGF-Endoret)
against Staphylococcus aureus and
Staphylococcus epidermidis strains.
→ Clin Exp Dermatol.
2012 Aug;37(6):652–7.
22.
Drago L, Bortolin M, Vassena C,
Taschieri S, Del Fabbro M.
Antimicrobial activity of pure
platelet-rich plasma against
microorganisms isolated from oral
cavity.
→ BMC Microbiol [Internet].
2013 Feb [cited 2015 Jul 7];
13:Article47.
→ Available from
http://link.springer.com/article/10.11
86/1471-2180-13-47/fulltext.html.

Journal of
Oral Science & Rehabilitation

[15] =>

PRINT
L
A
T
I
G
I
D
ON
I
T
A
C
U
ED
EVENTS

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

[16] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Comparison
of new bone formation
between biphasic β-TCP bovine vs. β-TCP bovine
doped with silicon biomaterials in small and large
defects: Experimental study in dogs

Abstract

Introduction

Objective

The reconstruction of osseous defects remains
an important and unresolved issue in oral surgery. During the first year after tooth extraction, about 50% of the buccolingual ridge dimension will be lost.1 Healing processes after
dental extractions include the formation and
maturation of blood clots, the infiltration of immature mesenchymal cells and the formation
of a provisional bone matrix.2 Immature bone
becomes established quite early on in this
process to be replaced later by mature trabecular bone.3 Processes of hard-tissue modeling
and remodeling after tooth extraction have
been studied in the dog model.4, 5 It was demonstrated that the socket was first occupied
by a coagulum that was replaced by granulation tissue, provisional connective tissue and
woven bone. More often during this healing period, bone loss occurs in the walls surrounding
an extraction site with a reduction in the buccal
alveolar crest.6–8
There are various alternatives available for
the treatment of these osseous defects, the
most traditional and long established of these
being autogenous bone grafts, used to replace
the lost bone. However, this technique has certain disadvantages given that the quantity of
available bone is always limited and that it involves a second surgical site and thus increased cost and treatment time and may lead
to further problems at the bone graft donor
site, such as bleeding, infection and pain. For
this reason, different graft materials have been
developed that are intended to bring about new
bone formation.9–12

The aim of this study was to assess the bone regeneration of
critical-size mandibular defects filled with beta-tricalcium
phosphate (β-TCP) bovine biomaterial in dogs compared with
β-TCP bovine biomaterial doped with silicon at 12 weeks.
Materials and methods

The mandibular second, third and fourth premolars of six Beagle
dogs extracted bilaterally were used in this study. Three experimental groups were evaluated: Test A (hydroxyapatite [HA]/βTCP granules alone), Test B (HA/β-TCP granules plus 3% silicon)
and controls (empty defect). The animals were sacriﬁced at eight
and 12 weeks. Evaluation was performed by scanning electron
microscopy, X-ray microtomography (μCT) and histological and
histomorphometric analysis.
Results

Histological evaluation showed a higher volume reduction in Test
A compared with Test B (p < 0.05). Test B showed the highest
values for cortical defect closure and bone formation around the
granules, followed by Test A and the control group (p < 0.05).
Conclusion

Within the limitations of this animal study, it can be concluded
that HA/β-TCP plus 3% silicon increases bone formation in
critical-size defects and the incorporation of 3% silicon reduces the resorption rate of the HA/β-TCP granules.
Keywords

Bone graft, bone substitute, β-TCP, bone defect, dog, silicon.
16 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[17] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Among the alternatives available (allografts,
xenografts or synthetic bone substitutes), synthetic materials can be ideal for bone regeneration given that many characteristics of such materials—mechanical properties, porosity, degradation rate and composition—can be modiﬁed
according to the speciﬁc clinical requirements.13, 14
Biomaterial of porcine origin, which has high
biocompatibility, stimulates the formation of
new bone in contact with biomaterial particles.
This material is used for maxillary sinus elevation prior to implant placement.15–17
According to Tadic and Epple, synthetic calcium phosphate bone substitutes, such as hydroxyapatite (HA), tricalcium phosphate (TCP)
and biphasic calcium phosphate (BCP), offer excellent biocompatibility and are in common use
as alternatives to autologous bone.18 In particular, BCP ceramics, consisting of mixtures of HA
and beta-tricalcium phosphate (β-TCP), are
widely used as bone substitutes. Although BCP
and β-TCP are more resorbable than HA bioceramics, an even higher resorption rate is desirable for bone repair applications whenever complete implant osseointegration and bone replacement are required in the midterm.
Recently, ceramics doped with silicon at different rates have become a subject for research
because of the biological beneﬁts of silicon in
their chemical composition.19 Zou et al. have reported that silicon-doped BCP enhances osteoconductivity and has been found to be nontoxic
in vivo at concentrations as high as 50,000 ppm,
producing no adverse effects in rats.20
Furthermore, it has recently been postulated
that silicon in the form of nanoparticles could
even be bioactive and beneﬁcial to the skeleton,
although the mechanisms by which silicates
regulate skeletal development and function remain unknown.21 The addition of silicon to TCP
can improve stability, provide better structural
properties and stimulate new bone formation in
small animal models.22, 19 The literature, however, includes few examples of in vivo research
into the beneﬁts of incorporating 3% silicon
nanoparticles into HA/β-TCP porous granular
structures.
The purpose of this in vivo study was to evaluate the biological effects of the incorporation of
3% silicon nanoparticles into HA/β-TCP by
histological and histomorphometric analysis,
scanning electron microscopy and X-ray microtomography (μCT) evaluation in canine bone
defects.

Materials & methods
Animals

Six male beagle dogs of 1.5 years of age and
weighing 12–13 kg each were used in the study.
The experiment protocol was designed in accordance with the Spanish and European guidelines
for animal experiments. The experiment was
approved by the Ethics Committee for Animal
Research of the University of Murcia (Spain), in
accordance with the European Union Council Directive of Feb. 1, 2013 (R.D.53/2013).
Surgical procedure

The animals were pre-anesthetized with acepromazine (0.12%–0.25 mg/kg), buprenorphine
(0.01 mg/kg) and medetomidine (35 mg/kg). The
mixture was injected intramuscularly into the
femoral quadriceps. Then an intravenous catheter was inserted (22- or 20-gauge diameter)
into the cephalic vein, and propofol was infused
at a slow constant infusion rate of 0.4 mg/kg/min.
Conventional dental inﬁltration anesthetic (articaine 40 mg, 1% epinephrine) was administered at the surgical sites. These procedures
were carried out under the supervision of a veterinary surgeon.
Te e t h e x t r a c t i o n
and grafting procedures

In both quadrants of the lower jaws, the second, third and fourth premolars (PM) and first
molars (M1) were used as experimental sites.
The alveoli corresponding to PM2, PM3 and
PM4 were classified as small defects and M1 as
large defects, respectively.
Teeth were sectioned with a carbide tungsten drill; the roots were removed with forceps,
without damaging the remaining bony walls.
Sulcular marginal incisions were made along
the vestibular and lingual areas adjoining the
alveoli, separating tissues to make the crestal
hard-tissue walls visible (Figs. 1a & b).
Prior to graft placement, the external dimensions of the post-extraction sockets (diameter) were measured using a caliper and
recorded. The mean alveolar ridge measurements of the extraction sockets were as follows: 3.8 ± 0.21 mm (PM2), 4.0 ± 0.5 mm
(PM3), 4.1 ± 1 mm (PM4) and 5.6 ± 0.07 mm
(M1).

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

17

[18] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Figs. 1a & b

Figs. 1a & b
Post-extraction sockets of
premolars PM2, PM3, PM4
and molar M1 (a);
4BONE XBM granules,
4BONE XBM plus 3% silicon
and control sites (b).

Biomaterials

Synthesis of tricalcium phosphate

The study used 4BONE XBM granules (MIS Implants Technologies, Bar-Lev, Israel), a widely
available bone substitute. This material consists
of a completely synthetic bone graft material
composed of 60% HA and 40% β-TCP, and features 70% interconnected macroporosity and
microporosity. It is available as granules of 0.5–
1 mm in size and is packaged in syringes that
must be hydrated with physiological saline prior
to use (following the manufacturer’s instructions; Fig. 1b). Two different forms of this material were used: 4BONE XBM bovine granules in
their manufactured form (without modiﬁcation)
and 4BONE XBM bovine granules plus 3% silicon, which was prepared by immersing 50 g of
4BONE XBM sequentially in a liquid solution
containing 3% silicon nanoparticles for 2 h.
Afterwards, the hydrated granules obtained
were heated to 134 °C for 1 h to dry the liquid content and to sterilize the material prior to use.

Tricalcium phosphate was synthesized by solidstate reaction from a stoichiometric mixture of
anhydrous CaHPO4 (Panreac, Barcelona, Spain)
and CaCO3 (Fluka) with an average particle size of
< 15 μm and a Ca/P ratio of 1.60. The mixture of
CaHPO4 and CaCO3 was heated in a platinum
crucible at 1,000 °C for 12 h, followed by slow
cooling. The obtained material was ground and
characterized by X-ray diffraction.
Study design

The alveoli (small defects and large defects) corresponding to the right hemi-mandible were
used as controls and were ﬁlled with 4BONE
XBM granules, after rehydration with sterile
saline, and the left hemi-mandible defects (small
defects and large defects) were ﬁlled with
4BONE XBM granules doped with 3% silicon as a
second test material. In summary, three treatment groups were created:

Synthesis of hydroxyapatite

Hydroxyapatite was synthesized by solid-state
reaction from a stoichiometric mixture of anhydrous calcium hydrogen phosphate (CaHPO4,
Sigma-Aldrich, St. Louis, Mo., U.S.) and calcium
carbonate (CaCO3, Sigma-Aldrich, St. Louis, Mo.,
U.S.) with an average particle size of < 15 μm and
a Ca/P ratio of 1.72. The mixture of CaHPO4 and
CaCO3 was heated in a platinum crucible at
1,200 °C for 6 h at a heating rate of 10 °C/min,
followed by cooling at a rate of 6.5 °C/min until it
had reached room temperature. The obtained
material was ground and characterized by X-ray
diffraction.
18 Volume 1 | Issue 1/2015

(i) bone defects ﬁlled with 4BONE XBM
granules alone (Test A)
(ii) small defects ﬁlled with 4BONE XBM
granules doped with 3% silicon (Test B)
(iii) control bone defects.
Samples were allocated to test groups using randomization software (Research Randomizer).23
Tissue flaps were repositioned without
tension-free adaptation using interrupted and
horizontal mattress sutures for wound closure
(Monoﬁl 4-0, Ancladén, Barcelona, Spain). During the ﬁrst week after surgery, the animals were
medicated with amoxicillin (500 mg b.i.d.) and

Journal of
Oral Science & Rehabilitation

[19] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Table 1

ibuprofen 600 mg t.i.d.) administered systemically. The sutures were removed after two
weeks. The dogs received a soft diet and a plaque
control regimen that included tooth cleaning
with the use of toothbrush and dentifrice, and
administration of a 0.2% chlorhexidine solution
three times a week until the end of the experiment (eight and 12 weeks).
Animal euthanasia

The animals were euthanized at eight (three animals) and 12 weeks (three animals) by means of
an overdose of Sodium Pentothal (Abbott Laboratories, Chicago, Ill., U.S.).
Micro-CT evaluation

Immediately after sacriﬁce at eight or 12 weeks,
μCT evaluation was performed to evaluate the
residual volume of graft material. Each specimen
was placed on the scanning platform of a GE
eXplore Locus μCT scanner (GE Healthcare, Piscataway, N.J., U.S.) and 360 X-ray projections
were collected (80 kVp, 500 mA, 26 min total
scan time). The projection images were preprocessed and reconstructed into 3-D volumes
(20 μm resolution). Each volume was scaled to
Hounsﬁeld units using a calibration phantom
containing air and water (phantom plastic); a plug
within the phantom containing HA was used as a
bone mimic for bone mineral/density calculations. The 3-D data was processed and rendered
(isosurface/maximum intensity projections)
using MicroView (GE Healthcare). Volumes were
imported into MATLAB (R2009b, MathWorks,
Natick, Mass., U.S.) for automated batch analysis. Brieﬂy, a ﬁxed cylindrical volume of interest
(14 mm diameter, 5 mm height) was applied to
each volume. As each volume was calibrated
using a ﬁxed standard, calcium phosphate, cortical bone, trabecular/woven bone and scaffold
content were determined using predefined
Hounsfield unit thresholds (> 3,000, 2,000–
3,000, 750–2,000, and 300–750, respectively).
Residual graft material was calculated as the
graft/total bone volume × 100, expressed as a
percentage at eight or 12 weeks for both test
groups (Table 1).

Residual volume

8 weeks
(Mean ± S.D.)

12 weeks
(Mean ± S.D.)

Te s t A

63.72 ± 5.1 %

43.91 ± 1.2 %

Te s t B

76.22 ± 1.6 %*

58.53 ± 1.1 %*

Statistical signiﬁcance was set at p < 0.05.

mandible was block-sectioned and the tissue
ﬁxed with 4% formalin. The samples were dehydrated in a graded ethanol series. The blocks
were inﬁltrated with Technovit 7200 resin (Heraeus Kulzer, Hanau, Germany) and polymerized
with ultraviolet light.
The polymerized blocks were then sectioned
in a buccolingual direction. Three slices were obtained per site and reduced by micro-grinding
and polishing using an EXAKT grinding unit
(EXAKT, Norderstedt, Germany) to an even
thickness of approximately 15–30 lm. The slides
were stained with the Lévai–Laczkó technique;
the entire circumference of each section (containing bone, grafted granules and connective
tissue) was traced manually to create individual
regions of interest.
Histomorphometric analysis

The percentages of residual graft material, connective tissue and new bone were calculated in
relation to the total measurement area (socket
walls). The central portion of each core was selected to avoid any potential bias. In this way,
both the coronal (remaining native host bone)
and the apical portions were excluded from
analysis (using a safe margin of 1.5–2 mm). Histomorphometric measurement of the samples
was conducted using ImageJ software (developed by the U.S. National Institutes of Health,
Bethesda, Md.). Descriptive evaluation and morphometric measurements were performed under a Nikon Eclipse 80i microscope (Tekno Optik,
Huddinge, Sweden) equipped with the Easy Image 2000 system (Tekno Optik) using 91–94
lenses (Fig. 2).
Histomorphometric evaluation

Prepared samples were photographed with a
Sample processing
digital camera using a 20× motorized optical
microscope (BX51, Olympus, Japan). These phoThe soft tissue of each mandible was dissected tographs were combined using computer softto leave exposed the bone surfaces. Each ware (cellSens Dimension, Olympus, Japan) to
Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

Table 1
Residual volume of graft
material at eight and 12
weeks.
At 12 weeks, both test
groups showed a reduction in
the volume of material in
comparison with eight weeks.
Test B showed slower
resorption expressed as higher
residual volume in comparison
with Test A at eight and 12
weeks.

[20] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Fig. 2

The Friedman test is the nonparametric equivalent of a one-sample repeated measures design
or a two-way analysis of variance with one observation per cell. Values were recorded as mean
± standard deviation. The Student’s t-test was
applied to compare mean averages and to quantify relationships between differences.
Friedman tests the null hypothesis that k related variables come from the same population.
For each case, k variables are assigned the rank
1 to k. The statistic is based on these ranks. Equal
means were regarded as the null hypothesis,
while the existence of signiﬁcant differences between means acted as an alternative hypothesis.
As signiﬁcant differences between the means
did exist, the null hypothesis was rejected. Signiﬁcance was set at p < 0.05.

Results

Fig. 2
Region of interest (ROI)
Each defect was identiﬁed by
one oriﬁce marked with
amalgam. The ROI was a
polygon delimited by the
lateral walls of the defect on
both sides, coronally by the
upper cortical and inferiorly
by the basal cortical
(5× magniﬁcation, Lévai–
Laczkó staining).
CDC = cortical defect closure;
CT = connective tissue;
NB = new bone;
MB = mature bone.

obtain high-resolution images of the entire sample. Regions of interest (ROI) were manually delimited to facilitate identiﬁcation of the different
tissues present in each sample. The following
variables were recorded at the two study times
(eight and 12 weeks):

At eight and 12 weeks, no animals had been lost
and the surgical zones showed no signs of inﬂammation. In all experimental sites, healing
was uneventful. After eight and 12 weeks of healing, keratinized mucosa was observed covering
the edentulous zones without dehiscences or exposure of bone or graft granules. The histomorphometric and histological results of new bone
formation, residual graft and connective tissue
after eight and 12 weeks of healing are described
below.
Micro-CT evaluation

Cortical defect closure: Percentage of new bone
present within the original defect walls in the ROI.
Residual material: Percentage of granules present
inside the ROI in relation to the total area (Fig. 2).
Connective tissue: Connective tissue or the connective tissue space present inside the ROI expressed as percentage.
New bone: Percentage of new bone present inside the marrow space and between the granules
in the ROI.

At eight weeks, Test B showed a higher residual
volume of graft material (76.22 ± 1.6%) in comparison with Test A (63.72 ± 5.1%; Figs. 3a–c).
A higher reduction in volume was observed at
12 weeks in Test B, which maintained almost
58.53 ± 1.1% of the original volume while supporting bone formation compared with Test A
(43.91 ± 1.2%; Figs. 3d–f & Table 1).

Statistical analysis

Cortical defect closure: All groups showed an
approximation of the borders and a subsequent
reduction of the original critical-size defect.
Test B showed the highest defect closure
(68.71 ± 1.2%); a mixture of new bone and granules
formed the new cortical bone. Test A showed partial closure (58.95 ± 3.4%) and the control group
showed the lowest defect closure (11.23 ± 1.8%).

Statistical analysis was performed using IBM
SPSS Statistics software (Version 20.0; IBM
Corp., Armonk, N.Y., U.S.). After descriptive
analysis, the Mann–Whitney U test was used to
evaluate the signiﬁcance of differences between
Test A and Test B.
20 Volume 1 | Issue 1/2015

Histological description at eight weeks

Journal of
Oral Science & Rehabilitation

[21] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Figs. 3a–c

Figs. 3d–f

Figs. 3a–c
Micro-CT evaluation of the
test groups at eight weeks.

The images represent a
comparison between the two
study times and the different
materials tested. Dotted
circles show the initial defect
size, illustrating the reduction
in graft volume in all groups.
The control group is not
shown, as control defects did
not receive any graft material
(a). Test A showed an
increased reduction in the
graft volume (b). Test B
showed a medium-volume
reduction (c).

Figs. 3d–f
Micro-CT evaluation of the
test groups at 12 weeks.

Both test groups showed signiﬁcant defect closure in comparison with the control group
(p < 0.05; Table 2).
Residual material: Test B showed a higher percentage of residual material than did Test A
(p < 0.05; Table 2).
Connective tissue: Connective tissue was higher
in the control group (87.32 ± 1.4%) compared
with Tests A and B (p < 0.05; Figs. 4a–c & Table 2).
New bone: New bone grew at the defect borders
and between the particles in both Tests A and B.
In the control group, new bone was only present
at the defect borders. Bone formation commonly
started in and around the 4BONE XBM graft particles. The highest amount of new bone was
found in Test B, followed by Test A and the control
group (p < 0.05; Table 2).

Histological description at 12 weeks

Under fluorescence microscopy, in both groups
at 12 weeks of healing, the presence of a hardtissue bridge that sealed the coronal part of the
extraction socket was observed. The bridge
was due to a continued small amount of new
bone formation with some areas of mature
bone. The material favored the growth of new
bone in two different ways: first, by creating a
new bridge between the defect walls and, second, through the actions of its components. At
12 weeks, the defect had completely closed in
the group treated with 4BONE XBM plus 3%
silicon compared with the group treated with
4BONE XBM alone. This marginal bridge was
mainly of woven bone with areas of lamellar
bone and some 4BONE XBM granules included
inside the new bone (Figs. 4d–f).

Table 2
Histomorphometry at
eight weeks.

Table 2

Histomorphometry
8 weeks
Control

Cortical defect closure
(Mean ± S.D.)

Residual material
(Mean ± S.D.)

Connective tissue
(Mean ± S.D.)
*b, c

New bone
(Mean ± S.D.)

11.23 ± 1.8%

—

87.32 ± 1.4%

Te s t A b

58.95 ± 3.4%

44.33 ± 2.1%

16.67 ± 1.7%

41.33 ± 1.2%*a

Te s t B c

68.71 ± 1.2%*b, a

49.86 ± 3.2%*b, a

12.87 ± 1.1%

45.78 ± 1.9%*a

Post hoc multiple comparisons
showed that cortical defect
closure and residual material
were higher for Test B,
connective tissue was higher
for the control group, and new
bone formation was higher for
Tests A and B in comparison
with the control group.

14.87 ± 1.5%

Statistical signiﬁcance was set at p < 0.05.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

The images represent a
comparison between the two
study times and the different
materials tested. Dotted
circles show the initial defect
size, illustrating the reduction
in graft volume in all groups.
The control group is not
shown, as control defects did
not receive any graft material
(d). Test A showed an
increased reduction in the
graft volume (e). Test B
showed a medium-volume
reduction (f).

[22] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Table 3

Table 3
Histomorphometry
in 12 weeks.

Histomorphometry
12 weeks

Post hoc multiple comparisons
showed that defect closure
and residual material were
higher for Test B, connective
tissue was higher for the
control group, and new bone
formation was higher for
Tests A and B in comparison
with the control group.
*

Cortical defect closure
(Mean ± S.D.)

Residual material
(Mean ± S.D.)

Connective tissue
(Mean ± S.D.)

New bone
(Mean ± S.D.)

Controla

26.45 ± 1.5%

—

71.65 ± 1.6%*b,c

27.54 ± 2.1%

Te s t A b

78.23 ± 1.2%

34.36 ± 1.1%

14.28 ± 1.9%

53.29 ± 1.7%*a

Te s t B c

86.11 ± 1.9%*b,a

36.24 ± 1.8%*b,a

10.37 ± 1.6%

58.92 ± 0.8%*a

Statistical signiﬁcance was set at p < 0.05.

Cortical defect closure: All groups showed a reduction in the defect size in comparison with the
eight-week study time. Test B showed the highest defect closure (86.11 ± 1.9%). Test A showed
increased closure (78.23 ± 1.2%) in comparison
with the eight-week study time, and the control
group showed the lowest amount of defect closure (26.45 ± 1.5%). Both test groups showed
signiﬁcant defect closure in comparison with the
control group (p < 0.05; Table 3).
Residual material: Test B showed a higher percentage of residual material (39.41 ± 1.3%) in
comparison with Test A (35.78 ± 2.9%) and the
control group (p < 0.05; Table 3).
Connective tissue: Connective tissue was the
highest in the control group (71.65 ± 1.6%), and
was lower in Tests A and B (p < 0.05; Table 3 &
Figs. 4d–f).
New bone: New bone was observed at the centre
of the defect and at the borders in Tests A and B; in
the control group, no new bone formation was
found. The highest amount of new bone was found
in Test B, followed by Test A (p < 0.05; Table 3).

Discussion
The purpose of the present work was to evaluate
the beneﬁts of incorporating 3% silicon into the
composition of a biphasic synthetic graft material
of HA/β-TCP, used in critical-size defects in dogs’
post-extraction defects. The current dog model
has previously been used in several experiments in
our laboratory to study various aspects of socket
healing.4–6 In the studies referred to, woven bone
started to form in the fresh extraction socket after
one week of healing and after four weeks the
socket was largely ﬁlled with woven bone (about
90% of the socket).
In our present study, cortical defect closure
was evaluated by histological and histomorphometric tests at eight and 12 weeks. Excellent de22 Volume 1 | Issue 1/2015

fect closure in both test groups with graft material
granules surrounded by new bone was found.
The present experiment demonstrated that
the early healing of an extraction socket grafted
with HA/β-TCP plus 3% silicon involved new bone
formation and a coagulum was replaced by a provisional granulation tissue matrix in which new
woven bone could be formed. The biphasic biomaterial was apparently involved in this process. HA
granules were occupied by large active multinucleated cells that most likely removed calcium
and phosphate ions from the small granules of the
biomaterial. Thus, in the grafted sites, substantial
amounts of newly formed bone could only be detected in the apical portion of the socket where the
graft material was absent. In the remaining portions of the grafted sockets, a mildly inﬂamed provisional matrix surrounded the majority of the
4BONE XBM granules.
The present results agree with those obtained
by El Backly et al., who compared the effects of
platelet-rich plasma and a silicon-stabilized
HA/β-TCP scaffold on healing critical-size defects
in rabbit calvaria, evaluating healing at four, eight
and 16 weeks.24
In the nongrafted control sites, large amounts of
woven bone had formed in most compartments
of the socket. This ﬁnding is in agreement with
observations from similar experiments that investigated tissue modeling and remodeling in
extraction sockets, as well as in mechanically
produced defects in the alveolar ridge in dogs.4, 5
Most of the graft particles present in the test
sites were surrounded by either a dense provisional matrix or newly formed woven bone, especially in the test group treated with 4BONE XBM
plus 3% silicon. Most of the 4BONE XBM granules were in direct contact with immature woven
bone.
The present study used CT and resin-embedded histology to evaluate healing evolution.
The results showed that the silicon-stabilized

Journal of
Oral Science & Rehabilitation

[23] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

Figs. 4a–c

Figs. 4a–c
Histomorphometric
comparison at eight weeks
between all groups.
Control defect: Bone
formation was observed
only at the defect walls, and
incomplete closure of the
defect was observed (a).
Test A: Bone formation was
observed around the periphery
of the granules; at the basal
zone, new cortical formation
supported by the granules
was observed (b).

Figs. 4d–f

Test B: A reduction in the
graft volume was observed,
with increased bone formation
around and inside the
granules (c).

Figs. 4d–f
Histomorphometric
comparison at eight and 12
weeks between all groups.
Control defect: Bone
formation was observed
only at the defect walls, and
complete closure of the
defect was not observed (d).

HA/β-TCP scaffold produced effective defect
closure and improved new bone formation. The
material was also very stable. These results
agree with research carried out by Kruse et al.,
who created noncritical-size defects in rabbit
calvarias, filling them with three different materials: synthetic HA/silica oxide-based test
granules, xenogenic HA-based granules, and
synthetic HA/silica oxide-based granules.25 It
was found that the incorporation of silica into
the HA provided comparable results to a standard xenogenic bovine mineral in terms of bone
formation and defect bridging in noncriticalsize defects.
The residual material in the present study
was higher in Test B, a finding that agrees with
several other studies that have affirmed that
incorporating calcium silicate into β-TCP cement increases the material’s stability and
mechanical properties. As demonstrated by

Velasquez et al., the addition of silicon to the
β-TCP ceramic structure enhanced its properties by reducing its resorption rate and thus increasing the material’s stability during the
bone formation processes.12 Similar results
were obtained by Wang et al.,2 who suggest
that 50 or 80% silicon could promote bone regeneration by stimulating osteogenesis, angiogenesis, and the proliferation and differentiation of osteoblast-like cells.26
The present study found connective tissue
present in higher percentages in the control
group in comparison with Tests A and B, which
agrees with research carried out by De Aza
et al., who implanted β-TCP and β-TCP doped
with 3 wt% dicalcium silicate ceramic (β-TCPss) in
critical-size defects in rabbit tibiae.14 They
observed organized collagen fibrils at the
β-TCPss–bone interface for TCP doped with
3 wt% dicalcium silicate ceramic after four

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

Test A: Bone formation was
observed around the periphery
of and inside the granules (e).
Test B: A reduction in the
graft volume was observed,
with increased bone formation
around and inside the
granules (f).

[24] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

weeks, whereas a collagen-free layer was present around the silicon-free β-TCP implants.
These findings suggest that the incorporation
of silicate ions into β-TCP ceramics promoted
bone remodeling processes at the β-TCPss–
bone interface, so that the stability rate of the
β-TCPss material decreased.14 Apparently, the
organized collagen network facilitated the
later mineralization of the collagen matrix,
aided by the silica content. Moreover, the introduction of calcium silicate into porous TCP bioceramics is an effective way to prepare bioactive bone grafting scaffolds for clinical use
and to control properties such as in vivo
degradability and osteoinduction of TCP.27
In the present study, new bone formation
was higher in Tests B and A in comparison with
the control group, which showed maximum
new bone formation after 12 weeks. These results agree with earlier studies incorporating
different kinds of calcium silicate into synthetic ceramic cements. The incorporation of
dicalcium silicate (C2S) into the structure of
β-TCP improved the materials’ integration and
compatibility, facilitating its capacity to bond
with natural bone and improving the rate of
new bone formation in comparison with a
C2S-free β-TCP composition.12 According to
Velasquez et al., the in vivo behavior of β-TCP
ceramic and C2S-doped β-TCP compositions
matched their in vitro behavior.12 The bioactivity and biocompatibility of these ceramics de-

pended on their initial C2S content. The results
of the study suggest that doping of the β-TCP
ceramic with 3% C2S promotes bone mineralization during implantation into natural bone.
Of all the compositions tested, the biphasic
material doped with 3 wt% C2S showed the
greatest bioactivity both in vitro and in vivo and
thus could be of interest for bone restorative
purposes in specific applications.12 It offers an
ideal matrix in regenerative procedures and
might be a promising candidate as an implant
material in orthopedic, oral and maxillofacial
applications owing to its mechanical and biological properties.12

Conclusion
Despite the limitations of this dog study, it may
be concluded that the use of this biphasic material favors new bone formation and allows
critical-size defects to heal without interfering
in the regeneration process. The biphasic material with 3% silicon increased the dimensional stability of the graft, a feature that offers
potential in areas that require dimensional stability and replacement by bone tissue.

Competing interests
The authors declare that they have no competing
interests.

José Luis Calvo Guirado,†
Pérez Albacete Martínez Carlos,†
José Manuel Granero Marín,†‡
Rafael Arcesio Delgado Ruiz,†§
Maria Piedad Ramírez Fernández,†‡
José Eduardo Maté Sánchez de Val†
Gerardo Gómez Moreno†**
†

International Dentistry Research Cathedra,
Universidad Católica San Antonio de Murcia,
Murcia, Spain

‡

Faculty of Medicine and Dentistry, University
of Murcia, Spain

§

Department of Prosthodontics and Digital
Technology, Stony Brook University, School of
Dental Medicine, Stony Brook, N.Y., U.S.

**

Department of Pharmacological Interactions,
Faculty of Dentistry, University of Granada,
Spain

24 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

Corresponding author:
Prof. José Luis Calvo Guirado
Calle Mozart, 4, 1º C–D
30002 Murcia
Spain
T +34 968 26 8353
F +34 968 26 8353
jlcalvo@ucam.edu

[25] =>

β-TCP bovine biphasic biomaterial increases bone formation in dog model

References
1.
Schropp L, Wenzel A, Kostopoulos L,
Karring T. Bone healing and soft tissue
contour changes following single-tooth
extraction: a clinical and radiographic
12-month prospective study.
→ Int J Periodontics Restorative Dent.
2003 Jul-Aug;23(4):313–23.

9.
Nomura T, Katz JL, Powers MP, Saito C.
Evaluation of the micromechanical
elastic properties of potential bonegrafting materials.
→ J Biomed Mater Res B
Appl Biomater.
2005 Apr;73B(1):29–34.

2.
Wang C, Lin K, Chang J, Sun J. The
stimulation of osteogenic
differentiation of mesenchymal stem
cells and vascular endothelial growth
factor secretion of endothelial cells by
β-CaSiO3/β-Ca3(PO4)2 scaffolds.
→ J Biomed Mater Res A.
2014 Jul;102(7):2096–104.

10.
Schwarz F, Herten M, Ferrari D,
Wieland M, Schmitz L, Engelhardt E,
Becker, J. Guided bone regeneration at
dehiscence-type defects using biphasic
hydroxyapatite + beta tricalcium
phosphate (Bone Ceramic) or a
collagen-coated natural bone mineral
(BioOss Collagen): an
inmunohistochemical study in dogs.
→ Int J Oral Maxillofac Surg.
2007 Dec;36(12):1198–206.

3.
Becker W. Treatment of small defects
adjacent to oral implants with various
biomaterials.
→ Periodontol 2000.
2003 Oct;33(1):26–35.
4.
Cardaropoli G, Araújo MG, Lindhe J.
Dynamics of bone tissue formation in
tooth extraction sites: an experimental
study in dogs.
→ J Clin Periodontol.
2003 Sep;30(9):809–18.
5.
Araújo MG, Lindhe J. Dimensional ridge
alterations following tooth extraction:
an experimental study in the dog.
→ J Clin Periodontol.
2005 Feb;32(2):212–8.
6.
Araújo M, Linder E, Lindhe J. Effect of a
xenograft on early bone formation in
extraction sockets: an experimental
study in dog.
→ Clin Oral Implants Res.
2009 Jan;20(1):1–6.
7.
Araújo MG, Liljenberg B, Lindhe J. βtricalcium phosphate in the early phase
of socket healing: an experimental
study in the dog.
→ Clin Oral Implants Res.
2010 Apr;21(4):445–54.
8.
Araújo MG, Liljenberg B, Lindhe J.
Dynamics of Bio-Oss Collagen
incorporation in fresh extraction
wounds: an experimental study in
the dog.
→ Clin Oral Implants Res.
2010 Jan;21(1):55–64.

11.
Pérez Sánchez MJ, Ramírez Glindon E,
Lledó Gil M, Calvo Guirado JL, Pérez
Sánchez C. Biomaterials for bone
regeneration.
→ Med Oral Patol Oral Cir Bucal. 2010
May;15(3):e517–22.

16.
Calvo Guirado JL, Gómez Moreno G,
Barone A, Cutando A, Alcaraz Baños M,
Chiva F, López Marí L, Guardia J.
Melatonin plus porcine bone on discrete
calcium deposit implant surface
stimulates osteointegration in dental
implants.
→ J Pineal Res.
2009 Sep;47(2):164–72.
17.
Calvo Guirado JL, Gómez Moreno G,
López Marí L, Guardia J, Marínez
González JM, Barone A, Tresguerres IF,
Paredes SD, Fuentes Breto L. Actions of
melatonin mixed with collagenized
porcine bone versus porcine bone only
on osteointegration of dental implants.
→ J Pineal Res.
2010 Apr;48(3):194–203.
18.
Tadic D, Epple M. A thorough
physicochemical characterisation of
14 calcium phosphate-based bone
substitution materials in comparison
to natural bone.
→ Biomaterials.
2004 Mar;25(6):987–94.

12.
Velasquez P, Luklinska ZB, Meseguer
Olmo L, Maté Sánchez de Val JE,
Delgado Ruiz RA, Calvo Guirado JL,
Ramírez Fernández MP, De Aza PN.
αTCP ceramic doped with dicalcium
silicate for bone regeneration
applications prepared by powder
metallurgy method: in vitro and in vivo
studies.
→ J Biomed Mater Res A.
2013 Jul;101A(7):1943–54.

19.
Maté Sánchez de Val JE, Calvo Guirado
JL, Delgado Ruiz RA, Ramírez
Fernández MP, Negri B, Abboud M,
Martínez IM, De Aza PN. Physical
properties, mechanical behavior, and
electron microscopy study of a new
α-TCP block graft with silicon in an
animal model.
→ J Biomed Mater Res A.
2012 Dec;100A(12):3446–54.

13.
Dutta-Roy T, Simon JL, Ricci JL, Rekow
ED, Thompson VP, Parsons JR.
Performance of hydroxyapatite bone
repair scaffolds created via threedimensional fabrication techniques.
→ J Biomed Mater Res A.
2003 Dec;67A(4):1228–37.

20.
Zou S, Ireland D, Brooks RA, Rushton N,
Best S. The effects of silicate ions on
human osteoblast adhesion,
proliferation, and differentiation.
→ J Biomed Mater Res B
Appl Biomater.
2009 Jul;90B(1):123–30.

14.
De Aza PN, Luklinska ZB, Maté Sánchez
de Val JE, Calvo Guirado JL.
Biodegradation process of α-tricalcium
phosphate and α-tricalcium phosphate
solid solution bioceramics in vivo: a
comparative study.
→ Microsc Microanal.
2013 Oct;19(5):1350–7.

21.
Beck GR Jr, Ha SW, Camalier CE,
Yamaguchi M, Li Y, Lee JK, Weitzmann
MN. Bioactive silica-based
nanoparticles stimulate bone-forming
osteoblasts, suppress bone-resorbing
osteoclasts, and enhance bone mineral
density in vivo.
→ Nanomedicine.
2012 Aug;8(6):793–803.

15.
Cardaropoli D, Cardaropoli G.
Preservation of the postextraction
alveolar ridge: a clinical and histologic
study.
→ Int J Periodontics Restorative Dent.
2008 Sep-Oct;28(5):469–77.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

22.
Martínez IM, Velásquez P, De Aza PN.
Synthesis and stability of α-tricalcium
phosphate doped with dicalcium
silicate in the system Ca3(PO4)2–
Ca2SiO4.
→ Mater Charact.
2010 Jul;61(7):761–7.
23.
Urbaniak GC, Plous S. Research
Randomizer [Internet-based computer
software].
→ Version 4.0.
[cited 2015 May 8]. 2013.
Available from:
http://www.randomizer.org/.
24.
El Backly RM, Zaky SH, Canciani B,
Saad MM, Eweida AM, Brun F, Tromba
G, Komlev VS, Mastrogiacomo M, Marei
MK, Cancedda R. Platelet rich plasma
enhances osteoconductive properties of
a hydroxyapatite-β-tricalcium
phosphate scaffold (Skelite) for late
healing of critical size rabbit calvarial
defects.
→ J Craniomaxillofac Surg.
2014 Jul;42(5):e70–9.
25.
Kruse A, Jung RE, Nicholls F, Zwahlen
RA, Hämmerle CHF, Weber FE. Bone
regeneration in the presence of a
synthetic hydroxyapatite/silica oxidebased and a xenogenic
hydroxyapatite-based bone substitute
material.
→ Clin Oral Implants Res.
2011 May;22(5):506–11.
26.
Fei L, Wang C, Xue Y, Lin K, Chang J,
Sun J. Osteogenic differentiation of
osteoblasts induced by calcium silicate
and calcium silicate/β-tricalcium
phosphate composite bioceramics.
→ J Biomed Mater Res B
Appl Biomater.
2012 Jul;100B(5):1237–44.
27.
Liu S, Jin F, Lin K, Lu J, Sun J, Chang J,
Dai K, Fan C. The effect of calcium
silicate on in vitro physiochemical
properties and in vivo osteogenesis,
degradability and bioactivity of porous
β-tricalcium phosphate bioceramics.
→ Biomed Mater [Internet].
2013 Apr [cited 2015 May
4];8(2):025008. doi: 10.1088/17486041/8/2/025008.

25

[26] =>

Complications after sinus floor augmentation

Complications of
postoperative swelling of the
maxillary sinus membrane
after sinus floor augmentation
Abstract
Objective

Conclusion

The aim of this article was to investigate postoperative
swelling of the maxillary sinus membrane that occurred one week after sinus ﬂoor augmentation.

A complication of this temporary swelling of the sinus
membrane was the migration of β-TCP granules toward the buccal side through the lateral window. It is
recommended that the lateral window be covered
tightly to avoid the migration of bone substitute materials in the lateral window technique.

Materials and methods

Maxillary sinus ﬂoor augmentations were performed by
the lateral window technique in 132 sites using betatricalcium phosphate (β-TCP) granules. Cone beam
computed tomography (CBCT) scans were taken before
surgery, the day of surgery, and one week, three months
and one year after surgery. The proportion of the area of
the postoperative swelling of the sinus membrane in relation to the remaining sinus cavity was determined and
classiﬁed into three types: Type 1, less than one-third;
Type 2, one-third to two-thirds; and Type 3, more than
two-thirds of the remaining sinus cavity. The sites were
divided into two groups based on the extent of lateral
window coverage: Group 1, not completely covered; and
Group 2, completely covered. The degree of migration of
the β-TCP granules was evaluated and classiﬁed into
three types: Type A, limited to the lateral window; Type
B, limited to the adjacent tooth; and Type C, extending
beyond the adjacent tooth.
Results

One week after surgery, swelling of the maxillary sinus
membrane occurred in all 132 sites (100%). The proportion of postoperative swelling was Type 1 at 24 sites
(18.2%), Type 2 at 65 sites (49.2%) and Type 3 at 43 sites
(32.6%). In Group 1, the extent of migration was Type A
at seven sites (38.9%), Type B at eight sites (44.4%) and
Type C at three sites (16.7%). In Group 2, the extent of migration was Type A at 110 sites (96.5%), Type B at one
site (0.9%) and Type C at three sites (2.6%).
26 Volume 1 | Issue 1/2015

Keywords

Sinus floor augmentation, cone beam computed tomography, swelling of the sinus membrane, biological reaction, complication.

Introduction
Conventional postoperative evaluation using
panoramic radiographs provides only 2-D information and may not be good enough to evaluate
the outcomes of sinus ﬂoor augmentation precisely. Recently, cone beam computed tomography (CBCT) was developed, and it offers the advantage of clear image quality at very low patient
radiation doses. CBCT has made it possible to
evaluate biological reactions of the augmented
area longitudinally using images taken in the
same direction. However, there remains considerable disagreement about how to reduce the
patient radiation dose from CBCT. The radiation
dose depends on the CBCT unit, exposure voltage, exposure current and imaging volume.
Okano et al. reported that the effective dose of
the 3D Accuitomo (J. Morita, Kyoto, Japan)
ranged from 18 to 66 μSv.1 According to data

Journal of
Oral Science & Rehabilitation

[27] =>

Complications after sinus floor augmentation

25 to 77 years (mean age of 53.5 years). All patients were in good health, and 24 patients
(21.4%) were smokers. The standard examination found no local or systemic contraindications
to the maxillary sinus ﬂoor augmentation. In 20
patients (15.2%), the maxillary sinus ﬂoor augmentation was performed bilaterally, and the
surgery was carried out in 132 sites in total.
All of the patients had been referred to our
clinic by their original dentists for sinus ﬂoor augmentation owing to insufﬁcient bone volume of
the posterior maxillae. Maxillary sinus ﬂoor augmentations were performed by the lateral window technique using only beta-tricalcium phosphate (β-TCP) granules (OSferion, Olympus
Terumo Biomaterials, Tokyo, Japan) over the period of March 2006 to June 2012. The surgeries
were performed by the same oral surgeon under
local anesthesia with intravenous sedation. After
the creation of the lateral window, the maxillary
sinus membrane was detached from the surface
of the maxillary sinus and elevated. The empty
compartment created by elevating the sinus
membrane was ﬁlled with β-TCP granules as the
bone substitute material.
Materials & methods
The sites were divided into two groups based
on the extent of lateral window coverage. The
Selection and
lateral window was not completely covered in
regulation of CBCT device
Group 1 and was completely covered with a titanium mesh plate and microscrews or only a reIn order to limit the radiation dose, 3D Accuitomo sorbable barrier membrane in Group 2.
was selected and an imaging volume size of
60 mm in diameter × 60 mm in length for the exCBCT evaluation
amination of maxillae was chosen. Furthermore,
the tube voltage was set at 80 kV and the tube The proportion of the area of the postoperative
current at 2 mA for 17.5 s of exposure time. In this swelling of the maxillary sinus membrane that
situation, the calculated effective dose was ap- occurred one week after surgery in relation to the
proximately 40 μSv.
remaining sinus cavity was determined and classiﬁed into three types (Fig. 1):

from Li, the effective dose from 3D Accuitomo
was 54 μSv, while that of CB MercuRay (Hitachi
Medical Systems America, Twinsburg, Ohio,
U.S.) using a panoramic ﬁeld of view was
560 μSv.2 Lofthag-Hansen et al. reported that
the calculated effective dose of 3D Accuitomo
was 52–63 μSv with a volume size of 60 mm in
diameter × 60 mm in length, tube voltage of
75 kV and tube current of 4.5–5.5 mA.3 Therefore, postoperative examination of sinus ﬂoor
augmentation using CBCT appears to be safe
when the appropriate CBCT device and parameters are selected.
We found that the maxillary sinus membrane
swelled one week after sinus ﬂoor augmentation. This previously unknown biological reaction
could not be identiﬁed on the 2-D radiographs
and has not been reported before. The aims of
this clinical study were to investigate this postoperative swelling of the maxillary sinus membrane using CBCT and to evaluate its complications. Furthermore, methods to prevent these
complications were considered.

Informed consent for CBCT scans

Type 1: Swelling of less than one-third of the remaining sinus cavity
Type 2: Swelling of one-third to two-thirds of the
remaining sinus cavity
Type 3: Swelling of more than two-thirds of the
remaining sinus cavity.

It was explained to all of the patients that the
total radiation dose of five CBCT examinations
was approximately 200 μSv and less than half
of that of old-type CBCT scans. All of the patients understood the importance of CT evaluations of the sinus floor augmentation and consented to five CBCT scans over the first year The degree of buccal migration of the β-TCP
after surgery.
granules through the lateral window was classiﬁed into three types (Fig. 2):
Patients and surgery

Type A: Limited to the lateral window
The patient population was 112 and consisted of Type B: Limited to the adjacent tooth
35 males and 77 females who ranged in age from Type C: Extending beyond the adjacent tooth.
Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[28] =>

Complications after sinus floor augmentation

Type 1

Fig. 1

Type 2

Type 3

Fig. 1
Classiﬁcation of the
postoperative swelling of the
maxillary sinus membrane that
occurred one week after the
sinus ﬂoor augmentation.
Three months after surgery,
the postoperative swelling had
disappeared spontaneously in
127 sites (96.2%).
Surg.

1 week

Results

3 months

Migration of β-TCP granules

Migration of the β-TCP granules toward the
Extent of postoperative swelling
buccal side through the lateral window was observed as a complication of the postoperative
Slight swelling of the maxillary sinus membrane, of swelling of the maxillary sinus membrane.
up to 4 mm, was observed in 21 sites (15.9%) before the surgery. One week after surgery, postop- Case 1 (52-year-old female, Group 1, Type 3,
erative swelling of the sinus membrane was ob- Type C, nonsmoker)
served in 132 sites (100%). Three months after sur- The sinus floor augmentation and the guided
gery, the swelling of the sinus membrane had bone regeneration technique were performed
disappeared spontaneously (Fig. 1) in 127 sites simultaneously, and a barrier membrane was
(96.2%).
placed without covering the lateral window
The number of sites according to the three completely (Figs. 4a–c). One week after surtypes of postoperative swelling is shown in gery, Type 3 swelling of the sinus membrane
Figure 3. In approximately 80% of the sites, the ex- was observed and some β-TCP granules at the
tent of the postoperative swelling constituted augmented area had disappeared (Fig. 4d,
more than one-third of the remaining sinus cavity: red arrows). According to the horizontal CBCT
slice images, the β-TCP granules had migrated
Type 1: 24 sites (18.2%)
toward the buccal side through the lateral winType 2: 65 sites (49.2%)
dow and moved beyond the canine (Fig. 4e,
Type 3: 43 sites (32.6%).
yellow arrows). Ten days after surgery, intraCBCT evaluation

28 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[29] =>

Complications after sinus floor augmentation

Fig. 2

Fig. 2

Surg.

Classiﬁcation of the buccal
migration of β-TCP granules
through the lateral window.

1 week

Type A

Type B

Type C

Fig. 3

Fig. 3
Incidence of the types of
postoperative swelling of the
maxillary sinus membrane
(n = 132).
Type 1
Type 2

Figs. 4a–c

Type 3

(a) The lateral window was not
completely covered by the
barrier membrane.
(b) A sagittal CBCT slice image
taken on the day of surgery.
The area to be augmented was
ﬁlled with β-TCP granules.
(c) A horizontal CBCT slice
image taken on the day of
surgery.

Figs. 4a–c

a

b

Journal of
Oral Science & Rehabilitation

c

Volume 1 | Issue 1/2015

29

[30] =>

Complications after sinus floor augmentation

d

e
Figs. 4d–i

f

g

Figs. 4d–i
(d) A sagittal CBCT slice image
taken one week after surgery.
Type 3 swelling of the
maxillary sinus membrane had
occurred. Some β-TCP
granules had disappeared
from the augmented area (red
arrows).
(e) A horizontal CBCT slice
image taken one week after
surgery. The β-TCP granules
had migrated toward the
buccal side through the lateral
window and moved beyond
the canine (yellow arrows).
(f) An intra-oral photograph
taken ten days after surgery.
The swelling at the sulcus
remained and a hard object
was palpable underneath the
gingiva.

h

i

oral swelling remained (Fig. 4f) and something
hard could be felt underneath the mucosa. As
one β-TCP granule had become exposed, the
migrated β-TCP granules and barrier membrane were removed six months after surgery
(Figs. 4g & h). One year after surgery, the
swelling of the sinus membrane remained and
the volume of the augmented area had decreased considerably compared with that on
the day of surgery (Fig. 4i).
Lateral window coverage and migration

(h) The migrated β-TCP
granules, the barrier
membrane and the
microscrews were removed.

The relationship between the degree of migration and lateral window coverage after one
week of healing is shown in Table 1. In Group 1,
β-TCP granules had migrated through the lateral window toward the buccal side in 11 sites
(61.1%), and Type C had occurred in three sites
(16.7%). In Group 2, Type A was seen in 110 sites
(96.5%), and Type C was observed in three sites
(2.6%) in spite of the full coverage of the lateral
window.

(i) A sagittal CBCT slice image
taken one year after sinus ﬂoor
augmentation.

Case 2 (70-year-old female, Group 2, Type 2,
Type C, nonsmoker)

(g) Six months after surgery, a
β-TCP granule became
exposed through the gingiva.

30 Volume 1 | Issue 1/2015

In this case, since the anterior wall of the maxillary sinus was very thin, the lateral window was
covered with two collagen membranes and the
wound was closed without a releasing incision
(Figs. 5a–d). One week after surgery, Type 2
swelling of the sinus membrane was observed
(Fig. 5e) and the β-TCP granules had migrated
toward the buccal side from all directions
(Fig. 5f, blue arrows).
Case 3 (43-year-old female, Group 2, Type 3,
Type A, nonsmoker)
The sinus floor augmentation was performed
and the lateral window was completely covered with a titanium mesh plate and fixed with
three titanium microscrews (Figs. 6a–d). One
week after surgery, Type 3 swelling of the sinus
membrane was observed and the trap door had
lifted up due to the pressure of the swelling
(Fig. 6e, yellow arrows). However, no β-TCP
granules had migrated through the lateral window (Fig. 6e), and the swelling disappeared
spontaneously three months after surgery
(Fig. 6f). One year after surgery, the titanium
mesh plate and screws were removed and the
implants were placed successfully (Fig. 6g).

Journal of
Oral Science & Rehabilitation

[31] =>

Complications after sinus floor augmentation

Table 1

Figs. 5a–f

Table 1
Group 1
Not completely covered

Group 2
Completely covered

Sites

18 sites

114 sites

Ty p e A

7 sites (38.9%)

110 sites (96.5%)

Ty p e B

8 sites (44.4%)

1 site (0.9%)

Ty p e C

3 sites (16.7%)

3 sites (2.6%)

Lateral window coverage and
migration of β-TCP granules
(n = 132).

Figs. 5a–f

(a) The area to be augmented
was ﬁlled with β-TCP
granules.
(b) The lateral window was
completely covered with two
pieces of resorbable
membrane.
(c) A sagittal CBCT slice image
taken on the day of surgery.
(d) A volume-rendered image
taken on the day of surgery.

(e) A sagittal CBCT slice image
taken one week after surgery.
Type 2 swelling of the
maxillary sinus membrane had
occurred.
(f) A volume-rendered image
taken one week after surgery.
The β-TCP granules had
migrated toward the buccal
side from all directions (blue
arrows).

The volume of the augmented area had been
retained, and a radiopaque line similar to that of
cortical bone was observed at the newly
formed floor of the maxillary sinus (Fig. 6h,
blue arrows).

Discussion
CBCT has changed the possibilities of implant
dentistry, especially in bone augmentation
techniques. Its low radiation dose makes it
possible to evaluate the augmented area longitudinally with images taken in the same direction. In this study, postoperative swelling of
the maxillary sinus membrane was evaluated
using CBCT at five stages. However, the radiation dose should be restricted even though that
of CBCT is very low. Therefore, selection of the

CBCT device and the parameters to be used was
very important to avoid the harmful inﬂuence of
radiation on the patients’ health.
The postoperative swelling of the maxillary
sinus membrane, which occurred one week after
the sinus ﬂoor augmentation, was an unknown
biological reaction. It occurred in all 132 sites and
disappeared spontaneously in 96.2% three
months after surgery. In a monkey model,4, 5 inﬂammatory cell inﬁltration was identiﬁed underneath the epithelial layer of the sinus membrane
four days after sinus ﬂoor augmentation. At 20
days after surgery, the sinus mucosa presented a
normal aspect with inﬂammatory inﬁltration of
limited size. Thus, this temporary postoperative
swelling of the sinus membrane was due to
mechanical stimulation from elevation of the
sinus membrane during sinus floor augmentation. Almost all of the patients reported no

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[32] =>

Complications after sinus floor augmentation

Figs. 6a–h

Figs. 6a–h
(a) A coronal CBCT slice image
taken before surgery.
(b) The area to be augmented
was ﬁlled with β-TCP
granules.
(c) A titanium mesh plate was
placed over the lateral window
and ﬁxed with three
microscrews.
(d) A coronal CBCT slice image
taken on the day of surgery.
(e) A coronal CBCT slice image
taken one week after surgery.
Type 3 swelling of the
maxillary sinus membrane had
occurred and the trap door had
become dislocated (yellow
arrows). However, the buccal
migration of the β-TCP
granules did not occur owing
to the rigid coverage of the
lateral window with the
titanium mesh plate and
screws.
(f) A coronal CBCT slice image
taken three months after
surgery. The postoperative
swelling of the maxillary sinus
membrane had disappeared
spontaneously and the trap
door returned to its original
position.
(g) One year after surgery, the
titanium mesh plate and
screws were removed. The
remaining β-TCP granules
were observed at the lateral
window and embedded in the
newly formed bone. Four
implants were placed
successfully.
(h) A coronal CBCT slice image
taken after placement of the
implants. A radiopaque line
similar to that of cortical bone
was observed at the newly
formed ﬂoor of the maxillary
sinus (blue arrows).

symptoms concerning the postoperative swelling
of the sinus membrane, and we had not previously observed this phenomenon.
In approximately 80% of the 132 sites, the
extent of the postoperative swelling constituted
more than one-third of the remaining maxillary
sinus cavity. As shown in Figure 1, even if the size
of the augmented area was almost the same, the
extent of the swelling was different. These results suggest that the extent of the postoperative swelling did not depend on the area of the detachment, and it was difficult to predict the
extent of swelling before surgery.
32 Volume 1 | Issue 1/2015

A complication of this postoperative swelling of
the sinus membrane was migration of the β-TCP
granules. This migration was brought about by
the pressure of swelling and the direction of
pressure was difﬁcult to determine. When the
pressure was toward the lateral window, the
β-TCP granules migrated toward the buccal side
of the alveolar bone through the lateral window.
This migration of the granules led to the loss of
β-TCP granules at the augmented area and resulted in unexpected poor bone formation as in
Case 1. Therefore, bone substitute materials
such as β-TCP granules act as a space maker for

Journal of
Oral Science & Rehabilitation

[33] =>

Complications after sinus floor augmentation

bone augmentation in sinus ﬂoor elevation. Ahn
et al. reported that little to no new bone formation was observed at the augmented area six
months after sinus ﬂoor augmentation using
blood-soaked collagen sponges as a space
maker.6 Scala et al. concluded that the void initially occupied by the coagulum after sinus
membrane elevation shrank substantially
during the observation period.4, 5 Furthermore,
Schweikert et al. reported the function of a titanium device as a space maintainer in sinus ﬂoor
augmentation in monkeys.7 They concluded that
shrinkage of the newly formed tissue was observed and the space-maintaining function of
the device was in doubt. The current study
found that the postoperative swelling of the
sinus membrane occurred in 100% sites and
the pressure of swelling was strong enough to
migrate the β-TCP granules toward the buccal
side. Therefore, blood-soaked collagen sponges
or clots would have collapsed under the pressure of postoperative swelling of the sinus
membrane.
The migration of bone substitute materials
posed the risk of wound dehiscence and infection. In Case 2, the buccal migration of the
β-TCP granules occurred even though the lateral window had been covered with two collagen membranes. When the postoperative
swelling was Type 2 or 3, the pressure of the
swelling was sufficiently strong to push the
membranes out of the lateral window. Therefore, we now cover the lateral window with a titanium mesh plate and screws, as was done in

Case 3. In the lateral window technique, it is
recommended that the lateral window be covered tightly to avoid the migration of bone substitute materials through the lateral window.

Conclusion
One week after sinus ﬂoor augmentation, postoperative swelling of the maxillary sinus membrane occurred in all 132 sites. The swelling
brought about the migration of the bone substitute materials. Furthermore, the migration of the
β-TCP granules caused loss of volume at the
augmented area and wound dehiscence. In order
to avoid the migration of bone substitute materials, the lateral window should be covered tightly
with a titanium mesh plate and screws for safety
in the lateral window technique for sinus ﬂoor
augmentation.

Yasuhiro Nosaka,*
Hitomi Nosaka*
& Yoshinori Arai†
*

Nosaka Oral Surgery Clinic,
Ashiya, Japan
†
School of Dentistry, Nihon
University, Tokyo, Japan

Competing interests
The authors declare that they have no competing interests.

Corresponding author:

Acknowledgments

Yasuhiro Nosaka
Nosaka Oral Surgery Clinic
2F Chambre-Ashiya
11-17, Nishiyama-cho
Ashiya, Hyōgo
659-0083
Japan

Some photographs of Cases 1–3 were excerpted from Nosaka Y. Sinus floor elevation:
avoiding pitfalls using cone-beam CT. Quintessence Publishing; 2010.

T +81 797 25 0545
F +81 797 25 0546
nosasen@aol.com

References
1.
Okano T, Harata Y, Sugihara Y,
Sakaino R, Tsuchida R, Iwai K, Seki K,
Araki K. Absorbed and effective
doses from cone beam volumetric
imaging for implant planning.
→ Dentomaxillofac Radiol.
2009 Feb;38(2):79–85.
2.
Li G. Patient radiation dose and
protection from cone-beam
computed tomography.
→ Imaging Sci Dent.
2013 Jun;43(2):63–69.

3.
Lofthag-Hansen S, Thilander-Klang
A, Ekestubbe A, Helmrot E, Gröndahl
K. Calculating effective dose on a
cone beam computed tomography
device: 3D Accuitomo and 3D
Accuitomo FPD.
→ Dentomaxillofac Radiol.
2008 Feb;37(2):72–9.
4.
Scala A, Botticelli D, Rangel IG Jr, De
Oliveira JA, Okamoto R, Lang NP.
Early healing after elevation of the
maxillary sinus ﬂoor applying a
lateral access: a histological study in
monkeys.
→ Clin Oral Implants Res.
2010 Dec;21(12):1320–6.

5.
Scala A, Botticelli D, Faeda RS,
Rangel IG Jr, De Oliveira JA, Lang NP.
Lack of inﬂuence of the Schneiderian
membrane in forming new bone
apical to implants simultaneously
installed with sinus ﬂoor elevation:
an experimental study in monkeys.
→ Clin Oral Implants Res.
2012 Feb;23(2):175–81.

7.
Schweikert M, Botticelli D, De
Oliveira JA, Scala A, Salata LA, Lang
NP. Use of a titanium device in lateral
sinus ﬂoor elevation: an experimental
study in monkeys.
→ Clin Oral Implants Res.
2012 Jan;23(1):100–5.

6.
Ahn JJ, Cho SA, Byrne G, Kim JH,
Shin HI. New bone formation
following sinus membrane elevation
without bone grafting: histologic
ﬁndings in humans.
→ Int J Oral Maxillofac Implants.
2011 Jan-Feb;26(1):83–90.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[34] =>

Epstein–Barr virus and periimplantitis

The prevalence and quantitative
analysis of the Epstein–Barr virus
in healthy implants and implants
affected by periimplantitis:
A preliminary report
Abstract

Introduction

Objective

Periimplantitis can be deﬁned as an inﬂammatory process of the periimplant soft and hard tissue with or without primary infection, associated
with clinically signiﬁcant, progressing crestal
bone loss after the adaptive phase after prosthetic loading.1 Numerous studies have analyzed
the bacterial ﬂora associated with diseased implants to possibly understand the role played by
the bacterial infection in the genesis of periimplantitis.2, 3 This research underlines a similar
microbial proﬁle between periimplantitis and
periodontitis, with high numbers of periodontal
pathogens in periimplant sites (Porphyromonas
gingivalis, Prevotella intermedia, Prevotella nigrescens and Aggregatibacter actinomycetemcomitans) conﬁrming data previously reported
by Leonhardt et al.4
Viruses, in particular the Epstein–Barr virus
(EBV) and other herpesviruses, appear to play a
role in the genesis and progression of human periodontitis.5 Viruses infect periodontal B lymphocytes6 exerting diminished ability to defend
against bacterial challenge and permitting the
overgrowth of periodontopathic microorganisms.
Besides in periodontitis, recent studies have
shown a correlation between periimplant infection and the presence of EBV. Jankovic et al.
found a high prevalence of Human cytomegalovirus (HCMV) and EBV DNA in the subgingival
plaque of periimplantitis sites, suggesting a possible active pathogenic role in periimplantitis.7
They showed a higher prevalence of EBV and
HCMV in periimplantitis sites compared with
healthy periimplant sites. In a split-mouth study,
Verdugo et al. suggested that EBV may be a
likely candidate in the etiopathogenesis of periimplant disease and that periimplantitis etiopathogenesis could be orchestrated and fueled

Viruses, in particular the Epstein–Barr virus (EBV), appear to
play a role in the genesis and progression of human periodontitis and periimplantitis. The aim of the present study was to
compare the presence of EBV in healthy periimplant sites or
those affected by periimplantitis.
Materials and methods

From January 2013 to December 2014, 50 consecutive subjects
with implants affected by periimplantitis and 50 subjects with
healthy implants attending for a routine check-up or spontaneous visits during the study period in three private clinics
(Rome and Genoa, Italy, and Belgrade, Serbia) were enrolled in
this clinical study.
Quantitative real-time polymerase chain reaction assays
for EBV were performed on every patient. The internal connections and external surfaces of the implants were evaluated. Independent sample t-tests or nonparametric Mann–Whitney
U tests were performed to check for any statistically signiﬁcant
difference in each continuous variable between the two groups of
patients (healthy vs. periimplantitis).
Results

Eighty-three patients (40 with healthy implants and 43 with
periimplantitis-affected implants) concluded the study. The
study evaluated 103 dental implants affected by periimplantitis
and 197 healthy implants (mean time of loading: 5.31 ± 2.6 years).
Although 28.6% of the healthy patients and 37.2% of the patients
affected by periimplantitis presented at least one site with EBV,
the differences were not statistically signiﬁcant (p > 0.05).
Conclusion

This study did not find a clear link between periimplantitis
etiopathogenesis and viral infection.
34 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[35] =>

Epstein–Barr virus and periimplantitis

by a combination of EBV and Gram-negative vided mailing envelopes. The internal connecanaerobic rods.8 The aim of the present study is tions and external surfaces of the implants were
to compare the presence of EBV in periimplanti- evaluated.
tis-affected and healthy periimplant sites.
Quantitative real-time
polymerase chain reaction

Materials & methods

assays for the Epstein–Barr virus

From January 2013 to December 2014, 50 consecutive subjects with implants affected by periimplantitis and 50 subjects with healthy implants attending for a routine check-up or spontaneous visits during the study period in three
private clinics (Rome and Genoa, Italy, and Belgrade, Serbia) were enrolled in this clinical study.
The inclusion criteria were systemically
healthy nonsmoker subjects treated with at least
one implant that had been functioning for at least
one year. Patients were periodontally healthy
and had not taken any systemic antibiotics, antiinﬂammatory drugs or oral antimicrobial agents
within the preceding six months.
Periimplantitis is commonly deﬁned as reported by the Estepona consensus meeting: an
infection with suppuration associated with clinically signiﬁcant progressing crestal bone loss after the adaptive phase.1 However, in the present
study, to ﬁnd a clinically feasible threshold, according to Renvert et al., periimplantitis was deﬁned when an implant presented radiographic
presence of bone loss of > 3 mm after implant integration, with a pocket probing depth of ≥ 4 mm,
bleeding on probing and/or suppuration.9
This human case–control study was conducted in accordance with the Declaration of
Helsinki and all subjects provided written informed consent prior to their entry into the study.
It conformed with the Strengthening the Reporting of Observational Studies in Epidemiology
guidelines.10
All clinical examinations were performed by
the same operators (LC, PP and MR) and subgingival plaque samples were collected with the
GUIDOR Perio-Implant Diagnostic Kit (Sunstar
Iberia, Barcelona, Spain). The sampling kit is intended for the collection and transport of samples containing periodontal and periimplant
pathogens. Brieﬂy, prior to subgingival plaque
sampling, each tooth was isolated with cotton
rolls. Absorbent paper points were inserted into
the periodontal pockets. After 15s, these paper
points were removed and placed into a 2 ml tube.
The tubes containing the sample were sent to the
Institut Clinident laboratory (France) in the pro-

Quantitative real-time polymerase chain reaction (PCR) assays were performed to detect the
presence or absence of and quantify EBV DNA in
the paper points. First, total DNA was isolated
using the QIAxtractor DNA Plasticware and QIAxtractor DX Reagents (Qiagen, Hilden, Germany) according to the manufacturer’s guidelines. Then, real-time PCR was carried out for
EBV using the Epstein-Barr virus quantitative
Real Time PCR kit (Diagenode, Liège, Belgium)
and the Rotor-Gene Q thermal cycling system
(Qiagen, Hilden, Germany).
Brieﬂy, quantitative real-time PCR assays
were performed in a volume of 25 μl, composed
of 12.5 μl of MasterMix Optima Multiplex 2X
DNA, 2.5 μl of EBV primers and double-dye probe
(FAM, emission 520 nm), 2.5 μl of internal control DNA, 2.5 μl of internal control primers
and double-dye probe (Yellow Dye, emission
548 nm), and 5 μl of DNA extract or EBV-positive
control or EBV-negative control or DNA Standard (for quantitative standard curve; all products by Diagenode, Liège, Belgium). Five EBV
DNA dilutions were used for the standard curve
(from 200 copies to 2,000,000 copies of EBV
amplicon/PCR reaction).
Assays were carried out on the Rotor-Gene
Q thermal cycling system with the following
program: 50 °C for 2 min, 95 °C for 10 min, followed by 45 cycles of 15 s at 95 °C, and 60 s at
60 °C. Fluorescence signals (FAM, emission
520 nm; Yellow Dye, emission 548 nm) were
measured every cycle at the end of the extension step. The resulting data were analyzed using Rotor-Gene Q Series Software (Qiagen,
Hilden, Germany).
Statistical methods

Normality of variables was assessed by graphical methods (mean of histograms) and conﬁrmed by the Shapiro–Wilk normality test and
the Levene test of homogeneity of variance. All
characteristics were summarized using mean
(standard deviation) median (range) or frequencies (percentages).

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

35

[36] =>

Epstein–Barr virus and periimplantitis

Table 1

N (%)

Mean ± S.D.

Median [min.–max.]

Number of implants assessed per subject

3.5 ± 2.2

3.0 [1.0–13.0]

Number of EBV-positive implants

0.8 ± 1.4

0.0 [0.0–6.0]

Positivity %

25.1 ± 39.5

0.0 [0.0–100.0]

2941.7 ± 4433.1

100.0 [100.0–9450.0]

396643.8 ± 144106
8.4

100.0
[100.0–6840000.0]

Healthy

42 (49.4)

Periimplantitis

43 (50.6)

Group

EBV-positive internal surfaces

Table 1

6 (7.1)

Internal surfaces, EBV copies
(highest value recorded)

Clinical characteristics
of the sample.

EBV-positive external surfaces

Table 2

25 (29.4)

External surfaces, EBV copies
(highest value recorded)

Differences between the
two groups of patients.

Healthy

Number of implants assessed per subject

Mean ± S.D

Median
[min.–max.]

4.7 ± 1.8

5.0 [2.0–9.0]

Yes
No

Subjects with
EBV-positive implants

Periimplantitis
N (%)

Mean ± S.D.

Median
[min.–max.]

2.4 ± 2.0

2.0 [1.0–13.0]

30 (71.4)
12 (28.6)

P-value
N (%)

0.001*
27 (62.8)
16 (37.2)

0.54

Number of EBV-positive implants

1.0 ± 1.7

0.0 [0.0–6.0]

0.6 ± 0.9

0.0 [0.0–4.0]

0.21

Positivity %

21.9 ± 37.7

0.0 [0.0–100.0]

28.3 ± 41.4

0.0 [0.0–100.0]

0.46

EBV-negative internal surfaces

39 (92.9)

40 (93.0)
1.00

EBV-positive internal surfaces

3 (7.1)

Internal surfaces, EBV copies
(highest value recorded)

3216.7 ± 53
98.2

100.0
[100.0–9450.0]

EBV-negative external surfaces

3 (7.0)
2666.7 ±
4445.6

100.0
[100.0–7800.0]

30 (71.4)

1.00

30 (69.8)
1.00

EBV-positive external surfaces

12 (28.6)

External surfaces, EBV copies
(highest value recorded)
*

805152.8 ±
2044335.3

2600.0
[100.0–6840000.0]

13 (30.2)
19558.5 ±
37449.4

A p-value of ≤ 0.05 was considered statistically signiﬁcant.

36 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

100.0
[100.0–109200.0]

0.69

Table 2

[37] =>

Epstein–Barr virus and periimplantitis

Fig. 1

Independent sample t-tests or nonparametric
Mann–Whitney U tests were performed to
check for any statistically signiﬁcant difference
in each continuous variable between the two
groups of patients (healthy vs. periimplantitis).
Chi-squared tests or Fisher exact tests were
used to assess whether a statistically signiﬁcant
change in proportions occurred in categorical
variables between the two groups of patients in
the same population.
All the analyses were computed using IBM
SPSS Statistics software (Version 20.0; IBM
Corp., Armonk, N.Y., U.S.). A p-value of ≤ 0.05
was considered statistically signiﬁcant.

Results
At the end of the study, the total population
consisted of 83 subjects (44 females, 39
males; mean age: 59.5 ± 11.3 years). Twentyfour females and 19 males were reported in the
group with periimplantitis, and 20 females and
20 males were reported in the healthy patients.
Seven patients belonging to the periimplantitis
group and ten to the healthy group refused to
undergo the microbiological analysis and for
this reason were excluded from the studied
sample.

Fig. 2

The study evaluated 103 dental implants affected by periimplantitis and 197 healthy implants (mean time of loading: 5.31 ± 2.6 years).
Clinical characteristics are shown in Table 1. In
Table 2, all of the differences between the two
groups of patients are expressed.
A statistically signiﬁcant difference (p< 0.001)
between the two groups (Fig. 1) was observed
in the total number of implants assessed per
patient, with a higher number in the healthy
subjects (4.7 ± 1.8) compared with patients
with periimplantitis (2.4 ± 2.0). For the other
evaluated variables, no statistically significant
difference was detected (p > 0.05; Table 2).
EBV was present in 12 patients (Fig. 2) in the
healthy group (28.6%) and in 16 patients in the
periimplantitis group (37.2%). Of the implants
affected by periimplantitis, 28.3% were positive for EBV, as were 21.9% of the healthy implants (Table 2). However, the differences between the two groups were not statistically
significant. The highest and the median values
recorded for EBV were higher among the
healthy subjects in both the internal and the external implant sites. Figures 3 and 4 show the
distribution of EBV in the internal and external
implant sites with lower contamination by EBV
in the internal implant connections with respect to the gingival sulci.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

Fig. 1
Difference in the number of
implants assessed between
healthy patients and patients
with periimplantitis.

Fig. 2
Subjects with EBV-positive
implants in the two groups.

[38] =>

Epstein–Barr virus and periimplantitis

Fig. 3

Discussion
Fig. 3
Distribution of EBV in internal
sites in both groups.

Fig. 4
Distribution of EBV in external
sites in both groups.

Periimplantitis is one of the most controversial
problems affecting the outcome of implant
treatment. Different hypotheses have been
proposed about its etiology and definition—
even if the term “periimplantitis” appears to
have been improperly used to describe any
periimplant bone loss, irrespective of the complexity of the numerous factors that may contribute to
loss of marginal bone around implants.11
Various authors have put forward the hypothesis that periimplantitis could be associated
with EBV or HCMV. These viruses have been
suggested to alter the local host immune response in combination with periodontopathic
bacteria, with the potential to lead to periodontal and periimplant tissue destruction.7
In fact, it is well known that the great majority of the human population (more than 90%)
are infected with EBV. This particular virus establishes specific communication with the
host, changing the expression of its own genes
in different cell types, depending on its differential status. During primary infection, EBV initially infects oral epithelial cells in the lytic form
and subsequently infects B cells, where the
virus assumes one of three different types of
latency lifelong. Occasionally, the latent infection reactivates and changes into lytic infection. The differentiation of memory B cells with
the EBV genome into plasma cells after antigen
stimulation activates the lytic EBV infection.
The reactivation most commonly occurs in tonsillar plasma cells, as well as in tonsillar B cells.
This is one of the reasons that the saliva from
immunocompromised but also immunocom38 Volume 1 | Issue 1/2015

Fig. 4

petent persons often contains infectious EBV,
with or without any signs of infection. EBV can
change the immune response of the host with
a speciﬁc inﬂuence on the immunopathogeneses of infection. The cytokines secreted
during EBV infection can inﬂuence local immunopathology.
The results of the present study rejected the
hypothesis that periimplantitis could be associated with EBV; in fact, no statistically signiﬁcant
differences were found regarding the presence
of EBV in healthy or periimplantitis-affected
sites (28.6% of the healthy patients and 37.2% of
the periimplantitis-affected patients presented
at least one site with EBV).
This is in contrast to previous studies, in
which a signiﬁcantly higher presence of EBV
was found in subgingival samples from periimplantitis lesions than from healthy periimplant
sites. In fact, both Jankovic et al. and Verdugo et
al. found a signiﬁcantly higher presence of EBV in
the periimplantitis-affected sites.7, 8
The absence of signiﬁcant differences between the groups could lead to the rejection of
the hypothesis of the pathogenic key mechanism
of viruses in the incidence of periimplantitis.
However, this could be because the present
study had a retrospective design. This limitation
could jeopardize the detection of EBV, which is
thought to activate immunological response
only in the early stage of disease.12 This could be
indirectly conﬁrmed by the fact that most parts
of the sites in the periimplantitis group were under the limit of quantiﬁcation. At the same time,
interactions between EBV and herpesviruses
could be supposed to have an effect on the host
response.7

Journal of
Oral Science & Rehabilitation

[39] =>

Epstein–Barr virus and periimplantitis

Various authors have proposed that microbiological contamination of the internal implant connection indicates bacterial leakage
along the implant–abutment interface, abutment–prosthesis interface, and restorative
margins.13, 14 The results of the present study
confirm viral leakage with the presence of EBV
in the implant connection, even if with a lower
detection frequency with respect to the periimplant sulci. Three periimplantitis-affected
implants and three healthy implants presented
with EBV with no statistically significant differences between the two groups. That slightly
less of the virus was found in patients with
periimplantitis-affected sites compared with
healthy sites may indicate that the intensive local immune response in the case of periimplantitis reduces the amount of virus. However, in four sites, the virus was only found in
the periimplant sulci. This could confirm the
impressive turnover and interaction between
bacteria and viruses, which could only be supposed in a retrospective study with one time
point such as the present one. This particular
interaction is likely mediated by cytokines produced during viral and bacterial infections.
Tumor necrosis factor α, interleukin 1 and interleukin 6 have a great impact on the pathogenesis of periimplantitis. In this paper, we focused
our attention on virus detection only and
maybe this is the most important limitation of
the study. For this reason, an observational
prospective study focused also on bacteria
could clarify the interactions between these
microbiota and maybe the microbiological scenario of periimplantitis.

Conclusion
Within the limits of the present study, no statistically signiﬁcant differences were found regarding the presence of EBV in healthy or periimplantitis-affected sites. This study failed to ﬁnd a link
between periimplantitis etiopathogenesis and
viral infection.

Competing interests
The authors declare that they have no conﬂict of
interests related to this study. The study was partially supported by Institute Clinident (Aix-enProvence, France), which provided technical
support, and Sweden & Martina (Padua, Italy),
which provided diagnostic test kits.

Acknowledgments
The authors wish to acknowledge the skills and
commitment of Dr. Audrenn Gautier in the supervision of the study.

Luigi Canullo,†
Paolo Pesce,‡
Nathalie Pailler,§
Matteo Simonetti,‡
Mia Rakic,**
Tanja Jovanovic††

Corresponding author:

†

Private practice in Rome, Italy, and Istituto
Stomatologico Toscano, Viareggio, Italy

T + 39 347 620 1976
F + 39 06 841 1980
luigicanullo@yahoo.com

‡

Department of surgical and diagnostic
sciences, University of Genoa, Italy

Institut Clinident, Aix-en-Provence, France

Institute for Biological Research “Siniša
Stanković,” University of Belgrade, Serbia

Dr. Luigi Canullo
Via Nizza 46
00198 Rome
Italy

††

Institute for Microbiology and Immunology,
School of Medicine, University of Belgrade,
Serbia

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[40] =>

Epstein–Barr virus and periimplantitis

References
1.
Albrektsson T, Buser D, Chen ST,
Cochran D, De Bruyn H, Jemt T, Koka
S, Nevins M, Sennerby L, Simion M,
Taylor TD, Wennerberg A.
Statements from the Estepona
consensus meeting on periimplantitis, February 2–4, 2012.
→ Clin Implant Dent Relat Res.
2012 Dec;14(6):781–2.
2.
Leonhardt Å, Dahlén G, Renvert S.
Five-year clinical, microbiological,
and radiological outcome following
treatment of peri-implantitis in man.
→ J Periodontol.
2003 Oct;74(10):1415–22.
3.
Shibli JA, Melo L, Ferrari DS,
Figueiredo LC, Faveri M, Feres M.
Composition of supra- and
subgingival bioﬁlms of subjects with
healthy and diseased implants.
→ Clin Oral Implants Res.
2008 Oct;19(10):975–82.
4.
Leonhardt Å, Renvert S, Dahlén G.
Microbial ﬁndings at failing implants.
→ Clin Oral Implants Res.
1999 Oct;10(5):339–45.

6.
Kato A, Imai K, Ochiai K, Ogata Y.
Prevalence and quantitative analysis
of Epstein–Barr virus DNA and
Porphyromonas gingivalis associated
with Japanese chronic periodontitis
patients.
→ Clin Oral Investig.
Epub 2014 Dec 18.
7.
Jankovic S, Aleksic Z, Dimitrijevic B,
Lekovic V, Camargo P, Kenney B.
Prevalence of human
cytomegalovirus and Epstein-Barr
virus in subgingival plaque at periimplantitis, mucositis and healthy
sites. A pilot study.
→ Int J Oral Maxillofac Surg.
2011 Mar;40(3):271–6.
8.
Verdugo F, Castillo A, Castillo F,
Uribarri A. Epstein–Barr virus
associated peri-implantitis: a splitmouth study.
→ Clin Oral Investig.
2015 Mar;19(2):535–43.
Epub 2014 May 7.

9.
Renvert S, Roos-Jansåker AM,
Lindahl C, Renvert H, Persson RG.
Infection at titanium implants with or
without a clinical diagnosis of
inﬂammation.
→ Clin Oral Implants Res.
2007 Aug;18(4):509–16.
10.
Von Elm E, Altman DG, Egger M,
Pocock SJ, Gøtzsche PC,
Vandenbroucke JP. The
Strengthening the Reporting of
Observational Studies in
Epidemiology (STROBE) statement:
guidelines for reporting observational
studies.
→ J Clin Epidemiol.
2008 Apr;61(4):344–9.
11.
Pesce P, Menini M, Tealdo T,
Bevilacqua M, Pera F, Pera P. Periimplantitis: a systematic review of
recently published papers.
→ Int J Prosthodont.
2014 Jan-Feb;27(1):15–25.
12.
Niller HH, Szenthe K, Minarovits J.
Epstein–Barr virus–host cell
interactions: an epigenetic dialog?
→ Front Genet [Internet].
2014 Oct 21 [cited 2015 Jun 22];
5: 367. Available from:
http://journal.frontiersin.org/article/1
0.3389/fgene.2014.00367/full.

5.
Slots J. Herpesviruses in periodontal
diseases.
→ Periodontol 2000.
2005 Jun;38(1):33–62.

40 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

13.
Canullo L, Penarrocha-Oltra D,
Soldini C, Mazzocco F, Penarrocha M,
Covani U. Microbiological
assessment of the implant-abutment
interface in different connections:
cross-sectional study after 5 years of
functional loading.
→ Clin Oral Implants Res.
2015 Apr;26(4):426–434.
Epub 2014 Mar 26.
14.
Cosyn J, Van Aelst L, Collaert B,
Persson GR, De Bruyn H. The periimplant sulcus compared with
internal implant and suprastructure
components: a microbiological
analysis.
→ Clin Implant Dent Relat Res.
2011 Dec;13(4):286–95.

[41] =>

/ŶƚĞƌĐŽŶƟŶĞŶƚĂů,ŽƚĞů&ĞƐƟǀĂůŝƚǇͮƵďĂŝh

Call for Abstracts - Now Open!
Abstracts may be submitted via internet using
online submission module – www.wioc2015.com
Abstracts should be prepared in English.
Maximum 2 oral presentations and max. 2 poster
presentations by the same presenting author will
be accepted for presentation at the Conference
Accepted abstracts will be published on the
conference website
For all enquiries regarding abstracts:
please contact wioc2015@mci-group.com

Important Dates www.wioc2015.com
Conference Dates: 10 - 13 November 2015
Abstract Submission Deadline: 1 September 2015
$EVWUDFW1RWL²FDWLRQRI$FFHSWDQFH30 September 2015
Organized by:

Official Designation Partner

Conference Secretariat: MCI Middle East – Tel: +971 4 311 6300, Fax: +971 4 311 6301, Email: wioc2015@mci-group.com

[42] =>

Osteopontin expression in anorganic bovine bone

Immunohistochemical
osteopontin expression in bone
xenograft in clinical series of
maxillary sinus lift
Abstract

Introduction

Objective

Osteopontin (OPN) human gene contains seven
exons, spans ∼11.1 kb, and maps to the long arm
of chromosome 4 (4q13).1, 2 OPN is expressed by
a single-copy gene as a ∼34 kDa3 nascent protein that is extensively modified by posttranslational events; it is secreted as a noncollagenous acidic bone matrix of single-chain
phosphoglycoproteins with diverse functions,
including cell-binding activity4 and angiogenesis.5 OPN has calcium-binding properties and is
expressed by cells in a wide variety of tissues, including bone, tooth and cartilage, and in activated macrophages and lymphocytes.6
Data are available on the structure, location
and properties of OPN, but the biological function of this protein in bone remains uncertain.
OPN inﬂuences bone homeostasis by different
mechanisms. This polypeptide chain undergoes
extensive post-translational modiﬁcations, including glycosylation, phosphorylation and sulfation, and the precise modiﬁcation pattern depends on the species and tissues in which the
protein is synthesized.7 The functional signiﬁcance of post-translational modiﬁcations in OPN
is poorly understood.
Bone remodeling is a regulated process in
which removal via osteoclasts is followed by
bone formation via osteoblasts.8 The presence of
OPN has traditionally been interpreted as an indicator of bone formation. In bone, OPN is produced by osteoblastic cells at various stages of
differentiation,9 including differentiated osteoblasts, and by osteocytes.10, 11 The protein is primarily made by cells of osteoblastic lineage, and
it is also expressed by ﬁbroblastic cells in embryonic stroma12 and at wound-healing sites.13 OPN
is found in situ in osteoblasts and accumulates in
mineralized bone matrix during endochondral

The objectives of this study were to examine osteopontin (OPN)
expression in bone and anorganic bovine bone (ABB) in maxillary sinus grafts after six months of healing and to study its relationship to morphological and immunohistochemical results
and to patient variables and habits.
Materials and methods

Forty maxillary sinus lift procedures were performed in 40 consecutive patients. Bone cores were obtained from implant receptor sites at implant placement for histological, morphometric and immunohistochemical studies.
Results

Histomorphometric analysis found 32.75 ± 14.0% vital bone,
39.49 ± 17.4% connective tissue, and 27.75 ± 21.8% remnant ABB
particles. OPN expression was diffuse in 77.5% (31/40) of ABB
samples and focal in 22.5% (9/40); it was diffuse in 80% (8/10) of
pristine bone samples and focal in 20% (2/10). OPN immunostaining of ABB particles was intense in 45% of maxillary sinus lift
biopsies, moderate in 27.5%, mild in 10%, and absent in 17.5%.
OPN expression was mainly detected at the interstitial boundary
of bone with ABB particles and within osteocyte lacunae and bone
canaliculi.
Conclusion

Immunohistochemical expression of OPN is related to bone
remodeling and maturation changes in maxillary sinus lift procedures with ABB xenograft.
Keywords

Anorganic bovine bone, bone remodeling, intrasinus graft, immunohistochemistry, osteopontin.
42 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[43] =>

Osteopontin expression in anorganic bovine bone

and intramembranous ossiﬁcation.14 It has also
been reported to enhance osteoblastic differentiation and proliferation and increase alkaline
phosphatase activity.15 Increased OPN expression at injury or infection sites likely results from
the release of growth factors (e.g., platelet-derived growth factor) or cytokines (e.g., interleukin1) that activate different transcription factors, such as Fos and Jun, which are capable of
upregulating OPN transcription.16
Hence, besides promoting bone formation,
OPN has been implicated in bone resorption.17
Various mechanisms have been proposed to underlie this biological function. Phosphorylation
of OPN appears necessary for the inhibition of
biological crystal formation and for the formation of calcium carbonate crystals.7 OPN is a potent inhibitor of the mineralization process, because it is binding to hydroxyapatite (HA), inhibits the formation of HA crystals18 and the
growth of HA crystals,19 and promotes the inhibition of bone mineralization.20 OPN plays an important role in osteoclastogenesis and osteoclast activity. Its expression is upregulated
during the maturation of monocytes into
macrophages,21 a process that presumably occurs as circulating monocytes extravasate and
migrate through the tissue.16 Parathyroid hormone-induced RANKL signaling normally augments the number and activation of osteoclasts,
but this increase is disrupted in the absence of
OPN.22 The neutralization of OPN suppresses osteoclastogenesis in vitro, whereas its addition
enhances osteoclastogenesis in OPN-/- cells.23
However, Chellaiah et al. reported an increase in
the number of osteoclasts in OPN-/- mice as a
compensatory mechanism for the decreased activity of OPN-/- osteoclasts, because OPN-deﬁcient osteoclasts do not migrate and are unable
to resorb bone.24, 25 Hence, bone-resorbing activity could only partially be restored by exogenous
OPN,24 indicating that autocrine OPN is important for osteoclast activity.26
Anorganic bovine bone (ABB) is a deproteinized, sterilized bovine cancellous bone comprising calcium-deﬁcient carbonate apatite.27
ABB is frequently utilized as a bone substitute in
maxillary sinus lift procedures when insufﬁcient
autogenous cortical bone (ACB) is available for
the graft.28 ABB particles are similar to human
cancellous bone in crystalline and morphological
structure.29 They are natural, osteoconductive
bone substitutes that promote bone growth in
periodontal and maxillofacial osseous defects.

The particles provide a scaffold and a matrix for
bone cell migration and are integrated into the
natural physiological remodeling process. It has
been suggested that deproteinized cancellous
bovine bone can induce new bone formation
through osteoinductive mechanisms.30 It has
also been reported that the application of ABB in
a collagenous matrix induces the formation of
membranous and endochondral bone in vivo and
that ABB exerts high angiogenic activity.31 In previous studies, however, no OPN was detected in
bovine bone slices, and no staining was observed
in osteocytes, blood vessels, cement lines or typical sites of OPN expression.32 In an animal study,
Araújo et al. described OPN expression in ABB
particles during early healing of the post-extraction socket.13 Our group described a similar phenomenon in humans during late healing after
sinus grafting, observing OPN expression not
only in the ABB particles, but also within their
canalicular system. These observations differ
from previous ﬁndings in ultrastructural studies
in a rat model that suggested that OPN accumulated at the mineral front and was progressively
incorporated deeper into the bone, but by the further deposition of new bone matrix.33
The objectives of this study were to examine
OPN expression in bone and ABB in maxillary
sinus grafts after six months of healing and to
study its relationship to morphological and immunohistochemical results and to patient variables and habits.

Materials & methods
Study design and subject recruitment

This clinical case series was reviewed and approved by the institutional review board of the
University of Granada Faculty of Dentistry
(Spain) prior to subject recruitment. The study
was conducted according to the principles of the
Declaration of Helsinki for experimentation with
human subjects.34
Totally or partially edentulous patients needing a sinus lift were screened and included in the
study if they met the following inclusion criteria:
age between 18 and 85 years, Physical Status I or
II according to the American Society of Anesthesiologists,35 absence of uncontrolled systemic
disease or a condition known to alter bone metabolism (e.g., osteoporosis or diabetes mellitus),
O’Leary plaque score of ≤ 20%,36 and ≤ 5 mm of

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

43

[44] =>

Osteopontin expression in anorganic bovine bone

remaining bone height from measurement on a
panoramic radiograph.37, 38 Exclusion criteria
were the following: antibiotic intake in the previous three months, prescription for more than six
months of medications known to modify bone
metabolism (e.g., bisphosphonates or corticosteroids), pregnancy or intention to become pregnant at the time of the screening, the presence of
an untreated chronic sinus condition (e.g., cyst or
tumor) or sepsis, a history of cancer or radiation
to the oral cavity, complications of these conditions affecting the sinus area, and consumption
of > 10 cigarettes/day. Patients smoking up to 10
cigarettes/day39 and alcohol consumers were included in the study. For the statistical analysis,
patients who smoked ≥ 1 cigarettes/day were
considered smokers and those having ≥ 1 alcohol-containing drinks/day (> 10 g of alcohol/day)40
were considered alcohol consumers. Patients
who met the inclusion and exclusion criteria
were required to read, understand and sign the
informed consent form before being enrolled in
the study.
Surgical procedures

Patients were asked to take 875/125 mg amoxicillin/clavulanate (or, if allergic to penicillin,
300 mg clindamycin) t.i.d. for ten days, starting
two days before the surgery to minimize infection risk. All surgical procedures were performed
under local anesthesia (articaine with epinephrine 40/0.01 mg/ml, Sanoﬁ-Aventis Deutschland, Frankfurt/Main, Germany). The procedure
proposed by Galindo-Moreno et al.41 was followed, using a bone scraper (Safescraper, Meta,
Reggio Emilia, Italy) to harvest ACB from the lateral wall and expose the Schneiderian membrane. After the membrane lift, sinus cavities
were grafted with scraped ACB in combination
with ABB particles sized between 250 and
1,000 μm (Geistlich Bio-Oss, Geistlich Pharma,
Wolhusen, Switzerland); the ratio of ACB to ABB
in the composite graft was 1:1 v/v.42 A maximum
of 5 cc of graft material was used per sinus cavity.
After bone grafting, an absorbable collagen
membrane (Geistlich Bio-Gide, Geistlich Pharma,
Wolhusen, Switzerland) was placed over the lateral aspect of the bony window. Flaps were then
carefully approximated and sutured with 3-0
surgical silk (Laboratorio Aragó, Barcelona,
Spain) by primary intention.
After a six-month healing period, a trephine
(internal and external diameters of 3 mm and
44 Volume 1 | Issue 1/2015

4 mm, respectively) was used to harvest bone
core biopsies from the alveolar crest in which implants were prosthetically planned. Implants
(OsseoSpeed, Astra Tech, Mölndal, Sweden; Microdent, Microdent Implant System, Barcelona,
Spain) were placed in a two-stage approach.
Histological study

The trephine biopsies were ﬁxed in 10% buffered
formalin for 24 h, decalciﬁed in Decalciﬁer I
(Surgipath Europe, Peterborough, UK), containing formaldehyde (10% w/v), formic acid (8%
w/v) and methanol (1% w/v), for 24 h at 37 ºC in
an oven and embedded in parafﬁn. Then, 4 μm
sections were cut along the central axis of the
biopsies and dewaxed and hydrated for staining
with hematoxylin–eosin, periodic acid–Schiff,
Masson’s trichrome and Goldner’s trichrome. A
millimeter scale in the eyepiece of a BH2 microscope (Olympus Optical, Tokyo, Japan) with a
40× objective was used to count osteoblasts, osteoclasts and osteocytes per mm². Results were
expressed in terms of the number of positive cells
per mm2.
Bone histomorphometry was performed
semi-automatically on Masson’s trichromestained sections, assessing ten randomized
images with a 10× objective, using a microscope
equipped with a digital camera (DP70, Olympus
Optical, Tokyo, Japan) connected to a computer
and applying ImageJ software (Version 1.48; developed by the U.S. National Institutes of Health,
Bethesda, Md.). Separate quantiﬁcations of vital
bone, ABB particles and connective tissue were
performed, expressing the results as percentages of each compartment.
Immunohistochemical analysis

Decalciﬁed and parafﬁn-embedded sections
were dewaxed, hydrated and heat-treated in
1 mM EDTA buffer for antigenic unmasking. Sections were incubated for 60 min at room temperature with pre-diluted OPN polyclonal antibody
to identify cellular and interstitial expression and
with the following pre-diluted monoclonal antibodies (all from Master Diagnóstica, Granada,
Spain): CD34 (clone QBEnd/10) to identify endothelial cells; CD56 (clone 56C04/123A8) to
identify osteoblasts; tartrate-resistant acid
phosphatase (TRAP; clone 26E5) to identify osteoclasts; CD68 (clone KP1) to identify monocytes and macrophages; and vimentin (clone V9)

Journal of
Oral Science & Rehabilitation

[45] =>

Osteopontin expression in anorganic bovine bone

Fig. 1

Fig. 1
Trabecular bone formed
throughout the ABB particles
in a maxillary sinus lift biopsy
(Masson’s trichrome stain,
10×).

to identify mesenchymal cells (as positive control). The immunohistochemical study was done
on an automatic immunostainer (Autostainer
480S, LabVision, Fremont, Calif., U.S.), using the
micropolymer-peroxidase-based method followed by development with diaminobenzidine
(Ultravision Quanto, Master Diagnóstica,
Granada, Spain). A millimeter scale in the eyepiece of a BH2 microscope (Olympus Optical,
Tokyo, Japan) with a 40× objective was used to
count the number of positive cells and vessels
per mm².

Results
Histological and histomorphometric results

After six months, a normal woven and lamellar
pattern of trabecular bone had formed throughout the graft in all patients who had received
ABB plus ACB (1:1) grafts, and biopsies from the
augmentation area contained this trabecular
bone in different proportions. Image analysis revealed 32.75 ± 14.0% vital bone, 39.49 ± 17.4%
connective tissue, and 27.75 ± 21.8% remnant
ABB particles (Fig. 1). ABB particles were detectable in the trabecular bone in a slightly
Statistical analysis
smaller proportion than in the original graft. In
The Shapiro–Wilk test was used to assess the the pristine bone, 48.93 ± 15.4% was vital bone
normality of variables. After descriptive analy- and 51.07 ± 20.8% connective tissue.
sis, the Student’s t-test or Welch test for unequal variances and the Spearman correlation
Immunohistochemical results
coefficient (rho) were used to evaluate the significance of differences. Clinical, morphologi- OPN expression was diffuse in 77.5% (31/40) of
cal and morphometric variables were com- ABB samples and focal in 22.5% (9/40); it was
pared between the presence and absence of diffuse in 80% (8/10) of pristine bone samples
OPN in cells and ABB particles using the Stu- and focal in 20% (2/10). The presence of OPN
dent’s t-test. A p < 0.05 was considered signif- immunostaining on ABB particles was intense
icant. IBM SPSS Statistics for Windows (Ver- in 45% of maxillary sinus lift biopsies, modersion 20.0; IBM, Armonk, N.Y., U.S.) was used ate in 27.5%, mild in 10%, and absent in 17.5%;
for the data analyses.
it was distributed within the lacuno-canalicuJournal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[46] =>

Osteopontin expression in anorganic bovine bone

Fig. 2

a

Fig. 2
Immunohistochemical
expression of OPN.
(a) OPN location on
boundary of ABB particles
with trabecular bone
(micropolymer-peroxidasebased method, 20×).
(b) Detail of OPN deposits in
lacuno-canalicular network
and location on boundary
of ABB particles near to
osteoclast (micropolymerperoxidase-based method,
60×).

lar system of ABB particles and on their surface
close to osteoclast-like cells (Fig. 2).
At six months, OPN expression was principally observed at the interstitial boundary of
bone with ABB particles and within lacunae
and bone canaliculi, forming a star shape (Fig. 2),
with no expression in the trabecular bone or interstitium. Cortical OPN expression was directly correlated with the number of osteocytes per mm2 (rho coefficient = 0.405,
p = 0.045, Spearman test), with OPN expression in cement lines (rho coefficient = 0.757,
p < 0.001, Spearman test) and with OPN expression in osteocytes (rho coefficient = 0.432,
p = 0.012, Spearman test).
A direct correlation was found between
OPN expression in ABB particles and in monocytes and macrophages (CD68-positive cells;
rho coefficient = 0.583, p = 0.009, Spearman
test). OPN expression in osteocytes was inversely correlated with the number of osteoblasts (CD56-positive cells) per mm2 (rho
coefficient = -0.828, p = 0.042, Spearman
test).
A vascular bed was formed in the nonmineralized tissue by vessels of different calibers in
the graft area and by capillary vessels among
the adipocytes in the bone marrow area, with a
mean in the biopsies of 86.28 ± 56.6 CD34positive vessels per mm2. OPN expression in
osteocytes was directly correlated with the
number of vessels per mm2 (rho coefficient = 0.828, p = 0.042, Spearman test).
TRAP expression was directly correlated
with the count per mm2 of osteoclasts (rho coefficient = 0.532, p = 0.015, Spearman test),
monocytes and macrophages (rho coeffi46 Volume 1 | Issue 1/2015

b

cient = 0.622, p = 0.008, Spearman test), and
osteoblasts (rho coefficient = 0.391, p = 0.048,
Spearman test). TRAP expression was correlated with the local and diffuse expression of
OPN (rho coefficient = 0.439, p = 0.022, Spearman test; Fig. 3).

Discussion
In this study of bone xenografts in a clinical
series of maxillary sinus lift, immunohistochemical OPN expression was detected not
only in osteocytes and on ABB particles, but
also within the lacuno-canalicular system of
ABB particles and close to osteoclast-like cells
on their surface.
Bone formation or resorption requires adhesion molecules (arginine–glycine–asparagine
sequences), such as ﬁbronectin, ﬁbrinogen, vitronectin, Type I collagen, OPN or bone sialoprotein, to attach osteoblasts or osteoclasts to
surfaces for remodeling.43 Because ABB particles are free of proteins,44 protein expression
on the particles must derive from proteins absorbed from the environment. The above
chemotactic factors may have stimulated and
directed the migration of cells to the foreign
material.13
Microchannel pores (< 10 μm) of ABB may
be relevant for osteogenic cell attachment, migration, proliferation and differentiation.45 At
the same time, the inner surface of ABB particles becomes considerably enlarged, favoring
the formation of new vessels and therefore the
inward growth of new bone within the particles.31 A greater microporosity also expands

Journal of
Oral Science & Rehabilitation

[47] =>

Osteopontin expression in anorganic bovine bone

Fig. 3

the scaffold surface and may enhance cytokine
adsorption.46 The interconnectivity of the
pores in ABB particles and their hydrophilic
properties explain the presence of OPN within
the lacuno-canalicular system. This explanation is supported by the distribution of OPN
found in our samples from the surface to the
core of the particles, with the lacuno-canalicular system of the remnant ABB particles clearly
depicted by the staining. Although the biological relevance of this finding remains unclear, it
may be related to the cellular recolonization
and revascularization of ABB that has been observed after six months of healing.31 In this previous study, a direct correlation was found between OPN expression in osteocytes and
CD34-positive endothelial cells (rho coefficient = 0.828, p = 0.042, Spearman test). As already noted, one of the functions of OPN is related to angiogenesis,5 which is impaired in
OPN-deficient mice.47 Images of ABB particles
after six months of graft maturation were compatible with neovascularization and central re-

a

b

c

d

sorption, implying the integration of this biomaterial within the functional and biomechanical system of the neoformed bone.
Whereas most noncollagenous proteins are
more or less homogeneously dispersed throughout bone, ultrastructural immunocytochemical
studies have consistently found OPN to be predominantly distributed at cement lines in remodeling bone and at laminae limitans.48, 49 These sites
represent matrix–matrix and cell–matrix boundaries, respectively, and are therefore important in
the bone formation process.6 Cement lines demarcate the boundary between older and newer
bone and characteristically have a high OPN content. The origin of OPN in the cement line has been
controversial,32, 50 and osteoclasts and osteoblasts
may both be involved. OPN may initially play a role
in osteoblast adhesion or early calciﬁcation events
in the cement layer.51 Subsequently, the more diffuse distribution of OPN throughout the bone matrix may inﬂuence osteoclast activity during resorption and the transformation of woven and
lamellar bone.6 Our ﬁndings support this proposi-

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

47

Fig. 3
(a) Immunohistochemical
expression of OPN in
osteocytes and cement lines in
pristine bone (micropolymerperoxidase-based method,
10×).
(b) Detail of OPN expression in
osteocytes (micropolymerperoxidase-based method,
20×).
(c) Immunohistochemical
expression of CD56 in
osteoblasts around trabecular
bone (micropolymerperoxidase-based method,
10×).
(d) Immunohistochemical
expression of TRAP in
osteoclasts around ABB
particles (micropolymerperoxidase-based method,
40×).

[48] =>

Osteopontin expression in anorganic bovine bone

Pablo Galindo Moreno,*
Pedro Hernández Cortés,†
Miguel Padial Molina,*
María Luisa Vizoso,‡
Vicente Crespo Lora,‡
Francisco O’Valle‡
*

Oral surgery and implant
dentistry department,
School of Dentistry,
University of Granada, Spain

†

Department of orthopedic
surgery, San Cecilio university hospital, Granada, Spain

‡

Department of pathology,
Faculty of Medicine, and
Institute of Bio-pathology
and Regenerative Medicine,
University of Granada, Spain

Corresponding author:
Prof. Pablo Galindo Moreno
Calle Recogidas, 39, 5º Izq
18005 Granada
Spain
T +34 958 52 0658
F +34 958 52 0658
pgalindo@ugr.es

tion, given that OPN expression in the cement
lines may indicate bone formation or destruction
as a function of the cells attached to the particle
surface. However, this dual behavior of OPN remains unclear.
OPN can be expressed in numerous tissues52
and by multiple cell types,14 including osteoblasts
and osteoclasts.53 Kunii et al. conﬁrmed the expression of OPN mRNA and protein in human osteocytes32 using different antibodies.52 Osteocytes have multiple functions and regulate different processes in bone homeostasis.54 After six
months of healing, osteocytes present in the new
vital bone in our biopsies consistently expressed
OPN. OPN expression in osteocytes was inversely
correlated with the count of osteoblasts (CD56positive cells) per mm2 (rho coefﬁcient = -0.828,
p = 0.042, Spearman test). Araújo et al. detected
OPN expression on ABB particles in dogs during
the early stages of healing.13 According to their
study, after the migration of polymorphonuclear
cells to the ABB surface, these cells are replaced by
TRAP-positive cells (osteoclasts), which will remove material from the surface of the xenograft.13
Subsequently, osteoblasts will attach to the remodeled surface and bone apposition will begin.
However, OPN behavior is likely different during
the late stage of healing. In the present samples,
osteoblasts were rarely observed in the ABB particles, and a signiﬁcant inverse relationship was
found between OPN expression and CD56 expression (rho coefﬁcient = -828, p = 0.04, Spearman test). This higher expression with fewer
osteoblasts and the positive correlation between
OPN and CD68 expression (rho coefficient = 0.583, p = 0.009; rho coefﬁcient = 0.938
p = 0.006; Spearman test, respectively) indicate
that OPN expression on ABB particles promotes
resorption at six months of healing. In support of
this hypothesis, it is known that OPN can both activate osteoclasts for bone matrix resorption and
induce their migration in an αvβ3 integrin-dependent manner.55, 56 Nakamura et al. demonstrated
that αvβ3 integrin plays a key role in osteoclast
migration, which is essential for efﬁcient osteoclastic bone resorption.57 Perrotti et al. reported
that multinucleated cells generated on ABB were
positive for the αvβ3 subunit of vitronectin,58 the
main integrin-mediating osteoclast cell attachment to the bone matrix;59 hence, this mechanism
may be functional on ABB particles. OPN is a ligand for the αvβ3 integrin through an RGD sequence.60 The osteoclast cell membrane must be
sealed to the substrate by means of cell surface
48 Volume 1 | Issue 1/2015

receptors and proteins of the integrin family
before beginning its proteolytic activity. The
binding of OPN to the αvβ3 integrin in the sealing zone or podosomes appears essential to the
reorganization of the actin cytoskeleton for osteoclast motility.61 Additionally, osteoclast adhesion and osteoclast migration are mediated
by phosphorylated OPN,62 and this biological
event is regulated by endogenous TRAP.63 Interestingly, TRAP and OPN expressions
showed similar patterns on ABB particle surfaces at six months of healing in our samples,
indicating the close relationship between OPN
expression and the osteoclastic resorption of
ABB. Questions have been raised about this resorption of the particles,64, 13 but this proposition is supported by our histological findings on
these particles of bone-remodeling units with
multinucleated cells in different stages of differentiation (CD68 positive and TRAP positive)
that promote these phenomena. In our view,
these results may in part explain OPN-mediated ABB resorption during the late stage of
graft healing.
Our ﬁndings support the proposal that osteoclasts are the source of OPN in bone cement lines
during remodeling.32 The detection of OPN expression within lacunae represents clear evidence of the secretion of OPN by osteoclasts, because exogenously added OPN has no access to
these sites.23

Conclusion
Immunohistochemical expression of OPN is related to bone remodeling and maturation changes
in maxillary sinus lift with ABB xenograft.

Acknowledgments
The authors are grateful to María Dolores Rodríguez Martínez and Jorge A. Payá for technical
assistance and to Richard Davies for assistance
with the English translation.

Competing interests
The authors declare that they have no competing
interests. This investigation was supported in part
by Research Groups #CTS-138 and CTS-583 (Regional Government of Andalusia, Spain).

Journal of
Oral Science & Rehabilitation

[49] =>

Osteopontin expression in anorganic bovine bone

References
1.
Young MF, Kerr JM, Termine JD, Wewer
UM, Wang MG, McBride OW, Fisher LW.
cDNA cloning, mRNA distribution and
heterogeneity, chromosomal location, and
RFLP analysis of human osteopontin
(OPN).
→ Genomics.
1990 Aug;7(4):491–502.
2.
Hijiya N, Setoguchi M, Matsuura K,
Higuchi Y, Akizuki S, Yamamoto S. Cloning
and characterization of the human
osteopontin gene and its promoter.
→ Biochem J.
1994 Oct;303(Pt 1):255–62.
3.
Oldberg A, Franzén A, Heinegård D.
Cloning and sequence analysis of rat bone
sialoprotein (osteopontin) cDNA reveals an
Arg-Gly-Asp cell-binding sequence.
→ Proc Natl Acad Sci USA.
1986 Dec;83(23):8819–23.
4.
Milam SB, Haskin C, Zardeneta G, Chen D,
Magnuson VL, Klebe RJ. Cell adhesion
proteins in oral biology.
→ Crit Rev Oral Biol Med.
1991;2(4):451–91.
5.
Matusan-Ilijas K, Behrem S, Jonjic N,
Zarkovic K, Lucin K. Osteopontin
expression correlates with angiogenesis
and survival in malignant astrocytoma.
→ Pathol Oncol Res.
2008 Sep;14(3):293–8.
6. Sodek J, Ganss B, McKee MD.
Osteopontin.
→ Crit Rev Oral Biol Med.
2000;11(3):279–303.
7.
Taller A, Grohe B, Rogers KA, Goldberg HA,
Hunter GK. Speciﬁc adsorption of
osteopontin and synthetic polypeptides to
calcium oxalate monohydrate crystals.
→ Biophys J.
2007 Sept;93(5):1768–77.
8.
Sims NA, Gooi JH. Bone remodeling:
multiple cellular interactions required for
coupling of bone formation and resorption.
→ Semin Cell Dev Biol.
2008 Oct;19(5):444–51.
9.
Zohar R, Lee W, Arora P, Cheifetz S,
McCulloch C, Sodek J. Single cell analysis
of intracellular osteopontin in osteogenic
cultures of fetal rat calvarial cells.
→ J Cell Physiol.
1997 Jan;170(1):88–100.

10.
McKee MD, Nanci A. Osteopontin and the
bone remodeling sequence: colloidal-gold
immunocytochemistry of an interfacial
extracellular matrix protein.
→ Ann N Y Acad Sci.
1995 Aug;760:177–89.

19.
Pampena DA, Robertson KA, Litvinova O,
Lajoie G, Goldberg HA, Hunter GK.
Inhibition of hydroxyapatite formation by
osteopontin phosphopeptides.
→ Biochem J.
2004 Mar;378(3):1083–7.

11.
Sodek J, Chen J, Nagata T, Kasugai S,
Todescan R Jr, Li IW, Kim RH. Regulation
of osteopontin expression in osteoblasts.
→ Ann N Y Acad Sci.
1995 Aug;760:223–41.

20.
Altıntaş A, Saruhan-Direskeneli G, Benbir
G, Demir M, Purisa S. The role of
osteopontin: a shared pathway in the
pathogenesis of multiple sclerosis and
osteoporosis?
→ J Neurol Sci.
2009 Jan;276(1–2):41–4.

12.
Giachelli CM, Schwartz SM, Liaw L.
Molecular and cellular biology of
osteopontin: potential role in
cardiovascular disease.
→ Trends Cardiovasc Med.
1995 May-Jun;5(3):88–95.
13.
Araújo MG, Liljenberg B, Lindhe J.
Dynamics of Bio-Oss Collagen
incorporation in fresh extraction wounds:
an experimental study in
the dog.
→ Clin Oral Implants Res.
2010 Jan;21(1):55–64.
14.
Choi ST, Kim JH, Kang EJ, Lee SW, Park
MC, Park YB, Lee SK. Osteopontin might
be involved in bone remodelling rather
than in inﬂammation in ankylosing
spondylitis.
→ Rheumatology (Oxford).
2008 Dec;47(12):1775–9.
15.
Jang JH, Kim JH. Improved cellular
response of osteoblast cells using
recombinant human osteopontin protein
produced by Escherichia coli.
→ Biotechnol Lett
2005 Nov;27(22):1767–70.
16.
Denhardt DT, Noda M. Osteopontin
expression and function: role in bone
remodeling.
→ J Cell Biochem Suppl.
1998;30–31 Suppl:92–102.
17.
Ishijima M, Ezura Y, Tsuji K, Rittling SR,
Kurosawa H, Denhardt DT, Emi M, Nifujia
A, Noda M. Osteopontin is associated with
nuclear factor κB gene expression during
tail-suspension-induced bone loss.
→ Exp Cell Res.
2006 Oct;312(16):3075–83.
18.
Goldberg HA, Warner KJ, Li MC, Hunter
GK. Binding of bone sialoprotein,
osteopontin and synthetic polypeptides to
hydroxyapatite.
→ Connect Tissue Res.
2001;42(1):25–37.

21.
Krause SW, Rehli M, Kreutz M,
Schwarzﬁscher L, Paulauskis JD,
Andreesen R. Differential screening
identiﬁes genetic markers of monocyte to
macrophage maturation.
→ J Leukoc Biol.
1996 Oct;60(4):540–5.
22.
Ihara H, Denhardt DT, Furuya K, Yamashita
T, Muguruma Y, Tsuji K, Hruska KA,
Higashio K, Enomoto S, Nifuji A, Rittling
SR, Noda M. Parathyroid hormoneinduced bone resorption does not occur in
the absence of osteopontin.
→ J Biol Chem.
2001 Apr;276(16):13065–71.
23.
Standal T, Borset M, Sundan A. Role of
osteopontin in adhesion, migration, cell
survival and bone remodeling.
→ Exp Oncol.
2004 Sep;26(3):179–84.
24.
Chellaiah MA, Kizer N, Biswas R, Alvarez
U, Strauss-Schoenberger J, Rifas L,
Rittling SR, Denhardt DT, Hruska KA.
Osteopontin deﬁciency produces
osteoclast dysfunction due to reduced
CD44 surface expression.
→ Mol Biol Cell.
2003 Jan;14(1):173–89.
25.
Tani-Ishii N, Tsunoda A, Umemoto T.
Osteopontin antisense
deoxyoligonucleotides inhibit bone
resorption by mouse osteoclasts in vitro.
→ J Periodontal Res.
1997 Aug;32(6):480–6.
26.
Suzuki K, Zhu B, Rittling SR, Denhardt DT,
Goldberg HA, McCulloch CA, Sodek J.
Colocalization of intracellular osteopontin
with CD44 is associated with migration,
cell fusion, and resorption in osteoclasts.
→ J Bone Miner Res.
2002 Aug; 17(8):1486–97.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

27.
Carinci F, Piattelli A, Degidi M, Palmieri A,
Perrotti V, Scapoli L, Martinelli M, Laino G,
Pezzetti F. Genetic effects of anorganic
bovine bone (Bio-Oss) on osteoblast-like
MG63 cells.
→ Arch Oral Biol.
2006 Feb;51(2):154–63.
28.
Tadjoedin ES, De Lange GL, Bronckers AL,
Lyaruu DM, Burger EH. Deproteinized
cancellous bovine bone (Bio-Oss) as bone
substitute for sinus ﬂoor elevation: a
retrospective, histomorphometrical study
of ﬁve cases.
→ J Clin Periodontol.
2003 Mar;30(3):261–70.
29.
Yildirim M, Spiekermann H, Biesterfeld S,
Edelhoff D. Maxillary sinus augmentation
using xenogenic bone substitute material
Bio-Oss in combination with venous blood:
a histologic and histomorphometric study
in humans.
→ Clin Oral Implants Res.
2000 Jun;11(3):217–29.
30.
Schwartz Z, Weesner T, Van Dijk S,
Cochran DL, Mellonig JT, Lohmann CH,
Carnes DL, Goldstein M, Dean DD, Boyan
BD. Ability of deproteinized cancellous
bovine bone to induce new bone
formation.
→ J Periodontol.
2000 Aug;71(8):1258–69.
31.
Galindo-Moreno P, Padial-Molina M,
Fernández-Barbero JE, Mesa F, RodríguezMartínez D, O’Valle F. Optimal microvessel
density from composite graft of
autogenous maxillary cortical bone and
anorganic bovine bone in sinus
augmentation: inﬂuence of clinical
variables.
→ Clin Oral Implants Res.
2010 Feb;21(2):221–7.
32.
Dodds RA, Connor JR, James IE,
Rykaczewski EL, Appelbaum E, Dul E,
Gowen M. Human osteoclasts, not
osteoblasts, deposit osteopontin onto
resorption surfaces: an in vitro and ex vivo
study of remodeling bone.
→ J Bone Miner Res.
1995 Nov;10(11):1666–80.
33.
McKee MD, Farach-Carson MC, Butler WT,
Hauschka PV, Nanci A. Ultrastructural
immunolocalization of noncollagenous
(osteopontin and osteocalcin) and plasma
(albumin and α2HS-glycoprotein) proteins
in rat bone.
→ J Bone Miner Res.
1993 Apr;8(4):485–96.

49

[50] =>

Osteopontin expression in anorganic bovine bone

References
43.
Hallman M, Thor A. Bone substitutes and
growth factors as an
alternative/complement to autogenous
bone for grafting in implant dentistry.
→ Periodontol 2000.
2008 Jun;47(1):172–92.

34.
Schücklenk U, Ashcroft R. International
research ethics.
→ Bioethics.
2000 Apr;14(2):158–72.
35.
American Society of Anesthesiologists.
ASA Physical Status Classiﬁcation System
[Internet].
→ Schaumburg, Ill.: American Society of
Anesthesiologists; [updated 2014 Oct 15;
cited 2015 Jul 1]. Available from:
http://www.asahq.org/resources/clinicalinformation/asa-physical-status-classiﬁca
tion-system.

44.
Wenz B, Oesch B, Horst M. Analysis of the
risk of transmitting bovine spongiform
encephalopathy through bone grafts
derived from bovine bone.
→ Biomaterials.
2001 Jun;22(12):1599–606.
45.
Habibovic P, Yuan H, van der Valk CM,
Meijer G, van Blitterswijk CA, de Groot K.
3D microenvironment as essential element
for osteoinduction by biomaterials.
→ Biomaterials.
2005 Jun;26(17):3565–75.

36.
O’Leary TJ, Drake RB, Naylor JE. The
plaque control record.
→ J Periodontol.
1972 Jan;43(1):38.
37.
Wang HL, Katranji A. ABC sinus
augmentation classiﬁcation.
→ Int J Periodontics Restorative Dent.
2008 Jul-Aug;28(4):383–9.

46.
Weibrich G, Trettin R, Gnoth SH, Götz H,
Duschner H, Wagner W. Bestimmung der
Größe der speziﬁschen Oberﬂäche von
Knochenersatzmaterialien mittels
Gasadsorption [Determining the size of the
speciﬁc surface of bone substitutes with
gas adsorption].
→ Mund Kiefer Gesichtschir.
2000 May;4(3):148–52. German.

38.
Zinner ID, Small SA. Sinus-lift graft: using
the maxillary sinuses to support implants.
→ J Am Dent Assoc.
1996 Jan;127(1):51–7.
39.
Levin L, Herzberg R, Dolev E, SchwartzArad D. Smoking and complications of
onlay bone grafts and sinus lift operations.
→ Int J Oral Maxillofac Implants. 2004
May-Jun;19(3):369–73.
40.
Galindo-Moreno P, Fauri M, Ávila-Ortiz G,
Fernández-Barbero JE, Cabrera-León A,
Sánchez-Fernández E. Inﬂuence of alcohol
and tobacco habits on peri-implant
marginal bone loss: a prospective study.
→ Clin Oral Implants Res.
2005 Oct;16(5):579–86.
41.
Galindo-Moreno P, Ávila G, FernándezBarbero JE, Aguilar M, Sánchez-Fernández
E, Cutando A, Wang HL. Evaluation of
sinus ﬂoor elevation using a composite
bone graft mixture.
→ Clin Oral Implants Res.
2007 Jun;18(3):376–82.
42.
Galindo-Moreno P, Ávila G, FernándezBarbero JE, Mesa F, O’Valle-Ravassa F,
Wang HL. Clinical and histologic
comparison of two different composite
grafts for sinus augmentation: a pilot
clinical trial.
→ Clin Oral Implants Res.
2008 Aug;19(8):755–9.

47.
Duvall CL, Taylor WR, Weiss D, Wojtowicz
AM, Guldberg RE. Impaired angiogenesis,
early callus formation, and late stage
remodeling in fracture healing of
osteopontin-deﬁcient mice.
→ J Bone Miner Res.
2007 Feb;22(2):286–97.
48.
McKee MD, Nanci A. Osteopontin at
mineralized tissue interfaces in bone,
teeth, and osseointegrated implants:
ultrastructural distribution and
implications for mineralized tissue
formation, turnover, and repair. Microsc
Res Tech. 1996 Feb;33(2):141–64.
49.
McKee MD, Nanci A. Osteopontin: an
interfacial extracellular matrix protein in
mineralized tissues.
→ Connect Tissue Res.
1996 Jan;35(1–4):197–205.
50.
McKee MD, Nanci A. Osteopontin
deposition in remodeling bone: an
osteoblast mediated event.
→ J Bone Miner Res.
1996 Jun;11(6):873–5.
51.
Ganss B, Kim RH, Sodek J. Bone
sialoprotein.
→ Crit Rev Oral Biol Med.
1999;10(1):79–98.

50 Volume 1 | Issue 1/2015

52.
Kunii Y, Niwa S, Hagiwara Y, Maeda M,
Seitoh T, Suzuki T. The
immunohistochemical expression proﬁle
of osteopontin in normal human tissues
using two site-speciﬁc antibodies reveals a
wide distribution of positive cells and
extensive expression in the central and
peripheral nervous systems.
→ Med Mol Morphol.
2009 Sep;42(3):155–61.
53.
Merry K, Dodds R, Littlewood A, Gowen
M. Expression of osteopontin mRNA by
osteoclasts and osteoblasts in modelling
adult human bone.
→ J Cell Sci.
1993 Apr;104(4):1013–20.
54.
Bonewald L. Osteocytes as multifunctional
cells.
→ J Musculoskelet Neuronal Interact.
2006 Oct-Dec;6(4):331–3.
55.
Holt I, Marshall MJ. Integrin subunit β3
plays a crucial role in the movement of
osteoclasts from the periosteum to the
bone surface.
→ J Cell Physiol.
1998 Apr;175(1):1–9.
56.
Chellaiah MA, Hruska KA. The integrin
αvβ3 and CD44 regulate the actions of
osteopontin on osteoclast motility.
→ Calcif Tissue Int.
2003 Mar;72(3):197–205.
57.
Nakamura I, Pilkington MF, Lakkakorpi PT,
Lipfert L, Sims SM, Dixon SJ, Rodan GA,
Duong LT. Role of alpha(v)beta(3) integrin
in osteoclast migration and formation of
the sealing zone.
→ J Cell Sci.
1999 Nov;112(22):3985–93.
58.
Perrotti V, Nicholls BM, Horton MA,
Piattelli A. Human osteoclast formation
and activity on a xenogenous bone
mineral.
→ J Biomed Mater Res A.
2009 Jun;90A(1):238–46.
59.
Nakamura I, Duong LT, Rodan SB, Rodan
GA. Involvement of αvβ3 integrins in
osteoclast function.
→ J Bone Miner Metab.
2007 Nov;25(6):337–44.
60.
Reinholt FP, Hultenby K, Oldberg A,
Heinegård D. Osteopontin—a possible
anchor of osteoclasts to bone. Proc Natl
Acad Sci U S A. 1990 Jun;87(12):4473–5.

Journal of
Oral Science & Rehabilitation

61.
Ory S, Brazier H, Pawlak G, Blangy A. Rho
GTPases in osteoclasts: orchestrators of
podosome arrangement. Eur J Cell Biol.
2008 Sep;87(8-9):469–77.
62.
Saad FA, Salih E, Glimcher MJ.
Identiﬁcation of osteopontin
phosphorylation sites involved in bone
remodeling and inhibition of pathological
calciﬁcation. J Cell Biochem. 2008
Feb;103(3):852–6.
63.
Ek-Rylander B, Andersson G. Osteoclast
migration on phosphorylated osteopontin
is regulated by endogenous tartrateresistant acid phosphatase. Exp Cell Res.
2010 Feb;316(3):443–51.
64.
Schlegel AK, Donath K. BIO-OSS—a
resorbable bone substitute? J Long Term
Eff Med Implants. 1998;8(3–4):201–9.

[51] =>

www.DTStudyClub.com

Y education everywhere
and anytime
Y live and interactive webinars
Y more than 500 archived courses
Y a focused discussion forum
Y free membership
Y no travel costs
Y no time away from the practice
Y interaction with colleagues and
experts across the globe
Y a growing database of
scientific articles and case reports
Y ADA CERP-recognized
credit administration

Register for

FREE!

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

[52] =>

Removal of partially erupted mandibular third molars

Evaluation of the effect
of supervised plaque control
after the surgical removal of partially erupted mandibular
third molars on the periodontal condition distal to second
molars affected by localized periodontal disease:

A randomized blind
clinical study

Abstract
Objective

Conclusion

The objective of this study was to evaluate the effect of
supervised plaque control on the periodontal condition
distal to the second molars after the extraction of partially erupted mandibular third molars.

The removal of the third molar improved access for
self-performed plaque control. This, together with subgingival debridement, improved the periodontal status at
the second molars.
Keywords

Materials and methods

All of the 33 patients had a probing pocket depth (PPD) of
7.4 mm (S.D. ± 1.5) and bone loss of 4.4 mm (S.D. ± 2.0)
distal to the second molars. After the surgical extraction
of the third molars and subgingival debridement of the
distal site of the second molar, the patients were randomly assigned to a test group or a control group. The
test group received oral hygiene information and professional dental hygienist treatment one month after the
extraction. The control group did not receive any speciﬁc
information or treatment.
Results

At six months, the percentage reduction of plaque at the
distal sites of the second molars from the baseline value
was 69% and 47% in the test and control groups, respectively. The PPD reduction was 3.4 mm and 3.5 mm in the
test and control groups, respectively. These values
were statistically significant compared with baseline
(p < 0.001). The radiographic measurements found a
bone gain of 0.7 mm and 0.8 mm in the test and control
groups, respectively.
52 Volume 1 | Issue 1/2015

Extraction, third molar, semi-impacted tooth, local periodontitis, plaque control.

Introduction
Population studies have suggested that the visible presence of a third molar increases the risk
of periodontal inﬂammatory disease at second
molars1–3 adjacent to both symptomatic and
asymptomatic third molars.4, 5 This was also the
case in young subjects (18–40 years of age) with
low severity of periodontal disease in the overall
dentition.1, 3, 5
In young subjects, when the early stages of periodontal pathology are detected in the third molar
region, the removal of third molars may improve
the periodontal status at the distal sites of second
molars.6, 7 Studies also indicate that the removal of
third molars in younger individuals compared with
older subjects decreases the time needed for the

Journal of
Oral Science & Rehabilitation

[53] =>

Removal of partially erupted mandibular third molars

extraction and decreases the risk of complications.
The age of 25 appears to be critical, after which
complications increase more rapidly.8
In a retrospective study of 215 patients,
Kugelberg et al. found that two years after the
surgical removal of impacted mandibular third
molars, 43.3% of the cases exhibited a probing
pocket depth (PPD) of > 7 mm and 32.1% showed
intrabony defects of > 4 mm distal to the mandibular second molars.9 The postoperative plaque
control score indicated that in most of the participants the level of plaque control at the distal surface of the second molar was not optimal. Leung
et al. showed that a regime of strict plaque control prevented residual pockets at periodontally
involved second molars six months after the removal of the third molar.10 Kan et al. investigated
the periodontal condition distal to mandibular
second molars 6–36 months after routine surgical extraction of adjacent impacted third molars
in 158 subjects under 40 years of age.11 Three
possible risk indicators were associated with localized increased PPD at the distal surface of the
mandibular second molar: third molar mesioangular impaction; pre-extraction signs of bone
loss; and inadequate post-extraction local
plaque control.11
The aim of the current study was to evaluate
the effect of supervised plaque control after the
extraction of partially erupted mandibular third
molars on the periodontal condition distal to the
second molars.

Materials & methods

pital (Borås, Sweden) for extraction of mandibular third molars. The protocol of the study was
approved by the Central Ethical Review Board at
the University of Gothenburg (Sweden). The patients who met the inclusion criteria were informed about the diagnosis and treatment plan.
They were also informed of the purpose of the
study and gave their consent for participation.
In order to be included in the study, the patients had to be 18 years of age or older, have a
partially erupted third molar in need of extraction, present with bone loss distal to the adjacent
second molar of > 2 mm (as measured from available radiographs) and a PPD of ≥ 6 mm, but otherwise be healthy from a periodontal perspective
(i.e., no bone loss of > 1 mm and no PPD of ≥ 5 mm
at the residual dentition; Fig. 1a). Patients with
medical conditions that could compromise healing at the extraction site were excluded.
Clinical examination

The following clinical variables were recorded at
the baseline examination by one examiner (ASP)
at the distal surface of the second molars:
Plaque index (PI): The presence or absence of
plaque was determined after staining with disclosing solution (Rondell Blue, Nordenta,
Enköping, Sweden) at the distal sites of the second molars.
Bleeding/suppuration on probing (BoP/Sup):
The presence or absence of bleeding/suppuration up to 15 s after probing was determined.

PPD: Pocket depth was measured in millimeters
with a manual PCP-15 periodontal probe (HuThe subjects involved in this study were selected Friedy, Leimen, Germany) to the nearest millifrom consecutive patients referred to the de- meter at the distobuccal, distal and distolingual
partment of oral surgery at Södra Älvsborg Hos- surfaces of the second molars.
Patient recruitment

Figs. 1a & b

Partially erupted third molar in
a patient without periodontal
disease except distal to the
second molar (a).
The bone-level measurement
before extraction of the third
molar (b).

b
Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[54] =>

Removal of partially erupted mandibular third molars

Radiographic bone loss: The presence of bone
loss distal to the second molar of > 2 mm was assessed on available digital bitewing or periapical
radiographs (Fig. 1b).
Tr e a t m e n t

Surgical phase
All of the patients received an analgesic prior
to surgery (1 g Alvedon, AstraZeneca, Mölndal,
Sweden). The treatment was performed under
aseptic conditions. After local anesthetic had
been administered, a mucoperiosteal incision
was placed using a #15 Bard-Parker blade according to the technique described by Nordenram.12 Bone removal and sectioning of the third
molar were performed with a low-speed rotary
instrument under constant irrigation with sterile saline. After tooth extraction, the granulation tissue and follicular remnants were removed from the extraction alveolus. Correction
of the anatomical architecture of the bone was
performed under saline irrigation. The distal
surface of the second molar was carefully
scaled with hand instruments. After saline irrigation, the flap was repositioned in order to
cover the alveolus and sutured with two (occasionally three) sutures (VICRYL, Ethicon, Somerville, N.J., U.S.).
After the surgery, the patients were randomly assigned to a test group or a control
group by opening closed envelopes containing
the group assignment.

Postoperative treatment
The sutures were removed seven days after the
surgery. After suture removal, the patients in the
control group did not receive any speciﬁc information or treatment. However, the patients in
the test group were informed about the importance of good oral hygiene, especially distal to
the mandibular second molars; furthermore,
they were instructed on how to use a special
toothbrush (Compact Tuft, Tepe Munhygienprodukter, Malmö, Sweden) to clean distal to the
second molars.
At the one-month examination, the patients
in the test group were recalled by a dental hygienist at the Department of Periodontology,
who was not aware of the aim of the study. The
patients received supra- and subgingival scaling
and oral hygiene reinstruction and motivation if
needed. Plaque and gingival bleeding at the
distal sites of the mandibular second molars
were also recorded in the following way:
PI: The presence or absence of plaque was determined in the same manner as at the baseline examination.
Gingival bleeding index (GI): The presence or absence of bleeding was determined after running
the probe in the gingival sulcus distal to the
second molars.13
Six-month re-evaluation

At six months, all of the patients were recalled for
a control visit. This visit was performed by a perioPostoperative adverse events
dontist (GS), who was not aware of the group asTwo patients came to the clinic before the su- signment. At this time, the following parameters
ture removal because of postoperative pain. At were recorded:
this point, the extraction alveoli were rinsed
with sterile saline and a prescription for stronger PI: The presence or absence of plaque was deteranalgesics was given, but there was no need for mined in the same manner as at the baseline exthe prescription of antibiotics.
amination.

Figs. 2a & b

Six-month control. Clinically
healthy gingival condition
distal to the second molar,
with a PPD of 3 mm (a).
Bone-level measurements (b).

a
54 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[55] =>

Removal of partially erupted mandibular third molars

BoP/Sup: The presence or absence of bleeding/
suppuration was determined in the same manner as at the baseline examination.
PPD: Pocket depth was measured in the same
manner as at the baseline examination (Fig. 2a).

and calculated standard deviation of 1.1 mm from
previous studies,10, 11 Type I error and 80%
power, the calculated sample size was 20 subjects per group.

Fig. 3
Flowchart of the study.

Dropout
A radiograph, aiming to control the area distal to During the study period, four patients in the test
the mandibular second molars after extraction, group and three in the control group dropped out
was also taken at this appointment using the par- from the study; one moved and the others did not
alleling technique.14
attend the six-month examination (Fig. 3).
Fig. 3

Pl, BoP, PPD,
radiographic bone level
Extraction of third molar
40 patients

Baseline and six-month
radiographic measurements

20 allocated to
control group

20 allocated to
test group

Dental hygienist
treatment (PI and GI)

4 dropped out

3 dropped out

Pl, BoP, PPD,
radiographic bone level

16 patients

17 patients

1-month examination

The radiographs were evaluated by a second
periodontist (AT), who was not aware of the
study design. The bone loss distal to the second
molar at baseline and at the six-month examination was measured. Thus, the distance between
the cemento-enamel junction and the most
coronal level along the root surfaces at which the
periodontal space was considered to have a normal width15 was measured using a program for
digital radiographic images (Planmeca Romexis,
Helsinki, Finland) with 10× magnifying power
and a precision of 0.1 mm (Fig. 2b). The presence
or absence of an alveolar bone defect (i.e., a bony
defect 2 mm wide and 2 mm deep) was also
recorded.

Baseline (40 patients)

Clinical criteria for healthy or
diseased sites after treatment
At the re-evaluations, the surface distal to the
second molars was considered healthy if there
was a PPD of ≤ 4 mm without BoP/Sup. The presence of periodontal disease was determined
based on a PPD of ≥ 5 mm with BoP/Sup.

Data analyses

Sample size calculation
Based on an anticipated difference in mean PPD
of 1.0 mm between the test and control groups
Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

6-month examination

Each mandibular second molar was regarded
as an independent observation. The Wilcoxon
signed-rank test and Mann–Whitney U test
were applied to test the difference in PPD and radiographic bone loss within and between the two
groups at baseline and the six-month examination. The Fisher exact probability test was applied to assess differences in treatment outcome
in the test and control groups. A p-value of < 0.05
was considered to be statistically signiﬁcant.

[56] =>

Removal of partially erupted mandibular third molars

Table 1
Clinical features of patients
and teeth included in the
study.

Table 1

Test

Control

All

16 (5 female)

17 (9 female)

33 (14 female)

21–48
(mean 30.1, S.D. ± 8.9)

19–36
(mean 24.8, S.D. ± 5.0)

19–48
(mean 27.3, S.D. ± 7.8)

Smokers

1

2

3

Number of teeth #48

9

11

20

Number of teeth #38

7

6

13

Horizontal

8

6

14

Mesio-angular

8

10

18

Vertical

0

1

1

Disto-angular

0

0

0

Number of patients
Age

Number
of molars
according to
angulation

Results

One-month examination

At one month after the extraction of the third
molars, only 4 of the 16 (25%) distal sites of the
The 33 subjects (14 females and 19 males) who second molars presented with plaque (Table
completed the study had a mean age of 27.4 2a) and 5 showed bleeding after running the
(S.D. ± 7.8; range: 19–48). Sixteen subjects probe in the gingival sulcus.
were allocated to the test group and 17 to the
control group. No difference in age was noted
Six-month examination
between the test and control groups. Only
three were smokers, one in the test group and At six months after extraction, 5 out of the 16
two in the control group (Table 1).
(31%) distal sites of the second molars preA total of 33 mandibular third molars (20 on sented with plaque in the test group, compared
the right and 13 on the left side) were examined. with 9 out of 17 (53%) in the control group, with
The majority had a mesio-angular or horizontal a reduction of 69% and 47%, respectively, from
position (Table 1). The presence of plaque was the baseline value (Table 2a). The presence of
noted at all distal sites of the second molars, BoP was recorded at 6 out of 16 (38%) in the
and 29 of these sites had BoP (Tables 2a & b). test group, compared with 8 out of 17 (47%) in
The mean PPD at the distal sites of the second the control group (Table 2b). The mean PPD
molars, based on the deepest value measured measured at the distal sites of the second moat three points (distobuccal, distal and disto- lars was 4.1 mm (S.D. ± 1.1) in the test group and
lingual), was 7.4 mm (S.D. ± 1.5), with no differ- 3.8 mm (S.D. ± 1.4) in the control group. None
ence between the test and control groups of these measurements were statistically sig(Table 2c).
nificantly different between the two groups
The radiographic measurements at the base- (Table 2c). The PPD reduction with respect to
line examination showed that 26 molars had the baseline value was 3.4 mm in the test group
bone loss of up to one-third of the root length, and 3.5 mm in the control group. Both values
and 7 molars between one-third and two-thirds, were statistically significantly different from
while bone loss exceeding two-thirds of the the baseline values (p < 0.001). No difference in
root length was not recorded in any molars the healing pattern was observed between the
(Table 2e). The mean (± S.D.)/median bone loss test and control groups with respect to the
was 4.9 (2.4)/3.6 mm for the test group and presence of a PPD of < 5 mm without BoP/Sup.
4.5 (0.9)/4.2 mm for the control group, and no Only one pocket distal to the second molar with
statistically signiﬁcant difference was noted in a PPD of 6 mm with bleeding was recorded in a
this respect between the two groups (Table 2d). patient in the control group.
Baseline examination

56 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[57] =>

Removal of partially erupted mandibular third molars

Plaque

Baseline

1 month

6 months

Te s t ( 1 6 )

16

4

5

Control (17)

17

0

All (33)

33

0

BoP

Baseline

6 months

Te s t ( 1 6 )

14

6

9

Control (17)

15

8

14

All (33)

29

14

Table 2a

Table 2b

PPD

Baseline

6 months

Bone loss

Baseline

6 months

Te s t ( 1 6 )

7.5 (1.5)/7

4.1 (1.1)/4

Te s t ( 1 6 )

4.9 (2.4)/3.6

3.5 (1.6)/2.9

Control (17)

7.3 (1.5)/7.5

3.8 (1.4)/4.5

Control (17)

4.5 (0.9)/4.2

3.1 (1.4)/3.3

All (33)

7.4 (1.5)/7

4.0 (1.2)/4

All (33)

4.4 (1.6)/4.1

3.2 (1.5)/3.3

Table 2c

Table 2d

Tables 2a–e
Baseline

6 months

Bone loss
≤ 1/3

Bone loss
1/3–2/3

Bone loss
> 2/3

Bone loss
≤ 1/3

Bone loss
1/3–2/3

Bone loss
> 2/3

Te s t ( 1 6 )

13

3

0

15

1

0

Control (17)

13

4

0

16

1

0

All (33)

26

7

0

31

2

0

Clinical and radiographic
measurements at baseline and
at the one- and six-month
examinations.

Table 2e

The radiographic measurements found no bone
loss in either group. The bone level (mean/
median) at six months was 3.5/2.9 mm in the test
group and 3.1/3.3 mm in the control group, with a
gain of 0.7 mm in the test group and 0.8 mm in
the control group with respect to the baseline
value (Table 2d; Figs. 4a & b).

Discussion
The results of the present study showed that in
subjects presenting with localized periodontal
disease distal to mandibular second molars the
periodontal condition improved at six months
after extraction of the adjacent partially erupted
third molars and subgingival plaque debridement. All of the distal sites of the second molars
showed a clinically significant reduction in PPD
and the radiographic measurements indicated
bone gain distal to the second molars for both
the test and control groups.
The presence of periodontal disease at the
second molars adjacent to third molars in subjects with low severity of periodontal disease in

the overall dentition has been reported in other
studies.1, 3, 5 None of the patients included in
our study had signs of periodontal attachment
or bone loss at the dentition except distal to the
second molar. However, considering the young
age of the sample (mean age of 27.4, S.D. ± 7.8)
and the radiographic mean bone loss distal to
the second molar of 4.9 mm (S.D. ± 2.4), the
annual rate of bone loss distal to the second
molar (if calculated from the age of 17) was approximately 0.4 mm/year. This rate is comparable to the annual bone loss (> 0.2 mm/year) in
subjects with rapid disease progression described
in longitudinal epidemiological studies.16–18
When early stages of periodontal pathology are detected, the removal of third molars
may improve the periodontal status at the distal sites of second molars.6, 7 In our study, both
the test and control groups showed relatively
good plaque control distal to the second molars
after the removal of the third molars. This may
be related to easier access for self-performed
plaque control distal to the second molars once
the third molars had been extracted. The test

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

57

Table 2a: Plaque present at the
distal sites of second molars.
Table 2b: BoP present at the
distal sites of second molars.
Table 2c: Mean
(± S.D.)/median PPD (mm)
at the distal sites of second
molars.
Table 2d: Mean
(± S.D.)/median radiographic
bone level (mm) at the distal
sites of second molars.
Table 2e: Number of second
molars with distal bone loss
with respect to root length.

[58] =>

Removal of partially erupted mandibular third molars

Figs. 4a & b

Figs. 4a &b

Radiographic images before
and six months after the
extraction of tooth #38. The
bone healing distal to tooth
#
37 is noticeable.

group, who received the dental hygienist treatment at one month after the extraction, presented with a lower number of sites with
plaque and sulcular gingival bleeding compared with the control group, but the differences did not reach statistical significance.
At the six-month evaluation, both groups
had a clinically relevant PPD reduction distal to
the second molars, and only one patient (in the
control group) presented with a PPD of 6 mm.
Thus, no additional surgical periodontal treatment was needed, except in one patient. In this
respect, it should be underlined that, after the
extraction of the third molars, meticulous debridement distal to the second molars was performed, together with removal of the granulation tissue. In a literature review, Aloy-Prósper
et al. also concluded that debridement of the
distal radicular surface of the second molars,
together with oral hygiene control, reduced
PPD values after the extraction of third
molars.19 Leung et al., in their clinical study,
concluded that plaque control prevented residual pockets at periodontally involved second
molars six months after the removal of the adjacent third molar.10
In our study, no bone loss distal to the second molars was recorded. In a study evaluating
the adjunctive effect of guided tissue regeneration in conjunction with surgical removal of an
impacted third molar, Karapataki et al. concluded that an intrabony defect distal to the
second molars would depend on the existing
amount of periodontal ligament of the second
molar and whether this was affected by periodontal disease before surgery.20 Thus, undiagnosed periodontal lesions and the presence of bacteria on the root surface of second
molars might affect wound healing in the area
and develop into a persistent intrabony defect.
These defects require surgical treatment at a

later time.21 In our study, the periodontal condition distal to the second molars in all of the
patients (except one in the control group) at the
six-month evaluation did not require additional
periodontal surgical treatment.
Kan et al. investigated the periodontal condition distal to mandibular second molars
6–36 months after routine surgical extraction
of adjacent impacted third molars in 158 subjects under 40 years of age.11 Three possible
risk indicators were associated with localized
increased PPD: third molar mesio-angular impaction; pre-extraction signs of bone loss; and
inadequate post-extraction local plaque control.11
In our study, the majority of the patients
(76%) were under 30 years of age, without
compromised general condition, only three
were smokers and none had periodontal disease, except at the distal sites of their second
molars. Furthermore, 79% of the subjects had
bone loss distal to the second molars not exceeding one-third of the root length and no patient presented with bone loss exceeding twothirds of the root length. All of these factors
could have had a positive effect on the healing
pattern. The moderate bone loss distal to the
second molars at baseline could also have had a
positive effect on the soft-tissue healing, preventing concavity in the gingiva, which could
have been a retaining factor for plaque.
In the interpretation of similar studies, it is
important to distinguish between those reporting results on totally impacted and on partially erupted third molars. Moss et al. reported
results from 7,000 subjects (mean age of 62)
and found that the PPD at the first or second
molars was significantly higher when partially
erupted third molars were present, compared
with totally impacted third molars.2 Similarly,
in 52- to 74-year-old patients in the Dental

58 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[59] =>

Removal of partially erupted mandibular third molars

Atherosclerosis Risk in Communities Study,
the presence of visible third molars was associated with a 50% increased probability of a PPD
of > 5 mm at adjacent second molars.22 This
finding has also been confirmed in a group of
5,831 young adults (18–34 years old) in the
U.S. Third National Health and Nutrition Examination Survey, where the presence of visible
third molars was associated with twice the
probability of a PPD of > 5 mm at the adjacent
second molars.1

Conclusion
In the presence of localized periodontal disease
distal to second molars, early diagnosis, extraction of the third molar and debridement at the
distal site of the second molar were an effective
treatment of localized periodontal disease, because no additional surgical periodontal treatment was needed at the six-month follow-up.

Competing interests
Regarding postoperative events, only two
patients in our study came to the clinic before
suture removal because of postoperative pain.
At this time, the extraction alveoli were rinsed
with sterile saline and a prescription for
stronger analgesics was given, but there was
no need for any antibiotic prescription. This
confirms the findings that the removal of third
molars in younger subjects compared with
older subjects decreases the risk of complications; the age of 25 appears to be critical, after
which complications increase more rapidly.8 It
should be underlined that in our study the removal of third molars was performed by an experienced dentist in this area of dentistry
(ASP), who meticulously removed the plaque
and calculus accumulated at the distal sites of
the second molars.

Anne-Sofie Pipkorn,* †
Giovanni Serino,‡ †
Alberto Turri§ **
& Maryam Mir Taramsari‡

The authors declare that they have no competing
interests.

Acknowledgments
This project was supported by grants
#VGFOUSA-P-289301 and VGFOUSAP 152431
from the research and development unit for
primary care and dental services, Southern
Älvsborg County (Borås, Sweden).

Corresponding author:

Department of oral surgery, Södra Älvsborg
Hospital, Borås, Sweden

Dr. Giovanni Serino
Department of periodontology
Södra Älvsborg Hospital
501 82 Borås
Sweden

Research and development unit for primary care
and dental services, Southern Älvsborg County,
Borås, Sweden

T +46 33 661 3750
F +46 33 616 1235
giovanni.serino@vgregion.se

*

†

‡

Department of periodontology, Södra Älvsborg
Hospital, Borås, Sweden

§

Brånemark Clinic, Institute of Odontology,
Gothenburg, Sweden

**

BIOMATCELL VINN Excellence Center of
Biomaterials and Cell Therapy, Gothenburg,
Sweden

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

59

[60] =>

Removal of partially erupted mandibular third molars

References
1.
Elter JR, Cuomo CJ, Offenbacher S,
White RP Jr. Third molars associated
with periodontal pathology in the
Third National Health and Nutrition
Examination Survey.
→ J Oral Maxillofac Surg.
2004 Apr;62(4):440–5.
2.
Moss KL, Oh ES, Fisher E, Beck JD,
Offenbacher S, White RP Jr. Third
molars and periodontal pathologic
ﬁndings in middle-age and older
Americans.
→ J Oral Maxillofac Surg.
2009 Dec;67(12):2592–8.
3.
Blakey GH, Gelesko S, Marciani RD,
Haug RH, Offenbacher S, Phillips C,
White RP Jr. Third molars and
periodontal pathology in American
adolescents and young adults: a
prevalence study.
→ J Oral Maxillofac Surg.
2010 Feb;68(2):325–9.
4.
Marciani RD. Is there pathology
associated with asymptomatic third
molars?
→ J Oral Maxillofac Surg.
2012 Sep;70(9 Suppl 1):S15–9.
5.
Dicus-Brookes C, Partrick M, Blakey
GH 3rd, Faulk-Eggleston J,
Offenbacher S, Phillips C, White RP
Jr. Removal of symptomatic third
molars may improve periodontal
status of remaining dentition.
→ J Oral Maxillofac Surg.
2013 Oct;71(10):1639–46.
6.
Blakey GH, Parker DW, Hull DJ,
White RP Jr, Offenbacher S, Phillips
C, Haug RH. Impact of removal of
asymptomatic third molars on
periodontal pathology.
→ J Oral Maxillofac Surg.
2009 Feb;67(2):245–50.
7.
Montero J, Mazzaglia G. Effect of
removing an impacted mandibular
third molar on the periodontal status
of the mandibular second molar.
→ J Oral Maxillofac Surg.
2011 Nov;69(11):2691–7.

8.
Pogrel MA. What is the effect of
timing of removal on the incidence
and severity of complications?
→ J Oral Maxillofac Surg.
2012 Sep;70(9 Suppl 1):S37–40.

14.
Eggen S. [Simpliﬁcation and
standardization of intraoral
radiography technics].
→ Quintessenz.
1969 Jul;20(7):109–12. German.

9.
Kugelberg CF, Ahlström U, Ericson S,
Hugoson A. Periodontal healing after
impacted lower third molar surgery.
A retrospective study.
→ Int J Oral Surg.
1985 Feb;14(1):29–40.

15.
Björn H, Halling A, Thyberg H.
Radiographic assessment of marginal
bone loss.
→ Odontol Revy.
1969; 20(2):165–79.

10.
Leung WK, Corbet EF, Kan KW, Lo
EC, Liu JK. A regimen of systematic
periodontal care after removal of
impacted mandibular third molars
manages periodontal pockets
associated with the mandibular
second molars.
→ J Clin Periodontol.
2005 Jul;32(7):725–31.
11.
Kan WK, Liu JK, Lo, EC, Corbet EF,
Leung WK. Residual periodontal
defects distal to the mandibular
second molar 6–36 months after
impacted third molar extraction.
A retrospective cross-sectional study
of young adults.
→ J Clin Periodontol.
2002 Nov;29(11):1004–11.
12.
Nordenram Å. Lambåteknik vid
exstirpation av den retinerade tredje
molaren I underkäken. En kritisk
värdering och redovisning av en
speciell metod [Flap technique in the
extraction of the impacted lower
third molar. A critical assessment and
account of a special method].
→ Sven Tandlak Tidskr.
1970 Oct;63(10):687–94. Swedish.
13.
Ainamo J, Bay I. Problems and
proposal for recording gingivitis and
plaque.
→ Int Dent J.
1975 Dec;25(4):229–35.

60 Volume 1 | Issue 1/2015

16.
Löe H, Ånerud Å, Boysen H, Morrison
E. Natural history of periodontal
disease in man. Rapid, moderate and
no loss of attachment in Sri Lankan
laborers 14 to 46 years of age.
→ J Clin Periodontol.
1986 May;13(5):431–45.
17.
Papapanou PN, Wennström JL.
A 10-year retrospective study of
periodontal disease progression.
Clinical characteristics of subjects
with pronounced and minimal
disease development.
→ J Clin Periodontol.
1990 Feb;17(2):78–84.
18.
Hugoson A, Laurell L. A prospective
longitudinal study on periodontal
bone height changes in a Swedish
population.
→ J Clin Periodontol.
2000 Sep;27(9):665–74.
19.
Aloy-Prósper A, García-Mira B,
Larrazabal-Morón C, PeñarrochaDiago M. Distal probing depth and
attachment level of lower second
molars following surgical extraction
of lower third molars: a literature
review.
→ Med Oral Patol Oral Cir Bucal.
2010 Sep;(15)5:755–9.
20.
Karapataki S, Hugoson A, Kugelberg
CF. Healing following GTR treatment
of bone defects distal to mandibular
2nd molars after surgical removal of
impacted 3rd molars.
→ J Clin Periodontol.
2000 May;27(5):325–32.

Journal of
Oral Science & Rehabilitation

21.
Karapataki S, Hugoson A, Falk H,
Laurell L, Kugelberg CF. Healing
following GTR treatment of intrabony
defects distal to mandibular 2nd
molars using resorbable and
non-resorbable barriers.
→ J Clin Periodontol.
2000 May;27(5)333–40.
22.
Elter JR, Offenbacher S, White RP Jr,
Beck JD. Third molars associated
with periodontal pathology in older
Americans.
→ J Oral Maxillofac Surg.
2005 Feb;63(2):179–84.

[61] =>

1 Year Clinical Masters Program
TM

in Implant Dentistry
12 days of intensive live training with the Masters in Heidelberg (DE), Reims (FR), Athens (GR)

Live surgery observation and hands-on with the masters in their own
institutes, plus online mentoring and on-demand learning at your own pace
and at your own location.
Learn from the Masters of Implant Dentistry:

Registration information:
12 days of live training with the Masters
in Heidelberg (DE), Reims (FR), Athens (GR) + self study

Curriculum fee: €11,900
(Based on your schedule, you can register for this program one session at a time.)

Collaborate
on your cases

University
of the Paciﬁc

and access hours of
premium video training
and live webinars

you will receive
a certiﬁcate from the
University of the Paciﬁc

Tribune Group GmbH is the ADA CERP provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry.

Details on www.TribuneCME.com
contact us at tel.: +49-341-484-74134
email: request@tribunecme.com

100 C.E.

CREDITS

Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

[62] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

A volumetric
3-D digital analysis of
dimensional changes to the
alveolar process at implants
placed immediately into
extraction sockets

Abstract
Objective

The objective of this study was to validate the use of a
novel method to elaborate 3-D data on dimensional
changes to the alveolar process after one year of healing at implants placed immediately into extraction
sockets.
Materials and methods

Ten consecutive subjects were recruited and included in the test. Impressions were taken using
polyvinyl siloxane before tooth extraction and one
year after implant placement, and gypsum casts
were obtained.
The two casts were digitalized using a laboratory
laser scanner and imported into two different analysis software programs for 2-D and 3-D analyses. In
order to analyze global errors of the 3-D procedure,
a contralateral control site was included.
Results

The 2-D analysis indicated a tendency to higher horizontal resorption of the alveolar process in the central regions compared with the mesial and distal regions. Similar results were observed at the lingual/palatal aspect
and in the global horizontal variation.
The 3-D analysis found that, when the absolute values
were taken into account, the larger the region of interest,
the higher the volume loss, with a positive linear correlation between the two variables (R2 = 0.9346; y = 0.126x).
62 Volume 1 | Issue 1/2015

The global volume loss in percentage was 12.7 ± 3.1%,
of which 5.9 ± 1.9% was at the buccal and 6.8 ± 2.2% at
the lingual/palatal aspects. The difference between the
two aspects was not statistically significant. Small
variations in volume at the control sites were also observed that represented the errors included in the 3-D
analysis.
Conclusion

The 2-D method can be very useful for understanding
changes at a localized point. The 3-D method proposed
is faster, more accurate at expressing the volume loss
and correlated to the dimensions of the analyzed region.
The use of this method is consequently highly recommended.
Keywords

Implant dentistry, bone healing, extraction socket,
Type I placement, immediate implant, IPIES (implants
placed immediately into extraction sockets).

Journal of
Oral Science & Rehabilitation

[63] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Introduction
A recent systematic review of the literature regarding dimensional changes to the hard and
soft tissue after tooth extraction was
evaluated.1 A vertical hard-tissue loss of 11–
22% after six months of healing was found.
When the combined hard- and soft-tissue dimensional changes were considered, a variation
of +0.1 to -0.9 mm after six months and of +0.4
to -0.8 mm after 12 months was found. A horizontal dimensional reduction of the hard tissue
of between 29% and 63% was observed six to
seven months after tooth extraction. When the
combined hard- and soft-tissue dimensional
changes were considered, a loss of 1.3 mm after
three months and of 5.1 mm after 12 months was
found. Moreover, the reduction was more rapid
during the ﬁrst three to six months, followed by
a minor gradual reduction in dimensions thereafter.
In that review, the methods of measurement
of the dimensional variation between the time of
extraction and the subsequent period of reanalysis were also reported. For the hard tissue,
radiographs, computed tomography scans,
cone beam computed tomography scans, or reentry surgical procedures that included stents
or other references were used for the analysis of
the dimensional changes. For the combined
hard- and soft-tissue dimensional changes, the
casts mainly were analyzed.
Dimensional changes to the alveolar process
may be analyzed using digitalized images
(meshes) obtained by various 3-D digital methods: on casts, using laser scanners and structured-light 3-D scanners,2 or chairside using 3D intra-oral photogrammetric systems.3 The reproducibility of these methods has been shown
to be high and their use for analyzing dimensional variations of the alveolar process has been
recommended.4–6 Many of the recent studies
that have used 3-D systems to analyze dimensional variations of the alveolar process, however, lost substantial information in transforming 3-D data to 2-D measurements.7, 8
Volumetric data instead were reported in a
clinical study in which augmentation procedures were used at implants placed in edentulous ridges reduced in volume.9 In the study, a
grid was superimposed on the images so that
both the global difference in volume before and
after treatment and the differences in speciﬁc
areas were reported.

2-D variations of the hard tissue around implants placed immediately into extraction
sockets have been reported in clinical studies,10, 11 and, in an animal study, combined
hard- and soft-tissue 2-D changes have been
analyzed.12 However, there is a lack of studies
that report volumetric data on combined hardand soft-tissue variation at implants placed
immediately into extraction sockets in humans
using a 3-D system. Hence, the aim of the present study was to validate the use of a novel
method to elaborate 3-D data on dimensional
changes to the alveolar process after one year
of follow-up at implants placed immediately
into extraction sockets.

Materials & methods
The research protocol was approved by the ethics
committee of Azienda Ospedaliera di Padova, Department of Neurosciences, University of Padua
(protocol #2629P; 10 April 2012).
Patient selection

In order to be recruited for the study, the patients had to meet the following inclusion criteria: willing to participate for the duration of the
study and to provide informed consent, at least
18 years of age, in good general health, presence of a tooth to be extracted, willing to accept
the immediate placement of an implant into
the extraction socket, and presence of adjacent
teeth both mesially and distally. The following
exclusion criteria were adopted: pregnancy or
untreated dental disease. Smoking status was
recorded, but was not considered a contraindication to treatment. Patients were advised that
smoking is associated with an increased risk of
implant failure.
Ten consecutive subjects were recruited.
Written consent was obtained from the patients.
All patients received a careful dental and periodontal examination, followed by oral hygiene
instructions and dental and periodontal treatment, when necessary. All treatments and follow-ups were carried out in one clinic in Italy between September 2012 and September 2014.
An impression using polyvinyl siloxane (Sky
Putty and Sky Light, Sweden & Martina, Due Carrare, Italy) was taken before tooth extraction
(Time 0 = T0) and a gypsum cast was obtained
(ORTOTYPO 4, LASCOD, Sesto Fiorentino, Italy).

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

63

[64] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Figs. 1 & 2
The two meshes (red T0 and
purple T1) superimposed
together were cut seven times
vertically and six times
horizontally using a Python
script for Rhinoceros.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Subsequently, local anesthesia was administered and the tooth was extracted. An implant
was immediately placed into the extraction
socket and no ﬁller material or membrane was
used. Implants with a ZirTi surface (Premium TG,
Sweden & Martina, Due Carrare, Italy) were
placed. A cover screw was placed on top of the
implant and resorbable sutures were provided.
No temporary prosthesis was seated. Antibiotics
(amoxicillin 875 mg and clavulanic acid 125 mg
b.i.d. for six days) and analgesics if needed were
prescribed and the patients were enrolled in a
maintenance follow-up. A porcelain-fused-tometal crown was provided to the patients approximately three months after placement. Another impression was taken 12 months after implant placement (Time 1 = T1).

Canada). The meshes (digital models) generated in this manner were imported into 3-D
elaborating mesh software (Geomagic Studio
and Geomagic Qualify, Geomagic, Berlin, Germany) and cleaned of defects.
The meshes were transformed from a surface to a solid. Subsequently, teeth surfaces
that coincided on the meshes obtained from
both casts were selected and the two digital
models were superimposed, accepting values
of average convergence distance of < 0.1 mm.
The 2-D analysis was performed using the
occlusal plane as the reference plane.7 From
this reference, a perpendicular plane in the lingual– or palatal–vestibular direction (crosssection) was created and the two meshes superimposed were cut (Figs. 1 & 2).

Fig. 3
A vertical 2-D cut was taken in
the middle. In red is the
section of the ﬁrst mesh (T0)
and in black the second mesh
at (T1). The distance between
two points was taken for the
measurements in absolute
values.
Fig. 4
The width of the alveolar
process was also measured.
The red line represents the
width at T0 and the blue line
at T1.

The grid used to section the meshes was made
by taking the middle point of the vestibular
The casts obtained from the first and second marginal gingiva of the tooth to be extracted as
impressions were digitalized using a 3-D laser the reference point (0) and creating vertical and
scanner (Dental Wings 7Series, Montreal, horizontal planes starting from that point:
2-D digital analysis

64 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[65] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Fig. 5

Fig. 6

Vertically: Seven vertical planes located at +3,
+2, +1, 0, -1, -2 and -3 mm from the mesial (+3) to
the distal aspect (-3);
Horizontally: Six horizontal planes at 0 (vestibular marginal gingiva), -1, -2, -3, -4 and -5 mm
from the most coronal (0) to the most apical (-5).

Fig. 7

The occlusal plane, the cutting procedure and the
distance analysis were performed with automated
Python scripts for Rhinoceros software (Robert
McNeel & Associates, Seattle, Wash., U.S.) to reduce human error during elaboration. A total of 42
points for horizontal variation for each side was
tested: 42 at the buccal aspect and 42 at the lingual/palatal aspect. The vertical variation was
measured at seven points at the buccal aspect and
seven points at the lingual/palatal aspect. Using
the measures of the alveolar process at T0 and at
T1, the dimensional variations (Δ) were expressed
in absolute (Fig. 3)and relative (Fig. 4)values (in respect of the total alveolar width).

the technical procedures applied to obtain the
casts. Finally, the delimited areas were elaborated by closing the holes and obtaining a solid
that represented the buccal and lingual/palatal
volume changes (Fig. 6). The ﬁle containing the
data on the solid was exported in STL format and
imported into Rhinoceros for volumetric analysis.
In order to obtain standardized data, the
solid was further elaborated using the Geomagic software. Only the outer surfaces were
maintained, while the rest of the solid was
eliminated.
The two outer surfaces were combined together with bridges and, after closing the gaps
(between bridges), another solid was generated that represented the global volume of the
alveolar process delimited into the ROI (V-ROI;
Fig. 7) before volume changes (i.e., at T0). Similar procedures were applied to the corresponding contralateral control site to obtain volume
changes between T0 and T1.

3-D digital analysis

Vo l u m e t r i c a n a l y s i s

The 3-D analysis was performed by subtracting
the volume of the second mesh (T1) from that of
the ﬁrst mesh (T0), generating a resulting volume that represented the difference between
the two meshes (Boolean difference). Consequently, the software automatically deﬁned the
limits of the volume loss. The region of interest
(ROI) was manually delimited mesially and distally using as limits a plane crossing through the
middle of the crown of the two adjacent teeth.
The limits of the ROI were decided on because
the main volume changes were included in that
region, as indicated by the mesh-to-mesh deviation (Δ; Fig. 5) performed with the Rhino Open
Projects for Rhinoceros plug-in.
Using the Geomagic software, the two
meshes (T0 and T1) were further cleaned of the
teeth and of apical imperfections derived from

The average convergence distance represents
the misﬁt between the two meshes. The differences in volume (Δ) between the meshes of the
two periods at the extraction sites were calculated as total amount (V-tot), as well as for the
buccal (V-b) and lingual/palatal (V-l) aspects
separately, and expressed in mm3.
In order to reduce the variability associated
with the use of absolute measurements in mm3
due to the dimensional variability of patients’
arches, the relative percentage of loss was also
calculated in relation to the V-ROI at T0. Percentages of the total amount (V-tot%) and of the buccal (V-b%) and lingual/palatal (V-l%) aspects
were obtained.
At the control sites, the same methodology
for measurements was applied for both absolute
and relative (percentage) values, and the results

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

Fig. 5
The mesh-to-mesh deviation
utility in Rhino Open Projects.
The red area represents the
volume loss. The area most
affected by resorption
corresponds to about the
vertical middle line of the two
adjacent teeth.
Fig. 6
Palatal and buccal volumes,
isolated from the rest of the
model during 3-D elaboration.
They represent the volume
loss in the ROI and can be
measured as absolute values
in mm3.
Fig. 7
ROI volume of the ﬁrst mesh,
which represents the volume
of the alveolar process at T0,
expressed in mm3.

[66] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

were used to deﬁne the global errors of the procedure due to the Boolean method, superimposition, impression taking, gypsum casting and 3-D
scanning.
Data analysis

tively, and a global volume loss of 144.1 ± 61.2
mm3 was observed. The global volume loss in
percentage was 12.7 ± 3.1%, showing a lower
variability of the results between sites compared with the absolute values (Table 5). The loss
was 5.9 ± 1.9% at the buccal and 6.8 ± 2.2% at
the lingual/palatal aspects, the difference not
being statistically significant. Small variations
in volume at the control sites were also observed that represented the errors included in
the 3-D analysis.

Mean values and standard deviations were
calculated for the 2-D data, while mean values and standard deviations, as well as the
25 th , 50th (median) and 75th percentiles, were
calculated for the 3-D data. Differences in the
volumetric variation (Δ) between the implant
Discussion
and the contralateral sites were analyzed using the Wilcoxon signed-rank test. The level
of significance was set at α = 0.05. In case of
2-D analysis
normal distribution, a t-test was also performed.
The 2-D analysis demonstrated a reduction of the
dimensions at both the buccal and lingual/palatal
aspects. However, the analysis of each intersecResults
tion point and the comparison of all of the patients
were very demanding. Moreover, the variability
2-D analysis
per intersection point was very large, making
drawing conclusions using this method difﬁcult. It
At the buccal aspect (Table 1), a tendency to higher is, of course, possible to select just one intersechorizontal resorption of the alveolar process was tion point and compare it with the lingual/palatal
seen in the central regions where tooth extraction aspect or with that of other patients. However, to
was performed compared with the mesial and dis- perform a complete analysis of the phenomenon,
tal regions. Moreover, the resorption had a ten- 42 intersection points (such as those that comdency to be higher at the coronal aspects com- posed the grid) were analyzed.
pared with the apical. The horizontal resorption
2-D analysis offers advantages for investigavaried between 3% and 25%, depending on the in- tion of defect shape and for analysis of local deterception point from which it was analyzed, the fects. However, limits to consider include the use
highest variation being in the central/coronal re- of 2-D numbers to express 3-D aspects, the lack of
gions, and the lowest being at the mesiodistal/api- information about the size of the area affected by
cal regions. Similar results were observed at the the resorption, and the huge amount of data that
lingual/palatal aspect (Table 2) and in the global must be recorded and that require a great deal of
time to analyze.
horizontal variation (Table 3).
Moreover, great variability in resorption exists,
The vertical resorption of the alveolar process
analyzed on the seven vertical cutting planes was depending on where the volume loss is investihigher in the mesial and distal regions compared gated. In the present study, a horizontal mean
with the central regions at the buccal aspect. A global volume loss of 3.8–43.9% in the analyzed
tendency to higher resorption was seen in the cen- area made it impossible to summarize the phetral regions at the lingual/ palatal aspect (Table 4). nomenon with a unique number that expresses
the volume loss. For the vertical loss in the 2-D
analysis, the results have to be reported in mil3-D analysis
limeters, since it does not seem to be appropriate
When the absolute values were taken into ac- to report data in percentages because of the lack
count (Table 5), it was observed that the larger of a reference dimension.
the ROI, the higher the volume loss, with a positive linear correlation between the two vari3-D analysis
2
ables (R = 0.9346; y = 0.126x). The volume loss
was 69.7 ± 39.1 mm3 and 74.3 ± 29.8 mm3 at The 3-D analysis showed that shrinkage of the volthe buccal and lingual/palatal aspects, respec- ume of the alveolar process occurred at both the
66 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[67] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Table 1

Table 1
VP3

VP2

VP1

VP0

VP-1

VP-2

VP-3
2-D analysis. Mean values and
standard deviations of the
horizontal reduction of the
buccal aspect of the alveolar
process at the 42 intersection
points in %.
HP = Horizontal plane;
VP = Vertical plane.

HP 0

-14.8 (7.1)

-17.5 (4.6)

-24.0 (24.0)

-16.8 (17.8)

-20.0 (15.9)

-18.0 (10.5)

-12.5 (5.7)

HP -1

-12.7 (6.5)

-15.7 (7.0)

-17.6 (8.2)

-15.9 (7.5)

-15.7 (6.1)

-12.5 (3.3)

-9.5 (4.4)

HP -2

-9.1 (5.6)

-11.0 (5.8)

-12.2 (5.1)

-11.9 (4.1)

-10.6 (3.4)

-9.2 (3.8)

-7.0 (3.6)

HP -3

-6.7 (5.1)

-8.1 (5.5)

-8.8 (5.0)

-8.9 (4.7)

-8.3 (4.3)

-6.7 (3.7)

-5.0 (2.9)

HP -4

-4.6 (4.7)

-5.7 (5.3)

-5.9 (5.0)

-5.6 (4.4)

-5.1 (3.7)

-4.1 (2.9)

-3.0 (2.3)

HP -5

-2.6 (3.7)

-3.3 (4.3)

-3.6 (4.2)

-3.4 (4.2)

-3.1 (3.9)

-2.6 (3.1)

-2.0 (2.4)

VP3

VP2

VP1

VP0

VP-1

VP-2

VP-3

HP 0

-9.4 (3.9)

-14.7 (4.2)

-19.9 (7.8)

-24.1 (14.1)

-20.9 (8.4)

-19.7 (9.5)

-17.9 (13.6)

HP -1

-7.6 (5.6)

-11.1 (5.6)

-14.6 (9.2)

-17.7 (12.7)

-15.4 (10.1)

-11.8 (6.6)

-8.5 (4.6)

HP -2

-4.1 (3.1)

-6.0 (3.7)

-7.6 (4.6)

-8.7 (4.8)

-8.1 (4.5)

-6.8 (3.9)

-5.2 (3.0)

HP -3

-2.7 (2.0)

-3.3 (2.3)

-4.3 (2.8)

-4.8 (2.7)

-4.6 (2.4)

-4.1 (2.1)

-3.5 (2.0)

HP -4

-1.7 (1.4)

-2.0 (1.8)

-2.7 (2.0)

-2.9 (1.8)

-2.9 (1.8)

-2.8 (1.8)

-2.7 (1.7)

HP -5

-1.2 (1.3)

-1.1 (1.4)

-1.5 (1.7)

-2.0 (1.9)

-2.2 (1.6)

-2.1 (1.5)

-2.1 (1.5)

VP3

VP2

VP1

VP0

VP-1

VP-2

VP-3

HP 0

-24.2

-32.2

-43.9

-40.9

-40.9

-37.8

-30.4

HP -1

-20.4

-26.8

-32.2

-33.6

-31.1

-24.3

-18.0

HP -2

-13.2

-17.0

-19.8

-20.6

-18.7

-15.9

-12.2

HP -3

-9.4

-11.3

-13.1

-13.7

-12.9

-10.8

-8.5

HP -4

-6.2

-7.6

-8.6

-8.5

-7.9

-6.9

-5.7

HP -5

-3.8

-4.4

-5.2

-5.4

-5.3

-4.7

-4.0

Table 2

Table 2

2-D analysis. Mean values and
standard deviations of the
horizontal reduction of the
lingual/palatal aspect of the
alveolar process at the 42
intersection points in %.
HP = Horizontal plane;
VP = Vertical plane.

Table 3

Table 3

buccal and lingual/palatal aspects after tooth extraction and immediate placement of an implant in
the extraction socket. A global volume loss of
12.7% was observed, being 5.9% at the buccal and
6.8% at the lingual/ palatal aspects. The difference
was not statistically signiﬁcant. These outcomes
differ from those reported on 2-D variations of the
alveolar process13 or of the bony crest.10, 11 In those
studies, however, a single reference point was
used, while the global volume of the ROI was analyzed in the present study. Moreover, the studies
on bony crest variation did not include measurements of soft-tissue dimensions. It has to be considered that the procedure used in the present
study allowed for the use of 2-D data too regarding
a single intersection point or single plane, and this
may have permitted a more complete analysis.
The 3-D method can be affected by various errors related to the impression, model fabrication,
3-D scanning (reverse engineering phase), mesh

2-D analysis. Global horizontal
reduction of the alveolar
process in % represented by
the sum of the mean values of
the buccal and lingual/palatal
reduction at the 42
intersection points.
HP = Horizontal plane;
VP = Vertical plane.

creation, 3-D elaboration and superimposition.
In the present study, the dimensional variations
between the two periods (T0 and T1) at the contralateral sites were also analyzed. Small variations were found, most likely due to the errors
included in the method. The differences between the implant sites and the contralateral
sites were highly statistically significant. This,
in turn, meant that these errors did not affect
the data that this 3-D method produced and the
volume differences found were not due to the
case or to errors, but to the biological phenomenon of resorption.
In the present study, a positive linear correlation between the global volume of the ROI and
the volume loss was found. This means that the
larger the jaw, the larger the resorption. This observation makes it senseless to investigate volume loss with a superimposed standardized
grid for analysis. In fact, in the present study, a

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

67

[68] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Table 4

Table 4
Vertical plane

Buccal aspect

Lingual/palatal aspect

3

-1.4 (0.6)

-1.1 (0.5)

2

-1.2 (0.4)

-1.2 (0.6)

1

-0.8 (0.5)

-1.5 (0.6)

0

-0.5 (0.7)

-1.3 (1.2)

-1

-0.6 (0.9)

-1.5 (0.8)

-2

-0.9 (0.6)

-1.1 (1.6)

-3

-1.2 (1.0)

-1.0 (1.6)

2-D analysis. Mean values and
standard deviations of the
vertical reduction of the buccal
and lingual/palatal aspects of
the alveolar process at the
most coronal of the seven
intersection points in mm.

Table 5

Test implant site

3

Δ V-b mm

Δ V-l mm

3

Δ V-tot mm

V-ROI mm

Δ V-b%

Δ V-l%

Δ V-tot%

Mean (S.D.)

69.7 (39.1)

74.3 (29.8)

144.1 (61.2)

1202.9 (524.4)

5.9 (1.9)

6.8 (2.2)

12.7 (3.1)

Median
(25 ; 75th percentiles)

63.8*
(34.4; 105.4)

75.5*
(49.6; 88.8)

134.3*
1288.5
(106.0; 174.5) (895.3; 1557.8)

6.4*
(5.4; 7.1)

6.7*
(5.6; 8.3)

12.9*
(11.8; 13.4)

Mean (S.D.)

1.98 (1.74)

3.31 (4.04)

5.29 (5.24)

1202.9 (524.4)

0.18 (0.13)

0.39 (0.42)

0.57 (0.50)

Median
(25 ; 75th percentiles)

1.73*
(0.60; 3.31)

2.67*
(0.17; 3.61)

4.02*
(2.23; 7.11)

1288.5
(895.3; 1557.8)

0.19*
(0.11; 0.26)

0.20*
(0.02; 0.77)

0.45*
(0.18; 0.98)

th

Contralateral
control site

th

3

3

*

A p-value of < 0.05 between the test and control sites.

Table 5
3-D analysis. Mean values,
standard deviations (S.D.),
medians, and 25th and 75th
percentiles of the volume
reduction of the alveolar
process in absolute values in
mm3 and in % at the test and
control sites.

standardized grid was used with squares of
1 mm in dimension and not a grid that was
adapted in dimensions to those of the alveolar
process. It has to be considered that the distance between the two adjacent teeth is not the
same in different locations and in different subjects, so the area covered by a standardized grid
does not include the whole ROI. Moreover, the
measures taken in each intersecting plane do
not represent the same position in all patients.
Consequently, the grid should be adapted to the
dimension of the space between the two adjacent teeth. The use of 2-D analysis may be comparable if used in the middle of the ROI be
cause it is a reference plane easily detected in
all models.
From a clinical perspective, the 3-D method
may help clinicians to understand in a more objective manner what happens to the alveolar
process after tooth extraction and the immediate placement of an implant. Differentiation between hard- and soft-tissue loss cannot be expressed by the data from this 3-D method and
requires a different approach, such as surgical
re-entry or radiographic assessment. The 3-D
68 Volume 1 | Issue 1/2015

analysis used in the present study was found to
be fast, accurate and noninvasive.

Conclusion
The 2-D method can be very useful for understanding changes at a localized point. The 3-D
method proposed is faster, more accurate at expressing the volume loss and correlated to the dimensions of the analyzed region. The use of this
method is consequently highly recommended.

Acknowledgments
The competent contributions of engineers
Gianpaolo Savio, Matteo Turchetto and Andrea
Cerardi in the automation of the 2-D processes of
measurement are highly appreciated. Special
thanks go to L.O.R.I. (Noventa Padovana, Italy) and
Loripadova Tecnologia (Noventa Padovana) for
support in the 3-D processing and to the Ariminum
Research and Dental Education Center, Ariminum
Odontologica, for data analysis and interpretation.
The implants and impression material were provided by Sweden & Martina (Due Carrare, Italy).

Journal of
Oral Science & Rehabilitation

[69] =>

Vo l u m e t r i c 3 - D d i g i t a l a n a l y s i s

Competing interests

Isacco Szathvary,† Marco Caneva,‡
Martina Caneva,‡ Eriberto Bressan,§
Daniele Botticelli‡ & Roberto Meneghello†

The authors declare that they have no competing
interests related to this study.

†

Department of Management and Engineering,
University of Padua, Italy

‡

Ariminum Research and Dental Education Center,
Ariminum Odontologica, Rimini, Italy

§

Department of Neurosciences, School of Medicine
and Surgery, University of Padua, Italy

Corresponding author:
Dr. Daniele Botticelli
Viale Pascoli 67
47923 Rimini
Italy
T +39 0541 39 3444
F +39 0541 39 7044
daniele.botticelli@gmail.com

References
1.
Tan WL, Wong TL, Wong MC, Lang
NP. A systematic review of postextractional alveolar hard and soft
tissue dimensional changes in
humans.
→ Clin Oral Implants Res.
2012 Feb;23 Suppl 5:1–21.
2.
Cerardi A. Caratterizzazione
meccanica, geometrica e funzionale
di dispositivi biomedicali [doctoral
thesis].
→ [Padua]: University of Padua;
2010 [cited 2015 Jul 16]. 199 p.
Available from: http://paduaresearch.
cab.unipd.it/2833/.
3.
Windisch SI, Jung RE, Sailer I, Studer
SP, Ender A, Hämmerle CH. A new
optical method to evaluate threedimensional volume changes of
alveolar contours: a methodological
in vitro study.
→ Clin Oral Implants Res.
2007 Oct;18(5):545–51.
4.
Strebel J, Ender A, Paqué F,
Krähenmann M, Attin T, Schmidlin
PR. In vivo validation of a threedimensional optical method to
document volumetric soft tissue
changes of the interdental papilla.
→ J Periodontol.
2009 Jan;80(1):56–61.

5.
Thoma DS, Jung RE, Schneider D,
Cochran DL, Ender A, Jones AA,
Görlach C, Uebersax L, Graf-Hausner
U, Hämmerle CH. Soft tissue volume
augmentation by the use of collagenbased matrices: a volumetric
analysis.
→ J Clin Periodontol.
2010 Jul;37(7):659–66.
6.
Lehmann KM, Kasaj A, Ross A,
Kämmerer PW, Wagner W, Scheller
H. A new method for volumetric
evaluation of gingival recessions: a
feasibility study.
→ J Periodontol.
2012 Jan;83(1):50–4.
7.
Vanhoutte V, Rompen E, Lecloux G,
Rues S, Schmitter M, Lambert F. A
methodological approach to
assessing alveolar ridge preservation
procedures in humans: soft tissue
proﬁle.
→ Clin Oral Implants Res.
2014 Mar;25(3):304–9.
8.
Schneider D, Schmidlin PR, Philipp A,
Annen BM, Ronay V, Hämmerle CH,
Attin T, Jung RE. Labial soft tissue
volume evaluation of different
techniques for ridge preservation
after tooth extraction: a randomized
controlled clinical trial.
→ J Clin Periodontol.
2014 Jun;41(6):612–7.

9.
Friberg B, Jemt T. Soft tissue
augmentation in connection to dental
implant treatment using a synthetic,
porous material—a case series with a
6-month follow-up.
→ Clin Implant Dent Relat Res.
2012 Dec;14(6):872–81.

13.
Schropp L, Wenzel A, Kostopoulos L,
Karring T. Bone healing and soft
tissue contour changes following
single-tooth extraction: a clinical and
radiographic 12-month prospective
study.
→ Int J Periodontics Restorative Dent.
2003 Aug;23(4):313–23.

10.
Botticelli D, Berglundh T, Lindhe J.
Hard-tissue alterations following
immediate implant placement in
extraction sites.
→ J Clin Periodontol.
2004 Oct;31(10):820–8.
11.
Sanz M, Cecchinato D, Ferrus J,
Pjetursson EB, Lang NP, Lindhe J. A
prospective, randomized-controlled
clinical trial to evaluate bone
preservation using implants with
different geometry placed into
extraction sockets in the maxilla.
→ Clin Oral Implants Res.
2010 Jan;21(1):13–21.
12.
Caneva M, Botticelli D, Morelli F,
Cesaretti G, Beolchini M, Lang NP.
Alveolar process preservation at
implants installed immediately into
extraction sockets using
deproteinized bovine bone mineral—
an experimental study in dogs.
→ Clin Oral Implants Res.
2012 Jul;23(7):789–96.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

69

[70] =>

Success of implants placed after direct sinus lift

Influence of smoking
and oral hygiene
on success of implants placed after direct sinus lift

Abstract

Introduction

Objective

Placing implants in the posterior maxilla can be a
complex procedure when there is atrophy of the
alveolar ridge and maxillary sinus pneumatization.
In some cases, these anatomical limitations may
be overcome using sinus lift procedures.1 The success rates of implants placed after sinus lift are
similar to those of implants placed in mature bone.2
However, the residual alveolar bone height appears to inﬂuence implant survival. Rios et al. conducted a systematic review and divided the outcomes into two groups according to residual bone
height: ≤ 4 mm in Group 1 and > 4 mm in Group 2.3
The implant survival rate was 96% (range:
80–100%) for Group 1 and 99% (range: 97–100%)
for Group 2.3
In addition to bone atrophy, factors such as
smoking and poor oral hygiene have been suggested to increase the risk of implant failure in the
posterior maxilla.4 Several studies have addressed
the association between smoking and the outcome of implants placed using conventional techniques;5–7 however, few studies have addressed
the inﬂuence of smoking on the success of implants placed after direct maxillary sinus lift. In all
of the published studies, higher tobacco consumption yielded higher complication and/or implant
failure rates;8–15, 1, 16–19 however, this effect was not
always statistically signiﬁcant (Table 1).6, 12–14
The inﬂuence of oral hygiene has frequently
been considered in implant studies. In some studies, poor hygiene was associated with higher periimplant marginal bone loss.20 Contrarily, other
studies did not ﬁnd this relationship.21–23 However,
evidence relating patient oral hygiene to the outcome of implants placed after direct sinus lift procedures is scarce. Only one study was found, and it
reported a statistically signiﬁcantly higher implant
failure rate in patients with poor oral hygiene.11
The objective of this study was to evaluate the
inﬂuence of smoking and oral hygiene on the success and periimplant marginal bone loss of implants placed in one-stage and two-stage direct
sinus lift procedures.

The objective of this study was to evaluate the inﬂuence of smoking and
oral hygiene on the success and periimplant marginal bone loss of implants placed in one-stage and two-stage direct sinus lift procedures.
Materials and methods

A retrospective clinical study of patients who underwent direct sinus
lift and implant placement was conducted. Forty-six patients with 58
direct sinus lifts were included and a total of 102 implants were placed.
Cigarette consumption was quantiﬁed and the level of oral hygiene determined at the time of surgery using a simpliﬁed calculus and plaque
index. Bone loss and implant success (according to Buser’s criteria)
were monitored after 12 months of prosthetic loading.
Results

The success rate for implants placed after direct sinus lift was 93.1% at
12 months. There was a higher success rate in nonsmokers (94.2%)
than in smokers (90.9%), with a mean bone loss of 0.52 mm (range:
0.21–0.84 mm) in nonsmokers and 0.60 mm (0.24–0.92 mm) in
smokers at the 12-month follow-up. The success rate in patients with
poor oral hygiene was lower (81.8%) than in patients with good
(95.5%) or regular hygiene (92.3%). Furthermore, there was a mean
bone loss of 0.51 mm (0.21–0.82 mm) in patients with good oral hygiene, 0.57 mm (0.24–0.82) with regular hygiene and 0.66 mm with
poor hygiene (0.32–0.92 mm). There was no statistically signiﬁcant
relationship (p > 0.05) between bone loss or implant success and
smoking or oral hygiene.
Conclusion

Within its limitations, the present investigation suggests that smoking and poor oral hygiene may negatively inﬂuence the outcome of implants placed both in one-stage and two-stage direct sinus lift procedures. However, differences were in no case statistically signiﬁcant
and studies with larger sample sizes should be conducted to corroborate or refute these ﬁndings.
Keywords

Sinus lift, oral hygiene, smoking, bone loss.
70 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[71] =>

Success of implants placed after direct sinus lift

Materials & methods

Data collection

The study was approved by the University of Valencia ethics committee (#H1410262226693).
All patients gave written informed consent before surgery, in accordance with the principles of
the Declaration of Helsinki.

Patient oral hygiene was evaluated using the
Simpliﬁed Oral Hygiene Index (OHI-S).24 This was
obtained by measuring the presence of debris and
calculus on the buccal surfaces of the maxillary
right central incisor, mandibular left central incisor and maxillary ﬁrst molars, as well as on the lingual surfaces of the mandibular ﬁrst molars. The
criteria for classifying debris were as follows: no
debris, no stains (0); soft debris covering less than
one-third of the tooth surface (1); soft debris covering more than one-third, but less than twothirds of the exposed tooth surface (2); and soft
debris covering more than two-thirds of the exposed tooth surface (3). The criteria for classifying calculus were as follows: no calculus (0);
supragingival calculus covering less than onethird of the exposed tooth surface (1); supragingival calculus covering more than one-third, but
less than two-thirds of the exposed tooth surface
(2); and supragingival calculus covering more
than two-thirds of the exposed tooth surface (3).
The OHI-S was obtained from the combination of
the two subindices. The grading scale was 0–1.2
(good oral hygiene), 1.3–3 (regular oral hygiene),
or 3.1–6 (poor oral hygiene). Each patient was
classiﬁed as having good oral hygiene, regular
oral hygiene or poor oral hygiene.
The implant success rate was recorded according to the clinical and radiographic criteria of
Buser et al.25 Implants were classiﬁed as successful if they fulﬁlled all of the criteria (absence of clinically detectable implant mobility, absence of pain
or any subjective sensation, absence of recurrent
periimplant infection, and absence of continuous
radiolucency around the implant after 12 months
of loading) and as failed if any criterion was not
met.
Radiographic examination was performed
with an X-Mind intra-oral system (ACTEON
MÉDICO-DENTAL IBÉRICA, Sentmenat, Spain)
and an RVG intra-oral digital receptor (RVG 5100,
Carestream Dental, Atlanta, Ga., U.S.). In order to
reproduce the patient alignments, the Rinn XCP
system (DENTSPLY, Des Plaines, Ill., U.S.) was
used with a bite registration material in the area in
which the parallelometer was ﬁxed. Marginal implant bone loss was measured in millimeters using
the RVG software. For measurement purposes,
two visible and easily locatable reference points
were selected at the junction point between the
implant and prosthetic restoration. A straight line
was traced between these two reference points

Study sample

A retrospective clinical study was performed
between September 2009 and June 2012 of
patients treated with dental implants placed in
one-stage (simultaneous) and two-stage (delayed) direct sinus lift procedures. A minimum
follow-up period of 12 months after implant
loading was requested. Patients who failed to
attend scheduled follow-up visits were excluded.
Surgical procedures

All of the procedures were performed by two
expert surgeons, professors at the Oral Surgery
Unit, Department of Stomatology, University
of Valencia, under local anesthesia with 4% articaine and 1:100,000 epinephrine (Laboratorios Inibsa, Lliçà de Vall, Spain). Full-thickness
flaps were raised. A window in the sinus lateral
wall was made with round tungsten carbide
burs and finalized with ultrasonic tips. The
sinus membrane was detached with curettes
and elevated using a bone graft material.
A xenograft (Geistlich Bio-Oss, Geistlich
Pharma, Wolhusen, Switzerland) was used as
the only bone graft material (1.5–2 g). The
sinus window was covered with a resorbable
membrane (Geistlich Bio-Gide, Geistlich
Pharma, Wolhusen, Switzerland). The implants used in this study were TSA implants
with an Avantblast surface (Phibo Dental Solutions, Sentmenat, Spain). Implants were placed
in the same surgery if the residual bone height
was 4–6 mm, or delayed by six months if the
height was < 4 mm.
All of the patients were prescribed the same
postoperative medication: amoxicillin and
clavulanic acid (Augmentin, GlaxoSmithKline,
Madrid, Spain) 500 mg/8 h for seven days,
ibuprofen (Bexistar, Laboratorio Barcino,
Barcelona, Spain) 600 mg/8 h for three days,
and a 0.12% chlorhexidine mouthrinse (GUM,
Sunstar Americas, Chicago, Ill., U.S.) t.i.d. for
seven days.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

[72] =>

Success of implants placed after direct sinus lift

Fig. 1
Radiographic assessment of
bone level at implant loading.

Fig. 2
Radiographic assessment of
bone level 12 months after
loading.

Fig. 1

Fig. 2

and was considered to represent zero height. In
order to determine bone loss, a perpendicular line
was traced mesial and distal to the implant from
zero height to contact with the bone (Fig. 1). The
difference between the value recorded at the time
of implant loading and after one year of loading
was used to calculate bone loss mesial and distal to
the implant. The largest value, either mesial or
distal, was used as the bone loss value for that implant (Fig. 2).26
Smoking and oral hygiene were recorded at the
time of surgery. A patient who smoked > 1 cigarette/day was considered a smoker following the
deﬁnition by Wallace.27 Bone loss and success
were recorded at 12 months of prosthetic loading.

months thereafter. Implant lengths and diameters
are detailed in Table 2.
Seven implants failed, all prior to loading, yielding an overall implant success rate of 93.1% at 12
months of loading. Five of these implants had been
placed simultaneously and two implants six
months after the grafting procedure. The survival
was 90.0% for implants placed simultaneously
and 96.2% for delayed implants. Overall, the mean
periimplant marginal bone loss was 0.58 mm
(range: 0.24–0.95 mm). Implants placed simultaneously had a mean bone loss of 0.62 mm (range:
0.21–0.97 mm) and implants placed in a second
procedure of 0.54 mm (range: 0.27–0.93 mm;
Table 3).
With respect to smoking, 69 implants were
placed in nonsmokers and 33 in smokers. Nonsmokers presented a higher implant success rate
at 12 months (94.2%) and lower mean bone loss
(0.52 mm; range: 0.21–0.84 mm) than smokers
(90.9% and 0.60 mm; range: 0.24–0.92 mm;
Table 4). However, these differences were not statistically signiﬁcant.
In relation to oral hygiene, 47 of the 102 implants were placed in patients with good oral hygiene, 42 with regular and 13 with poor hygiene. In
patients with poor oral hygiene, the success rate at
12 months was lower (81.8%), compared with patients with regular (92.3%) or good hygiene
(95.5%). Mean bone loss at 12 months was
0.51 mm (range: 0.21–0.82 mm) in patients with
good oral hygiene, 0.57 mm (range: 0.24–
0.82 mm) in patients with regular hygiene, and
0.66 mm in those with poor hygiene (range: 0.32–
0.92 mm; Table 5). The observed differences were
in no case statistically signiﬁcant. The survival rate
of implants placed in patients with poor oral hygiene was lower than in patients with regular or
good hygiene. These differences were close to statistical signiﬁcance (p = 0.058).

Statistical analysis

A descriptive analysis was performed of the study
variables, with their corresponding frequency distributions and measures of central tendency and
dispersion. Statistical comparisons between the
groups were conducted using the chi-squared test
and Student’s t-test. The SPSS for Windows statistical software package (Version 15.0; SPSS,
Chicago, Ill., U.S.) was used throughout. Statistical
signiﬁcance was considered for p < 0.05.

Results
Fifty patients treated with direct sinus lift and implants were monitored during the study period.
Four patients failed to attend scheduled follow-up
visits and were thus excluded. The ﬁnal sample
consisted of 46 patients (16 men and 30 women)
with a mean age of 49 (range: 29–69 years). These
patients underwent 58 direct maxillary sinus lift
procedures and received a total of 102 implants in
the grafted sites: 50 were placed simultaneously
with the sinus lift procedure and 52 were placed six
72 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[73] =>

Success of implants placed after direct sinus lift

Table 1

Study

No. of patients

B lo mq vist et a l. 8
Jensen et a l. 9
Kan et al. 10
Kan et al. 11
Levi n et al. 12
Beaumont et al. 13
Pel eg et al. 14
B aron e et a l. 15
Huynh-Ba et al. 1
L i n et a l. 16
Test or i et al. 17
Zi nser et a l. 18
C ha et al. 19

No. of implants

49
1007
60
60
56
45
731
70
57
75
106
224
161

Relationship between smoking
and implant success (p-value)

Relationship between oral hygiene
and implant success (p-value)

0.977
< 0.05*
0.027*
0.027*
0.06
> 0.05
0.394
< 0.05*
0.025*
< 0.05*
< 0.05**
0.009*
0.0003*

NS
NS
NS
< 0.05*
NS
NS
NS
NS
NS
NS
NS
NS
NS

314
2997
228
228
— (143 DSL)
— (59 DSL)
2132
287
116
155
328
1045
462

*Signiﬁcant differences; **signiﬁcant differences only for > 15 cigarettes/day.

Table 1

Table 2

Length (mm)
10.0
11.5
13.0

3.6

Diameter (mm)
4.2

5.5

1
10
0

8
48
19

13
3
0

Effect of smoking and oral
hygiene on success of
implants placed after direct
sinus lift (DSL = direct sinus
lift; NS: not studied).
Table 2

Table 3

Implant placement
Immediate
Delayed
To t a l

No. of implants

No. failed

50
52
102

5
2
7

12 months after loading
Success rate (%)
Mean bone loss (mm)
90.0
96.2
93.1

0.62
0.54
0.58

p > 0.05

p > 0.05

Number of implants placed
according to length and
diameter.
Table 3
Number of implants placed
and failed, success rate and
mean bone loss according to
immediate or delayed
placement of implants.

Table 4

Smoking status

No. of implants

Nonsmokers
Smokers

69
33

12 months after loading
Success rate (%)
Mean bone loss (mm)
94.2
90.9

0.52
0.60

p > 0.05

p > 0.05

Table 4
Number of implants, success
rate and mean bone loss in
relation to smoking.

Table 5

Oral hygiene

No. of implants

Good
Regular
Poor

Table 5

12 months after loading
Success rate (%)
Mean bone loss (mm)

47
42
13

95.5
92.3
81.8

0.51
0.57
0.66

p > 0.05

p > 0.05

Number of implants, success
rate and mean bone loss in
relation to oral hygiene.

Discussion
Direct maxillary sinus lift is a predictable procedure. Pjetursson et al. performed a systematic
review to assess the survival of implants after sinus
lift.28 Meta-analysis indicated an estimated an-

nual failure rate of 3.48% (95% conﬁdence interval: 2.48–4.88%), which translated into a threeyear implant survival of 90.1% (95% conﬁdence interval: 86.4–92.8%).28 These results are similar to

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

73

[74] =>

Success of implants placed after direct sinus lift

Luis Martorell Calatayud,*
Javier Romero Millán,*
David Peñarrocha Oltra,*
Maria Peñarrocha Diago,*
Berta García Mira*
& Miguel Peñarrocha Diago*
Oral Surgery Unit,
Department of Stomatology, Faculty of Medicine
and Odontology, University
of Valencia, Valencia, Spain

*

Corresponding author:
Dr. David Peñarrocha Oltra
Clínicas odontológicas
Gascó Oliag, 1
46021 Valencia
Spain
T & F +34 963 86 4139
david.penarrocha@uv.es

those obtained in the present study: a success
rate of 93.1% for 102 implants placed after 58
direct sinus lifts.
The mean bone loss at 12 months was
0.62 mm for simultaneously placed implants
and 0.54 mm for those placed in a second
stage. No statistically significant differences
were observed. These results were similar to
those of Felice et al.: one year after loading,
one-stage-treated implants lost an average of
1.01 mm of periimplant bone and two-stage
sites about 0.93 mm.29 Similarly, after one year
of follow-up, Jodia et al.30 reported a marginal
bone loss of between 0.68 and 1.22 mm for simultaneously placed implants, and Kahnberg
and Vannas-Löfqvist31 of 0.8 mm for implants
placed in a delayed mode.
In the literature, smoking has often been
associated with a higher failure rate for conventionally placed dental implants,32–35, 7 worse
osseointegration, as well as more frequent
periimplantitis, bone loss and bleeding.36, 37
However, in studies published on sinus lift,
there is no unanimity regarding the effect of
smoking on treatment outcomes. In five of the
reviewed studies (Table 1), statistically significant differences were found, observing a
higher success rate in nonsmokers than in
smokers.9, 10, 11, 15, 1 In one study, only smoking
> 15 cigarettes/day and a residual ridge height
of < 4 mm were significantly associated with
reduced implant survival.17 In other studies,8,
12–14
no statistically significant relationship
was found between smoking and implant success, although failure rates were higher among
smokers. Moreover, Levin et al. observed relevant complications in one-third of the smokers,
compared with only 7.7% of the nonsmokers.12
A recent systematic review evaluated the
effects of tobacco smoking on the survival rate
of dental implants placed in areas of maxillary
sinus lift. Eight studies, three prospective and
five retrospective, were included. Smoking was
associated with increased implant failure rates
in most individual studies and in the overall
meta-analysis. However, when only prospective studies were considered, no significant differences in implant failure were observed between smokers and nonsmokers.38 Similar results were obtained in this study: the implant
failure rate and bone loss were slightly higher
in smokers, but with the available sample
size these differences were not statistically
significant.
74 Volume 1 | Issue 1/2015

The literature clearly demonstrates the negative
response of the periimplant mucosa to plaque
accumulation;39–41 however, there is disagreement regarding the inﬂuence of oral hygiene on
the success of conventionally placed implants.
Mombelli et al.,21 Smith and Zarb,22 and Baelum
and Ellegaard argue that hygiene did not inﬂuence implant outcomes (success and bone loss)
in the short term.23 However, Lindquist et al. observed a higher bone loss in patients with poor
oral hygiene.5 The inﬂuence of hygiene on the
success of implants placed after direct sinus lift
has been more rarely studied. Kan et al.11 evaluated oral hygiene according to the modiﬁed
plaque index as described by Mombelli et al.21
and reported a failure rate of 1.4% in patients
with good oral hygiene, 13.9% with fair hygiene
and 60% with poor oral hygiene; the differences
between the groups were statistically signiﬁcant.11 In our study, a lower implant success rate
was found in patients with poor hygiene (81.8%),
compared with patients with regular and good
hygiene (92.3% and 95.5%, respectively). The
differences did not reach statistical signiﬁcance,
but the comparison between poor hygiene and
the other two categories tended to signiﬁcance
(p = 0.058). In fact, a difference of over 10% with
such a predictable treatment technique may be
considered of clinical relevance, and the lack of
statistical signiﬁcance is probably related to the
small number of patients with poor oral hygiene.

Conclusion
Within its limitations, the present investigation
suggests that smoking and poor oral hygiene
may negatively inﬂuence the outcome of implants placed both in one-stage and two-stage
direct sinus lift procedures. However, the differences were in no case statistically signiﬁcant,
and prospective studies with larger sample sizes
and longer follow-up are necessary to corroborate or refute these ﬁndings.

Competing interests
The authors declare that they have no conﬂict of
interests related to this study.

Journal of
Oral Science & Rehabilitation

[75] =>

Success of implants placed after direct sinus lift

References
1.
Huynh-Ba G, Friedberg JR, Vogiatzi D,
Ioannidou E. Implant failure predictors in
the posterior maxilla: a retrospective study
of 273 consecutive implants.
→ J Periodontol.
2008 Dec;79(12):2256–61.

11.
Kan JY, Rungcharassaeng K, Kim J, Lozada
JL, Goodacre CJ. Factors affecting the
survival of implants placed in grafted
maxillary sinuses: a clinical report.
→ J Prosthet Dent.
2002 May;87(5):485–9.

21.
Mombelli A, van Oosten MA, Schürch E Jr,
Lang NP. The microbiota associated with
successful or failing osseointegrated
titanium implants.
→ Oral Microbiol Immunol.
1987 Dec;2(4):145–51.

2.
Schlegel A, Hamel J, Wichmann M, Eitner
S. Comparative clinical results after implant
placement in the posterior maxilla with and
without sinus augmentation.
→ Int J Oral Maxillofac Implants.
2008 Mar-Apr;23(2):289–98.

12.
Levin L, Herzberg R, Dolev E, SchwartzArad D. Smoking and complications of
onlay bone grafts and sinus lift operations.
→ Int J Oral Maxillofac Implants.
2004 May-Jun;19(3):369–73.

22.
Smith DE, Zarb GA. Criteria for success of
osseointegrated endosseous implants.
→ J Prosthet Dent.
1989 Nov;62(5):567–72.

3.
Rios HF, Avila G, Galindo P, Bratu E, Wang
HL. The inﬂuence of remaining alveolar
bone upon lateral window sinus
augmentation implant survival.
→ Implant Dent.
2009 Oct;18(5):402–12.
4.
Peñarrocha M, Palomar M, Sanchis JM,
Guarinos J, Balaguer J. Radiologic study of
marginal bone loss around 108 dental
implants and its relationship to smoking,
implant location, and morphology.
→ Int J Oral Maxillofac Implants.
2004 Nov-Dec;19(6):861–7.
5.
Lindquist LW, Carlsson GE, Jemt T.
Association between marginal bone loss
around osseointegrated mandibular
implants and smoking habits: a 10-year
follow-up study.
→ J Dent Res.
1997 Oct;76(10):1667–74.
6.
Bain CA, Weng D, Meltzer A, Kohles SS,
Stach RM. A meta-analysis evaluating the
risk for implant failure in patients who
smoke.
→ Compend Contin Educ Dent.
2002 Aug;23(8):695–9, 702, 704 passim;
quiz 708.
7.
d’Avila S, dos Reis LD, Piattelli A, Aguiar KC,
de Faveri M, Borges FL, Iezzi G, Oliveira NT,
de G Cardoso LA, Shibli JA. Impact of
smoking on human bone apposition at
different dental implant surfaces: a
histologic study in type IV bone.
→ J Oral Implantol.
2010 Apr;36(2):85–90.
8.
Blomqvist JE, Alberius P, Isaksson S.
Retrospective analysis of one-stage
maxillary sinus augmentation with
endosseous implants.
→ Int J Oral Maxillofac Implants.
1996 Jul-Aug;11(4):512–21.
9.
Jensen OT, Shulman LB, Block MS, Iacono
VJ. Report of the Sinus Consensus
Conference of 1996.
→ Int J Oral Maxillofac Implants.
1998;13 Suppl:11–45.
10.
Kan JY, Rungcharassaeng K, Lozada JL,
Goodacre CJ. Effects of smoking on
implant success in grafted maxillary
sinuses. J Prosthet Dent. 1999
Sep;82(3):307–11.

13.
Beaumont C, Zaﬁropoulos GG, Rohmann K,
Tatakis DN. Prevalence of maxillary sinus
disease and abnormalities in patients
scheduled for sinus lift procedures.
→ J Periodontol.
2005 Mar;76(3):461–7.
14.
Peleg M, Garg AK, Mazor Z. Healing in
smokers versus nonsmokers: survival rates
for sinus ﬂoor augmentation with
simultaneous implant placement.
→ Int J Oral Maxillofac Implants.
2006 Jul-Aug;21(4):551–9.
15.
Barone A, Santini S, Sbordone L, Crespi R,
Covani U. A clinical study of the outcomes
and complications associated with
maxillary sinus augmentation.
→ Int J Oral Maxillofac Implants.
2006 Jan-Feb;21(1):81–5.
16.
Lin TH, Chen L, Cha J, Jeffcoat M, Kao DW,
Nevins M, Fiorellini JP. The effect of
cigarette smoking and native bone height
on dental implants placed immediately in
sinuses grafted by hydraulic condensation.
→ Int J Periodontics Restorative Dent.
2012 Jun;32(3):255–61.
17.
Testori T, Weinstein RL, Taschieri S, Del
Fabbro M. Risk factor analysis following
maxillary sinus augmentation: a
retrospective multicenter study.
→ Int J Oral Maxillofac Implants.
2012 Sep-Oct;27(5):1170–6.
18.
Zinser MJ, Randelzhofer P, Kuiper L, Zöller
JE, De Lange GL. The predictors of implant
failure after maxillary sinus ﬂoor
augmentation and reconstruction: a
retrospective study of 1045 consecutive
implants.
→ Oral Surg Oral Med Oral Pathol
Oral Radiol.
2013 May;115(5):571–82.

23.
Baelum V, Ellegaard B. Implant survival in
periodontally compromised patients.
→ J Periodontol.
2004 Oct;75(10):1404–12.
24.
Greene JC, Vermillion JR. The simpliﬁed
oral hygiene index.
→ J Am Dent Assoc.
1964 Jan;68(1):7–13.
25.
Buser D, Mericske-Stern R, Dula K, Lang
NP. Clinical experience with one-stage,
non-submerged dental implants.
→ Adv Dent Res.
1999 Jun;13(1):153–61.
26.
Boronat A, Peñarrocha M, Carrillo C, Marti
E. Marginal bone loss in dental implants
subjected to early loading (6 to 8 weeks
postplacement) with a retrospective shortterm follow-up.
→ J Oral Maxillofac Surg.
2008 Feb;66(2):246–50.
27.
Wallace RH. The relationship between
cigarette smoking and dental implant
failure.
→ Eur J Prosthodont Restor Dent.
2000 Sep;8(3):103–6.
28.
Pjetursson BE, Tan WC, Zwahlen M, Lang
NP. A systematic review of the success of
sinus ﬂoor elevation and survival of
implants inserted in combination with sinus
ﬂoor elevation.
→ J Clin Periodontol.
2008 Sep;35(8 Suppl):216–40.
29.
Felice P, Pistilli R, Piattelli M, Soardi E,
Barausse C, Esposito M. 1-stage versus 2stage lateral sinus lift procedures: 1-year
post-loading results of a multicentre
randomised controlled trial.
→ Eur J Oral Implantol.
2014 Spring;7(1):65–75.

19.
Cha HS, Kim A, Nowzari H, Chang HS, Ahn
KM. Simultaneous sinus lift and implant
installation: prospective study of
consecutive two hundred seventeen sinus
lift and four hundred sixty-two implants.
→ Clin Implant Dent Relat Res.
2014 Jun;16(3):337–47.

30.
Jodia K, Sadhwani BS, Parmar BS, Anchlia
S, Sadhwani SB. Sinus elevation with an
alloplastic material and simultaneous
implant placement: a 1-stage procedure in
severely atrophic maxillae.
→ J Maxillofac Oral Surg.
2014 Jul-Sep;13(3):271–80.

20.
Lindquist LW, Carlsson GE, Jemt T. A
prospective 15-year follow-up study of
mandibular ﬁxed prostheses supported by
osseointegrated implants. Clinical results
and marginal bone loss.
→ Clin Oral Implants Res.
1996 Dec;7(4):329–36.

31.
Kahnberg KE, Vannas-Löfqvist L. Sinus lift
procedure using a 2-stage surgical
technique: I. Clinical and radiographic
report up to 5 years.
→ Int J Oral Maxillofac Implants.
2008 Sep-Oct;23(5):876–84.

Journal of
Oral Science & Rehabilitation

Volume 1 | Issue 1/2015

32.
Bain CA, Moy PK. The association between
the failure of dental implants and cigarette
smoking.
→ Int J Oral Maxillofac Implants.
1993 Nov-Dec;8(6):609–15.
33.
Lambert PM, Morris HF, Ochi S. The
inﬂuence of smoking on 3-year clinical
success of osseointegrated dental
implants.
→ Ann Periodontol.
2000 Dec;5(1):79–89.
34.
Nitzan D, Mamlider A, Levin L, SchwartzArad D. Impact of smoking on marginal
bone loss.
→ Int J Oral Maxillofac Implants.
2005 Jul-Aug;20(4):605–9.
35.
Galindo-Moreno P, Fauri M, Ávila-Ortiz G,
Fernández-Barbero JE, Cabrera-León A,
Sánchez-Fernández E. Inﬂuence of alcohol
and tobacco habits on peri-implant
marginal bone loss: a prospective study.
→ Clin Oral Implants Res.
2005 Oct;16(5):579–86.
36.
Haas R, Haimböck W, Mailath G, Watzek G.
The relationship of smoking on periimplant tissue: a retrospective study.
→ J Prosthet Dent.
1996 Dec;76(6):592–6.
37.
de Souza JG, Bianchini MA, Ferreira CF.
Relationship between smoking and
bleeding on probing.
→ J Oral Implantol.
2012 Oct;38(5):581–6.
38.
Chambrone L, Preshaw PM, Ferreira JD,
Rodrigues JA, Cassoni A, Shibli JA. Effects
of tobacco smoking on the survival rate of
dental implants placed in areas of maxillary
sinus ﬂoor augmentation: a systematic
review.
→ Clin Oral Implants Res.
2014 Apr;25(4):408–16.
39.
van Steenberghe D, Klinge B, Lindén U,
Quirynen M, Herrmann I, Garpland C.
Periodontal indices around natural and
titanium abutments: a longitudinal
multicenter study.
→ J Periodontol.
1993 Jun;64(6):538–41.
40.
Crespi R, Capparè P, Gherlone E. A 4-year
evaluation of the peri-implant parameters
of immediately loaded implants placed in
fresh extraction sockets.
→ J Periodontol.
2010 Nov;81(11):1629–34.
41.
Matarasso S, Rasperini G, Iorio Siciliano V,
Salvi GE, Lang NP, Aglietta M. A 10-year
retrospective analysis of radiographic
bone-level changes of implants supporting
single-unit crowns in periodontally
compromised vs. periodontally healthy
patients.
→ Clin Oral Implants Res.
2010 Sep;21(9):898–903.

75

[76] =>

Guidelines for authors

Authors must adhere
to the following guidelines

Informed consent

Title

Patients have a right to privacy that should not be violated without informed consent.
Identifying information, including patients’ names, initials or hospital numbers, should
not be provided in the manuscript or visual material unless the information is essential
for scientiﬁc purposes and the patient (or parent or guardian) has given written informed
consent for publication. Informed consent for this purpose requires that an identifiable
patient be shown the manuscript to be published. Authors should disclose to these
patients whether any potential identifiable material might be available via the Internet
as well as in print after publication. Nonessential identifying details should be omitted.
Informed consent should be obtained if there is any doubt that anonymity can be maintained. For example, masking the eye region in photographs of patients is inadequate
protection of anonymity. If identifying characteristics are altered to protect anonymity,
authors should provide assurance that alterations do not distort scientiﬁc meaning.
When informed consent has been obtained, it should be indicated in the manuscript.

The title should not exceed 35 characters. Capitalize
only the ﬁrst word and proper nouns in the title.

Human and animal rights

Author information

The following information must be included for each
author:
– Full author name(s)
– Full afﬁliation (department, faculty, institution,
town, country).
For the corresponding author, the following information should be included in addition:
– Full mailing address
– Email address.

When reporting experiments on human subjects, authors should indicate whether the
procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2013 (www.wma.net/en/30publications/ 10policies/b3/index.html). If doubt exists whether the research was conducted in accordance
with the Declaration of Helsinki, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the
doubtful aspects of the study. When reporting experiments on animals, authors should
indicate whether institutional and national standards for the care and use of laboratory
animals were followed. Further guidance on animal research ethics is available from the
International Association of Veterinary Editors’ Consensus Author Guidelines on Animal
Ethics and Welfare (www.veteditors.org/consensus-author-guidelines-onanimalethics-and-welfare-for-editors).

Preparing the manuscript text
General

Abstract and keywords

The manuscript must contain an abstract and a maximum of ﬁve keywords. The abstract should be selfcontained, not cite any other work and not exceed 250
words. It should be structured into the following separate sections: objective, materials and methods,
results, and conclusion.
Structure of the main text

The body of the manuscript must be structured as
follows:
– Introduction (no subheadings)
– Materials and methods
– Results
– Discussion
– Conclusion

The manuscript must be written in U.S. English. The
main body of the text, excluding the title page, abCompeting interests
stract and list of captions, but including the references, may be a maximum of 4,000 words. Excep- Authors are required to declare any competing ﬁnantions may be allowed with prior approval from the cial or other interests regarding the article submitted.
publisher.
Such competing interests are to be stated at the end
of manuscript before the references. If no competing
Authors will have the opportunity to add more infor- interests are declared, the following will be stated:
mation regarding their article, as well as post videos, “The authors declare that they have no competing inpresent a webinar and blog on the DT Science web- terests.”
site.
Acknowledgments

It is preferred that there be no more than six authors.
If more authors have participated in the study, the Acknowledgments (if any) should be brief and incontribution of each author must be disclosed at the cluded at the end of the manuscript before the referend of the document.
ences, and may include supporting grants

76 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

[77] =>

Guidelines for authors

References

Requirements for tables

Authors are responsible for ensuring that the information for each reference is complete and accurate.
All references must be cited within the manuscript.
References appearing in the list but not in the manuscript will be removed. In-text citation should follow
the citation–sequence format (e.g., “as discussed by
Haywood et al.,15”) using superscript numbers placed
after the punctuation in the relevant sentence. The
references must be numbered consecutively.

Each table should be supplied separately and in Microsoft Word format. Tables may not be embedded as images and no shading or color is to be used.

Tables should be cited consecutively in the manuscript. Place the references to the tables in your article
wherever they are appropriate, whether in the middle
or at the end of a sentence. Every table must have a
descriptive caption, and if numerical measurements
are given the units should be included in the column
The reference list must be numbered and the refer- headings.
ences provided in order of appearance. For the reference list, the journal follows the citation style stipuSupplements/supporting material
lated in Citing medicine: the NLM style guide for authors, editors, and publishers. The guidelines may be DT Science allows an unlimited amount of supportviewed and downloaded free of charge at
ing material (such as datasets, videos or other additional information) to be uploaded. This material
should be presented succinctly (in English). The auwww.ncbi.nlm.nih.gov/books/NBK7256/
thor bears full responsibility for the content. Color,
animated multimedia presentations, videos and so
List of captions
on are welcome and published at no additional cost
Please provide the captions for all visual material at to the author or reader. Please refer briefly to such
material in the manuscript where appropriate (e.g.,
the end of the manuscript.
as an endnote).
Abbreviations

Abbreviations should be used sparingly and deﬁned
when ﬁrst used. The abstract and the main manuscript text should be regarded as separate documents
in this regard.
Typography

– Use Times New Roman regular with a font size
of 12 pt.
– Use double line spacing with blank lines separating sections and paragraphs.
– Type the text unjustiﬁed and do not apply
hyphenation at line breaks.
– Number all of the pages.
– Use endnotes if necessary, but not footnotes.
– Greek and other special characters may be
included.

Preparing the visual material

Submit your research and
clinical articles to
Prof. Ugo Covani at
covani@covani.it

Requirements for images

Each image should be supplied separately and the following formats are accepted: PSD, TIFF, GIF and
JPEG. The image must have a resolution of 300 dpi
and must be no smaller than 6 cm × 6 cm.
Please number the images consecutively throughout
the article by using a new number for each image. If it
is imperative that certain images be grouped together,
then use lowercase letters to designate these in a
group (e.g., “Figs. 2a–c”).
Place the references to the images in your article
wherever they are appropriate, whether in the middle
or at the end of a sentence. Provide a caption for each
image at the end of your article.

Journal of
Oral Science & Rehabilitation

For all other requests,
contact
Nathalie Schüller at
n.schueller@dental-tribune.com
T +49 341 4847 4136
Dental Tribune International Publishing Group
Holbeinstr. 29
04229 Leipzig
Germany
www.dtscience.com
www.dental-tribune.com

Volume 1 | Issue 1/2015

77

[78] =>

Imprint: About the publisher

Publishing team

Editorial board

Publisher

Editor-in-Chief

Torsten R. Oemus
t.oemus@dental-tribune.com

Ugo Covani, Pisa and Camaiore, Italy
Co-editors

Managing Editor
Nathalie Schüller
n.schueller@dental-tribune.com

Daniele Botticelli, Rimini, Italy
José Luis Calvo Guirado, Murcia, Spain
Miguel Peñarrocha Diago, Valencia, Spain

International office

Concept & design

Associate editors

Dental Tribune International
Holbeinstr. 29
04229 Leipzig
Germany

Christian Majonek, Rhowerk
www.rhowerk.com

Antonio Barone, Pisa, Italy
Luigi Canullo, Camaiore, Italy
Rafael Arcesio Delgado Ruiz, Stony Brook, N.Y., U.S.
David Peñarrocha Oltra, Valencia, Spain

T +49 341 4847 4302
F +49 341 4847 4173
info@dental-tribune.com
www.dental-tribune.com

Digital Manager
Serban Veres
serbanveres@gmail.com
Copy editors

Scientific advisers
Pablo Galindo Moreno, Granada, Spain
Georgios Romanos, Stony Brook, N.Y., U.S.
Giovanni Serino, Borås, Sweden

Sabrina Raaff
sabrina@greenbadger.co.za

Statistical advisers

Hans Motschmann
h.motschmann@oemus-media.de

Marco Tallarico, Sassari, Italy
Francesco Tessarolo, Mattarello, Italy
Executive board

International administration
Chief Financial Officer

Daniele Botticelli, Rimini, Italy
Luigi Canullo, Camaiore, Italy
Torsten R. Oemus, Leipzig, Germany

Dan Wunderlich
d.wunderlich@dental-tribune.com

Board of reviewers

Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com

Copyright regulations
The Journal of Oral Science & Rehabilitation is published quarterly by Dental Tribune International (DTI).
The journal and all articles and illustrations contained therein are protected by copyright. Any utilization
without the prior consent of the authors, editor and publisher is prohibited and liable to prosecution.
This applies in particular to duplicate copies, translations, microﬁlms, and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher.
Given no statement to the contrary, any submissions to the editorial department are understood to be
in agreement with full or partial publishing of said submission. The editorial department reserves the
right to check all submitted articles for formal errors and factual authority, and to make amendments
if necessary. Articles bearing symbols other than that of the editorial department, or that are distinguished
by the name of the author, represent the opinion of the afore-mentioned, and do not have to comply
with the views of DTI. Responsibility for such articles shall be borne by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise,
no responsibility shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are
excluded. The legal domicile is Leipzig, Germany.
Printer
Löhnert Druck | Handelsstr. 12 | 04420 Markranstädt | Germany

78 Volume 1 | Issue 1/2015

Journal of
Oral Science & Rehabilitation

Marcus Abboud, Stony Brook, N.Y., U.S.
Marco Álvarez, Mexico City, Mexico
Conrado Aparicio, Minneapolis, Minn., U.S.
Shunsuke Baba, Osaka, Japan
Franco Bengazi, Brescia, Italy
Andrea Edoardo Bianchi, Milan, Italy
Manuel Bravo Pérez, Granada, Spain
Eriberto Bressan, Padua, Italy
Marco Caneva, Trieste, Italy
Juan Carlos De Vicente Rodríguez, Oviedo, Spain
Stefan Fickl, Würzburg, Germany
Joseph Fiorellini, Philadelphia, Pa., U.S.
Abel García García, Santiago de Compostela, Spain
Gerardo Gómez Moreno, Granada, Spain
Federico Hernández Alfaro, Barcelona, Spain
Carlos Larrucea Verdugo, Talca, Chile
Baek-Soo Lee, Seoul, South Korea
Dehua Li, Xi’an, China
Aleksa Markovic, Belgrade, Serbia
José Eduardo Maté Sánchez de Val, Murcia, Spain
Alberto Monje, Ann Arbor, Mich., U.S.
Yasushi Nakajima, Osaka, Japan
Ulf Nannmark, Gothenburg, Sweden
Wilson Roberto Poi, Araçatuba, Brazil
Alessandro Quaranta, Dunedin, New Zealand
Maria Piedad Ramírez Fernández, Murcia, Spain
Idelmo Rangel García, Araçatuba, Brazil
Fabio Rossi, Bologna, Italy
Hector Sarmiento, Philadelphia, Pa., U.S.
Nikola Saulacic, Geneva, Switzerland
Alessandro Scala, Pesaro, Italy
Carlos Alberto Serrano Méndez, Bogotá, Colombia
Andrew Tawse-Smith, Dunedin, New Zealand
Cemal Ucer, Manchester, U.K.
Joaquín Urbizo Velez, La Habana, Cuba

[79] =>

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

I would like to subscribe to

CAD/CAM
cone beam
cosmetic dentistry*
DT Study Club (France)***
gums*

€ 44/magazine (4 issues/year;
incl. shipping and VAT for customers
in Germany) and € 46/magazine
(4 issues/year; incl. shipping for customers
outside Germany).** Your subscription will
be renewed automatically every year until
a written cancellation is sent to
Dental Tribune International GmbH,
Holbeinstr. 29, 04229 Leipzig, Germany,
six weeks prior to the renewal date.

implants
laser
ortho
prevention*
roots

4 issues per year | * 2 issues per year
*** €56/magazine (4 issues/year; incl. shipping and VAT)

** Prices for 2 issues/year are € 22
and € 23 respectively per year.

Shipping address

City

Country

Phone

Fax

Signature

Date

PayPal | subscriptions@dental-tribune.com

Credit Card
Credit Card Number

\ SUBSCRIBE NOW!

Expiration Date

Security Code

fax: +49 341 48474 173 | e-mail: subscriptions@dental-tribune.com

[80] =>

) [page_count] => 80 [pdf_ping_data] => Array ( [page_count] => 80 [format] => PDF [width] => 595 [height] => 842 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => Journal of Oral Science & Rehabilitation No. 1, 2015

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Contents [page] => 04 ) [3] => Array ( [title] => About [page] => 06 ) [4] => Array ( [title] => Immediate replacement of failed dental implants owing to periimplantitis [page] => 08 ) [5] => Array ( [title] => Comparison of new bone formation between biphasic β -TCP bovine vs. β -TCP bovine doped with silicon biomaterials in small and large defects: Experimental study in dogs [page] => 16 ) [6] => Array ( [title] => Complications of postoperative swelling of the maxillary sinus membrane after sinus floor augmentation [page] => 26 ) [7] => Array ( [title] => The prevalence and quantitative analysis of the Epstein–Barr virus in healthy implants and implants affected by periimplantitis: A preliminary report [page] => 34 ) [8] => Array ( [title] => Immunohistochemical osteopontin expression in bone xenograft in clinical series of maxillary sinus lift [page] => 42 ) [9] => Array ( [title] => Evaluation of the effect of supervised plaque control after the surgical removal of partially erupted mandibular third molars on the periodontal condition distal to second molars affected by localized periodontal disease: A randomized blind clinical study [page] => 52 ) [10] => Array ( [title] => A volumetric 3-D digital analysis of dimensional changes to the alveolar process at implants placed immediately into extraction sockets [page] => 62 ) [11] => Array ( [title] => Influence of smoking and oral hygiene on success of implants placed after direct sinus lift [page] => 70 ) [12] => Array ( [title] => Guidelines for authors [page] => 76 ) [13] => Array ( [title] => Imprint [page] => 78 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

[cached] => true )